Survey shows elderly healthcare lacks focus

The median age of the population of Sri Lanka is increasing due to the decline in fertility and mortality rates. The growing number of older adults increases demands on the public health system, and on medical and social services.

Chronic diseases affect older adults disproportionately, contribute to disability, diminish quality of life and increase health and long-term care costs. Increased life expectancy reflects, in part, the success of public health interventions, but, now public health programmes must respond to the challenges created by this achievement, including the growing burden of chronic illnesses, injuries, disabilities, psychological disorders and increasing concerns about future caregiving and healthcare costs.

Geriatrics or geriatric medical care is a speciality that focuses on the healthcare of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults. As people age, their physical health becomes fragile. Their psychological health too becomes increasingly at risk due to the impact of negative life events such as accumulated traumatic experiences, and poor social and economic factors. Therefore, healthcare of the elderly needs to be responsive to these conditions to provide an elderly-friendly service. However, up to now, there has hardly been any information on geriatric facilities available in public and private health institutions.

It is timely that the Health and Indigenous Medicine Ministry and the Census and Statistics Department (DCS) in collaboration have conducted a survey on Service Availability and Readiness Assessment of Health Institutions in Sri Lanka in 2017. Among the other much-valued information, the survey-report fulfils a major requirement for the planners, administrators and policymakers of healthcare system in identifying the level of availability of health services in institutions for elderly care, capacity of the institutions to provide elderly care services, and which components in the chain of elderly healthcare delivery need more attention and improvement, so that a quality health service for the growing elderly population is available and delivered.

Growing elderly population

The elderly population in Sri Lanka has grown rapidly in the past several decades. They were an unprecedented 2.5 million in 2012, and this is still increasing. One in eight Sri Lankans is 60 years or over. According to unpublished data, by 2017, the elderly population has reached a level of 16 percent. This is in contrast to one in twenty persons a few decades ago.

Demographers project that the aged will double by 2041. Every fourth person in the country will then be an aged person. The numerical growth of the elderly has been happening almost invisibly and inaudibly. Sri Lanka has progressed through a demographic transition of declining mortality and fertility rates. Starting in the mid-1940s, the death rate declined from 19.6 to 6.0 per thousand.

Subsequently, the fertility rate or the average number of children born also began a downward trend, declining from 5.5 to 2.4. The declining mortality is reflected in the steadily rising life expectancy at birth.

There are certain health conditions that are expected to be a challenge to our healthcare system with the increasing ageing population. These conditions include chronic illnesses such as cancer, obesity, diabetes and psychological disorders such as dementia and Alzheimer’s. The elderly are also increasingly likely to suffer from accidental falls.

Health status

The changing age structure has many and serious implications in almost all aspects of life. The disease profile has already changed from a predominance of infectious and acute diseases to rising chronic, degenerative and expensive-to-treat diseases. The ageing population will increasingly put pressure on health systems with the rise of chronic cancer, diabetes and cardiovascular diseases.

The DCS in collaboration with the Community Medicine Faculty of the Colombo University has conducted a year-long household survey on health in 2014, covering the entire country. Data collected in the survey include the prevalence of illnesses - both chronic and acute; the places from which the treatments were received; accidents; places of accidents; health screening; smoking and alcohol use and possession of health insurance. The survey has shown that chronic illness, as can be expected, increases with age. Almost 55 percent of the elderly population suffers from at least one chronic illness. That is, one in two elderly persons is living with a chronic illness. This implies living with pain, discomfort, inconvenience and continuing life-long medication.

Readiness

The Service Availability and Readiness Assessment (SARA) of health institutions is a survey conducted by countries at regular intervals to assess and monitor the availability of health services and the readiness of health institutions to provide expected services. These surveys generate evidence to support policy reforms, planning, implementing and monitoring of the health services provided by the health system. A SARA survey was conducted for the first time in Sri Lanka in 2017, jointly by the DCS and the Health and Indigenous Medicine Ministry, fulfilling a long-felt need.

The survey covered several service sectors including maternal and child health, infectious diseases such as HIV/AIDS and other sexually transmitted infections, tuberculosis, malaria, rabies and dengue; chronic non-communicable diseases including diabetes, cardiovascular disease, chronic obstructive pulmonary disease, chronic kidney disease and cancer; mental health; care for elders and the disabled; and gender-based violence.

The SARA Sri Lanka - 2017 measured the overall availability and readiness of each of the services provided through the network of the government and the private sector healthcare institutions.

Objectives of survey

One of the objectives of the survey was to describe the availability of general health services in terms of basic amenities (infrastructure), basic equipment, diagnostic capacities, standard precautions, essential medicines, surgical management and transfusion services in the state sector and private sector health facilities in Sri Lanka.

To describe the availability of trained staff, equipment, diagnostic capacities and medicine or commodities to deliver services related to key health areas; assess the readiness of the health facilities to deliver general health services and assess the readiness of the facilities to deliver other services were other objectives. Because of the rapidly growing demand, information was also gathered on elderly care service availability and readiness.

Service availability

In general, service availability in health institutions is very impressive. Among the basic amenities, a source of improved water supply was available in almost all health facilities (99 percent) and sanitation facilities were available in approximately 91 percent of public health facilities and all private hospitals (100 percent).

Emergency transport service was available in the majority of public hospitals (91 percent to 100 percent).

Availability of basic equipment was high in all facilities especially those with in-ward facilities. Most individual tracer items required for standard precautions were available in more than 80 percent of health facilities. The percentage of facilities offering primary laboratory tests was high for blood glucose test using a glucometer.

However, there was a wide variation in the availability across different types of facilities. Availability of advanced laboratory tests such as liver and renal function tests was low among all health facilities.

However, the lipid profile testing was available in a large percentage of tertiary care hospitals and private hospitals with more than 50 beds, but low in other facilities. Availability of radiological tests (X-ray) was high and found in most tertiary care hospitals (95 percent), secondary care hospitals (79 percent), and private hospitals with more than 50 beds (89 percent).

Service readiness index

According to the SARA - 2017 report, the general service readiness index is a composite measure designed to combine information from five domains, namely, basic amenities, basic equipment, standard precautions, laboratory diagnostics, and essential medicines. The results revealed that the general service readiness index score for hospitals in Sri Lanka was 79 out of 100, with a score of 77 out of 100 in public sector health facilities and 83 out of 100 in private sector health facilities.

Service availability and readiness

Older people have a need for more health monitoring and treatment than younger people and the pattern and causes of their illness are different. They need extraordinary care and geriatric treatments that are expensive. Therefore, the provision of long-term healthcare is a serious issue. Promoting healthy lifestyle and broadening the use of clinical preventative services are critical to preserving the health of older adults and reducing healthcare costs and long-term care needs. The SARA - 2017 reveals that the availability of elderly-friendly wards was as low as 20 percent among all hospitals that are expected to provide this service. Only 18 percent of public health facilities and 22 percent of private hospitals had elderly-friendly wards. Availability of health staff with training on care for elderly was extremely low, as indicated by low presence of trained medical officers or consultants (seven percent), nursing officers (seven percent), attendants (six percent) and labourers (four percent) at health facilities.

Older people have a need for more health monitoring and treatment than younger people and the pattern and causes of their illness are different. They need extraordinary care and geriatric treatments that are expensive. Therefore, the provision of long-term healthcare is a serious issue. Promoting a healthy lifestyle and broadening the use of clinical preventive services are critical to preserving the health of older adults and reducing healthcare costs and long-term care needs.

The SARA - 2017 reveals that the availability of elderly-friendly wards was as low as 20 percent among all hospitals that are expected to provide this service. Only 18 percent of public health facilities and 22 percent of private hospitals had elderly-friendly wards. Availability of health staff with training on care for the elderly was extremely low, as indicated by the low presence of trained medical officers or consultants (seven percent), nursing officers (seven percent), attendants (six percent) and labourers (four percent) at health facilities.

Conclusion

Healthcare systems in all countries continue to evolve in response to the changing demographics, disease burden and rapid technological advances. The SARA Sri Lanka - 2017 report provides scientifically valid baseline data to inform policy decisions and strategic planning and scaling-up of health services in the health sector, focusing on service availability and readiness in public and private sector health facilities in Sri Lanka.

Since overall service availability and readiness are low in elderly care, there is a need to consider more investments for these services in Sri Lanka. The relevant categories of health staff should be trained on care for the elderly, together with the expansion of services for elderly care to lower level hospitals.

To conclude, the provision of quality assured healthcare services for the elderly population is a challenge that requires a multi-sectoral approach and strategies. Failure to address the health needs today could develop into a costly problem tomorrow.



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