Valuing Caregivers: Financial and Psychosocial Support

Parliamentary Speech, 13 February 2019

Introduction

Mr Speaker, I stand in support of both motions but will focus on caregiving, in particular. I would also like to declare my interest as the Immediate Past President and current member of Society for WINGS — an IPC that empowers women to age well.

It’s been said that there are only four kinds of people in the world: those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need a caregiver. Indeed, I was recently at a corporate event and met a most unlikely caregiver — Siti, a young professional in her twenties who became emotional when sharing her caregiving challenges with her three unmarried aunts in their 60s — one suffering from diabetes and depression, another from ovarian cancer and the third from kidney failure. Caregiving affects all of us yet this role is, ironically, one of the most undervalued in our society.

Challenges: Informal Caregiving

The psychosocial wellbeing of caregivers must be top of mind for our caregiving policies. Mr. Speaker, we have not done a comprehensive national study on caregiver health (which I highly recommend we do) but segmented studies revealed that our caregiver population is certainly facing increasing risk with their mental health. 1 in 5 elderly caregivers suffer from depression according to a study by Duke-NUS. A study by IMH in 2017 noted a pooled prevalence rate of 40.2% for depressive symptoms among caregivers of stroke survivors. Yet another study found that caregivers of cancer patients are at greater risk of developing depression than the general population.

Wendy* is one such caregiver who was a respondent to a study by Aware on the financial cost of caregiving. She is 51 years old, single, and caregiver to her mother who has dementia. She hired a foreign domestic worker to help yet is the “emotional anchor” for her mother. Caregiving has taken a toll on Wendy emotionally, physically and financially — she’s had panic attacks and experiences high levels of anxiety. Then there’s Ivan*, in his 50s, who’s struggling to cope with the severe care needs of his 85-year-old mother with dementia. Unable to deal with his mother’s mounting behaviour issues last year, he had a series of anxiety attacks and ended up in hospital himself.

We all know that with smaller families, there are fewer family caregivers. Over the past few decades however, Singaporeans have been fortunate to have an army of efficient, dedicated and relatively affordable foreign domestic workers. They form an important part of our informal care workforce. Yet the same Duke-NUS study found that, I quote, “families who hire domestic helpers are also not necessarily able to relieve this mental stress. In fact, some feel that having domestic help increases this stress. About half of the respondents polled hire domestic helpers and of these, about 55% of the domestic helpers do not have experience caring for the elderly or have areceived training in doing so.” Unquote

Mr. Speaker, the economic impact of caregiving on the caregiver, and on Singapore, is obvious. The Labour Force Survey 2018 shows that 75,800 women and 13,000 men or 88,800 in total cite caregiving to families/relatives as the main reason for being out of the labour force. This number does not include caregivers who have had to scale back on work commitments in other ways, for example, by moving to part-time or ad-hoc work.

Wendy, whom I mentioned earlier, scaled down on her working hours and now earns less than $2,000 a month, about one-fifth of what she used to earn. Ivan quit his job to look after his mother, after she repeatedly forgot to turn off the gas at home. Another caregiver, June*, stopped working completely when her husband was diagnosed with Parkinson’s disease. She is 60 years old and sole caregiver to her husband as they have no children. Their only monthly household income of $1,000 comes from renting out a room in their HDB flat.

Challenges: Formal Care Services

Did these caregivers lessen their caregiving burden with formal care services? Wendy tried daycare but her mother reacted violently against it. She’s now considering the nursing home option but the guilt is immense and she’s been putting it off despite her own deteriorating emotional and physical health. Then there’s the cost of nursing home fee that she will struggle to afford with her drastically reduced income. June’s husband goes to daycare but she holds much guilt because he does not like it there yet she needs that time to go to the hospital gym to exercise her knee. June spends around $300–400 on daycare (after government subsidies) plus $100 on transport to her husband’s daycare a month against her $1000 rental income.

Mr. Speaker, suffice to say, most of us would like to be cared for in the comfort of our own homes. However, in consideration of caregiver health, the increasingly complex care needs of our seniors and shrinking families, formal home-based and community care services is a critical and practical necessity.

While the Government has been busy increasing capacity in recent years, more needs to be done to improve affordability and quality of these services. The ElderShield Review Committee report estimated that, including transport, consumables and formal homecare services, it could cost caregivers as much as $3,100 per month to look after a severely disabled senior at home, well above the $2,400 median monthly fee for looking after severely-disabled residents in VWO-run nursing homes.

The ‘Care Where You Are’ report by Lien Foundation notes that co-payment of care fees remains a key concern for families, although means-tested Government subsidies for long term care have been increased to cover up to two-thirds of Singaporean households since 2012. Even for those who are not severely disabled, daycare and homecare services can cost $900-$2,200 per month before subsidies, excluding transportation costs. Families eligible for subsidies must co-pay between 20% and 70%. Those with a per capita monthly household income of more than $2,600 do not qualify for subsidies at all. Costs may therefore deter even middle-income families from using formal long-term care services, especially since many find it cheaper to hire a foreign domestic worker instead.

However, foreign domestic workers — and even family caregivers themselves — may not be trained enough to handle complex care needs and, sometimes, could end up compromising the wellbeing and health of vulnerable seniors, leading to unnecessary hospital stays.

Homecare is expensive too and appears underfunded with charity dollars, even after accounting for government subsidies. While the CareShield Life insurance scheme will undoubtedly be useful, given the strict eligibility criteria and that the scheme is optional for older cohorts; how many will join remains to be seen.

Even as we work out ways to improve affordability, emphasis must be made on quality and outcomes. In recent years, many sophisticated new care models — such as the Integrated Home and Daycare Programme — have sprung up. Anecdotal evidence shows that these schemes are good at enabling seniors to be cared for well in the community. Yet in order to convince skeptical caregivers of the effectiveness of these programmes, outcomes should be tracked and made public.

Recommendations:

Mr Speaker, before suggesting some ways forward made in consultation with caregivers and the community, I would like to highlight that Singapore is ageing from a position of relative strength. We have a largely healthy population and there has been considerable focus in recent years on harnessing the blessings of longevity. Yet we can, and should, do more.

While the importance of enabling seniors to age at home is widely acknowledged, the Lien report also noted that Government spending on home-based and centre-based care — at $240 million in 2016 — accounted for only 2.5 percent of the overall $9.8 billion healthcare budget for the year. The spend in the last 2 years are not yet available. The Government should consider recalibrating the healthcare budget to enable seniors to age and be cared for at home. More subsidies can be targeted at seniors who are not severely disabled — and therefore do not qualify for ElderShield or CareShield Life — but likely to benefit from professional rehabilitative care.

To better support caregivers’ psychosocial wellbeing needs, the Government can consider giving seniors flexible care packages, for families to use as they wish, whether for daycare, home-care, respite care services, for transport fees and consumables or to pay a family member or friend for elder-sitting. Respite care should be enhanced to an integrated approach to include counselling and self care training services as well.

Another way forward is to accord the long overdue recognition and appreciation to family caregivers with an allowance or payment, in both cash and CPF credits. This also ensures some level of financial security for them. The payment should vary by the number of Activities of Daily Living the care recipient requires assistance with.

To enable caregivers to continue working while providing care, the Government should consider converting paid childcare leave into a longer quantum of family care leave of at least 10 days. And allow it to be used for the care of any family members, including older relatives. In addition, employers should be a partner in this effort to provide flexible work arrangements on request by employees as well as consistently value the caregivers within their organisations through awareness and appreciation efforts.

Above all, Mr. Speaker, we should collectively embrace caregiving — not as the burden of a few, but a responsibility of all. There is an urgent need for more informed collective conversations among Singaporeans about what kind of care system we want for our grandparents, parents — and eventually ourselves — and how much we are willing to pay for it, whether through premiums and/or taxes, for those who can afford it and to support those who cannot. Because, Mr Speaker, to care for those who once cared for us is one of life’s greatest honours.

Thank you.

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Anthea Ong is a Nominated Member of Parliament. (A Nominated Member of Parliament (NMP) is a Member of the Parliament of Singapore who is appointed by the President. They are not affiliated to any political party and do not represent any constituency. There are currently nine NMPs in Parliament.)

The multi-sector perspective that comes from her ground immersion of 12 years in different capacities helps her translate single-sector issues and ideas across boundaries without alienating any particular community/group. As an entrepreneur and with many years in business leadership, it is innate in her to discuss social issues with the intent of finding solutions, or at least of exploring possibilities.

She champions mental health, diversity and inclusion, environment — and volunteerism in Parliament.