Eldercare
September 5, 2019
What are the issues?
- Caregiving for older persons disproportionately affects women, due to persisting unequal gender norms that frame care as female work. As more of Singapore’s population grow older with fewer younger persons to support their care needs, the burden of caring for older persons falls more on women.
- An analysis of the Labour Force Survey from 2016 to 2018 shows a 9% marked increase—from 263,000 to 286,500—in the number of women who cited family responsibilities as the main reason for being out of the labour force. These women make up more than 90% of the people who are outside the labour force because of family responsibilities.
- Limitations in the caregiving that foreign domestic workers can perform, and the underutilisation of formal care services, create pressures on female family caregivers, who often find themselves still shouldering a heavy burden to enable ageing in place.
- AWARE’s 2019 research found that caregiving has impacted the retirement adequacy of family caregivers in the following ways:
i) Increased time spent on caregiving results in several changes in caregivers’ employment status, ranging from a reduction of working hours to complete withdrawal from the labour force;
ii) These changes in employment status are accompanied by a loss in personal income and CPF contributions;
iii) Caregivers’ monthly expenditure increases due to care-related costs that have to be paid for out-of-pocket.
What changes do we want to see?
- A more equal distribution of care: regulation and licensing of private providers of eldercare services, including home-based care services; expanded Cluster Support services; a national database/registry of family caregivers.
- Better balance of work and care for working caregivers: the statutory right to request flexible work arrangements; paid eldercare leave and family care leave for sandwiched caregivers; anti-discrimination legislation to deal with age-related and other forms of workplace discrimination.
- Financial recognition for caregiving labour: a Caregiver Support Grant matching prevailing CPF contribution rates for employers and the salaries of paid care workers.
- Reduced out-of-pocket expenditure on care-related expenses: modification of CareShield Life to reduce the three Activities of Daily Living (ADLs) minimum requirement; take into account the effects of dementia; make premiums gender-neutral, and increase payout level.
What are we doing about it?
- Published “Make Care Count”, our 2019 research report comprising 22 qualitative interviews with family caregivers and 22 sharings with academics, healthcare professionals, caregiver support networks and home and community-based care service providers.
- Organising “Make Care Count… in the National Budget” on 5 October 2019. The free public event featured a panel discussion on our aforementioned research findings, and invited participants to suggest care-related recommendations for AWARE to include in our January 2020 submission to the National Budget.
Read about our research on migrant domestic workers providing eldercare here.
#MakeCareCount: our public campaign
Singapore’s ageing population has placed the heavy burden of caregiving upon the nation’s younger generations—a burden that tends to fall disproportionately on women. The psychological effects of caregiving, such as stress, burnout and depression, are well-documented. But what about caregiving’s financial impact, and the way it affects an individual’s retirement adequacy?
Here are the stories of four Singaporeans—three women and one man—who are primary caregivers for an older person. These profiles fall into three distinct categories, based on the level of financial burden (income, work situation, expenses) that caregiving has brought them.
In the first category is Corey, whose grandmother is financially independent, and for whom caregiving has had no impact (as yet) on his employment and earnings.
In the second category is Grace, who is financially supporting her father with contributions from her siblings and cousins. With this shared burden, Grace’s work and earnings have seen little impact from caregiving.
In the last category are Mei Ling and Kris, who are footing their mothers’ caregiving expenses almost entirely on their own. With little to no support from other family members, these women have had their employment and/or earnings substantially impacted by caregiving.
We asked these four individuals to share their experiences of the cost of caregiving, focusing on care expenditure and employment status, and reflect on their abilities to retire comfortably. The figures included here are self-reported and in some cases, rounded off.
Mei Ling
Mei Ling looks after her 86-year-old mum, who moved in with her from Johor Bahru after having a stroke 17 years ago.
“We had to manage her going from living in her own house with a car, to coming to live in a room in a flat. For both of us it was a loss of independence and freedom. That transition was challenging. It took five years for us to find harmony. She was an independent working mom. So I never expected that I’d have to care for her to this extent, where I have to watch over her because of her dementia—right down to her diet and physical activities, timely taking of her medication and her risks of falling. I had no idea.”
Mei Ling is employed, though her earnings saw a significant drop after she became a caregiver, and “it takes a real effort to stay in the workforce” now. However, work “also gives me sanity—we need to recognise that. Give women the ability to go out and work somehow. As a caregiver, you have to really focus on finding time, and sometimes you just don’t have any left for yourself. But having time for proper self-care is so important to ageing well.”
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“Being single, I pay for my mother’s living expenses,” says Mei Ling. “My brother contributes every now and then, but he has his own family.”
Mei Ling’s recurring expenses from caregiving for her mother include:
- Foreign domestic worker salary ($660/month)
- Special dietary requirements ($350/month)
- Rehabilitation sessions ($700/month)
- Physiotherapy ($150/month)
- Medication ($400/month)
- Transportation fares ($350/month)
“My mum goes to the rehab centre three to five times a week. Because she’s non-Singaporean, we pay $40 a day. It’s costly, but we decided to do that for her, and we’ve been doing it for 15 years. It keeps her mobile, physically active and emotionally connected. If not—if you just put them at home with a helper—they will dim away.”
One-off expenses include home safety adjustments for her apartment ($4,000), as well as her mother’s surgeries (hip and brain), which came to $116,000.
Kris
Kris’s mum is 86. Her vascular dementia was confirmed in 2014, though her memory discrepancies started becoming noticeable in 2012.
Kris has lived with her mum for most of her life. “I took it largely upon myself to look after my mom, simply because I was the single one of two siblings. I am the younger one, and I was running my own business. My sibling had not lived with us for 30 years, so it felt like my responsibility—a natural extension of my care and role as daughter.”
Like many other caregivers, Kris says she had no idea how much caregiving would cost—“if I did, I might have done things very differently.”
“I made the decision to work from home in 2014, thinking that it would be easier for me to juggle work and mum’s caregiving from one location. That’s when all the costs associated with her caregiving escalated. However, my business and income were impacted because of my loss of focus, juggling housework and caregiving. My savings started to deplete. From 2012 to 2016, I spent about $100,000 supporting my mother’s needs, her medical expenses, the maids’ salaries, etc.” She started using some of her mother’s own savings in 2016.
Kris’s recurring expenses from caregiving for her mother, after subsidies and grants, include:
- Foreign domestic worker salary ($700/month)
- Cabs for appointments ($40/month)
- Medication ($400/month)
- Hospital/IMH check-ups ($50/month)
- Supplements ($130/month)
One-off expenses include equipment such as a hospital bed, commode and wheelchair (approx. $2,100 for three items), liver tumour surgery ($4,000) and hospitalisation for a vasovagal attack ($1,000 with Medisave).
“The existing Pioneer Generation Disability Assistance Scheme grant of S$100 a month hardly covers the minimum necessities. My household is a typical small household—we don’t live luxuriously. We’re talking about meeting basic needs.”
While being self-employed has its downsides, Kris says, “I’m sure many people out there who are employed have had to forsake a lot of time with their parents.”
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Before she started caregiving for her mum in earnest in 2014, Kris says she “had been quite happily single, attending to my business, with a decent social life”.
Becoming a caregiver made her come to a realisation: “that there would not be anyone to look after me when I am old—unless I became attached to somebody and started my own family, which would be quite late in life. Now I am seeing someone. Still, because of our ages, we’re not about to start a family now. So the hopes for any support from a biological daughter or son are zero.”
Kris wonders who she will turn to in her own old age. “My compatriots would be my age; they’d be struggling to look after themselves too. Maybe a nursing home if I could afford one.” She can’t think of retirement; having comfortable retirement savings seems implausible at this point.
Kris suffered caregiver burnout in 2015. This was brought on by various factors, including not getting enough sleep (because of her mum’s nightly needs), issues with her helpers, not having time for herself and her work, and a newfound strain on her relationship with her sibling.
She believes that instituting caregiver leave and flexible work arrangements would help others, “so that the caregivers themselves can at least have some time for themselves to avoid burn-out. Compassion, understanding and support are needed for our workplaces to change.”
What else? “Monetary help will always be useful. Network support also, so that people don’t feel so isolated and alone in caregiving.”
Grace
Grace is a full-time IT consultant and divorced mother to a six-year-old daughter. She is the primary caregiver to her father, who is bed-bound. Grace is what is known as a “sandwiched” caregiver—looking after someone a generation older and a generation younger than herself.
Grace’s family is from the Philippines. Besides Grace, her daughter and her parents, Grace’s brother and his daughter also live in her flat.
“Though he has to pay for his children’s schooling,” Grace says, “my brother helps financially, and also with manpower, to run errands—so luckily it is not all on me, and my work isn’t really impacted. I’m grateful that my siblings and cousins provide support whenever they can.”
However, as the only Singaporean citizen of the household, much of the financial burden falls upon Grace. “Whenever my father needs to go to hospital, I have to be the one who goes. Most of my Medisave is being used up, but we still have huge outstanding hospital bills.”
“It’s also difficult for us to all go out at the same time. Today is Sunday; my mother is at church and it’s the helper’s day off, so I have to stay at home.”
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Grace’s father had a stroke in 2015 and has been bed-bound ever since. Prior to that, he was diagnosed with Alzheimer’s and dementia.
“It’s been four years already,” says Grace. “The recurring expenses are high. Plus I need to hire a helper so I can continue to have income.”
Her parents’ PR applications were not successful, and they receive no subsidies on medical and hospital bills. The recurring expenses from caregiving for Grace’s father include:
- Foreign domestic worker salary ($650/month)
- Ambulance transportation ($200/month)
- Physiotherapy ($250/month)
- Consumables, such as adult diapers, oral swabs, suction catheters, dressing, wipes, underpads ($300/month)
- Medication ($200/month)
- Special dietary requirements ($500/month)
Other expenses include a hospital bed, lifter, wheelchairs, air mattress and suction machine, which came to a total of $3,000 (all purchased second-hand). A four-night hospital stay would run up to $8,000. He receives surgery every three months, which costs $2,500 each time.
Corey
Unmarried with no kids, Corey currently lives with his grandmother, for whom he is the eldest grandchild. Corey is moderately involved in her day-to-day care and manages her money and affairs.
Altogether, their monthly caregiving expenses come to approximately $1,100 after subsidies and grants. Corey’s grandmother receives a total of $220 of direct financial support every month from the Foreign Domestic Worker Grant and the Pioneer Generation Disability Assistance Scheme. “Much of the regular expenses come from the medication,” Corey notes. “Only Duloxetine and Eperisone are not subsidised, but that alone costs more than all the others combined.”
Their one-off expenses include:
- Non-emergency ambulance trips ($300)
- Transfer/back support belt ($90)
- Commode ($95)
- Geriatric chair ($170)
- Grab bars and ramps ($120)
- Legal arrangements, such as preparing a will and LPA ($360)
Corey’s grandmother has also been hospitalised three times for strokes of increasing severity. The last hospitalisation cost $12,200, after subsidies that covered more than half of the original cost.
Although his grandmother is financially independent for now, Corey knows that won’t be the case forever. He predicts that within the next three to five years, he will have to bear at least a third of the financial burden of her care. “While two of her children are also likely to be supporting her, a third of medical bills is still significant for anybody to shoulder. Strokes are a slippery slope, so the expectation is that her situation will only get worse.”
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“We have had a close relationship since I was a child,” Corey says about his grandmother. “She’s a woman who left such a deep impact on me with her care, patience and love. Her latest of three strokes left her function-impaired in the left side of her body, unable to walk and requiring assistance for most Activities of Daily Living (ADLs). Prior to the strokes, she led a very active and social life, going to the gym regularly, indulging in her love of line-dancing and meeting her friends for coffee or shopping.”
Currently Corey contributes to bills in their shared home and gives his grandmother a small allowance. On top of his full-time employment, he spends an average of 10 hours a week accompanying her to her medical appointments, mediating any issues with their helper and managing her finances and her affairs.
Even though he doesn’t worry about finances for now, for Corey, “the emotional and psychological toll is significant. Believe me when I say I want to quit daily. But for her, I choose to remain in this situation daily.”
1. Typical recurring eldercare expenses include medication and supplements, consumables such as adult diapers and wound dressing, and a Foreign Domestic Worker’s salary, levy and living costs. Existing subsidies that might cover some of these items for Singaporeans include the Seniors’ Mobility and Enabling Fund, Pioneer Generation Disability Assistance Scheme and Foreign Domestic Worker Grant and Levy Concession.
2. Impaired mobility is a common part of growing old. It may necessitate the purchase or rental of a wheelchair, walking frame or stick, or a hoist to assist in lifting a care recipient in and out of bed. The Seniors’ Mobility and Enabling Fund and Pioneer Generation Disability Assistance Scheme may cover some of these expenses for Singaporeans. While mobility devices like wheelchairs experience extensive wear and tear with use, the financial support is available for a one-time purchase only.
3. For most caregivers, medical expenses are frequent. They can include hospitalisation (for anything from surgery to injuries sustained from falls), GP or specialist visits, and transportation costs to and from treatment facilities. Pioneer Generation subsidies or the Community Health Assist Scheme (CHAS) might cover some of these expenses for Singaporeans. However, transport and other out-of-pocket costs can add up.
All photographs by Callan Tham.