GUIDELINES
FOR
NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR H EALTH OF O LDER PERSONS IN THE W ESTERN PACIFIC REGION
WHO Library Cataloguing in Publication Data Guidelines for national policies and programme development for health of older persons in the Western Pacific Region 1. 3. Health services for the aged. Program development 2. 4. Health policy. Guidelines
ISBN 92 9061 281 9 The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland or to the Regional Office for the Western Pacific, Manila, Philippines, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1998 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this organization, which was created in 1948, the health professions of some 180 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. By means of direct technical cooperation with its Member States, and by stimulating such cooperation among them, WHO promotes the development of comprehensive health services, the prevention and control of diseases, the improvement of environmental conditions, the development of human resources for health, the coordination and development of biomedical and health services research, and the planning and implementation of health programmes. These broad fields of endeavour encompass a wide variety of activities, such as developing systems of primary health care that reach the whole population of Member countries; promoting the health of mothers and children; combating malnutrition; controlling malaria and other communicable diseases including tuberculosis and leprosy; coordinating the global strategy for the prevention and control of AIDS; having achieved the eradication of smallpox, promoting mass immunization against a number of other preventable diseases; improving mental health; providing safe water supplies; and training health personnel of all categories. Progress towards better health throughout the world also demands international cooperation in such matters as establishing standards for biological substances, pesticides and pharmaceuticals; formulating environmental health criteria; recommending international nonproprietary names for drugs; administering the International Health Regulations; revising the International Statistical Classification of Diseases and Related Health Problems; and collecting and disseminating health statistical information. Reflecting the concerns and priorities of the Organization and its Member States, WHO publications provide authoritative information and guidance aimed at promoting and protecting health and preventing and controlling disease.
TABLE OF CONTENTS FOREWORD Summary of keypoints 1. introduction 1.1 1.2 1.3 1.4 1.5 2. Global Population Ageing Ageing in the Western Pacific Region Implications of Population Ageing in the Western Pacific Region Existing Policy and Programmes for the Health of Older Persons in the Region The Need for Policy and Programmes for the Health of Older Persons v 1 4 4 5 7 8 10
principles 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 Rights of Older Persons Quality of Care Life Course Perspective Healthy Ageing Productivity and Participation of Older Persons Access to Comprehensive Care Family/ Community Orientation Cultural Perspective Traditional Care and Practices Gender Variation Cohort Perspective Rural/ Urban Distinction 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 20 22 23
3.
POLICY formulation 3.1 3.2 3.3 3.4 3.5 National Policy Declaration Health Care Financing National Coordinating Mechanism Ministry Focus Coordination of Agencies
4.
elements of a comprehensive health care programme for older persons 4.1 Health Education, Health Promotion and Disease Prevention Primary Health Care Home and Community-based Care Rehabilitation Specialist Medical Services Mental Health Services Sheltered Residential Care Human Resources Development Roles for Nongovernmental Organizations Research, Information and Development
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4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 5. 6.
Implementation Conclusion
Acknowledgements Bibliography Annex 1 - Guidelines for development of a framework for implementation of community-based and in-home Programmes for care of older persons Annex 2 - Check List
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foreword
Population ageing is one of the most important public health challenges that will face countries of the Western Pacific Region of WHO in the coming century. To respond to the forthcoming demographic transition, New horizons in health, the framework document on development of health policies and services in the Region, has one of its main themes “improving quality of life in later years”. This recognizes the importance of specifically addressing the health needs of people as they grow older. The dramatic demographic changes that are occurring throughout the Region have resulted in an unprecedented rate and level of population ageing in the Region as a whole. While there is great variation between countries in current levels of population ageing, increases in life expectancy, reductions in fertility and consequent increases in the proportion and numbers of older people are virtually universal. There is need for a strategic public policy approach that responds to the social, economic and health needs of an ageing population. Governments are increasingly called upon to ensure the provision of appropriate health care and support services needed by older persons. The resources of individuals and families often cannot meet these requirements without public assistance. Demand for essential health care increases with age as a consequence of age-related increases in incidence of chronic diseases and disability. The Western Pacific Region of WHO has responded to the need to address the health implications of population ageing by sponsoring a series of projects to research the health needs of older persons and compile information on ageing in the Region. Several regional workshops have been convened on policy and planning, human resource development and the planning and implementation of community-based services for older persons. In addition, a training manual on Quality health care for the elderly has been produced. These guidelines for national policies and programme development are an important part of this process. They are particularly intended for
the governments of those countries and areas that have yet to put in place comprehensive policies and programmes for the provision of health services and care for their ageing population. However, I hope all countries and areas of the Western Pacific Region will review their national policies on health for older persons and that the guidelines will prove valuable as they assess the current situation and formulate plans for the future.
S.T. Han, MD, PhD Regional Director
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
SUMMARY OF KEY POINTS The Western Pacific Region of WHO is home to a very large and rapidly growing proportion of the World’s older population. Action is required now to develop more positive and proactive approaches to ensuring the health and well-being of ageing populations so that major problems in maintaining the quality of life and health of this group in the future can be avoided. This action will reduce the potential for adverse impacts that increasing morbidity and dependence associated with population ageing may bring. This document provides a broad guide for the action that governments should take now in responding to the health and care needs of their ageing populations. The key points are summarized below:
KEY POINTS 1 2 3 4 5 6 7 8 The rights of individuals must be maintained and protected as they age. Quality assurance should be introduced to cover all aspects of health care of older persons. Ageing must be approached as a life-span process, not simply as an issue that applies to a particular age group. The primary focus of health care for older persons should be on attainment of ‘healthy ageing’, not just the treatment of disease. The positive contribution of older persons to development and as a resource for their families, communities and society must be recognized. Full access to comprehensive health services should be ensured for older persons. The integral relationship between older persons and their families should be recognized, supported and promoted by health services. Positive cultural traditions should be respected in providing health services for older persons.
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9 10 11 12 13 14 15 16 17 18 19 20 21
Traditional health care methods where practised should be integrated into general health service delivery for older persons. Gender differences in both health and lifestyle should be recognized and taken into account in addressing the health care needs of older persons. The diversity of older populations should be recognized and differences between cohorts of older persons should be taken into account. Potential inequities in provision and access to appropriate health care between older persons living in urban and rural settings should be addressed. Every nation should have a comprehensive policy on health and care for older persons. Every nation should make appropriate provision for funding of health services for the older population so that lack of ability to pay never prevents access to needed health services. A national coordinating mechanism should be in place to provide direction and oversight of national health policies and programmes related to population ageing. A mechanism should be in place to ensure the effective coordination of government departments and agencies in providing health services and care for older persons. Ministries of Health should establish a clearly defined and resourced ‘focal point’ on ageing. Specific programmes should be introduced to provide for health education, health promotion and disease prevention related to ageing. Training of non-professional and professional primary health care workers in all aspects of health care of older persons should be introduced. Community-based services for health care of older persons should be developed as an alternative to institutional care. Older persons should have access to comprehensive rehabilitation services when needed.
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Specialized and academic geriatric medicine resources should be systematically developed to provide education, research and leadership in the development of health care for the older population. The mental health needs of the older population should be considered and psychogeriatric services should be developed in conjunction with geriatric medical services. Provision of sheltered residential services should be systematically planned, monitored and controlled to ensure proper standards of care and appropriate levels of provision. Priority should be given to ensuring appropriate training at both undergraduate and graduate levels for all health care personnel involved in care of older persons. Governments should take account of the essential role that nongovernmental organizations (NGOs) can play in providing health services and care for older persons and the NGOs should be supported to do this. Existing information should be reviewed and made more accessible to planners and policy-makers and new information on health of older persons should be gathered and analyzed systematically .
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1 Introduction 1.1 Global Population Ageing At present there are more than 545 million people in the world aged 60 years or over. By the year 2000, this number is expected to rise to 614 million, and to over one billion by the year 2020. The average life expectancy at birth of the world’s population is also projected to increase from 64.4 years in 1995 to 70.6 years by the year 2020 (United Nations 1994).
Figure 1. Population aged 60 and over in developed and developing countries 2000000 1800000 1600000 1400000 Thousands 1200000 1000000 800000 600000 400000 200000 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Developing countries Developed countries
year
Source: World Population Prospects, U.N. 1994
In the developed world, ageing has been an accepted sphere of research and policy formulation for some time. However, until recently, little attention has been given to ageing in developing countries. From 1950 to 1975, the older
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population was fairly evenly distributed between developed and developing regions. Since then, the rate of increase of older persons in the population has been greater in developing than developed countries, and projections indicate a definite change in the pattern by the year 2000. By that time, older persons will number about 614 million, over 62% of whom will be in the developing regions. By 2025, the absolute number is projected to double to 1.2 billion, 72% of whom are projected to be living in the developing regions (Figure 1).
1.2 Ageing in the Western Pacific Region It has been widely recognized that the demographic trends of the past decades in many countries of the Western Pacific Region are leading to unprecedented increases not only in absolute numbers, but also in the proportions of elderly people. The combination of the demographic transition and accompanying epidemiological transition along with a period of generally rapid industrialization in most countries of the Region have been identified as key factors contributing to the impending ‘crisis’ in provision of adequate health care and social support for older persons, especially in developing and newly industrialized countries. The Western Pacific Region presents a picture of great diversity in terms of population and demographic characteristics. At one end is China, which has a population of more than a billion, and at the other are island states with populations of only a few thousand. The proportion of older persons to the total population also shows great differences between countries, from about 4% of the population in Cambodia to about 20% in Japan. Life expectancy at birth for the Region is expected to increase from 68.8 years in 1995 to 74.4 years in 2020. However, extremes can be seen between Japan, where life expectancy at birth is 80 years and Cambodia and the Lao People’s Democratic Republic, where the corresponding figure is just under 50 years (figure 2). Figure 2. Life expectancy projections for elected countries of the region 90 85 80 75 70 65 60 55 50 45 1990 Life expectancy in years
Cambodia China Japan Philippines Republic of Korea Singapore
2000
2010
2020 Year
2030
2040
2050
Source: World Population Prospects, U.N. 1994
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It is anticipated that the population of the Western Pacific Region will age faster than the world population. In 1995, the population of those aged 60 years and over was almost the same for the Region and the world, at about 9%. By the year 2050, the Region is expected to have 20% of its population over the age of 60 years, compared to the global percentage of 16 % (Figure 3).
Figure 3. Percentage of population aged 60 years and over (Regional vs Global) 20 18 16 14 Percent 12 10 8 6 4 2 0 1990 2000 2010 2020 Year 2030 2040 2050 Western Pacific World
Source: World Population Prospects, U.N. 1994
The speed at which the population is ageing in some countries is also particularly rapid. For example, population projections reveal that between 1995 and 2020, the population aged 60 years and over will increase from 20% to 30% in Japan; from 5.4% to 9% in the Philippines; from 9% to 14% in China; and from about 9% to 17% of the population in the Republic of Korea (Figure 4). This proportion of the population will more than double in Singapore (10% to 23%), while modest increases are expected in Cambodia (4.2% to 5.8%).
Figure 4. Proportion of the population aged 60 years and over in selected countries 35 30 25 Japan Percent 20 15 10 5 0 1990 Philippines Republic of Korea Singapore Cambodia China
2000
2010
2020 Year
2030
2040
2050
Source: World Population Prospects, U.N. 1994
In countries of the Western Pacific Region, there is a particular need to address the issue of ageing in view of the large proportion of developing countries, and the rapid urbanization, industrialization, modernization and
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economic changes that are characteristic of the Region. As the absolute number and proportion of the population of older persons in the Region is growing rapidly, there is a need for increased emphasis on the health and health care needs of older persons.
1.3 Implications of Population Ageing in the Western Pacific Region The rapid increase in the number of older persons has significant implications in both societal and economic terms. Specifically, there are implications for many areas such as health care, the financing of the needs of older persons, accommodation and the role of the older persons in a rapidly changing and urbanizing society. It has been feared that, as the population ages, the economically active age groups will not be able to support the dependent age groups, mainly children and older persons, who are traditionally believed to consume but not to produce economic output. The incidence of disease and disability also increases with advancing age. Moreover, there are special problems of diagnosis, assessment, management and care of people in the older age groups. The experience of developed countries shows that these groups generate a greater demand for health and social services, including modern health care technologies applied to their medical needs. In many countries, governments have accepted the responsibility of supporting the needs of older persons. Therefore, in cases where the present supply of human resources and facilities for health care are inadequate, these services are strained even further. Decreasing fertility, mortality and family size bring about a situation where there are more elderly with fewer family members to care for them. There is increasing urban migration to seek better economic opportunities, and the younger generation increasingly tend to favour nuclear families. So even while the cultural and societal norm of caring for older members of the family remains strong, some changes in family values or loosening of family ties that undermine traditional family-based approaches to the care and support of older people are noted. The increasing numbers and proportion of older persons will mean that more facilities and services will be required to meet their specific needs. Combined with this greater need for services, a shift in the age distribution of dependants from the young to predominantly older groups will ultimately place pressure on future government and public outlays. Governments need to instigate appropriate policies to respond to this. This will require a fundamental shift in
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orientation to put ageing and health in a broader and more positive context. A life-span perspective is needed and investment must be made in the achievement of healthy ageing. Thus more emphasis needs to be given to preventive measures that promote health and maintain function and independence among older persons.
1.4
Existing Policy and Programmes for the Health of Older Persons in the Region Notable progress has been made over the last 15 years in the Region as there has been an evident upsurge in awareness and attention given to the health needs of older persons by the great majority of countries, although some reluctance by governments to act in response to the special health problems and needs of older persons has also been observed. In 1990, when the Western Pacific Regional Office convened a Regional Workshop on Human Resource Development in the Health Care of the Elderly, approximately half of the participating countries had some policy. In 1993, 85% had a focal person in government responsible for health care of older persons, and approximately 60% had some policy of varying scope. The extent to which programmes have developed varies between groups of countries in the Region (Table 1). For example, Australia, Japan and New Zealand, which are demographically older and more highly developed, have well established policies and programmes for health of older persons. The demographically “middle-aged” newly industrialized countries and areas which show clear evidence of population ageing, such as Hong Kong, China and Singapore, have likewise established their own systems. The upper-middle income, rapidly developing countries, such as Malaysia and the Republic of Korea, have made recent initiatives in the development of health services for older persons, and China, which is among the demographically middle-aged developing countries, has now given more attention to the development of health services for older persons. At the other end are the demographically “still young”, lower-middle and low income developing countries such as Fiji, the Philippines and Viet Nam which are now beginning to initiate health services for older persons, and the “very young”, low income, least developed countries, such as Cambodia and Lao People’s Democratic Republic, where the health of older persons is still a low priority. Several countries have established national focal points for the care of older persons and some countries, such as Australia, Japan, New Zealand, Singapore, Mongolia and the Philippines, have enacted legislation devoted to older persons.
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
In many countries, issues on health and care of older persons are addressed as part of their comprehensive health programmes. As previously stated, while issues related to the ageing of the population are beginning to receive more attention from governments, they are still generally a relatively low priority in most countries. Awareness is not necessarily being transformed into the development of national policy and programmes and it therefore follows that allocation of resources is often inadequate. In many places, there is a lack of appropriately trained personnel to contribute to programme development and implementation. World Health Organization sponsored events and advocacy have contributed significantly to the increased interest and activity in the health of older persons. The World Health Organization has collaborated with countries in determining the nature, extent and magnitude of health and health-related problems of older persons through support of epidemiological studies, in-depth analyses and reviews of health sector responsibilities, and compilation and dissemination of comparable data on health.
Table 1. Broad Grouping of Selected Countries and Areas in the Region by Demographic characteristics, Economic and Health Infrastructure Development for Older Persons Classification Countries and areas Australia, Japan, New Zealand Hong Kong, China, Singapore Guam, Malaysia, Republic of Korea Economic Development High income Health Infrastructure Development Highly Developed Established system of care for older persons Established system of care of older persons More recent initiatives in development of health services for older persons Increasing attention given to development of health services for older persons Beginning to initiate health services for older persons Older persons not yet recognized as a major concern
Demographically older Demographically middle aged
High income, newly industrialized Upper middle income, rapidly developing
People’s Republic of China
Lower middle income
Demographically young
Fiji, Philippines, Viet Nam Lao PDR, Cambodia, Papua New Guinea
Lower-middle income, low income developing countries Low-income, least developed countries
Demographically very young
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1.5
The Need for Policy and Programmes for the Health of Older Persons Given the demographic projections, changing socioeconomic features and increasing trend of urbanization, the ageing population has definitely become a major challenge for policy-makers and health care providers. Older persons are a particularly vulnerable group in terms of maintenance of health. They are especially at risk from the adverse effects of the lack of public policies through inequitable access to financial, technological and other social resources. They may be discriminated against by inappropriate legislation and frequently lack a supportive environment outside the family situation. They suffer more frequently from chronic conditions than do other community groups and have much less political power. In the Western Pacific Region it is envisioned that, by the beginning of the next century, most countries and areas will have formulated national health policies for older persons, community-based health programmes for older persons will have been developed and health promotion activities throughout life will have been implemented. Although ageing and health care of older persons is often not yet a priority issue for policy-makers and health planners in many countries of the Region, there is a growing need to pay more attention to the important health issues associated with population ageing. At present, the relative numbers and proportion of older people in most countries of the Region are still relatively small and the impact of population ageing on social and health services is only now becoming evident. During the next few decades, this sector of the population will grow rapidly both in absolute numbers and proportional terms, and consequently the ageing population will present a major challenge to health care policy-makers and providers in the future. Thus a major task is to establish guidelines for policies to guide the Region’s preparations for health of older persons over the coming crucial years. As resolved at the 47th Meeting of the Regional Committee of the Western Pacific Region held in Seoul, Republic of Korea in 1996, Member States were urged to: • formulate policies and strengthen programmes to improve the health and quality of life of older persons consistent with the concepts outlined in New horizons in health; collect gender-specific data on health issues related to ageing; and strengthen intercountry cooperation.
• •
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2 PRINCIPLES The underlying principles that govern policy development for health care of older persons are already enunciated in a number of World Health Organization and United Nations Documents. In this respect important underlying principles are embodied in: • • • • • • • • • Alma Ata Declaration on Primary Health Care Health for All by the Year 2000 The Vienna Plan of Action The UN General Assembly Resolution United Nations Principles for Older Persons United Nations Global Targets on Ageing World Summit for Social Development The WHO Western Pacific Region policy framework document New horizons in health, and The Principles of the WHO Programme on Ageing and Health.
These various sources have been taken into account in the formulation of the guidelines set out below.
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2.1
Rights of Older Persons Older people must be acknowledged as integral members of society and must have the right to Key Point 1 The rights of individuals enjoy good quality of life and full equity in must be maintained and access to services necessary for optimal health. protected as they age. “A fundamental principle in the care of older persons should be to enable them to lead independent lives in the community for as long as possible” (Vienna Plan of Action). “They must have access to the same services and opportunities, contribute in the same areas, and enjoy and participate in the activities and challenges which are available to people of other ages” (10-Year Plan For Aged Services, South Australian Government 1995). The rights of older persons should be maintained in all circumstances and provision must be made to ensure they are protected in circumstances where they are receiving care of any kind.
2.2
Quality of Care As health and other care services for older persons develop in response to increasing needs, it is important to ensure that all caring services whether public, private or charitable, are provided in a way that ensures that adequate standards of care are applied and that quality of care is monitored and maintained. Appropriate mechanisms should be put in place to monitor quality of care and to provide mechanisms for periodic accreditation of programmes and facilities. Quality assurance provisions should be extended across the whole range of care provision, including community based and sheltered residential (institutional) services. A continuous Quality Improvement approach should be used by all services. Key Point 2 Quality assurance should be introduced to cover all aspects of health care of older persons.
.
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2.3 Life Course Perspective Health in old age is determined by the patterns of living, exposures and opportunities for health protection over the life span. Thus the health of older persons should be viewed in the context of the whole of life. “A healthy childhood and adulthood is probably the most important determinant of healthy ageing” (New horizons in health, WHO/WPRO 1995). Action to ensure quality of life in old age can begin well before older age, however defined, is reached. In order to maximize disability-free and productive living at older ages, it is essential to achieve the earlier prevention or at least delay in the onset of the major noncommunicable diseases. Programmes directed to the health of older persons, to be ultimately effective, will need to work collaboratively and facilitate the efforts of those seeking to improve the lifestyles, environmental risk exposures and opportunities for health protection at earlier ages. This is especially true of the prevention of those disorders that at least in part have their origins in earlier life, such as osteoporosis, vascular diseases and most cancers. Key Point 3 Ageing must be approached as a life-span process, not simply as an issue that applies to a particular age group.
2.4 Healthy Ageing It is now recognized that older persons are highly diverse with respect to almost any characteristic, whether it is health, functional status, living arrangements, economic or social circumstances. Frailty, ill health and disability tend to increase with age on average, but it is recognized that many older persons exhibit excellent health and function independently in most if not all areas of their lives. The primary objective of health policies directed to older persons must be to promote the attainment and maintenance of healthy and ‘successful’ ageing in advanced years. The emphasis should be upon people-centred health maintenance and improvement through promotion of positive health and healthy lifestyles, in addition to traditional goals of disease prevention, treatment and rehabilitation. The challenge is to understand and promote those factors that keep people healthy, with a focus on both personal and external resources. Key Point 4 The primary focus of health care for older persons should be on attainment of ‘healthy ageing’, not just the treatment of disease.
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2.5
Productivity and Participation of Older Persons In the past, policies directed to older citizens have tended to emphasize their differences and dependencies, and to marginalize them. It is now recognized and accepted that older persons are equal members of society and have a significant continuing role to play within their families, communities and nations. “They must have access to the same services and opportunities, contribute in the same areas, and enjoy and participate in the activities and challenges which are available to people of other ages” (10-Year Plan For Aged Services, South Australian Government 1995). Marginalization of the older members of society should be avoided and efforts should be made to ensure recognition of the contribution of older persons to national productivity and development. Key Point 5 The positive contribution of older persons to development and as a resource for their families, communities and society must be recognized.
2.6
Access to Comprehensive Care Comprehensive health care must be available to older persons. These services should be Key Point 6 Full access to compreaimed at minimizing the deleterious effects of hensive health services disease and should promote the achievement should be ensured for older of personal health potential and high quality persons. of life for the whole of the population. It is important to view health services for older persons in the context of the general organization of health care systems and health services delivery as they are in place nationally and locally. The special needs of older persons are then taken into account within these general systems. It is important to introduce specialization in geriatric medicine and other gerontological disciplines, particularly where special attention is being focused on older persons for the first time. This is important to ensure that there is an appropriate focus for training and research, and that centres of excellence can be developed to set national benchmarks in the care of older persons.
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2.7 Family/Community Orientation Due recognition and support should be given to the networks of older persons, that is, their families, neighbourhoods and communities. Often it is these informal sources of support that offer the most significant assistance. In the Western Pacific Region, many members of the older population are an integral part of family structure and thus inter-generational relations and exchange are very important. With increasing life expectation, multi-generational families will become more common and in many situations those aged 60 years to 74 years (the so-called ‘young-old’) will be caring for their 75 and older (‘old-old’) parents. Policymakers and planners will need to be sensitive to these aspects of family life, in particular by having specific policies in place that encourage families to care for their older members, and by encouraging older people to remain in the community. Within the Region there are also changes occurring in patterns of inter-generational co-residence and the strength of family linkages. Social changes such as migration, urbanization and increased numbers of women in the labour force have meant that generations of a family may live separately and therefore many more older people, particularly women, are living alone. Community services such as home help, community centres and day care must therefore be oriented towards helping older people remain in the community as long as possible. It must also be recognized that there are traditional care practitioners in many countries who have the trust of older persons, and who, at times are more readily available than formally trained workers. Any comprehensive system of aged care should take such practitioners into consideration and ensure that steps are taken to include these practitioners in the development and delivery of care strategies for older persons. Key Point 7 The integral relationship between older persons and their families should be recognized, supported and promoted by health services.
2.8 Cultural Perspective There is an extraordinary diversity of cultures throughout the Western Pacific Region. Beliefs, behaviours and attitudes to health and ageing are greatly influenced by traditions, religious beliefs and values, so these elements must be taken into account in any regional approach to dealing with the issues associated with ageing. These beliefs and values form part of the ethical framework that underpins decision-making in health care. There are many positive influences on ageing such as traditional respect for elders and the role of families in providing care, that need to be Key Point 8 Positive cultural traditions should be respected in providing health services for older persons.
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fostered and utilized to contribute to attainment of improved quality of life for older persons.
2.9
Traditional Care and Practices Traditional health practices should also be taken into account (see above). The opportunities available to various cultural groups for healthy ways of living are also significantly influenced by social values and economic factors. Cultural beliefs and values are clearly defined for many of the Region’s older persons and need to be considered when interventions aimed at improving well-being in older age are planned. In health care delivery, the need for establishment of links between traditional and mainstream care should be recognized and services should, wherever possible, be integrated. Key Point 9 Traditional health care methods where practised should be integrated into general health service delivery for older persons.
2.10 Gender Variation The importance of recognizing and responding to the differences in experience of ageing between men and women has been increasingly recognized throughout the world. Differentials in mortality, morbidity and disability have been widely described. In addition, the vital role of women as carers must be taken into account. In the Western Pacific Region, culturally-based attitudes and practices will also influence gender-related responses to ageing. There must be specific strategies aimed at the major health concerns of men and women. While neither group must be neglected at the expense of the other, the special and gender specific issues that impact upon the health experience of each must be considered. Account should also be taken of the apparent greater burden of morbidity borne by older women in spite of their increased longevity compared to men. Key Point 10 Gender differences in both health and lifestyle should be recognized and taken into account in addressing health care needs of older persons.
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2.11 Cohort Perspective Research studies have demonstrated substantial variation between different cohorts of older people. There is now some evidence that successive age cohorts may exhibit improved health and well-being over those born earlier. Certainly any analysis of ageing issues and programmes designed to deal with these should take account of cohort variations as far as possible. Planning processes need to consider that the recipients of programmes now at the planning stage may ultimately be younger cohorts with somewhat differing experiences, attitudes and expectations of ageing than the present older people. This is especially true of countries that are rapidly developing demographically and socioeconomically. Key Point 11 The diversity of older populations should be recognized and differences between cohorts of older persons should be taken into account.
2.12 Rural/Urban Distinction In many countries in the Region, there are dramatic differences between urban and rural populations, and due care must be taken to ensure that appropriate policies are in place to deal with each. In many circumstances, older persons in rural areas have less access to essential health care services and support. Other factors, such as the shift of younger people from rural to urban locations may compound the disadvantages experienced by older persons living in rural areas. Key Point 12 Potential inequities in provision and access to appropriate health care between older persons living in urban and rural settings should be addressed.
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3 POLICY FORMULATION
3.1
National Policy Declaration A national policy on health and care of older persons is an important step in achieving a framework for the development of services for older persons. Such a policy should recognize that achievement and maintenance of health and well-being in old age is both a health and a social welfare issue, and that it requires consideration of other areas such as education, housing, social security and the environment as well. Key Point 13 Every nation should have a comprehensive policy on health and care for older persons.
The focus of the policy should be to preserve the dignity, independence and autonomy of older persons in the context of the family and community in such a way that ageing will be a positive and fulfilling phase of life. In this general context, health care services must ensure the provision of accessible, effective and quality health care including preventive, rehabilitative and community services sensitive to and encompassing fully a nation’s traditional cultural values. The policy should incorporate the principles of health promotion and prevention of chronic disease and disability. Appropriate provision of acute care services and general medical care should be ensured in a way that recognizes the integral
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role of primary health care and the need for a continuum of care that extends to rehabilitation, community services and long-term care for the chronically ill and disabled. The detailed consideration and recommendation of a National Policy on Health and Care of Older Persons to Government should be the task of a duly constituted National Council on Health of older persons as set out in section 3.2. Japan Health and medical services for the aged in Japan had previously been defined in the Law for the Welfare of the Elderly, however in order to comprehensively cope with the increasing number of older persons, the Law for the Health of the Elderly was enacted in 1983. The objective of this law was to improve the health and welfare of older persons through comprehensive health care services for prevention of disease, medical services and rehabilitation. The significance of this legislation was to legalize and therefore mandate the health services. Municipalities are responsible for the provision of these services. A ten-year strategy to promote health care and welfare for the older persons (The Gold Plan) was drawn up in 1989 and implemented in 1990 to develop the infrastructure for public health care and welfare services for the older persons by 1999. This Gold Plan was revised in 1994 and the revised plan implemented in 1995.
3.2 Health Care Financing The cost of individual health care services can be a major barrier to access to comprehensive medical and health care. A national approach to development of policies for health financing, health insurance and medical, pharmaceutical and health care service payments is essential. There are many models for financing health care services for older persons, including direct government provision, public and private health insurance and other approaches. Such policies need to be formulated within the general policy framework for health care for each individual country. Minimum provision should ensure that no older person is denied basic health and long-term care due to inability to pay. Key Point 14 Every nation should make appropriate provision for funding of health services for the older population so that lack of ability to pay never prevents access to needed health services.
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People’s Republic of China Free health insurance is available for older persons who have been employed previously. While state and collective employees (mostly urban-based) enjoy these benefits either totally (state employees) or partially (collective employees), most rural workers or those in the growing private sector are not covered. In order to improve access to health and medical care for people living in rural areas, the Chinese government has been developing the Co-operative Medical Insurance System. In 1996, the coverage rate of this system had increased by 6.41% (from 10%) in rural areas, thus an additional 5.6 million older persons living in rural areas had been covered by the Co-operative Medical Insurance System and this trend continues to rise. Many of the 31 provincial administrative regions of China are making efforts to expand the coverage rate of the Cooperative Medical Insurance System under the guidance of the Ministry of Health.
Republic of Korea Health care services for older persons are currently financed by two types of programmes in the Republic of Korea: (1) Medical Insurance Two medical insurance programmes cover the elderly: Medical Insurance (MI) and Civil Servant and Private School Employee Medical Insurance (CSPSEMI). The current MI scheme was established to cover all nationals except those covered by CSPEMI and the Medical Assistance Scheme (MA). The MI covers medical services such as diagnosis, inpatient and outpatient treatment, operations and nursing, e.t.c. As of 1997, the MI covers 86% of the population. CSPSEMI covers 10.9% of the total population. It has similar benefits to the MI scheme. (2) Medical Assistance (MA) MA was introduced for low income persons. The programme is financed by general tax. In 1997, this programme covered 3.5% of the population and 9.5% of those aged 65 years and over.
3.3
National Coordinating Mechanism A National Council on Health of Older Persons should be established under the highest possible aegis in recognition of the wide implications and inter-sectoral nature of the undertaking. It should have direct lines of communication with the relevant Ministries and, in order to ensure its effectiveness in carrying out its task, should be supported by reasonable budgetary provision. A small secretariat should be established to facilitate the work of the Council. The membership of the Council should ensure both representation of all legitimate interests and representativeness of the people most affected by ageing, i.e., Key Point 15 A national coordinating mechanism should be in place to provide direction and oversight of national health policies and programmes related to population ageing.
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there should be intersectoral and community involvement. In addition to health, the sectors that should be involved include welfare, labour, housing and education. Appropriate nongovernmental organizations should be invited to take part and some community representation should be achieved by appointing prominent citizens (preferably senior). The National Council on Health of Older Persons could be established as an element within the national coordinating mechanism on ageing generally, where such exists. Alternatively, it may be established independently. The terms of reference of the National Council on Health of Older Persons could include: • Formulation of national policies with respect to ageing including, in the first instance, a draft national policy on health and care of older persons for reference to the National Government. Stimulation of development of national planning to implement agreed policies and subsequent monitoring and reporting on progress in implementation of the plans. Raising and maintaining public awareness about the issues of health and ageing and the needs of older persons and their families. Raising and maintaining political awareness and commitment to health and ageing issues. Ensuring relevant inquiry and research into the health situation and the needs of the older persons. Interaction and participation in international activities on health and ageing including United Nations sponsored initiatives and nongovernmental activities through such organizations as the International Federation on Ageing and the International Association of Gerontology. Philippines The Philippine Government seeks to promote a better quality of life through the provision of an integrated and comprehensive programme and services. In 1996, the Philippine National Programme was established as an attempt to tackle the elderly issue with a multi-disciplinary and multi-sectoral approach. Among the many agencies involved are the Department of Health, the Department of Labor and Employment and the Department of Interior and Local Government. A well-defined role for each agency is established to facilitate the close cooperation and integration of the different aspects of service delivery at different levels.
•
• • • •
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Malaysia The Malaysian Government established a National Advisory and Consultative Council which comprises government, nongovernment and appropriate interested individuals in 1996 under the Ministry of National Unity and Social Development. The Council advises on the overall implementation of the National Aging Policy by the various agencies concerned. A National Health for the Elderly Council was established under the Ministry of Health in 1997. The Council acts as the main body for monitoring policies pertaining to health of the older persons as well as health standards and norms. The Family Health Development Division in the Public Health Department of the Ministry provides the focal point for health of older persons in the Ministry and serves as the Secretariat of the Council.
3.4
Ministry Focus To ensure that the development of health services for older persons proceeds in a rational, integrated and comprehensive manner, an identifiable focus for advocacy, planning, training and administration within the Ministry of Health is essential. This requires at least the establishment of a specific office or ‘focal point’ and the appointment of a responsible senior officer within the Ministry. The ‘Health of Older Persons Office’ could be given the role of servicing the National Council on Health of Older Persons referred to above and would need to liaise closely with the appropriate sections of the Ministry of Social Welfare or its equivalent. The Office should receive a basic budget and project personnel should be appointed to ensure that its coordinating role can be carried out effectively. Key Point 17 Ministries of Health should establish a clearly defined and resourced ‘focal point’ on ageing. Singapore The Ministry of Health in Singapore takes a lead in the coordination of health care services for the older persons. A Division of Elderly Services was set up in the Ministry to strengthen the national infrastructure for the delivery of health care services for the older persons and to build a network of health care services for the elderly. The Division also provides secretariat support for the 1997 InterMinisterial Committee on Health Care for the Elderly.
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3.5 Coordination of Agencies The provision of comprehensive geriatric and aged care services requires close cooperation and the integration of many aspects of service delivery. The stakeholders in this respect are diverse and include national and local governments, the health system, the social welfare system, other government areas such as education, housing and culture, nongovernmental organizations, old people themselves and their organizations, families and the wider community generally. Key Point 16 A mechanism should be in place to ensure the effective coordination of activities of government departments and agencies in providing health services and care for older persons.
One of the most critical factors in achieving rational and coordinated planning is good communication between those involved. In this respect, the National Council on Health of Older Persons previously referred to has an important role to play. However, at the same time, it is essential for the key government departments and services at the local level to work closely together and to develop a clear understanding of their respective roles. Some overlap is inevitable for a variety of reasons. This is mainly because the needs of older persons at various times do not clearly separate into medical, social, physical and mental areas. These needs usually reflect a complex set of medical, functional, social, economic, family and community circumstances that interact in various ways and which require a multi-disciplinary and intersectoral approach if they are to be dealt with effectively. It is particularly important that the Ministries of Health and Welfare work closely together in planning and delivering services to the older people. Within health systems, an integrated approach is necessary to ensure effective and efficient delivery of health care to older persons. National policies are important in providing the broad framework for development of more decentralized structures at regional, district and local levels. Coordination of services is important down to the level of delivery of services to individuals. In many circumstances, the introduction of ‘managed care’ or ‘coordinated care’ that provides integrated assessment and an identified ‘care manager’ has been shown to result in more appropriate and more efficient delivery of needed services to individuals while also contributing to greater empowerment of the individual older persons and their families in receipt of care.
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4 Elements of a comprehensive health care programme for older persons
4.1
Health Education, Health Promotion and Disease Prevention An important first step is health education aimed at giving all people an intelligent understanding of health and its determinants so that they can make informed choices and take responsibility for their own health and for the health of those who depend upon them.
Key Point 18 Specific programmes should be introduced to provide for health education, health promotion and disease prevention related to ageing.
HEALTH PROMOTION
PREVENTION
OPTIMUM HEALTH FOR HEALTH
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As defined in New horizons in health, ‘Health promotion refers to the sort of measures that can be taken to encourage and enhance what people can do themselves in conjunction with their families, communities and nation, to improve and manage their own health.’ Many of the diseases in persons of working age and among the young old (60-74 years) that cause disability are preventable to a significant degree. Action should focus on the prevention of these diseases, including hypertension, diabetes mellitus, obesity, heart disease, stroke and chronic lung disease. Increased attention should be given to these problems in preventive and health promotion activities. There is also scope for initiation of secondary preventive measures through the early detection and management of problems associated with ageing through the primary health care services. Consideration should be given to instituting a system of regular medical and social assessment of the older population (70 years and more) with a view to instituting appropriate interventions to prevent or ameliorate the effects of chronic disorders. Advice on nutrition, social support needs, activities and early treatment of medical disorders can be instituted through this mechanism. The prospects of preventative measures are considerable with improved social support, access to social activities and surveillance of at-risk groups such as those living alone, the disabled, the recently bereaved or those recently discharged from hospital. An important aspect of prevention and health promotion with respect to ageing is the broader education of the community. Strategies should be developed to better inform the population on issues associated with health and ageing and to enunciate national policies regarding family and community responsibilities for care of older persons. The National Council on Health of Older Persons referred to above could develop a suitable programme for informing and educating the wider community in these areas in association with the general education authorities and the media. Thus, there are real opportunities for the application of health promotion principles generally to the health of older persons.
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Hong Kong, China At present there are seven Elderly Health Centres (EHC) in Hong Kong. These Centres aim to promote the health and well-being of older persons in the community and they have three main objectives: • • • to enhance the knowledge of the elderly on common health problems; to screen for common health risk factors and community diseases; and to promote community participation.
To achieve these objectives, EHCs provide the following services to people aged 65 and over: • • • screening tests to detect common risk factors for prevention and early treatment of common diseases; individual counselling with a health booklet issued to each client; health education and health promotion in the form of health talks, workshops, health promotion classes and self-help groups to enhance the knowledge of the elderly on common health problems and to better equip them and their carers for care of these problems; and enlisting community participation in the organization of health education and promotion activities.
•
The above services can be grouped into two major components, health screening and health promotion, both being equally important. To enrol as a member of an EHC, an annual fee is charged, however this is waived for people receiving Comprehensive Social Security Allowance. Each enrolled individual is entitled to a complete health assessment and they are free to join any health promotion activities organized by the EHCs.
Viet Nam Following an epidemiological survey of the health of older persons in four geographic areas of Viet Nam that demonstrated problems in health status of the older population, two test Elderly Health Centres (EHC) have been established. The immediate objectives of the EHC in the test areas are: • to assess the current situation and needs of the elderly and potential capability of communities to provide services for older persons in selected communities; to raise awareness, understanding and capabilities among community leaders, medical workers, welfare officers, volunteers and the older people themselves; and to establish and test different programmes for providing services to older persons which can later be replicated across the country.
•
•
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4.2 Primary Health Care Primary health care services should incorporate a specific component directed to health and care of older persons. Provision for the special needs associated with ageing should be ensured within development plans for primary health care and expressed in associated policies, service plans and care delivery. Attention should be given to appropriate training of existing and future primary health care personnel in care of older persons. Key Point 19 Training of non-professional and professional primary health care workers in all aspects of health care of older persons should be introduced.
In some countries of the Region there are good primary health care systems already in place and these services should be encouraged to include health care of older persons as a fundamental component of their system. The primary health care system has the potential to contribute to the health care of older persons if staff are appropriately re-oriented and trained to take on this responsibility. Primary health care services for older persons should also be fully integrated with general community services. Singapore Government primary health clinics provide approximately 20% of primary health care, with the remainder provided by private practitioners. Outpatient care for the older people is obtainable through a network of clinics. Elderly patients aged over 65 years pay half the cost charged to other members of the public. Senior Citizens Health Care Centres are located in some clinics and offer a range of community-based health services including health screening and assessment, rehabilitation and occupational therapy, dental care and health education programmes. Elderly psychiatric outpatients are followed up at the Institute of Mental Health as well as some clinics. Other specialist clinics, such as those offering care for arthritic and rheumatic patients are also emerging.
4.3 Home and Community-Based Care A critical issue to be faced in provision of health services and care for older persons is the need for community-based services. Guidelines for development of a framework for implementation of community-based and in-home programmes for care of older persons are provided as a supplement to these comprehensive guidelines (Annex 1). Key Point 20 Community-based services for health care of older persons should be developed as an alternative to institutional care.
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As far as possible older people should continue to be cared for in the community in a family setting. This approach provides both better quality of care and is less expensive overall than residential (institutional) alternatives. Experience in many parts of the world now suggests that it is possible to care for older people in the community even in situations where, by strict assessment criteria, they would normally qualify for either special accommodation or permanent long-term residential (nursing home-type) care. There are several models of community care provision that may be chosen by a country, depending on its specific circumstances. A common model is through the provision of coordinated (or managed) care. In these arrangements, there is usually a single point of entry and assessment and a range of services is made available to meet individual needs through a number of providers within a prescribed budget allocation. The use of resources is the responsibility of a care coordinator, or case manager. However organized, a network of community services is necessary, in any event, to support families in maintaining their role as care givers for the frail and disabled elderly. Types of services which are often included are: • • • • • • • • • • visiting nursing services, general home care support, meals, allied health professional advice and services of all types, incontinence advice and support, and other programmes directed at particular common disabilities, home alteration services aimed at increasing the safety and useability of the home, aids (equipment) to daily living, transport, personal care services, and in-home respite care and other programmes designed to reduce the stress and care burden of family members.
In addition, day-care programmes can be very useful in providing ongoing surveillance and rehabilitation for disabled elderly as well as providing respite for the family carers. Through grouping, they also extend the ability of workers to reach greater numbers of people simultaneously. They also provide important social and recreational opportunities for the older person. It is very important for the ultimate provision of efficient and effective programmes that these kinds of services be provided within an overall integrated framework of comprehensive care for older persons. It is also important that all staff recruited into community elderly care receive appropriate training.
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Japan A variety of non-profit organizations in which community residents participate are active nationwide in the field of in-home services. As of June 1995, there were 691 of these community participation welfare service organizations in Japan. The structure of these organizations varies, including community mutual aid societies to company co-operatives, agricultural co-operatives, livelihood co-operatives and workers collectives. The types of services provided also vary, ranging from providing companionship and support for household work, such as cleaning, shopping and meals preparation, to long-term care services such as assistance with toileting and bathing. An example of one such community organization is The Foundation of Healthy and Fulfilled Life Development, which was established in 1991 supported by the Ministry of Health and Welfare. This organization trains instructors who can assist the older people in the community with various aspects of daily life.
4.4 Rehabilitation The World Health Organization defines medical rehabilitation as: “The process of medical care aiming at developing the functional and psychological abilities of the individual and, if necessary his compensatory mechanisms, so as to enable the person to obtain self-dependence and lead an active life.”
Key Point 21 Older persons should have access to comprehensive rehabilitation services when needed.
Rehabilitation is a broad concept which should be incorporated into all aspects of health care delivery. Good hospital and community rehabilitation services are an essential component of any comprehensive health system. Adequate numbers of appropriately trained allied health professionals working within a well-defined rehabilitation network are essential if the best possible functional and social outcomes of medical care are to be achieved. The rehabilitation of older patients with complex chronic and often multiple disorders is an important consideration. Older patients must, when needed, have access to the services of multi-disciplinary rehabilitation programmes including not only physical treatments but also family counselling, training of carers in the basic elements of home care, provision of necessary aids to daily living, home modification as required and the supply of appropriate prosthetic and orthotic services. Families and communities need to be supported and encouraged to become more involved in health care of older persons and thus facilitate the rehabilitation and reintegration into society of the disabled, and people living with chronic
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illness including psychosocial disorders. The public will need to be given the knowledge and skills to engage in self care and rehabilitation activities. It is essential that geriatric and rehabilitation services are developed in a coordinated way so that services can be provided most efficiently to older persons and disabled as well as to younger patients in need of rehabilitation. Singapore Community hospitals in Singapore provide rehabilitative care for sick older persons who have been discharged from an acute hospital and whose health has the potential to improve. These older persons undergo therapy to help them gain optimal function for daily life. The average length of stay in community hospitals is one month. Depending on the individual’s state of health, they are discharged to appropriate long-term care facilities or their own homes. For those discharged to their own homes, they can continue the rehabilitation therapy at day-care centres that provide maintenance therapy for the elderly. At present there are four community hospitals in Singapore, three of which are run by charitable organizations. They provide 370 beds. Planning for two more community hospitals is under way.
4.5
Specialist Medical Services Older persons, and especially the very old, are more likely to need acute medical care than younger people. However, because of their relatively small number in most populations, they represent significant but nonetheless minority users of general health services. As the numbers of older people increase, their relevance to acute general health providers will also increase, and if alternative services are not available older persons may become inappropriate users of acute hospital facilities. Key Point 22 Specialized and academic geriatric medicine resources should be systematically developed to provide education, research and leadership in development of health care for the older population.
Education on the special needs and appropriate care of older patients is necessary for virtually all health workers as increasing proportions of their patients are in the geriatric age group. Attention should be given to issues such as access, assessment, rehabilitation and effective discharge planning in relation to geriatric patients who are treated in the acute hospital situation. The most effective way to ensure that the necessary clinical expertise is developed, and effective training provided, is through the creation of specialist geriatric medical services and academic departments of geriatric medicine and
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gerontological programmes in other faculties involved in the training of health care professionals at both undergraduate and graduate levels. General medical services provided to older patients within general hospital systems should be periodically reviewed with the aim of identifying opportunities for improvement in assessment and care of geriatric patients in general hospital beds. Hong Kong, China Hospitals provide secondary and tertiary medical services to older persons, including acute care, extended care, ambulatory care and outreach medical care. Acute care services are provided to older persons who require intensive medical, nursing, rehabilitation and technological input. Those requiring continuous medical and nursing care for extended periods of medical rehabilitation are being cared for in extended care settings. In addition, more than 95% of general infirmary patients are older persons. Pre-discharge planning for older persons in various clinical specialties has been introduced. Together with the strategy of providing geriatric input to all major acute hospitals, this will allow early assessment and intervention, enhance continuity of care and better coordinate post-discharge care in community settings. The need for hospitalization will also be reduced.
Singapore There are three Geriatric Medicine Departments which have been set up in acute hospitals in Singapore to cater to the treatment and hospitalization needs of the elderly sick with complicated medical problems. Singapore’s first onestop Geriatric Centre was opened in November 1994 in a government hospital. The Geriatric Centre provides a range of specialist services from acute inpatient care to rehabilitation care, and community-based care services which include home medical care, home help service and home nursing care.
4.6 Mental Health Services As populations age, a number of mental healthrelated problems emerge as significant issues. Foremost amongst these is dementia. Other important conditions are depression and psychoses of later life. The appropriate management of these problems in older people calls for high-level skills in psychiatry, psychology and other related disciplines. Consideration should be given to the development of psychogeriatric services and programmes that are integrated with other aspects of care for the older Key Point 23 The mental health needs of the older population should be considered and psychogeriatric services should be developed in conjunction with geriatric medical services.
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persons as the demand for these services increases as a result of population ageing.
4.7
Sheltered Residential Care While community and family care are the mainstay of services for older persons there will always be a minimum necessary requirement for sheltered residential programmes. This fact is already evident in many countries, where residential care is currently being provided particularly for those older people who have no home or family, or those whose families are unable or unwilling to provide care in their homes. Key Point 24 Provision of sheltered residential services should be systematically planned, monitored and controlled to ensure proper standards of care and appropriate levels of provision.
To ensure that the residential care provided is appropriate, a variety of steps should be taken to ensure that it fits into the nation’s spectrum of required elderly care services, and that it is properly regulated and monitored to ensure that it serves the best interests of its users. The provision of culturally appropriate accommodation is important in many settings. The essential elements of a rational residential programme for the elderly are: · Assessment of need No one should be admitted to residential (institutional) care without the benefit of informed professional multi-disciplinary assessment based upon agreed criteria. It is important that national criteria for admission to residential care be established to guide the development and use of such facilities. · Range of residential care Needs of residents will vary from the need for shelter and sustenance to complex medical and nursing care. Provision of accommodation should match these variations in dependency levels. · Standards of Care Standards of care should be determined and agreed and a method of monitoring should be put in place. The monitoring authority should have powers to recognize good practice and to take action against those who do not meet the standards.
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·
Good design Accommodation should be designed to meet all of the physical, behavioural and social needs of residents. An overriding principle is that the environment should be as culturally appropriate and homelike as is possible given the resident’s care needs and disability. Republic of Korea The government has developed special residential care facilities for elderly people with dementia, which make up approximately 5% of the total elderly population. There are currently four facilities in operation which care for 553 older persons. The government is to open a further 70 facilities by the year 2005. Singapore Residential care in nursing homes and chronic sick hospitals is available for those older persons who cannot be cared for in their homes. Nursing homes cater for those who require long-term residential care. In 1997 there were 46 nursing homes in Singapore providing 4420 beds. It is planned to increase the number of nursing home beds to 7000 by the end of the decade. Chronic sick hospitals cater for those who require long-term medical and nursing care of a level higher than that provided in nursing homes. Chronically ill patients usually have more severe physical and functional disabilities which require nursing and medical attention. Chronic sick hospitals are currently provided by two charitable organizations and there are 280 beds. There are also three hospices (90 beds) providing inpatient care for the terminally ill. Nursing homes and chronic sick hospitals are licensed by the Ministry of Health under the Private Hospitals and Medical Clinics Act. These establishments must comply with the standards for services and facilities laid down in the regulations.
4.8 Human Resources Development Key Point 25 Priority should be given to ensuring appropriate training at both undergraduate and graduate levels for all health care personnel involved in care of older persons.
The preparation of the health services workforce to deal effectively with issues associated with ageing and the management of chronic disease and disability is the most essential factor in any medium- and long-term plan to improve services in these areas.
A comprehensive plan for human resources development in the health care of older persons needs to be developed in consultation with the appropriate authorities.
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Training must be considered at all levels, including volunteers, family carers, community groups, care staff, community services staff, hospital personnel and the full range of professional staff involved in provision of care and services to older persons. In countries where geriatrics is not yet a well developed specialty, selected medical staff should be given the opportunity of participating in experiential programmes designed to expose them to the principles of good geriatric medical practice. This training could take the form of 3, 6 or 12 month training attachments to suitable clinical geriatric teaching units in association with some formal course work as appropriate. Training could be undertaken from both the level of primary health care (general practitioner) or specialist general physician (already qualified in general internal medicine). Systematic training opportunities should also be developed for other health professionals, particularly nursing staff. In this case emphasis should be given to a multiple skills approach rather than specialization. Selected nursing personnel should also be given the opportunity of higher training in this area and should then train others in local settings. Attendance by professional staff working in geriatrics at appropriate international conferences should also be encouraged so that they are kept aware of the current international developments that may be relevant to development of services nationally. A central resource of training materials including curricula, manuals, training films and videos, interactive self-education computer packages and other resource materials should be developed in whatever setting is appropriate for a particular country. Training programmes should generally focus on the need to enhance the ability of health workers to transfer their skills and knowledge to individuals and communities. It must be remembered that there is a hierarchy of training with a small core of highly trained specialists at the apex of the pyramid, supported by larger numbers of lesser trained personnel. At every level the worker needs support from someone with a higher level of training and expertise. There must also be opportunities for “self-help”. Voluntary groups with special interests in particular issues can greatly extend the help that can be offered to older persons and their carers. Professional, trained staff should encourage and support the development of such groups. The Alzheimer’s Association, which operates in many countries is a good example of such a group.
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People’s Republic of China The Ministry of Health has established an in-service postgraduate training system for physicians which includes geriatrics as a component. This type of training is also offered in nine medical schools and is available to nurses and community health care managers. Other hospitals and community health care facilities also carry out training programmes based on their own requirements.
Malaysia At present there are five geriatricians in Malaysia, three of whom are in the Ministry of Health and two in the University. Health professionals such as doctors, nurses, physiotherapists and occupational therapists are offered geriatricspecific training opportunities both locally and overseas, and they then act as the core trainers for the country. A training module was developed and a trainers training was conducted in 1996. From 1997 to 2000, training of health personnel for the purpose of programme implementation is being carried out.
4.9 Roles for nongovernmental organizations In many countries the nongovernment sector is an important provider of medical, health and long-term care services for older people. Opportunities for governmentnongovernmental organization (NGO) cooperation in provision of comprehensive services to older people should be enhanced wherever possible. Specifically, active support and funding should be provided by governments in the development of NGO health-related services for older persons where these services complement the provision of public services. Key Point 26 Governments should take account of the essential role that NGOs can play in providing health services and care for older persons and NGOs should be supported to do this.
Nongovernmental organizations involved in provision of services for older persons are also an important source of advice to government and mechanisms should be in place that ensure NGO input into policy formulation and national planning for care of older persons.
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Singapore The Ministry of Health in Singapore assists and works closely with Voluntary Welfare Organizations (VWO) to establish community hospitals, chronic sick hospitals, nursing homes, day rehabilitation centres and home care services to cater for the needs of older persons. The Ministry provides direct financial assistance, professional education and input and administrative support to all VWOs providing health care services. Substantial government assistance is provided for VWOs to build and run health care facilities for sick older persons. Other forms of assistance provided to VWOs include the allocation of government land for building, training of nursing aides, provision of guidelines on nursing home standards and nursing care requirements, recruitment of nursing and ancillary staff and the waiving of fees for medical treatment for needy older persons.
Philippines In recognition of the needs of older people, Republic Act 7432 was passed by the legislative body. This law recognizes the contributions of senior citizens to nation building and grants benefits and privileges to them. Senior citizens have banded together in many municipalities and have organized regional federations and a national federation. The National Federation of Elderly Persons is composed of 14 regional federations, whose members include 3650 associations with a total membership of 205 600 older persons throughout the country. These local and national associations can empower older people to plan and run community health care services in their respective areas.
4.10 Research, Information and Development The development of services for older persons in any nation should be supported by a systematic research and information programme. Planning for the future development of these services should be based as far as possible on sound and timely factual information on the present and projected national situation. Current collection of demographic and health care services data should be reviewed to ensure that information is provided for older persons in a useful fashion. Thus demographic projections are required by five-year age groups at least to age 85 years and should as far as possible be categorized by other relevant characteristics including sex, citizenship, ethnicity, occupation e.t.c. Such information will be of substantial value in planning. Services for older persons should be required to collect standardized data on assessment, service provision, clinical indicators and outcomes which can be used in the evaluation of services and in assessment of their cost effectiveness and efficiency. Key Point 27 Existing information should be reviewed and made more accessible to planners and policy-makers and new information on health of older persons should be gathered and analysed systematically.
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‘..the importance not just of survival, but of quality of existence is recognized. With the increasing proportion of elderly populations, ways of sustaining and preserving health in this large group are becoming an even more significant consideration. It is not enough just to live longer, the concept of adding life to years and increasing the number of years lived free from ill health, needs to be addressed’ (New horizons in health, WHO/WPRO 1995). The establishment of clear objectives for attainment of quality of life in later years and development of associated indicators to monitor progress towards achieving them is important. Appropriate mechanisms will need to be put in place to gather the necessary data systematically and in view of the rapid changes occurring in societies everywhere. Attention must also be given to the analysis, presentation and promulgation of available data on health and ageing so that the information can be effectively understood and used by policy- and decisionmakers. In addition, such information should be used to educate the wider public. Republic of Korea The Korean Institute for Health and Social Affairs (KIHASA), an independent statutory authority, conducts systematic research to support the development of health policies for older people. Surveys on older persons conducted by KIHASA provide information on health status, health behaviours, and the degree of medical utilization of older people. The Korean Institute of Gerontology, which is a nongovernmental organization, also conducts research into older people.
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5 IMPLEMENTATION For many countries, the steps from the formulation of principles and policies to active implementation are difficult. Often, particularly in the area of ageing, the development of practical programmes is left to ad hoc arrangements in response to immediate pressures and systematic planning and development is neglected. While there is no absolute prescription for systematic action on health and ageing that is universally applicable in all situations, some appropriate broad directions can be defined. The following broad plan for national review and implementation of health policies and programmes for older persons is offered as a guide. The extent to which each of the 11 points below applies to individual countries and the order of their implementation will vary according to socioeconomic, demographic, cultural, structural and political considerations. All, however, deserve consideration and should be taken into account in any comprehensive national review and planning of health services and care for older persons for the future.
1.
Establishment (or strengthening) of national framework for action The first step must be to adopt a national approach to assessing the overall circumstances and health needs of an ageing population and responding to these. For countries where such strategies are already in place nationally, it may be necessary to raise the profile of such activities and strengthen the structures and processes involved. In many countries this requires ageing to be included on the agenda of the national planning process.
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The importance of population ageing and the health of older persons for development and the social and economic well-being of the country as a whole needs to be acknowledged. A clear long-range vision needs to be developed leading to the formulation of a clearly articulated national policy on health for older persons. The decision to address these issues must be endorsed at the highest level and it is important to secure political commitment to pursuing their resolution. An appropriate structure for reviewing needs, identifying appropriate alternative responses, reporting and recommending action to government must be put in place.
2.
Legislation and funding Action to develop national objectives and targets for provision of health services and care for older persons must be supported by appropriate legislation and budget provisions. To avoid major problems in the future, governments must take steps now to put in place the necessary legislative framework to support the health and care needs of ageing populations. Appropriate provision in national budgeting processes is essential to ensure implementation of necessary programmes and services directed to the health of older persons.
3.
National review of health care needs of an ageing population Each country needs to have a comprehensive review of the circumstances and needs of its older population. The data for such a review can come from many sources including census information, national health and social survey data, national morbidity and health data, information from individual health and welfare surveys, health services utilization data and other sources. The analysis of the primary and secondary data identified must be undertaken systematically to identify the characteristics and health needs of older persons. Once achieved, such an analysis needs to be updated periodically to reflect changing socioeconomic conditions, environmental changes, shifts in expectations, changes in services provision, impacts of introduced policies and services and other changes. In some countries virtually no systematic effort has yet been initiated in this respect, in others such processes are already in place but need to be further developed and enhanced to provide timely, comprehensive and policy relevant information.
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4.
Review of national goals and objectives for health of older persons A series of specific goals and objectives should be formulated at national level based on the needs identified and the resources available, and consistent with the principles set out in Section 2 of these guidelines. These objectives should be developed in full consultation with health care providers and consumers representatives and must be quantifiable and assessable at national level. Time-frames for their achievement must be specified. They should, at least, include objectives for improvement in national healthy (disability free) life expectancy, reductions in morbidity in key areas among the older population; levels of provision and access to health care services including preventive, primary health care, acute, rehabilitative and long-term care services and facilities, and improvement in quality of life. Indicators to measure achievement of specific goals and objectives must be developed and periodically applied to assess progress.
5.
Definition of relative roles of government, nongovermental organizations, the private sector, the family and the community The relative roles of all of the relevant sectors must be considered in the overall context of national government policy. Special consideration should be given to family needs and especially to the support required by families to continue their traditional role of care and support for older family members. The potential for partnerships between the various sectors and mechanisms to facilitate these arrangements such as development grants, government subsidy e.t.c., should be explored. In many circumstances the role that can be played by nongovernmental organizations is particularly important, especially in view of their relative flexibility and capacity to effectively respond to emerging needs of older people and their families unhampered by the constraints that frequently apply to the bureaucratic procedures of government.
6.
Review of existing policies Existing policies impacting on the health of older persons must be critically reviewed and subjected to political, professional and community (consumer) scrutiny and critique. Opportunities for improvement and gaps in policy coverage need to be identified in this process.
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7.
Review of existing services and programmes A comprehensive review should be periodically undertaken of all current health care services for older persons. The review should include consideration of at least the following: • • • • • • Disease Prevention and Health Promotion Primary Health Care Medical Services Secondary and Tertiary Services Community Care Long-Term Care
The purpose of such reviews is to identify the comprehensiveness, appropriateness and quality of current health care delivery to the older population. Action should then be taken to correct any deficiencies in these respects.
8.
Formulation of planning norms, national standards and quality assurance requirements Planning norms for provision of programmes, services and facilities for health care for older persons should be developed at national level. Such norms should be directed to achieving a comprehensive and balanced provision of care. Where appropriate the norms need to be supported by any necessary and appropriate legislative and regulatory provisions. National practice standards for health care of older persons should be put in place to ensure achievement of acceptable quality of care in both community and residential settings. Attention also needs to be given to the establishment of quality assurance and accreditation processes on a national basis to assess, monitor and raise the quality of care provided in various setting for older persons.
9.
Review of human resources development needs Training of health care personnel for care of older persons is an essential need that must be met with foresight and timely action. Human resource needs should be estimated in the light of proposed programme developments and plans should then be instituted in collaboration with the other appropriate authorities to institute the required undergraduate and post-graduate training activities to ensure an adequately prepared workforce.
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Consideration should also be given to carer training programmes and to public education.
10.
Research and development For continuing improvement and development of health care services for older persons to be effectively achieved, efforts must be backed by research undertaken within countries. A national research agenda should be developed and resources sought to support it. Research capabilities may be enhanced by international collaborative efforts. Priorities for research should be formulated in accordance with national needs and should reflect the level of development of health care services for the older population within each country generally.
11.
Continuous cycle of review – further development outcome assessment – review The processes outlined in the above ten steps do not achieve final ends in themselves. The improvement and development of health care for older persons is a continual process that requires constant reappraisal and consequent renewal of objectives, strategies and achievements. As each cycle of review, action and reappraisal concludes so another should begin.
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6 CONCLUSION There is no need for the increase in longevity and in the numbers and proportion of older persons in populations to constitute a burden on health systems or society generally in the future. Systematic investment now in improving, restoring and maintaining the health of older persons in the population will ensure improvement in health, function and productivity of future older generations and ultimately benefit older persons themselves and the rest of the population. Policies are required now to provide the necessary impetus and commitment to addressing the challenge of population ageing everywhere. The extent to which specific areas of policy are included in the policies of any given country will depend on a variety of factors including the population, level of socioeconomic development and demography of the country concerned. All of the elements set out in these guidelines deserve consideration for incorporation into national policy wholly or in part or, where appropriate, in some modified form consistent with current national circumstances. Some policies not appropriate to present circumstances may be considered for adoption at a future time. The Western Pacific Region includes a diverse range of countries in terms of population, socioeconomic development and demographic structure. Specific elements of these guidelines will only be currently relevant to certain countries and the way in which the guidelines apply will need to be varied accordingly. However, the principles and full range of issues contained in this document need to be addressed and considered, and then acted on according to national circumstances by each of the countries of the Western Pacific Region.
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ACKNOWLEDGEMENTS This document has been developed in collaboration with the Centre for Ageing Studies, Flinders University of South Australia, a WHO Collaborating Centre on Ageing. WHO Westtern Pacific Regional Office wishes to thank Professor Gary R. Andrews, the project director; Ms Penny Edwards, project officer; and Dr Ludomyr Mykyta, project adviser. The contributions of the following who provided comments, suggestions, constructive criticism and inspiration is acknowledged: Dr Nana Apt, President, African Gerontological Society. Accra, Ghana Mr Abdulla Baginda, Executive Chairman, USIAMA (Golden Age) Foundation, Kuala Lumpur, Malaysia Dr Christopher Beer, Former Chief Executive Officer, HelpAge International, London, United Kingdom Dr Paul Cheung, Chief Statistician, Department of Statistics, Ministry of Trade and Industry, Singapore Dr Margaret Cornelius, Acting Assistant Director, Primary and Preventive Health Services, Ministry of Health, Suva, Fiji Dr Kiyumichi Fujisaki, Director, Department of Public Health Administration, National Institute of Public Health, Tokyo, Japan Dr Dalmer Hoskins, Secretary General, International Social Security Association, Geneva, Switzerland Dr Nobuo Koinuma, Professor, School of Medicine, Tohoku University School of Medicine, Sendai, Japan Sharod D. Gokale, President, International Federation on Ageing, India Mr Stephen King, Asia Regional Representative, HelpAge International, Chiang Mai, Thailand
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Dr David Lozada, Director, Noncommunicable Disease Control Service, Department of Health, Manila, Philippines Dr Julian Malmo, Deputy Director, UN International Institute on Ageing, Valletta, Malta Ms Normala Manap, Director, Division of Interagency Collaboration and International Exchange, Tsao Foundation, Singapore Dr Nor Aini Bte Moh’d. Noor, Assistant Director, Family Health Department, Ministry of Health, Kuala Lumpur, Malaysia Mr Kyong-Ho Park, Director, Elderly Welfare Division, Ministry of Health and Welfare, Republic of Korea Professor Sang Chul Park, Professor and Director, The Ageing and Physical Culture, Research Institute, Seoul National University, Seoul, Republic of Korea Dr Michael Price, Head, Geriatric Medicine Department, Westmead Hospital and Community Health Services, NSW, Australia. Dr Tony Setiabudhi, HelpAge Indonesia/Yayasan Emong Lansia, Jakarta, Indonesia Dr Jin Shengguo, Deputy Division Director, Division of Elderly Care and Rehabilitation, Department of Medical Administration, Ministry of Health Beijing, China Dr Alexandre Siderenko, Officer in Charge, UN programme on ageing, New York, USA Dr Hiroshi Shibata, Vice-Director, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan Mrs Joanna Tan Soek-Cheng, Assistant Director, Project and Funding, Division of Elderly Services, Ministry of Health Singapore, Singapore Professor Tran Duc Tho, Director, National Institute of Gerontology, Hanoi, Viet Nam Dr Mary Anne Tsao, President, Tsao Foundation, Singapore Professor Zhu Hamnin, Vice-President, Hua Dong (East China) Hospital, Shanghai, China Dr Xu Dalin, Vice-Director, Health Bureau, Jing An District, Shanghai Municipality, China
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BIBLIOGRAPHY Andrews, G.R. (ed.) Ageing in South East Asia, A Five Country Study. The Centre for Ageing Studies, The Flinders University of South Australia, 1993. Andrews, G.R., Esterman, A.J., Braunack-Mayer, A.J., and Rungie, C.M. Ageing in the Western Pacific, A four-country study. World Health Organization, WPRO, Manila, 1986. Commonwealth Office for the Aged. Healthy Ageing and Well-being, Developing a Structure for Action. Discussion Paper. November, 1985. Commonwealth of Australia. Continuing Participation in Community Life. The Australian Government’s Commitment to Older People. AGPS, 1995. Department of International Economic and Social Affairs. The World Ageing Situation: Strategies and Policies. United Nations, New York, 1985. Economic and Social Commission for Asia and the Pacific. Lifelong Preparation for Old Age in Asia and the Pacific: A Draft Policy Framework. January, 1996. Japan Ageing Research Centre. Ageing in Japan, 1994. Office for the Ageing. Draft 10 year Plan for Aged Services. South Australia, 1995. Phillips, D.R. Ageing in East and South-East Asia. Great Britain, 1992. Phillips, H.T. and Gaylord, S.A. (eds.) Ageing and Public Health. New York, 1985. South Australian Health Commission, Office of the Commissioner for the Ageing. Health of Older Persons Policy and Discussion Paper - Draft. December, 1994. The World Bank. Averting the Old Age Crisis, Policies to Protect the Old and Promote Growth. Oxford University Press, Oxford, U.K.,1994. Thomae, H. and Maddox, G.L. (eds.) New Perspectives on Old Age, A message to Decision Makers., New York, 1982.
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United Nations General Assembly. Global Targets on Ageing for the Year 2001 - a practical strategy. Report of the Secretary-General, September, 1992. United Nations General Assembly. The Copenhagen Declaration and Programme of Action, World Summit for Social Development, 6-12 March 1995. UN, New York, 1995. United Nations General Assembly. Conceptual framework of a programme for the preparation and observance of the International Year of Older Persons in 1999. Report of the Secretary-General, March, 1995. United Nations World Assembly on Ageing. Vienna International Plan of Action on Ageing, 26 July - 6 August 1982, Vienna, Austria, United Nations, New York, 1983. United Nations World Assembly on Ageing. Vienna, 26 July - 6 August 1982. Health Policy Aspects of Ageing, Report of the World Health Organization. March, 1982. United Nations, Vienna. Centre for Social Development and Humanitarian Affairs. The World Ageing Situation 1991. United Nations, New York, 1991. United Nations, Vienna. Centre for Social Development and Humanitarian Affairs. Profiles of National Coordinating Mechanism on Ageing. Second Ed. UN, New York. U.S. Bureau of the Census. International Population Reports, p. 25, 92-3, An Ageing World II. U.S. Government Printing Office, Washington, D.C., 1992. White House Conference on Ageing. The Road to an Ageing Policy for the 21st Century. Final Report, February, 1996. World Health Organization. Ageing and Health, A programme perspective, Geneva, July, 1995. World Health Organization, Regional Office for the Western Pacific. Health of the Elderly, July, 1996. World Health Organization, Regional Office for the Western Pacific. Regional Seminar on National Policy Planning for Health of the Elderly , Manila, Philippines, November, 1993. World Health Organization, Regional Office for the Western Pacific. Draft Action Plan for Health Care for the Aged in Fiji, Suva, June, 1996. World Health Organization, Regional Office for the Western Pacific. Review of WHO/WPRO Health of the Elderly Programme. Manila, Philippines, January, 1996.
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World Health Organization, Regional Office for the Western Pacific. Women’s Health Series Volume 2. Women’s Experiences of Ageing in the Western Pacific Region: A Diversity of Challenges and Opportunities. Manila, 1995. World Health Organization, Regional Office for the Western Pacific. Western Pacific Region Data Bank on Socio-economic and Health Indicators, Manila, Philippines, June, 1994. World Health Organization, Regional Office for the Western Pacific. New Horizons in Health. June, 1995.
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ANNEX - 1
Guidelines for Development of Framework for Implementation of Community-based and In-Home Programmes for Care of Older Persons 1. Introduction Old age per se is not necessarily accompanied by serious illness, disability and dependence. Advanced age does however mean an increased vulnerability to a range of potentially disabling conditions. A significant minority of older persons will experience chronic disabling illness at some time. The public and private health services available generally to the community may be inappropriate and insufficient to provide the necessary services to such an older person and their family. Care of older persons in the community who exhibit frailty, chronic illness or disability beyond the capability of immediate family and other informal support arrangements to satisfactorily cope with calls for a system of formal inhome assessment, management, rehabilitation and long term care aimed at maximizing the older persons independence and avoiding unnecessary institutionalization. These guidelines propose a series of considerations that should govern the development of an effective national framework for the implementation of such programmes.
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A comprehensive approach to implementation of community-based, in-home care programmes must consider both national policy and local organizational and service issues.
2.
National policy on long term care 2.1 It is important for any community-based services provided by government, non-profit organizations or the private sector to be planned and implemented in the context of a comprehensive national system of long-term care for older persons. It is most common for such systems to be devised for the advice of government by a formally established and appropriately structured top level national advisory council. The structure of such an advisory council should reflect the multisectoral and multidisciplinary nature of the task and the necessary involvement of all levels of government in partnership with nongovernmental organizations, the community and families. One of the first tasks of such an advisory body is to confirm the justification for formulation of national policy and establishment of a national system of long term care by reference to: the demography, epidemiology, health and social care needs of older persons in an ageing population and the potential impact of ageing on the quality of life, health and well-being of older persons themselves, their families, society and the implications for national development. Another task of the advisory body is to set forth, for government adoption, the basic principles that should underpin the provision of a long term care system for older persons. Such principles must be drawn up in the context of each country’s political, social and cultural context but as a minimum should encompass the rights of older persons to access services that: are suitable to their assessed needs, provide for personal choice, are comprehensive and coordinated, and provide high quality, effective and efficient services. A further critical consideration at the outset is to establish the appropriate nature and sources of funding to ensure sustainable long-term care. Here again, an appropriate funding arrangement
2.2
2.3
2.4
2.5
2.6
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possibly incorporating elements of public funding, social insurance and user payment in various combinations must be devised taking into account broader national considerations.
3.
Loci of responsibility for long-term care of older persons 3.1 A comprehensive long-term care system providing communitybased in-home care is inevitably a complex arrangement involving health and social welfare bodies, government authorities and agencies, non-profit and private organizations, community groups, families and older persons and their organizations. Such a system also must interact with other major related national programmes including health and hospital care services, and social welfare programmes including income security provisions where these are in place. Consequently it is essential for the mandates and specific role and responsibilities of participating sectors, agencies, services and units to be defined to avoid dispute, overlap and confusion in practice. To implement a national system a responsible lead agency should be designated and provided with the necessary resources. The need for multisectoral involvement and wide community consultation should be acknowledged. The active involvement of non-profit and private agencies in addition to the government should be sought to ensure a comprehensive and coordinated approach to providing care.
3.2
3.3
4.
Identification of needs and establishment of norms for level of provision 4.1 Historically the establishment of levels of provision of care for older persons has generally been arbitrary and based on ad hoc consideration of the services provided in the past as a result of demand and supply forces rather than any rational approach. The determination of need is a complex process and many countries have now instituted more formal and structured processes for determining needs of the community and establishing norms for provision of long-term care. The definition of needs and the identification of the characteristics, numbers and location of target populations for long term-care can be identified through:
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· ·
analysis of existing census information, data collections, past surveys and studies of older persons and their carers community consultations with all ‘stakeholders’ involved in longterm care of older persons including older people themselves and their families the conduct of purposely designed new national and local studies and surveys.
· 4.2
Through these and other methods national norms can be formulated that provide a basis for planning and also for controlling the future provision of long-term care services and the balance between different forms of provision. For example using these approaches the Japanese authorities estimated that about 1.5% of their population aged 65 to 69 years were in need of long term care rising to 11.5% for those aged 80 to 84 and 24% for those aged 85 years and over. Such figures when derived can be analysed in conjunction with demographic projections to identify future requirements for care. Studies throughout the world have identified the family, especially female children of older persons, as the main source of long term care. Both older persons and their family members in many studies have expressed a preference for in-home care provided principally by family members rather than institutional care. The burden on family care givers needs to be recognized and this too can be systematically identified and measured so the need to provide support to sustain the ability of families to continue this role can be taken into account. It seems likely that the level of need for long-term care by gender, age and social circumstances will mostly be very similar from country to country. However different social, cultural and environmental circumstances will prevail. Also, variation in existing arrangements and provisions as well as differing attitudes and expectations means that each country must establish its own appropriate norms and be prepared to review these periodically as circumstances and experiences change over time.
4.3
4.4
5.
Review of existing systems, services and programmes 5.1 Prior to any major development of community-based long-term care for older persons a comprehensive review of existing programmes and services should be undertaken in order to
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establish the baseline situation. 5.2 The following questions among others should be addressed in such a review: · What are the existing sectors, groups, units, organizations and agencies involved in the provision of community -based services for older persons? What are the specific programmes and services currently provided? What are the criteria for assessing older persons for provision of services? What are the financial arrangements for funding and payment for services provided? What are the arrangements for coordination of services provided to individuals and what are the existing relationships and linkages between various service providers?
· · · ·
5.3
Based on the findings of such a review an assessment of the existing deficiencies and gaps in service provision should then be made as a basis for planning and future development.
6.
Definition of community-based services to be provided 6.1 The range and scope of community-based services provided to older persons and their carers should substantially be defined by the needs analysis carried out nationally as set out above. There are however a number of basic services that may be provided in any community-based programme for older persons. These include the following: In-home services including : · · · · · · · assessment home help services (basic housekeeping, cleaning and home duties assistance) delivered meals home nursing assistance with bathing personal care in-home respite care
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· · ·
household shopping home alterations laundry services (especially for incontinent persons) certain specialist services such as incontinence support, dementia support and mobility assistance medical assessment and care
· ·
Day care services · · · · · · · assessment meals bathing and grooming recreations physical activities nursing care special dementia care
6.
Linkages to other services The above in-home and day care services may be linked to community rehabilitation programmes that provide active rehabilitative services including medical, nursing, allied health and assistive devices services aimed at restoration and maintenance of function for disabled older persons. Linkages should also be established with hospital -based services and with institutional long term care facilities particularly to ensure a continuity of care as people may move from one mode of care service to another. In addition the types of services identified above may be linked to broader preventative and health promotive activities that may include identification of ‘at risk’ individuals, screening, health education and health promotion programmes that may also be directed at well older persons. Apart from direct care provisions community programmes may extend into wider activities aimed at maintaining the activity and productivity of older community dwelling adults in such programmes as older volunteer services, self help, foster grandparenting schemes and local income generating schemes for older persons.
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6.2
It should be stressed that the above are indicative only and the precise activities that are included in particular home-care programmes will be governed by many factors that should be taken into account in national and local planning and development.
7.
Organizational structures 7.1 As noted above the level and range of organizations involved in the provision of long-term care for older persons and especially for community-based care may be quite complex. In addition government instrumentalities may vary according to the size, political and structural organizations of government in each country. The precise role should be defined for each level viz. national, provincial and local levels of government where they exist. In general, national government will be involved primarily in policy, national guidelines and standards and in funding while provincial and local government may be involved more directly in provision of services. A very common form of structure in provision of communitybased care for older persons is where non-profit organizations are subsidized by government to provide services. The type of NGO involved may vary and the level and range of services provided by individual organizations will also vary considerably. In these circumstances governments have an important role in ensuring comprehensive coverage and in monitoring and enforcing basic standards and quality of care. Many countries at present do not have clearly articulated national policies and funding arrangements and subsidy provisions are not managed systematically. While the requirements for community-based care for older persons is small and provision is relatively patchy this situation may tend to prevail. As demand inevitably increases, there becomes an urgent need to systematically approach the issues from a national and local perspective and the sooner action is taken by government to put in place the appropriate policies, enact necessary legislation and plan systematically the better placed any national and community will be to cope with the ageing of its population and the needs of the community for these services in the future.
7.2
7.3
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7.4
In circumstances where provision of community-based services remain limited and the national policy and organizational frameworks outlined above have yet to be developed there is a valid case for demonstration programmes at local level to act both as a preparatory exercise to meet future demand and to help catalyse the progress towards more comprehensive services in the future. The experience of rapidly ageing societies in the Western Pacific Region such as Japan, Hong Kong (China) and Singapore has been that it is better to put the necessary structures for comprehensive and coordinated national provision of long term care for older persons in place in advance of the urgent need for such services as the increase in proportion and numbers of the older population eventually demand.
8.
Assessment 8.1 Especially in a long-term care system provided by a substantial subsidy from national government and/or long-term care insurance a systematic approach must be taken to the identification (and certification) of individual need. A fair and objective system of professional assessment within prescribed standards for certification is necessary to ensure the most appropriate application of limited resources and to maximize the efficiency and effectiveness of the services provided. Even if the control of government funded or subsidized services is not a consideration assessment is essential to establish need and to ensure the provision of quality of care. Assessment in formal sense has been defined as: ‘A multidimensional, usually inter-disciplinary, diagnostic process used to quantify an elderly individual’s medical, psychosocial and functional capabilities and problems with the intention of arriving at a comprehensive plan for therapy and long term follow-up’ 8.3 An essential component of assessment to determine need is involvement of the older persons themselves and their carer(s). Ultimately, the assessment procedure and subsequent provision of care involve the wishes of the older person to whom care is to be provided and they should be enabled to make those decisions
8.2
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with the assistance of the people who are making the formal assessment of their need. 8.4 The level and sophistication of assessment will depend to a considerable extent on the nature of the organizations and the services for which the individual assessment is being undertaken. It should be recognized however that assessment is a very central process in provision of quality services to older persons and as such is a powerful element in influencing their quality of care and indeed their quality of life and well-being. Wherever possible assessment arrangements should be coordinated and comprehensive and multiple assessments by many agencies should be assiduously avoided through coordinated care arrangements. Comprehensive assessment of an older person seen as in need of community support should incorporate all the following elements. Though the degree of depth to which each factor is pursued will depend on the nature of the assessment and individual circumstances: · · · · Demographics Social support ADL/IADL Nutritional Status Mental Health Status - mood & cognition Sleep Health related behaviours Medical history Medication System Review Physical examination & performance-based functional assessment Financial circumstances Psychosocial relationships/elder abuse Caregiver(s) Physical environment including home itself Community resources
8.5
· · · · · · · · · · · ·
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Other specialist assessment such as diagnostic and laboratory testing may be undertaken as dictated by the specific health and medical circumstances of the individual and the judgement of their medical care adviser. 8.6 Assessment procedures and documentation must be established to include these elements and others that may be necessary for particular programmes. This comprehensive approach to assessment serves a number of key functions including: · · · Allocation of scarce resources on basis of demonstrated need Matching of needs to correct care options Providing data base for: planning individual programmes of care, needs based planning, identification of gaps in service, evaluation, and meeting reporting requirements of authorities
9.
Coordination of care 9.1 With development of community-based care services for older persons it has become apparent from the experience of many countries that as programmes are developed and expanded frequently under differing auspices older people and their carers may be faced with a bewildering array of different programmes and multiple organizations. In addition many programmes in these circumstances will have individual mechanisms for care assessment. A major problem with the provision of multiple programmes in the community is the potential for overlap, duplication, even unproductive competition, and sometimes conflicting provision of specific services to individuals. A comprehensive system of provision of community-based services needs to be supported by a systematic approach to assessment in the first instance followed by an organized method of developing a care plan tailored to individual needs and developed in consultation with the older person and their informal carer.
9.2
9.3
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
9.4
Once an appropriate care plan has been agreed it is necessary to ensure that care arrangements are managed efficiently and are periodically reviewed. Assessment should be seen in this arrangement as an ongoing process that helps monitor the older persons’ changing circumstances and needs and make provision for adjustment of any care plan according to any change in circumstances.
10.
Quality assurance 10.1 10.2 All community-based services for older persons should be supported by a system of continuous quality management. Outcome standards should be established for all services provided and a system of monitoring and improving quality of care should be instituted. Human resources development All personnel working in community-based programmes should receive appropriate basic training and be given the opportunity of continuing education to maintain knowledge and skills. Training opportunities should also be extended to volunteer personnel. Training should also be made available to prepare and help informal carers to more effectively carry out their functions in providing ongoing care and assistance in the home.
11. 11.1
11.2 11.3
12.
Evaluation and planning 12.1 The introduction of new services especially as a part of demonstration programmes should incorporate built-in plans for evaluation at the outset. Evaluation is essential to test the efficacy and the efficiency of community-based interventions and care and to assist in the determination of the wider application of the services and programmes developed on a trial basis. Evaluations may have both a summative purpose (designed to test and report on the extent to which a service or programme has achieved the objectives set for it) and formative purpose (designed
12.3
12.4
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
to provide guidance on the further development and directions of a service or programme).
13.
Research and development 13.1 Community-based care for older persons is in many circumstances in an early stage of development. It is important to provide the necessary conceptual and factual underpinning of programmes and services being provided. Systematic collection of data and its scientific analysis is essential to support the formulation of community needs and to measure the impact and outcomes of services provided. 13.2 The ongoing development of community-care services for older persons should be guided by information obtained through evaluation as mentioned above and through a systematic approach to epidemiological and health systems (operational) research in the field. 13.3 Cross-national and international collaborative efforts in research should be encouraged so that the experience of other countries that may be at different levels of development in terms of their community-based services for older persons can share experience, technical expertise and findings to mutual benefit.
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
anneX - 2 Check List This checklist is intended as a self-administered guide to the development of health care services for older people at national level.
1.
Does your country have a national policy on ageing or the health of older persons? Yes N o
Comments:
2.
Is there a national coordinating mechanism responsible for health of older persons in your government? Comments: Yes N o
3.
Is there a specific office or ‘focal point’ within the Health Ministry which concentrates on health services for older persons ? Comments: Yes N o
4.
Is there a systematic research and information programme to support the development of care services for the elderly? Comments: Yes N o
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
5.
Is the general population informed on issues associated with health and ageing through preventive and health promotion activities? Comments: Yes N o
6.
Does the primary health care service incorporate a specific component directed to health and care of older persons? Comments: Yes N o
7.
Are existing and future primary health care personnel given appropriate training in care of older persons? Comments: Yes N o
8.
Are community-based health care services presently provided in your country? Yes N o
Comments:
9.
Are the following types of community-based services provided? • visiting nursing services • allied health professional advice and services • incontinence advice and support • home alteration services • aids to daily living • in-home respite care • day-care programmes Comments: Yes Yes Yes Yes Yes Yes Yes N o N o N o N o N o N o N o
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
10. Is training on health care of older persons provided to staff involved in communitybased health programmes? Comments: Yes N o
11. Are hospital and community rehabilitation services a component of your country’s health system? Comments: Yes N o
12. Are residential care services available to older persons in your country? Yes N o
Comments:
13. Are appropriate assessment criteria in place to determine individual need for admittance into residential care facilities? Comments: Yes N o
14. Are there a range of accommodation alternatives for residential care from relatively independent to dependent ‘intensive’ care? Comments: Yes N o
15. Is there appropriate legislation and regulation in place to ensure that the dignity and identity of older persons in residential care situations are respected and maintained? Comments: Yes N o
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GUIDELINES FOR NATIONAL POLICIES AND PROGRAMME DEVELOPMENT FOR HEALTH OF OLDER PERSONS
16. Are specific design requirements applied when residential care facilities for older persons are being developed? Comments: Yes N o
17. Is specific training on health care of older persons provided to the health services workforce? Comments: Yes N o
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