1. INTRODUCTION The SAOPF and, indeed, the entire older persons sector, would like to thank the Honourable Minister of Health, Dr. Aaron Motsoaledi for granting us an opportunity to engage with him on the many challenges experienced by older persons, especially indigent older persons, in accessing public health services. For the delegation it is indeed a unique and ground breaking opportunity to not only highlight issues and challenges but also to focus on recommendations and ways to ensure proficient and sensitized health care services for older persons.
It is unrealistic however, given the extent of the problem, to expect that consequent, holistic and sustainable outcomes to many of the challenges presented will be the result of a one-off meeting. To this end we would like to propose that the Minister appoint a committee, which would include the stakeholders present to conduct robust and on-going discussions regarding public health services for older persons.
Considering that population ageing is a global phenomenon, the older persons sector would be unwise not to seek formal, structured and on-going interaction /partnership with the DOH; the development of an encompassing national strategy responsive to the varied and changing needs of older persons with particular focus on indigent older persons, being one of the primary objectives.
HIV treatment & Services
Older persons face discrimination around HIV services because of incorrect assumptions about their sexuality, including the belief that the disease only affects younger people. The dominant risk factor among the 50 plus age group is the same as for other age groups. Heterosexual and homosexual sex, intergenerational sex, STIs and substance abuse are also present in this age group. A Human Sciences Research Council (HSRC) report in 2009 on HIV prevalence rates found that men over the age of 50 are an HIV/AIDS priority risk group. The HSRC study also showed that communication programmes aimed at educating older persons about the pandemic had failed them - 37.8% of people in the 50 years and older age group are not getting the message. The Treatment Action Campaign (TAC) and the South African National AIDS Council (SANAC) has been very quiet on the subject of treatment for older persons in respect of HIV/AIDS and the provision of ARV’s to older persons living with the disease.
In respect of goal 6 of the Millennium Development Goals, approximately 3% of South African children, 18 years and younger are HIV positive. In addition, child headed households are a new and increasing phenomenon and AIDS related deaths are the primary factors contributing to the increase in the large number of orphans. Although there is very little data on the exact number of AIDS related orphans in South Africa, it is estimated that presently there are approximately 700 000. This has resulted in older persons having to become the primary caregivers to their adult children and then having to care for the young who are orphaned.
This burden on older persons has received little attention in discussions and in policy and programme development to support AIDS orphans. What is equally disconcerting is that the crucial role that older people play in the care of adults affected by HIV and AIDS and AIDS orphans is seldom recognized. In most cases, the care they provide is without financial or any other form of support, almost as if the responsibility has been passed onto them by the state. It is axiomatic that the majority of older persons know little or nothing at all about HIV/AIDS, the resources and training to provide proper care are severely lacking and this places them at risk of infection. Many therefore feel isolated and helpless and the care that they are forced to provide is often traumatic from a psychological and emotional point of view. The African Union Policy Framework and Plan of Action on Ageing of 2003 identifies HIV and AIDS as a major problem facing older persons in Africa, and urges member states to support and protect affected older persons in their contribution to the fight against the disease. The framework explicitly encourages the integration of older persons’ interests in this regard in state policies and intervention.
Summary of Challenges
The possibility of HIV infection in the age group 60+ is hardly considered hence delaying diagnosis and management;
The dominant risk factor among the 50 + age group is the same as for other age groups;
Older Persons are not considered as a high risk because of the myths and beliefs that they are no longer sexually active;
Men over the age of 50 are an HIV/AIDS priority risk group;
The prevalence of older PLWHA if not accurately recorded due to diagnostic services being inaccessible;
There is a lack of information and programs specifically targeting older persons resulting in risky uncaring and behaviour - 37.8% of people in the 50+ age group are not getting the message;
The burden on older persons as primary care givers receives little attention in policy and programme development to support AIDS orphans; scant attention is given to informing them on how to protect themselves from infection.
There is a lack of information targeted towards Older PLWHA’s about treatment even when on ARVs;
Training to older persons as care givers to provide proper care are severely lacking and this places them at risk of infection;
Most caregivers are knowledgeable about HIV/ AIDS, but some hold unorthodox and fatalistic beliefs about the disease;
Older persons are excluded from AIDS prevention, screening, counselling and therapeutic programmes;
Older Persons are not supported with the same intensity as younger people - not enough pre- counselling and post-counselling done.
Age-friendly HCT services for older persons such as mobile facilities or incorporation with geriatric clinics; rapid test kits needed;
Inclusion of older persons’ indicators in country strategies, desegregated data according to gender and age, information on people above 49 years that visit HCT facilities and their sero-status in age cohorts of 5 or 10 years, that is, 50 to 59; 60 to 69; 70 to 79; 80+;
Research to be done in the field of HIV/AIDS dementia complex;
Development and implementation of care and support models for older persons who are primary care givers to their adult children, orphans and vulnerable children living with HIV/Aids;
Most of the Residential Facilities initially accommodated healthier older persons, but currently these facilities are mostly occupied by the frail. Frail care comprises mainly health care. The standard of services required by legislation such as the National Health Act (Act No. 61 of 2003) and the Older Persons Act (Act No. 13 of 2006) necessitates the employment of Registered Nursing Professionals, Enrolled Nurses and Enrolled Nursing Assistants in Residential Care Facilities. These posts are not funded by the Department of Social Development or the Department of Health, resulting in the inability of NGO’s to offer salaries and benefits that can compete with the private or government sector. As a result, appropriately qualified staff is difficult to find and retain. Proportionally the biggest line-item contributing to the cost of Frail Care in any residential facility is the salaries of care and nursing staff. Salaries for care/nursing staff is the single highest line item of any residential facility. In addition, there is a substantial difference in the costing models for subsidies used by provinces; no standard currently exists. I In provinces such as the Free State & Limpopo where the subsidies are higher than in other provinces, they are still grossly inadequate to ensure compliance with the Regulations of the Older Persons Act (Norms and Standards).
There is a scarcity of qualified nursing staff in South Africa, residential facilities are unable to pay market related salaries; salaries are also not regulated by the Department of Labour. It is practically impossible for NGO’s to compete with the private sector and to pay staff fair wages. Personnel of residential facilities are expected to work exceptionally long hours for low salaries, training of staff is not always adequate due to financial constraints all of which translate into a risk factor for the abuse of older persons.
The requirements of the National Health Act, no 61of 2003 indicate a clear need for the training of nursing care staff members in Residential Care Facilities. This training should be provided by the DOH as the custodian of this legislation.
From current existing legislation administered by the DOH and the DOSD it is clear that the two departments have co- responsibility in providing care for frail older persons. It is therefore of utmost importance that both these Departments find ways and means of cooperation in order to jointly fulfil their respective legal obligations. Although, historically, government departments do not always work together in managing co-responsibilities, the SAOPF believes that an example can be set by the DOH and DOSD in regard to vulnerable older persons. The SAOPF and stakeholders therefore request that the DOH take into account the legislative requirements of residential facilities and gives consideration to ways in which they can assist them to meet them.
In many areas no district surgeon is available to attend to the medical needs of poorer older persons. Although residential facilities go to great lengths to network with doctors, the District Surgeon, for example, may have to serve four villages and is thus not always readily available. The SAOPF is aware of the critical shortage of District Surgeons in some provinces and that, in most rural areas; they are only available on a part-time basis. However, the situation requires some sort of strategy as the need, especially in rural areas, for regular visits of the district surgeon to residential facilities is critical.
The requirements of the National Health Act, 2003 indicate a clear need for the training of nursing care staff members in Residential Care Facilities. This training should be provided by the DOH which is the custodian of this legislation. At present there is a clear need for the DOH to fulfil this obligation. It would also be of great value to residential facilities should the DOH utilize appropriately qualified DOH nursing professionals to assist with the monitoring and evaluation of service standards in such facilities.
There is a dire need for long term care facilities for persons with severe and multiple disabilities who are younger than 60 years of age. Current legislation stipulates only such persons 60 + years of age may be admitted to residential care facilities for older persons. The DOH should assist NGO’s in coming up with an alternative for persons with severe and multiple disabilities who are younger 60 years. Facilities should also be regulated not to refuse admission / continued stay of Dementia /Alzheimer’s patients should they have the medical capacity to care for such individuals.
It is expected of a Residential Care Facility to send a staff member to accompany an older person to hospital, which depletes the number of staff available at the facility. Once the older person has been admitted to hospital, the escort is usually not taken back to the Residential Care Facility, which further depletes the number of staff on duty at the facility. This is especially problematic with regards to night shift staffing.
The services of State Dieticians to assist Residential Care Facilities would be extremely helpful in planning for the provision of appropriate nutrition. Current DOH requirements regarding appropriate nutrition necessitate the availability of updated Nutritional Guidelines for Residential Care Facilities.
Summary of Challenges
Frail care comprises mainly health care, costs associated with frail care are extremely high and funded exclusively by the DSD. Due to financial constraints, facilities are unable to provide the standard of care required by legislation such as the National Health Act, 2003 (Act No. 61 of 2003) and the Older Persons Act, 2006 (Act No. 13 of 2006).
Salaries for nursing staff are only subsidized by the DSD, this places an immense financial burden on residential care facilities; subsidies are hugely inadequate;
Residential Care Facilities are unable to compete with the private sector and cannot pay market related salaries to professional nursing and care staff, which impacts directly on service delivery. Salaries of nursing personnel employed at residential care facilities are not regulated by the Department of Labour;
DOH and DSD not currently working together to fulfil their respective legal obligations in terms of the National Health Act, (Act No. 61 of 2003) and the Older Persons Act, (Act No. 13 of 2006)
Medical sundries for frail care units of Residential Care Facilities not funded by the DOH; this adds to the financial burden.
No District Surgeons are available to attend to the medical needs of indigent older persons, especially in rural areas and in other areas District Surgeons are not always available due to heavy workloads;
Current legislation stipulates only such persons 60 + years of age may be admitted to residential care facilities for older persons.
Some facilities should are refusing admission / continued stay of Dementia /Alzheimer’s patients should whilst having the medical capacity to care for such individuals.
Residential Care Facility staff is expected to accompany older persons to hospital, this is problematic considering facilities are operating with the minimum of staff.
No State Dieticians allocated to assist Residential Care Facilities in the planning of menus for the provision of appropriate nutrition.
DOH look into ways and means of how to assist the Residential Care Facilities for Older Persons in the provision of the standard of service required by the National Health Act, 2003 and the possible cross subsidising and training of nursing personnel;
DOH to consider assisting residential facilities by supplying medical sundries such as urine bags, blood pressure cuffs, medical instruments, scales and weights, adult nappies etc.
It is recommended that, when a State doctor leaves a rural area to live and work elsewhere, arrangements should be made for interim medical care services until such time as a permanent replacement is found;- no interruption of services
It is suggested that the salaries of Registered Nursing Professionals, Enrolled Nurses and Enrolled Nursing Assistants in Residential Care Facilities be subsidized / partly subsidized by the DOH in order to achieve the required quality of nursing care in Residential Care Facilities;
Utilizing of appropriately qualified DOH nursing professionals to assist with the monitoring and evaluation of service standards in residential care facilities;
Improved communication between the DOH, other State Departments and NGO’s would assist the practical implementation of DOH policies and legislation;
DOH and DSD consider establishing an inter-ministerial task team to explore and formulate a Memorandum of Understanding as is currently in place in the Western Cape between the Departments of Health and Social Development around many issues including the provision of frail care;
Facilities should also be regulated not to refuse admission / continued stay of Dementia /Alzheimer’s patients should they have the medical capacity to care for such individuals.
home / Community and Home Based Care
Home-based care is considered by some to be an appropriate policy response to the growing care needs of older persons that are being presented in both developed and developing countries. Keeping older persons in their communities for as long as possible so that s that they are able to continue with their roles of advising, educating and transferring skills to their children and grandchildren through story-telling, and by passing on cultural values and religious beliefs requires CBCSS. The growing elderly population, and the HIV/AIDS epidemic, with their related care needs, have meant that the issue of care provision has taken on increasing policy significance in recent years. Caring for older persons has become everyone's responsibility but in reality these services are mostly provided by NGOs, FBOs and CBOs. Poorly funded NGOs, FBO’s and CBOs, however, have not been able to meet the demand for services. In many rural areas CHCSS are almost non-existent. Previously, district nurses were utilized to provide some community based services, and although this has been discontinued, it is an option worth re-examining given the immense need for this service.
CBCSS are being implemented in a fragmented manner in most provinces, some projects being subsidised by the Department of Health and others subsidised by the Department of Social Development. An intersectoral approach by the DOH & DSD and other role-players should be followed as the commonly accepted principles for home and community based care include many elements such as physical, social, emotional, economic and spiritual needs. A collaborative and integrated effort is fundamental to successful delivery of home and community based care. This would mean different state departments should be joining hands with NGOs and communities to develop this. As it is imperative that “health” be the outcome of all Home-based and Community based care, the Department of Health should take a leading role together with the Department of Social Development to take this service to where it is needed most-i.e. in indigent communities.
The issue of frail / home based care cannot be discussed without acknowledging the major role that the caregivers play. Care givers on the whole are not given adequate support but even more so, older care givers are marginalized in terms of training and financial support. Older persons themselves take on the role of caregivers in caring for those orphaned by HIV and AIDS and often experience discrimination as they are excluded from policies and programs at provincial level. No policy and/or programs currently exist to address the support needs of older caregivers, given the large numbers of older persons that fulfil this role; development of policies / programs in this respect is desperately needed. Caregivers in general render services under conditions of extreme deprivation lacking formal support from government and receiving limited support from NGOs. In addition most caregivers lack basic equipment (e.g. latex gloves, plastic aprons) to protect themselves against HIV infection. The United Nations (UN) Madrid International Plan of Action on Ageing of 2002 commits signatory member states to improve their assessment of the impact of the disease on older persons, and to ‘introduce policies to provide in-kind support, health care and loans to older caregivers to assist them in meeting the needs of [adult] children and grandchildren’. The Plan calls specifically for adequate information, training in caregiving skills, medical treatment and care, and social support for older caregivers.
Summary of Challenges
Home / community based care services mostly provided by poorly funded NGOs, FBOs and CBOs- who are hence unable to meet the demand;
In many rural areas home and community based care services are almost non-existent;
District nurses are no longer being utilized to provide some community based care services;
Implementation of CBCSS are fragmented in many provinces, some projects being subsidised by the DSD and others by DOH;
A holistic approach by the DOH & DSD and other role-players is lacking as the commonly accepted principles for home and community based care which should include many elements such as physical, social, emotional, economic and spiritual needs;
A collaborative and integrated effort between different state departments, NGOs and communities is desperately needed for the successful delivery of home and community based care;
Large numbers of older persons fulfil the role of caregivers, no policy and/or programs currently exist to address their support needs;
Train older persons to administer Rapid Tests and provide rapid test kits;
Training of OPs and THPs on drug use (pharmaco-vigilance);
Caregivers typically render care under conditions of extreme deprivation. They lack formal support and receive only limited support from NGOs;
Most caregivers lack basic equipment (e.g. latex gloves, plastic aprons) to protect themselves against HIV infection;
Policies to provide in-kind support, health care and loans to older caregivers are lacking and this is not in-line with South Africa’s commitment to the United Nations Madrid International Plan of Action on Ageing of 2002.
Capacitating NGOs, FBOs & CBOs with increased funding to provide CBCSS;
Programs aimed at developing Community and Home based care services in rural areas especially KZN and the Eastern Cape;
Re-examining the program whereby district nurses provide some home and community based care services to help alleviate the need;
DOH along with the DSD and other role-players to develop a holistic approach in line with commonly accepted principles for home and community based care that includes needs in terms of physical, social, emotional, economic and spiritual wellbeing;
DOH to join hands with other state departments and role-players in developing a collaborative and integrated effort for the successful delivery of home and community based care;
It is imperative to take this service to where it is needed most- indigent communities and hence the DOH should take a leading role seeing that “health” be the outcome of all home and Community based care; the DSD along with NGOs should be the key partners in this;
Formal support, development of policies and/or programs and provision of basic equipment to address the support needs of the large numbers of older care givers;
Government at provincial level should review and reformulate policy and programmes to ensure non-discrimination against and the inclusion of older caregivers and their NGOs.