Taiwan Today

Eighty-three-year-old Yu-Yeh Chih (于葉治) has for years lived with her eldest son and his family in suburban Taipei. Although blind since age 50, she continued to help out for many years, doing the laundry and dishes for the entire family and taking care of her young grandchildren when her daughter-in-law went to the market. Even today, despite high blood pressure and difficulty walking without a cane, she washes her own clothes and dishes. But the years are catching up with Yu-Yeh. She suffers continually from aching muscles and dizziness, and last year she was taken to the emergency room twice after fainting.

Responsibility for Yu-Yeh's care rests solely with her son Yu Chun-pin (于俊斌) and his wife. Although Yu, at 60, is nearing retirement himself, he pays all the medical bills for his mother, who has no insurance, as well as her living expenses. His wife cooks her mother-in-law's meals and takes care of her physical needs. Yu has two younger brothers, but he does not expect them to contribute to their mother's care. Only on occasion does his brother or sister-in-law come over in the evening so that he and his wife can go out.

Yu has no complaints with this arrangement. He has never considered sending his mother to an institution or to stay with another relative. Nor does his wife, who has already raised five children, complain about the constant attention she must pay to her mother-in-law's needs. After all, Yu and his family live for free on his mother's property and will eventually inherit it. But more importantly, Yu simply considers it natural that he should care for his mother in her old age. "It is my responsibility," he says. "It's the tradition that the eldest son cares for the parents." Had his father not passed away many years ago, Yu would no doubt be caring for him as well.

He is not sure, however, that his own offspring will be so obliging. After he retires in five years, Yu and his wife would eventually like to live with their only son, but they know that attitudes are changing. "Some of my married daughters refuse to live with their in-laws, and my son might marry someone who feels the same way," Yu says. "Chances are, my wife and I are going to be living alone in our old age." He hopes that at least his children will be able to pay some of his medical expenses. "My wife and I do have some savings, but we'll lose our labor insurance when we retire," he says. "If we get sick, we might need some financial help."

Such uncertainty about the future is becoming increasingly common among people like Yu who are nearing retirement. Although the family support network is still relatively strong, it is starting to become more diffuse. In many cases, the eldest son and his wife are no longer the sale means of support, but other children—younger sons as well as daughters—are also pitching in. Some aging parents even shift periodically from one adult child's home to another, spending a few weeks or months in each place in order to distribute the burden more equally. And a growing number, like the Yus, are finding themselves almost entirely on their own. From 1976 to 1991, the number of senior citizens living alone or with only a spouse nearly doubled, from 17 percent to 32 percent.

Busy daughters-in-law, as Yu suggests, are one reason why fewer parents are living with their sons. The number of wives who work is steadily increasing—from 35 to 44 percent in the past ten years—leaving fewer women at home to care for their parents-in-law full time. But the general decline in the number of extended families is also due to urbanization and changing demographics. Often it is simply a matter of distance, a result of the migration from rural to urban areas that began in the 1960s. "Young people have moved to the cities for economic reasons," explains Chen Chao-nan (陳肇男), a research fellow at the Institute of Economics, Academia Sinica. "But many old people decide to stay in the countryside and thus live apart from their children."

At the same time, Chen says, many elderly today are better educated and have more savings than in the past, making it easier for them to live independently. Another factor in the increase of senior citizens living on their own is the large number of military men that came to Taiwan with the Nationalist government in the 1950s. "These young soldiers were uprooted from the mainland and relocated in Taiwan," Chen says. "A great number of them never married and now live alone in their old age."

Taiwan's declining birth rate is expected to add further to the number of senior citizens who will have to take care of themselves. In the past, when couples had an average of five children, it was conceivable that at least one of them would be able to care for them in their old age, and often the rest could take up the slack. But today's average of two children per couple means that, overall, less financial and physical aid will be available for the elderly.

Making the future even more uncertain for the elderly is the simple Fact that they are living longer. From 1945 to 1993, life expectancy increased by thirty years, to 72 years for men and 77 for women. Coupled with the reduced birth rate, this means that the society as a whole is getting older. Those over 65 now make up just over 7 percent of the population, the percentage set by the United Nations for defining an "aged society." And in another thirty years, according to the Ministry of the Interior's Population Administration, the proportion of senior citizens is expected to reach as high as 20 percent.

Chen points out that when the elderly live to a more advanced age, they need extra care—for everything from bathing and dressing to doing household chores, shopping, preparing meals, and managing their finances. "Probably you won't need this type of help at 65," he says, "but when you get to 80 or 90, chances are you'll need help with some things if not with everything."

If Taiwan's adult children can no longer assume full responsibility for their elderly parents, how will society as a whole care for the aged? The problem is not yet acute, but it is expected to become much more so in the years to come as a quickly increasing number of elderly people need care. At present, the social welfare system is inadequate to begin filling in for what has long been the family's job. "The service the elderly need is multidimensional—they need personal, nursing, and medical care, as well as social services and even emotional support," says Wu Shwu-chong (吳淑瓊), a professor at the Institution of Public Health, National Taiwan University. "Our formal support system is still in its infancy. And we don't have a long-term care system to provide for the disabled elderly. We don't have the resources, the manpower, or the facilities."

Currently, the formal support system is largely restricted to about eighteen government-run institutions, which give priority to low-income senior citizens, and thirty-five licensed private homes. These facilities serve a total of about 12,000 persons. Residents are generally required to be in good basic health and be able to assume responsibility for their own daily needs, although some homes do provide nursing care.

The island's largest home for the elderly is the Taipei city government's Fraternity House, set up in 1964. It accommodates about 820 residents, most of whom use the facilities free of charge. According to Chen Chih-chang (陳志章), a social worker at Fraternity House, a second facility offering more specialized nursing care is scheduled to open this year. "We have to expand because there's such a demand," he says.

The Provincial Changhua Nursing Home for the Elderly, which opened in 1990, also provides nursing care for some of its 265 residents, but only as a supplemental service. Despite the name, it basically serves elderly people who do not need acute care. Unlike the other government-run homes, Changhua caters mostly to paying residents. Only one hundred of its 422 beds are reserved for low-income senior citizens, who are admitted free, although this policy may have to be changed. "It seems we'll have to increase the number of beds for elderly people without family, because they usually don't have any informal care network," says social worker Chen Ming-chen (陳明珍). "Coming to an institution is the only option if they no longer can take care of themselves."

The government also runs fourteen homes for veterans, which care for about 18,000 residents. Another 112,000 retired servicemen are registered at these homes but do not live on the premises, although they collect a monthly US$260 in government support that is distributed through the homes.

Besides several hospital-based nursing centers, the only facility that specializes in caring for elderly who are disabled or bed-ridden is the Chiang Ching Foundation nursing home, which can accommodate sixty-two persons. The home started operating in February this year in the south-island city of Kaohsiung and is currently under government review for a license. Many other unlicensed homes are also helping to fill the growing demand for elderly care. Wu estimates that the number of such homes is increasing rapidly, with 140 operating in Taipei city alone and accommodating about 4,000 people.

Unlike the Chiang Ching home, most of these facilities do not even bother trying to get licensed, either because they cannot meet the requirements or because the licensing process is too complicated. Wu worries that they may not provide adequate facilities or qualified personnel because they are not subject to any regulated standards. "No one oversees the safety, sanitation, and service quality of these private nursing homes," she says. "But they are obvious evidence of a high demand for formal service in caring for the elderly."

Although the need for establishing a better and more extensive system of formal care for the elderly is urgent, it is not the only answer. As Chen Chih-chang of the Fraternity House points out, "Institutionalization has its demerits." Life in a nursing home can be impersonal and lonely, a situation made worse, according to Professor Wu, by the fact that many of the largest homes are located in rural areas that are often far from residents' homes. "Institutions are like concentration camps," Wu says. "Psychologically, it's bad for the elderly, because you have to uproot them from their community. I think making them Iive so far from their homes and their families is pretty cruel."

Wu and many others in the field believe that institutions should remain only a supplement to the traditional family network. At the same time, the types of supplemental help available need to be broadened. "I don't think we should do away with the children's support system, because it's an Asian vantage point," says Chen Chao-nan of Academia Sinica. "I suggest keeping the elderly in the family as long as possible. But we can't let the family take all the responsibility." Chen advocates developing strong daycare and home care systems that can help keep the elderly at home with minimal burden on family members.

Wu points out that Taiwan currently has very few community-based programs of this sort. Daycare centers and qualified caretakers that can come directly into the home are especially important, she says, now that an increasing number of young and middle-aged women—the traditional day-to-day caregivers for the elderly—are working. She suggests combining resources and personnel from government health and social service departments as well as recruiting volunteers.

The island's first daycare center for senior citizens was set up by the Taipei city government in 1989. It is open to anyone over 65 and still in good health—up to a maximum of twenty-four people—and cares for them during regular office hours, from nine to five Monday through Friday and Saturday mornings. The standard fee of US$77 dollars per month is waived for low-income senior citizens. The center also conducts regular medical checkups free of charge and provides breakfast, lunch, and entertainment. About a dozen other daycare centers sponsored by local social service departments operate around the island. Last year, they provided care for about 120,000 people. But while these centers receive numerous inquiries, many of them are only partly full. Lee Lin-feng (李臨鳳), a social worker with the Department of Social Services, Ministry of the Interior, believes more families would use daycare if transportation were provided. But severe understaffing makes it difficult even to find a driver. "The main problem is a lack of personnel," she says. "We need volunteers to help social workers carry out the task."

Home care is also just starting to take hold. In the past few years, nearly every city and county social service department has started its own home care program. These catered to about 410,000 people last year, providing basic care such as fixing meals and offering companionship, as well as health care by registered nurses. But Lee finds that the home care system is not run efficiently. "The basic care part of the program," she says, "is overseen by the Department of Social Services and the health care part is overseen by the Health Department. We need to incorporate the two sides in order to provide better home care."

One of the major problems in developing more home care programs is a lack of nurses specializing in the field. Currently there are only about fifty government-certified home health care nurses, who have been trained under a program the Department of Health started in 1991.

Most of these nurses are either based at a hospital and go out to work in patients' homes as needed or they provide specialized care in nursing homes, About twenty people also graduated from a two-year program for supervisory home care nurses, although this course was discontinued in 1989 because more nurses were returning from similar training programs overseas.

Another obstacle to expanding home care is that it is not covered on most insurance policies or in the National Health Insurance plan that is due to go into effect at the end of this year. Only 50 percent of the elderly have insurance at all, and their policies usually cover only acute medical care and hospitalization. A small number of people retiring under civil service or teachers' insurance plans have home health care coverage, although this will no longer be the case once public employees are included under the national plan. "Everyone had hoped that national health insurance would get rid of the financial barrier to health care for the elderly," says Wu Shwu-chong. "But the draft law does not mention long-term care."

The draft does mention coverage for chronic diseases, however. And the Department of Health has encouraged hospitals to reserve a certain number of beds for chronic disease patients. Wu has counted 5.800 such beds across the island. She expects the number of elderly people living in these hospitals to grow once the expense is covered by insurance—a situation that not only promises a dismal environment for many elderly people, but also will add sharply to the overall costs of caring for the aged. "Among all types of long-term care, hospitalization is the most costly." she says. "Encouraging old people to live in chronic disease hospitals will increase the financial burden on society." For this reason, she strongly advocates including daycare and home care in the national health plan. "Besides," Wu says, "what the elderly need is home, not a hospital."