Older Persons in Southeast Asia: An Emerging Asset

4. National Long-Term-Care Severe Disability Insurance in Singapore

National Long-Term-Care Severe Disability Insurance in Singapore 97 4 NATIONAL LONG-TERM-CARE SEVERE DISABILITY INSURANCE IN SINGAPORE Gerald Choon-Huat Koh To appreciate the issues involved in a long-term-care disability insurance (LTCDI) scheme, one must first understand the nature of disability in older persons: its epidemiology, the natural progression, and prevention. These issues will be discussed in the first part of this chapter, followed up by a brief overview of LTCDI schemes around the world. However, for the second part, Singapore will be used to contextualize the discussion on the non-financial aspects of such schemes (that is, social, rehabilitative, costs of care, life expectancy, and public policy considerations). Epidemiology of Disability in Older Persons Disability is often associated with older persons, especially the old-old (age 75 years and above). Frailty and disability among older persons accounts for the burden of care often feared by governments of countries with an aged population, defined by the Population Division of the 98 Gerald Choon-Huat Koh Department of Economic and Social Affairs, United Nations, as when 10 per cent or more of its population is aged 60 years and above (United Nations 2002). In the United Kingdom where 20 per cent of its population is aged 60 years and above (UK National Statistics Online 2001), a study by Melzer et al. (1999) found that 15.7 per cent of those aged 65 years and above was disabled and that there were three times more disabled persons aged 75 years and above (old-old) than those aged 64 to 74 years (youngold ). In Singapore, where only 8.5 per cent of its population was aged 65 years and above in 2006 (Ministry of Health 2006), a study by Yadav in 1997 found that 20.5 per cent of Singaporeans aged 60–64 years was handicapped whereas 64.6 per cent of those aged above 85 years was handicapped (Yadav 2001). He also found that both the incidence and severity of handicap increased with greater age. Yadav had defined a handicap as “a limitation to perform one or more tasks associated with daily living (namely self-care, mobility, and verbal communication) due to a disability”, which was based on the World Health Organization’s (WHO) definitions used in the International Classification of Impairments, Disabilities, and Handicaps (ICIDH). These findings are in contrast to the national survey of communityliving non-institutionalized senior citizens aged 55 years and above, done two years earlier in 1995, which found that the prevalence of disability in activities of daily living (ADL) was low among the study population: only 1.9 per cent of those studied needed supervision or assistance in mobility, and 2.0 per cent was dependent for toileting, 1.1 per cent for feeding, 2.7 per cent for bathing and grooming, and 1.1 per cent was incontinent (National Advisory Council on Family and Aged 1995). However, when analysing those aged 75 years and above, 6.0 per cent needed supervision or assistance in mobility, and 6.0 per cent was dependent for toileting, 3.7 per cent for feeding, 8.1 per cent for bathing and grooming, and 3.7 per cent was incontinent. These percentages would have been higher if older persons living in sheltered or nursing homes were included in the study. The significant difference in prevalence rates of disability between Yadav’s study and the one by the National Advisory Council on Family and Aged is probably due to the different definitions of disability used. This illustrates the need to specify the defining criteria for disability when comparing national prevalence rates between countries. National Long-Term-Care Severe Disability Insurance in Singapore 99 Unrelenting Decline or Dynamic Recovery? The disability status of an older person is also not static. Hardy and Gill (2004) found that 81.0 per cent of newly disabled community-dwelling older persons aged 70 years and above regained independence in four key ADLs (bathing, dressing, walking, and transferring) within twenty-one months of their initial disability episode, and a majority remained independent for at least another six months. Moreover, older persons may experience several episodes of disability in their lifetime with recovery after each episode. Hardy and Gill reported in another paper that they had assessed ADL function in the abovementioned cohort on a monthly basis (Gill, Hardy and Williams 2002). They defined the prevalence rate of disability as the...