Talking about Ageing: The Greying Elephant in the Room

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Most of us would prefer growing old in comfortable and familiar surroundings, but this may be a luxury that more and more of us will not be able to afford. Malaysia’s population is ageing, costs are increasing, and the nation is still unprepared for future challenges.

We live in unprecedented times: more people are living longer and have healthier lives than ever before. The Department of Statistics Malaysia has revealed that the life expectancy of Malaysians has been rising – from 72.2 years in 2000 to 74.7 years in 2016.1

This holds true for the rest of the world. The United Nations reported a 48% increase of people aged 60 years and above between 2000 (607 million) and 2015 (901 million). By 2030, the figure should hit 1.4 billion people by 2030.2

In other words, within 13 years, the number of people aged 60 years and above in the world will equal China’s entire population in 2013.

The United Nations World Assembly on Ageing in Vienna decided in 1982 that individuals aged 60 and above are deemed “older persons”. (This article will refer to this group as “the elderly”). Coincidentally, 60 is also our minimum age for retirement from the workforce as gazetted and enforced by the Minimum Retirement Age Act 2012 of Malaysia.

The Cost of Growing Old

Penang’s elderly population has been rising in number from 151,400 people out of 1.55 million in 2009 to 197,200 out of 1.66 million in 2015 (Figure 1). Nationally, this group will constitute more than 15% of the population by 2030.

“Seniors who have worked all their lives to take care of their families deserve to have an enjoyable and peaceful later phase of life,” says Dr Ong Hean Tee, a general practitioner who once served as state exco member for housing in 1982. “With healthcare programmes and better nutrition, seniors are living longer and this is what’s giving rise to the ageing population.”

According to the World Economic Forum, the ageing population in Asia is growing faster than in any other region in the world. The continent is currently home to more than half the world’s population of elderly people and by 2050, one in four across the Asia-Pacific region is expected to be an elderly person.3 Many such countries are in fact in transition from an exhausted “demographic dividend” to paying a “demographic tax” as a study by the Asia Pacific Risk Center in Singapore has shown.4

Penang is as ensnared in this crisis as most of the rest of the world. As identified by the Department of Statistics, the fertility rate has been declining from 3.0 in the year 2000 to just 2.0 in 2013 and 2014.

With more people surviving past their seventh decade today than any other time in recorded history, it is more crucial than ever that the healthcare system begins preparations to address the health concerns of the increasing number of elderly people.

In low-income and lower-middle-income countries, public sector financing of elderly health consumption is expected to increase only marginally.5

Generally, Malaysia’s public spending on health stayed at an average of 4% between 2009 and 2013, and increased slightly to 4.2% in 2014 (Figure 3). The rising cost of healthcare, coupled with the increasing number of non-communicable diseases, would put significant stress on the country’s budget.

Perhaps the most pressing concerns about retirement are financial. Generally, the minimum retirement age used to be 55. But in July 2013, the federal government raised it to 60 for private sector employees.

This change was made mainly because in 2003 the Ministry of Human Resources reported that as many as 86% of Employees Provident Fund (EPF) contributors did not have sufficient savings to last them through retirement (based on an expenditure of RM720 per month over 20 years).6

Warga Mas drive.

Even more disconcerting is the fact that 70% of the surveyed EPF contributors exhausted their savings within 10 years. In 2010 EPF data showed that as many as 73% of contributors had saved less than RM50,000 when they reached 54 years of age. Should a retiree live up to age 80 (an additional 26 years), this would provide an average of RM1,923 per year to survive on, translating to RM160 a month.

The problem of insufficient savings is less pronounced for civil servants where pensioners are given 50% of their last drawn salary for life, and their spouses will continue receiving this amount in the event of the pensioner’s death. However, this only passes on the fiscal stress to the government’s coffers. Retirement Fund Incorporated’s (KWAP) CEO Wan Kamaruzaman Wan Ahmad has stated that ever-growing pension liabilities placed on the government amounts to some RM300bil, with an impending payout for 1.6 million civil servants.7

Care and Homes for the Elderly

Needless to say, the demand for nursing or day care homes is also on the rise.

“We have more residents now than before,” says Pam Chow, manager of Glory Days nursing home, which has seen its business grow since 1988 to three branches in Jalan Vermont, Jalan York and soon Jalan Free School. Its Jalan Vermont branch is a threestorey bungalow that currently houses about 40 residents made up mostly of the elderly, plus one or two younger stroke patients and even an occasional coma patient. Chow has 20 staff on hand, including a retired nurse serving as the matron. “I do not think children nowadays have time to take care of their parents,” she adds.

There is a distinction between retirement homes and nursing homes: A retirement home is a private facility – usually a fully equipped service apartment – that caters to those elderly who are very independent and have but minimal medical problems. These live in their own private units and the lodging packages may include meals which are sometimes customised. There are also social outings and recreational activities to help them pass the time. Fees for such homes may cost an average of RM2,200-RM5,000 a month.

A nursing home, on the other hand, provides 24-hour skilled and trained nursing care for the elderly who require an intensive level of medical care and attention. There are some such homes that provide short-term rehabilitative stays for those recovering from an injury, illness or surgery. The cost per month for a spot in a nursing home ranges from RM1,600 for open wards to RM3,500 for a small room on sharing basis.

While there are plenty of nursing homes in Penang, the same cannot be said of retirement homes. Ong believes there is a demand, and has been working on that idea for several decades. He calls it Serenity Village, a concept inspired by his travel tours of retirement homes in Australia, England and the US. “It is actually a holistic concept of looking after the wellbeing of senior citizens,” he says. “Once a senior citizen checks into this facility, they live there worry-free and enjoy good quality of life, and then pass away with peace of mind. The village is sensitive to most if not all the needs of the residents.” Serenity Village was to have had three facilities: service apartments, a recreational centre and a healthcare centre that includes a nursing ward.

But Ong’s grand idea never took off. In 1996 his company got as far as purchasing land in Batu Kawan from the Penang Development Corporation, but the Asian financial crisis struck, forcing him to return the land to PDC. He is still trying to resurrect Serenity Village, but dealing with property developers has been frustrating. “It’s a billion-dollar business. Unfortunately, developers are very hesitant to get into this because there’s no precedent. Developers are also reluctant to pay for intellectual property.”

There are also homes run by charitable institutions, such as the widely-regarded Penang Home for the Infirmed and Aged. Established in 1954, it currently houses more than 200 residents, including 70 invalids, and has a staff of 55, more than 30 of whom are nurses. While admission is free, entry requirements are strict: potential clients must be aged 60 and above, a resident of Penang, homeless, poor, relatively mobile and not a recipient of a pension. “We have roughly 10 people looking after 70 invalids,” says welfare officer Tan Chin Hwa. “This is very taxing.” Similar charitable homes include Silver Jubilee Home for the Aged and the Little Sisters of the Poor.

There are also day care centres for the elderly, such as Friends of Seniors in Paya Terubong, founded by gerontologist Wong Yuen Ping. Wong had been based in Singapore, working with the National Council of Social Service and the Health Promotion Board, before she decided to move back to Penang.

At her day care, Wong focuses on three key elements in caring for the elderly: their physical health, their social interactions and their mental activity level. “The social aspect is where the elderly get together and form social roles and interactions among themselves. We keep them mentally active by providing them with board games that are elderly friendly, rather than just letting them watch TV and be passive. We also have simple exercises to keep them mobile and active.”

But Wong has a problem: Friends of Seniors does not have a license.

Mahjong playing is good for mental stimulation.

The issue facing many private nursing homes in Penang is that many are unlicensed and unregulated, and the staff not properly trained. This has led to complaints of neglect and elderly abuse. Living spaces are overcrowded, and there is poor sanitation and hygiene. “You have homes that are not well staffed, and even then the staff can be totally untrained,” says Yap Soo Huey, state assemblyperson of Pulau Tikus. “Caring is a very stressful job and it requires technical knowledge. In order to ensure that all care homes are appropriately skilled and staffed, some regulations need to be put in place.”

Health Minister Datuk Seri Dr S. Subramaniam announced in February this year that a Private Aged Healthcare Facilities and Services Bill 2017 would be tabled in March. Should it pass, then all private aged care institutions in Malaysia will be regulated and must adhere to a set of established standards.8

Although the demand for nursing homes is increasing, there is a lack of space and a shortage of trained staff. Some homes operate in residential areas and are subjected to license approval by the councils for building use conversion. This comes at a hefty cost.

“We actually applied for a license twice in the past four years but could not afford to submit the architecture plan,” says Wong. Before being granted the license to run a nursing home, the operator has to obtain approval from three agencies: the Fire Department, Health Department and the council (i.e. the Penang Island City Council or Seberang Perai Municipal Council), which requires the building submission plan to be drafted by a certified architect. Wong had no problems with the first two criteria, but the council requirements are too much, she says. “The requirement is so stringent, and to get an architect and submit a plan costs RM10,000-RM20,000. Most welfare organisations won’t be able to come up with the money.”

Another issue the homes face is location: neighbours simply do not like the idea of having a nursing home close by. “It’s a nationwide problem when setting up a senior citizens’ home. It’s difficult to find a suitable location,” says Yap.

Among Malays, like many other groups, the act of sending one’s parents to an old folks’ home is generally frowned upon. “It is against our religious teachings about filial piety. No matter how tough it gets, the family strives to stay together,” retired teacher Puan Noriah, 73, says. “It is common for Malay families to do things together. Even a hospital visit has almost everyone in the family tagging along.

“Culturally, the Malays are very family-oriented and this allows for the consistent bonding and strengthening of relationships among family members. From young, they are taught that filial piety is one of the utmost commandments in their Quranic studies. Even a simple scoff at your parents is considered a sin, let alone sending them away to an old folks’ home when they are frail. Usually, elderlies who are in these homes are without family.”

Public spaces such as Esplanade are where oldies can meet up and chat.

One stark difference that sets the Malay community apart is the kampung. “In the kampung, the spirit of neighbourliness is strong,” says Noriah. Some of these kampung houses sit on tanah keturunan pusaka (inherited land), so the Malay elderlies are always presented with the choice of moving back to their own kampung should they have tasted enough of urban life. As it takes a village to raise a child, it should also take a village to care for an elderly.

Elderlies showing off their artwork.

Yap for her part believes that our concept of care homes is outdated.

“We are still 30 years behind. Developed Asian and Western cities these days usually set up a facility that welcomes both kids and the elderly. They found that when children are given the opportunity to spend time with senior citizens, they grow up more thoughtful and mature. And when senior citizens have the opportunity to hang out with kids, they stay healthy and mentally alert for longer, and are happier in general.”

Yap is aiming to move in that direction, at least for her constituency in Pulau Tikus. “We’re going to engage the community to look at how we should revitalise the Balai Rakyat on Jalan Cantonment. It’s a public building that is underutilised, so I think it would be good to run that as an activity or community centre.”

However, growing old has a potentially brutal side, too: cases of elderly abuse or neglect are often not reported as it is not mandatory, unlike child abuse, for which the obligation to report cases is enshrined in the Child Act 2001. The elderly may refrain from reporting physical abuse to their doctors or outsiders as the perpetrators are often their own family members and children, and sometimes out of fear of provoking further abuse.9

Ong recounts a complaint he had received once: “There was one nursing home in my housing estate in Island Park that was illegal and unlicensed. At 5am, they stripped the residents and made them sit in the garden and then they gave them a bath by spraying them with a garden hose. You see the gross indignity.”

Elderlies exercising.

Some, however, say the problem is overblown. “The public is quick to judge from the outside – especially when they are not looking after any elderly,” says Tan. “Some elderly can be demanding and adamant in their ways. This always poses a problem, such as whenever an elderly person insists on walking even though their legs are weak. As a caregiver, we assist them by being there and handing them a walking stick or walker but this invites their anger and we end up getting scolded by them.”

Datuk Lawrence Cheah, president of Rose Charities and former president of the Senior Citizens Association, says that a domestic act that protects the elderly from physical abuse should be in place. “Singapore has one act called the Maintenance of Parents Act for this very reason. Basically the main thing the government has to do now is to mandate that all nursing home caregivers are officially trained to provide proper care for the elderly.”



Public-Private Initiatives

Beyond homes, there are state-funded and charity-funded initiatives designed to help the elderly. Rose Charities, for one, organises large events to celebrate special occasions and cultural festivals throughout the year. In February the charity body hosted the event “Celebrating Chinese New Year & Valentine’s Day with Seniors” at Straits Quay.

Pusat Aktiviti Warga Emas (PAWE) is a place set up for the elderly by the Ministry of Women, Family and Community Development to conduct recreational activities within the community. This especially provides the elderly from the lower income group with a platform for participating in programmes relating to religion, recreation, therapy and rehabilitation, health talks, and workshops. Membership is free; however, there are currently fewer than 50 PAWEs in Malaysia.

There is also a public Senior Citizen Day Care Centre for the elderly who are without medical conditions and who are able to take care of themselves. The family members would just need to send their elderly dependents to the centre for the day and pick them up when the day is done. It is in fact an important requirement by the centre that the elderly are there voluntarily, and are not being forced to be there by their family.

Since 2009 the state government has been disbursing RM100 for every registered elderly in Penang under the Warga Emas programme. From 2009 to 2015, the total disbursed through this programme until 2015 was RM112.4mil.

Yap says the money is too little and would rather see it go elsewhere. “We are too simplistic in how we deal with welfare. If we pull together all the RM100, I can operate a multigenerational community centre. The benefits will be more far-reaching.”

Others, however, argue that the actual amount isn’t the point. “It is to appreciate the contributions of senior citizens,” says Phee Boon Poh, Penang State Executive Councillor for Welfare, Caring Society and Environment. “RM100 is very little, but we give them something to look forward to. When you have something to look forward to, your life feels much better.”

Armenian Street Park is one such pocket park where the elderly can go to socialise and relax.

“It’s a form of recognition,” Cheah concurs. “For old and poor people, it’s something, and it means a lot.”

Taking Pointer

Apart from family-friendly policies, the built environment in which the elderly lives is also important. For instance, it has been known that walkable green spaces play a positive role in the health of the elderly living in cities.10 “When you are retired, what do you do? A lot of people want places where they can meet up with friends for a chat. I think governments should recognise their senior citizens’ contributions to the economy by providing public spaces for them,” Yap says.

Phee echoes this sentiment. “As we age, we should become freer and not be confined within four walls. Older generations require places to go such as pocket parks – those with trees and seats where they can sit and talk to their friends in the same community.”

Taking this idea further, a new idea of extending the use of children’s playgrounds to adults and senior citizens was introduced in 2013. Air Itam assemblyperson Wong Hon Wai explained that the “Three Generation Playground for All” is equipped with exercise equipment that catered for adults and senior citizens so that they could all enjoy the park at the same time. The walkability of such neighbourhood parks is also a factor.11

Birthday celebration at the Senior Citizens Association.

Another aspect to be improved is medical facilities. “Our general hospital is facing an over-demand and undersupply situation,” Yap says. “The government needs to look into providing community nurses, which would really help senior citizens who are unable to get to the hospital. Singapore did a study where they worked out that it is cheaper to run community nurses than sending patients to the hospital.

Friends of Seniors’ Wong Yuen Ping says that there are lessons Malaysia can learn from Singapore, particularly the concept of ageing in place. “Ageing in place is about ensuring that the elderly have the best support in whichever environment they are in. Whether they are staying in their own homes or in nursing homes, we make sure they pass their days happily. In Singapore, they have home help services where the elderly stay in their own homes and have meals delivered to them. If they need housekeeping, there are also services available at a nominal charge.”

Investing in the welfare of the elderly is as important as investing in the young. A well-rounded healthy and happy society brings dividends to all involved.

And this is not something to be done in the future. It should begin now.

1 “Malaysians' Life Expectancy at 74.7 Years in 2016.” The Sun, October 31, 2016, accessed March 5, 2017 http://www.thesundaily.my/ news/2043996.

2 United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Ageing 2015 (ST/ESA/SER.A/390)

3 Eduardo Klien and Yoriko Yasukawa, “Asia’s Population is Ageing Fast. Here’s What We Can Learn.” World Economic Forum, September 5,2016, accessed March 6, 2017.https://www.weforum.org/agenda/2016/09/asia-pacific-ageingwhat-we-can-learn.

4 Asia Pacific Risk Center, 2016. “Advancing into the Golden Years: Cost of Healthcare for Asia Pacific’s Elderly.” (Executive Summary). Marsh & McLennan Companies,. 13.

5 United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Ageing 2015 (ST/ESA/SER.A/390).

6 Ministry of Human Resources,. “About Minimum Retirement Age: Why Enact the Minimum Retirement Age?” http://minretirementage.mohr. gov.my/general/about-minimum-retirement-age/

7 “Civil servants may pay for own retirement fund”, Free Malaysia Today, July 25, 2016, accessed March 7, 2017. http://www.freemalaysiatoday. com/category/nation/2016/07/25/civil-servantsmay- pay-for-own-retirement-fund

8 Yuen Meikeng, “Better old folks homes under new Act,” The Star, October 16, 2016, accessed March 7, 2017. http://www.thestar.com.my/news/nation/2016/10/16/better-old-folks-homesunder-new-act-operators-with-inadequateaccommodations-and-care-to-face-fines

9 S. Indramalar, “Change needs to happen to protect seniors from being abused,” StarTwo, The Star,. June 10, 2016, accessed on March 7, 2017. http://www.star2.com/family/seniors/2016/06/10/change-needs-to-happen-to-protect-seniors-frombeing-abused

10 Takano, T., Nakamura, K., & Watanabe, M. “Urban residential environments and senior citizens’ longevity in megacity areas: the importance of walkable green spaces,”. Journal of Epidemiology and Community Health, 56(2002):(12), 913-918,http://dx.doi.org/10.1136/jech.56.12.913

11“Playgrounds for three generations,” The Star, October 7, 2014, accessed on March 8,. 2017.http://www.thestar.com.my/news/community/2013/10/07/playgrounds-for-three-generations

Jeffrey Hardy Quah is a freelance writer and editor.

Evelyn Teh is a senior analyst in the Urban Studies section of Penang Institute. A graduate in Marine Biology and Environmental Management, she enjoys writing and reading non-fiction. She also dabbles in photography and her works can be found at evelynteh.com.



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