A review of the long-term care policies under COVID-19 in Thailand’s aging society: implications for ASEAN countries

Introduction

Population aging is a global phenomenon happening all over the world. According to United Nations’ estimation, one in six people will reach 65 years old or over by 2050 (United Nations, 2019a). The Association of Southeast Asian Nations (ASEAN) is not an exception to this trend. ASEAN, initially established in 1967, is now composed of 10 countries – Brunei, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam (Baker, 1989). There has been a rapidly growing trend of population aging in the ASEAN countries as the population aged 60 years or over was projected to be more than double from 59.5 million in 2015 to 127 million in 2035 (ASEAN, 2015). It was also reported that South-Eastern Asian and East Asian countries covered the largest aging population in the world (260 million) in 2019 (United Nations, 2019b).

Among the ASEAN countries, Thailand, along with Singapore, remains to have the largest proportion of older adults (United Nations, 2019a). By 2021, Thailand has become the third most rapidly aging country globally, with people aged 60 years and above accounting for 20 percent of the total population (ERIA and ABCD Centre, 2021). To meet the need of a growing older population, the considerable challenges Thailand is facing include long-term care plans and aging-friendly environments (HelpAge Asia, 2021). Hence, it is crucial to obtain a comprehensive understanding of what is being implemented in Thailand to deal with its rapidly aging population and plan for appropriate care strategies.

In response to the demographic change of aging societies, long-term care (LTC) is formulated globally to ensure that older peoples’ demands for social care and health care are met. World Health Organization (WHO) regards LTC as “all activities undertaken by others to ensure that people with, or at risk of a significant ongoing loss of capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms, and human dignity” (WHO, 2015). While formal LTC has already been framed in developed countries decades before (Barber et al., 2021), many ASEAN countries are not yet prepared for the rising needs of older people and, consequently, do not yet have a formal provision of LTC services to meet the needs of their aging population.

Thailand is one of the leading countries in ASEAN that has been making significant progress in establishing its own LTC system. Since 2016, Thailand government has introduced a proactive community-based LTC program and identified ways to shift regular institutional care to community-based care in 1,000 out of 7,255 sub-districts (Asian Development Bank, 2020a) and they are being scaled up annually. However, many challenges remain and need to be addressed.

To better prepare for the rapidly aging societies, ASEAN countries are expected to prioritize LTC provision for older people, considering that Asian older adults heavily rely upon informal care. Research evidence reveals that understanding the determinants and facilitators of LTC for older adults in ASEAN is still limited. In addition, the evidence-based recommendations to support the public health leaders and policymakers in addressing and improving the LTC strategies among ASEAN population aging are essential not only for the current time but also for the next few decades.

In March 2020, the WHO (2020b) called for strong combat mechanisms in the South-East Asia region toward the global pandemic of COVID-19, as older adults worldwide continue to be at greater risk of severe illness and death. While the ASEAN geriatric and LTC care system is not yet ready for the complexity of caring for the older population, the COVID-19 pandemic has magnified this problem.

Objectives of the study

All things considered, a narrative analysis relating to the responses of the ASEAN countries, especially Thailand, toward the aging society situation and the COVID-19 pandemic was this study’s approach to inquiry. This review aimed to explore the most updated aging society situation in the ASEAN countries; to have an overview of how their LTC is being prepared; how has COVID-19 affected older people; and how ASEAN countries, including Thailand, are preparing for geriatric care in the post-pandemic times.

Methods

A narrative review using guidance for the assessment of review articles was conducted (Baethge et al., 2019) as shown in Figure 1.

Characteristics of included literature

A database search resulted in 16 pieces of literature that met the inclusion criteria. Of the 16 literatures identified, eight were official reports from international agencies or organizations (United Nations, World Health Organization, The ASEAN Secretariat, HelpAge International, Asian Development Bank, and World Bank Group); four were scientific articles; three were national reports from Thailand, and one from an online database (Statista).

Demography and population aging trend in ASEAN countries and Thailand

An estimated data from the United Nations (United Nations, 2019b) on top ten countries with the largest percentage point increase in the share of older people from 2019 to 2050 reported that 9 out of 10 countries were from the Eastern and South-Eastern Asia region. Interestingly, two countries in the list were from Southeast Asia: Singapore (20.9 percent) and Thailand (17.2 percent).

Based on the statistics from the ASEAN datasheet in 2020 (United Nations, 2020), there were approximately 74 million older adults who were 60 years old and above in the ASEAN countries. Among that, more than 36 percent (27 million) were in Indonesia, followed by 17.6 percent (13 million) in Thailand and approximately 16 percent (12 million) in Vietnam. However, the projected proportion of the aging population differs depending on each country as presented in Figure 2.

Figures 3a and 3b illustrate the proportion of older people in Thailand. The National Economic and Social Development Council of Thailand states that the proportion of people aged 60 and over was more than 18 percent among the 66.5 million people in 2020. This number will reach 31.4 percent in 2040 (NESDC, 2019). Accordingly, as one of the upper middle-income countries, Thailand had an estimated old-age dependency ratio in 2015 and 2020 at 18.5 and 22.6 and is expected to reach 28.6 and 51.4 in 2025 and 2040, respectively (United Nations, 2019b). On the other hand, the aspect of the social issue causes the aging society’s problems to be of more concern. Since urbanization expanded and female education improved, the extended family is reducing while the nuclear family increases over time (Phayungphong, 2020). Hence, the empty-nest situation is increasing. It has been found that the percentage of older adults live alone tends to be continually increasing (Suwanrada, 2008; Knodel et al., 2013; Chamchan, 2018). Higher life expectancy and lower fertilization rate (World Bank, 2019a; 2019b) are also the co-factors affecting the aging society situation that Thailand has to prepare for solutions.

Existing LTC strategies in ASEAN countries and Thailand

The highly increasing care need due to the high prevalence of chronic disabilities and morbidities among older people, combined with the rising LTC need, has alarmed the public policymakers to address the consequences of these changes.

In 2013, a regional consultation on LTC for older people was organized by the WHO Regional Office for South-East Asia (WHO, 2019), aimed to promote LTC for older people in these countries. The Regional Framework was developed based on various guiding principles recognized at both global and regional levels, aiming to impact healthy aging in the region through multiple strategies. One of the strategies is to provide a comprehensive system of LTC at home, in communities, or within institutions.

Focusing on Thailand, the LTC system is public domain-driven and comprises both health and social care aspects (Thonchaithanawut, 2019). This undergoing system functioned under the directions and support from multiple sectors and authorities. Currently, the system relies on the Universal Health Coverage (UHC) system. In 2015, the UHC system covered more than 73.7 percent of Thailand’s total population.

According to The National Health Security Office (NHSO) of Thailand (Thonchaithanawut, 2019), Thailand’s community LTC is being implemented by adopting the following six main strategies:

1. Information: with accurate number of the dependent older adults by each dependency level.

2. Collaboration: with collaboration in each community within primary health care setting to provide prevention, care, and rehabilitation.

3. Financing mechanism: develop the financial mechanism for the community-based long-term care system.

4. Human resource development: meet the needs of community-based long-term care services.

5. Knowledge management: the long-term care knowledge management and relating data and information to monitor and assess the services.

6. Legal framework and regulations: under the legal support framework to enable the stakeholders involved with the long-term care system.

Regarding the funding system, NHSO is responsible for allocating the capitation for all eligible persons (Thai people aged 60 and over with dependent conditions). The local government is another player supporting community-based long-term care. It plays the role of non-medical services and financial management support.

A person screened as a dependent is eligible for the public community-based long-term care with four benefit packages based on older adult’s dependency level and cognitive function. The first group of the community-based LTC benefit packages refers to the older adults who need help when eating and toileting but can still move independently. Older adults in this group will receive health services at least once a month and non-medical care and housing services at least twice a month covered by lump-sum compensation, not over 4,000 Baht (around 120 USD) per capita. The second group refers to the elderly who needs help when eating and toileting, still have the ability to move independently but are suffering from cognitive impairment. This group receives health services at least once a month and non-medical care and housing services at least once a week, covered by lump-sum compensation of about 3,000-6,000 Baht (around 90-180 USD) per capita. The third group refers to the elderly who lack the ability to move and need eating and toileting assistance or those who suffer from severe illness. Older adults in this group receive services similar to the second group, with lump-sum compensation covering about 4,000-8,000 Baht (around 120-240 USD) per capita. The last group of the LTC benefit packages refers to the persons of the third group with end-of-life stage. This group receives health services at least twice a month, receives non-medical care, and housing services at least twice a week, covered by lump-sum compensation of about 5,000-10,000 Baht (around 150-300 USD) per capita (Thonchaithanawut, 2019).

Facilitators and challenges of the LTC system in Thailand

One of many facilitators that enabled the LTC system in Thailand to achieve three UHC components was its supply-side, such as infrastructure at the district level, which has been continually developed and maintained since 1970. In this regard, Thailand’s primary health care system is accessible to the local residents. This profound and well infrastructured primary health care and UHC is the foundation for Thailand’s public community-based LTC system (Thonchaithanawut, 2019). The other reported facilitators were the investment in research evidence for policy and program design with support from many stakeholders. Still, there are some challenges for Thailand to overcome. In particular, the quality control agency for community-based LTC, workforce, and shared responsibilities for coordination from many government agencies and authorities are still on the way for development (Asian Development Bank, 2020b).

COVID-19’s impact on health and well-being of older people in ASEAN countries

COVID-19 has been reported to disproportionately affect older people and those with chronic health conditions. Although most middle-income countries in ASEAN had the social assistance systems that could support poor and vulnerable groups throughout the pandemic, a comprehensive picture of the pandemic’s impacts on older people and other vulnerable groups is still not yet available for longer-term predictions (ASEAN Secretariat, 2020).

The significant impact of COVID-19 on older people can be categorized as (1) the impact on health and care; (2) violence, abuse and neglect; and (3) income security and social protection (HelpAge International, 2021). Older people are at higher risk of severe health complications and death from COVID-19 due to their underlying health risks because of old age. Moreover, social issues on older people during the pandemic have serious implications not only for physical health but also mental health such as anxiety, stress, and depression, which have been recently reported in many ASEAN countries (Srifuengfung et al., 2021; Pothisiri and Vicerra, 2021; Marini et al., 2020; Catindoy et al., 2021).

Regarding income security and social protection of older people, it was explained that because older Asian people mainly work in the informal sector, which provides little protection against income shocks, they need to rely on family support, savings and work. However, under much pressure during the pandemic, family support may be inadequate (HelpAge Asia, 2021).

In Thailand, for the total confirmed COVID-19, aging cases as of July 2021 were 44,804 or about 0.39 percent of total 11,627,130 aging people, but the percentage of the death cases among confirmed cases was found to be at 10.44 percent (DOP, 2021). Some existing and active policies were utilized to respond to the COVID-19 outbreak that benefited Thailand’s aging population. For example, the government had set the target number of the COVID-19 vaccination for older adults at 10,906,142 people because the aging population was one of the six priority groups at that time (DDC, 2021). As a result, from 28 February to 31 July 2020, there were 2,876,581 people reported as the aging population whose vaccinated or about 21.45 percent of the total number of aging people in Thailand. Focusing on social aspect, the pandemic situation has brought about more challenges and uncertainty to Thai’s labor market, which seriously affected the social protection for the Thai aging group. It was reported that the people who take care of older people lacked the financial support for aged care. Also, population aging is shrinking the working-age population. Generally, this pandemic has exposed the vulnerable aging group, which has brought social protection to the forefront (Moroz et al., 2021). For information management related to health behaviors, thanks to the community-based LTC in Thailand, especially in rural areas, rural aging has benefited from the community network of Village Health Volunteers (VHV). VHV provided information during the pandemic as they had a higher level of disease knowledge compared to the urban residents. However, this function might not work well when considering the frequently updated disease development access (Vicerra, 2021). In the health resource utilization issue, when some areas in Thailand were overwhelmed with a lot of cases of COVID-19 and the supplies in those areas were not enough, there were strategies to circulate the medical staff from other areas and set up emergency COVID-19 field hospitals. This harmonized strategy acts as the social health protection for its citizens (Chongsuvivatwong, 2021). Also, the Thai government suggested prioritizing and providing free COVID-19 vaccines for older adults as soon as possible (Wanlapakorn, 2021).

Discussion

Policy windows and policy challenges

Thailand’s LTC system, as the proposed example for ASEAN countries in this study, has been gradually developed and reinforced since the first introduction of LTC definition in 2009 (NHCO, 2009). Thailand has focused on the community-based approach, including family caregivers and VHV as the primary service providers on the activity of daily living part (Thonchaithanawut, 2019). Considering the fact that the establishment of a proper LTC system is inevitable in any country with the growing aging population, and the time scope of this study was during the COVID-19 pandemic, the evidence on the updated LTC policies from most of the countries in ASEAN in response to older adults’s care still remained scarce. Our results highlighted a stronger focus on this emerging and important aging issue. Although there are considerably remaining challenges to overcome (Asian Development Bank, 2020a), other countries with uncompleted LTC systems can learn from what Thailand is doing, starting with a clear definition of LTC in their own context and defining the eligibility criteria for the target population. In addition, an integrated model of programs of services for LTC at the community level, while utilizing potential resources in the community for supporting older people, could be effective strategies for countries in ASEAN.

When the COVID-19 pandemic emerged, dependent older adults were one of the most vulnerable group who needed the most assistance. The vast impact of COVID-19 on the older population in ASEAN has been widely reported among countries in the region (ASEAN Secretariat, 2020; HelpAge Asia, 2021; Srifuengfung et al., 2021; Pothisiri and Vicerra, 2021; Marini et al., 2020; Catindoy et al., 2021) including impacts on health well-being and social protection. The pandemic has awakened governments of the countries to realize the cruciality of a well-established healthcare system in the time of emergency and in preparation for possible future challenges, focusing on vulnerable populations. Moreover, the pandemic has strengthened the critical importance of community services to support health and social care for the aging population. Considering the specific impact of COVID-19 responses on older Thai people in meso-level and micro-level, including each community-based LTC management and personal health behaviors during the pandemic, the authors also found that VHV could be a potential mechanism to raise COVID-19 awareness under the LTC system. This function might not work well when considering the issue of accessing frequently updated disease development (Vicerra, 2021). These obtained pieces of literature could urge policymakers to understand the urgent needs for enhancing awareness and resources utilization toward improving healthcare and LTC for older people, the need to offer immediate solutions during the pandemic, and the timely provision of protection for the older population. Protection such as prioritizing the older adults to receive vaccines, just like in Thailand (Chongsuvivatwong, 2021), to ensure that they are protected and adequately cared for.

Conclusion

This review has provided an updated overview of the aging situation, existing LTC strategies, and how the older adults in ASEAN countries were affected by the COVID-19 with focus on Thailand. These results might be helpful to further inform future policy direction by supporting public health workers and policymakers to understand the current incomplete healthcare system, the inadequacy to face unexpected situations such as the COVID-19 pandemic, and to better prepare for post-pandemic challenges and other possible future crisis.