Care homes: New norm for Nepal?

Senior citizens claiming to be satisfied in care homes should be seen as a survival strategy rather than a badge of admiration.

Poonam Thapa

Poonam Thapa

The Kathmandu Post



December 16, 2022

KATHMANDU – There are various types of care homes in Nepal that operate under the differing aegis of the Ministry of Women, Children and Senior Citizens/Social Welfare Council, the Company Act 2006 and local governments. Today, there has yet to be a validated directory of care homes. In 2021, the National Health Facility Survey by the Ministry of Health and Population included all health services and outlets except gerontology, geriatric care, nursing homes, assisted living/old age care homes or companies that provide health at home. A list of 24 public hospitals with geriatric guidelines where seniors can get free treatment is available, but there is no indication whether these hospitals are linked or are in partnership with existing care homes, even though medical and health care is a mainstay of many of these homes.

The Annual Report of Health Services 2020/21 has an over hundred-page write-up on family welfare without any mention of senior care. However, there is a separate chapter called geriatric and gender-based violence linked to One Stop Crisis Management Centres without any indication of utilisation by the elderly. Neither are care homes under the shared remit of the Department of Health Services; they would have been better off if they were. Furthermore, there needs to be an updated coordinating mechanism or a well-publicised instrument to redress grievances by families or residents.

In 2017, there were at least 70 old-age care homes in Nepal, with a total of 1500 residents. In 2018, Angalo Jeevan Bahumulya Pratishtan, foreseeing a gap in research data, commissioned a randomised field study on the socio-economic situation of senior citizens living in 15 of the 32 licenced care homes in Bagmati province with a focus on the quality of services and support for residents therein. The sample size was 200 out of 480 residents; of these, 60 were from the two-state care homes (Devghat and Pashupati), and 140 were from 13 private/sponsored homes in five districts, including Kathmandu Valley. Seventy-five percent of the residents were between 70 to 89 years old; all were sufficiently lucid. Fully paid, commercial care homes were not included in the study as they were priced out for most seniors, which is the focus of Angalo’s work. A desk review of journal articles published between 2018-22 confirmed Angalo’s finding rather than overtly contradicting it.

Care homes are not necessarily a bad concept. Often, they may be the only option for seniors to find physical help and emotional support. Nevertheless, there are enough cases where sending parents away has become an act of deliberate cruelty and where care homes are preying upon the desperation of families and their residents. Actions taken by both parties are always a choice, and hence the motivations and the mindfulness of the people concerned truly matter. Even 1 percent of any violence is disturbing, but 33 percent in care homes, much of it harmful like withdrawing food and clothes, verbal abuse, or isolation is unacceptable. Unlike everyday life, there is no gender divide in the type of violence, as both women and men are at the receiving end, mainly at the hands of staff.

Seniors in Bagmati province were in care homes when their utilitarian years within a family were considered over, and their dependency on resources of earning children increased. Resident couples were rare; significant numbers were widows, less so widowers, and quite a few singletons. Religion or upper caste background was no barrier to being sent away. Senior citizens are not a heterogeneous group. Hence, people in care homes cut across every social and economic class as well as employment status, with those who defined themselves as better off and the poor dominating one-third of each side of the spectrum.

There was general satisfaction with food and lodging but not clothing and hygiene in private/sponsored care homes. Frailty tests were non-existent, and healthcare treatments were problematic, particularly in state-run homes. Health conditions varied but were more often than not related to being old/older. These conditions could be treated with nutritional supplements and the right kind of physical activity. With the exception of TV, social life and outside excursions were severely lacking, as was indoor entertainment. Most residents said they liked to sleep, but inactivity was a vicious cycle, and oversleeping or resting could be a marked sign of depression. A good number of these homes did not access the free care provided by the government, while in other cases, care homes complained that staff of local public health facilities would not show up for scheduled visits.

There seems to be a laissez-faire attitude from all sides, like older people’s lives or pain do not matter. Regular and authoritative supervision or monitoring is almost non-existent, and the state-run homes are not the role models.

Education and employment were not ready-made options for the current older generation in homes. Nearly 60 percent defined themselves as small farmers from what were rural areas in the past. Many residents perceived government policy towards them as moral but said it was too little, too late. They were optimistic about the elderly but were cautious about saving for the future and not relying on family members. A few people who could combine savings schemes, contributory provident funds, and employer/child support had a decent standard of living. Such residents, however, remained hesitant to demand quality assurance for fear of being returned to family or relatives.

For the destitute, the universal social pension was a lifeline. For those whose basic needs were sponsored, it helped pay for extra necessities; but in both cases, the financial support was empowering. However, access to social pensions was unequal, especially among the uneducated, poor and rescued. Most often, the cause was the lack of proof of citizenship and required documentation. The numbers of such people were small, but to be deprived of identity in old age is harsh, and solutions need to be found by the local government to see it as a facilitator rather than an obstacle. It was heart-warming that even with so little, quite a few senior residents opted to help their compatriots, and there was cooperation between sponsored care homes in the districts of the study area.

Residents were clear they would opt for the care homes they were in even if they had a choice. Yet two-thirds ‘chose’ to join one and learnt to accept and be happy within its four walls, and a significant number never wanted to return to their family. The loss of connection to all that was familiar remained painful, as did death, but it had not been dealt with as a mental health issue. The word ‘choice’, in the sense of a resident saying, “I choose to come to a care home and wish to be here forever”, is a double-edged sword. It is so especially when 58 percent said they had assets seized and documentation taken with impunity, abused or increasingly isolated, neglected or ignored by family members. A few seniors said they did not feel safe and secure in the family homes they built. Hence, the high response of satisfaction, regardless of poor standards in care homes, should be seen as a survival strategy for the seniors rather than a badge of admiration.

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