Questions/Answers

Kalasin Municipality has been moving toward an aging society as its country, Thailand. The number of elderly has been increased from 3,427 (9%) in 2007 to 5,469 (16%) in 2019. Challenges faced in its community are commonly found in aged society including physical and mental health of the elderly, health care costs, nursing home care, and other socio-economic issues such as social isolation, loneliness, lack of care and attention from other family members. Furthermore, the issues may also impact to overall productivity of the family members who have to leave their work to take care of the elderly. Appropriate care especially rehabilitation care, health promotion, and attention from their family members along with support from related institutes in the community are important to promote good quality of life for the elderly. Health promotion for all elderly in the community is the main objective of the project managed by Kalasin Municipality. Stakeholder participation among public and private institutes as well as civil society and community is a key success factor of the Integrated Long-term care services for elderly project of Kalasin municipality. The project has been developed and implemented based on roles and strength of each party, both health and non-health organization, participated in the project. Although conflict of rules and regulation of governance of different public organizations had occurred, the same ultimate goal for all elderly had made it easy to solve the conflicts.

Accessibility to public services has been a challenge for frail elderly, disabled, and vulnerable individuals. Kalasin Municipality and other 22 organizations in the community has continued to collaborate in providing services for all, not only for the elderly but also for others in needs. The services include proactive service of the emergency health service hotline (call 1132); basic health screening; screening for DM, hypertension, and cervix cancer; community volunteers, palliative care for end-staged patients, as well as funeral services for the poor.

Goal 10: Reduced inequalities within and among countries 10.2 By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status. The project aims to promote accessibility to public service both health and non-health services for all, especially the frail elderly and vulnerable individuals living in the community in order to increase their quality of life. Although it aims to promote quality of life of all, especially the frail elderly and vulnerable individuals, economic productivity and social outcome could also be gained.

The project can be sustained in terms of social, economic and environmental by stakeholder participation both from local and national level. In terms of budget, for example, local health security fund established from matching funds between the National Health Security Office (NHSO) and local government administration office, in this case is the Kalasin Municipality. Budget from the NHSO allocated from the government based on the National Health Security Act is calculated based on the number of population in the community. Budget from local government administration office is collected from local tax and fiscal budget. Other sources of income may include donations from community and interest. Other type of fund established by the community for the community include “One Baht Fund”, “Recycle fund for vulnerable”, “environmental volunteer fund” for house repair and environmental improvement for elderly and disabled. In terms of organization and governance, quality of life improvement center for elderly and disabled has been established and overseen by the community committee. Memorandum of understanding among Kalasin Municipality and related organization in community is also signed. Furthermore, trained community volunteer providing long-term care services for frail elderly and disabled has also arranged. Financial system to support cremation and basic living cost has been set-up.

Different types of elderly require various interventions from organizations having different roles, budgeting, and regulations. Governance under community committee consisted of members from related stakeholders is a key success factor. However, revising related rules and regulations of each public administration to allow cross activities and budget allocations among different ministry is also important for achieving their shared goal to promote quality of life for all elderly. Regarding the long-term care services for elderly, senior citizen school has been set-up to provide health education and to promote health promotion and physical activities in elderly. Basic health services and screening are also included. Community participation through health volunteers, and caregivers is also another key to succeed. Furthermore, house survey also conducted in order to make sure that all population can access the public services as needed.

In Kalasin Municipality, elderly in all age and gender having health problem(s) are assured access to public services as needed. Quality of life improvement center has been established to proactively provide services including health assessment, basic assistant, 1132 hotline for 24-hr medical referral service, volunteer group to provide palliative care for end-stage patients, and financial support for cremation of the poor.

Different interventions are provided for each type of elderly. Results are following: Active group: senior citizen school established having 352 elderly students teaching 6 aspects of knowledge aiming to promote self-care, to entertain and reduce stress, and to increase physical activities of the elderly. Housebound group: health volunteers, long-term care volunteers, and multi-disciplinary care teams have engaged in health promotion and screening services. Health promotion services have been scheduled. In the past four years, six times a year of the services had been provided. The number of elderly access to services in the past 4 years includes 1,712 cases of eye screening; 1,680 cases of teeth and oral cavity care. Bedridden group: Long-term care services from multi-disciplinary team, health volunteers, long-term care volunteer, care givers, and care managers have been set-up. Referral service system has also been set-up to refer patients to health facilities on-time to reduce health problems and complications.

In order to face the challenges from moving to the aging society, Kalasin Municipality has been urged to concentrate on services for different types of elderly since 2011. Related activities have been implemented based on approval of community committee to respond to community’s contexts and needs. Some initiatives, such as long-term care services for the frail elderly, were proposed by the provincial or national level. However, progress of the initiatives were varied. Kalasin Municipality has shown progress in the project. The following describes some examples of related initiatives. Active group: senior citizen school has been implemented since 2015. Housebound group: long-term care volunteers have been introduced since 2014. Bedridden group: Long-term care services from multi-disciplinary teams and other stakeholders from quality of life improvement center has been set-up and received matching budget from the NHSO since 2016. Cremation fund for the poor has been set-up since 2011 with THB270,000 endowment. Currently, supporting fund with average of THB36,000 will be paid to the family of the dead. After five years of implementing the project for elderly since 2014, the number of active elderly group has been increased from 86.4% to 89.09%; the number of housebound elderly group has been reduced from 12.21% to 10.18%; and the number of bedridden elderly group has been reduced from 1.55% to 0.73% in 2019, respectively.

Key challenges of promoting related public services to all elderly are the lack of public service staff and limitation of official rules. The first challenge has been solved by promoting community participation in related services such as having health volunteers, long-term care volunteer, and caregiver participating in services for frail elderly, and “Juti-sukhawadee” volunteers to prepare peacefulness end-of-life for end-stage elderly. The last challenge has continued to improve by revising related rules and regulation of stakeholders affiliated with different ministries such as ministry of interior, ministry of public health, ministry of social development and human security for a smoother operation.

Public services for all population are usually classified by type of services organized by different ministry. When considered the population by age group, some services especially for elderly may be required collaboration among different stakeholders having different rules and regulations in terms of both roles and budgeting. Kalasin Municipality is one of a local administration office joined Long-term care service project of the NHSO to promote health and quality of life of frail elderly. Each community joining the project has freedom on how to implement the project. The Kalasin Municipality’s model chose to implement for all elderly in their community.

Three related activities, i.e., home health care by long-term care volunteers, health promotion group learning, and elderly school were integrated into quality of life improvement center for elderly and disabled. The center is managed by the community committee to promote long-term care for elderly.

Achievement of Kalasin Municipality in implementing the model has attracted other local administration offices (LAO) to visit and learn from its model. There are more than ten visits since 2017 as follows: three visits from Khonkaen municipality, Surajtani municipality, and Wangluang municipality (Roi-et province) in 2017; two visits from Talad municipality (Nakhon Rachasima province) and Nongpaen Kalasin in 2018; and seven visits from other local administration offices from Nontaburi, Khon Kaen, and Kalasin province in 2019. These local administration offices had applied some aspects of implementing the project to their community.

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Financial resources used in the project is Local Health Security Fund collected from the NHSO based on the number of population, Kalasin Municipality matching fund with the NHSO, and other stakeholders in the community. Human resources used in the project include health professionals such as doctors, dentists, nurses, public health officers, physical therapists are government officers; other community volunteers such as long-term care volunteers, community health volunteers, caregivers, environmental volunteers, “Juti-sukhawadee” volunteers; and other organizations in the community such as Kalasin university, provincial social development and human security, non-formal education office.

Kalasin Municipality’s long-term care services includes the activities to promote quality of life for the elderly as follows: 1. Social supporting system by long-term care volunteers within the community and among the elderly to support and take care of each other. 2. Health support by long-term care volunteers and public services for medical emergency through 1132 hotline for 24-hr. 3. Arranging the environment by long-term care volunteers such as installing the appropriate railing or toilets for the elderly. 4. Field service at home to ensure the elderly have access to public welfare and funds.

Yes

The project has been evaluated and gained awards both at provincial and national level as follows: LTC fund award winner in municipality class of Kalasin province, and of the 7th region in 2018; and best Local Health Security Fund award winner in 2019. Other awards include the Golden King Prajadhipok’s Institute (KPI) award winners for local administration offices having high performance on strengthening public, private, and civil society network in 2018; and Golden King Prajadhipok’s Institute (KPI) award winner for local administration offices having high performance on strengthening peace and reconciliation in 2019.

Community members has collected data using Community Health Impact Assessment (CHIA) tool to evaluate community capability, environment, and health impact factors in order to propose public policy for elderly. The proposed policy covers five related aspects, i.e., service mechanism, society, health, environment, and economic aspect.

The project aim is to promote quality of life of all elderly. During 2017 – 2019, the number of bedridden elderly improved to be housebound elderly was increased from 6.3% (3 from all 48 bedridden cases) in 2017, to 15.4% (2 from all 13 bedridden cases) and 11.1% (2 from all 18 bedridden cases) in 2018 and 2019, respectively There is a registered nurse hired by Kalasin Municipality to be a central case manager of multi-disciplinary professional team to manage the quality of life improvement center and elderly school established since May 2018.

The project has been developed and implemented based on roles and strength of related stakeholders, not only in health and non-health organization but also local and national level, participated in the project. Key factors within the community are described in question 4.c. However, relationship of stakeholders in terms of institutional at local and national level is different. At the local level, all stakeholders are responsible only for the role of their institution; therefore their budget would be used only for their responsibility. Community committee would play an important role for every stakeholder to share their plan and action and reduce redundant intervention. At the national level, related central government agencies, plays a key role to promote implementation of the local offices. Related committees or workshop organized by the central offices may be arranged in order to reduce conflict of rules or regulation among related stakeholders. As a result, many of the new rules have been announced; and many of the regulations have been revised in order to promote the progress of the project at the local level.

Before the project was promoted nationwide, central committee or agencies had been facilitated issues related to elderly. For example, five-year strategy of long term care service for frail elderly had been developed and approved by the National Health Security Committee to include in benefit package for universal coverage (UC) scheme in 2013. Benefit package for the UC scheme had been developed during 2013 – 2014. Working group (s) or sub-committee (s) had been set-up as needed. Capacity building and training were arranged for related key personnel during 2015 – 2016. Volunteer for pilot locations and information system were discussed and prepared during 2015-2016. UC scheme budget managed by the NHSO was first launched to pilot locations in 2016. Each of location administration offices had freedom to choose how to implement the project suitable to the context of their community.

Key lessons learned from this project include: 1. promoting stakeholder participation in decision making since the beginning of the project 2. designing integrated services that cover all types of elderly from home to hospital to promote continuity care for elderly 3. willingness of good governance in financing management of all stakeholders 4. collaborating actions and implementation to understand situation and reduce problems 5. having strong leadership to increase acceptance and cooperation from community Key challenge found from the project is that frail elderly usually living alone especially in day time when their family member(s) are working. This may cause problem in drug adherence, complications, or injury. Kalasin Municipality is planning onwards to establish a day care for elderly and disabled people in the community.