ADAPT TO AGING THROUGH INTERGENERATIONAL SELF-HELP CLUB: CASE STUDY OF VIETNAM
Abstract: The speed of population aging in Vietnam is among the fastest ever projected, top five in the world according to United Nations Population Fund (UNFPA, 2011). Meanwhile, the country is still at developing stage, with low middle-income level. This combination of limited time and resources makes it harder for Vietnam to address demographic transition. The Vietnamese government has been learning from other countries’ experience, especially Japan. Nevertheless, the differences in social, economic situation, speed of the aging process and level of development suggest that Vietnam should also consider a tailored approach. Since 2006, the country has been implementing a community led model called Inter-generational Self-help Club (ISHC). The ISHC model has proved to be sustainable, comprehensive, affordable and effective. The model receives strong buy in from the government and the community and has been integrated into national programs and policies. The idea behind ISHC is to promote healthy and active aging. Through ISHCs, older people in specific and the whole community in general, are cared for and more importantly, promoted. As a result, older people’s image is improved. Their untapped abilities are harnessed to become agents of social development rather than passive beneficiaries. Many other developing and even developed countries have learned from Vietnam’s ISHC model to effectively adapt to aging.
ISHC’s suitability to aging population in Vietnam
Globally, our population structure is moving from young toward aging. This situation arises when at least 10% of total population are 60 years and above (or 7% if calculated based on number of people from 65). The trend appeared firstly in the 20th century and has steadily escalated in the 21st century, especially in Asia. Factors such as increased life expectancy, declining fertility and mortality rate are main causes of aging population. In other words, aging population is a natural tendency if society develops normally.
The tailwind of golden population is fading, and Vietnam is heading toward a sharp demographic turn. The transition to aged population happens so quickly while the economy is still at low-middle income level. Adaptation to aging must now be put at the center of Vietnam’s long-term development strategy.
While developed countries in Europe and North America such as Sweden, France, Canada, the U.S.A had up to one hundred years ahead of aging demographic change, Vietnam only has 15 years (World Bank, 2016). That is the total amount of time to redesign pension, health care, labor and other public policies, then implement them effectively to match with a senior society. So far, Vietnam has not had any national programs or policies addressing aging specifically. The closest ones are Resolution No. 21-NQ/TW and Resolution No. 137/NQ-CP in 2017 on the new demographic situation; and the National Plan of Action on Older People period 2012-2020. Still, these papers aim at population issues as a whole and are not detailed enough to be a guideline on aging adaption. Additionally, aging and older people are two separate concepts. While “older people” refer to a group of citizens from 60 years and above, “aging” concerns every age, both “current old” and “future old”. As a result, a program on older people may address today’s but not long-term development issues. Later paragraphs will shed light on how ISHC is able to respond to both.
There are other gaps in Vietnam’s aging situation that ISHC was designed to fill. A notable example is the balance between care and promotion of older people. At the moment, most of our laws and policies are designed to provide care for older people. There are certain sentences in the Law of the Elderly 2009 that mention promotion, but to date they stay mostly general, without detailed guidelines, indicators and monitoring systems. Do Vietnamese people need more care than promotion of their capabilities? The answer is no. According to 2009 Population Census, approximately 50% of older people in Vietnam are young old (below 70 years old) and 35% are middle old (below 80 years old). Due to better living standard and health care, people remain healthy and active long after passing the 60 years old point, let alone their accumulated life experience which make them valuable assets of society. Younger old and middle old mostly are not weak and frail, they need more promotion than care. If society and policy makers do not take into account detailed statistics as mentioned above and view older people as one single group with similar characteristics (weak and frail, dependent), the country will certainly lose a huge amount of human resources and development setbacks are undoubting. ISHC was built on the foundation on promoting older people’s role, through capacity building, opportunities and favorable conditions. Regardless of their age, older people are encouraged to take care of themselves, invest in business, participate in social activities and helping others.
ISHC is a village-based model, aiming to improve older people and community’s well-being through inter-generational and self-help approaches, with special attention given to those from more vulnerable groups. It is an original model of HelpAge International in Vietnam and partners; and was firstly implemented in Vietnam 13 years ago in Thai Nguyen province. In Vietnam, ISHC is among very few community-led models to achieve national advocacy success. In 2012, its replication was set as an indicator in the National Action Program of Older Persons period 2012-2020, aiming at least 50% of communes in Vietnam has ISHC by 2020. In 2016, the model was acknowledged in Prime Minister’s Decision No. 1533 on National replication of Inter-generational Self-help Club, set the target of at least 2,000 ISHCs nationwide by 2020. In the same year, Ministry of Health (MOH) also mentioned ISHC in their National Healthcare Proposal for Older people period 2017-2025. Finally, in 2017, ISHC model was identified in the collaboration program between Vietnam Association of the Elderly (VAE) and MOH on promoting health and care for older people.
ISHC’s successful advocacy achievement mostly comes from its evidence-based benefits and its widely recognized advantages. In 2014, the Institute of Social and Medical Studies (ISMS), in its evaluation study, concluded ISHC to “contribute substantially to health promotion activities of older people”. The 2015 Assessing Results of United Nations Population Fund (UNFPA)’s Piloted Community-Based Model on Care for Older Persons in Ben Tre and Hai Duong Provinces conducted by the Development and Policies Research Center (DEPOCEN) described ISHC to be “making lasting impacts and long-term improvements”. The ISHC also receive international recognition. In details, a four-country study in 2017 by University of Oxford revealed ISHC to be “transforming” and “making a real difference to lives of older people”. Many evaluations and reports by HelpAge aging network also agreed on ISHC’s positive impacts on older people and community. In details, evaluation report of Korea International Cooperation Agency (KOICA) funded ISHC replication project in 2016 on 96 ISHCs in Thanh Hoa province stated such figures: after joining ISHC, 87,6% members have health improved, 87,3% have an income increase, 89% feel more confident, 86% feel happier, 100% ISHCs strengthen local solidarity and ownership.
To achieve all of the above does not require indefinite support from external resources but ISHC will maintain the momentum itself. To invest in ISHC is a one-time investment, which community and government gain infinite benefits (as long as ISHC operates). ISHC are highly cost-effective and are value for money. Vietnamese government only needs to invest 0.04% of GDP in ten years to have 100,000 ISHCs in Vietnam (meaning each village has one) (data calculated by HelpAge). In fact, in provinces that ISHC has been implemented, local contribution from community into ISHC, apart from government support, is always very high. ISHC is a successful model of community mobility.
Up to June 2019, there are roughly 1,800 ISHCs in 56/63 provinces/cities of Vietnam (data provided by VAE). These clubs have been actively contributing to the promotion and care of older people in Vietnam.
The inter-generational organizational structure implies that ISHC is a club for people of all ages. In details, it is required that about 70% of club members are from 55 years old and above, 30% are younger. This ensures ISHC’s continuity as well as creates an environment for multi-generations interactions and support. Older members of the club have knowledge and rich life experiences to share and set example, while younger members helping actively with club activity organization and management. “I had never participated in activities with persons of my parents’ age before. It is more interesting than I thought. Before I did not pay attention to my health. But after receiving advises from other senior members, I now measure my blood pressure every month. I have my role in the club too, that is helping to write down the communication knowledge and share back to those who cannot remember well”, said a 35-year old member of ISHC in Thanh Hoa province. Apart from being multi-generational, the club also welcomes both male and female members. The 70% ratio still applies, with 70% of club members are female and 30% male. There are two reasons why ratio of female members is higher. Firstly, in terms of statistics, there are more older women than older men in our society (as women have higher life expectancy). Secondly, women are often in more disadvantaged and vulnerable condition. According to 2011 Vietnam National Survey on Aging (VNAS), women scored less than men in almost all categories, from education level, health, level of care received to income, etc. Furthermore, ISHC also makes sure to have female representative leadership by requiring that in the club’s management board (CMB), 2-3 members are women. These criteria do not mean male and female members are not equal in ISHC, rather than that, the ISHC aims to ensure gender equity through women empowerment. The last condition of ISHC’s membership is based on social condition, with 70% of club members with a disadvantaged background. The ISHC’s definition of disadvantage is defined as economically and/or socially difficulty, for instance, poor/near poor, single headed household, older people living with their spouse only, older people who have to take care of grandchildren either full-time and part-time, main care givers in family, people with chronical diseases, people with disability, victims of domestic abuse, families affected by HIV/AIDS to name but some. The remaining 30% of members are people with better condition and are willing to provide support to others. This is also one of ISHC’s strategies to promote capable older people’s abilities.
For easier management, CMB establish sub-groups within the ISHC. Each ISHC has about 50-70 members, which are divided into 5-6 smaller groups; 1-2 members then assigned group leaders. Group leaders help CMB organize ISHC activities and more importantly monitor and care for every member in their groups, making sure no one is left outside. In the future, if any CMB member resign from his/her position, new CMB member can be chosen from one of the sub-group leaders, who already has leadership experience. This is one of ISCH’s methods to ensure continuous leadership. Analyzing from another angle, during ISHC monthly meeting, CMB encourage members to discuss in their groups. This smaller scale discussion helps members feel more comfortable when giving opinions, slowly increases their social engagement and confidence.
All in all, the ISHC welcomes members regardless of age, sex and living conditions; even the club’s leader board reflects this diversity. The ISHC is then divided into small sub-groups for effective management. This characteristic boosts self-help spirit, social sharing among community members and ensures inclusive development.
ISHC’s comprehensive activity areas
The ISHC has eight main activities areas. They are (1) mental and social care, (2) health care, (3) income security, (4) right and entitlement, (5) life-long learning, (6) volunteer-based home care, (7) self-help and community support, (8) resource mobilization. According to VAE, there are about 60,000 clubs for older people in Vietnam. Many older people are also members of social (political) organizations such as Association of the Elderly, Women Union, Farmers Association, War Veteran Union. Yet most of these organizations and clubs are conventional, single-functional and interest-based. They have certain limitations when it comes to meeting a person’s various needs/interests. For example, according to VNAS 2011, the main reason why older some older people do not continue working is because of their deteriorated health. As a result, providing an older person with loan only will not be enough to increase his/her income. He or she also needs health improvement activities and other labor support when needed; not to mention livelihood training and technical assistance. Being multi-functional also gives the ISHC higher flexibility and thus, it can be adopted into different community settings. Finally, the ISHC activities are in synergy with each other which increases efficiency and makes the ISHC sustainable.
The World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Within the ISHC, activities are designed to reflect all aspects of healthy aging. For mental and psychological care, the club creates a safe and opened environment for older people to interact with each other and freely share their opinions/problems (without being judged). Specific acts include getting together at least once a month at monthly meeting, joining community charity work, practicing physical exercise in a team, performing in cultural events, etc. Each club will have at least one performance team for members to showcase their talents. Singing and playing games are included in monthly meeting to create joy. As a result, older people feel more positive and confident. Under a study by Aberdeen and Sterling Universities, Scotland, the head of research, Professor Emily Rogalski came to the conclusion that older people who live confidently and positively are nearly 19% resilient than those of the same age. There is also a strong link between one’s positive thinking and a reduced risk of dementia. Regarding physical health, the ISHC focuses on the philosophy that disease prevention is best than treatment. ISHC also gives priority to respond to non-communicable diseases as they account for the majority of mortality causes in Vietnam, especially among older people (World Health Organization, 2008). Through increasing self-care knowledge, encouraging the practice of physical exercises and regular health monitoring (check up at least two times per year, monthly measurement of blood pressure and weight), ISHCs help to prolong older people’s healthy stage as long as possible. These are simple to do and effective yet cost from zero. In addition, not only older people but younger members are also advocated to monitor and protect their health. Later life is the reflection of young lifestyle, so caring for older people should start from when they were younger. This point further explains why the club model must be inter-generational. Moreover, the ISHC set an indicator for 100% club members to have health insurance at least after two years of membership. The ISHC will monitor this in a record and either instruct the person how to buy health insurance or provide financial and other technical/legal support if needed. There are other cases where ISHCs effectively support the health sector. For instance, ISHCs have been supporting commune health centers to organize health check-up, share their record of members’ health indicators and spread health related knowledge. For smaller portion of people who are weaker mentally and/or physically, the ISHC set up a team of about ten volunteers to provide care at home two times per week for at least five needy people. The ratio is two care givers per person to share workload and reduce risk of abuse if the care giver is not monitored. Health care providers shortage is often a matter for aging society. However, it is only a matter because local community’s capacity remains untapped. As explained above that older people can divided into different groups with different abilities, homecare volunteers of ISHCs are mostly near old and younger old who are still able to provide comfort and care to others. Main activities of homecare volunteers are befriending, doing house chores, providing information, helping clients practice simple physical exercise and massage, ensuring escorting service, etc. All are doable by the local community and will already have a huge impact on a person’ life if provided. The ISHC sustain this group of volunteers through its monthly activities, opportunities to enhance skill and public acknowledgement of their effort. Investing more in community-based care model such as ISHC, instead of care centers/nursery, is more suitable and economical for Vietnam. Firstly, the demand for intensive medical care of older in Vietnam is limited compared to health promotion activities and self-care. According to a survey on older people in 2,240 households, it turned out that the percentage of older people who needs daily living support is pretty low, only 13.3% need activity of daily living support even for the oldest age group of 85+ (Hoi, Thang, Lindhom, 2007). Secondly, volunteer-based homecare activity of ISHC allows older people to age in place, without having to move out of their familiar neighborhood (to a nursery or care center). Importantly, this approach of providing long-term care is affordable for the majority older people and even the country budget. As the cost of maintaining separate care facilities is enormous and only a small portion of older people can access, preceding countries in aging such as China and Japan have also advised Vietnam to focus more on community-based care model (like ISHC) and turn it into the basis of the country’s long-term care system (Asia Development Bank’s long-term care study, 2018). Furthermore, for ISHCs who can afford, they can recruit care givers of higher expertise (retired nurses and doctors for instance) to provide more complex care, with financial support from the ISHC. This advanced area is called “paid care assistant” and already piloted successfully in Hai Phong city, Bac Ninh, and Thanh Hoa province, where ISHCs use their loan interest to pay for paid care assistants (how ISHC activities complement each other).
Apart from providing homecare services, ISHC also tend to cash support, house repair, labor support with farm work, assistive devices or any other needs of older people. This is possible under the self-help and community support, resource mobilization and right and entitlement activity areas of ISHC. For instance, in Thanh Hoa, an ISHC donated cash to 19 disadvantaged persons to pay for daily needs and medical needs. In Ninh Binh, a blind lady had had her house door broken for 40 years, before it was fixed by the newly established ISHC in her hometown. In Thai Binh, ISHCs collaborated with Fatherland Front to give wheelchairs to paralyzed community members. Those who have difficulty in mobility are escorted to communal events. In Hai Phong, a member’s health insurance information was incorrect so the ISHC helped to inform related stakeholders to get it fixed. Obviously, if the ISHC is not multi-functional, it will not be able to provide comprehensive support. This is extra important for older people as they often have more difficulties in accessing information and limited mobility to reach out to different stakeholders for each of their need.
The ISHC not only bring benefits to its members, but the entire community. Apart from the fact that anybody in the village is welcomed to participate in ISHC activities, the ISHC also organize at least one community support session every month. They carry out cleaning ups, contribute labor to build public construction or giving recommendations on concerned local issues. The ISHC acts as a bridge between local community and authority and strengthens community bond through its diverse acts.
To increase members’ income, the ISHC give out loans and provide technical support. The income generating fund of the ISHC comes from various sources: Fatherland Front’s Poverty Reduction Fund (Hai Duong, Thanh Hoa), Older People Care and Promotion Fund (Thanh Hoa, Ho Chi Minh, Da Nang, Hoa Binh), local government funding (Hai Duong, Vinh Phuc, Ninh Binh), local fund raising (Hai Phong, Phu Tho, Ben Tre, Tien Phong). Ideally, ISHC should have at least 50 million VND of income generating fund at the point of establishment and 100 million VND after two years of operation. The money will be disbursed to members under micro credits with 1% monthly interest rate. The collected interest rate goes entirely back to the ISHC and will be divided into two halves. One half credited back to the income generating fund. The other is added to ISHC’s operating fund. Therefore, every month, the ISHC will generate its own income to maintain operation and organize activities for members. Because of this, members are more encouraged to borrow from the club to enrich club fund. The disbursement process is age friendly and its criteria are non-discrimination. Apart from loans, members also receive technical and labor support from the ISHC. This is very important as older people may not be able to continue the same work they had done when they were younger, especially labor-intensive work. Each ISHC establishes a group of at least five economic volunteers. These are members who are good at income generating activities and willing to share knowledge and skills with each other. Through this activity, older people’s role is once again highlighted. Life-long learning is one pillar of WHO’s healthy and active aging agenda and an important part of ISHC. Every month, ISHC organizes communication sessions during monthly meetings, with topics on income, self-care or rights and entitlement for members. Rather than just sharing their individual knowledge, CMB are trained of interactive and two-way communication to increase members’ participation and understanding. Tools such as bonus cards and gifts are also given to members who actively participate. Apart from communication for members, at least two times per year, ISHC also deliver communication to wider public either directly or through loudspeaker. Theses knowledge and skill ultimately increase older people’s ability to take care of themselves and their families.
In addition to their eight main activities, under required circumstances, the ISHC can expand its activities to climate adaptation and disaster risk reduction or transparent governance.
ISHC monthly meeting
An ISHC must meet at least one time per month in a meeting. This is the occasion for every club member to meet and share with each other. One ISHC meeting often has six parts with sessions such as entertainment, physical exercise, reporting, discussion, birthday celebration, planning and rewarding. The meeting will be less than two hours and will always be engaging and participatory. ISHCs even have special assistance for those with difficult hearing and seeing by using micro, big boards and descriptive communication documents with pictures. One more advantage of ISHC is that it is village-based. This requirement ensure participation and even though who have difficulty mobility or limited time can arrange to join.
Key for success
Firstly, the ISHC must have strong CMB. Under ISHC’s regulation, each ISHC has five CMB members who will oversee and organize all activities of the club. The ISHC’s performance depends substantially on CMB’s leadership. As a result, they must be chosen carefully. Among five leaders of ISHC, 2-3 should be female, 2-3 are older people (from 55 years old), at least one has disadvantaged background and ideally to include at least one representative of local authority in the ISHC to strengthen ISHC linkage with local authority. Since ISHC has diverse membership, CMB membership should reflect this as well. In addition, CMB members must commit to a two-year volunteer term and ensure time and health to lead various ISHC activities. Finally, people chosen to be leaders of the club should have characteristics like willingness to help, enthusiasm, responsibility and open-mindedness.
Secondly, ISHC is given proper training and support. Initial training on ISHC operation for CMB is important, because even though this model is not complicated, it is different from conventional older people’s clubs and require quite well-rounded skills such as communication skill, resources management and mobilization skill, etc. Normally, it takes an ISHC about two years to be completely self-sustained and self-managed. Therefore, ISHC need regular monitoring and support when conducting monthly meetings and activities from managing bodies.
Thirdly, ISHC must be able to generate its own income. If the ISHC cannot afford its operation but rely on external resources, not only will activities not sustainable but ISHC’s ownership is low. Each ISHC should have at least three sources of income namely a membership fee, interests from loans and local fundraising. Different sources of income will ensure ISHC’s financial stability and sustainability. Activities such as health check-ups, monthly meetings, self-help and community support, therefore, can be maintained as long as the ISHC exist.
Next, ISHC needs to follow the model’s standard regulation. One advantage of the ISHC model is that it has been standardized to a set of criteria and indicators under ISHC regulation. Abiding to these rules and ISHC can maintain its edge in aging adaptation and community development. The rule also requires all activities of the ISHC be carried out upon members’ collective agreement to ensure transparency of information and equity.
Members’ active participation in ISHC activities also play important role in ISHC performance. In order to ensure high rate of attendance, CMB needs to understand members’ need to design suitable sessions as well as create a motivating environment for members to raise their opinions.
ISHCs hardly succeed without AE’s guidance and monitor. According to a study on Older People University of Oxford, one of the reasons why ISHC in Vietnam perform better is due to AE’s participation along every step of ISHC operation, from establishment, to organization of activities, monitoring and evaluation. AE will help ISHC solve problems outside of their abilities, especially personnel. AE will also link ISHC more effectively with local authority and other related stakeholders such as health centers, agriculture extension unit, etc. Moreover, AE’s encouragement is very important. Since ISHC, especially CMB, operate based on volunteerism, on time recognition and appreciation will motivate CMB for the long-term.
Last but not least, ISHCs often perform better with support from local authorities and related stakeholders. This is crucial especially during early stage of development when ISHC is mobilizing resources for club fund or looking for suitable club venue. In return, communities with ISHC show higher result on income, health, social development and satisfaction. If ISHC representatives are invited to participate in local socio-economic development plan, ISHC will become a strong driving force for local advancement.
To successfully replicate ISHC, for provinces without ISHC before, the first step is to establish pilot models. This piloting stage allows local community to understand ISHC’s benefits and decide if the model is that local community need. Management bodies of ISHC such as local authority, CMB and local AE will also have a chance to build their capacity at this stage and draw lessons if any. Next, ISHC will be standardized or modified to fit with local context. ISHC’s design gives it high flexibility to be adapted into any settings. Then, ISHC is ready to be marketed to wider public to call for support. And if successfully, moving on to franchising stage. In Vietnam, different provinces are in different stages of ISHC replications, some just started like Hoa Binh, Vinh Phuc, Thai Binh, some already achieved the last stage like Thanh Hoa with more than 700 ISHCs already.
Current challenges to ISHC mostly from mobilizing initial income generating loan fund and building ISHC capacity building. The demand to replicate is very high while local government and community do not have enough time and resources yet to redirect their priorities into ISHC. The training of ISHC require expertise and experience which only a few organizations like HelpAge, VAE and several government bodies can provide at the moment. ISHC appeared more than ten years ago but not strongly replicated until recent years, therefore it is still a new model in most provinces/cities. To tackle the situation and completely harvest ISHC’s benefits, the Vietnamese government will need further communication of ISHC’s benefits as well as establishing a concrete collaboration scheme among related stakeholder to support ISHCs, especially financing and technical support scheme.
ISHCs in Vietnam have reached a certain reputation not only internally, but also internationally. Other countries namely Thailand, Myanmar, Bangladesh, Indonesia, Japan, Korea, India, Jamaica, China, Australia, the U.S.A, the UK, etc. have already visited and/or learnt from Vietnam’s model. ISHC may go by different names in other countries but its inter-generation and self-help remain. This is truly Vietnam’s contribution to aging adaptation initiatives in the world.
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*Chu Viet Nga, National Program Manager; HelpAge International in Vietnam
VIetnam Journal of Family and Gender Studies, Volume 14, Dec 2019, Page 46-57
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