This article was downloaded by: [University of Wisconsin Oshkosh]On: 06 October 2014, At: 10:17Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Gerontological Social WorkPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wger20

“Many Helping Hands”: A Review andAnalysis of Long-term Care Policies,Programs, and Practices in SingaporePhilip A. Rozario a & Amanda Leigh Rosetti ba School of Social Work , Adelphi University , Garden City , NewYork , USAb Brooklyn Community Services PROS , Brooklyn , New York , USAPublished online: 10 Sep 2012.

To cite this article: Philip A. Rozario & Amanda Leigh Rosetti (2012) “Many Helping Hands”: AReview and Analysis of Long-term Care Policies, Programs, and Practices in Singapore, Journal ofGerontological Social Work, 55:7, 641-658, DOI: 10.1080/01634372.2012.667524

To link to this article: http://dx.doi.org/10.1080/01634372.2012.667524

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Journal of Gerontological Social Work, 55:641–658, 2012Copyright © Taylor & Francis Group, LLCISSN: 0163-4372 print/1540-4048 onlineDOI: 10.1080/01634372.2012.667524

“Many Helping Hands”: A Review andAnalysis of Long-term Care Policies,

Programs, and Practices in Singapore

PHILIP A. ROZARIOSchool of Social Work, Adelphi University, Garden City, New York, USA

AMANDA LEIGH ROSETTIBrooklyn Community Services PROS, Brooklyn, New York, USA

Using the political economy perspective to examine key long-termcare policies and provisions, we uncover some ideological under-pinnings of policy-making in Singapore. Family involvement, aninherent part of the long-term care system, is overtly reinforcedby legislations and policy imperatives. Further, the governmentencourages and expects the participation of nonstate actors in theprovision of services as part of its Many Helping Hands approachto welfare provision. In our analysis, we argue that the govern-ment’s emphasis of certain ideology, such as self-reliance andcultural exceptionalism, allows it to adopt a residual and philan-thropic approach in support of its macro-economic and legitimacyconcerns.

KEYWORDS long-term care policies, Singapore, filial piety,political economy

Since its independence from British rule in 1965, the Singapore governmenthas successfully transformed the country into a developed city-state with apostindustrial economy. In its earlier days, the government had to focus onmore immediate and pressing concerns that included addressing high unem-ployment, expanding primary health and education, regenerating its urbanenvironment and clearing slums (Wijeysingha, 2005). Singapore’s relativelyrapid economic achievements have also contributed to a commonly shared

Received 30 May 2011; revised 8 February 2012; accepted 14 February 2012.Address correspondence to Philip A. Rozario, School of Social Work, Adelphi University,

One South Avenue, Box 701, Garden City, NY 11530-0701, USA. E-mail: rozario@adelphi.edu

641

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

642 P. A. Rozario and A. L. Rosetti

national narrative of economic survival and the need to maintain its globaladvantage.

An island-nation in Southeast Asia, Singapore’s multi-ethnic populationcomprises three main ethnic groups: Chinese (74%), Malays (14%), andIndian (9%; Singapore Department of Statistics, 2011). This diversity con-tributes to the government’s commitment to multiculturalism, often definedas the equal treatment of its citizens regardless of their ethnic/religious affilia-tions (Kong & Yeo, 2003). However, in its promotion of multiculturalism, thegovernment expects that individuals and/or collectives bear the responsibil-ity of ensuring their respective cultural vibrancy (Chua, 1997, cited in Kong &Yeo, 2003). This is evident in the Committee on Ageing Issues (CAI, 2006)report, which does not address the challenges of late-life cultural diversity.Singapore is also a rapidly aging society, in part because of its effective familyplanning program where the government reduced its total fertility rate from4.6 births per woman in 1965 to 1.28 births in 2008 and improvements in itslife expectancy from 65.8 years in 1970 to 80.9 years in 2009 (Yap, 2009b).Although its population is currently relatively young, the proportion of olderadults over 65 years is expected to rise to more than 20% by 2030 (Reisman,2009). As a result of this projected demographic revolution, the governmenthas been worried about the social and economic ramifications of a rapidlyaging society (Vasoo, Ngiam, & Cheung, 2000; Yap, 2008). Indeed, this is acommon concern among policymakers the world over, in that governmentsworry about the possible threats presented to the economic viability of publicpensions and the increasing burden of health-related costs (Vincent, 1996).

In 1982, in anticipation of a burgeoning aging population, the Singaporegovernment appointed a Committee on the Problems of the Aged toaddress the attendant social, economic, and political challenges (Teo, Mehta,Thang, & Chan, 2006). In its first report, the Committee outlined a wide rangeof policy concerns that addressed late-life employment, financial security,health and recreational needs, community-based and institutional long-termcare services, and family relations (Ministry of Health [MOH], 1984). Despitesome controversial recommendations (Vasoo et al., 2000), the report hasbeen influential in guiding policy-making efforts regarding eldercare inSingapore and many of its recommendations have since been adopted andimplemented.

In this article, we begin with a brief review of the political economy ofaging perspective. This perspective will frame our examination of Singapore’scurrent long-term care policies, programs, and practices. Then, we brieflypresent a working definition of long-term care, which broadly includes twodimensions: locations of care (community-based vs. institutional care) andtypes of care providers (informal vs. formal care providers). Next, we exam-ine salient ideological underpinnings of social policy-making, as well aspolitical economic conditions that facilitate the enactment of these policies.Following this, we briefly overview specific long-term care policy areas that

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 643

span home-based, community-based, and institutional-based programs andpractices in Singapore. Finally, we discuss some common and distinctivefeatures of policy-making in Singapore in comparison with its Asian andWestern counterparts.

POLITICAL ECONOMY OF AGING

Wijeysingha (2005) argued that the political economy approach is the mostappropriate framework for the examination of social policies because it isuseful in uncovering the fundamental and interactive relationship betweenthe state and market. Social policies reflect the dominant ideologies ofthe ruling elite and, as Estes (2001) further argued, articulate the strugglesbetween the economic system of capitalism, the state, and the class. In ourexamination, we highlight some national economic goals that are served bycertain long-term care policy choices, which the Singapore government pro-motes and valorizes. Another important aspect of the political economy ofaging is the concept of ideology, which Estes (2001) defined as “world viewsthat reflect the social position and structural advantages of their adherents”(p. 17). In promoting a particular set of ideologies, social policies inad-vertently construct one’s imagination of how old age is experienced andthe possibilities for societal intervention to deal with a predefined set ofproblems associated with aging.

DEFINING LONG-TERM CARE

Long-term care services essentially refer to services that are designed toaddress health, personal, and social needs of people whose physical func-tioning are compromised as a result of chronically disabling conditions andfrailty (Mui, Choi, & Monk, 1998). An estimated 5% of older Singaporeansare dependent in one or more activities of daily living (CAI, 2006). Thereare at least two dimensions of long-term care to consider: location ofservice provision and type of care providers. In terms of location, theseservices may be provided in either community-based or institutional set-tings. Indeed, community-based services allow older adults with diminishedphysical capacities to remain living in the community so as to delay insti-tutionalized care. Regarding type of care providers, there are two broadcategories of long-term care services, informal and formal service providers.Unpaid informal services are chiefly provided by immediate family members,and sometimes by extended and nonfamily members in the informal socialnetwork; formal services encompass any services that are paid for by pub-lic and/or private funds (Mui et al., 1998, p. 3). The Singapore governmenthas an explicit expectation that families remain at the frontline of support

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

644 P. A. Rozario and A. L. Rosetti

for their older relatives (CAI, 2005). For example, the Committee on theProblems of the Aged advocated for stringent admissions criteria for institu-tional care to ensure that adult children do not shirk their filial responsibilities(MOH, 1984).

Institutional care for older adults includes postacute, intermediate careand long-term care; the former aims at restoring the functioning of the personand the latter slows the rate of decline (Kane, 2005). An estimated 2.7% ofolder adults receive intermediate or long-term care services at any one time(MOH, 2006).

IDEOLOGICAL UNDERPINNINGS OF LONG-TERMCARE POLICIES

Despite its claims to multiculturalism, the Singapore government initiallydrew upon Confucian principles to promote Asian values as a counterpointto the encroachment of Western values in Singapore society (Kong & Yeo,2003) and an alternative to demands for improved human rights practicesand increased democratization (Ghai, 1998). Over the years, these principleshave been strategically reinterpreted and promoted by the government tojustify its social welfare arrangements and provisions, as well as to legitimizeits authority (Tremewan, 1998) and guide its long-term care policy-making.Elsewhere, Rozario and Hong (2011) argued that the Singapore governmenthas modernized its expectations of filial piety to include adult daughtersregardless of their marital status, even though by tradition married daughtersare not responsible for the well-being of their own parents.

Arguments that highlight the positive aspects of traditional Asian val-ues, the product of “positive Orientalism” (White & Goodman, 1998, p. 5),seek to explain differences between Eastern and Western societies from theperspective of cultural exceptionalism, while ignoring the political economyrealities that drive such policy-making. In essence, this juxtaposition dispar-ages Western approaches to welfare arrangements and provisions becausethey “are not only economically too expensive for Asian states to copybut also culturally inappropriate in that they foster laziness and depen-dency” (White & Goodman, 1998, p. 11), as well as conflict with Singapore’s“avowedly capitalist” (Wijeysingha, 2005, p. 191) and self-reliant ideology.However, it is too simplistic to evaluate long-term care policies and pro-grams in Singapore using the lens of Western welfare provision. Indeed,Tremewan (1998) argued that, despite its seemingly antiwelfare stance,“large scale provision of state welfare has been a fundamental factor in[Singapore’s] sustained economic growth” (p. 78). According to Wijeysingha(2005), the public welfare system in Singapore serves two objectives; “devel-oping resource infrastructure . . . and providing a welfare safety net for themost disadvantaged” (p. 191).

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 645

In this article, we discuss how the Singapore government addresses theseeming contradiction between its anti-welfare stance and its long-term careprovisions for frail older adults and their families. For example, the Singaporegovernment is known to take a selective approach in dealing with its pol-icy concerns and is always looking to the experiences of other countries,Western or otherwise, for best practices in the area of eldercare policies, pro-grams, and practices (Teo et al., 2006). For example, despite being criticalof the treatment of older adults in the West, the Committee on the Problemsof the Aged urged the Singapore government to update its legislation oninstitutional care along the lines of the Dutch and British legislation, which itconsidered good models of “stringent admission criteria” (MOH, 1984, p. 40).Further, Teo et al. (2006) argued that much of the policy-making consider-ations in Singapore are driven by an “economic logic” (p. 26), specificallythe considerations of any program’s affordability and sustainability and itsimpact on the country’s economic viability. As such, the maintenance ofrigid admission standards for subsidized institutional care effectively ensuresthat families will delay the institutionalization of their older relatives, andthus bear the brunt of the caregiving burden. In this review and examinationof long-term care policies, programs, and practices in Singapore, we cautionreaders against attributing these differences solely to positive Orientalism.

In line with its antiwelfare stance, the government has emphasizedthe guiding principle of Many Helping Hands, which promotes the activeinvolvement of nonstate actors to meet the needs of the less fortunate inSingapore (Yap, 2008). This principle enables the state to undertake a phil-anthropic approach to its social welfare function. In doing so, the state actsas the coordinator, facilitator, and regulator of social service provision underthe umbrella of a quasi-governmental body, the National Council of SocialServices, through a network of religious and nonreligious welfare orga-nizations (Wijeysingha, 2005). Further, the Many Helping Hands principleis in line with the type of multiculturalism that the government sanctionsbecause the principle encourages the involvement of ethnic and religiousnonprofit organizations in long-term care provision. From a service deliveryperspective, the principle of Many Helping Hands promotes a mixed econ-omy approach to long-term care services in that it creates room for private,for-profit providers to provide services to those who can afford such services.

Underlying the principle of Many Helping Hands is the notion of acommunitarian approach to eldercare. Indeed, this evokes a romantic imageof old Singapore, where villagers come together for mutual aid to thebetterment of the community. However, the government stance is clearlyindividualistic, in that it holds individuals personally responsible for theirold age and expects them to be self-reliant. When necessary, the fam-ily is expected to actively support those who are indigent and frail (Yap,2008). The governing ideology of self-reliance justifies residual state provi-sion (Rozario & Hong, 2011). In practice, means-testing of subsidized services

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

646 P. A. Rozario and A. L. Rosetti

and programs ensures that older adults and their children bear part of or allthe cost of long-term care services, which reinforces the notion of sharedresponsibility (Teo et al., 2006).

Despite governmental fears that formal services might supplant famil-ial involvement, the majority of frail older Singaporeans continue to rely ontheir families for their daily needs (Ministry of Community Developmentand Youth Services [MCYS], 2005) and familial involvement may persisteven when formal care services become involved in the older adult’s care.Indeed, family caregivers form the backbone of the long-term care servicesin any country; and in this aspect, Singapore is no different. However, unlikemany countries where the role of families is often assumed and implied, theSingapore government has explicitly upheld the ideal of familial support oftheir elderly relatives, especially in the provision of long-term care services(A. Chan, 1999; MOH, 1984). Göransson (2009) argued that filial obligationsto older parents are not only influenced by feelings of indebtedness andrepayment that adult children feel, but are also actively reproduced by mod-ern day legislations. We develop this argument further in our examination ofthe 1995 Maintenance of Parents Act [MPA].

The government’s overt expectation of familial involvement, that is thecrowding in principle, is legitimized and socially accepted because of thesalience of filial piety in Singapore (A. Chan, 1999). Singapore’s rediscoveryof Confucianism in the 1980s provided the government justifications for thevalorization of “strong family relations, benevolent paternalism, social har-mony and discipline, [and] respect for tradition” (White & Goodman, 1998,p. 8). As such, the government is able to carve out a residual role for itself,to provide a safety net for those who have no alternative means for theirown financial security, and where possible, to encourage the involvement offamily and nonstate actors in the provision of welfare services.

LONG-TERM CARE POLICIES AND PROGRAMS

Aging in Place

Long-term care “is essentially a social construct” that “reflects a combinationof historical accidents and underlying beliefs” (Kane, 2005, p. 2). As such,certain options are pursued more aggressively than others because of theircost and viability. For example, care at home is often touted as the moreattractive and cheaper alternative to institutional care, in part because of theheavy reliance on unpaid, informal caregivers who remain the backbone ofthat aspect of the long-term care system. Family care also evokes notions oflove and comfort even if this is not always the case for frail older adults andtheir family caregivers, especially in instances of elder abuse and caregiverburnout. Out-of-pocket and opportunity costs borne by family caregivers areoften not taken into account when determining the cost of home-based andcommunity care.

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 647

Prevention is a key element of policy-making endeavors in Singapore,because it potentially enables “every elderly individual physically and men-tally fit and active so that he can retain his normal living arrangements for aslong as possible” (MOH, 1984, pp. 16–17). This is part of the goal of socialintegration in later life that is aimed at facilitating older adults to age inplace and delay or avoid institutionalization (Yap, 2008). This initiative rec-ognizes the importance of housing as a long-term care issue and the need tocreate “barrier free environments” that provide “unhindered access” withinneighborhoods for older adults with different levels of physical functional-ity (CAI, 2006, pp. 13–15). Indeed, people with increasingly limited physicalfunctioning may have even fewer community-based options if their accom-modations are not barrier-free. Over the past few years, government-linkedpublic transportation corporations have introduced a number of disability-friendly accommodations, including “low floor public buses,” to achieve thegoal of “unhindered access” (Yap, 2008). These changes have also enabledpeople with decreasing levels of physical functioning to travel more inde-pendently or with assistance, thus increasing their mobility and extendingtheir productive engagement.

Accessibility within and around public high-rise apartment buildings inolder neighborhoods is another important element of aging in place. TheHousing and Development Board (HDB), which the Singapore governmentcreated in 1960 to address the housing crisis of a fledgling nation, is a majorprovider of affordable housing to its citizens. More than 80% of Singaporeanslive in public-supported housing, and an equally high percentage of themown these partially subsidized apartments, earning the government manyaccolades for successfully housing its populace (Tremewan, 1998). Withthe support of and co-payment by homeowners of subsidized housing, theHDB has undertaken a number of infrastructural improvement programs thatare targeted at expanding elevator access in existing apartment blocks andincreasing accessibility within neighborhood precincts (Yap, 2009a).

The expectation that homeowners copay a fraction of the cost of thesephysical improvement projects (Yap, 2008) effectively reinforces the principleof shared responsibility. For low-income residents of rental units, the gov-ernment fully funded the refurbishment of the interior and exterior spaces oftheir units to ensure greater mobility. Additionally, the HDB has embarkedon plans to build larger apartments to encourage intergenerational coresi-dence and has given priority to adult children who want to live closer totheir older parents. However, public response to the joint-living initiative hasbeen lukewarm and, as Göransson (2009) argued, may be reflective of “anemerging preference [among Singaporeans] for nuclear family units” (p. 129).

Community-Based CareReliance on informal caregivers. The family remains an important

source of instrumental, emotional, and financial support for older adults in

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

648 P. A. Rozario and A. L. Rosetti

Singapore. For example, about 92% of older adults reported that they reliedon their families when they were ill, and more than 87% said that they wouldturn to their family for financial help when in need (MCYS, 2005). Further,coresidence with an adult child remains relatively high, in comparison withSingapore’s Western counterparts (A. Chan, 2001), with at least 67% of olderadults reporting living with at least one child or more (Singapore Departmentof Statistics, 2011). Although the current living arrangements of older adultsappear to cohere with the precepts of filial piety, it also reflects the gov-ernment’s active efforts to ensure self-reliance among its citizens with thepromotion of familism (Teo et al., 2006) and provide an “attractive finan-cial arrangement” in terms of tax reliefs and preferential housing for adultchildren (A. Chan, 2001, p. 15).

Although Singaporeans are sometimes ambivalent about certain pub-lic intrusions into family life (Göransson, 2009), senior government officialshave always been candid about regulating the private lives of citizens(Tremewan, 1998). For example, the HDB changed its tenancy rules for itsrental properties to exclude new elderly tenants whose children are able toaccommodate them in their own homes or have the financial ability to pro-vide alternative accommodation (HDB, 2011). Further, the government playsa crucial role in ensuring that the curriculum for elementary and high schoolchildren include filial piety and respect for older adults (MOH, 1984, p.18).These efforts seek to redress any radiqcal transformation in familial expec-tations regarding family care in later life that may result from economic andsocial development. As such, governmental intrusions in the forms of socialpolicies often reinforce and reify notions of filial piety and familism (Yeoh &Huang, 2010), i.e., the salience of family in the life of frail elders. In turn,familism reinforces the notion that family care is the best form of care for frailolder adults, even if it is potentially problematic for caregivers and their carereceivers (Teo et al., 2006). Among caregivers of community-dwelling olderadults aged 75 and over, a 2010 nationally representative survey reported thatalmost 92% of the respondents agreed that children should be responsiblefor taking care of their elderly parents (A. Chan, n.d.).

The Singapore Tax Code provides an annual tax relief for adult childrenthat is contingent on their dependent parents’ living arrangements and activ-ities for daily living (ADL) functioning, for example, SGD $11,000 for eachcoresident parent with ADL needs vis. SGD $4,500 for a non-coresident par-ent who is physically independent (Inland Revenue Authority of Singapore,2011). However, only one adult child may claim this relief. As with anytax relief provision, these incentives are only applicable to caregivers whohave taxable income and do not benefit low-income caregivers and thosewho are not employed. In keeping with the Many Helping Hands princi-ple, the National Council of Social Services, a quasigovernment entity, fundsvarious nonprofit organizations to provide other forms of community-based

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 649

instrumental, informational, and emotional support to help caregivers per-form their caregiving duties (see section on formal noninstitutionalized care).Caregiving training programs are important. About 50% of caregivers of olderadults reported that they needed help with or information on keeping theirelderly relative safe at home (A. Chan, n.d.). Unfortunately, caregivers arenot often aware that these services are available and do not always use them(Teo et al., 2006).

Reliance on foreign domestic workers. Although much of the care thatfrail older Singaporeans receive may be in private households instead of insti-tutions, it is important to recognize that foreign domestic workers provide asignificant amount of this care. Almost half of the respondents in a nation-ally representative survey of older adults aged 75 years and over reportedthat a foreign domestic worker helped in the performance of at least oneactivity of daily living for the elderly care recipient (A. Chan, n.d.). Despiteits caution against being overly dependent on such workers, the governmenthas actively supported this dependence by loosening certain employmentrestrictions when these workers are hired to provide long-term care servicesin the home. For example, a reduced monthly levy of SGD $170 is imposedon employers of foreign domestic workers who have a frail older memberinstead of the usual fees of SGD $265 monthly (Reisman, 2009). Still, Reismanargued that employing a foreign domestic worker remains out of the reachof Singaporeans in the two lowest quintiles, where the median incomes areSGD$795 and SGD$2059 respectively.

Family caregivers receiving assistance from foreign domestic workerswere significantly less stressed than those without foreign domestic workers(A. Chan, n.d.), perhaps because much of the heavy lifting is done by foreigndomestic workers when families and older adults are able to afford such care.However, the relationship is not without its attendant costs. Göransson (2009)highlighted the ambivalence in the relations between the domestic workerand her employers. This ambivalence, as Yeoh and Huang (2010) asserted,lies in the fact that the live-in foreign domestic worker is neither a “familymember nor a trained employee” and can sometimes result in “conflict andtension,” which may “have spiraled into abusive situations” for the domesticworker (p. 78). Further, these domestic workers are often not trained, despitethe availability of eldercare training programs, because of cost considerationsby private maid agencies (Yeoh & Huang, 2010). Despite the exploitativenature, due to inadequate labor protections for foreign domestic workers,many Singaporeans do not perceive the exploitation (Göransson, 2009).

Legislating filial duties. Enacted in 1995, the MPA provides for indigentelderly parents to sue their adult children for financial maintenance in aspecial tribunal. Often, older adults who seek subsidized social and medicalservices for their long-term and health-care needs are referred to community-based or hospital social workers for a complete assessment that includes

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

650 P. A. Rozario and A. L. Rosetti

making a determination of the adult children’s financial ability and commit-ment in providing for the financial needs of their adult parent (Rozario, 2011).When children are financially able, but not forthcoming with their financialcontributions, social workers will often encourage their elderly clients topursue legal action with the tribunal. The tribunal adjudicates all claims anddecides on their merits and the liabilities of respondents, i.e., adult children(Göransson, 2009). In developing this legislation, proponents believed thatit would deter adult children from shirking their filial responsibilities, thuspreventing any deterioration of filial piety (MOH, 1984) despite the lack ofsuch evidence. The act also upholds the governing principles of self-relianceand personal responsibility among older adults and their families (Rozario &Hong, 2011). Göransson (2009) argued that in “making family the locus ofresponsibility, the act prevents an ageing population from becoming a bur-den to the state” (p. 89). Further, the legal expectations embodied in thelaw justify low governmental social spending, which, in turn, keeps personalincome tax rates low (Rozario & Hong, 2011).

Although the law has been effectively implemented (see Table 1), olderadults who have to resort to it are often financially desperate and theirapplication with the tribunal often exacerbates already tenuous family rela-tionships (Rozario, in press; Rozario & Hong, 2011). Despite the effectivenessof its implementation (Rozario & Hong, 2011), it is doubtful that most indi-gent parents who are successful in suing their adult children for supportreceive sufficient funds to be financially secure because such statistics are notpublicly available. To this end, Ng (2008) found that older adults who livedalone in Singapore often reported that their children were, themselves, finan-cially insecure because they were in poverty, had substance abuse problems,or were incarcerated. Further, Rozario and Hong (2011) argued that the MPApotentially creates structured desperation among indigent elderly parents.However, it is impossible to evaluate its effectiveness in deterrence, becausemost families do not question their responsibility to financially support theirelderly relatives.

Formal community-based care. Formal community-based care is seenas a cost-effective alternative to institutional care and enables frail older

TABLE 1 Statistics on the Number of Applications to the Tribunal for Maintenance of ParentsAct (2005–2010)

Applications 2005 2006 2007 2008 2009 2010

New applications 99 79 109 127 199 183Applications for

variance (changes)55 38 51 39 44 66

Total 154 117 160 166 243 249

Note. Information obtained from: http://app1.mcys.gov.sg/ResearchRoom/ResearchStatistics/FamilyServicesTribunalMaintenanceofParent.aspx

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 651

adults to remain in the care of their families within the community (Mehta &Vasoo, 2000) and, in turn, delays nursing home placement (MOH, 1984).As part of the government’s Many Helping Hands approach, nonprofits andother quasigovernment organizations are expected and encouraged to be anintegral part of the long-term care landscape and support families in theircaregiving efforts (Inter-Ministerial Committee on Ageing, 1999). In termsof service locations, some of these services are provided in the homes ofolder adults and their families, and others are provided at centers that aregeared toward a specific geographic location. These subsidized formal ser-vices are often contingent on the availability and involvement of family orother informal caregivers.

Home-based services span the continuum of medical to social needs,with overlaps in some of these services. Medically-focused, home-based ser-vices include mobile medical clinics that provide medical care to homeboundolder adults (Mehta & Vasoo, 2000); and home nursing services, which arelimited to nursing procedures such as “wound dressing, change of feedingtubes, and urinary catheters” as well as monitoring of vital signs (CAI, 2006,p. 80). In addition, home-based service providers that meet social needsinclude meal delivery, housekeeping services, personal care, and laundryservices to frail older adults who either live alone or with someone else(Agency for Integrated Care, 2011).

Further, to address the multiple needs of low-income community-basedfrail older adults, the National Council of Social Services and MOH fundedtwo pilot case management projects that were undertaken by two nonprofitorganizations to prevent unnecessary institutionalization or avoid overcon-sumption by these individuals with high needs (Inter-Ministerial Committee,1999; Mehta & Vasoo, 2000). These programs rely on the brokerage model,whereby the case managers identify appropriate and available community-based services to meet the needs of their clients and then coordinate theirclients’ service use (Mehta & Vasoo, 2000). Despite the income restrictions—a gross household income that is less than S$2,000 per month—Mehta andVasoo argued that case management services remain “unattainable to thosewho need it the most (i.e., the poorly-educated seniors without familiesor the frail seniors with multiple needs and problems)” (p. 134). Perhaps inresponse to this gap, the CAI (2006) recommended that the Ministry of Healthand the MC YS better integrate the hospital and community case manage-ment service systems to ensure that caregivers of frail older adults with highservice needs do not fall between the cracks and are linked appropriately tocommunity services.

Center-based programs may provide ambulatory medical-related ser-vices, such as senior citizens health care centers, to those who are recentlydischarged from hospitals (Mehta & Vasoo, 2000) or services that are tar-geted at the social needs of older adults. One such program specificallytargets older adults with dementia, and is often geared to provide respite

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

652 P. A. Rozario and A. L. Rosetti

to family caregivers. Another type, Neighborhood Links, addresses the socialand relational needs of older adults in specific neighborhood precincts and isoften informally self-managed by participants of these centers under the aus-pices of family service centers (Mehta & Vasoo, 2000). Neighborhood Linksare designed to be focal points in various neighborhoods for residents of allages, where neighbors can volunteer their services for those who are in need(Teo et al., 2006). The third type, Day Activity Centers, targets low-incomeelders who live alone or with another unrelated older adult and providesthem with information and referral services, as well as a support network(Mehta & Vasoo, 2000; Teo et al., 2006).

Institutional Care

Institutional care caters to those with chronic and debilitating conditionswho are no longer able to live in the community and includes communityhospitals, chronic sick hospitals, and nursing homes. Both community andchronic sick hospitals are conceptualized as intermediate care facilities thatprovide subacute care following a hospitalization episode (Committee onAgeing Issues, 2006); nursing homes provide “long-term skilled nursing carefor older persons” (MOH, 2006, p.2). In Singapore, nursing home care is seenas a last resort (Chen & Jones, 1989) and policymakers remain concernedthat less restrictive admission policies would not only result in overwhelm-ing demand, but also might undermine the government’s efforts to promotehome-based care and the practice of filial piety (MOH, 1984). Still, interme-diate care, such as community hospitals, serve an economic function in thatit provides subacute medical care to older adults at less cost and relieves thedemands on acute care hospitals.

As these services rely heavily on paid paraprofessional and professionalstaff to provide an intensive-level of care to frail and, often, older adults withlimited mobility and high-levels of needs, operating expenses for institutionallong-term care services can be relatively costly. Those who can afford itshigh cost can get these services from private for-profit organizations. Elderswith lower income may utilize subsidized care often provided by voluntarywelfare organizations [non-profit organizations that may include faith-basedorganizations], which are able to provide affordable and acceptable carebecause they rely on public philanthropy and government grants for theircapital and/or operating expenses.

Again, these institutionalized services are provided by nonprofit andfor-profit organizations as part of the Many Helping Hands principle tolong-term care. However, to offset the high cost of institutional care forthose who cannot afford the full fees, the government offers subsidiesto qualified individuals. These subsidies are financed by the earned inter-est from an endowment fund, Eldercare Fund, which was established in2000 with budget surpluses, with the initial aim of accumulating a capital

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 653

fund of S$1 billion. More recently, the government transferred an additionalS$700 million to the fund, raising its capital fund to S$2.5 billion (L. Chan,2011). In 2006, the MOH approved 23 of the 51 nonprofit and 8 of the 39 for-profit nursing homes to receive operational subsidies from the EldercareFund. Depending on the per capita household income of older residents/patients, and in consideration of their adult children’s income and expenses,the government may subsidize up to 75% of the operating costs of quali-fied older adults (Yap, 2008). As the government owns approximately 75%of land in Singapore and “has the power to acquire the remainder com-pulsorily” (Tremewan, 1998, p.77), it is, thus, able to provide free land forthe construction of nonprofit nursing homes and regulate land leases forthe for-profit sector. In addition to free land leases, the government maysubsidize 90% of the development cost of new nursing homes by nonprofitorganizations despite its deterrence to institutional care (MOH, 1984). Suchmeasures not only contain the capital funds needed by nonprofit organiza-tions to start new long-term care facilities, but also ensure their participationin the provision of long-term care services.

Described as the “centrepiece of Singapore’s social economy,” theCentral Provident Fund [CPF] was originally established to provide late-lifefinancial security to its members (Reisman, 2009, p. 39). In line with theprinciples of self-reliance and personal responsibility, the Singapore gov-ernment established the Elder Shield program, which automatically enrollsSingaporeans aged 40 and over with CPF accounts in a privately managedlong-term care disability program to finance long-term care services in laterlife (CAI, 2006). The original program provides a cash payout of SGD$300 for60 months to eligible policy holders to supplement the cost of formal servicesfor at least three of six activities of daily living (bathing, grooming, toilet-ing, feeding, mobility and transferring; Agency for Integrated Care, 2011).Long-term care insurance is, indeed, an attractive long-term care fundingmode because it ensures lower government spending during the benefitcoverage.

DISCUSSION

In this article, we specifically examined the Singapore government’s responseto its burgeoning aging population’s long-term care needs and found that thegovernment responded early and quickly to address the anticipated demandsfor long-term care and challenges of an aging society. Although our focushas been on long-term care specifically, the manifest aim of policy-makingconcerns in Singapore was to “empower individuals to age with dignity andsecurity, as integral members of society, in a vibrant and socially cohesivenation” with its focus on four broad areas including healthcare and eldercareservices (CAI, 2006, pp. i–ii). This is evident in the capital that is invested

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

654 P. A. Rozario and A. L. Rosetti

in the infrastructural improvements in public housing. Still, there are limitsto the preventative and developmental measures that the government under-takes because a significant segment of the population is not able to equitablybenefit from these efforts.

The strategic use of filial piety achieves a number of outcomes simulta-neously for the Singapore government. For one, it limits the imagination ofpotential long-term care services to those that specifically emphasize familyresponsibility. In doing so, it allows the government to take a philanthropicapproach to those without the means to do such, as well as to rely onnonprofit and for-profit organizations as part of its Many Helping Handsprinciple to long-term care. More important, the formalization of filial pietyin policy making in Singapore has a stabilizing effect on its populace becauseit “preserve[s] hierarchies and ensure[s] obedience” (Ghai, 1998, p. 32) andensures the continued involvement of adults children in the care of theirelderly parents. We argue that the enactment of the MPA reinforces the expec-tation of self-reliance because indigent elderly parents are expected to firstclaim financial support from their adult children. Further, the legalizationof familial financial support reinforces the ideology of familism (Göransson,2009), wherein the family is seen as the best source of support to meetthe older individual’s needs, even when the relationship may be conflictualand/or nonexistent. It is noteworthy that national surveys point to the impor-tance of family as a source of support for older adults in times of illness andfinancial difficulty (MCYS, 2005) although it remains questionable if this isa direct consequence of governmental effort. The ideology is also evidentin the government’s policy preferences for the home as the ideal locationfor delivering long-term care services and the high reliance on informal careproviders, mainly families of frail older adults. This also ensures that thegovernment is not seen as the primary and sole provider of social services.More important, the valorization of filial piety serves the purpose of manu-facturing a national identity that is uniquely Asian or Singaporean among itsotherwise multiethnic and multicultural population (Rozario & Hong, 2011),by constructing appropriate shared values for a young nation in the need toforge a common identity (Wijeysingha, 2005). Future research should investi-gate the potential impact of the MPA on creating and/or maintaining late-lifeincome insecurity among indigent elderly parents, as well as the long-termsocial and financial effects on adult children.

In its somewhat tumultuous beginnings in the 1960s, policy concernsfacing the government focused on economic development, job creation,housing development, and the expansion of public health and education.To this end, Wijeysingha (2005) argued that “the Singapore government setout to define and execute a political economy that was in accord with” theimperatives of a capitalist world economy (p. 191). Its economic successhas contributed to its national narrative that emphasizes economic survival,which we argue has been extended to its long-term care policies, as well. Forexample, the government fears the potential economic impact of its aging

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 655

population (Vasoo et al., 2000). Additionally, Wijeysingha (2005) highlightedtwo other principles that undergird the provision of welfare in Singapore,which are “market efficiency and the ability to pay” (p. 204). Indeed, marketefficiency is evidenced in the financial incentives, such as tax breaks to adultchildren and operational subsidies and land leases to both for-profit and non-profit organizations to provide long-term care services at lower cost and thusmore efficiently. Further, there is an expectation that service users will bearsome of the costs of these essential services, as seen in the subsidy scale thatthe government uses for accredited nursing homes that provide care to low-income elders as well as housing infrastructural upgrading projects. Further,the mixed economy encourages the participation of for-profit long-term careservice providers for those who can afford such services.

The importation of cheap foreign labor to provide long-term care ser-vices at home and in institutional settings is yet another aspect of marketefficiency. In its preference for informal caregiving as the mainstay in thecaregiving landscape, the Singapore government not only views the provi-sion of formal noninstitutional care as supplementary, but also as a means todefer institutional care. Although the reduction of levy for the employment offoreign domestic workers enables a significant proportion of families to hirea live-in formal caregiver at relatively affordable rates, such services remainunaffordable for low-income older adults and their families. Further, restric-tive admission policies for institutional care ensure that such care remainsa last resort for families. Indeed, it can be argued that the provision ofsubsidized long-term care services and programs meets one of the two objec-tives of the welfare regime in Singapore, that is, to provide “a safety net forthe most disadvantaged” (Wijeysingha, 2005, p.191). Future research shouldexamine if the government’s long-term care policies inadvertently place anunequally high burden on those who can least afford to hire a live-in foreigndomestic worker or purchase unsubsidized services in the mixed economyof long-term care services.

In its adoption of a developmental welfare regime (Walker & Wong,2005; Wijeysingha, 2005), the Singapore government engenders the “involve-ment of non-state societal actors” (Walker & Wong, 2005, p. 6) throughits Many Helping Hands campaign, which, in turn, effectively allows it topromote its communitarian ideology, as well as to take a philanthropicapproach to any social welfare provision. Of course, the seemingly commu-nitarian approach, often touted as uniquely Asian, is used as a counterpointto Western approaches that emphasize individualism and are perceived tonot only encourage dependency on the government but are also consideredunsustainable (Ghai, 1998; Walker & Wong, 2005). Indeed, the provision ofprivate long-term care insurance through the CPF system and the relianceon an endowment fund for funding subsidized long-term care needs of lowincome elders and their families are ways in which the government is ableto delegitimize entitlement claims by its citizens and reinforce self-relianceamong its citizenry.

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

656 P. A. Rozario and A. L. Rosetti

This review of long-term care policies, programs and practices inSingapore, in part, highlights the argument that “the position of elderlypeople in society and their relative standards of living is not simply ademographic or economic one [but] is essentially a political and moral ques-tion” (Vincent, 1996, p. 19). More important, this examination acknowledgesthe ubiquity and involvement of the government in the provision of publicwelfare, contrary to popular belief (Wijeysingha, 2005). However, the gov-ernment’s response to the “apocalyptic demography” is in part driven byits fear that the increased demands made by older adults will negativelyimpact its economic and political systems (Vincent, 1996, p. 3). In addition,members of the CAI (2006) recognized potential economic opportunities indeveloping “a silver industry” that is targeted at meeting the needs of olderadults in the marketplace (p. i). Using a political economy approach, weunderscore Singapore’s response to the long-term care needs of its agingpopulation as an attempt to not only preempt the economic strains of arapidly aging society, but also to remain economically competitive in theglobal capitalist system, as well as to promote certain ideologies that serveits national goals. The preference for services that are delivered in the homeand community over institutional settings, as well as the valorization ofinformal caregiving over formal care, are coherent with the effort to keeplong-term care cost low for the government. Indeed, it can be argued that itsphilanthropic approach to the provision of subsidized long-term care pro-grams and services is targeted toward sustaining its economic growth andviability, along with maintaining its global economic edge (Tremewan, 1998;Wijeysingha, 2005). This is evident in a policy recommendation that the pro-vision of social services for family caregivers of older adults is importantbecause of their “reduced capacity” as a result of their full-time employment(MOH, 1984, p. 34). Finally, it can be argued that the assurance of a means-tested safety net as well as reliance on nonstate actors to provide long-termcare services essentially negates any expectations of entitlement and rein-forces the family’s role in long-term care. Perhaps Singapore’s response toits long-term care needs reflects a fiscally conservative approach that is asmuch Western as it is Eastern.

REFERENCES

Agency for Integrated Care. (2011). Singapore silver pages. Retrieved from http://www.aic.sg/silverpages/aboutLTC/page.aspx?id=189

Chan, A. (1999). The role of formal versus informal support of the elderly inSingapore: Is there substitution? Southeast Asian Journal of Social Science,27(2), 87–110.

Chan, A. (2001). Singapore’s changing structure and the policy implicationsfor financial security, employment, living arrangements and health care.Singapore: Asian Meta Centre for Population and Sustainable Development.

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

Long-term Care in Singapore 657

Chan, A. (n.d.). Older adults and their caregivers: Characteristics and policy impli-cations. Retrieved from http://www.tsaofoundation.org/pdf/AP Angelique ChanRoundtable_Caregiving_18Ma.pdf

Chan, L. (2011, February 19). Elderfund top-up of $700m to hit target of $2.5b.The Straits Times. Retrieved from http://www.straitstimes.com/BreakingNews/Singapore/Story/STIStory_636664.html

Chen, A. J., & Jones, G. (1989). Ageing in ASEAN: Its socio-economic consequences.Singapore: Institute of Southeast Asian Studies.

Committee on Ageing Issues. (2006). Report on the ageing population. Singapore:Author.

Estes, C. L. (2001). Political economy of aging: A theoretical framework. In C. L. Estes& Associates (Eds.), Social policy and aging: A critical perspective (pp. 1–22).Thousand Oaks, CA: Sage.

Ghai, Y. (1998). Rights, duties and responsibilities. In J. Cauquelin, P. Lim, & B.Mayer-König (Eds.), Asian values: An encounter with diversity (pp. 20–42).Surrey, UK: Curzon.

Göransson, K. (2009). The binding ties: Chinese intergenerational relations inmodern Singapore. Honolulu: University of Hawai’i Press.

Housing and Development Board. (2011, February 21). Eligibility conditionsfor renting a flat. Retrieved from http://www.hdb.gov.sg/fi10/fi10323p.nsf/w/RentDirectHDBEligibility?OpenDocument#Family%20Support

Inland Revenue Authority of Singapore. (2011, February 24). Parent or handi-capped parent relief . Retrieved from http://www.iras.gov.sg/irasHome/page04.aspx?id=212

Inter-Ministerial Committee. (1999). Report on the Ageing Population. Singapore:Ministry of Community Development.

Kane, R. L. (2005). Changing the face of long-term care. Journal of Aging and SocialPolicy, 17(4), 1–18.

Kong, L., & Yeoh, B. S. A. (2003). The politics of landscapes in Singapore:Construction of “nation.” Syracuse, NY: Syracuse University Press.

Mehta, K. K., & Vasoo, S. (2000). Community programmes and services for long-termcare of the elderly in Singapore: Challenges for policy-makers. Asian Journal ofPolitical Science, 8(1), 125–140.

Ministry of Community Development and Youth Services. (2005). National survey ofsenior citizens. Singapore: Author.

Ministry of Health [MOH]. (1984) Report of the Committee on the Problems of theAged. Singapore: Singapore National Printers.

Ministry of Health, Integrated Health Services Division and Healthcare FinanceDivision. (2006). Intermediate and long-term care in Singapore. Singapore:Ministry of Health.

Mui, A. C., Choi, N. G., & Monk, A. (1998). Long-term care and ethnicity. Westport,CT: Greenwood.

Ng, G. T. (2008) Older persons with minimal or no family support: Past, present,and future. Social Development Issues, 30(3), 72–87.

Reisman, D. (2009). Social policy in an ageing society: Age and health in Singapore.Cheltenham, UK: Edward Elgar.

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014

658 P. A. Rozario and A. L. Rosetti

Rozario, P. A. (2011). ‘He was your father, he raised you’: Examining helping profes-sionals’ narratives on filial piety in Singapore. Qualitative Social Work. Advanceonline publication. doi: 10.1177/1473325011413000

Rozario, P. A., & Hong, S. I. (2011). Doing “right” by your parents in Singapore:A political economy examination of the Maintenance of Parents Act of 1995.Critical Social Policy, 31, 607–627.

Singapore Department of Statistics. (2011). Census of population 2010, Statisticalrelease 1: Demographic characteristics, education, language and religion.Singapore: Author. Retrieved from: http://www.singstat.gov.sg/pubn/popn/c2010sr1.html

Teo, P., Mehta, K., Thang, L. L., & Chan, A. (2006). Ageing in Singapore: Serviceneeds and the state. London, UK: Routledge.

Tremewan, C. (1998). Welfare and governance: Public housing under Singapore’sparty state. In R. Goodman, G. White, & H. J. Kwon (Eds.), The east Asianwelfare model: Welfare orientalism and the state (pp. 77–105). London, UK:Routledge.

Vasoo, S., Ngiam, T. L., & Cheung, P. (2000). Singapore’s ageing population: Socialchallenges and responses. In D. R. Phillips (Ed.), Ageing in the Asia-Pacificregion: Issues, policies, and future trends (pp. 174–193). London, UK: Routledge.

Vincent, J. (1996). Who’s afraid of an ageing population? Nationalism, the free mar-ket, and the construction of old age as an issue. Critical Social Policy, 16 ,3–26.

Walker, A., & Wong, C. K. (2005). Introduction: East Asian welfare regimes. InA. Walker & C. K. Wong (Eds.), East Asian welfare regimes in transition: FromConfucianism to globalisation (pp. 3–20). Bristol, UK: The Policy Press.

White, G., & Goodman, R. (1998). Welfare orientalism and the search for an EastAsian welfare model. In R. Goodman, G. White, & H. J. Kwon (Eds.), The eastAsian welfare model: Welfare orientalism and the state (pp. 3–24). London, UK:Routledge.

Wijeysingha, V. (2005). The welfare regime in Singapore. In A. Walker & C. K.Wong (Eds.), East Asian welfare regimes in transition: From Confucianism toglobalisation (pp. 187–211). Bristol, UK: Policy Press.

Yap, M. T. (2008). Singapore’s response to an ageing population. In L. H. Guan(Eds.), Ageing in South East Asian and East Asia: Family, social protections, andpolicy challenges (pp. 66–87). Singapore: Institute of South East Asian Studies.

Yap, M. T. (2009a). State of the Elderly in Singapore: Social well-being and goingforward (Release 3). Singapore: Minister of Community Development and YouthServices.

Yap, M. T. (2009b). State of the Elderly in Singapore: Trends in population ageingand profile of Singapore’s elderly population (Release 1). Singapore: Minister ofCommunity Development and Youth Services.

Yeoh, B. S. A., & Huang, S. (2010). Foreign domestic workers and home-based carefor elders in Singapore. Journal of Aging and Social Policy, 22, 69–88.

Dow

nloa

ded

by [

Uni

vers

ity o

f W

isco

nsin

Osh

kosh

] at

10:

17 0

6 O

ctob

er 2

014