Relevant studies on ageing – related issues

Eldercare policy and funding structure
 

ANSAH, J. P., EBERLEIN, R. L., LOVE, S. R., BAUTISTA, M. A., THOMPSON, J. P., MALHOTRA, R., & MATCHAR, D. B. (2014). IMPLICATIONS OF LONG-TERM CARE CAPACITY RESPONSE POLICIES FOR AN AGING POPULATION: A SIMULATION ANALYSIS. HEALTH POLICY (AMSTERDAM, NETHERLANDS), 116(1), 105–113. http://doi.org/10.1016/j.healthpol.2014.01.006
INTRODUCTION: The demand for long-term care (LTC) services is likely to increase as a population ages. Keeping pace with rising demand for LTC poses a key challenge for health systems and policymakers, who may be slow to scale up capacity. Given that Singapore is likely to face increasing demand for both acute and LTC services, this paper examines the dynamic impact of different LTC capacity response policies, which differ in the amount of time over which LTC capacity is increased, on acute care utilization and the demand for LTC and acute care professionals. METHODS: The modeling methodology of System Dynamics (SD) was applied to create a simplified, aggregate, computer simulation model for policy exploration. This model stimulates the interaction between persons with LTC needs (i.e., elderly individuals aged 65 years and older who have functional limitations that require human assistance) and the capacity of the healthcare system (i.e., acute and LTC services, including community-based and institutional care) to provide care. Because the model is intended for policy exploration, stylized numbers were used as model inputs. To discern policy effects, the model was initialized in a steady state. The steady state was disturbed by doubling the number of people needing LTC over the 30-year simulation time. Under this demand change scenario, the effects of various LTC capacity response policies were studied and sensitivity analyses were performed. RESULTS: Compared to proactive and quick adjustment LTC capacity response policies, slower adjustment LTC capacity response policies (i.e., those for which the time to change LTC capacity is longer) tend to shift care demands to the acute care sector and increase total care needs. CONCLUSIONS: Greater attention to demand in the acute care sector relative to demand for LTC may result in over-building acute care facilities and filling them with individuals whose needs are better suited for LTC. Policymakers must be equally proactive in expanding LTC capacity, lest unsustainable acute care utilization and significant deficits in the number of healthcare professionals arise. Delaying LTC expansion could, for example, lead to increased healthcare expenditure and longer wait lists for LTC and acute care patients.

ANSAH, J. P., MATCHAR, D. B., LOVE, S. R., MALHOTRA, R., DO, Y. K., CHAN, A., & EBERLEIN, R. (2013). SIMULATING THE IMPACT OF LONG-TERM CARE POLICY ON FAMILY ELDERCARE HOURS. HEALTH SERVICES RESEARCH, 48(2pt2), 773–791. http://doi.org/10.1111/1475-6773.12030 
Objective: To understand the effect of current and future long-term care (LTC) policies on family eldercare hours for older adults (60 years of age and older) in Singapore. Data Sources: The Social Isolation Health and Lifestyles Survey, the Survey on Informal Caregiving, and the Singapore Government’s Ministry of Health and Department of Statistics. Study Design: An LTC Model was created using system dynamics methodology and parameterized using available reports and data as well as informal consultation with LTC experts. Principal Findings: In the absence of policy change, among the elderly living at home with limitations in their activities of daily living (ADLs), the proportion of those with greater ADL limitations will increase. In addition, by 2030, average family eldercare hours per week are projected to increase by 41 percent from 29 to 41 hours. All policy levers considered would moderate or significantly reduce family eldercare ours. Conclusion: System dynamics modeling was useful in providing policy makers with an overview of the levers available to them and in demonstrating the interdependence of policies and system components.

ASHER, M. G., & NANDY, A. (2008). SINGAPORE’S POLICY RESPONSES TO AGEING, INEQUALITY AND POVERTY: AN ASSESSMENT. INTERNATIONAL SOCIAL SECURITY REVIEW, 61(1), 41–60. http://doi.org/10.1111/j.1468-246X.2007.00302.x 
Abstract: Singapore represents an instructive case study in responding to rapid ageing, growing inequalities, and significant relative poverty. Unlike other high-income Asian countries, it has relied on single-tier mandatory savings to finance retirement, housing, and to a lesser extent, healthcare. To address the low fertility rates, it has permitted the share of the non-citizen population to triple between 1990 and 2005 to nearly 30 per cent. This is subtly altering Singapore’s socio-political dynamics, while assisting in sustaining growth and competitiveness. The paper argues that Singapore has the fiscal, institutional, and organizational capacities for a modern multi-tier social security system. Singapore is, however, determined to continue with current inadequate and inequitable arrangements, requiring individuals and their families to bear disproportionate risks in financing retirement, healthcare, and short-term income support. This reflects conscious policy choices arising from a Darwinist vision of society, and the need for socio-political control.

CHAN, A. (2006). AGING IN SOUTHEAST AND EAST ASIA: ISSUES AND POLICY DIRECTIONS. JOURNAL OF CROSS-CULTURAL GERONTOLOGY, 20(4), 269–284. http://doi.org/10.1007/s10823-006-9006-2
Population aging is unique in Asia given the speed at which it is occurring and the immense social and economic changes that the region is experiencing at the same time. Compared to their Western counterparts, Asian governments have much less time to prepare for population aging. Asian countries that have traditionally relied on family-based support for older family members are worried that increased numbers of older adults may stress these family systems. At the same time, information concerning the effectiveness of formal programs for older adults is scarce. This paper reviews current research on informal support versus formal support of older adults in Southeast and East Asia, with a larger aim of assessing the current well-being of older Asians and suggesting areas of policy concern. Current research reveals that formal programs in the majority of Southeast and East Asian countries have very low coverage of today’s older adults, and the figures for future generations are not that much higher. However, family support of older persons may not be deteriorating as predicted by modernization theory. Asian families continue to play a major role in supporting older members, thus policies should focus on enabling Asian families to provide this support.

CHIN, C. W. W., & PHUA, K.-H. (2016). LONG-TERM CARE POLICY: SINGAPORE’S EXPERIENCE. JOURNAL OF AGING & SOCIAL POLICY, 28(2), 113–129. http://doi.org/10.1080/08959420.2016.1145534
Singapore, like many developed countries, is facing the challenge of a rapidly aging population and the increasing need to provide long-term care (LTC) services for elderly in the community. The Singapore government’s philosophy on care for the elderly is that the family should be the first line of support, and it has relied on voluntary welfare organizations (VWOs) or charities for the bulk of LTC service provision. For LTC financing, it has emphasized the principles of co-payment and targeting of state support to the low-income population through means-tested government subsidies. It has also instituted ElderShield, a national severe disability insurance scheme. This paper discusses some of the challenges facing LTC policy in Singapore, particularly the presence of perverse financial incentives for hospitalization, the pitfalls of over-reliance on VWOs, and the challenges facing informal family caregivers. It discusses the role of private LTC insurance in LTC financing, bearing in mind demand- and supply-side failures that have plagued the private LTC insurance market. It suggests the need for more standardized needs assessment and portable LTC benefits, with reference to the Japanese Long-Term Care Insurance program, and also discusses the need to provide more support to informal family caregivers.

D.A. REISMAN. (2005). MEDICAL SAVINGS AND MEDICAL COST: HEALTHCARE AND AGE IN A CHANGING SINGAPORE. INTERNATIONAL JOURNAL OF SOCIOLOGY AND SOCIAL POLICY, 25(9), 1–26. http://doi.org/10.1108/01443330510791153 
Singapore devotes less than 4% of its GDP to healthcare in part because its average citizen is young. As the country has become developed, the birth rate has fallen, life‐expectancy has lengthened and the cost of care has shown signs of escalation. This has occurred despite the extensive cost‐control measures built into the mandatory system of medical savings and the opt‐in supplement of medical insurance. The threat of care inflation is that much greater because of Singapore’s attempt to position itself as a regional treatment hub, because of rising incomes and expectations, and because of a shortage of doctors and nurses which is driving wages up. Old age is contributing to the problem but, the article shows, is not the only cause.

DAVID REISMAN. (2006). PAYMENT FOR HEALTH IN SINGAPORE. INTERNATIONAL JOURNAL OF SOCIAL ECONOMICS, 33(2), 132–159. http://doi.org/10.1108/03068290610642229 
Purpose – Singapore’s rapid economic progress has been accompanied by a series of experiments in medical savings and health insurance. This paper aims to examine the ‘three Ms’ – Medisave, MediShield, and Medifund – in order to establish the way in which the policy‐instruments are expected to deliver the status required.  Design/methodology/approach – The paper collects evidence on both outcomes and payments.  Findings – Results show that a nation in which the median citizen is under 40 is in a strong position to rely principally on individual medical savings accounts. The paper predicts that Singapore, as its population ages, will probably rely more heavily on risk pooling and insurance.  Practical implications – The practical implications are that an extension of insurance is inevitable, but that earmarked savings will probably remain the first line of defence.  Originality/value – The paper is the first to document the Singapore experience of payment for health. It draws inferences and makes recommendations that will be of interest to policy makers both in poorer and in richer countries.

LEE, W. K. M. (1999). ECONOMIC AND SOCIAL IMPLICATIONS OF AGING IN SINGAPORE. JOURNAL OF AGING & SOCIAL POLICY, 10(4), 73–92. http://doi.org/10.1300/J031v10n04_05 
The economic and social impacts of population aging in Singapore are examined, particularly their impact on labor supply and the extent to which traditional family and community care providers can meet the challenges of an aged population. The adequacy of public policy responses, such as the new employment policy and the Central Provider Fund, are explored. Government strategy to shift the burden of care to the family and other community providers is challenged.

LIM, M.-K. (2004). SHIFTING THE BURDEN OF HEALTH CARE FINANCE: A CASE STUDY OF PUBLIC–PRIVATE PARTNERSHIP IN SINGAPORE. HEALTH POLICY, 69(1), 83–92. http://doi.org/10.1016/j.healthpol.2003.12.009
Since becoming independent in 1965, Singapore has attained high standards in health care provision while successfully transferring a substantial portion of the health care burden to the private sector. The government’s share of total health care expenditure contracted from 50% in 1965 to 25% in 2000. At first glance, the efficiency-driven health care financing reforms which emphasize individual over state responsibility appear to have been implemented at the expense of equity. On closer examination, however, Singaporeans themselves seem unconcerned about any perceived inequity of the system. Indeed, they appear content to pay part of their medical expenses, plus additional monies if they demand a higher level of services. In fact, access to needed care for the poor is explicitly guaranteed. Mechanisms also exist to protect against financial impoverishment resulting from catastrophic illness. Singapore’s experience provides an interesting case study in public–private partnership, illustrating how a hard-headed approach to health policy can achieve national health goals while balancing efficiency and equity concerns.

MEHTA, K. K. (2006). A CRITICAL REVIEW OF SINGAPORE’S POLICIES AIMED AT SUPPORTING FAMILIES CARING FOR OLDER MEMBERS. JOURNAL OF AGING & SOCIAL POLICY, 18(3-4), 43–57. http://doi.org/10.1300/J031v18n03_04
This article critically examines the family-oriented social policies of the Singapore government aimed at supporting families caring for older members. The sectors focused on are financial security, health, and housing. Singaporeans have been reminded that the family should be the first line of defense for aging families, followed by the community-the state would step in as the last resort. Drawing from recent research and examination of the state policies, the author argues that more should be done to help family caregivers looking after elder relatives. Recommendations for innovative ways to recognize and reward family carers conclude the paper.

MEHTA, K. K., & BRISCOE, C. (2004). NATIONAL POLICY APPROACHES TO SOCIAL CARE FOR ELDERLY PEOPLE IN THE UNITED KINGDOM AND SINGAPORE 1945-2002. JOURNAL OF AGING & SOCIAL POLICY, 16(1), 89–112. http://doi.org/10.1300/J031v16n01_05 
The authors compare policy approaches in the United Kingdom and Singapore on social care for older persons. The context of these approaches is discussed showing the development of policies, in each country from the aftermath of the Second World War to the present. Given that Singapore is a former British colony, it is of interest to scholars of social policy to examine its welfare approach as compared to the welfare state approach espoused by the United Kingdom. Both nations are faced with the challenges of an aging population, which necessitates handling similar problems with strategies that are in harmony with their respective economic, social, and cultural contexts. This paper considers their divergence of philosophies and policies, concluding with the recognition that the major difference lies in national and governmental expectations regarding the extent of the financial and regulatory responsibility for care for older people carried by the individual, the family, and the state.

ROZARIO, P. A., & ROSETTI, A. L. (2012). ‘MANY HELPING HANDS’: A REVIEW AND ANALYSIS OF LONG-TERM CARE POLICIES, PROGRAMS, AND PRACTICES IN SINGAPORE. JOURNAL OF GERONTOLOGICAL SOCIAL WORK, 55(7), 641–658.
Using the political economy perspective to examine key long-term care policies and provisions, we uncover some ideological underpinnings of policy-making in Singapore. Family involvement, an inherent part of the long-term care system, is overtly reinforced by legislations and policy imperatives. Further, the government encourages and expects the participation of nonstate actors in the provision of services as part of its Many Helping Hands approach to welfare provision. In our analysis, we argue that the government’s emphasis of certain ideology, such as self-reliance and cultural exceptionalism, allows it to adopt a residual and philanthropic approach in support of its macro-economic and legitimacy concerns.

TEO, P. (2004). HEALTH CARE FOR OLDER PERSONS IN SINGAPORE. JOURNAL OF AGING & SOCIAL POLICY, 16(1), 43–67. http://doi.org/10.1300/J031v16n01_03 
Health care policy in Singapore is similar to that in the United States and the United Kingdom, where a residualist strategy is used to pass health care costs to individuals and their families, the rationale being that this enables the state to concentrate on devolution of care to the community and ensure efficient and affordable service to all Singaporeans. The services include public restructured hospitals and outpatient poly-clinics as well as community services such as community hospitals and hospitals for the chronically ill, nursing homes, day care centers, and home help services. Availability does not translate into optimum usage because current and potential users and their families are not able to match their financial and social resources with the services. Instead, the state acts as the case manager and places parameters on what individuals can access.

TEO, P., CHAN, A., & STRAUGHAN, P. (2003). PROVIDING HEALTH CARE FOR OLDER PERSONS IN SINGAPORE. HEALTH POLICY, 64(3), 399–413. http://doi.org/10.1016/S0168-8510(02)00201-4 
Health care social policy in Singapore has passed the burden of care to the individual and the family on the rationale that it would enable the state to contain the costs of long-term care by channelling some of its funds to community services and to providing essential health services to all Singaporeans and not just the older group. While a wide array of services has come into existence, there is a lack of integration between the available resources and needs of the individual/family and what has been availed at the community and state levels. Part of the problem lies in the stringent criteria to which the state allows subsidies to be used; the lack of understanding with regard to the profile of users of services; and the case manager approach in offering services. Mapping health care has proven more difficult than anticipated because ageing is a diverse experience, varying by gender, race, income, religion and intergenerational relationships. A social policy does not apply to a ‘universal citizen’ and services that exist in the public sphere should not exist as merely commodified services which require a great deal of institutional processing.