With participants drawn from across the globe, ranging from policy makers, funders, researchers, academics, experts from WHO Member States, and service providers, the high level meeting convened at the Hague aimed at putting ageing at the centre of the global development priorities and specifically to discuss a global agenda for action on population ageing, functional decline and dependence.
Securing a place for palliative care in the debate, several international, regional and national advocates of palliative care participated at this meeting including: the Worldwide Palliative Care Alliance, International Palliative Care Initiative of the Open Society Foundations, the African Palliative Care Association and the European Association for Palliative Care.
Central to the meeting was a review of available evidence on how to define and address the evolving needs of older people in relation to functional decline and dependence. The key issues, gaps and priority areas for future action including policy options and the roles and responsibilities of the various players in addressing the needs of older people were identified at this two day meeting, based on evidence and experiences of the participants.
Highly participative methodologies were employed at the meeting, to draw on the wider experiences of the participants from different contexts, including low and middle income countries, as well as the high income countries. These included: a plenary session, working sessions, plenary panel and concluding sessions. All these sessions addressed different issues including: defining terminologies, specific care forms in delivery models, which focused on palliative care and dementia, measuring progress and data to inform decision making and resourcing.
Several key issues emerged. In their opening remarks, Flavia Bustreo, Assistant Director- General Family, Women’s and Children’s Health at the WHO and Marcelis Boereboom, the Director General for Long-term Care in The Netherlands Ministry of Health, Welfare and Sport warned against looking at the issue of ageing, as a problem and challenge.
They emphasised the critical need to consider the opportunities embedded in caring for older people and called on delegates to think of sustainable systems that can be incorporated to harness these opportunities. Mr Boereboom further noted the need for re-organising systems to better respond to the needs of older people saying: “Quality of life of people will rely on the system, to organise alternatives for care.” He specifically noted that changes need to be made in regards to long-term care in The Netherlands as the current system has made people dependant on institutions.
His remarks provided a platform for discussing the issues of long-term care and the changes that need to be made to ensure sustainable systems, taking into consideration the finance and economic implication of long-term care.
Speaking on the opportunities for addressing needs of older people, Dr Peter Lloyd-Sherlock, University of East Anglia, noted that spending on long-term care can lead to savings in the long run, emphasising that low cost home care interventions present opportunities for re-organising care.
Drawing on lessons from the past and from each other at the meeting was critical in informing a joint agenda of action to better respond to the growing needs of older people across the world.
Responding to these remarks, participants noted common challenges for long term care of the elderly. For example, with regard to financing, there were questions and concerns on who is paying for the care, and who provides the care, and how to ensure equity and fair distribution.
Mr Hiroyuki Hori, Deputy Director of the Ministry of Health, Welfare and Labour in Japan, highlighted the challenge of measuring long-term and functional status of the elderly (I.e.: 65 years and above), including physical and mental status and estimating their care needs. He noted that this requires a national assessment, and shared best practices from Japan, where more than 5 million elderly people go through such assessment each year.
Evidence on preventing healthy elderly from being dependent is also a challenge in Japan. Prevention services, promoting community activities and resource mobilisation constitute Japan’s priorities in providing services to its senior citizens, and in addressing the rapid increase in ageing.
Sustaining care for older people was also a central issue for discussion.
Speaking to the gaps and challenges of long term care of older people, Dr Lloyd-Sherlock noted that two thirds of the global ageing population is in low and middle income countries, thus the care needs are huge, and therefore there is a need to modify care services.
The limited global engagement and state engagement, a focus on isolated elements such as insurance, health, and delegation of the issue of ageing to local governments coupled with fragmented interventions and low amounts of published research pose challenges and gaps for the response to the needs of older people.
Dr. Lloyd-Sherlock gave the example of Africa where there only 0.4% of relevant published research is contributing to the global debate. Other key gaps identified at the meeting were:
- Lack of commitment at the global, regional and national levels including at the policy and leadership level, also resulting into challenges with human and financial resources and insufficient coordination and integration
- Lack of evidence, including epidemiological data, best practices, needs etc. Available assessments and surveys are not always population based and lack of integrated data, assessment tools, mapping the knowledge of life transitions. There is also a need for usability testing
- Systems and models are not always sustainable
- Lack of skills (for both formal and informal carers), also due to a lack of integration in curriculum and defining jobs.
- The lack of support for home care, absence of data and lack of awareness, specifically in low income countries.
- The lack of universal benefits and coverage in some countries
- Lack of shared responsibility and imbalance in expectations (state versus family)
- Silos in financing mechanisms.
Reviewing these challenges led to the discussion on what an ideal system for addressing functional decline would look like. Through various working groups, sub-groups and plenary sessions, principles of an ideal or perfect system that can address functional decline and dependence were thoroughly discussed. Participants unanimously agreed that an ideal system should aim to have a rights based, adaptable, universal and sustainable model that helps older people to:
- Maintain the best possible functional wellbeing and social functioning
- Manage functionality
- Live and die with dignity (palliative care)
- Quality of life
- Integrates prevention, for example of non-communicable diseases and their causes as well as rehabilitation
- Considers societal norms and values, while able to manage associated tension and change
- Access to essential services and medicines
- Contributes to the wider process of positive health, social and economic development.
Home based and community care were highlighted as the primary and foundation model to responding to the needs of older people, and residential care was only seen as supplementary. Supporting home carers with training and financial benefits, among others, was therefore identified as an important intervention. Effective state regulation for health care and community care, the role of carers and all stakeholders in the sector, were also highlighted as critical elements for ensuring quality of services for older people.
Harriet Finne-Soveri from the National Institute for Health and Welfare in Finland emphasised the need to support informal carers who commit to the care of older people; the role of technology combined with education and information, including the training of older people themselves in areas such as self care. Ms Finne-Soveri also noted strategies such as vaccination against ailments such as influenza; control of hypertension and making available treatments; and exercise which can be effective in high resourced settings.
In considering key actions in responding to the needs of the ageing population and long-term care, overarching strategies such as integrated population based approaches and systems must be considered. There are multiple competing global and national priorities, and these can all be addressed through integrated systems.
The WHO will compile an outcome document from the meeting, which will be made available to the delegates for review and comment and thereafter will be finalised and used widely.