Volunteer provision of long-term care for older people in Thailand and Costa Rica

Abstract Problem Demand for long-term care services for older people is increasing rapidly in low- and middle-income countries. Countries need to establish national long-term care systems that are sustainable and equitable. Approach The Governments of Costa Rica and Thailand have implemented broadly comparable interventions to deploy volunteers in long-term home care. Both countries trained older volunteers from local communities to make home visits to impoverished and vulnerable older people and to facilitate access to health services and other social services. Local setting Costa Rica and Thailand are upper-middle-income countries with strong traditions of community-based health services that they are now extending into long-term care for older people. Relevant changes Between 2003 and 2013 Thailand’s programme trained over 51 000 volunteers, reaching almost 800 000 older people. Between 2010 and 2016 Costa Rica established 50 community care networks, serving around 10 000 people and involving over 5000 volunteers. Despite some evidence of benefits to the physical and mental health of older people and greater uptake of other services, a large burden of unmet care needs and signs of a growth of unregulated private services still exist. Lessons learnt There is scope for low- and middle-income countries to develop large-scale networks of community-based long-term care volunteers. The capacity of volunteers to enhance the quality of life of clients is affected by the local availability of care services. Volunteer care networks should be complemented by other initiatives, including training about health in later life for volunteers, and investment in community long-term care services.


Introduction
Long-term care refers to "the activities undertaken by others to ensure that people with a significant ongoing loss of capacity, or who are at risk of such a loss, can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity." 1 The World Health Organization's (WHO) World report on ageing and health in 2015 and related Global strategy and action plan recommend that every country should have a sustainable and equitable long-term care system for older people. 1,2 To date, research on long-term care policies in low-and middle-income countries remains scarce. 2,3 The Global strategy and action plan argues that volunteers may make a significant contribution to extending long-term care provision, especially in lower-resourced settings. 2 We describe and compare two promising examples of long-term care models for older people: Costa Rica in Latin America and Thailand in south-east Asia. Despite the many differences between these two countries, both have implemented broadly comparable interventions to deploy volunteers in long-term care, building on established programmes of health volunteers.

Local settings
Costa Rica and Thailand are selected here as examples of national long-term care schemes that make use of volunteers operating at the community level. These schemes developed independently of each other, with no direct support from WHO. Costa Rica and Thailand are upper-middle income countries, experiencing rapid economic, social and demographic transformation. In both, the proportion of the population aged 70 years or older is projected to double between the years 2000 and 2020 and is set to treble between 2000 and 2030 (Table 1). 4 In 2002, Thailand published a national plan for older persons and the following year a care volunteer programme for older people was established. 5 Since then, there has been rapid policy development, with an emphasis on communitybased services to support volunteers as well as family caregivers. 6 This builds on a previous initiative to train village health volunteers, initiated in 1997.
Costa Rica also has a well-developed infrastructure of primary health-care services and has pioneered several initiatives for older people, including a national long-term care network since 2010. 7,8

Approaches
In 2003 the Thai Government established the Home Care Service Volunteers for the Elderly programme for dependent older people. 9,10 Home-care volunteers from local communities are trained for 18 hours by the Ministry of Social Development and Human Security. Volunteers classify older people's level of dependency and identify individuals who do not have a family carer or are neglected. Each volunteer is responsible for around 15 older people in their respective communities. They provide a range of domiciliary care services, including assistance with eating, exercise and taking medicine, as well as liaising with local health workers, where appropriate. Volunteers receive Problem Demand for long-term care services for older people is increasing rapidly in low-and middle-income countries. Countries need to establish national long-term care systems that are sustainable and equitable. Approach The Governments of Costa Rica and Thailand have implemented broadly comparable interventions to deploy volunteers in long-term home care. Both countries trained older volunteers from local communities to make home visits to impoverished and vulnerable older people and to facilitate access to health services and other social services. Local setting Costa Rica and Thailand are upper-middle-income countries with strong traditions of community-based health services that they are now extending into long-term care for older people.  In 2010 Costa Rica's National Council for Older People established the Progressive Attention Network for Integral Elder Care. This nationwide scheme seeks to establish communitybased long-term care networks with a focus on impoverished and highly vulnerable older people. 7 Among other activities, the networks train retired teachers to act as unpaid community volunteer pensioners. This training is provided directly by the council and includes 3-day workshops, with a focus on geriatric health, integrated community care and identifying vulnerable older people. Applying a validated assessment tool, volunteers then identify vulnerable, dependent older people in their communities and report this information back to district health officers and the council. Volunteers are expected to make home visits at least once per month, or as the need arises. They provide a similar range of domiciliary services to those offered by the Thai volunteers, including assistance with nutrition, personal hygiene and taking medications. At the same time, the council is responsible for coordinating other local organizations, including nongovernmental organizations and government agencies, and for identifying local long-term care service priorities. Priorities vary, but typically include the provision of food supplements, free drugs and a US$ 100 monthly payment for domiciliary care. In 2015 the total cost of the programme was US$ 14 million. It is funded by a new, earmarked tax on the consumption of alcohol and tobacco, as well as a separate family allowance contribution, which includes a levy of 5% on the wages and salaries of public-and private-sector workers.

Relevant changes
By 2013, Thailand's home-care volunteers programme had been extended nationwide and had trained over 51 000 volunteers, reaching almost 800 000 older people, representing a potential starting point for a future extension of the service to all dependent older people. 6 A 2014 survey of 3694 older people and 179 carers showed perceived benefits to the physical and mental health of older people, but the precise effects were not quantified. 11 At the same time, evaluations from 498 local government representatives indicated that the perceived quality of services provided by volunteers has been variable. 6,11 In the 2014 evaluation, only 33% of 76 provincial administrative districts reported that the care provided by volunteers was sufficient to meet older people's long-term care needs. 11 A common complaint from service receivers was that volunteers were not able to deal with common geriatric health problems, only general social issues such as social isolation. This has given rise to a new volunteer caregiver training initiative with a stronger focus on health services, set up by the Ministry of Public Health in 2016.
In Costa Rica, 50 community networks were established by 2016, operating in health districts in every province and serving around 10 000 people aged 65 years and older, and involving over 5000 volunteers. The programme is now in the process of being formally evaluated. Preliminary indications show that the network has led to a rise in the numbers of older people making use of different long-term care services, particularly those related to nutrition and companionship. However, in 2015 only 443 older people received payments to cover the costs of home care, which suggests a more limited reach. The programme appears to be well targeted, with around half of beneficiaries combining a high level of dependency, income poverty and other aspects of social vulnerability. Despite the rapid roll-out of the programme, evidence points to a large burden of unmet care needs and the growth of unregulated private services, providing paid domiciliary carers and nursing home facilities. 7 Thailand has also seen a rapid expansion of unregulated, private long-term care services. 12

Lessons learnt
The main lessons learnt are summarized in Box 1. Comparing these two initiatives indicates that there is some potential for community volunteers to contribute towards long-term care provision for older people in lower-resource countries. This should, however, be only one element of a multipronged set of interventions integrating health and social care, as well as bridging formal and informal provision. Promoting long-term care volunteers is unlikely to be effective as a stand-alone policy.
Establishing networks of volunteers to support care and facilitate access to local services permitted the governments of both countries to rapidly scale-up long-term care provision for vulnerable groups of older people. This was done with relatively modest financial support and was built on previous experiences of government-supported community health volunteering. Even with ambitious interventions, however, keeping pace with growing demand for long-term care is extremely challenging. As seen in Thailand, there is a need for volunteers to be trained in long-term care, integrating health and social care services for older people. Lessons from the field Long-term care in Costa Rica and Thailand Peter Lloyd-Sherlock et al.
The capacity of volunteers to enhance the quality of life of clients was strongly affected by the local availability of other long-term care services.
Distinguishing between mainstream health services and social services is not straightforward, and responsibility often cuts across different state agencies.
This calls for a coordinated long-term care approach. In Costa Rica, this has been done at the local level through priority-setting by the government agency responsible. Thailand has taken a different approach by delineating the responsibilities of different agencies in a national development plan in 2009. 13 Finally, a rigorous, systematic evaluation of long-term care volunteer interventions is needed to identify good practice that may be transferable to other countries. ■ Competing interests: None declared.
Lessons from the field Long-term care in Costa Rica and Thailand Peter Lloyd-Sherlock et al.
Lecciones aprendidas Los países con ingresos bajos y medios tienen un margen para desarrollar redes a gran escala de voluntarios para realizar cuidados a largo plazo y de ámbito comunitario. La capacidad de los voluntarios para mejorar la calidad de vida de los clientes se ve afectada por la disponibilidad local de los servicios de atención. Las redes de cuidado voluntario deberían complementarse con otras iniciativas, incluyendo la formación para voluntarios sobre la salud en las últimas etapas de la vida y la inversión en los servicios de atención a largo plazo de la comunidad.