(WP)NUT/ICP/HEE/OO l-E Report series number: RS/90/GE/34/(PHL) English only
REPORT REGIONAL WORKSHOP ON HUMAN RESOURCE DEVELOPMENT IN THE HEALTH CARE OF THE ELDERLY
Convened by the Regional Office for the Western Pacific of the World Health Organization Manila. 5-9 November 1990
Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila. Philippines November 1990
WH-r)IWI'!(. -LJ Htuu<:. M,(·/,iJn l'~
NOTE The views expressed in this report are those of the participants in the Regional Workshop on Human Resource Development in the Health Care of the Elderly and do not necessarily reflect the policies of the World Health Organization.
This report has been prepared by the Office for the Western Pacific Region of the World Health Organization for governments of Member States in the Region and for the participants in the Regional Workshop on Human Resource Development in the Health Care of the Elderly, which was held in Manila, Philippines, from 5 to 9 November 1990.
CONTENTS
fw SUMMARy ............................................................................................................................ 1 1. INTRODUCfION ............................................................................................................... 3 1.1 1.2 1.3 1.4 2.
Objectives ...................................................................................................................... Participan.ts and resource persons ............................................................................ OrganIZation ................................................................................................................. Opening ceremony .......................................................................................................
3 3 3 4
PROCEEDINGS .................................................................................................................. 6 2.1 Summary of country reports .............................................. ........................................ 6 2.2 Summary of discussions ..... ....... ......... ..... ........... ..... ..... ......... ........... .......... ........... ...... 6
3.
CONCLUSIONS ................................................................................................................... 8 3.1 Characteristics of the regions ..................................................................................... 8 3.2 Factors contributing to the need for education and training for health workers in health care of the elderly.... ......................... ................................... ......... 9 3.3 Categories and levels of health workers involved in care of the elderly ....................................................................................... 9 3.4 Guidelines for education training in health care of the elderly................... ........ ........................................ ............... .......... 10 3.5 Regional resources for training in in health care of the elderly........................................................................................ 10 3.6 Research on health care of the elderly ..................................................................... 11 3.7 Action plan .................................................................................................................... 11 3.8 Other follow up............................................................................................................. 12 ANNEXES: ANNEX 1 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERS, CONSULTANT AND SECRETARIAT ................. 13 ANNEX 2 - AGENDA ................................................................................................... 19
ANNEX 3A - COUNTRY REPORTS .......................................................................... 21 ANNEX 3B - COUNTRY QUESTIONNAIRE SUMMARy ................................. 35
ANNEX 4 - BACKGROUND PAPERS ..................................................................... 37 ANNEX 5 - OU1LINES OF SPECIFIC COUNTRY PLANS OF ACI10N ............................................................................... 69 ANNEX 6 - PREVIOUS GUIDEliNES ................................................................... 71 ANNEX 7 - CURRICULUM FOR HEALTH OF THE ELDERLY IN THE UNDERGRADUATE MEDICAL COURSE IN THE SCHOOL OF MEDICINE IN AUCKLAND .................... 73 ANNEX 8 - SUGGESTED UNDERGRADUATE MEDICAL CURRICULUM PLANNING ............................................................... 75
SUMMARY
A Regional Workshop on Human Resource Development in the Health Care of the Elderly was held in the Regional Office for the Western Pacific of the World Health Organization, Manila from 5 to 9 November 1990. It was attended by 13 participants representing 13 countries (including temporary advisers). The increasing number and proportion of elderly people in the Western Pacific Region will call for great changes in the health workforce and in the training required. Japan has the longest life expectancy in the world coupled with an annual population growth rate of only 0.7%. Countries like the Republic of Korea have seen the life expectancy of their citizens increase by 10 years over the last three decades. The population of aged people in the developing countries is already as large as that of the rest of the world, and is growing faster. By the year 2000, the aged population in the developing world is expected to have increased by about 100 million, compared with 35 million in the more developed world. There is also expected to be a rapid increase in the population of newly industrialized countries, although in some cases this may be mitigated by a concurrent increase in mortality caused by the noncommunicable diseases. Not surprisingly, there is a rapidly growing demand for innovative models for long-term elderly care, with emphasis on community-based systems. This in its turn will clearly call for a reorientation in the training of the health personnel in this sector. The objectives of the workshop were: (1) to review current training possibilities in geriatrics and gerontology in the Region;
(2) to identify future training needs and to project future requirements for the health and well-being of the elderly in their societies; (3) to develop guidelines for undergraduate medical education on the well-being and health of the elderly; and (4) to develop guidelines for designing curricula, within the limitations imposed by existing funding, personnel and priorities, to train health workers to meet the increased needs expected. Despite the regional diversity reported by the participants, in all countries it is clear that the immediate family is an important support and this appears related more to cultural attitudes and traditions than relative affluence or a particular demographic picture. The extended family is reported to playa significant part in the case of the elderly in a majority of countries. It is not easy to predict from socioeconomic or demographic features which countries are likely to have a system of state pensions. The participants, with the temporary advisers, divided into two groups to address the various issues. Their conclusions were then presented in three plenary sessions to the workshop. The issues addressed were as follows: (i) Factors contributing to the need for education and training for health workers in health care of the elderly.
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(ii)
Categories and levels of health care workers involved in care of the elderly.
(iii) Guidelines for education training in health care of the elderly. (iv) (v) (vi) Regional resources for training in health care for the elderly. Research on health of the elderly. Action plan.
A systematic plan of action was proposed which indicates specific objectives to be achieved in a defined time frame.
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1. INTRODUCITON
A Regional Workshop on Human Resource Development in the Health Care of the Elderly was held in the WHO Regional Office for the Western Pacific, Manila from 5 to 9 November 1990. 1.1
Objectives The objectives of the workshop were: (1) to review current training possibilities in geriatrics and gerontology in the Region;
(2) to identify future training needs and to project future requirements for the health and well-being of the elderly in their societies; (3) to develop guidelines for undergraduate medical education on the well-being and health of the elderly; and (4) to develop guidelines for designing curricula, within the limitations imposed by existing funding, personnel and priorities, to train health workers to meet the increased needs expected. 1.2 Participants and resource persons
The workshop was attended by participants representing 13 countries, including temporary advisers. The full list can be seen in Annex 1. 1.3 Ofl~anization
The participants, together with the temporary advisers, divided into two groups to address the issues outlined in 1.1. Their conclusions were then presented in three plenary sessions to the workshop. Before doing so and in between the small group sessions, several papers were presented. In one of these, the operational officer, Dr Ian Damton-Hill, outlined the background to the Health of the Elderly programme. He began by re-emphasizing that much of the major burden of aging would be in this Region as the country reports ably testified (Annex 3). For example, there were expected to be 100 million Chinese over 60 years of age by the end of the century. It had been estimated that more than 70% of the developed countries' total health expenditures was spent on those aged 65 years and over. The World Health Assembly on Aging, which had taken place under United Nations auspices in Vienna in 1982, had called attention to the importance of international and regional cooperation in research and exchange of expertise and cooperation. WHO involvement in the health care of the elderly had at least three distinct approaches. There was the Global Programme of Work, (which includes the WHO Special Programme for Research on Aging), the Regional Plan of Action for the Western Pacific and the country programmes. The global programme had the overall objective of supporting the continuous evolution and adaptation of technology and other approaches aimed at protecting and promoting the health of the elderly. This would be done by countries developing and providing health care adapted to the
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specifi~ probl.ems of the ~lderly as an integral part of their health care delivery systems, and by cou!'tr~es ta~g apl?ro'pnat~ measures .tc? promo~e. t.he welfare of the elderly and ensuring their social mtegratIOn wlthm the If commumtles. AI.:tlVlhes proposed for the Eighth General Programm~?! ~ork.(1990-199~).~ere the excha~ging of information through workshops on successful mlhahves m such activities as commumty-based primary health care programmes intersectoral measures and personnel training, among others. ' I~ May 1987, the World Health Assembly, acting upon the recommendation of the Advisory Committee on Health Research had adopted a resolution requesting the establishment of an international research programme on aging. An agreement had been signed between WHO and the National Institute on Aging of the United States of America to host the WHO Special Programme for Research on Aging with the mandate to carry out research and development and to strengthen national research capability. The key areas identified were:
determinants of healthy aging, age-associated dementias, age-related changes in immune function, and nutritional changes associated with aging, with special emphasis on osteoporosis. The Regional Medium-Term Programme for Health of the Elderly had the specific objective of improving the well-being and quality of life of the aged through the provision of communitybased health services. The targets related to the establishment of national policy, adequate data bases and appropriate research, all with an emphasis on community-based health care of the elderly. Among other approaches was 'the promotion of the development of adequate facilities for teaching geriatrics and gerontology to different categories of health personnel as well as training courses in care of the elderly.. .'. 1.4 Opening ceremony
The Workshop was opened on behalf of the Regional Director, Dr S.T. Han, by Dr I. Geizer, who pointed out that the increasing number and proportion of elderly people in the Western Pacific Region would call for great changes in the health workforce and in the training required. Much of the burden of the increase in aging would be borne by the Region. Japan had the longest life expectancy in the world coupled with an annual population growth rate of only 0.7%. Countries like the Republic of Korea had seen the life expectancy of their citizens increase by 10 years over the last three decades. The population of aged people in the developing countries was already as large as that of the rest of the world, and was growing faster. By the year 2000, the aged population in the developing world was expected to have increased by about 100 million, compared with 35 million in the more developed world. There was also expected to be a rapid increase in the popUlation of newly industrialized countries, although in some cases that might be mitigated by a concurrent increase in mortality caused by the noncommunicable diseases. Not surprisingly, there was a rapidly growing demand for innovative models for long-term elderly care, with emphasis on community-based systems. That in its turn dearly called for a reorientation in the training of the health personnel in that sector. The World Health Assembly on Aging had called attention in 1982 to the importance of international and regional cooperation in research, training, exchange of expertise and cooperation. The Western Pacific Region of WHO had sponsored research in aging in four countries of the Region: Fiji, Malaysia, the Philippines and the Republic of Korea. The most pertinent findings were that many of the problems seen in western countries in caring for the
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elderly, such as the loosening of family ties, the decline of traditional obligati?ns .towa~ds older people and the increasing relative numbers of older people, were also occurnng m ASian and Oceanic countries. Just over 40% of the respondents in surveys made for those st~dies had re~OI'~ed a h~alth problem which affected activities of daily living, and that percentage mcreased .wlth mcreas~g age. Old age was not necessarily a time of ill-health, disability and misery, but a vanety of chr~mc disorders did occur more frequently among the elderly than among younger people. Havmg more than one disease at the same time was also commoner in old age. In many health services, the elderly were too frequently exposed both to neglect and to over-treatment. In the more affluent countries, the side effects of drugs, and other iatrogenic diseases, were a major reason for the admission of old people to hospitals. It was hoped, however, that the workshop would not concentrate exclusively on the problems of aging. Although physical aging was no respecter of persons and there were real increases in the likelihood of degenerative diseases as one became older, all were aware of the advantages of age in such dimensions as judgement. experience and wisdom.
With rapid development, industrialization and technological change, the aged were likely to become more dependent on governmental health and medical services. That raised urgent questions, such as: Who cared for whom. and how? What did an effective community support system consist of! What training did health workers in this area need? What health care did the elderly themselves provide? In the United Kingdom. it had been observed that it was the recently retired who supported the very elderly. One worrying aspect of the situation was the shrinking proportion of women aged between 45 and 60 willing to provide a major part of the care needed by the elderly, as they had in the past. In the four countries studied in the Western Pacific Region. around three quarters of the people surveyed lived with their children. In countries such as Australia, the figure would be much lower. For instance, in North America a third of the elderly lived alone and nearly half of those aged 75 or over did so. Despite the high number of the elderly being cared for at h()p1e in many countries of the Region, at some stage they and their families would need more support. Many of the elderly continued to work, but sooner or later they had to stop, and pensions and superannuation and welfare payments were available to relatively few of the elderly in the Region. Also, in general, the elderly living in rural areas were not well-provided for by health and community services. Ideally, full-time institutional care should be provided only when primary care, maintenance at home, community centres. day-care centres and day hospitals failed to meet the patient's needs. Such services differed from country to country but they always called for the training of health personnel in geriatrics, gerontology, communication. support and nursing. It was likely that the nursing profession would continue to become increasingly involved in the care of the elderly. An important factor to be aware of in both health care and training was that everyone eventually grew old and died. Health workers needed the skills and the confidence to support their patients in dying with all the dignity and grace, and freedom from pain whenever possible, that they would wish for themselves. He concluded by wishing the participants the best of luck in their deliberations. He looked forward to seeing conclusions that the countries of the Region could usefully apply to their own situation.
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I 2. PROCEEDINGS
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2.1
Summa'Y of count'Y reports
. . The nat~on~l programmes reflect the priority of the countries themselves but many of the ldentified proJechons, as w~ll.as the potentlal public ~ealth, and particularly health economic, proble~s are remarkably sunilar throughout the ReglOn. The current status of the various countnes represented at the workshop is to be found in Annex 3A but in the meantime the results of the country questionnaires have been summarized (Annex 3B). Out of the eleven countries that responded)ust under half (5) reported having a national policy on aging or health care of the elderly. Life expectancy from blrth ranged from an average of 50 years to 78.9 years with 6 countries in the seventies and 4 in the sixties. In all cases there has been a marked increase in the last 40 years, in some cases dramatically so. Although there was some variation in the way the total number of people over 60 was calculated, the figure, as a per cent of total popUlation ranged from 1.7% to 16.9%. The percentage over 80 years ranged from 0.3% to 2.3%. It was noted that the distribution of the population of the Region was moving from a pyramidal to an octagonal shape caused by decreases in infant mortality, fertility (zero or even negative popUlation growth), mortality in adults and mortality in the old and the old old. The dependency ratios generally mirrored the above information with, for example, Japan having a relatively smaller percentage of people earning compared with those who are not; as opposed to say, Fiji, with a dependency ratio double that of Japan. The dependency ratio does not necessarily tell us much about countries where the young begin to work as children and the elderly remain productive for longer than in many western countries. It was also interesting to note from the questionnaire responses that, despite the diversity shown above, in all countries, the immediate family is an important support and this appears related more to cultural attitudes and traditions than relative affluence or a particular demographic picture. The extended family was reported to playa significant part in the case of the elderly in a majority of countries. It was not easy to predict from socio-economic or demographic features which countries were likely to have a system of state pensions.
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Bya small majority of six to five, more countries reported providing training in geriatrics and gerontology but, as will be seen, this includes a great variety of approaches. It is clearly an appropriate time to be examining the question of training health personnel in the changing needs of aging populations. 2.2 Summa'Y of discussions
The consultant to the workshop, Professor Gary Andrews of the WHO Collaborating Centre attached to the Flinders University of South Australia in Adelaide, outlined the situation in the Region and spoke of the study of the elderly in four countries, and of which he was principal investigator. He also outlined the background to the present workshop. In 1981, there had been a health of the elderly workshop in WHO, Manila, followed by the World Assembly on Aging in Vienna in 1982. In 1983 there was a meeting in Singapore on training for health care of the elderly, a meeting convened by the International Association of Gerontology and the Global Programme of Health of the Elderly, which issued a report. The future directions decided on in this meeting can be seen in Annex 6, although there has not been a great deal of action. In 1985 there was an update in Malaysia in a meeting held by the Western Pacific Region and South-East Asia Region. At this meeting it was observed that the vast majority of training activities were occurring in nursing training although some medical schools were improving. The importance of an interdisciplinary approach was again emphasized.
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Dr Miriam Hirschfeld from WHO/Geneva spoke of the experience of nursing in the development of training in the health care of the elderly. She point.ed ~ut the relatively long . involvement of nursing in the health care of the elderly although thIS still needed to be formalIZed in some courses. She referred to the requirement to assess, plan and manage both needs ~nd. r~urces with the community. Attention and care are something that should move from the mdividual, to the family, into the local environment and finally into the community. She emphasized the need to focus not just on the very dependent infirm elderly but also on the healthy elderly who have independent, full lives. There was some discussion of the negative image of the elderly, which is often not lessened during training and may result from too little interaction with the healthy elderly. This mirrors society's often rather negative attitude. Concerning the needs in training, it was stated that knowledge alone was not enough. Skills, however, including cross-cultural, administrative and management skills, were essential. A different training emphasis is needed, depending on whether the healthy elderly are involved, those with acute illness, those with chronic illness or finally the very dependent elderly, including those people suffering from dementia. The Chairman, Professor David Richmond, outlined the sort of curriculum components in the undergraduate medical course in the School of Medicine in Auckland (Annex 7). He referred also in general terms to the fact that the need is not always of highly-trained, high technology health personnel who are expensive to train and whose training may not always be appropriate. Often, in fact, such highly trained people are less available in that they are urban-based, in large hospitals, or they emigrate. Both he and Dr Hirschfeld cautioned about expecting village health workers to work voluntarily, although in some environments this is reported to function effectively. One of the Temporary Advisers, Dr Nii-K Plange of the University of the South Pacific, spoke of the health care of the elderly in changing societies. Dr Plange had also been involved in the Fiji section of the four-country study. He outlined some of the demographic characteristics and trends of the elderly in changing societies, and the resources and constraints in the health care in such societies. He referred to epidemiological transition as infant mortality rates decrease, fertility declines and the number of elderly people in the population increases. Aging populations in changing societies are still predominantly rural, partly because of out-migration by the youth but also, as in Fiji, because of older people tending to migrate to rural villages. Resources for the care of the elderly are likely to become an increasing problem as changes occur that threaten the family as a traditional support system. His paper is in Annex 4. Finally, Dr Edward Leung, Chief Editor of the Hong Kong 10urnal of Gerontology and the other Temporary Adviser, spoke of the teaching of health care for the elderly in Hong Kong, were courses are available for medical practitioners, nurses, paramedical personnel and untrained personal care workers and welfare workers. The paper (also in Annex 4) describes what can be done with limited resources and great enthusiasm. 2.2.1 First round of discussions
The fIrst set of discussions had the following objectives, of which the first two were addressed by one group and the remaining two by the other group. These outcomes/objectives were to: (i) identify the factors which have resulted in a need to expand training and education for health care of the elderly; (ii) outline the arguments for training health workers in the care of the elderly;
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(iii) decide the range or types of health care workers to be trained and to what level Also . from where they will be recruited; and (iv) identify current barriers to the provision of training in the care of the elderly for health care workers, and specify ways of overcoming them. 2.2.2 Second round of discussions The second round of small group discussions had the following outcomes/objectives: (1) to identify the specific training needs in the field of health care for the elderly throughout the Region; (2) to recommend a strategy for promotion of training for health care of the elderly within the Region; (3) to propose possible methods for the implementation of improved programmes for training of health professionals and others in health care of the elderly, both nationally and regionally; and (4) to identify resources needed to achieve the above objectives and to propose possible approaches to international cooperation and exchange in the development of training programmes throughout the Region. 2.2.3 Third round of discussions The objectives/outcomes of this session were: (1) (2) (3) to develop general guidelines for education and training in health care of the elderly; to outline a plan of action at the national and regional level; and to propose a plan for follow-up of this workshop.
There were exhaustive and extremely productive discussions which have been briefly summarized and incorporated into the conclusions and recommendations. A more exhaustive summary of the small groups is available, on request, from the HEE unit at WHO, Manila.
3. CONCLUSIONS
The conclusions of the workshop can be considered under a number of specific headings. 3.1 Characteristics of the re&ions
The Western Pacific Region demonstrates a variety of characteristics which influence need, as well as the potential for development of education and training in health care of the elderly throughout the Region. Specifically the diverse geographic, demographic, socio-economic and cultural variations within the Region give rise to opportunities for mutually beneficial collaboration, exchange, and resource sharing between countries. The workshop participants noted the variation in levels of socio-economic development. The countries of the Region can be categorized as the most highly developed, newly industrialized, developing and the least developed countries. Some countries such as the Philippines and the
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Republic of Korea were noted as in transition from o~e category to another. Th~se differences in . . social and economic development were also reflected m the sta~es of demographl~ and epidemiological tra~sition, in health services devel?pment, and m levels of education and trammg resources available m each of the groups of countnes. Other relevant features were the relative geographic isolation of some of the island nations and the notable maldistribution of available education and training resources between the countries of the Region. This suggests a need for the development of regional resources and the need for strategies to be determined which provide opportunities for appropriate training for health workers in the countries with poorly developed education and training infrastructures. 3.2 Factors contributin~ to the need for education and trainin~ for health workers in health care of the elderly
The workshop participants enunciated a range of factors which have contributed to the now urgent need for health workers to be trained to be able to practise more effectively among their aging populations, and to provide high quality health care to the elderly in need. These factors include such elements as: changes in demography, socio-economic influences, cultural trends, changing expectations of the elderly, politico-economic shifts, changing disease patterns, changes in health care delivery systems and the pervading presence of popular myths concerning aging and the health of the elderly popUlation. The extent and universality of these trends is such that the workshop participants identified a need for population aging to be taken into account in all health care policy, planning and health programme activities both regionally, through WHO, and at the national level by country authorities. 3.3 Cate~ories
and levels of health care workers involved in care of the elderly
Workshop participants noted the various levels and wide range of categories of health workers for which training in health care of the elderly is relevant. While training is generally required over this whole range of categories and at all levels. the needs of individual countries vary greatly at present, depending upon the particular health care structures, available resources and level of development. Training for health care of the elderly should be conducted at both undergraduate and postgraduate levels. All undergraduate health professional courses should now include a significant component of education and training for health care of the elderly. Schools of health professional training should be persuaded, in response to the needs and directions outlined above, to review the content of their course curricula in order to assess the level and quality of exposure of students to relevant aspects of aging. Postgraduate training should include continuing education for appropriate groups of health workers and the opportunity for specialist training in each of the professions, especially nursing and medicine. There is a need to train a limited number of people from each country at the highest level to act as focal persons, leaders and national resource persons in the field. These persons should be selected from both the medical and nursing professions. They should be offered training in appropriate institutions in the developed countries of the Region. Some should be trained to full specialist qualification. There exists a need, at every level, to increase the local resources available to contribute to human resource development for health care of the elderly and to this end, emphasis needs to be given to building up in each country a core group of people able to act as local resources in this respect. Thus it is important to develop programmes directed at 'training the trainers'. It will be
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important that people in this category are carefully selected for their communications motivatio.nal ~nd .teaching s~ills. 0l?portunitie;; will ~ need to be developed for th~e people to apply theIr skills m appropnate settIngs, especially wlthm practical in-service schemes as well as in formal education and training settings. "Middle level" health professionals, including community nursing personnel, will need to be trained to act as local supervisors and team leaders, including nurses, allied health professional and public health practitioners. At the most basic level, training is necessary for primary health care workers who are responsible for the care of growing numbers of elderly. In most instances these personnel will be generalists working in the community. Provision will need to be made for training of some specialist workers in health care of the elderly, even in the less developed countries, while in the setting of the more developed countries of the Region there will increasingly be more emphasis given to this generalist category of health worker. Attention should also be given to the training needs of the nonprofessional categories of health workers, including the traditional health care providers who contribute significantly to the provision of caring services, especially in the less developed countries and in rural areas. 3.4 Guidelines for education training in health care of the elderly
Training approaches in health care of the elderly should be guided by a number of principles. These should include the following: (1) (2) The education and training provided should be conducted within a community setting. It should be student-oriented.
(3) A positive image of aging should be emphasized using as far as possible opportunities to expose students to active, normal aged people. (4) Training should give due emphasis to the multidisciplinary aspects of care of the elderly and should emphasize the team approach to assessment and care. (5) Clear aims should be stated for particular training programmes and educational objectives in terms of the knowledge, skills and attitudes to be acquired as a result of training. 3.5 3.5.1 Re~ional
resources for train inc in health care of the elderly
Resources for educational resource and curriculum development
A limited number of institutions and centres, generally only in the highly developed countries of the Region, are potentially able to provide a focus for regional curriculum development and to assist in the coordination of efforts, dissemination of information, and the production of material for training in health care of the elderly as well as being a source of consultant personnel. The participants recommended that one or two centres in the Region in Australia or New Zealand and Hong Kong or Singapore should be designated as WHO collaborating centres for these purposes. The designated collaborating centre( s) could then undertake a systematic programme of educational resource development, consultation and research aimed at improving education and training in health care of the elderly throughout the Region. This activity could be
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initiated through the creatio.n in the first inst~n.ce ~f a :Cur~iculum Planning/De~elopment Resource Committee" drawmg upon the participation m this workshop and pendmg the establishment of collaborating centres and a regional network as described below. 3.5.2 Resources in training
A wide range of training opportunities is available throughout the Region for various levels of graduate training in health care of the elderly for the various professional groups. However, the capacities of individual countries in this respect vary greatly. The participants considered that a systematic approach to the provision of training in this field in the Region should be developed. A network of appropriate training institutions and centres should be identified and fellowships should then be made available through WHO and other appropriate bodies to provide individuals with training appropriate to their needs. In this context participants noted that appropriate training often involves relevant experience in the field in relation to service delivery, administration, planning and development of programmes rather than simply academic work. Participants noted the urgent need for the development of improved infrastructure resources for those institutions and centres involved in accepting overseas students for training and experience. 3.6 Research on health care of the elderly
Participants noted the important relationship between education and training and research, both in researching the topic as well as the undertaking of educational research as a related activity. There is a great need for better data on aging in the Region to improve and broaden the knowledge base on aging and to support more relevant education and training. Every opportunity should be taken to encourage research in the field and to provide appropriate opportunities for both graduate and undergraduate students to be involved. 3.7 Action plan
A systematic plan of action is proposed which indicates specific objectives to be achieved in a defmed time frame. In the first instance a three-year plan of action is envisaged. Although this represents a substantial and ambitious commitment, participants felt that in view of the relatively little action taken on education and training for health care of the elderly consequent upon previous workshops, an urgent response is now justified. Participants recommended that specific indicators of progress should be established by the Curriculum Committee referred to above and that these would be practical and measurable so that they can be used to monitor progress. During the first half (18 months) of the plan, the following actions should be taken. (1) Establishment of a Regional Curriculum Planning/Development Resource Committee. (2) Designation of collaborating centres for curriculum development and resource identification, dissemination and research. (3) Establishment of a network of training centres.
(4) Development of appropriate curricula in consultation with such training centres to provide "training of the trainers" programmes on a Regionwide basis.
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~5) pevelopme~t of curricula and pro~ammes for training other health workers, mcludmg commumty health nurses, public health practitioners and others according to identified country needs.
(6) Development of guidelines and the fostering of improved training in health care of the elderly for non-professional community workers and for primary health care workers. (7) The promotion of extended and improved education and training for health care of the elderly in all health professional undergraduate teaching in the Region. The holding of a regional workshop on education and training of health workers for (8) care of the elderly under the auspices of the Asia/Oceania region of the International Association of Gerontology with World Health Organization endorsement in 1992. (9) During the second 18-month period, action should be taken to: (a) (b) (c) (d) continue and consolidate many of the initiatives begun in the first period; explore new directions based upon the experience gained and the evaluation of the initial activities; draw up on-going plans of action covering the succeeding three- to five-year period; and conduct, through WHO/Manila at the end of the three years, a further major regional workshop to review and evaluate progress and to identify future directions for education and training for health care of the elderly in the Western Pacific Region.
3.8
Other follow up
In addition to the formal actions proposed as a follow up of this workshop, participants noted the potential continuing informal contact, exchange and mutual support between those attending the workshop and it was strongly felt that this approach should be encouraged as a supplement to the actions recommended above.
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ANNEXl
LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERS, CONSULTANTS AND SECRETARIAT
1. PARTICIPANTS
AUSTRALIA
Prof Gerald Anthony Broe Professor in Geriatric Medicine Aged and Extended Care Department C25 University of Sydney RGH Concord, NSW 2139 Sydney Dr Lin Yan Physician-in-charge Department of Medical Administration Ministry of Public Health 44 Hou Hai Bei Yan Beijinl: Dr Zhang J u-xing Physician-in-charge Beijing Institute of Geriatrics Dahualu, Dongdan Beiiinl:
CHINA
JAPAN
Dr Kazuhiro Araki Deputy Director Division of the Health for the Aged Department of Health and Medical Service for the Aged Ministry of Health and Welfare 1-2-2, Kasumigaseki, Chiyoda-ku Tokyo 100 Dr Sommone Phounsavath Director Mahosot Hospital Vientiane
LAO PEOPLE'S DEMOCRATIC REPUBLIC
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Annex 1
MALAYSIA
Dr Ezaddin Mohamed Head. Department of Community Health Universiti Kebangsaan Malaysia Jalan Raja Muda Abdul Aziz 50300 Kuala Lumuur Prof David Eric Richmond Professor in Geriatric Medicine Department of Geriatric Medicine University of Auckland North Shore HospitalH Shakespeare Road Takapuna, Auckland 9 DrPuka Temu Senior Physician Department of Health Port Moresby General Hospital F.M.C. Boroko Dr Particia S. Fernandez Medical Specialist III (Training Officer) Rizal Medical Center Pasig, Metro Manila Dr Marina Miguel-Baquilod Medical Specialist I Non-Communicable Disease Control Service Department of Health San Lazaro Compound Sta. Cruz, Manila
NEW ZEALAND
PAPUA NEW GUINEA
PHILIPPINES
REPUBLIC OF KOREA
~iate
Dr Hyun-seung Kim Professor Department of Internal Medicine Yong-Dong Severance Hospital Yonsei University Do-Gok Dong, Kang-Nam Ku Seoul
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Annex 1
SINGAPORE
Dr Choo Wee Jin Philip Senior Registrar Department of Geriatric Medicine Tan Tock Seng Hospital Moulmein Road Sin&apore 1130 Dr Nguyen Chi Binh Assistant Director on Social Gerontology Institute of Gerontology Bachmai Hospital Hanoi
VIETNAM
2. TEMPORARY ADVISERS
Dr Nii-k Plange Head, Department of Sociology School of Social and Economic Development University of South Pacific P.O. Box 1168 Suva, Fiji Dr Edward Man Fuk Leung Senior Medical Officer United Christian Hospital 130 Hip Wo Street KwunTong Kowloon, Hong Kong
3. OBSERVERS
Ms Rose Anne J. dela Cruz Marketing Specialist IV Philippine Retirement Authority 2nd Floor, Producers Bank Building Buendia Avenue Extension Makati, Metro Manila
- 16-
Annex 1
Ma Alma G. Pontillas Marketing Specialist ill Philippine Retirement Authority 2nd Floor, Producers Bank Building Buendia Avenue Extension Makati, Metro Manila Ms Desiree A Tupaz
Marketing Specialist II Philippine Retirement Authority 2nd Floor, Producers Bank Building Buendia Avenue Extension Makati, Metro Manila
4. CONSULTANT
Prof Gary R. Andrews Director Centre for Ageing Studies 254 Greenhill Road, Glenside SA
5. SECRETARIAT
Dr N.V.K. Nair Director, Health Protection and Protection WHO Regional Office for the Western Pacific P.O. Box 2932 Manila, Philippines Dr I. Darnton-Hill (Operational Officer) Regional Adviser in Nutrition WHO Regional Office for the Western Pacific P.O. Box 2932 Manila, Philippines
- 17-
Annex 1
Dr Miriam J. Hirschfeld Chief Scientist for Nursing Division of Development of Human Resources for Health World Health Organization Geneva, Switzerland Dr A. Romualdez Director, Health Services Development and Planning WHO Regional Office for the Western Pacific P.O. Box 2932 Manila. Philippines MsT. Miller Regional Adviser in Nursing WHO Regional Office for the Western Pacific P.O. Box 2932 Manila, Philippines Dr Shinfuku Regional Adviser in Mental Health WHO Regional Office for the Western Pacific P.O. Box 2932 Manila, Philippines Dr I. Soetjahja Regional Adviser in Health Education WHO Regional Office for the Western Pacific P.O. Box 2932 Manila, Philippines
- 19-
ANNEX 2
AGENDA
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Opening ceremony Global and Regional WHO Programmes for Health Care of the Elderly Projection of health care needs and role of collaborating centres The experience of nursing in the development of training needs for health care of the elderly Health care of the elderly in changing societies Identification of likely health care personnel training needs Training requirements for health care of the elderly in the Western Pacific Region Training needs for the Western Pacific Region Teaching of health care of the elderly - experience in various levels of health care workers Development of guidelines for different situations Closing ceremony
- 21 -
COUNTRY REPORTS
ANNEX3A AUSTRALIA 1.
DEMOGRAPHY 1.1 Total population (1987)
16100000 2587790 (15.4%) 1798131 (11.1%) 358724 (2.1%) 76.3 years 3207800 50.6% 8.7/1000 births AU$l1 363.78
60 years and over (1989) 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years and over by year 2000 1.4 Dependency ratio 1.5 Infant mortality rate (1988) 1.5 Income per capita (1987/88) 2.
Carers of the elderly
In Australia, the mainstay of aged care is the family. Although elderly people struggle to remain independent for as long as possible, when help is needed the aged turn first to their families. The majority of carers in this setting are women. They may be elderly themselves, caring for an ailing spouse or for very elderly parents. 3. Health care of the elderly
There are a number of home care services such as domiciliary care, delivered meals, community nursing and council-based welfare services available to the elderly with priority given to those living alone. The services for the elderly in Australia are at present being reorganized (HACC) with costs to be shared by the States and the Commonwealth. The aim is keep people in the community and reduce growth in institutional care. At present, only about 7% of elderly people use community services. 4. Training for health care of the elderly
Training in the health care of the elderly is a priority for the health care professions. A survey conducted in 1985/6 of 41 educational institutions, health authorities and hospitals around Australia found that 78 programmes were offered in health care of the elderly. It was found that 32 specific programmes were offered and 46 were part of other courses. The majority of these programmes (30) were offered to nursing students with the next most frequent group being medical (24 programmes), followed by allied health and interdisciplinary groups of students. The majority of programmes (37) were offered at the undergraduate level and 10 at the post graduate level. In nursing, 4 programmes were offered at the basic level with 25 being offered at the post-basic level.
- 22 Annex 3A
PEOPLE'S REPUBLIC OF CIDNA 1. DEMOGRAPHY 1.1 Total population (1988)
1060 013 000 90 000 000 (8.4%) 59 000 000 (5.5%) 6 150 000 (0.58%) 69 years 130 000 000 45.6% 17.8/1000 births US$239 (Y885)
60 years and over 65 years and over 80 years and over 1.2 Life expectancy (1985) 1.3 Projected elderly population (60 yrs and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate (1988) 1.6 Income per capita (1988)
2.
Carers of the elderly
Traditionally high regard is paid to the elderly who lived in extended families. With rapid socioeconomic change, family patterns are moving towards a nuclear model. In 1987, 16.3% of the elderly lived alone, 29.2% in two.generational households and 50.0% in three. 83.8% of people over 60 years cared for themselves, 3.5% by spouse and 11.9% by children. 3. Health care of the elderly
There are three-tier medical and health networks in rural China (county level, township level and village level). 87% of the villages have health stations which provide 70% of the out· patient services. In the urban area, health care of the elderly is provided by health units at various levels depending on varying reimbursement. The problem is that free medicare is not available for all older people, especially in rural areas. Even in urban areas, there are still 19.6% of the elderly who have to pay their medical expenses by themselves. 4. Training for health care of the elderly
Human resource development in health care of the elderly has been given much attention as popUlation aging accelerates. There are four ways of training in geriatrics and gerontology. (1) (2) (3) (4) about 20·40 class hours of geriatrics in a few medical universities postgraduate training continuing education short-term training courses, workshops and seminars
Further training would require: a long-term training programme; the training of trainers; the development of textbooks for various health workers; and to train medical assistants working in the community to provide for health care of the elderly.
- 23 Annex 3A
FIJI 1.
DEMOGRAPHY 1.1 Total population (1986)
715375 12043 (4.61%) 18390 (2.93%) 2 599 (0.36%) 63 years 64000 71%
60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita 2. Carers of the elderly
17/1000 births FJ$1127.00
The majority of the elderly are cared for in the extended family, and community contexts. There are a small number of elderly, some infIrm, who are cared for in state and in governmental charitable institutions for the elderly. 3. Health care of the elderly
Front-line health care of the elderly is still mainly undertaken at home by relatives and by public health nurses. Medical practitioners both government and private might see some but only few since the majority of the elderly live in rural areas. There are no specialized nurses or agencies who undertake a particular responsibility for elderly health care. A government Rehabilitation Unit provides some assistance to elderly patients in need, but this also is not an elderly-specific unit. 4. Training for health care of the elderly
Nurses do not get special training in the health care of the elderly. Familiarity with hospitalized elderly patients is provided as a part of general training and practicals within the hospital but special emphasis on health care of the elderly is not provided . . Post-graduate training is not available in the country. Neither is in-service or continuing education in medicine or nursing. Most health workers go to Australia or New Zealand for further training.
-24 -
Annex 3 A
HONG KONG 1. DEMOGRAPHY 1.1 Total population (1990) 60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly popUlation (60 years and over by year 2000 1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita (1989) 5775300 748700 (11.6%) 511 800 (7.6%) 80600 (1.1%) 76.9 years 1125300 (17.8%) 44.3% 6.9/1000 births HK$ 85325
2.
Carers of the elderly
The principle of care for the elderly in Hong Kong is 'Care in the Community'. Thus most of the carers are from the community with the majority of them the immediate relatives of the elderly. The types of carers could be classified into family, community support network and residential service. 3. Health care of the elderly
The front-line health care of the elderly is provided by the general practitioner, health promotion centres, community nurses, geriatric physicians and paramedical personnel. 4. Training for health care of the elderly
Student nurses are offered elective subject in geriatrics. Introductory lectures on geriatric medicine are given in medical schools. A 4-week clinical attachment programme to a geriatric department is also provided. Other health workers have introductory lectures on geriatrics during their final year. Doctors and nurses working in geriatric units are offered in-service training at their hospitals. For medical and nursing staff undergoing overseas training, most of them are sent to the United Kingdom for further training.
- 2S Annex 3A
JAPAN 1. DEMOGRAPHY 1.1 Total population (1987) 60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita (1988) 2. Carers of the elderly Japan also has a tradition of elderly people living with their families but this is changing. 3. Health care of the elderly 121535000 20 539 000 (16.9%) 14 098 000 (11.6%) 2 795 300 (2.3%) 80 years 29 012 000 (22.1%) 35.8% 4.6/1000 births $23416
Public health nurses generally do front-line health care of the elderly. There are three tiers: health service, medical services and welfare services with home-helpers. There is a tenyear strategy to promote health care and welfare of the aged at home which will train 100 000 home helpers, increase institutional and temporary stay beds by some 500 000 beds and build 10 000 domiciliary care support centres. 400 Living Welfare Centres for the Aged in depopulated areas will also be developed. 4. Training for health care of the elderly
There is no special education for health workers of the elderly in Japan. Health workers such as medical doctors, public health nurses and others get training only in their routine educational programmes. All medical doctors get their post-graduate training for 2 years as an obligatory part of their courses for training in particular specialities (,Notation'). Subsequently they can do more specific post-graduate training as they wish but with the content being according to the policy of the hospital. Other health workers do not have such systematic programmes. Most of their training is given in the hospitals they are working at according to the policies of the particular institution. They usually go to the USA or Western Europe for training outside Japan.
- 26 Annex 3A
REPUBUC OF KOREA 1. DEMOGRAPHY 1.1 Total population (1990)
42792512 3181854 (7.4%) 2025561 (4.7%) 249146 (0.58%) 68 years 4780000 42.1% 12.4/1000 births US$4968
60 years and over 65 years and over 80 years and over 1.2 Life expectancy (1985) 1.3 Projected elderly population (60 years
and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita 2.
Carers of the elderly
In the past, until the mid 1970's, except for the care of the indigents who were cared for by the government, the individual's medical care was one's own responsibility. Most of the elderly were taken care of by their immediate and/or extended families. With the commencement of the Fourth Five-Year Economic Development Plan (19771981), the Korean government emphasized social development including the Medical Aid Programme for indigents, low-income groups, and the elderly as a form of public assistance. Recent trends indicate that many young and middle aged Korean people do not wish to be dependent on their family and are preparing themselves for their own well-being and health care in their old age. 3. Health care of the elderly
The public health nurses are doing the majority of the health care for the elderly at the health centres and sub-centres. The medical health care of the elderly is generally carried out by general practitioners. However, due to the chronic shortage of general practitioners in the rural areas, the physicians of the health centres and sub-centres care for the rural elderly. 4. Training for health care of the elderly
Health care for the elderly is incorporated by the nursing schools as part of learning general nursing care. The nursing training also includes additional training for the health care of elderly in the public health classes during the graduate courses. Most of the health care workers caring for the elderly are trained within Korea. However, advanced training is usually obtained from the USA.
- 27 -
Annex 3A
lAO PEOPLE'S DEMOCRATIC REPUBUC 1.
DEMOGRAPHY 1.1 Total population (1987)
3584 803 224300 (6.25%) 145012 (4.05%) 27631 (0.77%) 50 years 700000 (15-19%) 85.9% 118/1000 births US$ 170
60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years
and over by year 2000)
1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita 2. Carers of the elderly
The policy of the government is to give free health care to the people as needed. Generally old people are cared for by the extended family. 3. Health care of the elderly
The aged people attend rural centres for primary health care and for medical examinations. They stay with and are taken care of by their family with the aid of the traditional care providers. 4. Training for health care of the elderly
With the help of WHO, a care unit for the aged people could be provided. A course for health personnel in order to develop the knowledge of the medical staff in different categories is needed. The government hopes to extend care units in different areas of the country and to give training courses in Viet Nam or Thailand to medical staff.
- 28 -
Annex 3A
MAlAYSIA 1. DEMOGRAPHY 1.1 Total population (1987) 60 years and over 65 years and over 80 years and over 1.2 Life expectancy (1988) 1.3 Projected elderly population (60 years and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita (1988) 2. Carers of the elderly 17376800 1014800 (5.84%) 674 200 (3.87%) 96 600 (0.55%) 70.8 years 1529800 (6.82%) 69.6% 14.5/1000 births M$5477
A survey in 1984/85 found that 72% of the elderly were living with their children and that the majority of the elderly, especially women, depend upon their family for fmancial support. The Ministry of Welfare Services provides institutional services in terms of old folks homes and rehabilitation centres as well as financial assistance for some of the elderly. Similar services are also provided by voluntary organizations. But in general, only a small proportion of the elderly live in those institutions. Changes in the socioeconomic system with an increase in rural-urban migration, urbanization and female labor force, however, may lead to the decline of the traditional patterns of family support for the elderly, and the roles of the voluntary organizations are expected to increase. 3. Health care of the elderly
In general the health needs of the elderly are catered for by the public medical and health services in the country though some of the private medical services may be accessible to them. As there are almost no specialized agencies or specialized health personnel providing specific services for the health care of the elderly, the general practitioners (both public and private sectors) and the public health nurses form the majority of the front-line health care providers for these groups of populations. 4. Training for health care of the elderly
In general, the doctors, the nurses and other health workers get no specific training in the health care of the elderly, other than perhaps some general concepts or principles in their health problems and needs. However, a few seminars/workshops have been held to determine the health needs of the elderly in specific areas e.g. hearing, vision and dental.
- 29 Annex ]A
NEW ZEALAND 1. DEMOGRAPHY 1.1 Total population (1990)
3422 000 518 400 (15.2%) 373800 (10.8%) 75 400 (2.2%) 74.1 years 593400 40.7% 1O.1/tOOO births NZ$10 663
60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years and over by year 20(0) 1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita 2.
Carers of the elderly
Family members provide first line care for their elders where possible. The national philosophy in New Zealand is that older people should be enabled to remain in their own homes for as long as possible. To this end the Social Welfare Department provides assistance for elderly people with disabilities. When the family is no longer able to cope or there is no family, the State takes the major responsibility through Area Health Boards. There is a guaranteed Retirement Income Scheme for people over 60 years of age. 3. Health care of the elderly
Health services for the elderly are listed under three categories: medical; residential continuing care; and other continuing care services, home support services and accredited visitors' service. 4. Training for health care of the elderly
Most Area Health Boards provide a Postgraduate Diploma Course in Geriatric Medicine for nurses involved with health care of the elderly. Doctors receive training in their undergraduate years in geriatric medicine. Other health workers in the public hospital system do not have specific or specialized training schemes in the health of the elderly. There is a wide range of postgraduate continuing education and in-service training available in New Zealand. Health workers seeking further training in their profession would normally go from New Zealand either to Australia, United States of America or United Kingdom.
- 30 -
Annex 3A
PHILIPPINES 1. DEMOGRAPHY 1.1 Total population (1990)
61480180 2 872 087 (4.97%) 1740010 (3.14%) 190709 (0.31%) 64.6 years 4571554 72.7% 50.3/1000 births P 2 551
60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years
and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate (1990) 1.6 Income per capita
2.
Carers of the elderly
The fundamental responsibility for the care of the elderly in the Philippines lie within the immediate and extended family. By traditional and cultural values, strong family ties are a rule and high respect for the elderly is accorded by the children and grandchildren as a way of recognition through affection and all help in their own little way. The Department of Social Services and Development extends some care by way of nursing home institutions for the infirm aged; the Government Social Service and Insurance System (GSIS) and the Social Security System (SSS) provide pensions for those who have retired from the public service. The Department of Health manages referrals for management and rehabilitation on a case to case basis. 3. Health care of the elderly
The primary level of health care network provides basic health services to the aging population. Health education, promotion and primary care is advocated. With the evident lack of doctors and nurses, the midwife generally does the frontline health-care of the elderly for which they effectively utilize referral systems for further evaluation and management. 4. Training for health care of the elderly
There is a lack of adequate training of health personnel (doctors, nurses, midwives) in geriatrics and gerontology. There is an apparent need to modify the medical education curriculum to give due emphasis and consideration on geriatric medicine and gerontology, particularly in communication, support and nursing care.
- 31 -
PAPUA NEW GUINEA 1. DEMOGRAPHY 1.1 Total population (1988)
3661000 63000 (2.1%) 26900 (1.6%) < 5000 (most likely < 1%) 49.6 years 100000 71.0% 72/1000 births (per capita health expenditure K1.5 - 21.7)
60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years
and over by year 2000)
1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita
2.
Carers of the elderly
To date PNG has no service institutions for the aged. The previous extended family unit of the traditional rural society is now becoming more of a nuclear family unit who take less responsibility for the elderly, as the urban population grows and families are no longer willing to take on the full responsibility of caring for their elders. The caregiver now is the mother who in most instances takes on the responsibility of both her parents' care and that of her husband plus her own children. There are no compensatory services either in government or private enterprise to meet the needs of this carer, the mother of the family. 3. Health care of the elderly
In PNG there is no welfare policy nor geriatric services. Health care of the elderly is through the health care system. 4. Training for health care of the elderly Nurses and doctors do not get specific training in health care of the elderly. Health workers go mostly to Australia or U.K for further training. Postgraduate or inservice training is not available in the country.
- 32 -
Amum 3A
SINGAPORE 1. DEMOGRAPHY
1.1 Total population (1990) 60 years and over 65 years and over 80 years and over 1.2 Life expectancy 1.3 Projected elderly population (60 years and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate (1990) 1.6 Income per capita (1989)
2716700 220900 (8.1%) 157200 (5.8%) 25 700 (0.95%) 74 years 332300 46.2% 7.0/1000 births S$18 000
2.
Carers of the elderly
The majority of the elderly in Singapore stay in the community. Total percentage is 94.6% of which 45.5% live with children, 35.9% with children and grandchildren and 4.9% live with their spouses. 3. Health care of the elderly
The frontline care is provided by the primary care doctors. These can be from the government outpatient services run by the primary care doctors of the Ministry of Health. It provides a comprehensive service from polyclinics located throughout the island. Singapore has a special nursing service called the Home Nursing Foundation that caters especially to the elderly. They provide domiciliary home nursing for the frail elderly. Currently the majority of acutely ill elderly are seen by the acute hospital services. These services are divided into a hospital based and a community based service. 4. Training for health care of the elderly
Geriatric Medicine is taught in the basic nursing course as of 1989. In 1990, the first post basic course in gerontological nursing was started. Geriatric medicine has been taught to medical trainees in internal medicine from 1990 and has also been taught on an experimental basis to undergraduates from the past two years. Health workers working in the Geriatric Services are given overseas training for 3 to 6 months duration. There is a post basic education programme for Geriatric Medicine physicians. This is a 4 year programme after obtaining the post graduate qualification for internal medicine. Three years of the programme are conducted in Singapore with the fourth year overseas. Countries to which health workers have been sent for training in geriatric medicine include United Kingdom, Japan, Australia and New Zealand.
- 33 Aanex lA
VIETNAM 1. DEMOGRAPHY 1.1 Total population (1990)
64411713 4632490 (7.1%) 3057653 (4/7%) 447551 (0.6%) 63.3 years N.A 77.5% 60/1000 births US$184
60 years and over 65 years and over 80 years and over 1.2 Life expectancy (1979) 1.3 Projected elderly population (60 years
and over by year 2000) 1.4 Dependency ratio 1.5 Infant mortality rate 1.6 Income per capita 2. Carers of the elderly
Traditionally, the elderly in the country usually live together with their descendants of 2 to 3 generations. In the exceptional cases of widowhood, war victims or solitariness, they will come to live in a sanitarium or they will be given a house and will be attended to by social organizations. In the case of illness, they will be taken care of by their immediate families, by their neighbours and relatives. They will be attended and given medicines by government nurses and in many places, by doctors. 3. Health care of the elderly
Recently, health care for the elderly has enjoyed the assistance of Red Cross workers and the support of local funds. There has also been special treatment for the elderly in terms of medical care and medicine in the major hospitals. The Ministry of Labor and Social Affairs pays the pension for males 60 years of age and for females 55 years old and above. 4. Training for health care of the elderly
The training of geriatric personnel has been done as a responsibility of the Institute of Gerontology which has been seeking government approval for geriatrics and geriatric medical studies to be included in the regular curricula in high and middle medical schools. The Institute has also trained postgraduates at home and abroad for further studies on geriatrics. Institute doctors have paid visits to up-to-date geriatric centres in Japan, Sweden, Romania, USSR and Czechoslovakia and have taken part in workshops in Malaysia, Philippines and India. In addition to professional books for training on geriatrics, the Institute of Gerontology has worked together with different branches and departments in issuing a great deal of popular printed materials on ways to preserve health, to eat a good diet, to use medicines and to increase longevity.
COUNTRY QUESTIONNAIRE SUMMARY DEPENDENCY RATIO
POLICY
LIFE EXPECTANCY
)60
) 65
>80
~ AUS /
i 79.5 71.0 65 79.6 81.8
'3
.'1
~
] ..
.'1
'3
~ 4.7 4.8
j 6.4 6.1
.'1 11.1 5.4 2.57
'3
~ 0.7 0.4
j 1.4 0.8
....
~
(Xl 50.6 (1989) 45.6 (1990) 71.0 44.3 35.8 85.9 69.6 40.7 71.0 72.7 42.1 46.2 77.5% / (1989)
j ~ j ~~ B j / / x
" ~ 65/60 60 x x
1! J /(5) / (L)
73.1
76.3 69.5 63.5
6.9 8.6 (1989) 7.7 9.2 (1988) (1986)
15.4 8.4 1.68
2.1 0.6 0.36
/ / x
/
/ / x
/ / x
CHN FIJ
/ x
68.0 62 74.1 75.9 48 68.6
/
/
/ /
/
HOK JAP
x /
76.9 78.9 50 70.8
5.2 6.4 (1986) 14.6 19.2 (1988) 6.2 6.3 (1987) 2.8 3.1 (1988)
11.6 16.9 6.3 S.8
3.2 9.5 4.0 1.8 8.9
4.4 13.7 4.1 2.1 12.2
7.6 11.6 4.1 3.9 10.6 1.6
0.3 1.6 0.7 0.2 1.4
0.8 2.9 0.9 0.3 2.7
1.1 2.3 0.8 0.5 2.1
/ x
/
/ x
/(5) 65 55 55 60
/ x
/ / /
/ / x
/ /
loll UI
LAO MAA NEZ PNG PLP [OR
/ x
52 73.0
/
/ / / x
/(5) /(5)
x x
I
/ / x
x x x /
71.077.274.1 48.7 62.8 64.9 72
13.116.414.8 (1986) 2.1 (1988) 1.7 1.9 (1990) (1990) 1.8 7.4 8.1 (1990) 7.1
/
x
/ x
/ x
50.7 66.4 71.3 76 67.7
49.7 64.6 68.0 74 65.7
<I 0.3 0.4 0.3 0.58 0.95 0.6
/ / /
/ /
2.6
3.1
2.8 4.7 5.8 4.7
/ x x x
/ x
/ x x
65
/(L) /(L)
x
/ /
SIN / VTN /
/ /
55+ 60
I I
63.6
/
I
/
/
I loll
till
T
planning to incr~~sc to 60 not known or not available
- 36 Amlez 3D
ESTIMATED POPULATION AGED 60 AND OVER: AVAILABLE DATA FOR COUNTRIES OF THE WESTERN PACIFIC REGION OF WHO *
Country or Area
Populat 0n (x 10 )
3
60+
65+
(X)
(%)
Life Expectancy (years)
Dependency ratio (X)
AUS CHN CAl'1 FIJ HOK JAP KOR LAO MAA NEZ
15 758 1 059 522 7 284 691 5 456 120 754 41 066 3 594 15 448 3 247 3 511 55 120 2 559 60 059
14.5 8.2 4.6 5.5 1l.5 14.8 8.8 4.8 5.7 14.7 4.6 5.2 7.7 6.8
10.1 5.3 2.6 3.5 7.6 10.3 4.3 2.9 3.8 10.5 2.4 3.4 5.2 4.5
75.2 67.8 43.4 68.9 75.4 76.9 67.7 46.0 68.0 73.7 51.9 61.9 71.8 58.8
50.9 53.9 54.3 68.7 44.3 46.7 52.1 83.6 71.1 53.5 78.6 80.2 42.1 82.1
PNG PLP SIN VTN
* extracted from:
UN. World Population Prospects 1988. Department of International Economic and Social Affairs. Population Studies No. 106. ST/ESA/SER. A/106. New York. 1989.
- 37 -
ANNEX 4
BACKGROUND PAPERS
- 38 Annex 4
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE fOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL WORKSHOP ON HUMAN RESOURCE DEVELOPMENT IN THE HEALTH CARE OF THE ELDERLY Manila, Philippines 5-9 November 1990
WPR/HEE/HUT(I)/INF./1 25 October 1990
HEALTH CARE OF THE ELDERLY IN CHANGING SOCIETIES by Dr Nii-K Plange Reader in Sociology and Head of Sociology Department School of Social and Economic Development University of the South Pacific P.O. Box 1168, Suva, Fiji
The Inul 01 Ihis documonl doOi nol eonllilulo lormal publica lion, II Ihould nol be rovlowed, abllraeled or quOled wilhoul Iho .oreemonl or Ihl World HeaUh OroaniJllion, Aulhol'1l alan. are rllpan.ible lor views olprollod in ,Ionid artleln,
II
Co documonl ". Con,liluo P3S un. publica lion doll Ira robjol d'aueun complll randu ou ,hume ni d',ucunl cilallon •• n8 raulorlulion d. l'O,o"ni"l;on Mondlalo do la Sanli!. LoS opinIOns orprimeu danl los ,rticloll siones ,,'cnoaoeni QUo loutl Buleu".
n.
'a
- 39 Annex 4
TABLE OF CONTENTS
Page INTRODUcnON SOME DEMOGRAPHIC CHARACl'ERISTICS AND TRENDS OF THE ELDERLY IN CHANGING SOCIETIES DEMOGRAPHIC TRENDS AND TIiE RESOURCES IN CHANGING SOCIETIES HEALTH CARE OF TIlE ELDERLY 'RECIPROCAL SUBSIDIZATION' AND HEALTH CARE OF TIlE ELDERLY GOVERNMENT RESOURCES AND HEALTH CARE OF TIlE ELDERLY NON-GOVERNMENTAL ORGANIZATIONS AND CARE OF 1HE ELDERLY CONSTRAINTS IN HEALTH CARE OF THE EWERL Y IN CHANGING SOCIETIES CONCLUSION REFERENCES
1
2
7
9
t4
IS
16
16 18 20
UST OF TABLES Table 1: World Population Projection Table 2 In
2: Percentage of Total Population and Year P~rcentage
Older Age
Group~
by Region 3
Table 3: Age Categoric. and Table
Incre,,;;e by 2020
4
4:
l,it~ ~~I~~Y
ill ~Inh flH ~'1{;1i"'1 nr,Yr.hlJ1lll~ r.:nllnrri,,~ in 5 £xp~mlJture
1988 Table 5: GNP and PCI' Capita on Medical Services
7 8
Table 6: Population per Physician on Selected Countries Table 7: Characteristics of Acute amI Chronic Disease with Ag~
to IJ
Table 8: Number and Percentage of the Elderly in Ea~h Country living with their Children by Rural-Urban I)istribution Table 9: Number and Percentag<.: in Eltch Country Living with Others by Rural- Urban Distribution
12
UST OF FIGURES FIGURE 1 6
-40Annex 4
INTRODUCTION Increasingly, over the past decade, interest in the elderly especially their soeio-economic well-being and health has emerged in the world, including the developing countries. While research If, the developed world has spanned a lengthy period the same has not octurred in the developing or changing societies. 1'he reasons for the former are both lIclidemic and instrumental; the industrialized countries have expcrienceu the most dramatic examples of population ageing; lind government old-age pensions, and social !iCcurity entitlements, necessitate some research and data collection. The dramatic changes in population dynamics, leading to rugh densities of an aged and aging population anil ~owth of the toral population is now beginning to (Mur in the changing societies. Tru. is the result of decreasing infant mortality rates, with associated dtdine in fertility rates. Thl:> demollrapruc phenomenon is referred to as the "EpIdemiological Transition".
MOJIlwhill! there
j~
Jloo
ob~rvable
chonge9 in morbidity und mortality
r)a([crn~:
a change from communicable dl~ases to chronic ones WIth accompanying disability. longevity and increase III
life expectancy at hirth
The
coun[rie~
rekrred to a.s changing or ~prt'ad
deve!o~)ing so(;ietie~ a~
are many, the South
they vary considerably, and arc:
across the globe; from :'5 far
Pa,ific to Africa. Yd they will all lac;\: lin Identical health problem: "an agillil population wi th tormJdabh.: ami costly needs for care as they tace the burden of chronic tlisea,e" (Bicknell and Parks. 191>':1: 1). Existing ways dealing with this arc highlighted III
this paper.
- 41 -
SOME DEMOGRAPHIC CHARACfERlSTICS AND TRENDS OF TH£ ELDERLY IN CHANCING SOCIETIES In 1975, S2% of all people 60 years and over wefe in the developing
societies, in different, regional and country, proportions (Bi(';knell and Parks, 1989). This is certain to increase to about 60% by the year 2000 and 72% by year 2025. And by the year 2025 half of the 5U countries in the world with elderly populations over 2 million will be In
developin¥ countries (Bicknell and Parkli, 1989).
Altogether the population growth catc at' persons 55 years and O\'er in these changini SOCieties is 3.1% (Kinsella. 1989; vii). This is almost three limes as high
as in the developed world and UN demographic figures
arte~t
ro this. It shows the
aged population for the rest ot" the world. And this is increasing so that in nine years time those aged 65 and over will in(;rease by 100 million in the developing world compared to 3S miltion in the industrialized WOrld (Table 1).
Table 1: World Population
Proj~clion
Year/Area
Total Population (millions)
Popularion 65+
% oC
65
Oevelopjna Cguntries 1980 2000
3284 4297
129 229
3.9 4.7
Deyc.Jo.ped Countries
1980 2000
1131 1272
129
167
11.4 132
Source: UN Al,le and Sex Composition by Populalion by Country 1960·2000. New York. 1979.
- 42 -
Two years ago, 1988, persons IIllell 65 years and over in developing societies outnumbered those of the saDie age category in developed world by 13%;
159 million versus 140 million respectively (Kinsella, 1988: 1). It has been estimated that by year 2020 this number would rise beyond 47U million and double those of the develOped world. The increasing population density in the developing world vary regionally; with the Ccl[ibbean region containing the highest proportion (Table 2). Although At'rica's present older population is
low, it has the highest
growth rate for ages 55 aJld over. 'rhe stru(,;!ure of the population ageing also differ regionally and considerably among developing countries (Table 3). These differences are due to different historical. politic<u and sometimes SOcia-cultural factors.
Table 2: Percentage or Total Population in Ohltr Age Groups by Region and Year
Age Group RegiOn
Year
65 )'ears and over
75 years and over
Asia
19t5!!
200S 2020 Africa
4.5 6.1 8.3
1.3 20 2.7 0.7 0.8 1.0
1988 2005 2020
2.9 3.1
3.6 4.4
Latin America
19R8 2005
1.4 2.0 2.7 2.2 2.6
2020 Caribbean HIll!! 2005 2020
55 75 6.1
6.11 9.0
3.3
Sourl;e: US Bureau of Census, Cenrer for International R<':sl:an;h. International Data Base on Agillg, 1988.
- 43 Annex 4
Table 3: Ale CatealUrles and Percentaae Increase by 2020
Rec1on1Country
55 years and over
6S years and over
% Increase In 55 years and over by 1988-2020
6iiI: Sinsapore
11.9
S.S 3.3 4.5
234
Philippines Rep. of Korea
7.5 10.4
217 199
Aftig:
Malawi Zimbabwe Tunisia
6.3
2.7
151 220 166
6.0 9.9
2.8 4.4
Latin Ameri~ Caribbean Jamaica Mexico Guatemala
12.0
6.7 4.1
129 216 190
R.4 7.2
3.2
SQuth Pacinc Fiji'"
4.0 4.0
3.3 3.2
220 220
Solomon Islands'"
Source: Aging in the TIlied World, US Department of Commerce, Bureau of the
Census, 1988.
**.
Computed from recent popl.1lulion
~ensl.1s.
Otht:r Ib-pects of these trends are equally important; life expectancy (sec: Table 4) and its variation~
among the sexes; male/female ralio of the aging
- 44 -
population; rate of growth among the various ageing categories, and the ratio of the oldest to tru! general ageing population. In developing sClcit:ti('!s the number of
persons 75 years and over iln.: Increasing rapidly than those 6()·74 years (see Figure I), and by the year 2020 61% (or 150 million) of the world'; population aged 75 years and over 'Will be in the developing GOuntJies (Kinsella. 1988: 5).
Additionally the aging population in changing societies are still predomin.mtly rural; with approximately 30 percent of the aging population in urban areas. This is mainly the result of out-migration by the youth with corresponding urban to rural migration older people. There are ;;ome exceptions to this in both latin America (Uruloluay and Costa Rica) and Asia (fhilippin~s and Malaysia). Here older populations are more likely to resldt: (with their children) in urban arei!~
(Andrews et al. )989). while
In
Flil. lor t'xample. older people tenl1
to migrate to rural villages (flange. 19!!8a).
Table 4: Ufe
~xpectancy
at 8irth for Sdel:ted Develol'ing Countries in 1988
Region/Country
Years
Am Philippines Rep. of Korea Afrig
66
69 60 61
Zimbabwe Kenya Latin AmeriClI( Caribbean Jamaica Guatemala South PosWs Fiji
76 60
64
Solomon Islands
60
Figure:l Average Annual Growth Rate of Total, Older, and Oldest Old Populations, by Region: 1988 to 2020 Percent
55 and over 75 and over Talai, all ages
Africa
5 4
5 4
~~~~c~r~H Per---' __________________~A~s~la~_______________________
-____ ____ ____ ~ ~
3
;»F
3 2
2 1
o
LI_ _ _ _
~
____
~
____
~
_ _ _ _L __ _
~
____
~
_ _ _ __ J
o~!
L __ _ _ _L __ _
~
____
~
____
~
III
....
1985
1990
1995
2000
2005
2010
2015
2020
1985
1990
1995
2000
2005
2010
2015
2020
5------------------------------------4~==~~~~~~~=; 32
Percent
Latin America
5---------------------------------------
Percent
Ca-Ibbean
4-------------------------------------3 S
-==========
1-------------------------------------OLI----~----~----~----~--~
~--~::::::::::===~ 1990 1995 2000 2005 2010
2
-----
1~============~~----OLr-----L----~----~----~----~--~~--~
( ....
1985
2015
2020
1985
1990
1995
2(){)()
2005201020152020
- 46 - '
Amtez 4
DEMOGRAPHIC TRENDS AND THE RESOliRCES IN CHANGING SOCIETIES The demographic trends outlined above are indiCatIOn:; of changes in COJ1(CPCS and practice of health and health peeveluion and promotion over more than fifty years. However they throw up other imporlant problems for changing societies, and produces a health care problem now and the future. Health care now competes with other areas of socio-economic development concerns for budget allocations (Plange. 1989).
nus was
not the SCIme for the developed countries.
Their demographic tranSitionS .... as accompanied by fl:al growth. and growth in resources per capita together with $P~(;ltlC
policies lilce old age pensions;
unemployment insurances and social seCUrity for the elderly amI the working populatIOn as a whole. Me:mwhile professional training In
nlll'sing, mediCine and
various areas of spt:dahzation including geriatrks, and ort)er health rdato:d urt'<lS also develop.:d and are Mill developmg. InsLlrance poliCIes also became allmlable and expen(hlUre per capita on medl~al
ellrc grew. For example
In
the US
expenditure pel capita on medIcal services is more than the IOtal per-capita GNP in most developing countries.
Table 5: GNI) and Per Capita nil Medical Sl'Cvices [xp"nditllre
GNJ'
Expenditure
USA Approximateiy half of the woeld',; population
18.000
S2050
<75U
54-S80
-----_._-------------------Source: WorlU Development Report. 1986. World Bank.
- 47 Aunez 4
Contrary to this. many. if not all, of the changing societies are facing, and will continue to face, these demographic transitions in a grim economic context of
stlllnating and declining economic resources, tluctuation in commodity prices. hiah import prices, increasing external debt, unfavourable terms of trade and periods of structural adjustment. About sixty of these changing societies have per capita GNP under S1000. and per capita expenditures on health range from less than 5% to about 15% of GNP,! with very high. and varying. population per physician crable 6).
Table 6: POllUlation per Physician on Selected Countries
Country
Population I'er Physician 1980
Ethic.pia Ken)a Lesotho Philippine~
69,390 7.890 18.640 7.970
Papua New Guinea
Fiji·· ••
Solomon [sland· .. •
13.WO 12,000 10.000
I fnirl'" l(inar1nm
650
USA
520
SOlltce: Worlu Developmeor Report (1985). •••• Approximated on 1986 censu~ ligures.
1 In Fiji ior example health expenditure has declined recently by 31%; falling from as high as 3S milliOn to abollt 29 million. Per capita expenditure on heal[h has decreased. from 1"$37.00 to f'$25.30. with changes in budgetary allocations. This i$ bound to produce det~rioration ot the h~alth system and hl:alth services.
- 48 -
HEALTH CARE OF THE ELDERLY It is against this background. grim as it is. that we have to consider the health care of the elderly in the developing countries. And data is slowly becoming available with increasing interest and research (Tout. 1989; Andrews et aI. 1984; Chen, 1986; Plangc: 1989b).
In spite of socio-cultural differellces. changing SOCieties have some broad characteristics in common which impact on the health care of the: elderly. These are; large rural elderly population; rural life underpinned by agricultural cash/subsistence production; traditional norms and cusrom~;
extended family
relations. sometimes linking fatmlies into kin-rrlated village communities; migrated children who rrmit, various threals to the extended family, known tr<tdilional pharmacopeia; relatively minimal health semces, and itmlted access to health services in terms of proximity (espeCially IN rUfal peopld and number of doctors and health workers, and ab:>encc 01
speoailsts in problem5 of the c;«Ierly. Thrre
IS
alSO tile grallllal absorptlon ot women mlo the wage sector. In their urban
areas
also there are some similarities ill terms of livmg arrang~m~nts; e.xt~nded family relations, and relatively large househOld" in household arrangem~nt~
small~r
urban
home~
or Joint
when: m:cess<U)'. There are aho
somctlm~s
minimal, or
broken down, communiea!lons including transportation control regula!lons and mechani~ms
~y~lem:;;
disregard {(Itraftie
..... h.tch can be detrimenral to the elderly. Lagos
(Nigeria), Ac.:ra (Ghana). SUV!I (l'iji). Port Moresby (Papua New Guinea) arc some examples.
11 is however in the socio-ewnllmj, conrext of in developing countrie~
th~
family that the elderly
presenr various hl::aJth problems. The!>(; vary (onsiderably
- 49 Annex 4
from family to fllIJlily. But on the averllle health problems are chronic disability and <le&enerative and neopla:.tic diseases (see Table 7), whose treatment are
difficult. time consumina and many times intreusing financial
COSIS.
Table 7: Charaderl8tics of Acute aDd Chronic Disease with Ale
Acute
Chronic
Age
Younger Infec tions Easier Often easily Quick; low cOSt;
Older Degenerative and neoplastic
Cause Pn::vention
Much harder Usually difficult Lonjl-term; high cost; less effective
Oue Treatment
often very effective
Source: Bicknell, er al.. 1989.
and welfare policies and income by the elderly themselves, their health and general care rests On the family and orher kins-folk (Tout, Malaysia and Fiji fOf
19~9:
80; Apt 1981). 1n
example over 60% of the elderly identified the family as the
main source: 01 income and dependent On it for tinancial and other resourCeS as well as health care when ill. 1ndeed only 3% and 1% from fiji ami Malaysia
respectively reported that they had no one to help them it they became ill (Andrews et ai, 1984; Plange, 1988). While the percentages will vary among other developing societies (ckpenyong major suppOrt unit. C!
ai, 1986; Apt), the family still remains the
-50Amlez 4
In Asia and lhe South P&citic living arrangements in lilIge extended family households providc:s trn: resources for the health care of the elderly (Andrews er ai, 1984). and in Latin America. the extended family has been documented as beneficial to the elderly (Gonzalez. 1985). Very few of the elderly in Asia and the South Pacific do live alone; they live with their children (Table 8) or wilh others (Table 9) in both rural and urbltO ilIeas. In Samoa, Tonga, Vanuatu and other Pacific Island countries initial observations and discussions with some key informants show the pn:dominance of similar living arrangements as the main source tor chelf health ,are. And in India about 70% of the elderly in rowns are taken care of by their families (Parhilc, 1978).
llble 8; Number and Pe"enll&C or lhe f;llIerly In F.ach f.tlllniry \Iving witb tbelr Children by Rural-Urban ()istribution
Country N
Urban %
Rural N
Fiji Rep. of Korea Malaysia Philippines
244 458
77
357
79 70
82 81
318 436
293 405
83
222
67 73
Source: Aging in the Western Pacific: Four-country srudy, Western Pacific Reports and StUdies, No.1, WHO, WPRO, 1986.
This however contram sharply with findings from Zimbabwe which showed thar almost half of the aged urban African population live alone (Hampson, 19!12) and lacked "even the resources to buy tood ......
- 51 Alma; 4
Table 9: Number 804 Percentqe In Eacb COuntry Uvllll with Othen by Rural-Urban Distribution
Countl')'1 No. or People
Urban
Rural N
N
fll!. 0 3
1-3 4+
88 219
1 28 71
12 112 321
3 25 72
Bcp. or Kgrea 0 11
2 29
10 158 245
2
1-3 4+
161 381
38
69
60
Mllanla 0 9 p~
1-3 4+
-~
2 31
44
~
I
258 304
43 50
261
67
rbjllpulnes
0 1-3 4+
11
2 23 75
6
2
119
127 170
389
42 56
Source: Aging in the Western Pacilll:.
Specifically health care includes purchasing of oft-the-counter and
nfl'i''frinTinn Ilrwifli '~mtli~v~9n§
(where necessary~ to provide needed prosthesis,
provision of food and daily care for the bed-ridden and the tc.:rminally ill. and contribution to easing the inconvenience caused by ch!onic di~abilities,
which vary
with particular family situations. in performing the various activities of daily living.
- 52 Almez 4
Thou&h in families these health related responsibilities are undertaken by all members. at different times. women generally perform most of these as constituent part of their daily household activities.
Additionally the family context including many times grandchildren and visiting friends (and kin) provide some contact with others by the elderly and reduces the feeling of loneliness; a slate of affairs Which is detrimental to health. In rural area~ especially the villa.:e. as kin related community, also contributes to aspects of psychosocial well·being through provl(ling multiple contacts and interaction.
Then there are the remitlances from emigrated
~hllclren.
These enter
households from urban areas as well as metropolitan centers. In Fiji, Samoa, and "tonga n:miltances come as far as the West COilSt kind and cash to augment hou~holcl
or C<lJlada and the USA In both
pool at resources (Plange, 1988). On a
regular basis Cor example SlIITloan migrallts are more than reSident Samoans and their remittances contribute to household resoun;es: and about 40% at total national income (Connell, 1988: 14).
It is the,e contributory activities, informed hy traditIOnal norms oE elderly respect, traoltionaillving arrangt:nu::m~, dllJ
1,,,J;[;vu.l1 ulto!.,'-,!;l.\lru'lOftnl ,capon
sibility, and perhaps sometimes sheer necessity thm have provided the family With its reSilience, the threat of changing socia-economic condition> notwithstanding (Tout, 1989).
- 53 -
Amael[ 4
'RECIPROCAL SVBSIDfZAftON' AND llfAL1'H CARE OF TIlE ELDERLY 'The concept "reciprocal subsidization" (Plange, 1984; 1988: 1989), refers to the relevant, but often ignored, contribution$ that the elderly bring to the general resource pool of households ..uthin which their health are maintained. These refer to both material (like nouses, land, farms, etc.), cash, and in-kind contributions (like baby sitting, cooking, house maintenance, etc.) of the elderly which complement household resource:.. Thus for example where a father or a grandfather's house is the residence, lhis frees up otherwise rental payments or baby silting expenses and add 10 [he "eneral disposable income of the f,unily. Survey data from Asia and the South Pacific show that a higher percentage of rhe elderly own or partially own tnelr homes (74% in Fiji, 43% in Korea, 65% in Malaysia and 67% in the Philippines. Again observa[ion in orher South Pacific Island countries show similar situation. And in many parts of West Atnca the elderly, at different categories, worle in the mtormal seuors and thus contribute to the family'~ done out of 1)001
ot resources (Ekpenyong et al). Some of this work however is economic n(;(;<"ssl ty.
~heer
Addllional1y the presence of the elders en:;l.Ires cultural socialization in traditions and ceremonies which are relevant for self and socio-culrural identity. Data from recently completed in-depth studies in fiji (PI~n&c,
1988) confirm chis;
and survey data from the four-country study (Andrews et al) show that 71 % and 54% of the elders in Fiji and Korea, respectively, help care for children. Activities like tnese also demonstrate aspecrs of th~
productivity of elders, especially those
(and a majority of them) who are not disabled with any chronic or degenerative disease or disability.
- 54 -Annex 4
GOVERNMENT RESOURCES AND HEALTH CARE Of THE ELDERLY While the immediate "nurSing" and other care actiVities remain, largely, the responsibilities of families in many developina SOCieties, note should be taken of available government services; however meagre. Hospital, clinic or health centre services that an: available are utilized by the elderly, though perhaps, only in serious moments. In villages and rural centres these are available though not in the same numbers as urban arells where government health :;ervices seem to concentrate. Rural helilth services are many limes starved of facilities including even drugs. 2 In fiji for example survey H:~ults show that abom 37% ot the elderly had seen a doctor in the month prc<.;eding the survey; while 27% ol Koreans had done the same. Additionally there are other $Crvices like monthly or bi-monthly IIi~it~
hy eovr.rnmf.nI nlme~ Of h~i\lth personnel. While these may not be
specifically targeted to the elderly they do provide moments of conta.,;!, counselling, and sometimes referral. Observations in some of the village'> on the East Sepik river in the Wcwal<: region show periodic visit~
to health posts and by health
officers, while in Fiji nurses In rural areas do \isits. 3 Then there are the Old People's Homt!s; though not In
all but
som~
developing sOClcties. In Fiji and
Samoa a very small perumcage of the elderly reside in these homes; however they are mostly those with serious illness and disability which are sometimes beyond the caplibilitic:s of the tamily. In these horne;, professional ilHemion and care provid~d.
I~
2 Recent budget allocations in Fiji show a 30 per cenC decrease in travel and communications which are important for rural health mainrenanl;c and a 45-50 per cent decrease: for rural medical and nursing stations. 3 In November 1988 I travelled, together with the Assistant Secretary ot Health, on the East $epik Riwr visiting various Villages and providing some mllnv.lline on PrimaTY Heill". C"r~,l\n~ in Fiji 1 had. on several occasions. durin~ fic:ldworlc on tile elderly. travel with statI nurses to remote: Villages.
- 55 Annex 4
NON-GOVERNMENTAL ORGANIZATIONS AND CARE OF THE ELDERLY NGOs In developinl «Iuntries are beainning to take interest in the health care of Che elderly. either through the maintenance of Homes, mobile services, day
centres. and provision of the environment and
minimal skill for productive work.
In thelie relevant contributions to the obvious vacuum of Health Care of the Elderly created by govemments.lielp·Age mtematJonaJ /\as been of enormous ~IP in both resources and skills. Over the years, working thtOUIPt local instirutions, Help-Aie organizations have been established in many countrie:; in Africa. the Caribbean, Asia lind very recently the South Pacific. in Fiji. The: various projects
in health care and socio-economiC activity that lire funded and implemented by these organizations lire contributin". as suppOrt systems. to the care of the elderly. One importanc aspect of Help-Age's activity. m addition to health care. is the harnessing 01 existing skills among the healthy elderly and turning these into prodUctive activity; an exercise in status building. manual and mental stimulation. pride and productive IIlileing. And irs panicipi1tory merhod of doing Ihese, create environments for Inreraction and companionship; an important psychological need for the elderly.
CONSTRAINTS IN HEALTH CARE Oi" HIE ELDERLY iN CHA.'lGING SOCIETIES
Tho Ihreit of lociolt'conomie r.hllngr, Iralling In mierllfinn. nrhani7ittion, wage/salary work con~litute
some of the constraints on the health care ot the re~lIrchers
elderly in changing sociecies. These have been emphasized by
on agdng
from many developing countries in Africa. Asia. Latin America. the Caribbean and the South Pacific (Tout, 1989; Andrews et ai, 1984; Plange 1988a, 1988b). lncreasinllly lhe young, energetic, lind the resourceful migrate. not only from rural
- 56 -
areas to tuwns, hul a1:><o lilt devel"~d Cllunrrit'9. Thi~ mean~ a ~hrjnt;inll of [he family pool or resources, and even [hough remittances have been noted and are important their quality, quantity and especially frequency differ amon" families
(planae, 1989) and countries (Tout, 1989: Ch. 3) and cannot be taken for granted. Then also migration results in the departure of carers. t:specially young women who provide general household services; absen,e of companion~ within the househOld and vilIaaes. Unemployment and under-employment as characteristics of the wage/salary economy also affect family resources; especially in the ab:scmce of unemployment insurance payments. In a situation of unemployment or underemployment of breadwinners a problem of "inter-generational equity" in the allocation of household resources emerge. Where household budgets arc strained cuts are made and these alIeet etc. area.~
like nutrition. needed
drug~.
medical
che~ks.
The family
tholl~
still important can itself. in certain fJf8SI:lE:e
situation~.
especially
in urban areas of ,lcfJeloI'inl 3eCie9t:J;
irs
eWR SQRSlraiRI&; g"l"r~vdiA@i.
as more kinsmen arrive to share residence. produce eonaitions of poverty and ddnger~
e~pc(;ially
in low income urtlan areas,
to health; urban hOUSing developmenrs stair~
could also be constraints. Bulle with flight of
to accommodate young urban
worleers they are not very suitable for mobility of some 01 the: elderly and riotous uvmg with noise could also aUeet the elderly. Then there is the gem:raJ paltern of urban life and recreation Which is built for youCh and adults. Not the: elderly.
Anothee set of constraint is early mandatory rc:tirement (in many changing societies at age 55) without other avenues for deployment and sOl;lal security entitlt:ments. This undercuts im:ome. threatens autonomy with some potential
- 51
paycho-social stress for the retired elderly and possibly on the family 100. In some
cases at age 55 of retirement one's children and parents are still for.
alive; to be cared
Finally there is the constraints created by the absence of governmenl policies for the elderly. Thill means no old aie pensions; inadequate support for carers of t~
elderly. no policies on deployment let alone re-training. no
COnsideration to specific health needs of the elderly, existing prejudices on age and prodLlctivity. Consequently the family is left alone to bear an enormous resporus.ibility as needs change and elders experience longevity with ,llronic disabilities; but most importantly as the traditional socio-economic base: which IIlcvivu~ly
vluviJ" !"'M,6.'f
sy!t~1ft
tor [ftc oldorly clowly
Irodill. With ]Cute gerolllolo~
shoctaae: ot" health personn¢! and specialists in geriatrics and constraint is mLlltiplied with wor~
this
results for rural residents. Knowledge of
traditional herbs, leavc!s. etc., as forms of cure and h.:al th care and their availability
are
the means by wllich rural eltJers cope with some disabilities and the absence 3S
of modern drugs. But
the youth migrate this knowledge slowly disappears to
become "traailion"; what used to be done.
CONCLUSION The Care of the elderly will become a problem as changes occur to threaten the family iI:I
a tradi[ional support
~>,stem.
These changes are not orily
demoaraphiG. but related to structural changes in the economy which produce Llrbanization, migration and different forms of education, as well as concepts and practice of health; and aeu!.: shortages of resources. While the tamily has demonstrated some appreciable resilience the forces of change might overcome it,
- 58 Amaez 4
even if slOWly. In the absence of iovernment's elIotts this could produce a crisis situation for the elderly. While costs will be inCUrred to undercut other areas of relevant budgetarY allocation. a timely consideration of The potential problem with a view to training the requisite expertise in relevant areas, and providing appropriate support system for the elderly, the family. and other institutions of support. through carefully considered means cannot bI: overlooked. This perhaps is the challenge chat developing countries will have to far;e now.
- 59 .:.. Annex 4
REPERENCES Asn, N. 1'81. .U'lI it, 01_. 1461\: University of Ghona 19&1. Alto ditcuuione with Apt at Conferences in the Elderly in New York (1985) and Acapulco
(1989).
Bicknell, William J. III Parks, andy LolL 1989. "As Children SuIVive: Dilemmas of Aging in the Developing World", SocUlI SCience and Medicine, Vol. 28. No. 1. pp. S9-67. Chen. p.e.Y. 1986. The Health of the Elderly Malaysians: Findings and Policy Implications, University of Malaya, Kuala Lumpur. COMell, J. 1987. Migration, Employml!nt and Developments in the SOUlh Pacific. South Pacific Commission, Noumea. New Caledonia. Ekpenyoung. S., et aI. 1986. "Reports on Study of Elderly Nigerians", Center of Wesl African Study, University of Birmingham. Gonzalez, R. 1985. "Psychosocial Faclors (in the Care,; ot the Elderly)" in TowardJ 1M Well-being of tht: Elderly, PARD op cit Hampson, J. 1982. Old Agt:: A study of Ageing in Zimbabwe. Gweru and Hatitre: Mambo. Kinsella. K. 1989. U.S. Department of Commerce. Bureau of the Census, Aging in the World, International Population Reports serie!!, No. 79, p. 9S.
'Clon Amuricon Jit.Jlth Org:mintion (P.4\HO).
!~?~.
,!"':.''''?:rt
Th .. UI .. lI.h.o;n:: "f , ......
Elderly. PAHO Scientific Publications, 1\'0. 492.
Wa~hing(on
D.C., U.S.A.
Pathik, J.D. 1978. Our Elderly. Bombay Medical Researth Centre. Plange. Nii·K. 1985. for a place in the Sun: !';OT the Sunset in Australia in an Ageing World, Australian Association of G~rontology, Melbourne. Australia
- - ' 1988(a).
Aspects of Ageing in FijI. School of Social and Economic
Development, University ot the South Pacific.
_ . (1988b). Healill and Agiflg in Rllral Fiji. A qualitative study Of (Igeing in six rural ,'ommullilies in Fiji. School 01 Social and Economi~ Development, University of the South PaCific. ~lIV". fiji. _ . 1990. "Older Workers in a Developing Economy: An Overview of Fiji's Older Workers ami CUrrent Policies, lnlt'mulionui Federalion of Alling, (forthcoming). Tout, Ken. 1.989. Aging in Developi1l8 COllntries, Oxford University Prt.:ss.
- 60 -
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL WORKSHOP ON HUMAN RESOURCE DEVELOHiENT IN THE HEALTH CARE OF THE ELDERLY Manila. Philippines 5-9 November 1990
WPR/HEE/NUT(1)/INF./3 31 October 1990
TIlE TEACHING OF HEALTII CARE FOR TIlE ELDERLY IN HONG KONG - TIlE EXPERIENCE IN THE VARIOUS LEVELS OF HEALTII CARE WORKERS AND ITS MOST IDEAL CONTENT by
Dr Edward Man-Fuk Leung Chief Editor Hong Kong Journal of Gerontology c/o Dept. of Geriatric Medicine United Christian Hospital 130 Hip Wo Street Kwn Tong Kowloon. Hong Kong
Tho Illue 0' Ihia documant don nal conllilulo tormal publicallon, II Ihauld nOI ba ravlewed, abalraclod or quoted withoul Iha .graamanl 0' lho World Hoallh Organiulion. Authonl alon .. are ,aspon.iblo lor view. olprollod in ,Igned ....... : ... 1 __
Co dacumanl na can.lilLlo p3S una pubhealian. /I na doll 'alfO "abJal d'aueu" eampls rondLl au
r<l.uma ni d'llIcuna citation unl t'ILllarlsalion de l'Oroani'lIian Mandtale do II Sanl~. Las opinions OIprim601 dana los arlielea signes n·c n 030enl .... ",.. ',",uri .u~our'
- 61 Amaex 4
The teaching of Health Care for the elderly in Hong Kong _ the experience in the vnrious lavel of health care workers and its most ideal conten~
Dr. Edward Man-fuk LEUNG Senior Medic81 Officer Department of Geriatric Medicine United Christian Hospital. Chililf I:ditor' ,
Hong Kong Journal of Gerontology. 1. Bilckground
T),e aging of population i6 incipient throughout the world. Between 1950 and the 2025, the world population will grow by a factor of little more than three, the elderly population by a factor" of six, and the 'uld' old - th~~~ who are 80 years and al'love by a factor of ten l1l , By the year 2000, there wi11 be 80me eoo mi 11 ; ons elder 1y per50ns (aged 60 Years or more) in the ·.... orld, In which two thirds are in developing nationa lZl , With the majority of population located in Asia likQ China and India, this region will receive the major imp~ct of the aging population in the next 20 years~ Hong Kong stands no exception to this world trend. In tne past 20 years we have witnessed the 4g1ng of our population and this is going to continue in the next 20 years. 20 year population projection in Hong Kong i t is that the population aged 65 and over wi11 rise from II. f"igure of 424,000 (8~), in 1986 to 809,000 (13~) in 2005 which ;s nearly double the present ai:e of elderly population. The median age of the population will also increaae from 29 in 1986 to 40 in 2006 131 , Tho.e aged 86 and ovar will rise from 23,500 in 19H5 to 92,600 in 2006 (Tabl. 1) whiCh is more than 4 fold incr~a~e in 20 years, On the other hand the expectation of life for t.he Hong Kong po~ulation is w.ll comparable to other advanced countries (Table 2). 1n a ~stimatod
The aged, with their tendency to physical and mental frailty And to chronic di~easQs and disabi1ity, make heavy demands on health and Gocial. services. The e1derly composed the majority to receive health ~are in an aged society. Henco. it is important that all doctors and o~h.r health care professionals should have adequate knowledge about the &geing proce8S, diagnosis and management of ill health in the elderly, Under this impact, the tp.aching of Geriatric l-ledicine and Gerontology to different 1~ve 1s of hea 1th care workers wou 1d form the assent i a 1 background for provld;ng an eff~ctiv~ and compr~hensiye care to the .1derly "i.JbJects. In this aspect the Asian countries need to talt.e forQ~1cht i0to the education programmes.
- 62 -
Alma: 4
Table 1 Population distribution (thousand,)
Age group 014 I:' (,4 f.f! &: over 1'15 & (,vcr ivied,... " c'lge
1986 1996 1991 2001 2006 1272123'j',,1 1229(21 'M,l ] 208(2OCH.) 1143(18%) 1069( 16%) 3828(69'~) 4077(70'1I~
·124 ( 8";,) 23 2') (.4'~';,)
534 ( 9'lh) 35 (.6'J(,1
4279(70%) 4471(70%) 648(10%) 748(12'111) 48 (.8 ')/.) 71 ( 1%)
4649(71'!(~
809(13%1 92(1.4%)
-----
32
35
37
40
Table 2 Expec:ta1lon of life at birth
Country 1986 1996 Mal;-- . Ti~·KClng-74-.0---7-::6-.1· .J,1pan 75.1 76.4 tlS/\ 72.0 73.9 Female I·ion!] Kong 79.8 81.5 ,JlIpilfl
2006 77.3
77.2 75.9 82.9
USA
808 . 79.3
82.3 81.4
83.1 83.5
-63-
11. 1yp~s uf Health care Profesaional. involved in the care of elderly in Hong Kong
A. Med;cal Practitioners The elderly ar. major consumer of health .ervice. In United ~\.at.e:J, the oldest 11~ of the community occupy almost a third of a~ute hospital bads and acco~rts for almost 30~ of to~a' annua' .:<p~ndit.U,",1 on health oare' • Medic" practitioners in bot.h ~rimary health care .etting and hoapitals are seeing increaeing rhJmber of elderly patient. in Hong Kong. The prOVision of ~deQuato training of doctors aI's thu8 essential. Nurs6ts Nurses ar. involved in different types of care of .'derly, both for the healthy .'derly and the aick. 1n thv communi·t,)· ,;ett.ing, health nurses trained in geriatric. help t.o .et up and run healt.h maintenance programme for the .'derly, community nur(ies prOvide domicil fary and reh.b; 1 itation nur,in; ear. to ;~dividuals and familiel in tneir place of residence for ~romotin;. maintain;ng and restoring health of which .lderly are ~,
import.ant consumer, Nurses in both acute and long atay hoapital ward. are likely eo devote moat of the i I' nurs;"; ti me ; n the care of el del' 1y subJects, In aduition, trained nurses are import.ant personnel in Nursing Homes, Day care Centres and Day Hospital ••
Paramedical Peraonnel Elderly are more likely to sufftr from chronic and disabling cond i t 1 OtiS, "encfI funct i ona 1 asse.sment and rehab; 1 i tat; on form a.n important part of the healt.h care of elderly And enable ~lderly patients to ret.urn to the community t.hus reducing the demands of institutional car •• PhYliotherapi.t are therefore involved in different levels of health care for the elderly. In Hong KO"9 they ~ont.ribute towards the smooth running of Geriatric w~rdsf Day ~o&pital., Day Car. Centre. and care and At.tention Homes. C. C',
Nur~in~ Home, Day Care Centres and Home Help .ervice, Although most. of them are untrained, they however provided ~he first line care tor elderly both in the community and r.sidential setting. Th~refore, the training of th.a. peraonnel should not be neglect"d.
Untrained Persontll Care Workers and Welfare Workers PI~rsonal Care workers and Welfare Workers usually work in
- 64 -
.-..z
4
I!I. =x;Hting edueational programmes available for health car. workers. A. Doctor's Vn9.~£3raUyat. Tra;~-1Ds
150 and 140 doctors respectively each year. In the University of Hon; Kong 6 systemic lect.ures on GllIr 1a tr i c Med i c; ne are taught and .tudenta in the .econd c 11 n i cal year will receive 10 ,essione of 2 hours clinical t.eaching in a· Geriatric Unit. Howev.r, there is no full time academic teaching :.:>taff in Geriatric Med;cine in University of Hong Kong. The t-eachin~ of medical stud.nt.s depend. much on Geriatric Phyeicians in Gavernment Hospit.als. In the Chinese University of Hong Kong, one senior lecturer ;S recent1y appoint.ed in Geriatric Medicine. The Undergraduate programme consisted of 2 systemic lecture in the introductory cllnir.1I1 year. Medical .tudent. in their final clinical yaar wil' a~tend 4 weeks rotat10nal a~~.~hM.~t in variou~ ;.r1atric units in •• 01"19 Kong for clinic., t.eaChin;. Started this year Geriatric r~edicine lectur'e is also taught in the Department of Communit.y Medicine to emphasize on the healthy aspect. on aging to students, produ~e P.Qs..!:B~dyat§l
lmi"QrSity of Hong Kong and Chine.e University of Hong Kong, Thvy
There
are
two
medica'
achool.
in
Hong
Kong,
namely,
Til in j ng
For Medicine
wieh1ng to become IPec1alist in Geriatric in Hong Kong usually need to work in recognised ~arintric unit in Hong Kong. The basic reQuirement is that they should hays passed the MRCP(UK) examination. After thi. pcstgr~duate qualification they will need to undertake further tr·aining for 4 years in the apecialty of ;eriatr1c medicine which ~hould include acute ass.sement of elderly sick, rehabilitation, 10ng stay care and day ho.pital •. Apart from local in-eervice t.raining, Geriatric Phy.icians in Hong Kong a'80 receive overseas training in Geriatric units of United Kingdom.
doctor~
B. Nurses Courses ;n Geriatrics are offered to student nurses in Hong Kong since 1976. Student nurses may select geriatrics as ona of thai r three elective subjects. They will receive one week H:tunsive syst.mic lecture on care of the elderly patients including common diseasea, rehabilitation, psychology and nursing of the agad. After tne lectures they will be attached to the geri~tric wards for 8 weeks of clin1cal training. E9~g~~e
e.r. nYA.U,!..:l.£.U ion t.r a ; n 11"1 Q
At prasent there are no postgraduate eourse offered for g~riatric'nursing in Hong Kong, Moat of the nuraes working or specialising in geriatric, receive th.ir training in United Kingdom.
trlining
C. Paramedical Personnel Stud,es ;n Rehab;11tation SCience. including physiotherapy
- 65 -
and occupational therapy are off.red by the Hong Kong Polytechnic. Students in thee • • ubject.. are being taught on the common diseasea in e1darly and apeoial aspacte of geriatric medicine by the geriatric phY8ician. O. Welfare worker.
For welfare worker; thay are offered in-.ervice training I.H'ograrnme on the cara of elderly 1>), the Department of Appl ied ~o~ial Studies of Hong Kong Polytechnic. Tha cour.e run twice a year for welfare worker. nominated by their aganc;ea. The cour.e ~ i ms to p r 0'1 i de we 1f are workera 1n ret i dent i a 1 and commun i ty '38r'''';c.:, Botting. for the elderly with the basic knowledge and skill& in serving tha elderly. The courae objectives include.: li) To identify and recogni.e the specific n.ede and probleme of human ageing. l;;) To g~in a general knowledge of the rang. of aocial services provided by the government and voluntary sect.ore in meet.;ng theea needs. [iii I To ~9V&lop a poa1t1ve attitude in working with the elderly. iiv) To aCQuire currene ~once~\;,tI, ....... ,e. •• "' •• and to 11" .... 10g sit,; 11s 1n working with the .lderly in bot.h community and
resident.ial service aettins. Iv) TQ share skillS and experience. in relation t.o their work. The courae content are attached in the appendix. E. Postgraduate Courses in Ber1atri~8
and Gerontology
With the rising elderly population in the e08, there is heil"'Y demand for furt.her educational programme for nursing and other types of health care workers in Hong Kong, A significant number of courses have developed in Hons Kong in past few years .
.~~CQyr8._jn Geri.~r1c Madic;ne The Hong Kong GeriatriC SOciety in conjunction with the Department of Extra-mural Studte. of Univer,tty of Hong Kong sl.arted a chort course in Geriatric Medic;n. in 1987. Tht. courae aimed at providing health care prof •• siona' including nurses and ~aramedical personnel the basic concepts of geriatric medicine and practical skills in the care of the elderly in hospitals and community. This courae consisted of 15 one and half hour leetur"8s, The course con.iated of lecture. on topics: introduction to G.riatric mediCine, non-.pacific pre •• nta~ion of il1ne8s, nutrition. drug therapy. contu.ion. dementia, common d1seases In elderly SlJch as neurological disorders, stroke, cardiovascular, respiratory a"d jOint dieeaaes, incontinence, falls and acc1d.nts. role of day hospitalS and .ocial services for .lderlies in Hong Kong. Th* course content are attached in the appendix. CM...t..incate j n Gerontology In 1966, the Department of Extra-mural Studi •• of Univere'i ty uf Hong Kong with co-operllt1on from a group of gerontology worker~, which consisted of G.riatric PhysiCian, psychologist, ~nr.;~l Work~r, Social Scientiet, Bt.r~.d another course which i~ an ,.miverslty ce,.tificate c:ourse on ~'H'vflI:61~!lY. Tho COUrI•• nIT,f'.r for persons work1ng i~ ag1ng fi.ld. The aim ia to provide basic mult;-disciplina,.y knowl.dge to home admini&trators, nurses.
- -66 -,:
soc;al workers etc., and ita major focus in lntegr'ation of theory and practica. The duration of the courae i ill th; rty 'four 8easion' with three hours lecture. every week with ha1' yearly examination and ••• ignment a.aessment and project work, The objactivAS of the couree .re: (1) To eC1u1p the home manager. with fundamental knowledge in medicine, psychiatry, p.ych010gy, locial work, and management in an elderly setting. (ii) To enhance the p.rtieipant to have bettar understanding of th~ concept of 'total per.on oare' in re.ident1a1 .attings. (!;i) To integrata theory and practice through C1088 supervision and individualised project. ':""h£1 course is d1viaed into' major areaa including: ( i ) flhl(.inlng1~ll and mental changes in old age. Physical and mantal i"nes8es in elaerlY. I ii) Psychology of old age. ~iii) Social work in community c.n~r •• and re.idential homes. \,v) Management techniqu •• for community centres and r.sidential humes. The course content a~~ached in the appendix. fpr Elderly Social Seryice Provider, Thv course is organis.d by the Department Of Extra-mural 5tlldies of University of Hong Kong wit.h Social Welfare Department. It is intended for Social Workerl working for elderly. The format of teaching i. in form of lectures, case d;&cus~ions. group d1$~u.sion. and audiovisual presentation. The objectives Of the course are: (i) To introduce gerontology, how to approach it, and why i t is importBnt in our soeiety. (ii) To introduce currant theories of social gerontology. (Iii) To identify different aap.cta of the .lderly'" life: phy~iological Change over time; health atatuB in later years; psychological and social processes in later life: and ev.ryday ~oncern$ of the elderly. (iv) To outline current aocial policies and the debates ',lur'round1ng them, and ana1yze suggestions for linking these issues to the everyday concerns of the elderly. (v) To provide the context and framework for 80cial work practice. The course content i8 attached in the appendix. ~~~Q~_~rontology
~rofes&ional
course for Elderly HOme He,'th WQ(~ lhe course 10 organ; •• d by The Hong Kong Nurse .. Association. It started two years ago and ia now the third year of the course. Tt: is course aim to teach thoae hea 1th oar. workers of Dr 1vate nur!lin9 homes on the hadlth needa of the elderly and proper nursing care of the elderly in a residential settin;. The course contents are attached in the appendix. C~~j_~~~ Courte jn Geriatrics fQr~~ The course '8 or~tlrl;'.d by the Hong KanR G,riatric Society to replace the Short Couree in G.r;a~ric Medicine. It cone1sted orten onv hour 1ecture& on vlri OUI .apecta of care for the eld~r'y. The detail course content attached in the appendix.
LC~in;ng
- 67 -
Annex 4
IV, Idoal Mod.' for teaching of aer1atrics and GerontoloiY to health care workers in A.;an/Pacific Countriaa In the WHO wo,.kshop held in Edinbu,.gh, '982 a list of learnin; objectives in Geriatric Medicine and Geron~ology was pulJliahed which are hated b.low tSI ,
.-!. To encourage a humane and positive attitude towards (lId people and to demonstrate the satisfaction and fulfilment which comes from professional involvement with the elderly and their families. !.. To produce an Ilndcrl:!taIlJ;I\~ &r dcmogrlphir fil~~tf)n apd social changes in the a~'eiJ\g of societies . .1. To ::>l'ClI rc an understanding of age-related changes in the context of human d~'\'(·loprnent and an appreciation of the causes of disability in old age. PrevenliOl\ and mallagement of disability should be understood within bOl.h comlllUllily ano institutiullal settiJlg!!, 4, To teach the special features or presentation of disease in old age and the probl~ms oC therapy, Tht: problems associated with drug therapy in old age require !\pel'ial consideration, S. Til indicate the princi pies of rehabilitation and their application to the elderly, a major objeclive being tht: attainment and maintenance of optimum physical, social and mental function for each individual. 6. To demonstrate the importance of working as a member of a multidisciplinary tl'l\rn, with filII understanding and appreciation of the roles and skills of physiC't:lI1S, nurses, rehabilitation therapists. social workers and other team members. 7. '1'.') indicate the importance of acquiring skill in communicating effectively with tIll' dderly ami tlwsc involved in their care. This should be done in such a way as lo lead to fuller understanding of the importance of the family and the social IIr( work of care, 8. To ensure an undcrstanding of the illlportance of protecting the liberty of the individual, so that the elderly may retain maximum choice and control uver tlaeir own lifestyles and the manner in which they face death. 0. To reach an understanding of services available to old people and their families, with special emphasis on cummunity a$pects, and to stress the essential interdepenJence of these services and the need for effective co-operation between them <lnd families and other carers. 11). 'J'o indi~:at(' prlnciplt:l:I 4l.hi !'e!lponiibilitit'.~ Or c~>ntinuirTg care (or elderly pill iepts wit h irrt!fIH.:dia.hle disabilitic:s, anu of terminal care of dying patients.
-------------------------------------------------------
Leltrning objectives in gerontology and geriatric medicine-
-'._'._'- '---'- ----------------------------
- 68 Annex 4
Gtu~entsl to improve m41ti-diacipl'inary co-operation between VAnous types of gerontology health care workers, to enhance pnstgra~uate training in gerontology for health care professlonals, to organise basic reaearch and multidisciplinary research in aging.
, ~o ach1sve th,iS o.bject~ve, the moat idelll way is to set up (leptt~"me~ts of GerHltrlC Mod,c1ne and Gerontology in Postgraduate lnstltutlons to eo-ordinate Undergradua'C9 teaching Of health care
. For undergradUate taaching. 2111 students in the health care F,elds. inc'uding medical students, nuree., paramedical perlonne1 ~h~wJi be taught on subjects in g.riatric6 and g.rontology. The ~xi$tin9 emphasHl un ~)l.1 clra nf 1j-pe aged is in gene~al lnadequate. The number of lecturing houra and c\~n~c~l .tUOlii should ba increased. The courses should h~'p students to understand the physiological changes of aging, requirements of the aged, the common ailments in the aged and special techniqUes in treating elderly patients. The e.een~i81 .ubject is to help students to correct negative attitude towards the aged which have serious 8ffec~s When they are graduated and delivering the eare in the community. With the bettQr understanding of characteristics 01 aging it is more lik.ly that we can provide arl effectiY~ health care service for the elderly, The knowledge on health care for the eld.rly should be adeQuately asaessed by exam; nat 'on and project worKs. In the undergraduate stage ; t would be advisa~le that some of the courses should be provided Jointly to students like medical students, nurses, social workers no as to enhance the spirit of co-operation 1n health care for th~ aged whiCh most need the utilization of a multi-diaciplinary approach. The Department of Geriatric M$aicine and Gerontology should organ;S9 pODt~raduate courses and refresher courses for various types of health care workers. Th9 central role of .etting up this department is to help co-ordination and reduce the o~erlap~in9 of effort pay by different group; as observed in the Hong Kong experience which may cauee wastage both in terms of manpower and resources. The setting up of these department& could also help co-ordinate r.sgereh and help predict future needs of the SOCiety.
References: 1. Anstae ..
MJ (1969) Impact of the Aging World. Hong Kol.l9. ~Qur.,r;\A.Li2f Gerontologv (Jun 89) Vol. 3 No.1 p.3-5 2. World Health Or~&I';l!ation. (lSai) Health of the elderl)! Report of ft WHO Export Committse, Tlcbnicol Report Siries "'9
3. Census and Statistics Department. Hong Kong Popylation. A 20 year ~roject12n Nov. 1987. Hong Kong . 4. Oychtwald 1<'(1985) The Aging of Amer;ca : Overview. 1n WSl_l1n.~.§§'_.\inQ-.!:aaJth Promotion for the E1der1y Eds DYChtwald and Haclean. Aspen System Corporation. 0. T~aching GirontolQJlL_and Geriatric ~ed;cine: Report.n a Workshop, Edinburgh, 5-7 April 19S2. World Health orgarization pub1ication ICP/ADR 045(2)
..
- 69 -
ANNEX 5 OUTLINES OF SPECIFIC COUNTRY PLANS OF ACTION
(1)
Australia Approach various institutions such as: Cumberland College, University of Melbourne and Lincoln University to develop or strengthen courses in Medical/Social Gerontology. Also to collaborate in teaching, provide resources for training and to work out strategies for health care of the elderly.
(2)
China - write article on workshop for information to be published in Journal of Gerontology and Social Medicine - organize workshops - collaborate with the Department of Medical Education
(3)
Fiji Through the University of South Pacific, Community Medicine Department of Fiji School of Medicine and the Department of Preventive and Primary Medicine - consolidate current activities -NA.C.
- research - create more awareness - teaching of appropriate subjects
(4)
Hong Kong - explore with administrators the 'fuller' approach of a geriatric service e.g. the Australian model - establish a multidisciplinary Institute of Gerontology to assist and develop the teaching of geriatrics - to develop a manual where list of services etc. can be found - legislation for residential/nursing homes - guidelines for workers in residential/nursing homes
(5)
Japan - coordinate activities (resource persons) - home helpers for >40 years old - increase awareness of dementia in elderly
(6)
Laos - to obtain a fellowship for 1 doctor/2 nurses for overseas training - to develop a national programme in health care for elderly - to start an experimental unit in geriatric medicine
- 70 -
Annex
S
- to establish links and coordinate the actions of the different groups responsible for training in geriatrics i.e., Medical and Nursing Schools (7) Malaysia - follow up/consolidate 1986 workshop plans of action] - convince government - training of trainers (8) New Zealand - further develop and formalize the education of general practitioners in geriatrics - establishment of course/certification e.g. Diploma in Gerontology for nongraduates (9) Papua New Guinea - establish National Aging Council - workshops - send teachers - "resource" persons for training in geriatric/gerontology through scholarships or government (10) Philippines - approach "Assessment boards" to modify curricula for nursing, doctors, and other workers - to collect and develop teaching materials for the teaching of gerontology - to plan a short course for health care workers in the elderly health service (11) Republic of Korea - explore and further discuss with officers from Ministry of Health/Social Affairs the establishment of formal and informal links between those involved in policy, implementation and proceeding of health care - establishment of a department of geriatrics - the introduction of geriatric training into the medical and nursing courses. To hold further discussion and consultation with the Korean Medical Association and the Korean Nursing Association (12) Singapore - formalize the basic/undergraduate education for nurses/doctors - CME for general practitioners, both formal and informal - establishment of school of therapists (13) Viet Nam In collaboration with the Institute of Gerontology, follow up - training of nurses - oversees training e.g. Japan, Australia - workshops
- 71 -
ANNEX 6
PREVIOUS GUIDEUNES (Taken from HEALTH CARE OF THE ELDERLY· A REVIEW OF TRAINING PROG RAMMES IN ASIA AND OCEANIA Report on an International Workshop of WHO and International Association of Gerontology on Education and Training in Health Care of the Elderly WHO.1983 IRP/ADR 114 19801/20041 Singapore 26-29 January 1983 fUTURE DIRECTIONS There is a clear need for decisive steps to.Jards ir:plementing the training recom.;nendations of
che World Assembly on Aging.
Key activicies are;
review oE existing national education and training facilities; deve.lopment o'f a framework for training future he.alth yorkers in care of the p~ovision a.~ed;
of curricular ~aterial, learning resources, advice and consultation on a regional in key insLitutions throughout the Region) of deQonstration training progra~es
basis; ini~iation,
specifically direcced at health care needs of the elderly; im.plementation of a programme to "train the trainers" "ho will be responsible for ;noun[in~ educational prograomes on aging; tn pursuing these activities, a number of principles should be kepc in mind; ~n all educational initiatives undertaken, hu~anitarian issues associated yich aging should be stressed and the rights and dignity of the aged acknouledged;
aging should be pLesented 2S a no~al process, and its positive aspects reinforced so thac sta~eocypic vieu of the aged as deteriorating and dementing is destroyed;
t~e
due emphasis should be given to the need not only to provide knouledge and skills, but zlso to achieve a positive attitude to~a~ds aging and the aged; education should he base~
on studies of health
~are
needs;
the biological and psychological aspects of aging should be taught, along with the social diaensions of the aging process;
of mastering skills 1n healch care of ~he elderly should be recognized~ so that is adequate training in this area over the ~hole range of health care instruction, eSyecially for chose e~tering in primary nealth care; (he th~re
i~?ortance
wor~ers
the preventive aspec[s of health and aging should receive due pro~inence. and all health should be trained to recognize early disease and disability and be auare of the benefits of prev~ntive and early intervent~on approaches; instruccion in health care of the elderly should emphasize the team approach. possible, teaching should take place in an interdiscipli~a=y setting; Thus, ~here'/e!'
instt"uction should be given in all aspects of provision of care. including provision of acute, rehabili~ative, long-cerm care and conmunity and domicilia~y services. The i~porcance of the fa~ily in caring for the aged should be acknouledged; some specific guidelines for future accion now need to be ~echanisms developed~
such as the
folloui~~;
should be vigorously explored (0 achieve efficient exchange of educational information and learning resources bet~een institutions and countries. One such mechanism ~ould be to Eoster specific a~filiations betyeen educational ins:itutions and training p~ogrammes in different countries throughout the Region, including p~ovision for exchange of scudeats and teachers; [he present Guide should be revie~ed. updated and further developed by a small expert vorking grou? appointed Ear that purpose within the Asia/Oceania Region;
- 12 Annex 6
IRI'/ADR Hli 19801/20041
means should be sought to encourage educational institutions providing training Ln health <ace to consider the implications of aging in relation to their programmes. All clinical inscruction (vith the exception only of areas such as paediatrics and obstetrics) should incorporate the relevant aspects of aging in an integrated fashion. In addition, a speci:ic component of all relevant clinical courses should be set aside for instruction in gerontology. and health care of the aged per se; finally. this present initiative should be seen primarily as a starting point for ongoin~ activities throughout the Region. It is icportant to stress the need for timely response to population aging if future needs are to be eet. Great opportunities present for cooperative effort and support becueen countries ~n this respect.
CURRICULUM FOR HEALTH OF THE ELDERLY IN THE UNDERGRADUATE MEDICAL COURSE IN THE SCHOOL OF MEDICINE IN AUCKLAND COHPONENTS OF UNDERGRADUATE CURRICULUM RELATING TO HEALTH OF THE ELDERLY. SCHOOL OF MEDICINE. AUC[LAND. NZ 1990
Nom./Tltle of Cours. Biochlmhtry
Cour •• ObJectlvl'/ Topic Influence of Igting on hormonal.
Department
Yeers
Responsible Btochemistry
Tought Z
Compulsory (t) or Optional (0) (t)
No of hours Students
Formatjs lecture
1
I ,
nutrition.l and mltabolic 'SPlct of biochemistry Humin Reproduction and Oevelopment
I
8e .bl. to discus, current concepts of the .g.tng procesl and it. pO.libl, determlnantl.
Anatomy
3
(0)
1
Lecture
i
At first level b. oble to describe the ,fflets of ageing on human physiological proclssl •. 1) Geri.tric Organ SysteMS te.chlng. Z) G.r\ltric Attachments
i
Student I .hould be oble to: Oescribe nor •• t agetng procI.sI. and the WIY in which they modify dis.ase pr.sentation. Indicat • •• n.g.~.nt of COMmon
Hodlclno (Soctlon of GI"ltrtc
4 & 5
(1). (0) but Ix.mtnabl.) (Z) K
1)
9
Hodlclno)
(t) Z)
Lecture. O\lcu,.tons Rolo ploys Vldool COlRmuni ty
I
80
modlc.l probll~' of tho elderly (n .... d) . Describ. the us. of hOlpital and community .ervice. to promote independence of the older plrson. Renll Org~n
vlsltl Seminars \lard tllching Oellons t r I t Ions .. Hadlcine Hedic'ne
.... I
""
Systems
Ching •• tn ren.l function with .geing Carebrovaacular accidents
4 & 5 4
(0)
0.1
lecture. l.cture.
Neurology Organ Syatlm" Muaculo·sk.letal Or".n Syst.lIIs Re.pirltory Organ Sy.t •••
(0)
(
Hood Injury Confusion and dlMlntia
( 4 S
(0) (0) {OJ
(
altooorthri t II Oatloporo.t, Bronchial clrc(noMI
Medlcln. Hodl.ln. +Hlcroblology
S
0.5 4
Lectures lecture.
4 & 5
Chronic olrflow Ilmlt.tlon Tuberculo.i. Pn.WIont.
I ....
N~m./Tltte
of
Course Objectiv81/Tcpic
Oep~rtment
Coursa Lihlp~n
Responsible timing and charilcter of typical changes occurring with increilsing age. AWl rene IS 0 f ilgeism and of pricti,al ways doctors can improve IHulth .nd independence of oLder pat hnts. Know how to Ciire for dying pitients/grieving relativ8s. ~:
Y.iirs TiiUght 2 &3
Ccmpu(sory (C) or Optioniil ( 0) (e)
No of hours Students 11
Format
Development
Psychi.try and Behilviour.l Science
lecture' (wkolo dBS) Seminars
Community visits Projects
f ..,
Hi I
HfA Underltinding urinary incontinence in elderly women. Effects of ii981n9 on the immune system and related disorders that develop wi th age. P.ri~op8rativ. cilre of elderly patients, m.anagement of .lderly surgical patients
Pathology
HfA
NfA
NfA (e)
HfA
Gynlecology Orgiin Systems ImrTIunoLogy
o
& G
4
&
5
2
Lecturts
Molecul .. r Hedicina
3
(e)
3.5
lectures
eli nc .. I methods Surgic.1l C1 ini c.a I Attachments 1)
Surgery
4 &5
(e)
B
2)
Sm.ll group seminiirs one to one bedside teilching I
Hit
NfA He.1Sur.mlnt of dis~bility scr.ening for he.lth risks. He.lth .duciltion. T.rmlnat Ciir •. Age related factor. in drug distribution, rut abo l i AM, excr.tion, k.in.tics and dos.gl.
Community HeAlth Generll PrJctice
NfA 5
NfA (0)
NfA - B
HfA Seminars l.ctures Workshops 11. 5 )
!
.., I
G.neral Priict;c. Teaching
..
(but .xam;niibl.) PIHr\"llaco~ogy
B•• ic Pharmacology SH8 III C1 intcill Pharmacology Cardiovascular Or~al'\ Syst.ms
3
(e) (C) (C)
4 5
) )
6
L.ctur •• Slutl ~roup semin,rs Proj.ct (3rd ye.r) L.ctur.s
Aspects of myocardial infarction, con~.stiv. cardiac f.;lur. etc hl"e relev.nc. but not tOllught specifically on an age-related bilsis.
Hedicine
4 &5
(t)
1
HfA Total
hours/studen~.
..
Hf~
Physiology 18 hours ..123 hour.
HfA
NfA
0
NfA
Pr.-d In\C~l Course Clinical Cours. Tot.al
..ill
- 75 -
ANNEX 8
. SUGGESTED UNDERG~D.lJt\TE MEDICAL CURRICULUM PLANNING
Aims:
Undergraduate education in geriatric medicine within the Medical Curriculum To produce a medical graduate with the appropriate attitudes, core knowledge and basic skills
* *
to accept ageing as part of the life cycle
to communicate with elderly people, their families and carers effectively and appropriately
*
to functionally assess diagnose and manage the elderly who require rehabilitation and continuity of care in the community
* *
to promote health, maintain autonomy and reduce dependency of older people to continue appropriate education in aged care
Educational objectives in undergraduate medical education 1.
Knowledge
1. An understanding of the genetic, biological, social and environmental basis of successful aging within the human life cyc Ie. 2. An understanding of the genetic, biological, social and environmental basis of chronic degenerative diseases. 3. An understanding of the multiple causes of the common multifactoral syndromes of aging: gait disorder, immobility and instability, falls, incontinence, impairments of cognition and psychosocial function, impaired homeostasis, iatrogenic disease. 4. An understanding of the role of older people themselves, and family carers in maintaining older people in the community. 5. A knowledge of personal services and community resources available to maintain older people in the community. 6. A knowledge of ageist attitudes in health professions and the community II. Skills
1. Effective communication with the aged, their families and carers, other health professionals and the wider community. 2. Diagnosis through a problem solving functional approach to
- 76 -
Annex 8
history and clinical examination of the elderly producing medical, functional, social and mental state assessments. 3. Management of the multifactorial syndromes of aging and rehabilitation of their functional sequelae based on a team approach. 4. Effective participation with the family and community services in rehabilitation and continuing community care of the elderly.
s.
Effective participation with the primary care team in the community to prevent or reduce disability, prevent medical social breakdown and prevent inappropriate institutional care.
6. Effective management and continuing care for severely disabled elderly and the dying patient. III. Attitudes
1. A recognition of the rights of elderly people, their families and carers in determining their own health care. 2. An acceptance of the role of personal autonomy and independence in maintaining the health of the elderly. 3. An acceptance of the health professionals role in reinforcing self esteem and independence rather than creating dependency in the sick elderly. 4. A relationship with older people based on mutual respect and esteem and an understanding of ageist attitudes.