(WP)HSD/ICP/PHC/OO2-E
Report series number: RS/9S/GE/03(PHL)
English only
~i>ORT WORKSHOP ON COMMUNITY HEALTH CARE APPROACHES TO IMPROVE /; QUALITY OF LIFE IN THE ELDERLY
Convened by: WORLD HEALTH ORGANIZATION
1
REGIONAL OFFICE FOR THE WESTERN PACIFIC
Manila, Philippines 20-24 March 1995
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NOTE The views expressed in this report are those of the participants in the Workshop on Community Health Care Approaches to Improve Quality of Life in the Elderly and do not necessarily reflect the policy of the World Health Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Workshop on Community Health Care Approaches to Improve Quality of Life in the Elderly, Manila, Philippines from 20 to 24 March 1995.
CONTENTS
SUMMARY ................................................................................................... 1 1. INTRODUCTION ...................................................................... ·····.·········· 3 1. 1 1.2 1.3 1.4 2. Objectives .......................................................................................... Participants and resource persons ............................................................. Organization ....................................................................................... Opening ceremony ............................................................................... 3 3 3 3
PROCEEDINGS ........................................................................................ 5 2.1 Summary of country reports ................................................................... 5 2.2 Summary of presentations ...................................................................... 6 2.3 Summary of discussions ......................................................................... 8
3.
CONCLUSIONS ....................................................................................... 9 ANNEXES: ANNEX I LIST OF PARTICIPANTS ...................................................... 15 AGENDA .......................................................................... 21 COUNTRY REPORTS ........................................................... 23 SUMMARY ANALYSIS OF RESPONSES TO THE BRIEF QUESTIONNAIRE DISTRIBUTED TO PARTICiPANTS ................................................................... 53 MODEL ACTION PLAN FOR DEVELOPMENT OF COMMUNITY HEALTH CARE APPROACHES TO IMPROVE QUALITY OF LIFE IN THE ELDERLY .................................... 55
ANNEX 2 ANNEX 3 ANNEX 4 -
ANNEX 5 -
Keywords: Aged / Health services for the aged I Community health services / Quality of life / Home care services / Philippines
SUMMARY
A Regional Workshop on Community Health Care Approaches to Improve Quality of Life in the Elderly was held in the Regional Office for the Western Pacific of the World Health Organization, Manila, from 20 to 24 March 1995. It was attended by 16 participants representing 16 countries and areas in the Region. The objectives of the workshop were: (I) to promote home-based and community-based approaches to the care of the elderly and chronically ill; (2) to utilize experience in home-based approaches as incorporated in the Quality Health Care for the Elderly Manual as a basis for developing mechanisms for the transfer of current institution-based technology and skills to homes and communities; and to develop an action plan to support activities, including training and health (3) services research, for further strengthening home-based and community-based approaches in the care of the elderly. The urgency of the situation and response required varied by country, largely dependent upon countries' level of development and demographics. The 16 countries reflected the diversity within the Region. Participants discussed the following issues: - barriers to the development of community health care for the elderly at the country level; - principles for national development of community health care programmes for the elderly; and implementation of healthy aging and community health care for the elderly.
The final conclusions of the workshop focused on the following: (I)
the creation of a National Council on Aging or equivalent governmental advisory body to oversee the development of the national response to population aging and the needs of the elderly; a national policy on health and care of the elderly;
(2)
(3) the need for an identifiable focus for advocacy, planning, training and administration within national ministries of health; (4) the importance of close liaison between health and welfare services at all levels including the central authorities and field services; (5) training for health care workers in issues associated with aging, the management of chronic disease and disability, and community-based services;
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(6) development of mechanisms to increase awareness of the concepts of healthy aging, health promotion and protection, and community health care for the elderly among the elderly themselves, the general community, and existing community and family carers; (7) development of health education and health promotion programmes directed to the health needs of the elderly and their carers; (8) (9) (10) healthy aging as an integral component of general lifestyle programmes; the preference for the elderly to be cared for in the community in a family setting; establishing multidisciplinary care teams at community level;
(11) development of criteria of need for provision of various levels of care and support for the elderly; (12) access, assessment, rehabilitation and effective discharge planning to ensure a smooth transition of the elderly from hospitals back to the community and to improve continuity of care; (13) (14) (15) review of current systems collection of demographic and health care services; gender-specific characteristics and needs of older women and men; continuing support for health services research, and programme evaluation;
(16) the need for national workshops on strategic planning of community services for the elderly as a follow-up activity to the regional workshop; (17) a regional follow-up workshop to review progress towards implementation of national action plans for development of community-based health care for the elderly.
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I. INTRODUCTION
A Regional Workshop on Community Health Care Approaches to Improve Quality of Life in the Elderly was held at the World Health Organization Regional Office for the Western Pacific, Manila, from 20 to 24 March 1995.
1.1
Objectives The objectives of the workshop were: (I) to promote home-based and community-based approaches to the care of the elderly and chronically ill;
(2) to utilize experience in home-based approaches as incorporated in the Quality Health Care for the Elderly manual as a basis for developing mechanisms for the transfer of current institution-based technology and skills to homes and communities; and (3) to develop an action plan to support activities, including training and health services research, for further strengthening home-based and community-based approaches in the care of the elderly. 1.2 Participants and resource persons
The Workshop was attended by participants representing 16 countries (see Annex I). Mr W. Bruen (Australia) was elected Chairman, supported by Ms G.R. Estipona (Philippines) as Vice-Chairman and Dr T.K. Au (Hong Kong) as Rapporteur. 1.3 Organization
The workshop was conducted in both plenary session and small group discussion formats. Presentations delivered in plenary sessions provided the basis for small group discussions. Participants, together with Temporary Advisers, Consultant and Facilitator proceeded according to the stated agenda (Annex 2), and divided into three groups to address the issues outlined in 1.1. These were looked at in three categories as follow: (a) barriers to the development of community health care for the elderly at the country level; (b) principles for national development of community health care programmes for the elderly; and
(c) 1.4
implementation of healthy aging and community health care for the elderly.
Opening ceremony
The Workshop was opened on behalf of the Regional Director, by Dr B.P. Kean, Director, Programme Management, who emphasized the importance of high quality health care and community-based services for the elderly. WHO was committed, he said, to ensuring that the highest attainable standard of health was enjoyed as a fundamental human right by all people. Two concepts central to achieving positive health would be particularly important in the coming years: health promotion and
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health protection. Health promotion referred to the sorts of measure that could be taken to encourage and enhance what people could do themselves, with their families, communities and nation, to improve and manage their own health. Health protection recognized the fragility of human life, and the need to provide whatever reinforcement science and other advances in ./~ learning and understanding could bring. Several of the major targets for health for all by the year 2000, such as reduced infant mortality rates, and improved life expectancy and adult literacy, had been reached by most countries and areas of the Region. Frequently, however, where life expectancy had increased as a result of related sociodemographic changes, new areas of need had emerged. The rapid increase in numbers of the elderly had significant implications for many areas: their health care, the financing of their needs, their accommodation, and their role in a fast-changing and increasingly urban community. Looking at the health issues emerging in the Region, it was clear that the response must be immediate, creative, and an important part of public policy. Although generally in the Region, vaccine-preventable communicable diseases were decreasing sharply, noncommunicable diseases were increasing. Rather than each problem being tackled separately, on a programme by programme basis, the issues must be looked at holistically, as part of the larger context of positive health. This approach required different ways of using resources and expertise both in WHO and, probably, in other organizations. In the Western Pacific Region, three groupings of programmes were being explored, dealing with specific aspects of health promotion and protection. The first directed resources to aspects of preparation for life, focusing on the health of children. The second dealt with issues such as those relating to prevention of diseases and the protection of life. The third grouping was perhaps the one that was most pertinent to the workshop as it dealt with later years of life and quality of life. It had become generally accepted that it was not just survival, but quality of living that was important. With the increasing proportion of older people in populations in the Region, ways of sustaining and preserving health in this large group were becoming ever more important. A healthy childhood and adulthood was probably the most important determinant of healthy aging. Thus, a focus on quality of life in older age also addressed the issues of quality of life throughout life. However, several trends had adversely affected quality of life for the elderly. Urbanization and other societal changes had altered the level and character of family, community and institutional support which enabled individuals to attain a high quality of life. The number of people with chronic illness and disabilities in all age groups was increasing owing to the rise of degenerative diseases, accidents and other health problems associated with modernization. Technology-based interventions, frequently regarded as necessary to allow individuals to live lives of good quality, were expensive, complicated and, in many instances, of doubtful effectiveness. He concluded that the challenge facing all those in the health field today was to find ways to enable all individuals to acquire and maintain capabilities required to lead their lives to their full potential. This was particularly true of the need to improve the well-being and qual ity of life of the elderly.
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2. PROCEEDINGS
2.1
Summary of country reports
Dr A.G. Romualdez, Director, Health Services Development and Planning, gave a brief introduction and overview of New horiZOlls in health and the theme of quality of life; Dr R. Ratnaike, Temporary Adviser, elaborated upon the WHOIWPRO initiative on quality of hfe. Country papers were then presented. Four countries were featured as examples of countries which had implemented successful strategies for development of community health care options. Mr W. Bruen described the initiative of the Home and Community Care Programme in Australia. Dr Lin Van reviewed demographic trends in China together with policy on planning community-based programmes and training programmes for care of the elderly. Dr Zhu Han Min presented additional data on demography in China and described the network of community care for the elderly that had been established in Shanghai. Dr Y. Takigawa presented plans for reorganizing existing care services in Japan and Dr H.K. Shin described plans to strengthen community-based health services for the elderly in the Republic of Korea. The full text of these papers is given in Annex 3. Annex 4 gives a summary of pre-workshop survey data from participating countries. Other countries outlined the current situation. Cambodia: The country has been tremendously disrupted by years of conflict. Nearly half of the population is below the age of fifteen and deaths due to communicable diseases are high. At this stage, the major health problems are malaria, tuberculosis, diarrhoea, and other infectious diseases. There is urgent need for improvements in nutrition, and in reducing infant and maternal mortality. Since the Paris Peace Agreement in 1991. the Government has developed a national programme of socioeconomic rehabilitation, and provision of basic health services remains the priority. Cook Islands: Fundamental responsibility for care of the elderly lies within the extended family and friends. Although hypertension, diabetes, and cardiovascular diseases are prevalent among the elderly, there is no programme in training and management of health needs of the elderly at present. Fiji: The percentage of the population aged 60 years and over is 4.6%. National health services provide comprehensive care for all groups of people. The health care policy on the elderly focuses on preserving dignity, independence and autonomy in the context of family and community. This includes acute hospital services, residential care, and health promotion. Hong Kong: The percentage of the population aged 60 years and over increased from 7.4% in 1971 to 12.9% in 1991. Family care, neighbours and friends play an informal role in contributing to community health care for the elderly. Primary health care services play an important role in delivering community health care services for the elderly. There are 84 home help teams operated by nongovernmental organizations. Day care centres, social centres, and multiservice centres are available. Outreach services for the elderly at risk are also provided. The Government has been working on overcoming barriers and improving health care services. Lao People's Democratic Republic: The population is relatively young with a life expectancy of 48 years for males and 52 years for females. As yet, there are no policies on health care for the elderly. Malaysia: Rapid development and industrialization have all contributed to improvements in living conditions and length of life. Health care of the elderly is integrated into various programmes, including diseases prevention and rehabilitation. The country is
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into various programmes, including diseases prevention and rehabili~ation. The cou.ntry is working on developing community health care for the elderly, focusmg on commumty awareness, policy direction, organization, regulation, and training. New Zealand: Health services for the elderly are weJl established and have recently been revised. The reforms are not yet complete but include a partially contracted-out, privatized approach to health care delivery, in which purchase and provider functions are seperated. Concurrent with this direction, community-based care and caregiver support will be expanded in the plan. Philippines: Most of the elderly are cared for by family members. Health programmes focus on the control of factors that contribute to diseases among the elderly, such as cardiovascular disease, pneumonia, cancer, stroke, chronic obstructive pulmonary disease, and influenza. Community programmes have been successful in some parts of the country. There are 23 community-based programmes for the elderly at present. Samoa: The elderly are cared for by the family, supported and strengthened by community health nurses who have received some training in chronic diseases management in the elderly. Primary health care workers also contribute to supporting the family in care of the elderly. Singapore: The services provided by the Ministry of Health range from acute hospital care, intermediate hospital care, residential care and day care, to home nursing services. There are 15 home nursing centres and senior citizens' health care centres. Community psychogeriatric services, domiciliary medical services, hospice care, and institution-based services are also available. Tonga: Care of the elderly is provided by family members and nongovernmental organization.sas well as church groups aimed at keeping the elderly as independent as possible. Viet Nam: The Ministry of Health has developed a basic health care system covering the country. There is no specific programme for health of the elderly although some training courses are conducted. 2.2 Summary of presentations
2.2.1 Overcoming barriers: approaches to promoting healthy aging at community level Dr R. Erben, Regional Adviser, Health Promotion, described the background and development of New horizons in health, and its relationship to health promotion. The necessity for reassessment and reevaluation of traditional programme approaches had been affirmed in numerous forums. New horizons in health proposed a framework for a future direction that departed from the disease-centered orientation to emphasize a human development approach. She then briefly reviewed the three major themes in New horizons in health (Le. preparation for life, protection of life and Quality of life in later years), the rationale for major issues, subobjectives, approaches and indicators. Dr P. Lowry, Regional Adviser, Health Systems Development, addressed the concepts of primary health care and community health care. Together, they related to delivery of services to persons at the periphery, and employed the resources of the famil y and community health centre (CHC). Rural health workers in CHCs were de facto members of the community and, therefore, community leaders. Although their leadership role was substantial, rural health care workers might not be well trained in principles important to management of health care needs of the elderly, especially those which involved educational approaches. Therefore, it was likely that these competencies would have to be strengthened.
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Dr Chen Ken, Medical Officer, Traditional Medicine, speaking about traditional medicine, stated that it consisted of therapeutic practices which had been in use over many years, and were generally passed from one generation to another by oral tradition. It included such things as various forms of exercise (for example rai chi), traditional foods and dietary practices, and use of herbal medicines. Also covered by traditional medicine were some homeopathic practices, alternative practices, and the role of traditional healers in community health care. WHO sought to promote the safe use of traditional health interventions and incorporation of these practices into modern medicine, in curative, preventative, promotive, and rehabilitative aspects. Mr M. Anderson, Management and Research Support Officer, stressed the importance of intersectoral cooperation in accomplishing key priorities in primary health care. 2.2.2 Education and training needs for promoting healthy aging at community level Dr C. Sheehy, WHO Consultant, suggested it was necessary to enlighten health care workers, the elderly, caregivers and communities that many of the behaviours and problems of the elderly were not an inevitable part of aging. Education about illness in old age could help to prevent crisis situations through early detection and treatment of diseases that often presented typical and subtle changes at onset, and through distinguishing corrections between expected age-dependent changes and alterations that are clinically meaningful indicators of disease or illness. Motivation was an essential part of health promotion in both the elderly and their caregivers. 2.2.3 Monitoring healthy aging and quality of life outcomes of community health care Dr R. Ratnaike emphasized the importance of quality of life for healthy aging and provided information about the WHO quality of life measurement scale initiative. Quality of life generally included consideration of physiological and physical parameters, psychological and social well-being and social relationships, degree of independence, the influence of the environment, and dimensions of spirituality. Quantification of these domains was accomplished by use of indices and instruments. An indicator was a variable that attempted to measure directly or indirectly, change in status and/or the extent to which objectives and programme targets were attained. Categories of indicators included health policy indicators, social and economic indicators, and indicators of health care delivery. As a first step, 300 items had been contributed from focus group discussions, to form the original measurement tool. The scale had now been reduced to 100 items in an instrument titled WHOQOL (WHO Quality of life assessment) which was currently being tested. Scale items were constructed to include measures of intensity (e.g. How much do you worry about money?), capacity (e.g. How refreshed do you feel after sleeping?), evaluation (e.g. How is your health?), and frequency (How often do you feel sad?). Professor G. Andrews, Facilitator, explained the utility of such measures as healthy life expectancy and disability-free life expectancy in answering the need for national strategies for health promotion and health protection. These measures, which were being funded, developed, and refined by an international network of researchers (REVES), might also be useful in making country and national comparisons of population health and functional status. Dr Sheehy integrated the presentations of Dr Ratnaike and Dr Andrews into the issue of programme evaluation. Although programme evaluation had many dimensions, contemporary approaches focused on cost and quality of clinical care outcomes, and the experiential component of patients (that is, the personal interpretation of the health experience), also termed quality of life. Goal attainment and status measurement were typically measured incrementally as well as at the projected end point.
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2.2.4 New horizons in health, theme III project Mr Y.H. Yoo, Technical Officer, Health Care for the Elderly, presented an elegant example of how an ICP project proposal for health promotion support of the elderly, in and by the community, might appear. The recommended format would cover objectives, a short description of the project, planned approaches and outcome indicators. 2.3 Summary of discussions
2.3.1 Barriers to the development of community health care for the elderly at the country level Numerous barriers were ex.amined but those considered to be among the most formidable and the most in need of rapid address were: inadequate budgets and financial support; legitimate competition with other health and social policy priorities; inordinate competition and associated low profile of aging as a policy priority arising from lack of knowledge about the phenomenon of healthy aging and the needs of elderly people with illness or disability, and disagreement as to the proper role and sharing of responsibility between governments and families; cultural and ethnic diversity within countries, which makes achievement of unanimity or at least majority consensus on aging issues more difficult;
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- viewing the elderly as a burden rather than as sources of knowledge and esteem; - divergence of health and welfare authority functions, and insufficient collaboration among disciplines and services, and between national and district levels, which reduce the effectiveness of community care; lack of prestige and financial remuneration for health care workers in health care of the elderly in comparison with hospital-based specialities, which makes the field less attractive.
2.3.2 Principles for national development of community health care programmes for the elderly Key principles of national development included the following: Incorporation of a policy on aging into existing community and primary health care policy statements. This is helpful to an integrated, mainstream approach: more focused policy initiatives may be appropriate in countries with greater reliance on specialization. The importance of multisectoral cooperation and collaboration in policy formulation and decision-making. Social and health care workers, administrators in welfare, housing, and women's affairs, the elderly and their families, have particularly important roles to play.
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- The need for both quantitative and qualitative data for effective national development of programmes, as well as for later evaluation. The purpose and potential benefit of the data should be compared to the real or anticipated difficulties of data acquisition.
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- The need for training in many sectors, especially amongst health care professionals in practice, students in academic settings in preparation for professional roles, the elderly, their caregivers, and the general community. Attention to the principles of healthy aging is important in all stages of life. - The importance of standards of care, protocols and guidelines supporting consistency and quality of care. 2.3.3 Implementation of healthy aging and community health care for the elderly Needs assessment is a logical first step. Existing data sources may be used to assess trends. Additional indicators such as degree of disability, information about those who are caring for the elderly, how many of the elderly are not being adequately cared for, and resources and social development of the country, may be required. Assuming funds are required to conduct such an assessment, a national intersectoral task force, including social and health representatives, would work to draft recommendations, including costs and potential sources of funding, for example UNFPA, UNDP, World Bank. The complete action plan is outlined in the conclusions and the model action plan in Annex 5.
3. CONCLUSIONS
The Regional Director, Dr S.T. Han, closed the workshop. He reiterated the importance of quality health care for the elderly, and endorsed continued activities in this area. He said that quality of life in later years was one of three major themes on which the Western Pacific Region of the World Health Organization would concentrate its efforts in the coming years and community health care was the most appropriate strategy to achieving the goals linked to this theme. Community health care prevented premature institutionalization of the elderly. That was not to imply that institutionalization was not appropriate in some cases, or that it did not improve the quality of life. In fact, for those elderly people who did not have a minimum of resources and supporting families or friends, and were not healthy enough to live independently, institutionalization in some form could improve the quality of life by providing shelter, food, and other services needed. However, institutionalization should be used only as a last resort because it might curtail an old person's freedom and independence, and subsequently lead to decreased mobility and activity. Moreover, many surveys had found that institutional life was the least favoured choice of elderly people in Western as well as Asian countries. According to an international survey in 1991, less than 2% of Korean elderly people had answered that they would like to move into housing for the elderly when they needed care; 35% preferred to stay at home and 38% to move to a child's home. Among Americans, 8% wanted to move into housing for the elderly, 61.6% wished to stay at home, and 8% wanted to move to a child's home. With proper community health care, it was likely that the elderly would be able to stay in the community much longer while still enjoying their independence. Family and community members who cared for the elderly should be supported in their efforts by being taught appropriate health promotion and protection techniques. Family members and relatives might also be more willing to take care of their elders if they had access to community health care support, as this would reduce their burden of care.
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Another strength of community health care was its relatively low cost. The increasing costs of health care for the elderly were becoming a great burden on many nations as a whole, and on individual families. In Japan in 1985, for example, people aged 65 years and over represented about 10% of the total population but accounted for 38% of the nation's health care costs. In the case of developing countries, the absolute amount of health care expenditure for the elderly might not be as high as that of developed countries since they had smaller numbers of elderly people. Further, it might not be feasible for developing countries to invest large amounts of their budgets in programmes for health care of the elderly, because of other priority areas. Therefore, community health care would be an approach that developing countries could realistically initiate with limited resources. Dr Han endorsed the recommendation on education and training of health workers and care givers. Many countries in the Region had not paid specific attention to the health of the elderly until recently, with the result that there were few health workers, family or community members, who were equipped with proper knowledge of such health care. For this reason the Western Pacific Regional Office had developed the training manual Quality Health Care for the Elderly. If health workers did not have adequate knowledge and skills, it would be impossible to implement community health care programmes effectively. It was, therefore, important to stress the need to train health workers. He expressed the hope that the workshop would also be the beginning of a partnership to improve the quality of life of the elderly through initiatives for healthy aging. In regard to the health and well-being of the elderly, some concepts were still evolving. For example, the phrase "quality of life" had evolved to acquire new meaning in the context of health. There was a need to participate actively in the work being done throughout the world on this topic, including development and adaptation of quality of life indicators that were meaningful to the Western Pacific Region. However, because the concept of quality of life was dynamic and culturally sensitive, deciding on specific indicators was not easy. More work should be undertaken on this in the Region. WHO planned to continue refining the existing indicators and instruments to assess quality of life in the elderly. He encouraged participants to collaborate in further developing these ideas and in developing and expanding community health care programmes with a view to attaining the objectives of New horizons in health and to achieving the goals of healthy aging and improved quality of life for all old people in the Region. Dr Han extended gracious thanks and warm appreciation to the many people who had helped make the workshop a success. In particular, he acknowledged the contributions of the Chairman, Vice-Chairman, Rapporteur, Consultant, Temporary Advisers and Facilitators, and of Dr Lowry and Mr Yoo. The conclusions prepared by the rapporteur and consultant were discussed and agreed upon. A model action plan is given in Annex 5. In the broader context of the New horizons in health approach, the workshop agreed that action was needed at county level to improve the well-being and quality of life of the elderly through initiatives aimed at ensuring the provision of appropriate, accessible and affordable services, including those that promote the achievement of every individual's health potential and a high quality of life for all. Such action would focus on development of community health care approaches to improve the quality of life in the elderly. Community health care for the elderly refers to care and support aimed at enabling the elderly to remain physically, socially, and mentally fit, for as long as possible, as members of the community, either living by themselves or with members of their family, rather than providing the elderly with care in residential institutions outside the community to which they are accustomed. The Workshop recognized that a number of supportive actions would be
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important to facilitate this. The extent to which individual countries should consider implementing the specific elements recommended would vary according to nationally defined needs and resources. Action plans could include the following elements. (1) In accordance with the recommendations of the 1982 World Assembly on Aging, Vienna Plan of Action, the Workshop acknowledged the importance of a national advisory mechanism on aging. In this respect a National Council on Aging or some equivalent governmental advisory body could be created to oversee the development of the national response to population aging and the needs of the elderly. In recognition of the wide implications and intersectoral nature of the undertaking. such a body might include representation from ministries of health, social welfare and education as well as other relevant governmental and nongovernmental agencies. (2) For many countries a national policy on health and care of the elderly, expressed in some form, is an important step in achieving a framework for the future development of community services for the elderly. Policy statements on health care of the elderly may be integrated into existing directives about community and primary care. Policies should highlight the perspective that achievement and maintenance of health and well-being in old age is essentially both a health and a social welfare issue and that that requires consideration of other aspects such as education, housing. social security and the environment. (3) To facilitate the further development of health services for the elderly in a rational, integrated and comprehensive manner. an identifiable focus for advocacy. planning, training and administration within national ministries of health would be most advantageous. This may be achieved by the creation of a specific office or focal point designated as the Office on Aging or other appropriate title and the appointment of a responsible senior officer with support staff within the ministry. (4) In the implementation of community-based care for the elderly, close liaison will be needed between health and welfare services at all levels. including the central authorities and field services. Future workshops on community care for the elderly are encouraged to consider inviting representatives of welfare ministries. (5) It is vitally important that health care workers are appropriately trained to deal effectively with issues associated with aging, the management of chronic disease and disability, and community-based services. It is most desirable that training is undertaken at several levels and is directed to health personnel working in acute hospitals and to those health and non-health personnel working in community health care settings. The support of government and teaching institutions would facilitate the achievement of these objectives. (a) A multiskills approach to training is preferable to specialization. although training should be appropriate to the role or function of the worker. The WHO manual! is intended to support such training. (b) Current health professional training ;:urricula and continuing education curricula would benefit greatly from systematic review and supplementation where necessary. to include content relevant to healthy aging, health promotion and protection. and community health care for the elderly. Opportunities for different professions involved
I Quality health care for the elderly A manual for instructors for nurses and other health workec£' Manila. World Health Organization Regional Office for the Western Pacific. Western Pacific Education in Action Series. No.6, 1995.
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with the elderly to work together during their training is essential to understanding of multidisciplinary contributions and stronger linkages among services. (c) Participation in overseas programme would expose health care workers to the principles of good quality health care for the elderly, thereby enabling these workers to be utilized as local trainers upon return. (6) Mechanisms could be developed to increase awareness of the concepts of healthy aging, health promotion and protection, and community health care for the elderly, among the elderly themselves, the general community, and existing community and family carers. The collaboration of health care policy decision-makers is strongly endorsed in order to build consensus. (7) A health education and health promotion programme directed to the health needs of the elderly and their carers could be developed and tested with a view to its wider implementation within country primary health care networks. (8) Healthy aging should be pursued as an integral component of general lifestyle programmes directed at the whole popUlation, including children and younger adults. (9) Usually, it is better for the elderly to be cared for in the community in a family setting. This has been demonstrated to be generally less expensive than institutional alternatives and has been shown to be more compatible with the expressed desires of the elderly. Any decision to admit an individual to long-term institutional care needs, as far as possible. to be preceded by professional assessment and determination that the need for a protective environment outweighs the lessened independence of the elderly. Ultimately, the decision is made by and with the elderly and his/her family. (10) Multidisciplinary care teams could be established at community level, where they do not already exist. As noted in New Zealand, needs assessment may be simple, comprehensive or specialist depending on the individual situation being assessed. When appropriately utilized, multidisciplinary teams can facilitate access to and mobilize services for support of the elderly in the community, including family counselling, training of carers in the basic elements of home care, provision of necessary support and aids to daily living. home modification as required and the supply of other services. Emphasis needs to be placed upon promoting community services that provide an acceptably high quality of care. (11) Development of criteria of need for provision of various levels of care and support for the elderly is encouraged. Such criteria have been developed in some national care programmes for the elderly and these could be studied and adapted to particular local community and cultural circumstances. Ministries of health could determine, in consultation with key professional staff and providers of institutional care, the appropriate criteria for admission to institutional care and make such guidelines available to all those concerned. The rights of residents and standards for quality of care need to be developed and applied over time, particularly as the need for institutional care increases in the future. (12) Within the general health and hospital system, attention needs to be given to issues such as access, assessment, rehabilitation and effective discharge planning of elderly people who are treated in acute hospitals to ensure a smooth transition back to the community and to improve continuity of care. (13) Current systems for the collection of demographic and health care services data should be reviewed to ensure that information is provided about the elderly in a useful form.
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(a) Data on the elderly would yield more discriminating and purposeful information if divided into five-year age groups that distinguish between young/old, old/old and oldest/old and if classified by other relevant characteristics, including sex, citizenship, ethnicity and occupation. (b) Data routinely collected by ministries on morbidity, mortality and health services utilization could be more meaningfully interpreted if dissagregated to provide detailed information on older age groups.
(c) Data collected on services for the elderly, at present and as they are developed further, on assessment, service provision, clinical indicators and outcomes need to be standardiZed so that they can be used in the evaluation of services and in assessment of Quality of care, cost effectiveness and efficiency. (14) Special consideration needs to be given to the gender-specific characteristics and needs of older women and men. (15) The further development of community-based health services for the elderly would ideally be based on information obtained through systematic analysis of need. Efforts need to be directed to continuing support for health services research, and programme evaluation. In these respects collaboration at regional and global levels should be fostered in the further development of nationally and regionally appropriate valid measures and indicators of healthy aging and quality of li fe. (16) Consideration needs to be given to holding national workshops on strategic planning of community services for the elderly as a follow-up activity to this present workshop. (a) Prior to such a workshop a review of current services could be conducted and information obtained on services provided for the aged. The experiences of other countries may be relevant, including those areas identified in this report, and could also be reviewed. (b) The primary objective of such workshops would be to develop a comprehensive strategic plan for the development of care for the elderly.
(17) A regional follow-up workshop could be planned to review progress towards implementation of national action plans for development of community-based health care for the elderly. In the meantime, a regional network is endorsed with the cooperation of WHO and/or other agencies, to facilitate continuing communication and exchange of ideas. In particular, it is hoped that wider sharing of resources, training, reference materials and experiences from within the Region can be accomplished, together with mobilization of these regional resources to other areas.
- 15 -
ANNEX 1
LIST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISERS, FACILITATOR AND SECRETARIAT
1. PARTICIPANTS AUSTRALIA Mr Warwick Bruen Assistant Secretary Community Care Branch Department of Human Services and Health P.O. Box 9848 Canberra A.C.T. 2601 Dr Nhonh Bun Yay Deputy Director Department of Health Ministry of Health Phnom Penh Dr Zhu Han Min Deputy Director Hua Dong Hospital Shanghai Geriatric Institute Shanghai 200040 Dr Tingika Tere Medical Officer Ministry of Health P.O. Box 109 Rarotonga Sister Mereani Tukana Divisional Health Sister, Central Ministry of Health and Social Welfare Box 2223, Government Buildings Suva Dr Tak-kwong Au Medical and Health Officer, in-charge Kowloon Regional Office Department of Health 141F Golden Gate Commercial Building 136-138 Austin Road Kowloon
CAMBODIA
CHINA
COOK ISLANDS
FIJI
HONG KONG
- 16 -
Annex 1
JAPAN
Dr Y oichi T akigawa Deputy Director Division of Health for the Elderly Ministry of Health and Welfare 1-2-2 Kasumigaseki, Chiyoda-ku Tokyo 100 Dr Kongsap Akkhavong Chief of International Clinic and Geriatrics Mahosot Hospital Vientiane Dr Nor Aini Bt. Mohd. Noor Assistant Director Family Health Division Ministry of Health lalan Cenderasari 50590 Kuala Lumpur Ms Carol W. D'Audney Senior Analyst Ministry of Health P.O. Box 5013 Wellington Ms Gilda R. Estipona Nursing Program Supervisor Non-communicable Disease Control Service Department of Health San Lazaro Compound Rizal Avenue, Sta. Cruz Manila Mr Hong-kwon Shin Director Division of the Aged Welfare Ministry of Health and Welfare Kwacheon, Kvunggi-do Ms Mesepi Mulitalo Nurse Consultant Primary Health Care Health Department Private Bag Apia
LAO PEOPLE'S DEMOCRATIC REPUBLIC
MALAYSIA
NEW ZEALAND
PHILIPPINES
REPUBLIC OF KOREA
SAMOA
- 17 -
Annex 1 SINGAPORE Dr Gim Hong Yap Registrar Toa Payoh Senior Citizens' Health Care Centre Toa Payoh Polyclinic (Level 3) 2003 Lor 8 Toa Payoh East 1231 Dr Sunia Foliaki Medical Officer In-Charge, MCHlFP Ministry of Health GPO Box 59 Nuku'alofa Professor Tran Duc Tho Director National Institute of Gerontology Hanoi 2. CONSULTANT Dr Christine Sheehy Director of Nursing Research Maricopa Health System Maricopa Medical Center 2601 East Roosevelt Phoenix, Arizona 85008 United States of America J. TEMPORARY ADVISERS Dr Lin Yan Deputy Director Division of Health of the Elderly and Rehabilitation Department of Medical Administration Ministry of Health Beijing 100725 People's Republic of China Dr Ranjit Ratnaike Director, International Health Programme Department of Medicine The University of Adelaide The Queen Elizabeth Hospital 28 Woodville Road Woodville, SA SOIl Australia
TONGA
VIETNAM
- 18 -
Annex 1
4. FACILITA TOR Professor Gary Andrews Director Center for Ageing Studies The Mark Oliphant Building Laffer Drive, Science Park Adelaide, Bedford Park, SA 5042 Australia
5. SECRET ARIA T Dr P. Lowry Regional Adviser in Health Systems Development World Health Organization Regional Office for the Western Pacific Manila Philippines MrY.H. Yoo Technical Officer Health Care for the Elderly World Health Organization Regional Office for the Western Pacific Manila Philippines Dr R. Erben Regional Adviser in Health Promotion World Health Organization Regional Office for the Western Pacific Manila Philippines Dr Chen Ken Medical Officer Traditional Medicine World Health Organization Regional Office for the Western Pacific Manila Philippines Ms T. Miller Regional Adviser in Nursing World Health Organization Regional Office for the Western Pacific Manila Philippines
- 19 -
Annex 1 Dr Han Tieru Responsible Officer in Noncommunicable Diseases World Health Organization Regional Office for the Western Pacific Manila Philippines
- 21 -
ANNEX 2 AGENDA 1. Opening ceremony
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
New horizons in health: Quality of Ufe - a new direction of WHOIWPRO Plenary session and brief presentation: Concepts of healthy aging, quality of life and community care Country presentation: Examples of successful strategies for development of community health care options (Australia, Japan, Republic of Korea and China) Plenary session: Brief response from other countries Barriers to the development of community health care for the elderly at country level Small group discussion: Barriers to the development of community health care for the elderly at country level Plenary session: Reports on small group discussion Overcoming barriers - approaches to promoting healthy aging at community level Education and training needs for promoting healthy aging at community level Presentation and discussion on the use of Quality Health Care for the Elderly manual Principles for national development of community health care programmes for the elderly Small group discussion: Principles for national development of community health care programmes for the elderly Plenary session: Reports on small group discussion Monitoring healthy aging and quality of life outcomes of community health care Discussion on monitoring healthy aging and quality of life outcomes of community health care Healthy aging and community health care for the elderly - implementation Small group discussion: Implementation - healthy aging and community health care for the elderly Plenary session: Reports on small group discussion Presentation and discussion of New horizons in health, theme III project
- 22 -
Annex 2
21. 22. 23. 24.
Small group discussion: Potential programme at country level Plenary session: Reports on small group discussion Presentation and discussion of findings, conclusions and action plan Closing ceremony
- 23 -
ANNEX 3 COUNTRY REPORT:
AUSTRALIA The main problems that have to be solved by Australia in providing community health care for the elderly are as follows: (1)
Freeing up financial resources currently spent on hospital and nursing home care and redirecting them to community care.
(2) Recognizing that community services such as home care, meals on wheels, home maintenance, transport services and personal care are equally important for the health and well-being of the elderly as medical and nursing services. (3) Coordinating the efforts of the National Government, State (or provincial) goverrunents and municipal goverrunents in care provision. (4) Coordinating all the different providers of community health care to work together towards the same objectives; this includes private doctors as well as goverrunent funded services. The major initiative undertaken by Australia to address these issues is the Home and Community Care Programme (HACC). The HACC Programme is directed at assisting: (a) frail aged persons at risk of being admitted to long-term residential care (nursing homes or "hostels") when they don't need to be (b) (c) younger persons with moderate or severe disabilities carers of frail aged and disabled people.
The programme aims to provide a range of basic support and maintenance services aimed at enhancing people's independence in the community and avoiding premature or inappropriate admission to long-term residential care. The national goverrunent provides 60% of the funds and the State goverrunent 40% of the funds. In some States municipal government (or "local" goverrunent) provides some of the States, 40% contribution. The HACC programme provides funds for: community nursing home care services
- 24 -
Annex 3 personal care services meals on wheels community transport respite care day care centres allied health care (Physiotherapy, speech therapy, podiatry, etc.) home maintenance and repairs home modifications (ramps, rails, etc.) training programme development and evaluation.
The programme does not fund medical care. In Australia almost all community doctors are private doctors who charge fees. Australia has auniversal health insurance scheme called Medicare, financed through income tax, which helps pay most of the medical costs for all Australians. Funds for the Home and Community Care Programme come from two sources. Firstly, separate pre-existing programmes for community nursing, home care and meals on wheels have been combined into the single HACC programme. Secondly, money has been saved by reducing the rate of growth of long-term residential care in nursing homes and aged persons hostels. It is this diversion of funds away from expensive nursing home care and into community care that is the key to the success of the programme. Politically and administratively this has been difficult to achieve, but is based on three assumptions for which there is considerable research data available: older people prefer to stay in their own homes when they can older people are healthier and more independent staying in their own homes it is cheaper to care for people in their own homes than in institutions
Finally, I should mention another programme that is funded separately from HACC. Carer support is a crucial aspect of care of the elderly. In Australia 70% of care is provided by relatives or friends. Support is provided to these carers through information kits, "carers' associations, and respite care programmes to give carers a "holiday". In summary, funding, co-ordination and diversity of services are seen as the key to overcoming barriers to the development of successful community health care strategies for the elderly.
- 25 -
Annex 3 COUNTRY REPORT: CHINA (I)
1.
Introduction
Since the founding of the People's Republic of China in 1949, the highly improved standards of living, the accelerated progress in medical technology, the decline in birth rate and infam mortality, the comrol of communicable diseases, and improvements in nutrition, have all contributed to a longer life span of Chinese people, which in turn, is reflected in a higher proportion of the population reaching and overpassing the age of sixty. Chinese population has already moved from high fertility and high mortality to low fertility and low mortality which is termed by WHO as "the epidemiological transition. " This paper aims to provide a brief summary of the demographic aspects of population aging, characteristics. and the projected changes. It will review the current situation and trends in care of the elderly, community services. and basic training for health professionals working in the community. It will also review the overall national policy on planning of community-based programmes as well as training programmes in the care of the elderly in China. 2. Demographic aspects of population aging. characteristics, and projected changes Aging population
2.1
According to the latest census in 1990. China had mnore than 1.1 billion people, accounting for more than 20 per cem of the world's population. There were more than 97 million people aged 60 years and over, which constitutes 8.59 per cem of total popUlation. The number of age 65 years and over were more than 63 million or 5.58 per cent of Chinese popUlation. 2.2 Life expectancy
Life expectancy has been increasing steadily over time contributed by declining fertility and increased longevitiy. The life expectancy of Chinese people at birth in 1981 was 67.9 years, while in 1990 was 69.7 years (Table I).
Table 1. Life expectancy of Chinese people (years) 1981 Male At birth At age 60
Female
1990 Male 67.7 15.8
Female
2020 Male 71.8 17.3
Female
66.4 15.7
69.4 18.2
70.9 18.6
75.4 20.1
Population Census and Projection in 1982. 1990
2.3
Dependency ratio
Dependency ratio for the aged. defined as residents aged 60 years and over divided by residents aged 15-59 years, can be considered as an index of relative size of working age
- 26 -
Annex 3 people that support the aged. With a decrease in birth rate, dependency ratio for the aged in China was increasing from 13.04 in 1982 to 13.43 in 1990. 2.4 Infant mortal ity rate
Infant mortality rate, defined as the number of deaths of infants under one year of age divided by 1000 live births, has declined significantly in the last several decades as the result of improvement in medical, economic, and living standards (Table 2).
Table 2. Infant mortality rate change in China Infant Mortality Rate (per 1000 live births) Year Urban Rural 1958 1983 1991 1993 50.8 13.6 16.5 13.5 89.1 26.5 25.4 21.5
Ministry of Health: Chinese Health Statistical Digest, 1991, 1993 2.5 Total fertility rate
Family planning has been one of our national policies for a long time. As a result, the total fertility rate declined from some six births per woman before 1970 to 2.5 in 1982 and 2.3 in 1990. In general, the effect of fertility decline is much more substantial resulting in a small average family size in China. 2.6 Projected changes of the elderly population
The population in China has undergone some significant changes in recent decades. The elderly population is expected to expand rapidly in the next 30 to 40 years. It has been projected by United Nations that by the year 2000, the population of aged 60 years and over in China will increase to 130 million, accounting for II per cent of the total population; and by the year 2025, it will be 280 million, accounting for 20 per cent of Chinese population. From 1985 to 2025, the total population in China will increase 43 per cent; but the aged 60 years and over will increase 242 per cent in the same period. In comparison with population aging in the western developed countries, the aging of the Chinese population is going to be much more accelerated. Whereas in France, Sweden, the United States, and United Kingdom, it took from 45 to 130 years for the population of 65 years and over to grow from 7 to 14 per cent of their total population, it is projected that in China thi sprocess will take only 25 years. This rapid increase in absolute numbers and proportion of the elderly in China raises a considerable challenge to public policy, and has brought about various social, economic, medical, and political strains on a country's resource allocation.
- 27 Annex 3
3.
Resources and current situation of care of the elderly within the community
As many other developing countries, China has relatively limited resources of institution for the elderly. Although43 681 social welfare houses with 927 000 beds capacity are available, but most of them are for the elderly who have no economic income, no child, and unable to be cared in the community. 3.1 Family
Chinese society has always been characterized by its strong family structure. According to the national survey of health and medical serivces in 1993, 66.60 per cent of the elderly lived with their children or others (fable 3). The fundamental responsibility for care of the elderly lie within the immediate and extended family. By traditional and cultural values, strong family lies are a rule and high respect for the elderly is accorded by childred and grandchildren as a way of recognition through affection and all help in their own little way. The elderly are usually actively involved in the family life. The element of family support and the exchange of obligations are still the basis of family relations. Table 3. Living status Living status Living alone With spouse With children or others
or the elderly in China (%) Total 8.98 24.43 66.60 Urban 10.65 29.00 60.34 Rural 8.02 21.81 70.17
National Survey of Health and Medical Services, 1993 3.2 Community Service Centre
The community service centre is an agency aimed at helping the elderly and the disabled who can not look after themselves and cannot obtain regular help from relatives or others, to continue living in their own environment for as long as possible without the need for institutionalization. Community service centres provide services including washing clothes, cleaning houses, meeting daily shopping needs, personal care, and other services. Up to 1993, there are 3711 community service centre in China. Some of community service centres have day care service or short stay facility for the elderly. 3.3 Neighbourhood committee and village committee
Neighbourhood commitee and village committee are organizations in community level to deal with civil affairs. Neighbourhood committee is in urban area, village committee in rural area. In China, there are 107 000 neighbourhood committees and I 013 000 village committees in 1993. These organizations offer unique opportunities to support the elderly in communityh focusing on their needs and problems. Some, life for example, organizing residents to look after each other, introducing volunteer to care the elderly living alone, acting as a coordinator between consumer and community hospital.Many neighbourhood committee offices have wheelchair for the family member to bring their old parents to community hospital if needed. The Department of Civil Affairs gives economic assistance to the poor living in community through these organizations. In 1993, about 37 million persons (times) have received economic assistance.
- 28 -
Annex 3
Shanghai is the "oldest" city in China with 13.96 per cent of the population aged 60 years and over. The percentage of those living alone has been increasing gradually. In order to meet immediate help in case of need, a simple electronic bell has been installed in some of the neighbourhood committee offices with a button at their old resident's home. When the button is pushed, the staff at the office are informed and will come over immediately. 3.4 Volunteer activity
Guided by the Chinese Government, various efforts to improve care services for the elderly living alone are being complemented by a lot of volunteer activities organized by local government, enterprises, worker's union, some young people's organizations, and some religious agencies. Laundry, personal care, shopping and introducing medical services are provided through the volunteer help. For example, there are more than 26000 volunteer in Beijing responsible to help 5200 elderly living alone. 3.5 School for the aged
These are special schools for retired people in urban area. People come to school regularly to learn Chines handwriting, painting, gardening, living arrangement, psychology, sociology and basic knowledge of health promotion. There is no exact duration for each study. In rural area, school for the aged are mainly of those for learning specific technology in the field of agriculture. By the end of 1993, there are 5331 schools for the aged in China with more than 470 000 students. 3.6 Centre for the aged
Centre for the aged is a room or several rooms in community or in people's working units run by government agency, enterprise, neighbourhood committee or others. The elderly come to the centre for playing card or chess, reading newspapers and books, having lecture, or chatting with others. The centre also serves as therapeutic community in which old people search for and tind their own solutions for their own problems. 4. Community health care and current training programmes for community health workers
In general, community health care is based on national health servies. Health services are highly developed during the last two or three decades. Up to 1993, China has 60784 hospitals, 115 161 clinics, and 806 945 village health stations. There are 2.40 hospital beds, 1.18 physicians, and 0.91 nurse per 1000 populations. With this medical network, most of people in urban area can visit hospitals or clinics within half an hour travel time. 4.1 Home visiting programme
This programme started ten years ago. It is highly involved in community health care for the elderly who form about 80 per cent of patients visited. In urban area, majority of provider of the service is the hospital in street (community) level and clinic although Ministry of Health requires all hospitals to participate. In rural area, village health station and township hospital take part in this programme. The major services of home visiting are to follow up on the newly discharged from hospital, given injections, surgical dressings, and traditional therapy. Some of them have specific vehicle - "mobile hospital" for bringing physicians and nurses to patient's home. Currently, there are 600 000 home beds on this home visiting programme.
- 29Annex 3 4.2 Health promotion
"Getting prevention first" is the principle of organizing health care, and also for the aged care. According to national survey of health and medical services, 86.64 per cent of the elderly are healthy who can do their main ADL without any help (Table 4). Strategies to promote and maintain continuing good health and fucntion at old ages are the most costeffective means of achieving health and well-being in aging population. Some of health promotion programmes are below: Hospitals have set up posters for people to know the common diseases of old people and early detect. Schools for the aged invite medical expert togive lectures for the elderly on the topic of nutrition, self-care, prevention and control of diseases. More than ten pieces of health newspaper with the content of health of the elderly. Short programme on TV and radio regarding to health promotion, for example, reducing salt intake, getting away of smoking. About 12.46 per cent of the elderly take part in various kinds of physical exercise. Chinese Association of Sports for the Aged has more than 35 million members.
Table 4. Percentage of the elderly who can do their main ADL Total Without any help With some help With help Completely unable to 86.64 8.96 1.52 2.88 Urban 90.09 5.94 1.29 2.67 Rural 64.47 10.86 1.64 3.01
National Survey of Health and Medical Services, 1993 4.3 Community-based rehabilitation
The most common health care for the elderly and those with long-term illness in China is to be cared by family and friends at the home. However, often these care-givers are not familiar with simple and common care procedures for prevention, treatment, and rehabilitation of chronic diseases and conditions associated with aging and disability. Many community health workers do not know how to train and motivate the elderly or their family to provide appropriate health care and rehabilitation services at the home. This programme initially proposed by WHO and started in four provinces in 1987 with joint effort from health section, civil affairs, labour, education and others. In spite of limitations in resources, the communitybased efforts are clearly efficient and innovative with the obvious dedication and enthusiasm of the staff. 4.4 Special clinic for the aged
Ministry of Health requires general hospital to have geriatric clinic in area with "aged" society, and department or wards of geriatric medicine where conditions permit. Some general
- 30 Annex 3 general hospitals have a consulting clinic to the elderly. In Shanghai, Department of Health requires hospitals setting their priority to those over 70 years. Some hospitals in street (community) level provide out-reach services to neighbourhood committee. 4.5 Current training programmes for community health workers
There are many training programmes for community health worker in different area depending on their job description, the problems they have to solve, the level of development of the area, and their previous education. In the field of health care of the elderly, some of the ongoing training programmes are below: 4.5.1 Regular training at school China has 556 middle level health schools with 355410 undergraduate students. Since some of the schools located in their counties, the students will go back to work in their community in most instances after graduate. A teaching curriculum is available with nursing care for the elderly, prevention and treatment of diseases commonly in the elderly as well as the concept of aging. 4.5.2 Intensive training for primary health care workers A wide range of training opportunities are available for primary health care workers organized by Miistry of Health and local health authorities. The duration of the training is from four to eight weeks. In order to have a systematic training for them, a text book on the topic of "Guideline of Primary Health Care in Rural China" with a chapter - Health Care for the Elderly" has been published by Department of Medical Administration, Ministry of Health. Many of primary health care organizers have also received this training. 4.5.3 Long-term training for rural health workers in village level It is Ten-Year programme adopted by Ministry of Health in 1990. The general goal of this plan is that every rural health worker in village level must have received at least six months training in general medicine and public health by the year 2000. In this training programme, they will receive some training in health care for the elderly and the long-term illness. 5. Future plans of action
As a result of declining fertility, China is beginning to experience aging of the population. Social changes such as migration, urbanization, and increased female labour force participation mean that the generations of a family may live in different places, that they may live in a place where there is not housing to accommodate a multigenerational family, or that the traditionally female caretakers are working outside of home, in the past, several children take turns to care their dependent parents, but the decrease in the number of children within a family often means that care for dependent old parents cannot be easily shared by several brothers or sisters. The impact of this substantial demographic change on the provision of health services throughout the country, on both the total population and the elderly themselves, is recognized by the government. In 1991, a Five-Year Plan for Health Care of the Elderly was developed by Ministry of Health; and in 1993, the Plan of Action for Further Development of Community Service in China was adopted by Ministry of Civil Affairs, Miistry of Health, National Committee of Planning, and other 11 department, the major strategies are as below:
- 31 Annex 3 (1) to actively develop community service for the elderly applicable to China;
(a) strengthening leadership and administration in developing community service. By the end of this century, the total number of various kinds of community service facilities will be 260 000; 85 per cent of urban community will have one community service centre and one day care centre; (b) hospital in street (community) level and clinic should pay special attention to the development of home beds for the elderly;
(c) care network; (d) and spread. (2)
integration of health care for the elderly into the existing three-level health the pilot programme of community-based rehabilitation should be evaluated
to improve health care services for the elderly
to open geriatric clinics at general hospitals in the areas with "aged" societies, (a) and department or wards of geriatrict medicine where conditions permit; (b)
to improve rehabilitation service for the elderly; out-patient department setting priority to those aged 70 years and over;
(c) (3)
to enhance health education for the elderly (a) to
facilitate the ongoing health education programme for peasant;
(b) the coverage of health education for the elderly is required to reach 30-50 per cent in three to five years.
(4)
to develop training for health professionals
(a) some medical universities and middle level health schools are requried to have geriatrict course within five years. (b) all personnel engaged in community health care for the elderly will be trained at least once every five years.
(c)
introducing trainig to primary health care worker. REFERENCES
I. 2. 3. 4.
Ministry of Health: Chinese Health Statistical Diges, 1990, 1991, 1993. Ministry of Civil Affairs: A Report on the Development of China's Social Welfare Services, 1992. Ministry of Civil Affairs: The Year Book of Civil Affairs, 1994. Ministry of Health: The Five-Year Plan for Health Care of the Elderly, 1991.
- 32 -
Annex 3 5. 6. 7. 8. 9. 10. 11. 12. 13. Ministry of Civil Affairs et al: Plan of Action for Further Development of Community Service in China, 1993. Department of Health of Shanghai: The Five-Year Plan for Health Care of the Elderly in Shanghai, 1992. Shanghai Association of Gerontology: Report on the Seminar on Community Health Care for the Elderly, 1990. Ministry of Health: Report on national survey of health and medical services, 1994. National Bureau of Statistics: Report on national census in 1982, 1990. Lin Yan: The Demands and utilization of medical services of urban elderly in 9 provinces of China. Chinese Hospital Management, 1989, Vol. 9(9):35. Lu lei et al: Population Research, No.3, 1994. Population Science of China: China 1987 aged population over 60 years sampling survey data, 1988. He Hui De et al: Map of Aged Population in China, 1986.
- 33 Annex 3 COUNTRY REPORT: CHINA (2) I. Introduction
The greying of the population is now a worldwide phenomenon. China is a developing country with the highest population in the world. About more than half (55 per cent, 176 million) of the world's elderly aged 65 and over lived in developing nations, and 63 million in China in 1990. Owing to utilized economic resource in limitation, aging is emerging as a serious public health issue for developing as well as developed countries. According to the requirement all globe health strategies about "Health Care for all by 2000", the following targets are considered: what is the main object in elderly health care, how to develop prevention and health care for the elderly, what is a primary approach to promote health level and quality of life for elderly group in developing country, how to make all medical organizations join and put in primary health care and community medical service system. 2. Demography and population aging in China
The population groups aged 60 and 65 over years share 7.42 and 4.9 per cent of total Chinese in 1953, the proportion is predicted to be 10.2 and 6.93 per cent in 2000,22.98 and 17.44 per cent at its peak in 2040 respectively. Since then, the population aging will be moderated gradually. Table I shows the general trends in the proportion of the population aged 60 years between 1953-2025 in China. The absolute numbers of elderly in China have been the largest in allover countries until now. Table 1. General Trends in Population Aging in China 1953-2050 (in millions)
> 60 years > 65 years ------------------------------------------------------ ------------------Year Total Population Total numbers percentage Total numbers percentage
1953 1964 1982 1990 2000 2010 2020 2030 2040 2050
56744 69458 100 379 114333 127485 133 818 142414 146411 147097 154700
4154 4220 7665 9821 12748 16085 22302 30600 33803 31 384
7.32 6.08 7.64 8.59 10.2 12.02 15.66 20.90 22.95 21.85
2504 2453 4927 6379 8643 10 541 15092 19516 25653 23352
4.41 3.53 4.91 5.58 6.93 7.88 10.59 13.51 17.44 16.00
Comparing the length of years for the proportion of the aged over 65 years old to be 14% from 7%, it will take 27 years in our country, which is more fast than some Europe and north America countries (Table 2). There are four characteristics in this matter.
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Annex 3
Table 2. Speed of population aging in selected countries Year in which percentage of population 65 years and over reached and will reach 7% Shanghai City China United Kingdom Hungary Canada United States Australia Sweden France 1979 2000 1930 1941 1941 1944 1938 1890 1865 14% 2005 2027 1975 1994 2008 2012 2012 1975 1980 26 27 45 53 64 68 74 85 115
Country or Region
Number of years required
Source: US Bureau of the Census: International population reports P95192-3 An Aging World II p.13 2.1 Rapid increase of the population of the age
Two main ways are related to the population to age: (1) falling mortality rate leading to longer survival. Overall life expectancy at birth in our country is increased from less than 35 years in 1949 to more than 69 years in 1990; (2) a declining birth rate leading to higher proportion of individuals in older age group. In our country, a policy of reducing fertility by encouraging married couples to restrict their family to one child is advocated. This improvement in life expectancy is resulting in rapid growth of older population. The speed of aging in our country will be more rapid in future. The annual growth rate of older people will be coming to 2.74 per cent in 60 years. 2.2 Another important dimension of population aging is perfectural disparities
China is a large size of territory, the demographic and economic level is greatly different among regions. Table 3 shows the per cent elderly group and median age in China's provinces and autonomous regions and municipalities directly under central authority. The proportion of population aged 65 and over are significantly different among these regions, and ranges from 3.13 in Qinghai to 9.24 per cent in Shanghai. The population including elderly group as a whole is still predominantly rural, only 20 per cent people aged 60 years or more live in urban areas. Even by the year 2000, the majority of aging people about 80 per cent will be living in rural area in our country.
- 35 Annex 3 Table 3. Percent elderly, by age: 1990 in China Ordinal Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 60 years and over 13.96 10.44 10.27 10.24 10.21 9.46 9.06 9.00 8.89 8.79 8.66 8.53 8.27 8.53 8.11 8.27 7.9 7.69 7.63 7.68 7.53 7.26 6.43 7.10 6.35 6.22 6.16 5.24 5.15 8.59 Ordinal number 1 2 5 3 4 6 7 11 8 10 9 12 17 14 17 16 15 20 19 21 18 22 21 26 23 28 25 27 29 30 65 years and over 9.24 6.87 6.42 6.79 6.48 6.23 5.98 5.69 5.84 5.47 5.63 5.82 5.38 5.47 5.38 5.43 5.46 5.00 5.08 4.87 5.18 4.70 4.53 4.01 4.62 3.82 4.09 3.86 3.38 3.13 5.58 Ordinal number 1 5 2 6 3 7 16 4 8 10 18 15 19 22 19 23 13 21 24 25 14 26 9 17 28 II
Region Shanghai Zhejiang Beijing Jiangsu Tianjin Shandong Guangdong Liaoning Hebei Sichuan Henan Hunan Shanxi Hannan Anhui Guangxi Hubei Fujan Jiangxi Yunnan Shanxi Xizang Jilin Nei Mongol Guizhou Heilongjiang Gansu Zinjiang Ningxia Qinghai
Median age 33.91 27.70 30.61 25.58 30.13 26.37 24.66 27.88 25.97 25.72 24.33 24.79 23.96 23.03 23.96 22.08 25.07 23.43 22.75 22.73 24.93 22.35 25.93 24.64 22.05 25.36 23.75 22.01 21.93 22.28
20 29 30 27
all over country
A society's median age, another way to look at population aging always demonstrates the great difference in these regions and ranges from 21.93 in Ningxia province--a remote region to 33.91 in Shanghai City equaled that in United States in 1991 (Table 4). Table 4 shows the median age in 1990 in selected country.
- 36 Annex 3 Table 4. Median age in selected countries in 1991 Country United States Italy Shanghai City in China China Tunisia Malawi Median age 33.0 36.7 33.91 25.25 20.9 16.0
Source: US Bureau of the Census, Center for International Research, International Data Base on Aging China Census. 2.3 3. 3.1. A higher percentage of illiterate at the aged group and economic resource in limitation is other characteristic in this matter Strategy of the health care in the elderly Health condition in the elderly
Table 5 shows about 30 per cent of total elderly population stand in bad and worst health condition. The morbidity of many kinds of chronic disease is always higher in the elderly than in youth and midder person (Table 6). Table 5. Percent distribution of health condition in the elderly Region Urban Urial Town 15.0 17.5 13.5 Excellent 30.6 26.3 32.4 Good 18.0 17.2 18.7 Bad 10.0 8.2 11.4 Worst
Source: Random I % sample investigation in total population.
Table 6. Age, sex and morbidity of chronic disease (%)
Age group All age group 5565-
Male 6.45 20.01 27.28
Female
Total 6.61 21.16 26.08
6.77 20.26 24.92
Source: National survey of health and medical services, 1990
Table 7. Morbidity of chronic disease in the elderly (%)
- 37 Annex 3 Disease 60-69 Hypertension Coronary disease Chronic bronchitis Diabetes mell itus Cerebral Vascular disease Tuberculosis in lung Pulmonary heart disease Cataract Glaucoma Cancer Other 29.38 24.31 14.65 3.4 3.76 1.38 0.57 17.95 0.86 1.51 39.57 70-79 29.68 27.43 18.51 3.74 5.73 0.95 1.21 28.61 1.27 1.91 38.43 Age Total 80-89 31.16 34.11 18.93 4.9 10.16 1.40 0.93 50.70 1.98 2.22 41.82 >90 22.72 25.00 25.00 1.14 5.68 1.13 1.13 50.00 2.26 27.27 29.77 25.79 16.20 3.56 4.86 1.20 0.83 24.57 1.08 1.69 38.43
------------------------------------------------------------------
Source: Random sample survey in some communities in 1990. 3.2 Definite principle and approach of four class prevention in elderly health care
At aged group, classical approach to prevention must be modified because the possibil ities of primary prevention are very few, for example, coronary heart disease, hypertension cerebral vascular disease, diabetes millitus etc. began in middle of age, and the distinction between secondary (early diagnosis to stop the process of the disease) and tertian prevention (adequate treatment of established disease to diminish disability) become blurred in 1990, we proposed a new moditied approach to prevention in our work as follows: (I) Primary prevention
Preventable disease, injuries and adverse drugs reaction in aged period. Prevention of psychological disturbance. (2) Secondary prevention
Early diagnosis and treatment of new diseases occurred in aged period. Stop the progress of new disease and recover from injured function as far as possible. Major focus on seeking and revealing no-symptomic, obscure cancer and malignant tumour through performing effective check up. Monitoring the functional condition of main organs. Prediction and prevention of emergency and crisis of chronic disease through suitable and appropriate health care and medical service including improving life style. (3) Tertiary prevention
Reduction and limitation of serious degree of disability, handicap caused by chronic disease as far as possible.
- 38 -
Annex 3 (4)
The end point prevention
Reduce various painful feeling discomfort and various psychological pressure through attaching importance to symptomatic therapy, special and appropriate medical and social service. Death in comfort and dignity. According to requirement of prevention and health care in the elderly, the target concentrates on increase of quality of life and prolongation of active life expectancy in the elderly after utilizing appropriate intervention. Focus on economic and effective intervention methods for promotion of quality of life for elders. Selfcare, family care, community care as a main approach of intervention have been performed in recent five years. Method of intervention includes some harmful and behaviours modified, for example, quitting smoking, control of alcohol abuse, establish health behaviours, washing hands before meal, don't drink unclear water and so on. 4.
Establish "three level elderly health care network"
With regard to strengthening and improving the elderly health care work, it is of great significance to organize and realize the function of medical and health services at different levels in the medical care for the elderly. Shanghai is the largest city with 13 million population and the highest level of population aging in China (Table 8). Health care in the elderly is a serious problem owing to utilized economic resource in limitation. According to the requirement all globe health strategies about "Health for all by 2000" many medical organizations of the city have participated in the service of community health care for the elderly, and are beginning to find a model area in this respect.
Table 8. Trend of population aging in Shanghai City Year
> 60 older and over (%)
> 65 older and over (%)
1953 1964 1973* 1979* 1982* 1987** 1990* 2000*** Source:
3.58 6.07 10.20 11.54 14.06 16.16 Based on the data of census year 105 random sample investigation Prediction
1.97 3.60 5.92 7.15 7.43 8.60 9.24 12.28
* **
***
Since 1990, therefore we have primarily established a "three level eldercare network" which consists of the community, district and municipal medical and health services in some districts, marking efforts together and trying to extend the network to other districts and countries in search of a suitable approach and model of medical and health service for the continual development of urban elderly population aging. Under the leadership of the municipal and district bureau of health, the network operates to organize and convene its constitute hospitals, health care and research organs regularly for group discussion, synectic
- 39 Annex 3
design, gradational work division and coordination, to carry out plans of elderly health care at different stages as well as regular examinations and evaluations. Assignments and major responsibilities at different levels. 4.1 Municipal medical and health services
To investigate some problems concerning the elderly health care in this district, to suggest directory opinions and advices. (I) Investigating the current situation of the work in this district, suggesting essentials of the work, directions of future development and opinions of evaluation.
(2) Investigating and suggesting the plan and contents of further professional development and health education in elderly health care, undertaking further vocational training of elder care professionals in this district. (3) Receiving consultations and offering technical directions.
(4) Undertaking the organization and investigation of demography and epidemiology in this district as well as preventive health care measures, offering research information concerning care. 4.2 District medical and health services
To organize community medical and health services to satisfy the demands from the project to perform elderly health care in this district with supervisions and directions. (I) Offering opinions health care at different stages as reference to the district bureau of health for the design of plans.
(2) Organizing and directing community medical and health services to make efforts for the targets of eldercare project with regular supervision, examination and work generalization in this district. (3) Undertaking consultations and vocational training for community medical and health services. 4.3 Community medical and health services
To satisfy the demands from the project of elderly health care according to the actual condition of this district. (I) To grasp the dynamic variation of the fundamental data such as the demographic structure, health condition, spectrum of diseases and spectrum of mortality of aged population groups in these regions. (2) To take the responsibility of making efforts for the targets concerning elderly health care project. (3) To investigate characteristics, experiences, problems and their resolvent approach during performance of the work. (4) Organizing primary health care personnel in the community to raise their professional level.
- 40 Annex 3 4.4 5. Investigating current situation and characteristics about elderly health and medical care in other districts Formulate and establish objectives to community health care for older people by year 2000 in Shanghai
The strategic aim in community health care is of five systematic targets: Objectives health status, decrease risk factors, mass participation. Knowledge and training of professional personnel, data and monitoring which contain sixteen items as follows: 5.1 Increase average active life expectancy (health life expectancy) at age 60 at least 0.5-1.0 year the previous baseline data. 5.2 Reduce the proportion of loss of independent living ability to 5-10% from previous baseline data. 5.3 Decrease the incidence of adverse drug reactions among inpatient age 60 and over 10% from previous baseline data. 5.4 Increase the proportion of people aged 60 and over who participate in appropriate labour in the farm of physical exercise to at least 40 per cent. 5.5 Fifteen to twenty-five per cent of women aged 55 and older with an intact uterine cervix who have ever received a pap smear with the preceding year. Increase in 30% from previous baseline data. 5.6 Increase to at least 15-25 per cent the proportion of women aged 55 and older who received breast self-examination with the preceding year. Increase in 30% from previous baseline data. 5.7 Decrease the smoking rate in the elderly in 10-15 per cent from previous baseline data.
5.8 Increase to at least 60-80 per cent the proportion of patients with hypertension who received appropriate management and treatment. 5.9 Among all medical organizations in the city, the hospital, clinic and medical service should establish systems and measures for making things easy for aged people to seek medical care. 5.10 Formulate aged people health care regulations. 5.11 Further increase in and over 10% from the previous base of home sickbeds for aged people. 5.12 Establish aged people medical care and health care advisory organization. 5.13 Expand and increase cover rate of propaganda about hygiene and health care knowledge to at least 70-80% the proportion of people aged 45 and older in every community. 5.14 Enhance and heighten the level of knowledge about preventive disease and health care. Make 70-90% the proportion of aged people know that prevention of hypertension related to stroke, coronary heart disease, and study some knowledge about preventive accident. 5.15 Rate of training medical personnel in geriatrics at least 50% of medical personnel have received one special training.
- 41 -
Annex 3
5.16 Establish information treatment organization. At present time, the objective is being performed and the evaluation in middle period has been finished in January of this year. Under the leadership of the government, the aim of the project is to improve the quality of life concomitant with increasing life expectancy in the elderly. The main activities are to provide health education and develop self care, skill, techniques and rehabilitation with health care and effective service are to be in conformity with the level of economic development. We hope to establish a model to provide experience for other areas of China and developing nations in dealing with health care in the elderly. 6. Barriers
The community elderly health care is a systematic project, which demands coordination from all medical establishments. The medical workers at different levels have not attached much importance to the work of health care, which has not even been included in the overall health projects in many regions. There is a shortage of specialized contingents for elder health care. Researches fall short of overall planning and funds in many regions. REFERENCES: 1. US Department of Commerce Economics and Statistics Administration Bureau of the Census: International Population Report; p.95/q2-3. An Aging World II 1993. 2. Ministry of Health: the Five-Year Plan for Health Care of the Elderly. 1991 Ministry of Health: Strategy of Prevention and Health Care by 2000 in
3. China.
4. Zhu Han Min et al: Preliminary research on objective of health status in population aged 90 years and over; Symposium of oldest person and health, Shanghai China 1992.11. p.2-l2. 5. Zhu Han Min et al: Research on Active life expectancy in the elderly. Fifth National Geriatrics Conference Proceeding, 1993, Gongdon, China 1993 6. Ministry of Health: Chinese Statistical Digest, 1990.
7. Kane et al: Improving the Health of older people: A world view Published on Behalf of the WHO by Oxford University Press. 1990.
- 42 Annex 3 COUNTRY REPORT: JAPAN Summary
The fundamental ideas of the new care system(1) With "supporting the elderly's independence" as a fundamental tenet, we should establish a new care system by reorganizing existing systems.
(2)
The four main ideas of the new care system are: (a) (b)
selecting care services based on the elderly's own desires; unifying the care services; establishing a care management system; and introducing a social insurance system.
(c) (d) 1.
The fundamental tenet of care for the elderly
Because people are living together, care for the elderly is changing from "care at deathbed" to "care to support everyday life". Therefore, we should advocate "supporting the independence of the elderly" as a fundamental tenet of care for the elderly from now on. That is we should support the elderly in leading independent, high quality lives based on their own desire. 2. Reorganization of existing systems
Up to this time, the welfare and medical care systems have coped individually with the care for the elderly. But, there are many problems. Therefore, it is better to establish a "new care system" by reorganizing existing systems related to care services. 2.1 Problems with the current systems
2.1.1 Welfare (allocation) system: Customers cannot select their care services. Psychologically, customers are also reluctant to apply for the care services. 2.1.2 Medical care system: This system covers a considerable portion of care services, but it does not include care for everyday life, and there are limitations in the way it provides care services. 2.1.3 Pension system: The pension annuity is not effectively used because the elderly concerned about the expense of care, put the annuity away as to savings. 2.1.4 Lack of coordination among the systems: Elderly patients with similar conditions may be assigned to either a geriatric nursing home, geriatric sanatorium or geriatric hospital. These institutions have different functions and the expense on care are different. Each type of institution is controlled by a different system, and there is a lack of coordination among the systems.
- 43 Annex 3
3. 3.1
Basic ideas of the new care system Emphasis on prevention and rehabilitation
In order to achieve the objective of supporting the independence of the elderly, we must first place emphasis on prevention, making efforts to prevent the elderly from being bedridden. When the elderly need care, we should have proper facilities and systems to provide rehabilitation service. 3.2 Main ideas The four main ideas of the new care system are: (a) (b)
selecting care services based on the elderly's own desires; unifying the care services; establishing a care management system; and introducing a social insurance system.
(c) (d)
These ideas conform to the direction European and American countries are moving toward, such as the establishment of a public care insurance system in Germany. By establishing the new care system, we intend to strengthen the functions of all of the social insurance systems in Japan and to make the systems work more effectively. 3.2.1 Selection based on the elderly's own desires (a) Basic ideas
The fundamental principle is that the elderly should be able to make a decision in selecting a care service based on their own desires. In principle, care services should be provided in accordance with a contract agreed upon by both the elderly and the care service providers. However, when the elderly person is abandoned or cruelly treated, and he or she is reluctant to make his or her own decision, the administrative authorities should take urgent actions to protect the elderly person. This is supplemental measure to the care service contract. (b)
Requirements of care services
To ensure the elderly will be able in practice to select their care service, the following points are essential. (1) Universality of care service: All the elderly, regardless of differences in income or family structure, should have access to care services.
(2) Fairness of care services: There should be no irrational difference in customer's fees for service while customers receive similar services from different institutions. (3) Appropriateness of care services: The quality and substance of care services should be appropriate according to social standards, and capable of being properly appraised.
- 44 -
Annex 3 (4) Specialized care services: The customers should be provided with appropriate and easyto-understand information, and a system by which specialists support customers should be implemented. (c) (I)
Promotion of home care services
Home service arrangement
Many elderly wish to live continuously at home and in the familiar community if at all possible. It is important that we should help the elderly make. their won decision in selecting home care services. However, we should be careful not to make the elderly depend too much on home care, and not to put too heavy a burden on the family members. We should expand home services to a greater extent, and aim to the following objectives. (a) We should establish a system in which the elderly have access to the required service at the required day and time. (b) Even to the elderly who live alone or only with their spouses, if possible, we should help them continue to live at home.
(c) To the elderly with severe impairment or who live alone, we should establish a system where 24-hour services are available. (2) Assessment of care by family members
With reference to the elderly using institutional services, we should consider subsidizing the elderly who are taken cared of by their family members in order to be fair. However, we should be very careful in dealing with problems such as how to ensure proper care services will be provided by family members, or the concern about the elderly who may be locked up in the family. For example, to be eligible to receive subsidies, we may request family members to take care of training courses, to provide services under a specialist's supervision, and to agree to accept outside services when it is necessary. 3.2.2 Unification of care services We should unify the care services controlled under the various traditional systems into a new care system. (I)
Home service
We should establish a system that can provide comprehensive services including those provided by the health care, medical care and welfare systems. We should aim to provide a "service package" which properly combines each necessary service. (2) Institutional services
We should strengthen the functions of special geriatric nursing homes, geriatric sanatoriums, rehabilitation centres, and geriatric hospitals (in-patient medical care hospitals), and resolve the problem of inequality of fees imposed on customers by these institutions. In the future, we should aim to unify these institutions under one system. Realizing the diversity of the institutions, we should proceed step by step.
- 45 Annex 3
3.2.3 Establishment of care management (I) What is care management?
Current problems which must be addressed include: (i) the elderly do not have adequate knowledge about care services, (ii) the service providers are not properly coordinated. In order to cope with these problems, we should design a system to assist the elderly or their families to gain access to proper services with the help of care managers. Care management is expected to accomplish the following functions: (a) In response to requests by the elderly of their families, care managers will provide proper advice from the specialist's viewpoint. (b) Care managers must comprehend the needs of the elderly and accordingly prepare a care plan, including both basic policy and actual care services.
(c) Following the care plan, care managers will help the elderly to gain the access to the actual care services. Cd) Care management must make sure that proper services will be provided continuousl y . (2) How should the care management system function? (a) Care team
Care management is better conducted by a care team which consists of responsible persons from the health care, medical care, and welfare systems. The care team must be flexible, and be able to respond to the elderly's particular need at any time. At the same time, the judgment of medical specialists about the elderly's physical and mental conditions should be fully respected. (b)
Care management agency
It is better that the customers be able to choose a care management agency from among several agencies. Care management agencies should have adequate contact with local care service providers, and should have some capabilities in providing services by themselves. We would establish care management systems according to the actual environments in the local communities. 4. (I) Introduction of social insurance system What is a social insurance system?
As people live longer and longer, care problems become a common liability to every citizen. It is difficult to predict when and how long one will need care service, and how much will the expense for the services. Therefore, it is difficult for each person to prepare for the liability on his or her own. People should support each other, and it is better to cope with the care problems by applying a "social insurance system" which is based on the principle of social solidarity.
- 46 -
Annex 3 (2) How important is it to all citizens? To apply a social insurance system is important to all citizens. (a) To the elderly: Care services will be supported by the whole society.
(b) To the younger generations: Their concern about taking care of their old parents will be eased. When they become old, they too will benefit.
(c) To industry: Employee's welfare is improved. The system will prevent employees from quitting their jobs in order to provide family care.
In an aging society, care for the elder! y is a public responsibility, and to establ ish and implement this, social insurance system is a new way to take on this responsibility. (3) In comparison with public expense (care allocation) system
A social insurance system is more favourable than the public expense (care allocation) system for various standpoints. (a) (b)
The elderly will be able to select care services according to their own desires. The elderly have a stronger stipulated right to receive care service.
(c) The system can provide comprehensive services in responding to the elderly's needs. (d) (4) Duties and benefits are clear, and easily understood by all citizens.
The role of private insurance
Private insurance can playa role in supplementing the social insurance system. By implementing the social insurance system, we can consolidate the management systems, and it is expected that this will lead the private insurance agencies to extend their business. 4.1 (1)
Important issues concerning social insurance The insurer
The following ideas can be considered: (a) town and village offices should be the insurers; (b) insurers should be a larger organization; and (c) each organization shares the functir)fls. We should also discuss the roles of the insurers of medical insurance and pension insurance. In any case, each organization should support the others. (2) The insured persons/benefit recipients
In principle, we should consider stipulating the elderly of age 6S or above as the insured persons and the benefit recipients. We should also consider the younger generations as the insured persons for reasons of generation relationships. For the disabled people excluding the elderly, there should be a measure to provide comprehensive services. Whether it is appropriate to select the care service and consider it under the social insurance system should be carefully considered.
- 47 -
Annex 3 It is important that all citizens should fairly share the expense. We should also consider the following points: (1) The importance of pension benefits to the elderly, (2) The role of the insurers of medical insurance and pension insurance, (3) The subsidy of public expense. (4) Benefit and fee for service
We should properly assess the needs of the elderly, and conduct care management accordingly. In principle, we should provide actual services, but we should also consider reimbursement. We may consider requesting customers to pay a certain rate or amount of money as fee for service.
- 48 Annex 3 COUNTRY REPORT: REPUBLIC OF KOREA
1. 1.1
Trend of the Korean elderly population and their health status Trend of the Korean elderly population
The Republic of Korea has experienced the rapid growth in both the number of the aged people and their proportion of the total population. Whereas in 1960 only 726000 (2.9 per cent of the population) were the elderly 65 and over, in 1995 there are 2540 000 representing 5.7 per cent of the total population. This increasing trend is expected to go faster in the future so that the rate of the people aged 65 and over is estimated to be 6.8 per cent in 2000 and 12.5 per cent in 2020 to the total population. Such rapid growth of the Korean elderly population is largely owing to the decrease in the birth rate and the increase in life expectancy, resulted from improved public health measures and medical technology. 1.2 Health status of the Korean elderly
Many Korean elderly persons are frail and vulnerable to diseases as in other countries. A survey conducted in 1994 by the Korean Institute for Health and Social Affairs (KIHASA) showed that about 43.7 per cent of those aged 60 and over felt that their overall health condition was not satisfactory. The survey also reported that 51.7 per cent of respondents aged 60 and over experienced illness during the 15 days prior to the survey, and 85.9 per cent of the respondents had one or more chronic diseases such as pulmonary circulation, high blood pressure, diabetes, arthralgia, etc.. The survey also showed that 21.6 per cent of the respondents were not able to maintain their own daily lives without assistance from other people and 1.5 per cent of those aged 60 and over suffered from senile dementia. 2. Current major health programme for the elderly at the country level
The Republic of Korea has several major national health programmes for the elderly (1) medical insurance programme, (2) medical assistance programme, (3) free health check-up programme, (4) institutional care programme. lbe medical insurance programme which had been introduced in 1977 expanded its covcia;,:e to all people in 1989, making a great contribution to the promotion of the health status of Korean people, especially the elderly. The utilization rate of the insurance by the elderly 65 and over has increased year by year. Their visits to the medical facilities increased from 2.1 per year in 1989 to 4.5 in 1993. At the same time, the scope of benefits for the elderly has been expanded since the introduction of the medical insurance programme. For instance, the total period covered by the insurance was six months per year in 1977, but it was extended to 210 days in 1994, and will be 365 days in 2000. The Korean elderly with a low-income are protected by the medical assistance programme designed to assist the poor people who are not able to pay for their own medical cost. According to the programme, the poor elderly meeting certain kinds of requirements are
- 49 Annex 3 entitled to get medical services free or with low charge and the government pays for their medical cost from the national budget. In 1994 about $116 million was spent for the protection of 276 000 elderly persons 65 and over. The Korean government also has provided free health check-up services to the aged 65 and over since 1990. This service consists of two steps. The first is a routine medical test checking overall health status of the elderly applicants. The second is a precise test for those needing close examination after the first check-up. This programme contributes to the early detection and proper treatment of diseases and the total number of beneficiaries was about 145 000 in 1993. The free or low-cost institutional care programme is another important health programme for the Korean elderly with low-income. As of 1995 there are 50 nursing homes (36 free nursing home and 14 low-cost nursing homes) where about 2 800 aged people live receiving care services and the government subsidizes more than 90 per cent of total running costs of the facilities. 3. 3.1 Barriers to and strategies for the promotion of health status of the Korean elderly Barriers to the elderly health
3.1.1 Rising high medical cost for the elderly One of the serious barriers that the Korean Government faces is the rising medical cost for the elderly. As presented above. more than 80 per cent of the elderly 60 and over experience one or more chronic diseases needing long-term care. which causes high medical cost. The high medical cost is anticipated to keep rising with the continued increase in both the number of the elderly and the proportion of total population. However. the majority of the elderly with such chronic diseases. except some rich persons. are not able to get proper care andlor treatment due to their financial difficulty, which acts as a barrier to the promotion of their health status. Therefore. one of critical issues is how to develop effective measures to cope with the rising high medical cost for the elderly. 3.1.2 Weakness of family function as care-giver for the elderly With the growth of the aged population. the number of elderly needing care in daily life due to their physical andlor mental problems is expected to increase. In the past. the necessary care was mostly performed by family members such as son, daughter, daughter-inlaw, etc. However. the number of family care-giver has decreased in recent years because of factors like the changing values of family life, the nuclearizationof family. and the increase in the number of women with jobs and social activities. Consequently, the elderly have come to face more difficulties in maintaining their daily lives and thus, the Korean government is required to respond to the changing circumstance with effective measures.
- 50 Annex 3 3: 1.3 Maintenance of unfavourable life style In spite of much efforts of the government, many Korean elderly persons still keep an unfavourable daily lifestyle such as smoking, drinking, uncontrolled food-eating, shortage of physical exercise, etc. which produce bad effects upon their health. According to a recent survey, only 2.6 per cent of the elderly 60 and over do not smoke, and only 8.6 per cent of them do daily moderate physical exercise. So, the Korean elderly need more efforts to change such unfavourable habits for the promotion of their own health status. 4. 4.1 Strategies for the promotion of health status of the elderly Enactment of health promotion law for the elderly
The Korean government plans to introduce a special law called "the health promotion law for the elderly" to ensure the maintenance and promotion of health status of the aged persons. The major contents of the law shall be the following: (1) Strengthening the health education to change unfavourable lifestyles like smoking, drinking, heavy food-eating habit, etc. and providing regular health check-up services for the prevention and/or detection of chronic diseases.
(2) Introducing the home-visiting nurse services for the elderly in need, especially for the elderly living alone. (3) Increasing the number of nursing and/or treating facilities for the elderly with chronic diseases. 4.2 Strengthening community - based health care services for the elderly
The Korean government will put more emphasis on community-based health care for the elderly rather than institutional care through the following: 0) To establish the physical therapy room for the elderly in all health centres, and provide financial assistance to supplement necessary equipment and manpower like doctors, nurses, and therapists at the centres. The health centre is expected to play an important role as a primary centre for the elderly especially for those living in rural areas.
(2) To introduce the home-visiting nurse service for the elderly in need by posting nurs"s with special training in health centres or regional welfare agencies. 4.3 Expansion of special medical facilities for the elderly with chronic diseases
The Korean government also plans to increase the number of special nursing and/or treating facilities where the elderly with chronic disease needing long-term care are able to get proper medical services free or with low charges. As of 1995, six special medical facilities for those with chronic ailments like senile dementia are being constructed, and by 2000 twenty facilities will be established through the financial subsidy from the national budget.
- 51 Annex 3 4.4 Enforcement of health education and promotion of social activities
The proper health education and the adequate social activities of the elderly are crucial factors for the maintenance and promotion of their own health. Therefore, the Korean government will make more efforts to provide the elderly with health education such as dietary education, proper physical practice, not-smoking, etc. At the same time, the government will also continue to promote their social activities by creating more volunteer activity chance as well as employment opportunities.
- 53 -
ANNEX 4
SUMMARY ANALYSIS OF RESPONSES TO THE BRIEF QUESTIONNAIRE DISTRIBUTED TO PARTICIPANTS BEFORE THE WORKSHOP A total of 12 questionnaires were returned. (l) Is there a unit/department/ministry responsible for health of the elderly in your Government?
9 countries (75%) answered yes. (2) Does your country have a national policy on aging, the health ofthe elderly or some specific policy? 8 countries (66%) answered yes. (3) Does your country have a national programme for community-based care of the elderly? 4 countries (33%) answered yes. (4) Are community-based health care services provided at present in your country? 2 countries (17%) answered no. 7 countries (58%) indicated yes for all rural and urban areas. 3 countries (25%) indicated yes for some urban and some rural areas. (5) What type of services are provided: Countries indicating yes Home nursing Home help Respite services Meals on wheels Day care services Social activities/recreation Counselling Health Education 7 (58%) 7 (58%) 7 (58%) 5 (42%) 5 (42%) 6 (50%) 5 (42%) 8 (66%)
- 54 Annex 4 Others: Domiciliary therapy 1, Home maintenance 1, Home modifications 1, Health maintenance scheme 1, Exercises 1, Rehabilitation 1, Continence management 1. (6)
Which health workers are involved in community-based services? Physicians Registered nurses Nurse aides Allied health (paramedical) staff Social workers Primary health care workers Others: Village health workers 1, Personal care workers 1, Local community health workers 1. 6 (50%) 9 (75%)
7 (58%) 7 (58%) 6 (50%) 6 (50%)
(7)
Who provides services') Government? NGO? Private (for profit)? 8 (66%) 9 (75%) 7 (58%)
(8) Is training on health care of the elderly provided to staff involved in community-based health programmes? For physicians? For nurses? For others? 5 (42%) ofthese 2 (16%0 for all 6 (50%)ofthese 2 (16%) for all 4 (33%) of these 1 (0.8%) for all
- 55 -
ANNEX 5
MODEL ACTION PLAN FOR DEVELOPMENT OF COMMUNITY HEALTII CARE APPROACHES TO IMPROVE QUALITY OF LIFE IN TIlE ELDERLY
A model action plan could comprise the elements set out below. The extent to which individual countries should consider implementing the specific elements in the plan, and priorities, will vary according to existing structures and policies and their nationally defined needs and resources. The following broad elements should be considered: • A review of mechanisms at national level which contribute to coordinated action and national oversight of responses to population aging and the strengthening or creation of such mechanisms where this is considered necessary (Vienna International Plan of Action on Aging Recommendations for Implementation, Para 93, United Nations, New York, 1983).
• A review of national policies relevant to health and care for the elderly and further policy action as appropriate. • The creation, where needed, ofa focal point (Office on Aging) within the Ministry of Health. • The establishment of liaison and coordination between health and welfare authorities at all levels. • A review of undergraduate and graduate health and welfare professional training and the amendment as necessary of curicula content to give due emphasis to issues associated with agIng.
• The development of broader education and training opportunities in aged care directed to all community care workers, family and community care workers. • Wider promotion of issues associated with health promotion and protection and community health approaches directed to policy and decision makers and the general public.
• The development of a spccific programme of community based health promotion and protection integrated with primary health care services and focused on improving the quality of life in the elderly population. • A review and where necessary the reorientation of general health services to give due emphasis to the needs of the elderly. • The planning, fostering and where appropriate the direct provision of specified community based support services directed to the elderly, their families and community carers.
• The revision of existing data collection and health services monitoring activities to take fuller account of population aging and the situation of the elderly.
- 56 Annex 5
•
The further investigation and analysis of the needs of the elderly and their carers nationally and locally. Cooperation in international exchange and collaboration in the further development of indicators of quality of life, health and well-being among older populations and the application of such measures to monitoring population health and health care programme evaluation.
•
• The initiation of a strategic planning approach to the further development of community based health promotion and protection and care for the elderly. • Participation in the development of global and regional networks for the continuing exchange of information, training and reference materials and experiences of community based services for the elderly.
- 57 Annex 5
ACTIVITY A review of mechanisms at national level which contribute to coordinated action and national oversight and the strengthening or creation of such mechanisms where this is considered necessary Review of national policies relevant to health and care for the elderly and further policy action as appropriate. Creation, where needed, of a focal point (Office on Aging) within the Ministry of Health. Establishment of liaison and coordination between health and welfare authorities at all levels. Review of undergraduate and graduate health and welfare professional training and the amendment as necessarv of curicula content to give due emphasis to issues associated with aging. Development of broader education and training opportunities in aged care directed to all community care workers, family and community care workers.
PRIMARY RESPONSIBILITY Government
INDICATIVE TIME FRAME By end 1995
Government! Ministry of Health Ministry of Health
By end 1995
By beginning 1996
Government! Ministrv of Health! Ministr)' of Social Welfare Ministry of Health! ProfeSSional Education Authorities
On-going
By end 1996
Ministrv of Health! Ministry of Education
By end 1996
,
Wider promotion of issues associated with community health approaches directed to policy and decision makers and the general public. Development of a specific programme of community based health promotion and protection integrated with primal)' health care services and focused on improving the quality of life in the elderly population. Review and where necessarv the reorientation of general health services to give due emphasis to the needs of the elderly.
Ministr\' of Health! Health Education Division
On-going
Ministry of Health! PrimarY Health Division
Ministry of Health! Health Service Professional Organizations/ Health Care Facilities and Services
By beginning 1997
- 58 Annex 5
ACTIVITY Plan, foster and where appropriate the direct provision of specified community based support services directed to the elderly, their families and community carers. Revision of existing data collection and health services monitoring activities to take fuller account of population aging and the situation of the elderly. Further investigation and analysis of the needs of the elderlv and their carers nationally and iocally Cooperation in international exchange and collaboration in the further development of indicators of quality of life, health and well-being among older popUlations and the application of such measures to monitoring popUlation health and health care programme evaluation. The initiation of a strategic planning approach to the further development of community based health promotion and protection and care for the elderly. Participation in international networks for the continuing exchange of information, training, resources experiences of community based services for the elderly
PRIMARY RESPONSIBILITY Ministry of Health
INDICATIVE TIME FRAME On-going II
Ministry of Health
By beginning 1997
Ministry of Health
On-going
II
II
Ministrv of Health assisted bv International Agencies Including WHO
On-going • I
Government Ministrv of Health and Minist")· of Social Welfare Ministry of Health assisted by International Agencies including WHO
By mid 1996
On-going