Greying Asia

January 22, 2015 | Global Health and Travel

A wealthier, technology-savvy Asia is throwing its weight behind finding ways to take care of its rapidly ageing population. GHT looks at public and private sector preparations for Asia’s silver tsunami

By Corey Cooper

“Silver tsunami” is a term widely used in the past decade to describe the rapid increase of people over the age of 60 as compared to the overall population in Western countries, but only more recently has the moniker been heard more and more often throughout Asia.

Perceived in the majority of the last century as a developing region filled with young workers, Asia’s furious development and urbanisation in the past 30 years has led to falling birth rates as people compete for space and financial resources in increasingly crowded megacities. Meanwhile, the rapid advancement of medical care across the Asia-Pacific region has caused life expectancies to soar. As the cost of housing and medical care in countries from Japan to China to Singapore continues to rise, both governments and the younger generations find themselves increasingly burdened.

Projections from the United Nations Population Division show the proportion of seniors aged 65 and older will surpass the proportion of children (aged 0-15) in South Korea, Thailand, and China by 2030. Vietnam and Malaysia, meanwhile, will cross this threshold by 2040 and 2050 respectively.

According to a report in the Asia Nikkei Review, Japan’s old-age dependency ratio, or ratio of elderly people as a share of those who are working age, more than doubled since 1995 and is predicted to rise to 72 percent by 2050. China’s proportion of workers per older citizen is predicted to drop from 8 to 2.6 within the same time period, while South Korea’s dependency ratio will rise fivefold to about 65 percent.

“By the time Western countries began to age rapidly, they already had sophisticated and relatively generous social and income support systems. It is this combination of rapid ageing, relatively low levels of income per capita and limited welfare development that has given rise to the fear that Asia may get old before it gets rich,” the report said.

The region’s rising affluence and urbanisation has brought with it sweeping changes in lifestyle, which has in turn led to an alarming spike in chronic illnesses across Asia.

“We see a distinct difference between the developed and the developing countries in Asia. The more developed countries have begun to adopt a more western lifestyle and a more western diet. And it’s the diet and the sedentary behaviour that is really driving the whole issue of health among the young and old,” says Kim Walker, CEO of Silver Group, a Singapore-based business consultancy aimed at the 50+ market.

From 1997-2005, incidence of chronic diseases such as heart disease, diabetes, and cancer quadrupled in Southeast Asia, according to a report published in the UK medical journal The Lancet. Last year, China became the world’s second fattest country after the US, with 46 million Chinese adults obese and 300 million overweight according to a Washington University Institute for Health Metrics and Evaluation study.

These trends have unequivocally translated into a booming demand for healthcare services, prompting both the public and private sectors in countries across the region to massively expand healthcare and healthcare technology infrastructure.

“The increased demand for healthcare and healthcare/IT professionals is fueled by the region’s rapidly ageing population, the increase in chronic and disabling diseases and the general public’s high expectations in terms of improved quality, standards and delivery of healthcare services,” says Steven Yeo, executive vice president of DHR International, an executive search firm.

Singapore, for example, announced plans to double healthcare spending from S$4 billion (US$3.2 billion) to S$8 billion (US$6.4 billion) by 2017, as well as increase its hospital bed capacity in acute care hospitals by 30 percent and in community hospitals by 100 percent by 2020, Yeo wrote in a 2014 white paper.

Meanwhile, the long-term sustainability of Hong Kong’s public healthcare system is in question. “Overcrowding of the city’s medical facilities is extremely likely and the government will need to make plans to alleviate it,” Yeo says in his report.

Furthermore, medical inflation is no longer confined to Western countries. A 2012 Global Medical Trends report from Towers Watson showed that medical costs in Asia as a whole surged more than 10 percent in 2011, pointing to double-digit medical inflation rates in China, Indonesia, and India.

Rising healthcare costs throughout Asia, driven by rising standards and an increased demand for specialists and higher-quality care, will drive healthcare technology innovation and raise demand for healthcare IT professionals as well as qualified and innovative hospital/healthcare management professionals, Yeo says.

Increased healthcare burden leads to home-care solutions for seniors

In countries like Singapore, one way for the government to reduce taxpayer burden and reduce the strain on hospital and doctors has been to encourage home-based care for seniors.

Daljit Singh, president of India-based Fortis Healthcare, says homecare is going to become a growing trend for treating elderly patients suffering from chronic diseases, due to the growing cost of a hospital or doctor visit and the necessity for the younger generation to remain at work as opposed to taking care of their parents or relatives. “Home care will pick up, over a period of time,” he says, “and the reason is that, number one, the expense associated with patients coming to hospitals; and number two, the sheer need to have an attendant to get the older population to the hospital.”

In Asia as a whole, there is a big drive towards “ageing-in-place,” where seniors can obtain the healthcare services they need without having to visit the hospital, says Felix Lee, a healthcare portfolio manager for the Hinrich Foundation in Hong Kong. This model, Lee explains, brings the facilities in care and support that you need into the patient’s home as opposed to going to a healthcare facility.

“Singapore has done a lot in home-based services,” Lee says. “The aim is to keep patients out of hospital, so you don’t end up with bed-blockers who would over-prolong their stay.”

In September, Singapore’s Changi General Hospital rolled out a telehealth program to monitor 160 heart failure patients, ZDNet reported. Participants in the pilot received a personal health tablet, weighing machine and blood pressure monitor. Nurses from Eastern Healthcare Alliance, one of the Singapore government’s established regional health systems (RHS) to coordinate local healthcare efforts, will monitor patients remotely and can intervene if they detect an abnormality, the report said.

Eastern Healthcare Alliance is also participating in another telehealth pilot to monitor diabetes patients, says Dr. Chong Yoke Sin, CEO of Integrated Health Information Systems Pte Ltd (IHiS), a government- owned company responsible for implementing healthcare IT solutions across hospitals and clinics in Singapore. In the pilot, patients monitor their own blood pressure, blood glucose levels, blood oxygen level, and heart rates. The data is fed back to a central system that prompts a “tele-carer” for action, should readings be adverse.

“We are a healthcare system which is transforming from a episodic care focus driven by the acute hospitals in the past to more holistic regional health systems, comprising primary care from polyclinics and GPs to family medical centers, community hospitals, nursing homes and facilities that work together to provide continuity of care for the patient”, she says.

“Going forward, our healthcare systems need to be more proactive by way of ensuring better condition control for chronic patients, preventing unnecessary deterioration of their conditions resulting in re-admissions, and providing for better monitoring for preventive measures.”

IHiS is also implementing technology solutions to cut healthcare costs, ease pressure on staff and mitigate wait times at hospitals.

One example for increasing hospital efficiency, Dr. Chong says, is using robots to fill prescriptions in pharmacies and to analyse blood samples in laboratories. In the four hospitals in Singapore where it is being implemented, the automated pharmacy system has reduced average waiting times from 30 minutes to seven. Meanwhile, faster laboratory testing and automatic integration with patient’s electronic medical record (EMR) means that doctors can often get same-day access to test results, she says.

“The biggest factor in medical inflation is the rising cost of scarce and specialised manpower. IT systems serve to curb this rise by providing the ability to scale cost-effectively,” Dr. Chong says.

Singapore’s Ministry of Health has also funded its nursing home sector with a system that will be linked to its National Electronic Health Record (NEHR) system, which plans to integrate patient and provider data across the country’s public healthcare institutions, community hospitals, and eventually private providers into one network. According to Dr. Chong, with the new system, nursing homes will be able to use data from patients’ healthcare providers in order to more effectively administer medication and patient care.

Asia looks to elderly care solutions from Japan, the world’s ‘oldest’ country

Japan, whose over-65 population was the first in Asia to exceed its population of children, is now, out of sheer necessity, one of the most advanced countries in the world for elderly care. One example is in how the country is dealing with a surging population who suffer from dementia. Under a state-sponsored initiative, by 2013 over 4.75 million elderly caretakers had been trained in dementia care, according to an August 2014 article in Japan Times. Thousands of employees in banks, supermarkets, and other businesses have also been trained to deal with senior citizens who may have dementia, the article said.

Well-known for its technology, Japan has also been leading the way in developing robots that can make up for staffing shortfalls to care for the elderly.

“One of the areas that Japan is leading is in the use of robotics to help with the elderly population, not just taking care of elderly patients, but also easing the workload from those that have to support these elderly patients,” says Rhenu Bhuller, a healthcare industry consultant for Frost and Sullivan.

In October, for instance, Cyberdyne Inc., announced the release of a Hybrid-Assisted Limb (HAL) robot that gives nursing home employees extra power when lifting heavy objects. “Employee turnover is a serious problem for the nursing care industry,” Akira Hosokawa, a business planner for Cyberdyne, was quoted as saying in a Japan Times article covering the release.

In addition, Bhuller says, Japan remains one of the leading innovators in telemedicine. “Telehomecare implementation [in Japan] is one of the highest,” she says. Although telecare has been around for a while, Bhuller says that government policies throughout Asia, as well as improvements in technology, have now made it easier for healthcare systems across the region to implement.

“Before, the video technology wasn’t very good, so how would [a doctor] know if they’re seeing a skin lesion, if it can’t be clearly seen?” Bhuller says. “I think the reason why it’s starting to gain popularity is we’ve got better technology terms of quality of the voice, quality of the image, and the ability of the physician who is actually trained in telemedicine to be able to make a diagnosis through that.”

Community-based help for seniors in Singapore

While Singapore’s government continues to invest in healthcare IT infrastructure and improve home care, it is also investing in health education for seniors and trying to raise accountability among providers. Back in March, a group of doctors, insurance providers, industry leaders, and concerned patients launched The Good Life, a non-profit cooperative supported in part by government funding that helps answer Singaporeans’ questions about health and healthcare make more educated choices. Co-founder and geriatrician Dr. Carol Tan says the group conducts healthcare literacy programmes aimed at not only seniors, but also younger middle-class Singaporeans who also may be at high risk for developing chronic illnesses.

The Good Life members sign up for a yearlong personalised programme that begins with a visit to a specialist, who assesses a member’s health risks and thereafter works with nurses to provide personalised health coaching. Meanwhile, the organisation’s team reaches out to healthcare providers in the city and provides advice to patients on provider quality and affordability.

“There is a large out of pocket expense among middle-class Singaporeans,” Dr. Tan says. “There is good, comprehensive coverage, even subsidies for poorer patients, but the middle class are often faced with considerable costs. Meanwhile, private insurance often only offers coverage for inpatient procedures and does not cover preventative care for chronic conditions.”

The Good Life also organises seminars around the city to help seniors be more aware of the treatment options for chronic conditions related to ageing, such as osteoarthritis, and to be aware of excessive medical testing ordered by doctors when it may be unnecessary. Back in March at a doctors’ conference in Iceland, Dr. Tan gave one example as recognising that magnetic resonance imaging (MRI) testing for osteoarthritis in knees may not always be necessary, when a simple x-ray could be used for diagnosis. The cost savings to the patient, she says, can be in the thousands of dollars. “Healthcare costs, even for an ageing population or a chronic disease, isn’t an automatic thing,” Dr. Tan told The Establishment Post.

In response to how Singapore’s best practices could be adopted to suit the needs of other countries in the region, Dr. Tan emphasises that Singapore’s size often makes it easier to implement effective policies.

“Singapore is able to develop innovative solutions in regards to elderly care and healthcare because it is small, and it is easy to get all of the decision makers in one room, not to mention the fact that Singapore has a stable, effective government with funding available,” she says. “With regards to other countries, it is important to not adopt a one-size-fits-all [policy] but rather governments should seek their own solutions based on the resources that they have and their own populations’ health beliefs and needs.”

Trends shift towards “Active ageing” in Asia, as the next generation of seniors emerges

Increased wealth, access to a wide range of consumer products, and international influences play heavily in the lifestyle, healthcare and senior care options that Asia’s next generation of seniors are making.

“We’re witnessing a dramatic difference in behaviour and attitudes of the baby boomer generation (50 to 68 year olds), relative to their older counterparts,” Kim Walker of Silver Group says.

“Among other things, boomers are often tech savvy: they increasingly shop online, blog, and own smart phones. Also, they are prime targets for wearable health technology that can not only track their fitness but monitor blood pressure, heart rate, glucose levels, and other vitals.” Some forward-thinking businesses, Walker says, have responded in making these consumer products more ‘age-friendly’.

“Certain products which were once the domain of pharmacies and opticians, like health monitors and reading glasses, can now be found at duty free shops and bookstores in airports,” Walker says. “It’s an example of how products that used to be in the backroom now may be on the way to mainstream retail.”

An example of increased consumer choice among Asia’s seniors is the advent of Western-style aged care facilities. In 2011, Choe Lam Tan, a Malaysian-Chinese entrepreneur who immigrated to Australia in the 1980s, opened the Jeta Care Aged Care Centre, which offers assisted living and nursing home options for seniors in Johor, the Malaysian city bordering Singapore to the north.

Tan, originally an engineer, got into the senior living business after his father suffered a stroke, forcing Tan to nurse him for a year until his death. “I was happy to do my duty as a good son, according to Asian philosophy,” Tan explains, “but at the same time I wondered, do we really have to forego our careers to be good children?”

In Australia, Tan noticed a gap in the market for senior care among Brisbane’s growing Asian population. In 2002, he founded Jeta Gardens, the first aged care centre in Brisbane to have care that was culturally geared toward Asian residents, with Asian language-speaking staff, Asian meal options, and other amenities.
The facility hires qualified Australian caretakers of diverse cultural background and trains them how to give culturally-appropriate care to Asian seniors.

Three years ago, Tan, who is now 61, took the successful concept from Jeta Gardens and brought it to the Malaysian market. In Johor, he took a 40-year old dilapidated building and renovated it into an aged care facility built to Australian accessibility standards.

“I was thinking by the time I paid off my investors [from the Australia facility], I would be almost 70 years old, Tan says. “[Before that], I wanted to do something for Asians in Asia, whom, I believe, are looking for something.”

The development of Jeta Care in Johor did not come without challenges. At the time Jeta Care was set to open, Malaysia did not have clear standards in place for nursing homes. “They use hospital [standards] to guide nursing homes in Malaysia, which means, for example, you have to have one nurse for every four patients,” Tan says.

The regulation, he says, was not financially viable for a nursing home. “For example, you might be able to put about 45 beds, instead of 80. The income is so low, what can I do?” Eventually, Tan says he was able to reach a compromise with authorities at Malaysia’s Ministry of Health to be able to launch the facility.

Now that Tan’s first Asia facility is up and running, Tan says he plans to expand his model across the region. He has set up a consulting company that is exploring ventures elsewhere in Malaysia as well as Indonesia and China. His goal is to build aged care communities that target middle class consumers in those markets.

In adapting his Australia model for Asia, Tan says a key strategy is to provide a high level of care while keeping resident costs relatively low. “In Australia, for every person who lives with us, government funding covers about 75 percent of the cost,” he says. “But in Malaysia, there’s no money, not a dollar. For most residents, it’s the sons and daughters who are pulling the money.”

“The way we design, build, and operate, it has to be cost-effective at the end of the day for the target market,” he says.

Additionally, to appeal to Asian consumers, Tan says, aged care providers have to change cultural attitudes to eliminate the taboos that surround nursing homes.

“We have restaurant-style meals, a liquor license (if applicable), yoga classes, and hairdressers,” Tan says. “When you start to project the image [of hospitality], it can change people’s perception.”