Good practices for home and community care for older people

A Report of Meeting on Good Practices for Home and Community Care for Older People

29 June 2022, 12:30-13:45, BKK time (UTC+7)

Side Meeting of the Asia-Pacific Intergovernmental Meeting on the Fourth Review and Appraisal of the Madrid International Plan of Action on Ageing

This side event was organised by the Foundation for Older Persons’ Development (FOPDEV), in
partnership with HelpAge International in Vietnam (HAIV). A total of 76 people joined: 61 people
attended the meeting online and 15 people attended onsite.

Key messages

  • Population ageing has brought countries in Asia and the Pacific challenges in meeting the
    increasing care needs of the older population and there is an urgent need to develop policies
    and support community-based programmes on age care.
  • There are common challenges and several good practices in long-term care (LTC) among the
    countries that can be shared and learned and support each other.
  • Home and community-based approach is the main policy on long-term care for most countries
    and the two initiatives in Thailand and Vietnam are promising models for expansion of age care.

Opening remarks

Mr. Eduardo Klien, Regional Representative for Asia and the Pacific of HelpAge International. Key points include:
Countries in Asia and the Pacific region are rapidly ageing and changes in demographic characteristics, notably the reduction in family size and migration of young people, are key factors that affect the existing traditional approaches that older people are cared for by younger generations. This poses a key question for policymakers and family members- who will care for older people who need care and support?

The initial response of developing institutional care (care home) is not a viable solution considering the large scale of care needs. There is a need to develop a comprehensive care strategy to meet the increasing care needs of the older population. Various approaches have been developed and grown in the region, including home and community care.
It is critical that all these approaches are developed within a scope of a broader context of comprehensive national strategy encompassing, among other issues, financing, human resources, education and training of caregivers and community organisations.
Initiatives of the Foundation for Older Persons’ Development (FOPDEV) and HelpAge International in Vietnam (HAIV) are good examples of innovative ways of developing home and community care approaches that can be replicated and scaled up, which can contribute to the improvement of care and support for older people in the region.

Dr. Ha Thi Minh Duc, Deputy Director-General, International Cooperation Department, Ministry of Labor, Invalids and Social Welfare, Vietnam. Key points include:

Vietnam is one of the countries that is rapidly ageing. Most people suffer from chronic diseases after the age of 60. We need to act quickly to prepare for the future and it is the attention of the Communist Party of Vietnam to care for and promote the role of older people. Many young people migrate to big cities for jobs and that poses more difficulties to care for older family members. The government will have to put more effort to support them. But it is challenging to mobilise funds to respond to care needs. The government has a policy that focuses on a home and community care approach and the Intergenerational Self-Help Club model is one of the solutions. The ISHC promotes healthy ageing while providing care and support for disadvantaged people, using local resources. It has proven to be the best community-based care model in the country, so far. It is suitable for our culture, social and economic conditions.
The Prime Minister of Vietnam has approved the first and second ISHC replication projects, assigning the Vietnam Elderly Association, the organisation with a nationwide structure, to lead the implementation process in coordination with local authorities and other relevant agencies. The ISHC is also one of the targets of the National Plan of Action for Older People. It aims to have ISHC developed in 30% of
communities by 2030. Our aspiration is to build a care ecosystem with the engagement of key stakeholders in which the ISHC plays an important role. We thank HelpAge International for their continued support, particularly for developing this ISHC model. We need technical support from international organisations and development partners so we can learn and improve our care approach.

Presentation

In the presentation section, three experts on home and community care shared initiatives from their organisations.

Ms. Meredith Wyse, Senior Social Development Specialist – Aging and Care, Sustainable Developmen and Climate Change Department, Asian Development Bank
Ms. Wyse presented ‘The Road to Better Long-term Care (LTC) in Asia and the Pacific: Building Systems of Care and Support for Older Persons’ which is a summary of the outputs of the Technical Assistance Project on Strengthening Developing Member Countries’ Capacity in Elderly Care. This project was funded by the Japan Fund for Poverty Reduction and the Republic of Korea e-Asia and Knowledge Partnership Fund and worked closely with HelpAge International.
Country: The TA covered 6 countries, chosen because of their interest in the age care issue and their diversity: Indonesia, Mongolia, Sri Lanka, Thailand, Tonga, and Viet Nam.
Thematic focus: The TA focused on a situational analysis to understand the situation of care in each country and then did an in-depth study and capacity building around certain issues. The TA was framed around the process of planning for LTC with the involvement of stakeholders from different sectors, to analyse the care issue and develop a strategic plan for LTC. Lastly, the TA promoted regional learning because it is so important to learn about good practices and help each other.

Analytical framework: The TA used the WHO framework of health systems and framed it around the building blocks of LTC and looked at five key areas: the services across the continuum from home to residential care, governance and leadership, financing, information systems and the working force.

Commonalities: There were some commonalities across the countries. These included:

  • A strong commitment to ‘Ageing in Place’ at the policy level. It is well understood, prioritised
    and a main policy tenet.
  • A central role of families for LTC is highlighted and included in legislation in a number of these countries. However, it is not necessarily backed up by support for family caregivers, which is a big gap that needs to be addressed in moving forward to really strengthen the role of families.
  • There is a wide variety of non-family caregivers including government and non-governmental community groups and a very fast-growing private sector. There is a need to understand what the role of these agencies is really, and how they can be incentivised and collaborate effectively.
  • Community involvement by older adults in providing care and services – older people’s groups and volunteers. This is quite unique to Asia and the Pacific. The key question is what the roles of these actors are. Challenges: A few common key challenges were identified:
  • Sustainable financing and human resources were highlighted in all countries.
  • There were gaps between policies and practices.
  • How to build integrated care, how to build services that ensure that support needed among older people is provided – from health to social services.
  • How to capitalise on technology, how it can be used to really leapfrog LTC – designing systems, empowering older people, planning and monitoring.
    Recommendations: To move forward, the points below should be prioritised:
  • Develop LTC systems and services that provide a continuum of care, with a focus on home‑ and community‑based services, supplemented by residential care options.
  • Integrate LTC with health and social support services, with a specific focus on integration with primary care, and start to build up the necessary skills and experience for complex care, such as for advanced dementia.
  • Develop effective LTC systems, with clearly defined governance, roles, and mandates for each of the major stakeholders: government, the private sector, civil society, and the public.
  • Develop coordination mechanisms to enable collaboration across government stakeholders, such as the ministries of health, social welfare and social protection, education, and finance; and build systems to incentivize collaboration.
  • Prioritize the design and expansion of LTC financing systems to build systems that raise adequate funds to deliver services, pool financial risks, provide clarity of coverage, and offer incentives to drive efficiency.
  • Galvanize human resources by exploiting opportunities for job creation that arise from a growing demand for a wide range of positions, including care assistants and allied health professionals, and training and accrediting medical staff and allied businesses.
  • Develop support to family caregivers through social transfers, training, peer assistance, and increased availability of home‑ and community‑based care.
  • Foster the development and use of technology, including accessible and assistive devices that support persons to maintain their independence and technology to enhance service delivery, underpinned by support to increase digital literacy amongst older adults.
  • Recognize the place of LTC within the broader context of age-friendly communities, housing, transport, social protection, and healthy ageing programs; and support the role of these sectors in strengthening overall adaptation to ageing societies in the region.
  • Learn from global and regional practices in this rapidly emerging area, which will continue to increase in importance in tandem with the demographic transition underway in the region.

Ms. Tran Bich Thuy, Country Director of HelpAge International in Vietnam
Ms. Thuy Tran presented the experience of HelpAge International in Vietnam titled ‘Comprehensive community care services through Intergenerational Self-Help Clubs (ISHCs) in Vietnam’.
Vietnam is one of the fastest ageing countries in the world. It will take only 25 years to change from an ageing to an aged society and with the current population structure, Vietnam will have a very large older population in the coming decades, nearly 32 million in 2069. But The country has limited resources to respond to the needs of older people and take advantage of the ageing population. Getting old before getting rich has brought Vietnam challenges to meet its increasing care needs.
Care gaps: There is a growing number of older people with care needs while there is a reduction in informal caregivers. Many women, often main family caregivers, are now working and there is also an increase in the migration of young people to big cities or abroad to work or to study. An increase in non-communicable diseases makes care provision more complex. Growing care gaps can be narrowed down by 1) decreasing care demand by promoting prevention, self-care, active ageing, 2) increasing supply by supporting family caregivers and promoting engagement of volunteers in the provision of care and, 3) extending LTC services, particularly community-based carewhich is most preferred by older people in Vietnam.

ISHC development model: ISHC is a voluntary social organisation established at the community level in either rural or urban settings, with authority in decision making including the development process and use of resources belonging to community groups. An underlining assumption of ISHCs is that communities know best and with adequate support – training, resources, and opportunities – they can organize themselves to meet immediate and long-term needs for development. The ISHC model is motivated by trust in people, enhances full participation and ownership and treats people as assets and partners in the development process, which makes the model more responsive to local needs, more inclusive and cost-effective compared to traditional models in Vietnam.
A standard structure of ISHC is designed to promote full local participation and ownership – around 50-
70 members per group, most club members (70%) are older people, women and socially or economically
disadvantaged. It is managed by the club management board, comprised of 5 members, elected every
two years and at least 50% are women. Members are divided into neighbourhood groups and each
group has its own leader and focuses on different activities. A typical ISHC has at least eight components
including healthy and active ageing and home and community-based care.
ISHC scale-up: In 2021, 3842 groups were established in 61 provinces out of 63 provinces of Vietnam,
and with the Prime Minister’s Decision 1336, the country aims to expand to 6,500 groups in 2025. The 2021-2030 National Programme of Action on Older People also set a target of establishing ISHC in at least 80% of communities in the country.
Awards and recognition: The ISHCs have received several awards and recognitions including the grand
prize winner for the Healthy Aging Prize for Asian Innovation, included as a best practice in six WHO
publications, selected by UNDESA as best practice for contributing to achieving SDGs and by the World
Bank and JICA for promoting healthy ageing.

Home and community-based care of ISHC: Typically includes four components – social and personal care
(befriending, escorting, cooking, grooming, and physical rehabilitation, taking medications, etc.), living
support (cash and in-kind support and labour support, access to rights and entitlements, etc.) and
health services. The care management is led by one club management board member, acting as a care
manager. In each ISHC, 5-10 home care volunteers (HCV) are selected to provide social and personal
care, and each HCV provides a home visit for each client twice a week. For living support services, ISHC
works with community members and other stakeholders to provide various support needed. Health
services are linked with the government’s health providers for support.
Selection of home care volunteers: HCV can be anyone – young or old, man or woman, rich or poor who
is willing and has time to help others and lives close to the older persons they will serve, which will
enable them to provide services timely. HCVs of ISHC are mostly near-old and young-old (50-70 years)
and are normally members of ISHC so they can also benefit as members. After identifying and selecting
a volunteer, the IHSC matches the HCV with an older person who needs care, and the volunteer receives
training to ensure that they provide proper services.

Key learning on home and community-based care:

  • ISHCs can contribute greatly to addressing unmet and increasing community care needs,
    especially in low and middle-income countries (LMICs)
  • Systematic link between ISHCs with local health and social care system to ensure care quality
  • Investing in ISHCs to provide community-based care service is cost-effective and affordable for
    LMICs.

Mr. Janevit Wisojsongkram, Deputy Director, Foundation for Older Persons’ Development (FOPDEV)
Mr. Wisojsongkram shared the experience of FOPDEV in developing and implementing the Buddy Homecare social enterprise initiative in Thailand.
Thailand is moving toward an aged society. Currently, 18% (12 million) of the total population (66 million) are older people of which 56% are women. While a majority of older people are still active, 19% are homebound and 2% are bedridden, 12% live alone and 21% live with a spouse, which has led to increasing care needs in the country.

Long-term care main policy: Thailand promotes ‘ageing in place’ for both active and dependent older people and promotes other relevant policies including an age-friendly environment and health promotion, etc. to support this approach. For dependent older people, they are supported by family members, volunteers and community-based LTC programmes. Quality of life is not only adding years to life but also having longer healthy years, which will result in less spending on health, care and support services.

Stakeholders in LTC: The government is the main actor in promoting and providing LTC services through various programmes, and other stakeholders including NGOs, charity and community-based organisations are also significant contributors, particularly for community-based home care. The private sector can also contribute.

Buddy Homecare: FOPDEV’s initial concept of the Buddy Homecare (BHC) social enterprise initiative was to turn its existing (traditional) community-based home care into a business and use the profit to support the communities to implement health promotion activities to extend healthy years of life. The
social enterprise approach sits between a traditional charity and traditional business, but these days, businesses also support and implement corporate social responsibility programmes and charity organisations implement income-generating activities to contribute to their financial sustainability.
The current conceptual framework of BHC is 1) providing marginalised minority youths opportunities to escape poverty through the provision of training to become caregivers, 2) providing professional care services to customers to generate income and 3) giving back to society by offering health and care
services such as basic health-checkups and health care training through the traditional community-based home care scheme.
Social impact: The social impact assessment covering the 2017-2021 period showed that on average,
BHC served 80 paying customers per year. 65 youth benefited in various ways including becoming skilled
labour and earning better income and being able to support families. There were positive impacts on
the life of 600 older people from poor communities, including increased access to home care and
professional health care support and reduced medical expenses.
Up to the present, BHC provided 3.25 million Baht for training scholarships for the youths participating
in the BHC and spent 9.3 million Baht for employment of the trained youths and 2.5 million from the
BHC revenues and public donations for community-based care activities.
Social return on investment (SROI): The SROI conducted for the 2017-2019 period showed that for every
1 Baht invested in SE, the return is 5.10 Baht, which is high.
Awards and achievements: BHC has received several awards in recognition of its achievement and
innovation, including the grand prize of the Healthy Aging Prize for Asian Innovation of the Japan Centre
for International Exchange (JCIE) and the Win Win War (Willing, Able and Ready) Season 2 Award, the TV
show dedicated to promoting SE initiatives.
FOPDEV started its community-based home care in 2005, explored SE in 2008 and implemented it in
2012. Existing successful and good practices in age care can be turned into SE, which can contribute to
society and be financially sustainable.

Q&A and open discussion

Is there a cost study on ISHC specifically on personal care? There was a study on the whole model of ISHC
but not on separate costs of the personal care component. It costs 5,000-10,000 USD to establish one
ISHC, which includes the provision of initial technical support, training, and grants for ISHC to implement
their core activities. The cost also depends on the focus of ISHC in each location such as on healthy
ageing or livelihood, and the number of ISHC established. The greater number of ISHCs, the lower the
cost – the economy of scale.

Is there any initiative from the government in Thailand and Vietnam to respond to increasing age care
needs? In Vietnam, the government approved the National Programme on Health Care for Older People
with budget allocation, and the Ministry of Health works closely with the Vietnam Association of the
Elderly (VAE) and the private sector to support older people. In Thailand, the government set up the
Local Health Fund to support local authorities and communities in health promotion and community-
based long-term care. There is also the Universal Health Coverage Scheme that enables people including
older people to access health care services at hospitals, the National Community-based Long-term Care
Programme, and the law to promote SE initiatives e.g., tax exemption and start-up business.

How are ISHCs developed in remote and rural areas? In Vietnam, 65% of villages are in rural areas and it
is more challenging. The government has assigned VAE to lead and work with other sectors including the
health and social sector to support the establishment of ISHCs. VAE has a network across the country
including in remote/rural areas to support its efforts. In addition, ISHC is a community-based model and
communities have their own resources as well. What is needed is to create an enabling environment
and provide initial technical support so they know how to manage and then use their own resource to
operate ISHC.