Elder Care in Sri Lanka: Are we Prepared for the Future?

By: Thahira Cader for the Centre for Poverty Analysis (CEPA)

Sri Lanka’s Growing Older Population:

The outbreak of the COVID-19 pandemic cast a spotlight on the growing needs of older persons, aged 65 and above, and the rising demand for eldercare in Sri Lanka. During government-imposed lockdowns when existing support systems were disrupted and people were compelled to isolate themselves at home, the elderly population faced unique challenges. For example, limitations on digital literacy to access the virtual world had an insulating effect on many older persons who lived alone, and several found it difficult to access online systems to order essential supplies including medicines and groceries. These lived experiences have brought to light underlying issues and highlight the necessity of designing and implementing enhanced support systems for the adequate and sustainable provision of care for older persons in the long term, particularly in times of crisis.

It is projected that by the year 2042, persons over the age of 65 years will increase from 1.6 million to 4 million[1] and approximately one in every 4 persons will be over the age of 60 by 2042.[2] Generally, it has been observed that individuals within the working age population (approximately those between 18 to 60 years of age), or a family member within the home, bears the responsibility of caring for older persons at present. Yet a worrying trend is that the working-age population and those who could be potential care providers are also projected to decline in the coming years. Thus, with a growing older population and a shrinking pool of youth to provide long-term support and care work, Sri Lanka appears to be heading toward a care deficit.

At this juncture, a glimpse into what may lie ahead for the country gives rise to several pertinent questions: Is Sri Lanka prepared to meet the growing demand for eldercare? What are the challenges emerging in this sphere? What steps can be taken today to overcome the estimated care deficits of tomorrow? This blog article is an attempt to answer some of these questions, with the hope of initiating a discussion, raising awareness, and driving decision-making and policy reform to enhance the quality and capacity of care for older persons in the country.

Elder Care in Sri Lanka Today

The International Labour Organization (ILO) defines care work to encompass “activities and relations involved in meeting the physical, psychological and emotional needs of adults and children, old and young, frail and able-bodied.”[3] In Sri Lanka, eldercare forms a critical component of care work, alongside the provision of early childhood care and development.

The needs of older persons are not uniform and vary significantly depending on each individual’s level of mental and physical well-being. For example, some older persons may experience cognition-related problems that affect their memory or ability to process information at different stages of their aging, while others might experience difficulties with walking and mobility or suffer from non-communicable diseases (NCDs). Thus, care work in this context may include a range of diverse activities and services such as cooking, washing, cleaning, shopping, taking care of the ill or disabled, and even providing companionship and basic support for healthy older persons to enable them to live independently and with dignity.

Additionally, the provision of eldercare in the country cuts across both the formal and informal economies, spanning the health and social sectors as well as the private sphere, with care being provided at home. Longstanding social structures and traditions have ensured that families and even communities take on the responsibility of caring for their older family members, and they often  reside with their children or nearby, in both urban and rural areas.

The provision of care in Sri Lanka reflects a gendered dimension and is predominantly supplied by women within the home. This is largely due to the lack of quality specialized services, and socio-economic structures which make accessing paid services unaffordable for most. Therefore, at present, it is through unpaid care work that most of the existing care needs of the older population are met. This poses a significant barrier to women entering the workforce, whilst also placing a double burden on the groups of women engaged in both full-time paid work and the provision of (unpaid) care at home, a trend that was heightened during the pandemic.

Meanwhile, the option of providing professional paid care for older persons also exists, and the demand for such services has been rising over the years. Through institutional care, older persons who require shelter may find options for housing, and those in need of long-term care and specific nursing facilities have avenues for support. However, these services are limited, and the existing institutions in the country are often at capacity, struggling to meet the rising demands. In fact, it is reported that currently, only 6 state-run eldercare institutions are operating across the country with limited State funding, whilst other institutional care facilities are provided through private entities funded by non-governmental organizations (NGOs) or charitable foundations.

Aside from this, home-based paid care remains the preferred choice. Yet, the lack of resources and the inadequacies in providing standardized training for nurses and caregivers, as well as the exorbitant fees associated with providing private paid care at home remain barriers to making these services easily accessible and available to all income groups. Thus, paid care work at within the home remains accessible only to a minority of the population.

Changing Demographics and Increasing Care Deficits

In 2012, on average there were seven adult persons to provide support for one older person. However, this number is estimated to drop to less than 3 persons by the year 2032.[4] If the current trends remain the same, by the year 2032, Sri Lanka will require an additional 130,665 persons to ensure a minimum of 5 long-term care workers per 100 elderly persons. This estimated care deficit will increase to 165,091 by the year 2042.[5]

The increase in life expectancy and the higher rates of NCDs have contributed to the growing need for elderly care in the country. Additionally, changing social factors influenced by the COVID-19 pandemic, the economic crisis, and other circumstances, are affecting the ability of families to provide sustainable care to the older generation which contributes to this growing care deficit.

The prevailing economic crisis has placed a heavier burden on primary caregivers, including women, who are increasingly taking up paid-work to meet the rising costs of living. This has led to less time available to provide quality care for older persons living in the community. Other trends including the growth of nuclear families, and migration both overseas and within the country are some of the emerging patterns that are reshaping the social fabric and contributing to higher dependency rates and a growing need for eldercare.

Thus, it has become extremely challenging to meet this growing care deficit through family support alone. As circumstances compel individuals to gravitate away from traditional structures, it will become crucial for the State to step up in a formal capacity to provide resources, training, financial support, social security, and a regulatory framework to ensure that the country is better prepared to take care of the specific needs of its older population in the next decade.

The Challenges in Meeting Eldercare Deficits

To meet the future eldercare deficit, several gaps in the existing system must be acknowledged and addressed holistically.  Two of the key challenges identified at present relate to 1) the limited State support available for eldercare; and 2) the increasing deterrents for working in the care economy despite the growing demand for care work.

• Limited State Support

Although several laws and policies such as the Protection of the Rights of Elders Act and the National Charter for Senior Citizens are in place and aim to meet the growing needs of the elderly population in the country, there remains a lacuna in resources, funding and training programs for caregivers supported by the State. Additionally, whilst there are numerous health policies including the National Elderly Health Policy (2017) and the National Strategic Framework for Palliative Care Development in Sri Lanka (2019-2022) which cater to the older population, there remains a dearth of trained doctors possessing skills and knowledge in geriatric care. Evidently, the State medical sector has only two geriatric units for the entire country, one at the Colombo South Teaching Hospital in Kalubowila and the other in Kadugannawa, Kandy, complemented only by a handful of doctors undergoing training in this field at present.

The Protection of the Rights of Elders Act emphasizes that children cannot be negligent in providing care for their parents and a strong sense of responsibility is placed on them. However, the responsibility placed on the State to provide adequate support systems and assistance to these families to ensure quality and accessibility to essential services and social protection schemes remains minimal. Perhaps drawing from this, State and national authorities provide little support and assistance towards regulating and overseeing the small number of institutions and facilities providing care and nursing for older persons in the country at present. Thus, the quality of services and the standards of available professional care for older persons in the country are questionable.

• Deterrents for Working in the Care Economy

Although the care economy has been recognized as a bright spot in the future of work in Sri Lanka, there are several factors that deter individuals from willingly entering both the formal and informal sectors. Thus, despite the growing demand for elder caregivers in the country, the workforce in this sphere is rapidly shrinking.

For those individuals engaged in paid care work, these deterrents include the lack of decent working conditions with adequate safeguards guaranteed through laws and policy frameworks. For example, individuals engaged in paid care in the capacity of domestic workers often fall outside the scope of the law as they are not governed by a contract of employment or formal working arrangement and therefore have no opportunities or recourse to receive social protection, minimum wages, and pension schemes through their places of work. Even in the private sector, where care work may take place in a formal capacity, there is minimum protection for workers and the responsibility of ensuring and guaranteeing social protection falls in the hands of employers, with little compliance. Thus, the need for ensuring social protection mechanisms and the guarantee of basic rights that are accessible to all workers regardless of the type of employment or contractual relationship is vital, to encourage more skilled workers to engage in care work.

Aside from this, there are limitations on the available options for skills and training opportunities for paid care providers which has a direct impact on the long-term supply of care work in the country. There is no standardized curriculum for care-based skills, leading to a shortage of skilled labor. Additionally, because of the poor working conditions and negative social perception towards paid care work in the country, the small number of available skilled workers prefer to seek employment opportunities overseas, for better pay. Meanwhile, those engaged in informal care work have little incentive due to no prospects of career progression.

The focus in the sphere of elder care has also largely been geared towards ensuring the well-being of those being cared for, whilst the caregiver’s well-being has been sidelined. However, the emotional burden and stress associated with the provision of full-time care work, which often goes unaccounted for, has a serious impact on the overall quality of the care ultimately provided. Thus, the need for a basic regulatory framework to provide caregivers with minimum protections to ensure decent working conditions and dignity of labor is critical. This is especially so, in the face of growing demands for elder care, and a shrinking population of caregivers in the country.

A Way Forward

As Sri Lanka grapples with changing demographics and seeks solutions to tackle the growing needs of its elderly population, several avenues have been suggested as a way forward.

As a first step, a model of community-based care to support elders which relies on the strength of volunteers or caregivers living in the vicinity, has been proposed. This approach would allow for the strengthening and adapting of existing structures within local communities, allowing for the prioritization of specific needs of elders, minimizing the overall costs of services and improving accessibility to healthcare systems, with the necessary oversight and monitoring provided by the State. Most significantly, a community-based system will allow many elders to continue to exercise their independence and agency, whilst also receiving companionship and assistance to manage their daily activities. Likewise, creating facilities such as daycare centers for elderly persons to provide opportunities for socialization, exercise, participation in recreational activities and engagement with their peers may be a viable alternative, which will also contribute to their overall well-being and prevent rapid declines in functional ability.

Secondly, it is vital for State institutions to take responsibility to provide formal, standardized training and skill development for elder caregivers, to prepare for the increasing demand for formal care that is expected in the future. This could also entail training opportunities for volunteers and informal caregivers who are interested in supporting the community-based model.

Finally, it is essential to create an environment conducive to decent working conditions for care workers to increase capacity and the available workforce to meet the growing deficits. This may entail increasing awareness of the legal rights of care workers and improving the knowledge of employers on their responsibilities to hold them accountable, making laws more accessible and simple, reforming laws and policies to ensure specific categories of workers are guaranteed protection under existing frameworks, and providing workers with access to social security benefits regardless of their status of employment.

The goal of ensuring that the specific needs of the growing elderly population are met will require policy reforms and systematic planning across different sectors, to guarantee their health, well-being, and quality of life. Undoubtedly, this will involve long-term design and implementation which may not be achieved overnight. However, several measures, including those proposed in this discussion, may be initiated in the next few years and may serve to fast-track addressing many of the challenges that are already emerging in the sphere of elder care. This will contribute towards effectively meeting the projected care deficits expected by the year 2042, reduce additional burdens on the system, and ensure sustainable methods of providing elder care in the long term.

[1] Census of Population and Housing (2012)

[2] Census of Population and Housing (2012) and the population projections calculated for the period 2012-2042 as   part of this study by Dr Sunethra Perera.

[3] ILO Report, Care Work and Care Jobs for the Future of Decent Work (2018)

[4] CPH, 2012 & Population projection for 2012-2042 calculated by S. Perera

[5] CPH, 2012 & Population projection for 2012-2042 calculated by S. Perera

The article was first published on The Morning on 01 July 2023, https://www.themorning.lk/articles/Y0oCbz4K9xcXKxqev1CH