Older Population and Health System: a Profile of Thailand

Older Population and Health System: A profile of Thailand

I. Introduction to Thailand

The Kingdom of Thailand was established in the mid-14th Century, known as Siam until 1939. A revolution in 1932 led to a constitutional monarchy. It lies in the heart of Southeast Asia. The country shares a long border with Myanmar to the west and the north, Lao P.D.R. to the north and the northeast, Cambodia to the east and Malaysia to the south. Thailand is divided into four distinct geographical regions: the mountainous North, the fertile Central Plains, the semi-arid plateau of the Northeast and the peninsula South At present, there are around 62.3 million people, of which 32% live in urban areas. Although most of Thailand is agricultural, the social and economic developments have changed the economy rapidly to industrialized productions and service sectors.

After enjoying the world’s highest growth rate from 1985 to 1995 – averagely almost 9% annually – increased speculative pressure on Thailand currency in 1997 led to a crisis that uncovered financial sector weakness and forced the government to float the value of the Baht. Thailand entered a economic recovery stage in 1999. Nevertheless, the economic ordeal has a significant impact on country’s labor structure, population migration, urbanization and life styles. The Gross Domestic Product (GDP) per Capita is $7,248 in 2002. GDP- composition by sector is 11% in agriculture sector, 40% in industry and 49% in services. Average consumer price index (CPI) in 2001 is only 1.6%. The CPI in food and non-food are 0.4% and 2.2% respectively. More than 50% of the total population (32.17 million) is in the labor force, of which 42% in agriculture and the rest 58% in non-agricultural sector. The unemployment rate is 5.16% in 2001.

Currently, Thailand is experiencing among the most rapid rates of population ageing in the developing world. The demographic shift from younger to older population age structure in Thailand is a recent phenomenon. The rapidity of the current change in Thailand stands in contrast to historical developments in most Western countries. This implies that the country will face emergent issues related to social security, health care costs and intergenerational equity and so on in a far shorter time span than that happened in the West. These issues require appropriate policies and programmes development to deal with. Hence, it is imperative that Thailand has a well prepared National Policy and Programme on ageing as well as for long-term care services for older persons.

II. Population ageing in Thailand

1. Demographic Trends of Population Ageing

During the past several decades, Thailand has been one of the most successful countries in bringing down its fertility level within a short period of time. The total fertility rate has declined from over 6 births per woman in the mid 1960s to below 2 in the mid-1990s (Table 1). During the same period, life expectancy at birth increased from 55.2 years to 69.9 years for men and 61.8 years to 74.9 years for women. In the coming decades, besides the lowering of the growth rate, a major demographic consequence of this rapid fertility reduction will be an inevitable ageing of the population. Even more dramatic will be the rapid increase in the absolute size of the older population (aged 60 and over), a result of past high fertility levels and substantial declines of mortality.

19 A demographic transition can be indicated by age profiles or “Population Pyramid”. Figure 1 shows actual age profiles of the population of Thailand in 1960 and 1980, and projected profiles in 2000 and 2020. These four age profiles depict changes in population structure from a pyramid in 1960 towards a bell shape in 2000 and a vast shape in 2020.

Table 1 Life expectancy at birth and total fertility rate, 1960-2025.

Year Men-E0 Women-E0 TFR 1960-65 51.9 56.2 6.39 1970-75 57.7 61.6 4.99 1980-85 62.9 67.6 2.96 1990-95 65.4 71.8 1.94 2000-05 66.3 72.7 1.74 2010-15 69.9 75.7 1.85 2020-25 72.6 78.1 1.90

Source: United Nations, 1999a

Figure 1 Age profile of the population of Thailand in 1960, 1980, 2000 and 2020.

196 1980

200 2020 0

Source: Jitapunkul, S. and Bunnag, S., 1998

Table 2 presents the past trends and future projections of key demographic indicators related to population ageing in Thailand for the period 1980-2050 as estimated by the United Nations (United Nations, 1999a). Three main characters of the ageing population in Thailand are noted, namely a considerable change in the age structure of the population, a rapid increase

20 in the share of the older population, and an increase in the proportion female in the older age groups.

Trends in the growth rates and the sheer size of the older population are also remarkable. The older population is growing faster than the growth of the total population. The rapid increase in the proportion of the older population implies a sharp increase in the size of the elderly population. Thailand’s total population grew by 31 percent between 1980 and 2000, increasing from 46.7 million to just over 60 million at present. At the same time the population growth declined substantially, from 3 percent around 1970 to under 1 percent currently (Table 2A and 2B).

Table 2A Projected trends in selected demographic measures of the older population in Thailand, 1980-2050.

1980 1990 2000 2010 2020 2050

1) Population (in 1,000) Total 46,718 55,595 61,399 66,511 70,975 74,188 60+ 2,527 3,716 5,338 7,205 10,765 21,981 65+ 1,649 2,408 3,576 4,953 7,168 17,076 75+ 484 798 1,192 1,852 2,594 8,222 85+ - - 198 327 540 1,946

2) % Increase over 1980 Total - 19.0 31.4 42.4 51.9 58.8 60+ - 47.1 111.2 185.1 326.0 769.8 65+ - 46.0 116.9 200.4 334.7 935.5 75+ - 64.9 146.3 282.6 436.0 1,598.8 3) Population growth rate Total 1.7 1.0 0.8 0.6 -0.1* 60+ 3.9 3.6 3.0 4.0 0.9*

4) % of total population aged: < 15 40.0 31.9 25.2 21.6 19.8 16.8 60+ 5.4 6.7 8.7 10.8 15.2 29.6 65+ 3.5 4.3 5.8 7.4 10.1 23.0

5) % of the total older population aged: 70+ 38.3 39.6 41.3 45.1 41.3 57.3 75+ 19.2 21.5 22.3 25.7 24.1 37.4 85+ - - 3.7 4.5 5.0 8.9 6) % Female 60 + 54.7 54.8 55.5 55.8 55.6 54.9 75 + 58.5 59.9 60.0 60.7 60.6 59.0 85 + - - 65.2 65.4 65.4 63.7

7) Dependency ratio Total 83.2 62.9 51.3 47.9 53.8 86.5 <15 73.3 52.0 38.1 31.9 30.5 33.2 60+ 9.9 10.9 13.2 16.0 23.3 55.3

Source: Calculated from data provided in the United Nations, 1999b (* is the average rate during 2040-2050.)

21 Table 2B Projected trends in selected demographic measures of the population aged 50+ years in Thailand, 1980-2050.

Total

Age 50+ 60+ 65+ 50-59 60-69 70+

19801 11.3 5.5 3.5 5.9 3.3 2.1

50+ 60+ 65+ 50-59 60-69 70-79 80+ 19902 15.0 7.4 4.7 7.7 4.5 2.1 0.8 20003 18.0 9.4 6.1 8.6 5.8 2.7 0.9 20104 21.4 10.8 7.4 10.6 5.9 3.5 1.3 20204 28.8 15.2 10.1 13.7 8.9 4.4 1.9 20254 32.6 18.1 12.3 14.5 10.4 5.5 2.2 20504 41.4 29.6 23.0 11.8 12.7 10.8 6.2

Males

Year Age 50+ 60+ 65+ 50-59 60-69 70+ 19801 10.8 5.0 3.2 5.8 3.2 1.8

50+ 60+ 65+ 50-59 60-69 70-79 80+ 19902 14.4 6.9 4.2 7.5 4.4 1.9 0.6 20003 17.2 8.7 5.6 8.4 5.5 2.5 0.7 20104 19.9 9.7 6.4 10.3 5.6 3.0 1.0 20204 27.2 13.6 8.8 13.6 8.4 0.1 1.4 20254 30.9 16.4 10.8 14.5 9.9 4.8 1.6 20504 39.3 27.3 20.7 12.0 12.5 9.9 4.9

Females

Age 50+ 60+ 65+ 50-59 60-69 70+

19801 11.9 5.9 3.9 5.9 3.4 2.5

50+ 60+ 65+ 50-59 60-69 70-79 80+ 19902 15.7 7.9 5.1 7.8 4.6 2.3 1.0 20003 18.8 10.1 6.7 8.7 6.1 2.9 1.1 20104 22.9 12.0 8.5 10.9 6.3 4.0 1.7 20204 30.4 16.7 11.4 13.8 9.4 0.3 2.4 20254 34.2 19.7 13.7 14.5 10.9 6.1 2.7 20504 43.5 31.9 25.2 11.6 12.8 11.6 7.4 Source: National Statistical Office, 1984, 1994, 2001 Calculated from data provided in the United Nations, 1999b

The proportion of the population in their elderly years (60+) is anticipated to increase from 8.7 percent in 2000 to 10.8 percent in the year 2010, 15.2 percent in the year 2020, and 30

22 percent in the year 2050. The number of older persons will continue to rise, from approximately 5.3 million at present to 7.2 million in 2010 and will reach 11 million by 2020 (Figure 2). Based on the latest projections from the United Nations, the growth rate of the Thai older population is relatively high, over 3 percent per year. With the growth rate of 3–3.6 percent per year, the size of the older population will have doubling times of about 19-23 years. Thailand will become an ageing society within the next 10 years, according to the United Nations' definition.

Figure 2 Linear graph of total number and percent of the older population in Thailand, 1980 - 2050. Number (millions) Percent 30 30 number (million) percent 25 25

20 20

15 15

10 10

5 5

0 0 1980 1990 2000 2010 2020 2050

Source: Calculated from data provided by the United Nations, 1999b

Not only is the overall share of the population increasing, but the older population itself is also ageing as evidenced by an increase in the percent of older persons who are aged 75+ (Figure 3). The percent increase of the old-olds is greater than that of the overall aged population.

23 Figure 3 Characteristics of the young olds and the old olds – Area graph 100% stack.

Young-old (60-74) Old-old (75+) 100%

80%

60%

40%

20%

0% 1980 1990 2000 2010 2020 2050

Source: Calculated from data provided by the United Nations, 1999b

24 2. Feminisation of the aged population

In 1960-1965 the life expectancy (E0) at birth for males and females were 51.9 and 56.2 years respectively (Table 1). Thirty years later (1990-1995), the life expectancy at birth had more increased to be 65.4 for males and 71.8 for females. Since the females’ advantage in life expectancy is likely to continue in the future, projections indicate that the preponderance of older women will also continue. Among the older population, there are more women than men in every age group. The proportion of older females is greater at older ages (panel 6, Table 2A).

In addition, female older persons also live longer than their male counterparts (Jitapunkul, S., 1998). In 1991, the life expectancies of male and female older persons at the age of 60-64 were 18.79 and 21.95 years, respectively; at the age of 70-74, 12.81 and 14.79 years, respectively; and at the age of 80 and over, 9.30 and 9.81 years, respectively. The trend of the difference in life expectancy between sexes is more pronounced as shown by an increasing percentage of the ratios between the life expectancy (LE) of female and male older persons (Table 3). This shows that women live longer than men and will share a higher proportion among the old-olds. The result is a phenomenon of feminization among the aged population.

Table 3 Life expectancy (ex) of Thai elderly at different ages by sex in 1995-1996.

Age Male Female Percentage of ratios between ex of female and male

60 20.29 23.89 117.7 65 17.14 20.20 117.8 70 14.18 16.89 119.1 75 11.87 14.60 123.0 80 10.90 13.60 124.8

Source: Jitapunkul, S., 1998

Any of the very old would be women, often widowed and probably without adequate means of support. They are likely to have poorer health and worse financial situation compared to older men (Jitapunkul, S., 1998). Older women are thus considered more vulnerable and deserve a special attention and assistance.

3. Trends in the dependency ratio

The dependency ratio is a numerical measure of the economic burden imposed on the working population who must ultimately support people who are not in the labour force. The old age dependency ratio is an indicator roughly quantifies the demographic weight of burden that the current working age population has to bear in order to support the older persons. Changes in age structure that are taking place in Thailand translate into changes in dependency ratios defined in terms of age groups. In the past children constituted the major part of the dependency ratio, but this is changing. By the year 2050 about 64 percent of the dependents will be older adults. The increasing dependency burden of ageing populations would be more than offset by the falling dependency burden of young people during the early stages of aging (1990-2000). The total dependency ratio has declined and will reach the lowest level in 2010, but will rise again in the second decade of the next century (Figure 4). The aged dependency levels, however, will steadily increase from about 13 older persons per 100 persons aged 15-59 at present to 16 per 100 in 2010 and 23 per 100 in 2020 (Table 2A). The increase in the old-age dependency ratio implies that the burden of support for older persons will become heavier. This includes health care costs and other social and economic supports.

19 Figure 4 Total, child and aged dependency ratios of Thailand.

100 90 Total Child Aged 80 70 60 50 40 30 20 10 0 1980 1990 2000 2010 2020 2050

Source: Calculated from data provided by the United Nations, 1999b

4. Speed of population ageing

The speed of demographic change in Thailand is remarkable. The rapidity of population aging in Thailand (and some newly completed demographic transition countries) is alarming. The number of years expected to spend for shifting the proportion of the older population from 7 percent to 14 percent is much lower in Thailand than it was in many industrialized countries. As it is shown in Table 4, it took France 114 years, Sweden 85 years and Italy 63 years to shift from having 7 percent of its population in the 65 and over age group to having 14 percent in that category. In comparison, it took Japan only 26 years to make that change. But now Japan has serious competitors in Asia with Thailand and Singapore all expected to take fewer than 25 years to make the transition. The shorter time Thailand will take to become an ageing society means that the country also has a shorter time to adjust to and to plan for this rapid demographic change.

Table 4 Speed of population aging in selected countries.

Year the proportion of Year the proportion Number of years population aged 65+ of population aged required for the is 7% 65+ is 14% proportion of elderly to increase from 7% to 14% Developed countries France 1865 1 1979 2 114 Sweden 1886 1 1971 2 85 United States 1941 1 2013 2 72 Italy 1924 1 1987 2 63 Japan 1969 2 1994 2 26

Asian countries South Korea 2001 2 2023 2 22 Singapore 2000 2 2017 2 17 Thailand 2007 2 2029 2 22 China (excl. Hong Kong) 2002 2 2027 2 25

Sources: United Nations, 1956, 1999a

20 In conclusion, five notable characteristics of the rapidly growing older population in Thailand are: (a) ageing of the aged, (b) feminization of the aged population particularly among the old-olds, (c) rising of the total dependency ratio after reaching its nadir point in 2010, and (d) remarkable rapidity of population ageing.

21 III. Socio-economic profile of older persons and its implications

1. Income of Thai older persons and economic security

In 1994, 43.9 percent of Thai older persons had their income less than 10,000 Baht or 227 US$ (1 US$ = 44 Baht) per year. The median income was 10,000-19,999 Baht. Only 11.5 percent had income over 50,000 Baht per year. The older persons in urban areas had much higher income than those in rural areas. Compared with elderly men, elderly women are in a disadvantaged position (Table 5). The economic condition of older women, particularly unmarried women, appears to be least favourable. Women tend to depend on children and receive more indirect support than men do. Among older persons who were employed, 65.2 percent had their income less than 2,000 Baht per month and 20.8 percent had an income ranged between 2,001-4,000 Baht per month (Phananiramai, M. and Soonthornchawakarn, N., 2002).

Table 5. Income of Thai older persons (Baht) by area of living and sex, 1994.

Bath Total Urban area Rural area male female all Male Female all

<10,000 43.9 15.7 21.6 19 43 55.3 49.7 10,000 - 22 15.8 22.7 19.7 22.9 22.3 22.6 19,999 20,000 - 10.2 9.4 12.7 11.2 12.1 8.1 9.9 29,999 30,000 - 7.7 9.3 13.4 11.6 7.6 6.1 6.8 39,999 40,000 - 3.1 5.2 4.8 5 3.8 1.6 2.6 49,999 >50,000 11.5 41.2 22 30.4 9.6 5.1 7.1 Missing 1.6 3.4 2.8 3.1 1 1.5 1.3

Source: National Statistical Office, 1994

Children and work are the two predominant sources of income for Thai older persons. Only 4 percent of older persons receive regular income from pension. Nevertheless, more than 80 percent of Thai older persons had their own property or real estate. The sources of revenue are shown in Table 6.

19 Table 6 Sources of older persons’ revenue, 1994.

Percentage (i) Sources of Revenue

Children 84.5 Work 38.0 Spouses 21.4 Savings / Interests 17.1 Relatives 14.9 Pension 4.1 Assets / Property 1.6 Others 1.6

Source: National Statistical Office, 1994

Thirty-five percent of Thai older persons reported that their income was not adequate for themselves and their family’s expenses (Figure 9). Older persons in rural areas had a higher level of income inadequacy when compared with those in urban area. These findings suggest that a high proportion of the Thai older population cannot live with an acceptable quality of life unless they are supported by their offsprings or provided with adequate public welfare.

Figure 9 Adequacy of income of Thai older persons for their family’s expenses by sex and urban-rural area.

Source: National Statistical Office, 1995

20 2. Economically active older persons

A substantial share (31.9%) of older population remains economically active, especially men (Figure 7). Thai older persons living in rural areas remain economically active more than those living in urban areas. Economical activity of Thai older persons is concentrated in agricultural sector where most of them are self-employed (Figure 8).

Table 7. Percent distribution of older persons according to duration of stay in the present community and reason for moving, by residence, Thailand, 1995.

Bangkok Provincial Rural Total Urban

Duration of stay (in years)

0 – 4 11.1 5.4 2.7 3.7 5 – 9 10.6 6.7 2.5 3.6 10 – 14 14.2 8.9 2.0 3.8 15 – 19 11.2 9.1 2.8 4.2 20+ 46.4 56.3 54.3 53.7 Since birth 6.5 13.5 35.8 31.1 Total 100 100 100 100

Reasons for moving

Look for job 28.4 39.3 42.7 40.5 Follow family 14.8 26.1 33.9 30.6 Move to live with child 13.6 6.9 3.4 5.1 Help child with chores 7.8 5.0 1.6 2.7 Buy/inherit/build land/house 31.9 8.1 10.5 13.1 Other 3.2 10.4 6.4 6.1 D.K. 0.4 4.2 1.9 1.9 Total 100 100 100 100

Source: Chayovan, N. and Knodel, J., 1997

19 Figure 7 Percentage of economically active older persons by sex and urban-rural area, 1994.

Source: National Statistical Office, 1994

Figure 8 Percentage of economically active older persons by sector, 1994.

9.6

43.9 36.8 56.1 63.2 90.4

Whole country urban area

agricultural non-agricultural

Source: National Statistical Office, 1994

19 3. Educational level

Education is an important determinant of a person’s health and access to resources. Approximately thirty-one percent of Thai older persons have never attended school. Thai older women have much less opportunity to formal education compared with Thai older men. Among older men and women, 71 percent and 48 percent have finished grade 4 or higher level (Table 8).Older persons in rural area have a lower opportunity for formal education than older persons in urban area. However, being educated does not guarantee the literacy of them. The rate of no formal education is significant lower than the illiteracy rate.

Table 8 Characteristics of Thai women and men indicating a vulnerable situation for women.

Male (%) Female (%) Education Total Urban Rural Total Urban Rural No 19.4 14.4 20.6 40.9 33.0 42.7 Less than grade 4 9.6 6.5 10.2 10.6 6.6 11.6 Grade 4 59.5 47.3 62.3 44.3 45.2 44.1 Higher than grade 4 10.7 30.9 6.1 3.8 14.5 1.3 Others 0.8 0.9 0.8 0.4 0.7 0.3

Source: Jitapunkul, S., 1998

Data in Figure 5 indicates that although illiteracy level among elderly declined dramatically from 56 percent in 1980 to 25 percent in 2000, older persons are considerably less educated than the general population. Gender difference in the illiteracy level is pronounced. In 2000, the proportion of older women who are illiterate is twice that of older men (33.2% vs. 16.1%).

Figure 5 Percentage illiterate of Thai older persons by sex, 1980-2000, Thailand.

I 80Pe Total Male Female 70 60 50 40 30 20 10 0 1980 1990 2000

Source: Jitapunkul, S., 1998

19 Because of rapid social and demographic change in the past, the characteristics of older persons in the future is likely to differ considerably from that in the present or recent past. Previous studies have documented that future Thai older persons will differ significantly from the older persons of today in terms of their characteristics, needs, preferences and expectations. This is particularly clear in the case of education and number of living children.

Projection of educational composition of future Thai older persons separately for males and females using the cohort analysis approach by Christenson and Hermalin (Christenson, B. and Hermalin AL., 1991) indicated that proportions of illiteracy for both male and female older persons will decrease substantially from 1980 to 2020 and that the average educational level of the elderly population will continue to improve over the coming decades as the better educated cohorts succeed those less educated ones as time passes.

4. Household structure of older persons and number of living Children

At present 98 percent of the Thai older persons live with their families while only 2 percent live in institutions, mostly in Buddhist monasteries (Chayovan, N., 1999). For older persons who live in individual household, most of them (93%) live with their children and/or spouses. Nearly 4 percent live alone (Table 9)

Table 9 Living status by age and sex of Thai elderly according to persons they are staying with, (1994).

Living status (%)

Alone With spouse With children With other With non- +/- others +/- others relatives relatives

M a l e T o t a l 2.2 48.7 47.0 0.7 1.9 60-64 2.1 55.4 41.7 0.5 1.0 65-69 2.2 47.8 47.8 0.8 1.8 70-74 2.3 47.7 46.5 0.3 3.2 7 5 + 2.0 36.0 58.4 1.6 2.2

Female T o t a l 4.8 37.6 53.5 1.7 2.7 60-64 4.4 41.9 51.7 1.1 1.5 65-69 4.0 41.3 51.9 1.3 1.6 70-74 5.1 34.8 55.2 1.7 3.4 7 5 + 6.5 27.2 57.4 3.3 5.6

Source: Jitapunkul, S., 1998

Almost 50 percent of older persons in Thailand live in the three-generation households. One- third of older persons live in two-generation households. One-fifth of them live in one- generation households (mostly with their spouses). (Figure 6).

From the point of view of assessing the availability of potential support providers for older persons, the number of living children is of greater relevance than the cumulative fertility. Given the rapid fertility decline in the past three decades in Thailand, not only will the future older persons be better educated, they will also have fewer children. Estimates indicate that the present older persons have on average 5.1 living children (including step- and adopted children) while under the current low fertility the future older persons will average only 2.2 living children (Knodel, J., et al, 1992). Moreover the percentage with just two children will increase from 8 percent to 58 percent, while the percentage with five or more living children will decrease from 56 percent to only 4 percent (Table 10). The proportion of older persons who have no child increased slightly from 3.5 percent in 1986 to 4.4 percent in 1995 and the figure is expected to increase to 5.6 percent in the future (Chayovan, N. and Knodel, J., 1997).

20 Figure 6 Household structure of Thai older persons

20%

47%

One-generation households Two-generations households 33% Three-generations households

Source: Chayovan, N. and Knodel, J., 1997

Table 10 Percent distribution of current older persons according to their actual number of living children and percent distribution of future older persons according to their estimated number of children based on fertility preferences of recently married women, adjusted for step and adopted children.

Number of Current older persons Future Children Men Women Total Older persons 0 3.4 3.6 3.5 5.6 1 6.0 9.8 8.2 8.4 2 8.3 7.7 8.0 57.5 3 9.9 12.2 11.2 18.7 4 12.7 13.0 12.9 5.7 5+ 59.8 53.7 56.2 4.0 Total 100 100 100 100 Mean number 5.4 4.8 5.1 2.2

Source: Knodel, J., et al, 1992

The rapid fertility decline is often cited as a force that will undermine the traditional system of familial support for older persons. The reduction of the family size implies that there will be fewer children available to provide care and support for the future generations of elderly. In the coming decades, a nuclear family network of care for Thai older persons will inevitably dominate an extended care.

21 5. Informal care by family

Most of Thai older persons share the same house with their children (71%). Another 9.4 percent live in accommodations adjacent to their children’s homes and 7.4 percent dwell in the same community with their children (Chayovan, N. and Knodel, J., 1997). Among those who do not coreside with their children, 69-87.8 percent are regularly visited (at least once a month) by their children (Kamnuansilpa, P., et al., 1999; Chayovan, N. and Knodel, J., 1997). Ninety-three percent of older persons want their children to be their caregivers when they get older and need assistance (National Statistical Office, 1995). Approximately, 64 and 27 percent of the elderly were taken care of by their children and spouses respectively. Nearly 20% of the caregivers were also aged (National Statistical Office, 1995).

The available data on nursing home and residential home, at present, shows that less than 4,000 older persons are institutionalized for Long-term Care (LTC) (Jitapunkul, S., 2000). Hence, almost all older persons who need LTC received informal care provided by their families and relatives. It is certain that the proportion of those who are in need of utilizing formal care services will increase. However, the real matter on policy direction is how we support informal care system in order to keep the number of older persons who need to be placed in an institution as low as possible. It also has to assure that family and relatives are able to provide adequate care to their older people.

6. Double burden of simultaneously supporting children and older parents of the middle-age population (aged 40- 54)

Among the working-age population (aged 15-59), the middle-age population (aged 40-54) forms the core of the labour force. With population ageing, the people in this middle core increasingly shoulder a double burden, i.e. simultaneously supporting their children and their older parents. Ratios of older population supported by the middle-age population of Thailand are shown in Figure 10 (National Statistical Office, 1962; National Statistical Office, 1984; Human Resources Planning, 1995). The burden will remarkably increase in the 21st Century.

Figure 10 Ratio of older population supported by middle-age population.

Source: Calculated from data provided in the United Nations, 1999b

19 7. Roles of older persons

At present most of older persons in Thailand provide a crucial role as supporters both for their own families and communities such as taking care of their grandchildren, cooking, cleaning, looking after the house, financial support, joining social and religious activities. Some of them also socialize with groups of the same age such as senior citizen clubs, volunteer groups and recreation groups. Most of older persons in Thailand perform their leading roles in religious practices by supervising and giving useful information concerning the religious activities to the members of their families and communities. They also convey the folkway of life and culture to younger generations. In conclusion, it is clear that Thai older persons are still playing important roles in families and societies. However, lost of capability of self-care inevitably affects contributing roles of older persons (Yodpet, S., 2001).

8. Social value towards older persons in Thailand

Believes, values and traditions, which come from Buddhism, are social norms in Thai society. Living with older parents, showing respect and taking care of them are considered normal way of family life and are highly commended in Thailand. On the other hand, children who neglect their parents or behave improperly to them are blamed by the society. These social norms are still strong, even though intimate relationships between older persons and younger generations are difficult to maintain due to major cultural and economic changes in Thai society (Yodpet, S., 2002).

Human rights and dignity are international goals to be achieved. Eighty-four percent of Thai older persons consider themselves endowed with rights and dignity; the degree of which depends on the behaviour and attitudes of older persons toward others and vice versa. More specifically, older persons’ rights depend on the degree of respect given by their families. And older persons’ dignity is a consequence of the crucial performance they provided to the society.

9. Migration in later life

Information on the migration of older persons is useful for understanding their adjustment in life through interaction with their kins. The mobility of older persons may contribute to changes in the household composition. Migration of older persons tends to increase the proportion of multiple-generation households and reduce the proportion of single-person households, as well as increase the average size of households. Unfortunately, research on the migration of older persons in Thailand is extremely limited. This is partly due to lack of suitable data and partly to relatively little interest in this issue. A majority (70 %) of Thai older persons live in rural areas and about 30 percent in municipal or urban areas. Analytical data of the 1970 and 1980 census suggests that older population is less mobile than the younger adult (Chayovan, N., et al, 1990). The result of the survey in 1995 confirm that migration is not very prevalent among Thai older persons. After entering old age most of older people continue to live in the community in which they have lived during their working lives. Almost one-third of older persons have lived in the community since their birth, and more than half have resided in the community for more than 20 years. Only 4 percent of older persons can be considered recent migrants, defined as those who have lived in the community for less than 5 years. The level of migration among older persons is highest in Bangkok and lowest in rural areas (Table 9).

The reasons for migration were mainly occupational and family needs. Reasons cited include looking for a job (41%), following family (31%), buying or inheriting a house and/or land (13%), and moving to live with an adult child (5%).

20 10. Marital status

Having a partner or not in the later years of life is likely to have important implications for psychological, and perhaps, material well being of older persons. It also affects their living arrangements and support systems. Therefore, information on the marital status composition of older persons is important for assessing the psychological and material support needs of the elderly. Table 11 presents the marital status of older persons during 1980 and 2000. Trends towards increasing proportions of older persons being married, declining proportions widowed, divorced/separated and steadily increasing levels of single are observed for both sexes. The increase in the levels of married older males and females is in large part due to the marked gains in the joint probabilities of surviving. Gender differences in marital status are evident and seem to have persisted over time. There are more currently married older men than currently married older women, while there are almost four times as many widowed older women as men. Also, single and divorced/separated older women outnumber their male counterparts. The rate of single female living in urban area (5.2%) is two-time higher than the rate of single female living in rural area (2.4%) (National Statistical Office, 1995).

Table 11 Percentage distribution of older persons according to marital status and sex, 1980-2000, Thailand.

Sex/ Marital status

Year Single Married Widowed Divorced/ Don’t Monk D.K. Total separated know status

Male 1980 1.5 75.7 16.7 2.0 0.7 3.0 0.4 100 1990 1.5 77.6 16.2 1.8 0.6 2.2 0.2 100

2000 1.6 78.5 14.9 1.4 0.8 2.2 0.6 100

Female 1980 2.1 40.6 51.5 2.8 2.5 - 0.5 100 1990 2.4 46.1 46.8 2.6 1.8 - 0.2 100 2000 3.1 51.4 41.6 2.0 2.0 - 0.0 100 Source: National Statistical Office, 1984, 1994, 2001

The marital status growing most rapidly is the single female, from 2.1 percent in 1980 to 3.1 percent in 2000 (about 50% increase). There is likely to be a continuing increase in the prevalence of single females among those reaching old age in the first decades of the 21st century, as many younger cohorts of women remain unmarried.

The marital distribution of a cohort at any particular time is determined by its past experience with marriage, divorce, widowhood and remarriage, as well as by differential survival by marital status. Given the changes in the marriage patterns in the past two decades, cohorts entering old age in the next several decades will be different from the present older persons with regard to their marital status composition.

19 IV. Health Status of Older Persons

1. Mortality

The age-specific mortality rates of Thai population except among the highest age group have been declining for more than four decades (Figure 11). However, age-specific mortality rates have increased with age, with the highest rate in the age group of 70+ years (Table 12). This mortality pattern has been observed in both sexes.

Figure 11 Age-specific mortality rate (per 1,000 population) of Thai population in 1960, 1970, 1980, 1990, 2000.

1960 1970 1980 1990 2000

70 60 50 40 30 20 10 0 0- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70+

Source: Division of Health Statistics, Ministry of Public Health, 1965, 1975, 1986, 1996, 2001

20 Table 12 Age-specific mortality rate (per 1000 population) of Thai population in 1960, 1970, 1980, 1990, 2000.

Year Age group 1960(1) 1970(2) 1980(3) 1990(4) 2000(5) 0-4 19.49 9.3 4.6 4.8 1.8 5-9 3.16 1.8 1.4 1.4 0.6 10-14 1.89 1.2 0.9 1.2 0.4 15-19 2.01 1.8 1.7 2.8 1.1 20-24 2.82 2.5 2.5 3.7 2.0 25-29 3.22 2.7 2.4 3.6 3.9 30-34 3.95 3.2 2.6 3.7 4.7 35-39 5.37 4.1 3.6 3.7 4.5 40-44 6.74 5.6 6.0 4.1 4.5 45-49 8.32 7.3 7.7 4.6 5.2 50-54 10.72 10.1 10.4 6.3 7.0 55-59 13.72 13.0 12.3 7.1 9.1 60-64 20.35 19.5 19.8 8.3 13.4 65-69 27.27 27.9 27.3 8.4 20.1 70+ 61.67 63.69 25.3 34.5 60.6

Source: Division of Health Statistics, Ministry of Public Health, 1965, 1975, 1986, 1996, 2001.

According to the 1996 national data on mortality obtained from the Ministry of Public Health (Division of Health Statistics, Ministry of Public Health, 1996), 41 percent of Thai older men and 54 percent of Thai older women were recorded under “senility”. Another 6-7 percent of both sexes were recorded as “unknown causes”. Thus, more than 50 percent of the recorded causes of death of Thai older persons in 1996 were obscure. Nevertheless, from the available data, heart failure and cerebrovascular diseases are common causes of death in both male and female older persons. Whereas accidents and cancers are common causes of death among older men; diabetes mellitus, hypertension and septicaemia are common causes of death among older women (Table 13).

2. Morbidity and Behaviour Risk Factors

Findings from the National Health Examination Survey conducted in 1991 show that the pattern of chronic diseases among Thai older persons is quite similar to that in developed countries (Thailand Health Research Institute, National Health Foundation, 1996a) (Table 14). However, the prevalence rates of these chronic diseases such as hypertension and diabetes mellitus are lower than those obtained from interviews conducted in other national surveys and community studies (Jitapunkul, S. and Bunnag, S., 1998) including the National Survey of the Welfare of the Elderly in Thailand (SWET), which older persons were interviewed about diseases confirmed by their physicians (Thailand Health Research Institute, National Health Foundation, 1996b) (Table 15). According to these two national surveys, common important health problems among Thai older persons are osteoarthritis, hypertension, diabetes mellitus and hypercholesterolemia. These health problems are remarkable among those living in urban areas.

Many health problems, which affect the quality of life of older persons have been studied and summarized in Table 16 (Jitapunkul, S. and Bunnag, S., 1998; Jitapunkul, S., et al., 1999; Jitapunkul, S., 2000). Urinary incontinence, falls, dementia and major depression are rather common among Thai older women compared with men. Although the rate of hip fracture among the Thai older persons is relatively low (Suriyawongpaisal, P., et al., 1992), the evidence gained from the national disability study among the Thai elderly suggests that osteoporosis is more common than previously expected and is an important public health issue (Jitapunkul, S., et al.,1999) (Table 16).

21 Table 13 The top-10 causes of mortality among Thai elderly population in 1996 by sex.

Rank Male % Female % 1 Senility (R54) 41.3 Senility (R54) 53.7 2 Heart failure (I50) 10.5 Heart failure (I50) 8.8 3 Unknown causes of 7.2 Unknown causes of 6.3 mortality (R95-R99) mortality (R95-R99) 4 Cerebrovascular diseases 3.4 Cerebrovascular diseases 3.0 (I60-I69) (I60-I69) 5 Malignant neoplasm without 2.4 Diabetes mellitus (E10- 2.3 specification of site (C80) E14) 6 Accidents -unintentional 2.2 Other septicaemia - not S. 1.9 injuries (V01-X59) pneumococcus (A41) 7 Other unspecified disorders 1.8 Other unspecified disorders 1.5 of circulatory system (I99) of circulatory system (I99) 8 Malignant neoplasm of liver 1.8 Complications and ill- 1.4 and intrahepatic bile ducts defined descriptions of (C22) heart disease (I51) 9 Pneumonia (J12-J18) 1.8 Pneumonia (J12-J18) 1.1 10 Complications and ill- 1.5 Hypertensive disease (I10- 1.0 defined descriptions of heart I15) disease (I51) Code of the International Classification -10th (ICD10) in parenthesis. Source: Jitapunkul, S. and Bunnag, S., 1998

Table 14 Prevalence (%) of selected diseases among Thai older persons assessed by objective methods from the National Health Examination Survey I.

Male Female 60-64 65-69 70+ 60-64 65-69 70+ Diabetes mellitus* 4.1 4.3 4.2 4.4 6.8 5.5 Hypertension** 8.1 8.2 15.7 12.6 10.8 16.5 Chronic airway 4.3 5.3 7.9 3.4 4.6 5.0 0bstruction*** Coronary heart disease# 1.8 4.3 2.6 1.3 2.5 2.5 Hypercholesterolemia ## 15.1 13.9 11.8 25.5 25.1 21.4 Long-standing arthralgia@ 51.9 52.5 55.7 64.5 69.4 64.9 Long-standing back pain@ 49.5 53.7 50.2 52.6 52.6 54.7

* fasting plasma glucose above 140 mg/dl ** blood pressure above 160/95 mmHg *** peak flow rate below 80% of the predictive value plus historical criteria # using electrocardiogram criteria ## total serum cholesterol above 240 mg/dl @ duration for more than 6 weeks

Source: Thailand Health Research Institute, National Health Foundation, 1996a

22 Table 15 Prevalence (%) of selected diseases among Thai older persons assessed by subjective methods (interview) from the National Survey of the Welfare of the Elderly in Thailand (SWET) grouped by rural-urban area and sex.

Male Female Urban Rural urban rural Hypertension 19.2 12.9 29.9 17.1 Osteoarthritis 12.9 12.7 24.2 18.0 Heart diseases (including 8.1 3.8 12.1 8.5 coronary heart disease) Diabetes mellitus 11.0 2.3 12.7 4.6 Paralysis/paresis (major 6.1 2.1 2.8 1.2 stroke)

Source: Thailand Health Research Institute, National Health Foundation, 1996b

Table 16 Prevalence of other diseases and health problems according to other studies.

Male (%) Female (%) Urinary incontinence Established (6-month duration) * 10.8 18.9 regular (2 or more incidences per month) 5.6 8.9 Falls in the last 6 months 14.4 21.5 Dementia 2.2 4.1 Unipolar major depression 1-2 2-3 Established osteoporosis- incidence of hip <0.1 <0.1 fracture * 56%-urge; 21%-stress; 12.3%-mixed

Source: Jitapunkul, S. and Bunnag, S., 1998; Jitapunkul, S., et al, 1999; Jitapunkul, S., 2000

23 3. Risk factors for non-communicable diseases

Over one-third of Thai older persons have a body mass index (BMI) below 20; 25-50 percent of them have low concentrations of haemoglobin in their blood (Table 17). These findings suggest that malnutrition is a big problem of older persons in Thailand, particularly among the very old ones. A certain number of the Thai older persons are still smoking and/or drinking alcohol (Table 18A). Rates of smoking and/or drinking are high among men.

Table 17 Prevalence of low and high body mass index and anaemia among Thai older persons by age and sex.

Male Female 60-64 65-69 70+ 60-64 65-69 70+ BMI < 20 35 35.2 52.8 30.4 34.1 43.7 BMI > 30 2.2 1.2 0 6.6 6.5 3.8 Anaemia# 26.7 36.6 50.2 38.3 41 45.6 # Haemoglobin below 13 gm/dl in male and 12 gm/dl in female

Source: Thailand Health research Institute, National Health Foundation (1996a).

Table 18A Cigarette smoking and alcoholic drinking among Thai older persons

Male Female Urban Rural Urban Rural Smoker 35.5 58.6 7.3 11 Ex-smoker 37.9 29.6 9.6 7.5 Non-smoker 26.6 11.8 83 81.5

Drinker 29.9 39.2 7.9 15.7 Ex-drinker 32.2 37.8 10.6 14.9 Non-drinker 37.9 23 81.3 69

Source: Thailand Health Research Institute, National Health Foundation (1996a).

19 Table 18B showed percentages of selected health problems and risk factors of population aged 50 and over. Percentage of these selected health problems and risk factors decrease with age in both sexes. However, the decline might be a result of cohort effect, i.e. those who have health problems and risk factors died earlier.

Table 18B Percentage of selected health problems and risk factors by age-group and sex.

smoking Alcohol Obesity Diabetes mellitus Hypercholesterole Hypertension Risk factors mia Age-groups Male Female Male Female Male Female Male Female Male Female Male Female

50-54 57.7 8.3 14.0 3.2 2.9 8.3 3.1 5.8 15.9 23.9 8.1 11.8

55-59 54.0 6.9 14.4 2.7 1.7 6.0 4.8 7.8 13.9 26.4 10.7 11.2

60-64 51.6 8.3 12.2 3.2 2.2 6.6 4.1 4.4 15.1 25.5 8.1 12.6

65-69 46.7 7.4 8.6 2.2 1.2 6.5 4.3 6.8 13.9 25.1 8.2 10.8

70 + 42.1 7.5 6.6 2.7 0 3.8 4.2 5.5 11.8 21.4 15.7 16.5

Source: Thailand Health Research Institute, National Health Foundation (1996a).

Prioritization of diseases and health problems is essential for allocate of limited resources. Many methods for determining priority have been used. However, these methods are usually based on data of mortality, morbidity, disability, and effectiveness of preventive and curative measures. If, however, the main objective of health and social systems is to provide health and optimal social functioning for all, to improve health and well-being and not only to prolong life but also to maintain its quality in terms of autonomy as long as possible; disability must be at the centre of interest particularly among the older population. Thus, among the aged population, diseases or health problems, which affect performance and increase dependence status deserves a higher priority. Moreover, in developing countries such as Thailand witch have inadequate data on national mortality, the use of disability data from properly designed national surveys for prioritization is an appropriate solution.

From the national study on disability among older persons, the “Population Attributable Risk Fraction” of various diseases and health problems leading to disability have been determined (Jitapunkul, S., et al, 1999). The findings are shown in Table 19. Diseases/health problems with high priority among the female older persons are those affecting mobility and perception, hypertension, diabetes mellitus and dementia. Diseases and health problems rated by existing mortality data compared with those rated by population attributable risk fraction leading to disability. Significant differences in priorities can be noticed. Many diseases, which are not terminal, are rated a high priority by using disability data.

Table 19 Prioritization based on disability data from the National Health Examination Survey 2 using “Population attributable risk fraction” as criteria

Ran All cases Male Female k 1 Hemiparesis Hemiparesis Arthralgia or arthritis of knees 2 Arthralgia or arthritis of Contracture of arms Blindness knees and/or legs 3 Accidents Accidents (unintentional Accidents (unintentional (unintentional injuries) injuries) injuries) 4 Blindness Weakness of limbs Deafness or severely hearing loss 5 Kyphosis or Eye diseases Kyphosis or kyphoscoliosis kyphoscoliosis 6 Weakness of limbs Kyphosis or Hypertension kyphoscoliosis 7 Eye diseases Blindness Eye diseases 8 Deafness or severely Deafness or severely Hemiparesis hearing loss hearing loss 9 Hypertension Hypertension Weakness of limbs 10 Contracture of arms Ischemic heart diseases Diabetes mellitus and/or legs 11 Diabetes mellitus Lung diseases other than Renal diseases asthma 12 Ischemic heart Other heart diseases Dementia diseases 13 Other heart diseases Convulsion Ischemic heart diseases 14 Dementia Loss of hands-feet-fingers and/or toes 15 Renal diseases Contracture of arms and/or legs 16 Convulsion 17 Loss of hands-feet- fingers and/or toes

Source: Jitapunkul, S., 2000

4. Health expectancy

From disabilities and dependence data, health expectancies can be calculated including disability-free life expectancy and active life expectancy (Jitapunkul, S., et al, 1999).

Life expectancy (LE), long-term disability-free life expectancy (LDFLE), total disability-free life expectancy (TDFLE) and active life expectancy (ALE) by age and sex are shown in Table 20. Although older women live longer than older men, they also spend more years with disabilities. At the age of 60-64, Thai female older persons had a life expectancy of 23.89 years, and in average could expect to spend 7.23 years with long-term disabilities and 1.52 years with short-term disabilities, leaving 18.18 years of disability-free life. Older men, on the other hand, at the age of 60-64 years could expect to have 3.6 years of LE, 1.79 years of LDFLE, and 1.22 years of TDFLE, respectively; this is obviously less than older women. Thai women also spend more years in self-care dependence than men. Findings on the ratios between health and life expectancy demonstrate that Thai men spend proportionally more time leading a healthy life than Thai women (Table 21). While the importance of the gap between sexes in DFLE seems to diminish with age; the proportional time of disability for both men and women increases with age.

Table 20 Life expectancy (LE) and disability-free life expectancy (DFLE) including long- term disability- free life expectancy (LDFLE), total disability- free life expectancy (TDFLE), and active life expectancy (ALE) by age and sex.

Male Female LE LDFLE TDFLE ALE LE LDFLE TDFLE ALE

60 – 64 20.29 16.39 15.44 18.65 23.89 18.18 16.66 21.30 65 – 69 17.14 13.53 12.77 15.51 20.20 14.77 13.55 17.59 70 – 74 14.18 10.93 10.29 12.63 16.89 11.84 10.92 14.34 75 – 79 11.87 8.96 8.38 10.37 14.60 9.84 9.08 12.03 80 + 10.90 7.89 7.27 8.96 13.60 8.71 8.20 10.76

Source: Jitapunkul, S., et al., 1999

Table 21 Ratios of health expectancy versus life expectancy by age and sex.

Male Female LDFLE/LE TDFLE/LE ALE/LE LDFLE/LE TDFLE/LE ALE/LE (%) (%) (%) (%) (%) (%)

60 – 64 80.78 76.10 91.92 76.10 69.74 89.16 65 – 69 78.94 74.50 90.49 73.12 67.08 87.08 70 – 74 77.08 72.57 89.07 70.10 64.65 84.90 75 – 79 75.48 70.60 87.36 67.40 62.19 82.40 80 + 72.38 66.70 82.20 64.04 60.29 79.12

Source: Jitapunkul, S., et al., 1999

A study on healthy life expectancy of older persons suggested that the well-being of Thai older persons has been increasing during 1986-1995 (Jitapunkul, S. and Chayovan, N., 2000) (Table 22). However, the perceived health status, which is used for calculation of healthy life expectancy, is influenced not only by physical and mental well-being but by also socio-economic well-being. Hence, improvement of healthy life expectancy might be a result of social and economical development rather than a better state of health.

Table 22 Healthy life expectancy of Thai older persons in 1986 and 1995 i) Healthy Life Expectanc y

1986 1995 Male 60-64 9.46 13.45 65-69 7.33 10.78 70-74 5.43 8.02 75-79 4.07 6.34 80+ 2.68 5.87

Female 60-64 10.38 13.61 65-69 8.18 11.2 70-74 6.23 8.96 75-79 4.43 7.49 80+ 2.89 6.95

Source: Jitapunkul, S. and Chayovan, N., 2000

5. Secondary and tertiary health care levels

Community hospitals and general hospitals are the main secondary health care organisations of Thailand. Community hospitals provide health promotive programmes, disease preventive programmes and curative services. Rehabilitative services do not receive sufficient attention. They are designed to be the first referral centres. However, as mentioned earlier, many patients go directly to the big hospitals and cause a failure of the referral network. Every province has either a general hospital or a regional hospital or both. These hospitals are designed to be the second and the third referral centres, respectively. The university and specialize hospitals, which are in Bangkok and a few cities, are the third referral centres and very specialized centres, which provide sophisticated medical services. Except for the community hospitals, other secondary and tertiary health care institutes are located in the city areas. For the private sector, there is no formal referral system within the sector. Usually clinics or private hospitals refer patients to the second or the third referral centres of the public sector. Figure 12 shows the formal health care system and referal network among these health care organizations.

Figure 12 Health care system of Thailand

Public sector

Other provinces Bangkok

Health centre/ community health centre Public health centre (primary care level) (primary care level)

University hospital / Community hospital BMA hospital / st (1 referral level) Specialize hospital

General hospital (2nd referral level) Clinics

Private hospitals Regional hospital / University hospital / specialize hospital (3rd referral level) Private sector

6. Disability and dependence

The prevalence of long-term disability (6 months or longer), total disability (long-term plus short-term) and dependence status in self-care activities are high. Thai older women have a higher prevalence rate of disabilities and dependence than men in all age groups. The rate of disabilities increases with age (Table 23).

Table 23 Prevalence (%) of long-term disability, total disability and dependence in self- care activities among Thai older persons

Male Female All 60- 70- 80+ All 60- 70- 80+ 69 79 69 79 Long-term disability* 17.4 14.6 19.4 27.6 20.2 14.9 23.4 36 Total disability** 22 19.5 22.9 33.3 27.2 22.7 30.6 39.7 Self-care 5.7 4 5.4 16.1 7.9 4.4 8.9 20.9 dependence*** * Long-term disability is defined as having limitations in any activity for 6 months or longer. ** Total disability is defined as having long-term disability or having no long-term disability but short- term disability (recent limitation of activities due to current illnesses). *** Self-care dependence is defined as in need of help or supervision in any self-care activity of daily living including feeding, grooming, transferring, toiletting, dressing and bathing. Source: Jitapunkul, S., et al., 1999

Severity of long-term disability and total disability is shown in Table 24,25. Most of very severe and severe disabilities are contributed to long-term disability (Table 24). These findings suggest the health status of Thai older women is worse than that of Thai older men.

7. Functional Capacity

A national survey conducted in 1997 also showed rather high prevalences of dependence in activities of daily living. The prevalence increased with age and was high among women compared to their male counterparts (Table 26,27).

Table 24 Prevalence (%) of long-term disability according to mobility-severity among Thai older persons Male Femal e All 60-69 70-79 80+ All 60-69 70-79 80+ Overall 17.4 14.6 19.4 27.6 20.2 14.9 23.4 36 Not home bound 13.7 12.3 15.4 16.1 14.6 12.5 17.4 17.8 Home bound 2.5 1.7 2.7 6.9 3.5 1.3 4 12.5 Chair/bed bound 0.6 0.4 0.5 2.3 0.8 0.6 0.9 1.3 Totally dependent 0.6 0.2 0.7 2.3 1.2 0.5 1.1 4.4

Source: Jitapunkul, S., et al., 1999

Table 25 Prevalence (%) of long-term disability according to mobility-severity among Thai older persons Male Female All 60-69 70-79 80+ All 60-69 70-79 80+ Overall 22 19.5 22.9 33.3 27.2 22.7 30.6 39.7 Not home bound 18 16.9 19 20.7 21.1 19.6 23.9 21.5 Home bound 2.8 1.9 2.7 8 4 1.7 4.7 12.5 Chair/bed bound 0.7 0.5 0.5 2.3 0.9 0.8 0.9 1.3 Totally dependent 0.6 0.2 0.7 2.3 1.3 0.6 1.1 4.4

Source: Jitapunkul, S., et al., 1999

Table 26 Prevalence of dependence in selected activities of daily living among Thai older persons

Prevalence (%) of 95% confidence intervals dependence □ Feeding 2.4 1.9-2.9 □ Grooming 2.5 2.0-3.0 □ Dressing 3.4 2.8-4.0 □ Bathing 3.7 3.1-4.3 □ Walking indoor 8.0 7.2-8.8 □ Walking outdoor 11.5 10.5-12.5 □ Use a flight of stairs 22.7 21.4-24.0 □ Heavy housework 37.9 36.4-39.4 □ Use public transport 45.6 44.1-47.1 □ Cooking 45.8 44.3-47.3

Source: Jitapunkul, S., et al., 1999

Table 27 Prevalence of dependence in selected activities of daily living among Thai older persons by age-group and sex

60-69 years 70-79 years 80+ years Male Female

□ Feeding 1.3 2.6 7.4 2.0 2.8 □ Grooming 0.9 3.1 8.5 2.1 2.8 □ Dressing 1.6 3.8 11.0 2.8 3.8 □ Bathing 1.7 4.3 12.1 3.1 4.1 □ Walking indoor 5.5 9.0 17.4 6.8 8.8 □ Walking outdoor 6.2 12.7 34.6 7.9 14.2 □ Use a flight of stairs 19.7 22.5 37.6 18.3 25.9 □ Heavy housework 33.7 38.8 56.5 49.2 29.5 □ Use public transport 37.9 49.9 72.2 40.0 49.8 □ Cooking 37.9 49.6 74.5 60.9 34.5

Source: Jitapunkul, S., et al., 1999

V. Health System of Thailand

1. What is health system?

According to the definition of the World Health Organisation (World Health Organization. (2000), the health system is “All activities whose primary purpose is to promote, restore or maintain health”. It can be viewed and classified into formal and informal health system. The formal health system is organised and provided by the state and various organisations including those belonging to private enterprises and non-government organisations. Generally, the government is the main responsible actor of the formal health system. The informal health system, which shares a bigger part of heath system compared to the formal one, includes all activities for health, both directly and indirectly, of individual, family and community. The components of the formal and informal health systems are concordant such as health care activities, health activity financing and health education (Figure 13). Ironically, the World Health Organisation and other international and national agencies usually refer only to the formal health system.

Figure 13 A diagram of health system

Health system

Formal Informal system system

Formal activities on Activities of person-family-community on - health care - health care - financing - expense on health - information - communication and information - education - knowledge transferring - stewardship & policy - social value, ritual and culture -research - trial and experiences

The formal health system consists of various interrelated components, including health care system (provision of health services – both personal and non personal ones), health care financing, resource generation (human resources/personal, physical resources, research and knowledge, technologies) and stewardship (formulation of a strategic policy framework, building and sustaining partnerships, ensuring accountability and consumer protection). Although the first two components, health care system and health care financing, are often regarded as the prime components of the formal health system, the stewardship is the most important of all for giving an overall system design.

The following description of health system of Thailand will concentrate on the formal health system particularly the overall system design, the formal health care system and the health care financing.

2. Overall system design and reform of the formal health system

Countries all over the world including Thailand have made attempts to establish their own health systems, with varying degrees of competence and achievement. Health and welfare are closely linked and mutually supportive of social development. Activities to reach social goals can contribute to achieving health goals as well, i.e. cross-system goals. This could be possible only through the involvement of all parts of society. It is, therefore, imperative that health system development and welfare system development are conceived together and simultaneously implemented.

Before the 1st April 2001, the health system of Thailand might be classified into the “permissive health care system” category. The permissive health care system, according to political ideology, is the least socially organized health services responsible by a government or public. The Ministry of Public Health (MoPH) is the principle health care provider of Thailand and playing the essential role in health system reform.

The first generation of health care reform, the foundation of national health care system, started soon after 1922, the year of which the MoPH was found. Expansion of hospital number was the main strategy, which aimed to have hospital in every province and then in every district. Health care system paid more attention on curative care raher than other dimensions of care including health promotion, disease prevention and rehabilitation. Although there was no available data, “out of pocket” was considered a main source of health care finance at that time. Social assistance was the key welfare on health to the poors.

In 1973, the structure of the MoPH was reformed, which provided an opportunity not only for the expansion of medical provisions into the district level, but also on the strengthening of the role of public health activities. This structural reform of the MoPH paved the way for the second health system reform of Thailand, i.e. the promotion of “primary health care”. After the Alma Ata Declaration in 1978, the primary health care concept was promptly adopted. Community health posts were developed at the sub-district levels (Tambon and village) and responsed to the primary health care concept of community participation and a multisectoral approach and acted as a first site of contact between people and the national health care system. There was a strong commitment to assuring a minimum level of all health services, food and education, along with adequate supplies of safe water and basic sanitation. These were the key elements, along with an emphasis on public health measures relative to clinical care, prevention relative to cure, essential drugs, and education of the public.

In term of health care financing, the first and second generations of health system reform were supply-oriented. Nevertheless, most Thai population continued to depend on their own resources to pay for their health. Before 1990, health care security was available only for government officers, state enterprises’ employee and employees of the Red Cross Council. The Social Security Act was enforced on September 2, 1990 to cover the enterprises with 20 or more employees. It was also extended the coverage to the enterprises with 10 or more employees on September 2, 1993. From April 2002, the coverage has been extended to enterprises with one or more employees. Some Thai people are able to afford private health insurance. However, older persons and children aged 12 years and below were covered under the social assistance welfare. The social assistance welfare for older persons started in 1993. In 2000, only 30% of the whole population was protected in health care by social or private insurance. The rest were on either social assistance welfare (50%) or living without any health protection (20%) at all.

The third generation of health system reform, which was concerned with demand, was implemented on April 1st, 2001. The reform concentrated on health financing system as trying to make “money follow the patient” and started with coverage of people in the informal sector who had been on the social assistance scheme or had no any kinds of health care coverage. The reform is making an impact of health care system. Catchment areas were set up. Development of comprehensive community care is under way. At present, the reform is being in progress, which aims to recruit the total population into one system. Because the government policy is to provide services for nearly all kinds of health problems, sustainability of the system is concerned. It seems that the policy makers are not aware about the fact that,

if services are provided to all, then not all services can be provided. A mixed model between a model based on direct contribution from employee/employer and a model that relies on tax revenue and public provision may be the most suitable health financing system. Under the third generation of health system reform, Thailand is now placed in the “cooperative health system” type.

3. Formal health care system a) Main health care providers

The Ministry of Public Health (MoPH) is the main health care provider. According to stastistic of hospitals, the MoPH shares around 62% of total hospital number and beds. Other state organisations such as university and state enterprises also provide health care particularly the secondary and tertiary health care levels. Except the Bangkok Metropolitan Administration (BMA), other local governments/authorities rarely provide health care to their responsible people. At present, private sector shares around 25 percent of total hospital number and beds (Table 28). However, at the primary care level share of private sector (clinic) is more than 50 percent (Table 29). The MoPH and the BMA are the main providers for almost all of the public health services, particularly health promotion and disease prevention activities. In 2001 the Thai Health Promotion Foundation has been set up for the promotion of health activities. It is an autonomous state institute, which obtains revenue from 2 percent of tobacco and alcoholic beverage taxation.

Table 28 Hospitals and medical establishments with beds by type of administration, 1995, 1997, 1999.

Type of 1995 1997 1999 Administration Number Bed Number Bed Number Bed

Total 1192 102986 1212 115610 1345 135303 State 868 74235 878 82535 939 99195 - Ministry of 796 59055 801 64751 855 82085 Public Health - Other 72 15180 77 17784 84 17110 Ministries State Enterprise 11 2333 11 2360 22 2741 Bangkok 8 2165 8 2208 11 2360 Metropolis and Other Municipalities Private 305 24253 315 28570 373 31007

Source: Division of Health Statistics, Ministry of Public Health, 1996, 1998, 2000

Table 29 Health institutions without beds (no admission), 1995, 1997, 1999.

1995 1997 1999

- Health centre 8808 9472 * - Community Health Centre 522 413 * - Public Health Centre (Bureau of 61 60 57 Health, Bangkok Administration Metropolitan) - Clinics (Private) 10868 11441 10819

* unavailable data Source: Division of Health Statistics, Ministry of Public Health, 1996, 1998, 2000

b) Primary health care level

The primary health services in Thailand are provided through networks of “Health centres” and “Community health centres” run by the MoPH and “Public health centres” run by the BMA. The Public health centres, which are available only in Bangkok, are generally staffed by 1-3 physicians and allied personnel. These centres provide curative, preventive and promotive but rarely on rehabilitative services. The Health centres and the Community health centres of the MoPH are usually located in rural areas of other provinces and are mainly staffed by new types of community health workers, namely “Primary health workers”. Promotive and preventive provisions are the main functions of these centres. They also provide some basic curative care to people living in their responsible areas but rarely rehabilitative care. Community hospitals, which are the first referal centres in rural areas, also provide primary health services for people living in their responsible areas. However, most health care personnel at the primary health care level are not trained for old age care. Only some have attended the short course programmes provided by the MoPH and academic organisations.

According to the functions of these primary health service organisations, the success was significantly in term of public health activities but not curative and rehabilitative care. It is not uncommon for people with medical problems often self-refers to big hospitals located in Bangkok or provinces (general hospitals /regional hospitals /specialize hospitals /university hospitals). These secondary- and tertiary level hospitals take a large share of public health budget. Resources including physicians and other health personnel are pooled in Bangkok and other urban areas, which make poor distribution of resources across the country (Table 30). Among institutions of the Office of the Permanent Secretary for Public Health, the Ministry of Public Health, beds of regional hospitals increased by 36% during 1995 and 1999, while beds of general hospitals slightly decreased and beds of community hospitals increased only 21%. The number of health centres and community health centres increased only 6% during the same period (Table 31). Nevertheless, the recent reform on health system will inevitably ease the problem of resource distribution.

Table 30 Bed for general services and population per bed in Bangkok Metropolis and other provinces, 1995, 1997, 1999.

1995 1997 1999 Beds - Whole country 118417 132405 135303 - Bangkok Metropolis 25236 27327 28454 - Other provinces 93181 105078 106849

Population per bed - Whole country 501 457 455 - Bangkok Metropolis 221 205 199 - Other provinces 576 522 523

Source: Division of Health Statistics, Ministry of Public Health, 1996, 1998, 2000

Table 31 Hospitals and medical establishments with beds in rural area, Office of the Permanent Secretary for Public Health, Ministry of Public Health, 1995, 1997, 1999. Category of 1995 1997 1999 Establishment Number Bed Number Bed Number Bed

□ Regional hospital 17 12214 25 16336 25 16688 □ General hospital 73 22227 67 20795 67 22177 □ Community 695 22055 704 25130 712 26702 hospital □ Extended OPD 4 - 2 - 1 - □ Health centre 8808 - 9472 - 9559 - □ Community/public 522 - 413 - 355 - health centre

Source: Division of Health Statistics, Ministry of Public Health, 1996, 1998, 2000

4. Organization and its financing systems

Before 1991, the main health protection was available only for government officers (the civil servant medical benefit scheme; CSMBS), employees of the state enterprises and the poors under the social assistance welfare (the low in come and public welfare schemes) (National Statistical Office, 1993). At that time 68 percent of the population was not covered by any kind of health benefit schemes. (Table 32)

In 1990, the Social Security Act was enacted and provided protection for employee who has 20 employees or more. In 1993, the government expanded the public welfare scheme to cover the older persons (age 60 and over) and children from 0-5 years old. In 1993 the Social Security Act also expanded to cover the enterprises with 10 or more employees. In 1996, the public welfare was further expanded to cover children from 6-12 years. At that time the population who bought “Health Card” (public health insurance) increased to 15 percent. This expanded health protection reduced the number of population who had no health benefit schemes from 68 percent in 1991 to 37 percent in 1996 (Table 33).

In 2001, in order to cover 22 percent of the total population who was not covered by any kind of health benefit scheme, the new government announced the universal coverage policy on health care finance to cover the total population. The universal coverage scheme provides protection for people who are not covered by CSMBS, state enterprise benefit or social security scheme. Low income and public welfare scheme and health card scheme were withdrawn. On April 1st 2002, the universal coverage scheme was implemented in all provinces including Bangkok Metropolis. On the same day, the social security scheme expanded its coverage to include all employees. Therefore, by estimation, 87% are now protected by the universal coverage scheme, 11% by CSMBS and state enterprise benefit and 12% by social security scheme.

At present, therefore, there are three main financing systems in Thailand.

1. Universal coverage scheme: It covers the population in the informal sector who do not benefit from CSMBS, state enterprise benefit or social security scheme. The revenue of the universal coverage fund comes from tax revenue and public provision. The Office of Health Insurance is responsible for management of the universal coverage fund.

2. Social security scheme: It covers all employees in the private sectors and those who are not covered by any public insurance. Employees have to pay 3 percent of their wage/salary to the fund. Both the employers (3% of the employees’ wage/salary) and the government (2 percent of the employees’ wage/salary)

also contribute to the social security fund. The social security fund is under the management of the Social Security Office. The Social Security Fund provides 6 types of benefits for insured persons in the contingencies of non work-related as follows: sickness or injuries benefits, maternity benefits, invalidity benefits, death benefits, child allowance benefits and old-age pension benefits.

3. Civil servant medical benefit scheme (CSMBS) and state enterprise benefit: The civil servant medical benefit scheme (CSMBS) and state enterprise benefit are fully paid by the government (taxation) and state enterprises. The Ministry of Finance is responsible for the CSMBS and the state enterprises are responsible for medical bills of their employees.

Table 32 Health benefit coverage (% of total population) in 1991.

Scheme Total Urban Rural □ CSMBS and state enterprise 10 23 7 benefit □ Low income and public welfare 17 2 20 □ Health card scheme 2 0 2 □ Private employee benefit 2 7 1 □ Private insurance and others 1 0 1 □ Not covered 68 68 68

Source: National Statistical Office, 1993

At present, there is an attempt to combine these schemes to be under a single management system. Single purchaser gives an advantage on bargaining power with health care providers, which makes health system more efficient. However, financial load on the government is expected in the future, which will inevitably end up with taxation reform.

Table 33 Health benefit coverage (% of total population) in 1996.

Scheme Total Urban Rural

10 18 8 CSMBS and state enterprise benefit 6 13 4 Social Security 30 19 32 Low income and public welfare 15 2 19 Health card scheme - - - Private employee benefit 2 3 2 Private insurance and others 37 45 35 Not covered Source: National Statistical Office, 1998

5. Health personnel

In 1994, there were 17,255 primary health workers. Almost all of them worked at the health centres or community health centres, which were responsible for primary health care. In average, each primary health worker was responsible for 3,403 persons. The number of medical and health personnel by type of administration is shown in Table 34 and 35. There is a need for increasing medical and health personnel particularly dentists, pharmacists, physicians and rehabilitative personnel (Table 36). There is a high disparity in the distribution of medical personnel between Bangkok Metropolis and other provinces.

Because of the shortage of rehabilitative personnel, rehabilitation is available mainly at big pubic/private hospitals located mainly in cities and urban areas. In 1994, there were 107 rehabilitative physicians, 639 physiotherapists and 206 occupational therapists all over the country. Very limited rehabilitation services are available at the primary care setting. At present, there are cognitive rehabilitation services for older persons such as memory training programme but only in a few university hospitals.

Table 34 Medical and health personnel by sector, 1994 1994 Whole country - Physician 14098 - Dentist 2984 - Pharmacist 5575 - Nurse 51058 - Technical nurse 29880 - Physiotherapists 639 - Occupational therapists 206 - Primary health worker 17255 1. Public - Physician 10729 - Dentist 2279 - Pharmacist 3690 - Nurse 42572 - Technical nurse 29128 - Physiotherapists 416 - Occupational therapists 203 - Primary health workers 17202 2. Private - Physician 3217 - Dentist 682 - Pharmacist 1815 - Nurse 6786 - Technical nurse 750 - Physiotherapists 208 - Occupational therapists 3 - Primary health worker 53 3. Non-government organisations - Physician 152 - Dentist 23 - Pharmacist 70 - Nurse 1700 - Technical nurse 2 - Physiotherapists 15 - Occupational therapists - - Primary health worker -

Source: Bureau of Health Policy and Planning, 1995.

Table 35 Medical and health personnel in public sector by type of administration, 1994

1994 Total - Physician 10729 - Dentist 2279 - Pharmacist 3690 - Nurse 42572 - Technical nurse 29128 - Physiotherapists 416 - Occupational therapists 203 - Primary health workers 17202 1. Ministry of public health - Physician 6047 - Dentist 1363 - Pharmacist 2677 - Nurse 30648 - Technical nurse 27686 - Physiotherapists 260 - Occupational therapists 170 - Primary health worker 17082 2. Other ministries - Physician 4083 - Dentist 756 - Pharmacist 709 - Nurse 8892 - Technical nurse 1047 - Physiotherapists 107 - Occupational therapists 31 - Primary health worker 9 3. State enterprises - Physician 112 - Dentist 53 - Pharmacist 204 - Nurse 372 - Technical nurse 58 - Physiotherapists 19 - Occupational therapists 2 - Primary health worker 10 4. Bangkok Metropolis and other municipalities 487 - Physician 107 - Dentist 100 - Pharmacist 2660 - Nurse 337 - Technical nurse 30 - Physiotherapists - - Occupational therapists 101 - Primary health worker

Source: Bureau of Health Policy and Planning, 1995.

Table 36 Population per medical and health personnel of each category in Bangkok Metropolis and other province, 1994

1994 Population per physician - Whole country 4165 - Bangkok Metropolis 940 - Other provinces 6510 Population per dentist - Whole country 19677 - Bangkok Metropolis 4561 - Other provinces 30174 Population per pharmacist - Whole country 10532 - Bangkok Metropolis 2320 - Other provinces 16763 Population per nurse - Whole country 1150 - Bangkok Metropolis 356 - Other provinces 1501 Population per technical nurse - Whole country 1965 - Bangkok Metropolis 2196 - Other provinces 1944 Population per physiotherapists - Whole country 91887 - Bangkok Metropolis 21456 - Other provinces 140204 Population per occupational therapists - Whole country 285028 - Bangkok Metropolis 103305 - Other provinces 349587 Population per primary health worker - Whole country 3403 - Bangkok Metropolis 58721 - Other provinces 3097

Source: Bureau of Health Policy and Planning, 1995.

6. Development of LTC Policy and Provisions

Until recently, the meaning of long-term care (LTC) has not been well understood in Thailand. Generally, the public perceives LTC as long-term institutional care especially nursing home and residential home, but not the shelter service nor the home/community care. In fact almost all the elderly who need LTC received informal care provided by their families and relatives. The informal care provided by family is well recognized as the main strategy of the national policy for 15 years (National Committee on Ageing of Thailand, 1986). Although the first National Long-term Plan mainly emphasized the informal care of the family, it ignored provisions needed to support the family. This was the reason why while the crucial role of informal care of the family has been recognized, state organizations paid little attention on developing home/community services to assist the older persons and their caregivers. Thus, the availability of community-based services to support caring-capacity of family is very limited at present.

The available data on nursing home and residential home, at present, shows that less than 4,000 older persons are in institutionalized for LTC (Jitapunkul, S., 2000). Hence, most of the elderly who need LTC mainly received informal care in the communities. What is certain is that the proportion of those who are in need of utilizing formal care services will increase. However, what real matter on policy direction is how we are going to support informal care system in order to keep the number of older persons who need to be placed in institutions as low as possible. It also has to assure that families and relatives can provide adequate care to elderly people.

The Department of Social Welfare, Ministry of Labour and Social Welfare is a major state organisation responsible to social LTC services. Nearly all of state-owned social services in Thailand are run by this organization. In term of formal LTC provided by the state organisations, social services are advanced compared with health services. However, like in many countries, the formal LTC services in Thailand have begun with institutional services. The first institutional service for older person was established in 1956 and called “Home for Older Persons” (Department of Social Welfare, 2001). It provides service for the low-income elderly who cannot stay with their families or have no relative to stay with. The elderly who are eligible for staying in “Home for Older Persons” have to be independent in personal care and have no need for nursing care. However, when these elderly people get older, they turned frail and need personal or nursing care. Unfortunately, a public nursing home for older persons is not yet available in Thailand. Inevitably, the elderly living in residential homes who need special care have to be taken cared of by staff of the residential homes. Therefore, “Home for Older Persons” actually provides services, which range from shelter, residential home and nursing home. Inadequate resource for nursing care is the main problem of these residential homes. Recently, all over Thailand there are 20 residential homes (Home for Older Persons) under the supervision of the Department of Social Welfare.

Non-profit and for-profit private sectors have been the major contributors for nursing home services during the last decade (Jitapunkul, S., 2000). The major contributors are private hospitals and religion-linked non-government organisations. Since there is no specific ministerial regulation for nursing home, the nursing home can be registered under the ministerial regulation of acute hospital; and private hospitals with facilities to treat acute illnesses can immediately turn some beds for long-stay care service. Thus, data about the total number of nursing homes and their capacity is not available from registration. Quality accreditation of nursing home services is currently crucial.

For a decade, the concept of home/community care in the sense of LTC has been growing. Many models of community services in health and social care were studied (Jitapunkul, S., et al, 1996; Wongsith, M., et al, 1996). Although the Department of Social Welfare has no concrete idea or policy on LTC, it developed a Social Service Centre for Older Persons since 1979. In term of LCT, these centres provide day care and basic rehabilitative services. At present, there are 18 Social Service Centre for Older Persons (Department of Social Welfare, 2001). Most of these centres, attached to residential homes, are able to provide services to

limited number of older persons living within the distance of 5-10 kilometres. Other well established home/community services for LTC are not available.

Nevertheless, in 2001 the second National Plan for Older Persons (2001-2019) will be implemented (Drafting Committee of the Second National Plan for Older Persons, 2001). It includes strategies on LTC provisions which cover a wide range of activities from promoting and supporting informal care within the family, providing health and social services both in home/community and institutional, and developing shelter/accommodation services and environmental adaptation to fit in with activities of the elderly. Moreover, under the universal coverage scheme in health care finance, which is currently implemented, community health services must be provided by primary care centres. This will strengthen formal LTC for elderly people in the future. However, over-reliance on family care and the current economic problems may impede the progression of LTC development, particularly the home/community services and the state-owned nursing homes.