page 1 INTEGRATED RESPONSE OF HEALTH CARE SYSTEMS TO RAPID POPULATION AGEING II 1. BACKGROUND Today, the world s population aged 60 plus is virtually the same as the population of children under 5; by 2050, there will be three times more older people than young children indeed, by then, the older population will be bigger than the population of children under 15. Within the next 50 years the number of people older than 60 will triple, reaching 2 billion world-wide. The world population is ageing fast. While changes in age distribution took place in developed countries over the span of the last 100 years, the same changes will take place in developing countries over the short period of the next 25 years. This will inevitably mean that poorer societies will have much less time to prepare and adjust to the consequences of ageing, including the impact of ageing on the economy, increased health care needs and changes in social relations. Furthermore, this adjustment will be required within the constraints of very limited resources. This fast ageing process is the result of impressive gains in life expectancy at birth (LEB), reflecting fast declining mortality rates (particularly since the 1950's) followed by even faster declines in total fertility rates (TFR). This process is commonly referred to as the demographic transition and is followed by the epidemiological transition i.e., a shift from infectious to non-communicable diseases. Thus, as the population of older persons increases, there is often an increase in the proportion of the population experiencing chronic illnesses and disability and consequently an increase in the utilization of services. However, preliminary evidence from developed countries shows that the prevalence of chronic diseases and the level of disability in older age can be reduced through appropriate health promotion and NCD prevention interventions throughout the life course. Data from developing countries continue to show a high prevalence of risk factors for chronic conditions which are, on the whole, poorly managed. The end result is high rates of chronic diseases as well as high levels of disability among older people. These trends could be reversed with appropriate health promotion and prevention interventions. Health systems are urgently required to respond to the resulting epidemiological shift already observed in a number of developing countries. Policies are not in place and a piecemeal approach only aggravates ineffective and inefficient use of resources. Furthermore, mismanagement and missed opportunities to prevent or to adequately deal with age-related noncommunicable diseases impede the control of their incidence, prevalence and complications. Health systems must urgently address the lack of cohesiveness and interconnectedness between services within the health care systems and its users.
page 2 While the models embraced by affluent countries do offer some lessons they are, by and large, of limited relevance. This is because already developed countries not only had a much longer period of time to adapt to 'ageing', but they experienced the process of ageing while enjoying the benefits of socio-economic development. By contrast, developing countries are experiencing rapid ageing before a adequate level of social and economic development has been achieved. Furthermore, the premature onset of the most common NCDs (hypertension, diabetes CVD) which is often the case in the developing world in itself aggravates or precipitates poverty, not only of the affected individual, but also of the whole family unit. Thus, improved health systems in response to rapid ageing are necessary from a socio-economic as well as a developmental point of view. Improved effectiveness and efficiency of interventions may in the end result in increased productivity of individuals, families and nations. INTRA I: 2.1 OVERVIEW It is against this background that ALC, in collaboration with regional and country offices and national research teams, launched the INTRA I project in 2001, funded by the Government of the Netherlands. The INTRA I project was implemented in six rapidly ageing developing countries - Botswana, Chile, Jamaica, Korea Lebanon and Thailand. The overall aim of INTRA I was to examine the health system role and response to ageing with a particular focus on Primary Health Care (PHC). This was achieved through three main objectives: a) the development of a knowledge base that would assist developing countries in guiding future actions and policies towards integrated health care systems; b) building of interdisciplinary teams in each of the countries to address and lead debates about health systems transformation; and c) using the evidence to develop a "comprehensive" health care strategy that would further health promotion and prevention interventions at the PHC level. The strengths of the INTRA I project are recognized when evaluating the overall outcomes and processes across the six countries. The main outcomes include the production of: a) "country profiles on ageing" using both central and national existing data sources; b) health systems reports presenting an overview of the primary health care system and its role within the economic, social and political context of the country; c) descriptive survey results from three surveys involving both health care providers and users (aged 50 plus) of health services; and d) national country reports highlighting major findings and recommendations to better inform and guide evidence-based policies. Equally as important and essential to the implementation, were continuity and sustainability of the project as well as the process by which the objectives were reached. INTRA I fostered a bottom-up approach by drawing on the experience and expertise of local experts, by involving them in the design and tailoring of the country project according to their perceived needs, and by giving them complete ownership of the data.
page 3 2. 2 LESSONS LEARNED AND PRELIMINARY RECOMMMENDATIONS After analyzing the broad scope of the data resulting from the three surveys in INTRA I, four themes were highlighted as most relevant in understanding behavior and attitudes of both health service users and providers as well as their interaction with the health care system. These themes centered on: 1) access to health care services; 2) utilization of health care services; 3) risk factors and systemic responses to such factors; and 4) attitudes and behaviors of health care providers towards ageing. Below is a brief summary of the analysis of the four theme areas across the six countries followed by recommendations to be taken into account when designing the second stage of the INTRA project: INTRA II. Theme area Issues Recommendations Access and transportation Access to the health care system is not an issue for most older adults; waiting time at the health care facility is. Health care facilities need to consider both structural and organizational changes which might result in a decrease in waiting time at the health center. Examples of measures to be taken to decrease "waiting time": Increase the number of health care staff to meet the unstructured influx of users; Adoption of appointment systems, helping to regulate patients flow Implementation of age friendly policies and facilities Risk factor and targeted interventions: Advice from health care providers on risk factors such as smoking, alcohol, diet and weight is not always provided to those who have chronic conditions and to those who can best benefit from health promotion and prevention interventions. Demonstrates lack of coherency - patients with chronic conditions must be given appropriate information to reduce or control their risk factors for chronic illness and thereby improving their health. Include health promotion in the medical curriculum and in continuing education programmes; ( patient empowerment - user-provider information and education is needed) adopt structural changes that will facilitate providers to have sufficient time to provide information and advice; need for a case-manager who will ensure the continuity and follow up of pertinent information and care
page 4 When advice on certain risk factors, such as smoking cessation and healthy diet, is provided, it is offered inconsistently across age groups. promote a holistic approach vs the current change the prevailing paradigm from cure to care ; encourage a holistic approach to care. There are huge missed opportunities for health care providers to give patients basic information and advice on NCD risk factors. Risk factor behavior: smoking is still relatively high among male patients. Physical inactivity is common among both males and females. Prevalence of chronic illnesses (e.g. hypertension, diabetes, CVD) is relatively high in all participating countries Evidence suggests that systematic health and social interventions in older populations have a significant impact on health outcomes, quality of life, service utilization and cost. Therefore, an integrated approach to health promotion and disease prevention is needed to ensure that morbidity and disability levels remain low and functional capacity levels remain high. Utilization of health care services Preventive services vary significantly by gender; education level is an important determinant that affects older adults' health-seeking behavior; frequent visits (3-5 times a year) to the health care center is a significant predictor of preventive service use in most countries. Increase the health literacy level among older persons through community based training programs; give older persons more frequent appointments to follow up and monitor their conditions; use of peers in health education activities; involvement of older persons in the design of interventions i.e., older persons empowerment Training and perception of health care providers Although most of the health care providers responded positively to possessing appropriate skills and knowledge of NCDs and their management and in the application of their guidelines (such as hypertension and diabetes guidelines), there is evidence that practice is far from adequate Health care providers at PHC level can benefit from specific training and education in health promotion and prevention of NCD.
page 5 INTRA II 3.1 SCOPE AND BACKGROUND The achievement of "integrated health care services" is one of the fundamental objectives of a PHC model. It is within this context that INTRA I was evaluated and INTRA II was conceived. The lessons learned from INTRA I indicated the need to explore further the relationship between the provision of "integrated health services" and older persons health and well-being. INTRA II proposes to explore these relationships further by examining relevant factors that influence the organization, management, and delivery of integrated health services within the PHC system. This is based on the assumption that the provision of such services may lead to the compression of disability as individuals age while accelerated functional decline may be the result of the lack of such services. This project should also lead to a better understanding of the role that the community plays in supporting care and improving access and utilization of services. Taking into consideration the goals and objectives of a PHC model which reflects an integrated approach, INTRA II will focus on evaluating and applying the findings from the six INTRA I projects in order to provide an insight - a " starting point" - for the six INTRA II countries. The main approach to pairing INTRA I and INTRA II countries is to build on what is relevant and further our understanding of "integrated /comprehensive health care systems" and how they can be improved to benefit older persons. More specifically, INTRA II proposes to link quantitative information collected in INTRA I with qualitative information and insights gained through qualitative methods. With this approach, a methodology will be developed that will permit gaining insight into what is required when designing integrated health care systems for ageing populations. It will explore the interactions and the linkages between the health care systems and health care providers; and the perceptions of three groups of stakeholders - health care providers, users and policy makers - within the local community environment. The acceptability and feasibility of an integrated model will be investigated from the perspectives of the three stakeholders. 3.2 AIMS The overall aim of INTRA II is to shed light on the factors that influence the continuum of care process of older persons within the framework of Primary Health Care. This includes type of case management; level of coordination and collaborations between medical and social services and between and within professional groups; and user-provider involvement and education patient empowerment). Understanding these factors will help lead to the delivery of improved services and quality of care for older persons at the community level.
page 6 3.3 OBJECTIVES To achieve the above, INTRA II objectives are to: 1. Foster South-South cross-fertilization through the Evaluation of lessons learned from the INTRA I project Linkage of INTRA I data to INTRA II countries 2. Establish interdisciplinary national teams that will ensure relevance, appropriateness, continuity and practical application of the findings. 3. Implement qualitative research methodology for in-depth assessment and evaluation of the interrelationship and linkages between users, health care providers, and policy and decision-makers with regard to provisions of health services, health and ageing within the context of their communities. how current health policies in the participating countries address the needs of older persons and how such policies can be refined and improved. 4. Produce country profiles on the ageing population to include an overview of the health care systems in each of the six additional countries (adopting the same matrix as in INTRA I ) 5. Promote policies for the development of a comprehensive system of community care for older persons and family caregivers. 6. Develop recommendations for reorienting health services to better serve older populations in developing countries 7. Develop indicators to measure the implementation of recommended policies and interventions. 3.4 EXPECTED OUTCOMES 1. Meeting of the INTRA I and INTRA II national teams 2. A report on the applicability of INTRA I data to INTRA II settings 3. Standardized focus group methodology to evaluate the interrelationships and linkages between the various stakeholders/actors - users of PHC of 50+ years; health care professionals; and policy and decision makers 4. Country profiles on ageing which will include an overview of health care systems of the six additional participating countries 5. Recommendations for a comprehensive system, including the role of the community in the provision of care for older persons and family caregivers
page 7 6. Identification of process indicators to measure implementation 3.5 MAIN APPROACH Building on INTRA I strengths, INTRA II will adopt a bottom-up approach. This will be reflected in the use of national experts, who will have a critical role in designing and tailoring their country project according to their perceived needs. The first step in the process will begin with the production of country profiles on "population ageing" and of the health care system in the six additional countries, adopting the same common data matrix. The second step, through the process of "pairing," national teams from the INTRA II countries will carefully review the lessons learned from INTRA I and with insight and experience apply what is relevant to their country. The third step will be for national experts to conduct focus-groups to elicit the data needed to achieve the overall objectives. And finally, the national teams will meet to review and evaluate the evidence generated from the INTRA II research and develop appropriate policy recommendations for reorienting of health services to better serve older populations in developing countries. 3.5.1 ROLE OF WHO/ALC The INTRA II project will be coordinated by ALC at the HQ level. In this regard, ALC/WHO will be responsible for: scheduling, when needed, periodic teleconferences with each of the national coordinators and national teams to communicate the overall aims and objectives of the project; developing the methodology for focus group interviews; constructing the criteria for selecting national inter- disciplinary teams and establishing their role with respect to the implementation of the project in each country; organizing the meeting in 2004 in The Hague; and monitoring the overall progress of the project. 3.5.2 ROLE OF COUNTRY COORDINATORS The implementation of INTRA II at the country level will be coordinated by the national coordinators in collaboration with the national inter-disciplinary team. National teams will include representation from various Ministries, NGOs, academic institutions and local representatives of other relevant UN agencies. The role of the coordinators will be to guide and follow up with the various tasks and activities as defined in their terms of reference. National inter-disciplinary teams (see Annex 1 for role and function of national team experts) will review and apply relevant data from INTRA I as well as analyze and interpret INTRA II data for the use of policy makers. 3.6 COUNTRY SELECTION
page 8 The countries to be paired for INTRA II are Syria with Lebanon (EMRO) Ghana with Botswana (AFRO), Peru with Chile (AMRO), China Shanghai municipality with Korea (WPRO), Suriname with Jamaica (AMRO), and Sri Lanka with Thailand (SEARO). The selection has been made to reflect, at least in part, the realities of INTRA I countries with regard to their current health care system, political, economic, regional and other similarities. 3.7 METHODOLOGY Since INTRA I focused on ascertaining data using quantitative methods, INTRA II will complement and validate INTRA I data through the use of qualitative methods. Focus group methodology will include (full details in annex 2 ) Selecting focus groups within community Setting-up focus groups discussions and interviews Collecting, and interpreting data Reporting data and writing up the final report Topics to be addressed in focus groups (full details in annex 2 ) Needs and source of care Collaboration/coordination between the various components of the PHC and their interface with other areas of care provisions (secondary and tertiary care; LTC; social welfare; NGO sector) Continuity of care Formatted: Bullets and Numbering
page 9 3.8 ACTIVITIES* 1. Presentation of INTRA II protocol to country counterparts for feedback 2. Establishing inter-disciplinary teams in each country 3. Designation of country project coordinators 4. WHO/ALC to visit certain INTRA II countries to set up links and processes 5. INTRA II country team meeting including the "paired" INTRA I country coordinators (meeting agenda to be prepared by ALC) 6. Report on the assessment, applicability and evaluation of "INTRA I lessons learned and preliminary recommendations" 7. Compilation of country profiles 8. Adaptation of the standardized focus group methodology to specific country settings 9. Training of facilitators for focus groups 10. Sampling of focus groups 11. Focus group methodology 12. Analyzing and interpreting data from the focus group discussions 13. Preparation and finalization of country reports 14. Dissemination of country reports to other participating countries 15. Meeting in the Netherlands - discussion and conclusions of INTRA I and INTRA II 16. Final report and papers *some of the activities run in parallel 4. MEETING IN THE NETHERLANDS, 2004 ALC/WHO in collaboration with the Government of the Netherlands will convene a meeting from 21-23 June 2004 with the participation of country coordinators of both INTRA I and II, Regional Advisors on Ageing,WHO HQ officers, and experts from the host country. The aim of the meeting will be to facilitate the exchange of knowledge and experience from the twelve country projects towards general policy guidelines for the development of a comprehensive system of community-based care for older persons, and for reorienting health services to better serve older populations in the participating countries. 5. IMPLICATIONS AND FUTURE DIRECTIONS The project outcomes will facilitate the formulation of concrete action plans for health for older persons to be developed at local, regional and national level. This would enable Governments, WHO, and other stake holders to move forward toward concrete follow up actions of the recommendations embodied in the UN International Plan of Action on Ageing 2002 and WHO's Policy Framework on Active Ageing. New and innovative ways of advancing health for older persons must be planned, tried, and evaluated if the challenge of population ageing in developing countries is to be met
page 10. 6. CHRONOGRAM: ACTIVITY DATE RESPONSIBILITY 1. Establishing inter-disciplinary teams in each country 2. Presentation of INTRA II protocol to country counterparts for feedback 3. Designation of country project coordinators 4. WHO/ALC to visit certain INTRA II countries to set up links and processes 5. INTRA II country team meeting with "paired" INTRA I country coordinators (meeting agenda to be prepared by ALC) 6. Report on the assessment, applicability and evaluation of "INTRA I lessons learned and preliminary recommendations" 7. Compilation of country profiles 8. Adaptation of the standardized focus group methodology to specific country settings 9. Training of facilitators for focus groups 10. Sampling of focus groups 11. Focus group methodology 12. Analyzing and interpreting data from the focus group discussions 13. Preparation and finalization of country reports 14. Dissemination of country reports to other participating countries 15. Meeting in the Netherlands (June 2004) - discussion and conclusions of INTRA I and INTRA II 16. Final report and papers November 03 November 03 December 03 December 03 December 03 December 03 January 04 February 04 December 03 January 04 February 04 February 04 April 04 May 04 June 04 September 04 WHO/ALC WHO/ALC Country counter parts WHO/ALC National team ter parts WHO/ALC WHO/ALC and MoH NL s and WHO/ALC 7. BACKGROUND DOCUMENTS
page 11 1. United Nations, `Political Declaration and Madrid International Plan of Action on Ageing, 2002, Second World Assembly on Ageing, Madrid, Spain, 8-12 April 2002`, New York, 2003 2. WHO, `Active Ageing; a policy framework`, (WHO/NMH/NPH/02.8), Geneva, 2002 3. Country reports and profiles of the six INTRA countries: available on CD-ROM 4. INTRA I protocol 5. "World Population Ageing 1950-2050". Population Division, DESA, United Nations. 6. Integration of Health Care Delivery: Report of a WHO study group, World Health Organization, Geneva 1996. 7. Kodner D. Integrated care: meaning, logic, applications, and implication - a discussion paper. International Journal of Integrated care. 14 Nov 2002. 8. Andersson G Karlber I. Integrated care for the elderly. International Journal of Integrated care. Nov 2000 9. Hèbert R Durand P et al. PRISMA: A new model of integrated service delivery for the frail older people in Canada. International Journal of Integrated care. Vol 3 March 2003. 10. Rothman AA, Wagner EH. Chronic illness Management: What is the role of primary health care? Ann Intern Medicine 138:256-261, 2003 11. Korff M, Can care management enhance integration of primary and specialty care? BMJ 329; 605, 2004