The increase in the number of elderly persons in Asia as an outcome of its population ageing process is well-known. he preceding chapters and other literature have fully described the speed and magnitude in which the number of elderly persons will increase. This is not just a simple empirical phenomenon, as the ageing of the population has tremendous implications for the well-being of the elderly and the provision of services for them. The speed and magnitude of the ageing process directly translates into a corresponding rise in demand for a variety of services and programmes. When the demand increases, the supply of such services must also increase if needs of the elderly are to be met fully and at a reasonable cost. While the rise in demand can be clearly charted, it is far more difficult to map the locus of responsibility for supplying such services.
The non-governmental organizations (NGOs) are a major player in the provision of services to the elderly, in addition to the State and the private sector. Caring for the old has a long history in the realm of the voluntary sector. It was the NGOs, especially the religious institutions, which cared for the old and the poor for centuries before the State became involved. While the State, and lately the private sector, has become more active in the provision of social services, the NGOs still play an important role. As the demand for services increases, a new group of NGOs, managed by welfare professionals, has also emerged to meet the demand.
This chapter describes the NGOs' response to the population ageing process in Asia. It has four sections. In the first section, the divergent activities of the NGOs are identified and described. The relationship of NGOs with the State and the private sector is discussed in the next section. In the third section, strengths, gaps and weaknesses of voluntary services are examined. Finally, future scenarios of NGO activities are charted.
2. The Nature of NGO Activities
The activities carried out by the NGOs in helping the elderly can be grouped in a number of ways. The common approach is to group them by function, classifying them into various programmes or services. It is also possible to classify them into 'established' versus 'frontier' activities depending on the recency and the nature of the services provided. Others have proposed to classify them by the nature of the NGOs, whether they are community-based or whether they impose eligibility criteria. In this paper, the functional classification will be used.
The NGOs in Asia perform a variety of activities to improve the welfare and living conditions of the elderly. These activities are similar to those provided by the NGOs in the West, but the content and approach would invariably show cultural variations. The following is a list of activities that can be readily identified.
3. Residential Care
This is the most common and traditional service performed by the NGOs. Caring for the destitute aged is an established mission among religious or clan associations. However, the prevalence of such homes is low, reflecting a general trend of a low institutionalization rate in Asia. In recent years, homes for the aged have taken on a nursing function to care for those elderly that require long-term medical care. This is a new challenge for the NGOs, as the provision of nursing care is far more complicated and extremely taxing on resources. The necessity for doing so is obvious as the number of frail elderly increases in tandem with the total elderly population. More recently, some of the homes have also taken on the hospice function, providing a temporary home for those who are terminally ill. Again, this requires specialized expertise and new resources.
While the provision of residential care has been the traditional domain of the NGOs, the governments in Asia also provide homes to supplement the care for the aged sick or the destitute aged or to meet statutory requirements. As the demand for residential care increases, the private sector has also moved in. However, not many can afford the cost of placing an elderly person in an expensive privately-run home. There are also significant variations in standards among these privately-run homes. Some governments such as Hong Kong and Singapore have recently introduced stringent minimum standards for the management of these homes.
4. Day Care
This service includes day care centres, social visit programmes, counseling services plus other befriending schemes. Taken together, they address the social needs of elderly people. In the past, such activities were generally organized by the churches or temples in the community, or by clan or ethnic-based associations. They could also be based on trade or professional groups, or persons of similar background such as war veterans. More recently, professionally-run day care programmes have sprung up in Asian countries. They have no entry requirements and are non-religious in orientation. They are usually located in the community serving the elderly within a specific catchment area. These services are either provided by the State or by NGOs.
5. Rehabilitative and Day Nursing Care
Rehabilitative and day nursing services are in demand for the elderly who are recuperating from illnesses or corrective surgeries at home. While provision of home nursing facilities with visiting nurses is available in some countries, most governments find this service expensive to maintain. As a result, this service is usually available only in urban areas, and involvement by NGOs is restricted to those with sufficient resources. Rehabilitative centres are a more efficient alternative provided that the patients can travel to the centres to receive such assistance. Most NGOs serving the elderly strive to set up such facilities to meet the growing need for rehabilitative care.
In developing regions such as Asia, these rehabilitative and nursing services are generally in short supply, especially in rural areas. Family members are the expected care-givers, and the hospitals may end up as the dumping grounds when the family can no longer cope. However, rehabilitative services rendered by the NGOs are emerging. The State is becoming active in this area by either directly providing such service or by indirectly supporting the NGOs, as it helps avoid over-crowding hospitals, which are far more expensive to operate.
6. Financial Assistance
Some NGOs provide financial assistance to the aged poor. Although this is traditionally the domain of the State as part of its poverty alleviation programme, it is generally inadequate with the meagre provisions and stringent qualifying criteria. The NGOs serve as a back-up or as an alternative source. Assistance in kind is also provided by the NGOs, taking such forms as the provision of free meals or clothes.
Religious organizations are usually active in this area, as they are able to redistribute funds received through donations. The Community Chests or other welfare organizations perform a similar redistribution function. However, most NGOs see direct financial assistance as the last resort and as something for which the State has the ultimate responsibility.
7. Specialized Services
In recent years, with the increase in awareness of the needs of the elderly, services provided by the NGOs have become broader in scope as well as more specialized in nature. New services are being provided to cater to special needs. Some of these include suicide prevention programmes, care for the terminally ill, community-watch for those elderly living alone, or special medical counseling for those with degenerative ailments. These services are expensive and require both professional expertise and additional resources. At this time, they are usually small in scale or experimental in nature.
8. Education, Training and Research
In most developing countries of this region, education, training and research activities for the elderly are still in the developmental stage. There are no NGOs large enough to carry out these activities over and above their traditional service-oriented activities. Whatever they do would be on an ad hoc basis and small in scale. Recent efforts by international NGOs to encourage these activities are worth noting. The NGO HelpAge International has established an Asia Training Centre on Ageing (ATCOA) in Chiang Mai, Thailand to provide training programmes for the region. It organizes about 10 courses per year with topics ranging from the management of homes for the elderly to advocacy on ageing issues. The Japanese Organization for International Cooperation in Family Planning, Inc. (JOICFP) has conducted two consecutive three-year programmes to promote awareness of population ageing in the region. The workshops and seminars organized by JOICFP are well-known in the region and well-attended. Other organizations such as the World Health Organization and the Economic and Social Commission for Asia and the Pacific (ESCAP) have launched a series of surveys on the status of the elderly. Some gerontological societies in the region are active in their own countries in organizing educational activities. The Gerontological Societies of China, Japan, Singapore, Hong Kong are well-known examples of active organizations.
9. Advocacy
Some NGOs in Asia are active in advocacy roles, especially among community-based elderly groups. Some of these are invited into policy-making bodies dealing with issues related to population ageing. Others may take on a more aggressive political stance by actively lobbying for policy changes. The level and effectiveness of advocacy varies across countries, depending on the political system and the effectiveness of representation. Some success stories have emerged. The Pakistan Senior Citizens Association, formed in 1985, is active in organizing seminars and workshops, and is represented at the National Committee on Ageing. In Singapore, a similar association, the Singapore Action Group of Elders, is well- represented in government committees and working groups. In the Philippines, the Federation of Senior Citizens Associations, with a membership of over 1800 senior citizen's associations nationwide, is known to be a powerful organization active in the formulation of policy measures for the elderly. Its effectiveness is widely acknowledged.
10. Relationship of NGOs with the State and the Market
In most developing countries, the welfare of the elderly receives very low priority in resource allocation. It is often considered wasteful with little human capital returns. Government attention on welfare, if any, is often directed at the poor or the homeless. Ageing is often considered a personal or family matter rather than a social problem. It is not surprising that in the development plans of most countries, the elderly receive just a passing mention or no mention at all. The duty of caring for the elderly rests entirely on the shoulders of the family; based on the traditional value of filial piety. The NGOs are meant to supplement the family if necessary. This residual model of social welfare is prevalent, and most governments are unlikely and unwilling to take on a larger share of the responsibility. There is also a fear that development resource constraints would be made worse if funds are diverted for welfare purposes. For countries that are well-off, there is concern that welfare-oriented policies would lead to budget crises as has happened in the West.
There are, however, changes that have brought the State and the NGOs closer in partnership. Countries such as India have begun providing a direct subsidy to the NGOs, although on a very modest scale. Richer countries such as Hong Kong and Singapore have a clear policy on government subvention. In Singapore, for example, the government would undertake to build a residential home and then pass it on to the NGOs for management. The State's involvement in providing subsidy to welfare services for the aged is a recognition that the welfare needs of the elderly have grown to the extent that the NGOs need help to maintain a minimum standard of care. It is also a recognition that the State cannot be completely out of the picture in the care of the elderly. Politically, the elderly will increasingly be a force to be reckoned with, as in the case of Japan, the Philippines and Singapore. By providing financial support to the NGOs, the governments in Asia are able to demonstrate involvement, but avoid the direct and front-line responsibility of providing care to the aged.
There is little doubt that in the future the cooperation between the NGOs and the State will increase further. The NGOs have become an instrument through which the State can care for the elderly without being directly involved. It has also been argued that the quality of care provided by the NGOs is often better than that provided by government institutions. As community resources are utilized together with government subvention, there is less of a tendency for the elderly to become totally dependent on the government. However, as the NGOs expand into new areas of services or extend the scope of their activities, they face severe resource constraints. As most of the NGOs raise their own funds or obtain funds from the Community Chest, much effort is diverted into fund raising matters. This limits the amount of human resources available for providing direct service. Moreover, funds raised through the community are normally adequate for day-to-day operation or for modest expansion. It is not possible for an NGO to significantly expand its services through its own fund raising efforts. For an NGO to expand its services, government assistance is imperative.
As the NGOs move into specialized services, they require specialized training and professional guidance which may be available only in government institutions. It would be difficult, for example, for the NGOs to train and retain a large group of nurses for home nursing or rehabilitative functions. It would be advisable if either funds could be provided to the NGOs to employ nurses, or to have nurses seconded to the NGOs. The same could be said for other professionals or para- professionals whose services are required for the care of the elderly. Without the government providing additional financial resources, the NGOs would not be able to implement innovative services to meet the emerging needs of the elderly.
However, the development of specialized services by NGOs is unlikely to be rapid. The State is generally reluctant to move away from its emphasis on institutional care, which it considers as top priority among the existing services to the elderly. When the family fails to provide a home to the elderly, a safety net would need to be arranged to provide shelter for the elderly. Given this emphasis, most governments are keen to assist NGOs in the provision of residential care, but show great reluctance in supporting newer types of services. The growth of newer types of services would depend on three factors: whether the NGOs are able to raise funds on their own, whether the governments can be convinced that the services are essential and required, and whether the elderly themselves form pressure groups to demand such services. In the context of Asia, these factors are not likely to materialize in the immediate future.
In response to the demand for residential and nursing services, the private sector has moved in to establish profit-oriented nursing homes. These homes charge a premium in fees and are generally more costly than the homes managed by the NGOs. In Asia, these commercially-run homes are still in the minority, as affordability is a critical barrier. The need for these private homes depends to a large extent on whether the homes of the NGOs are able to meet the demand. To the extent that the NGOs are able to meet the demand, there would be little advantage for families to place the elderly in private homes. An example of the fact that demand for private homes is affected by the admission criteria of NGO homes is found in Singapore. To cultivate a strong sense of family responsibility, the government of Singapore directed in the 1980s that only the destitute aged could be accepted into government-funded or subsidized homes. The elderly with family members were not eligible for residence in such homes. As a result, vacancy rates rose among the NGO homes, and the demand for private homes increased correspondingly. An equilibrium returned after the government relaxed the 'destitute aged only' ruling.
The elderly in Asia really do not have the NGOs, the State and the private sector as three distinct choices for services. The reliance of the State on the NGOs for the provision of services effectively removes the State as a service provider to the average elderly. The private sector has yet to mature, and the lack of purchasing power and the social stigma associated with placing the elderly in private homes will continue to constrain the growth of the private sector homes or services. In the end, services offered by the NGOs are often the only choices available. If there is a vibrant NGO community offering a variety of services, as is the case in Hong Kong, Japan, the Republic of Korea, and Singapore, then the elderly will be well-served. If the NGO community is not strong, then the elderly would not enjoy an alternative to the traditional care givers of the family and neighbours.
11. Strength and Weaknesses of NGO Services
The NGOs serving the elderly in Asia comprise a divergent group of organizations. Many are affiliated with a larger organization which has a higher purpose, as in the case of a religious group or clan association. In the minority, are secular-based, professionally-run organizations. Associations of the elderly are even fewer and are more loosely organized. The key organizational dimensions of the NGOs are reviewed below.
12. Manpower
While the NGO staff are mostly motivated in their work, their working conditions are generally not as favourable as those in the private sector. High labour turnover is a problem that has to be continually addressed. Burnout is another problem that is endemic among the staff in NGOs serving the elderly, especially among those caring for the frail and the sick. Raising the salary to a competitive level or to compensate fully for the hard work may not be possible as funding is always limited. The problem is compounded in countries with labour shortages such as Hong Kong and Singapore. The lack of suitable staff has prompted the NGOs to hire expatriates to work in the residential homes or in the provision of nursing care.
Training of the staff up to a competent level in dealing with the elderly is another important area of concern. As the subject of ageing is a relatively new area, the institutions which provide training in the helping professions may not have sufficiently updated their curriculum to cater to this new area. Medical schools in developing countries are only beginning to give emphasis to training in geriatric illnesses. Schools of social work are also slowly changing their curriculum to equip students with the requisite skills in dealing with the elderly. Opportunities for continuing education on the job are often scarce, as non-formal education is still underdeveloped in Asian countries. This is one area that could be improved.
13. Fund Raising
NGOs survive on funds raised from the community. In countries where governments provide grants and subventions, the NGOs' dependency on community contribution is reduced but not totally removed. Fund raising mechanisms could range from a central fund-raising body such as the Community Chest to unsolicited donations. The Community Chest of Hong Kong, for example, is a very effective organization in fund raising. HelpAge India is another example of an agency which has been very successful in soliciting community contributions.
It has been observed that raising funds for the disabled or the handicapped is generally easier than raising funds for the elderly. This could be due to the perception that the elderly do not really need any assistance, and if they do, the family should be able to take care of them. NGOs providing services to the elderly should continue to educate the community, because without their financial contributions, service levels and standards would be severely affected.
14. Community Networking
To provide a comprehensive range of care to the elderly, a certain level of networking is essential. If the information on the frail elderly person recently released from a hospital could be passed on to a community service agency, then continuity of after-care services could be provided. Professionals of different disciplines could also exchange notes on how the elderly person could be best served. However, networking is never easy, as it takes time and effort to establish an effective system of communication and follow-up. If the NGOs are hard-pressed by day-to-day operations, there will be little incentive to take a broader systematic view.
15. Service Area
An NGO normally serves the surrounding area where it is located. Due to staffing and funding constraints, it normally does not have the capability to handle a large number of customers. Since NGOs tend to concentrate in urban areas, this gives rise to a situation in which the urban elderly are in a better position to receive services. Conversely, the elderly in the rural areas are less advantaged.
The unavailability of services to the rural elderly is an important issue. In Asia, the vast majority of the elderly are rural residents. It is, however, the minority in the urban areas that are enjoying the bulk of services. There are some organizations that implement out-reach programmes to assist the rural elderly. HelpAge International's work in Sri Lanka and India, with their local counterparts, are good examples. More substantial efforts by the NGOs to address the needs of the rural elderly are obviously needed.
16. Future Scenario
Future services provided by the NGOs will be affected by three factors. The first factor concerns the changes among the elderly themselves which will have a major impact on the services required. The rapid development of Asian countries has led to greater affluence among the populations. In turn, this means elderly persons themselves will have greater purchasing power. This can be seen from the example of the elderly tourists from Japan, Hong Kong, Republic of Korea and Singapore. As they become more affluent, the elderly also become more discerning in the type and quality of services that they want to receive. Services provided by the private sector will possibly pose greater competition to those provided by the NGOs in the future. In the developed countries, this has already been the case.
As the elderly become more educated over time, their taste and lifestyle will undergo changes as well. The social needs of the elderly are likely to evolve. Programmes and services which were once popular with the elderly may no longer be so as cohorts of elderly pass through. It is important therefore for the NGOs to be sensitive to the changing needs of the elderly so that services are appropriate.
The second factor affecting NGOs will be the changes in the support system for the elderly. Although the number of elderly has been increasing steadily in Asia, the traditional mechanism of delivering care through the family network remains largely intact. All Asian countries rely heavily on the family as the primary support agent for the elderly. To the extent that the family is effective in delivering care, the responsibility of the State and the NGOs will continue to be modest. There are, however, signs indicating that in future the family may not be as effective.
In many Asian countries, rural-urban or international migration occurs on a fairly large scale. An elderly couple may be left behind in their rural home while their children seek their fortune in the cities. Remittances from the children may help raise the standard of living if they are regularly received. But, a more immediate threat is the loss of care-givers to deliver personal care if required by the old couple. In the urban areas, isolation of the elderly and the loss of care-givers occur when the children move away from the parental home. This nuclear living arrangement is gaining prevalence as it suits the lifestyle of the younger couples. Even for those elderly residing with their children, their children may not have the time to perform the roles and duties of a care-giver. Dual career families are gaining popularity in Asian countries, especially in the urban areas. In countries where domestic help is readily available such as Hong Kong, Malaysia, and Singapore, it is common for dual career families to hire a helper to take care of the elderly at home.
These changes in the traditional support system suggest that there will be a greater role for the NGOs to play in the future. The responsibility of providing care will be gradually diverted from the family to the NGOs, especially if the elderly are frail or bed-ridden. Services provided by the private sector will also be in demand if the NGOs cannot cope. The trend is nonetheless clear: if the family cannot cope with caring for its ageing members, it will seek help from external bodies, and the NGOs are logically the best alternative.
The third and final factor impacting the NGOs in the future will be the momentum of change coming from within the NGOs and the relationship between the NGOs and the State. The present relationship between the NGOs and the State is expected to continue. There is little likelihood that the State would like to be more involved in providing direct care if the NGOs are available. The partnership could be strengthened as the State channels more resources to the NGOs. In exchange for additional resources, the State is likely to impose stricter service standards. The NGOs would have to be subjected to quality checks and other requirements, as is the case in more developed Asian countries.
As the number of the elderly increases, and more services emerge, the NGOs serving the elderly become an important interest group. The group may become a powerful lobby for more financial resources. Training, recruitment, and service standards could be set by the group as well as other peer-review procedures. In most Asian countries, there is already a mechanism for coordination which is located at the National Council of Social Services. This mechanism may take the form of a working group or committee engaging in fund-raising or reviewing service standards. In some countries, such as Hong Kong, this group has been active in drafting the government's welfare plan for the aged. In the future, this interest group is likely to play a more active role around the region.
17. Conclusion
The NGOs in Asia perform an important role in the care of the elderly. While their scale of operation may still be modest, it is expected to grow rapidly in the future. The partnership between the NGOs and the State is likely to be strengthened, with the State channeling more resources to the elderly through the NGOs. As the traditional support system loses its effectiveness, the NGOs can be expected to play a greater role. The programmes and services of the NGOs are likely to become more diversified and specialized in the future.