Network Approach: Elderly Health Care

We chose elderly health care as our topic and would like to analyze how through forming a network, we can provide elderly health care.

There is no existing elderly or geriatric health care policy or system in the country that has been made specifically targetting the elderlies. While certain facilities do exist that help the elderly, however, we feel the need for a concrete geriatric health care system as by 2025, 75% of the elderly population of the world will be living in the developing countries. (http://www.who.int/ageing/publications/alc_fs_ageing_policy.pdf) Given that developing nations like Bangladesh have already overburdened health systems, if attention is not given to elderly health care, we might be inviting future disastrous events.

At first, let us define elderly health care. Defining the problem would mean identifying people we consider the elderly and what health care services they might need. In identifying the health care services needed by them, we can also understand what problems might exist hindering the proper care of the elderly while they are sick.

Usually, people over 65 are considered to be elderly or senior citizens. In Bangladesh, elderly stipend is given to males aged 65 years old and beyond, and to females aged 62 years old and beyond, given that their annual income is less than 10,000 taka. This existing age limit can be a good option for defining the elderly population in the country.

Now, let us look at what services the elderly might need when it comes to health care. If we can determine their health needs, determining actors of the network who will work towards meeting these needs become easier. Determining problems that are specific to elderlies is also another way of determining required actors to mitigate the problems.

We have tried to create classifications in the health needs of the elderly. A rather easy classification is physical health needs and mental health needs. Under physical health needs, we have issues like- preventive health care, medical needs, chronic diseases, nutrition, disabilities etc. Mental health needs rise from the mental concerns of the elderlies such as- when children leave the houses for jobs, parents feel isolated and lonely. Again as elderlies retire, they find it hard to keep themselves occupied which might cause frustration and depression. Under physical health concerns, we have mentioned physical disabilities. Now, this creates two different targets, such as- elderlies who are disabled due to old age and the already existing physically disabled population of the country that has grown old.

The elderlies have certain problems in their lives that may hinder proper care of their health, such as-

• Financial constraint: As elderlies retire, there is a reduction in their income. This creates a financial constraint on their abilities to afford the necessities such as proper nutrition, health care etc.
• Lack of people to take care of them: A major issue regarding elderly care, in general, is that as people grow old, they become dependent on others to take care of them. They not only need emotional support and companionship but also at times, physical support in daily activities. However, with the growing trend of nuclear families, children usually leave in separate houses and the elderlies are left alone without the necessary familial support. Again, during an illness, children or family members can look after the elderly patients- an absence of which hinders elderly health care as well.

All these problems make the elderly a vulnerable demographic and hence we realize the necessity of a specific and separate health care system for them.

Now, let us try to see how elderly health care can be provided through the network approach.

Actors involved, how they interact and the kind of network they form:

The central actor in our network is the Ministry of Health and Family Welfare. The network formed is a hybrid network, including information diffusion network, service delivery network, problem-solving network, and community capacity building network. Different networks are formed for performing different purposes.

We have begun the network with the activity of policy formulation. In this activity, there will be actors who will provide policy guidelines and help in formulating a policy that will address the specifications of Elderly Health Care. There are three bodies here:

National Elderly Health Care Council: This will be headed by the Prime Minister and other members comprising of top-level officials of relevant ministries, civil society, the United Nations, WHO, UNDP, UNFPA, World Bank.

Inter-Ministerial Elderly Health Care Coordination Committee: This body will be headed by the Minister of Ministry of Health and Family Welfare with members of relevant agencies.

National Elderly Health Care Advisory Council: This will be a highly specialized committee composed of technical and specialized persons from among public and private sectors.

The network formed by these three actors is information diffusion network. In this network, policies and recommendations are determined through the sharing of information by different ministries, agencies and actors.

So now we have a policy regarding Elderly Health Care and this policy is received by the Ministry of Health and Family Welfare. The policy will include the different activities needed to be done for providing Elderly Health Care. Since the activities are multi-faceted, we will now see an interaction of different relevant agencies to implement the policy.

The network formed by the Ministry of Food, Ministry of Agriculture and Ministry of Fisheries and Livestock deal with the issue of food and nutrition of the elderly. Through the use of the existing policy, they will create a feasible system through which the nutrition of the elderly will be ensured. This is a problem-solving network. Problem-solving networks usually arise from information diffusion network. They use the policy provided by the information diffusion network and form a system that helps in implementing the policy.

We see an interaction between the Ministry of Food and Ministry of Social Welfare. Given that Ministry of Food is the central ministry in handling the nutrition issue for elderly and the Ministry of Social Welfare has extensive reach towards providing nutrition to the elderly ( either in form of money or food), these two ministries will interact with each other in a problem-solving network to ensure nutrition for the elderly.

We see an interaction between the Ministry of Women and Children’s Affairs and Social Welfare. In this case, they will focus on elderly women specifically and incorporate health services in their already existing programs for women or create new systems if they want to. This is also a problem-solving network as we see that using policy from the information diffusion network, they will create systems to provide health care to elderly women.

Ministry of Social Welfare given that it already has social safety net programs for disadvantaged and vulnerable people can work for providing elderly health care with the help of the Ministry of Health and Family Welfare. In this partnership, we can see an allowance given for health reasons to the elderly, as well as other services like medicines for chronically ill people can also be distributed.

Ministry of Local Government Engineering Department and Ministry of Housing and Public Work will work together to provide the infrastructure required for elderly health care. For example, construction of elderly-friendly staircases is one such infrastructure. Creating gerontology units in hospitals (i.e. expanding/renovating the hospitals) are also included in infrastructure development.

Ministry of Disaster Management will work in ensuring the health of the elderly before, during and after the disaster by including elderly health care in their existing pre, during and post-disaster programs.

An important part of elderly health care is spreading awareness. Awareness about the health risks that elderly face, food and nutrition of elderly, early signs of common geriatric problems etc is important when dealing with elderly health care. Another important aspect is to spread awareness about forming healthy lifestyle in adulthood so that certain geriatric health issues can be minimized. Awareness should be spread to three broad categories of people namely — the elderly, the middle-aged people who will move into elderly age group in the near future and younger people who are the caregivers of the elderly people about topics like physical exercise, avoidance of tobacco and alcohol and common knowledge about elderly health care. The key ministries who can spread this awareness are the Ministry of Education, Ministry of Information, Ministry of Religious Affairs, Ministry of Youth and Sports. They form an information diffusion network where they share information among each other and decide which topics they would spread awareness on.

Another important activity is to encourage the children and family members to take care of their elderly family member and relatives, both to keep them safe from illnesses and also during the time when they are sick. This can be done with the help of the Ministry of Education, Ministry of Information, Ministry of Religious Affairs, Ministry of Youth and Sports as well. They can arrange systems through which their specific targets are encouraged to provide care to the elderly when they are sick. This will also be an information diffusion network.

Given that an elderly health care system does not exist in the country, so creating one means we need people who will be trained to understand the specific health needs and care of the elderly. Such training can be given by a collaboration between the Ministry of Health and Family Welfare and Ministry of Education. This network is a community capacity building network as it is helping to build the capacity of people in elderly health care.

The network formed by public hospitals, private hospitals, NGOs, educational institutions, religious actors, nursing homes, hospice, PWD, EED, HED, old homes is a service providing network. The public hospitals include — public hospitals in the city corporation, the district headquarters hospitals, upazila health complex, union health centre, community clinic, specialised public hospitals etc. Both the public and private hospitals will cater to the health needs of the elderly. Apart from providing treatment when they are ill, they will also provide the service of periodic health assessment to check the symptoms of geriatric conditions and to treat elderly with chronic illnesses. Provision of prostheses and other medical aids, medicines for the chronically ill will also be provided by the public and private agencies. Old homes (run both publicly and privately) can provide the various elderly health care service as well as they look after a group of elderly people.NGOs play a key role in many sectors of elderly health care. One of their activities is to spread necessary awareness regarding elderly health care. There are NGOs who work for improving the mental health of people and these NGOs can work to treat the mental conditions of the elderly through activities such as — counseling, recreational activities, social gatherings etc..Educational institutes like- schools, colleges, universities play a key role in being the medium to spread awareness by providing information about elderly health care to the students. Religious actors like Imams can also help in spreading awareness about elderly health care knowledge as well as encouraging children to look after their elderly parents. Government and private sector can team up together to provide the service of nursing homes where elderly people who do not have family members to look after them can be admitted. Hospice care is a type of care where the facilities of the hospital can be provided inside the house for terminally ill patients who choose to spend their last days in their houses. Public Work Department (PWD), Health Engineering Department(HED), Education Engineering Department (EED) will provide the service of the infrastructure such as elderly friendly staircases,construction of geriatric units etc.

Problems that may affect the performance of the network :

Elderly Health Care service is a pretty vast and complicated network where different actors are working together. It will not be very unusual if problems arise now and then within the workings of the network. From the article “ Managing Natural Disasters in Bangladesh: Activating the Network Approach” written by Ferdous Arfina Osman, Asif M Shahan, Ferdous Jahan, we can see that there are certain problems that may cause the underperformance of a network. Two factors- bureaucratic attitude and managerial competence determine how well a network will perform.

When we talk about bureaucratic attitude, we consider two things — bureaucracy’s trust towards other actors and level of bureaucratic control. If the bureaucracy has low trust in other actors of the network, the performance of the network will be hindered. Lack of trust can arise from two places- inter-ministerial conflict and tension between government and non-government organizations. In trying to achieve elderly health care,inter-ministerial conflict can become an issue if the conflict arises from the replacement of jurisdiction. Earlier, elderly people were a concern of the Ministry of Social Welfare. Now that the focus shifts to Elderly Health Care, we see elderly people being a concern of the Ministry of Health and Family Welfare. As a result, the Ministry of Social Welfare may see this as an example of their power decreasing and their jurisdiction being taken away by another ministry. Thus, when the Ministry of Social Welfare will work in the same network with the Ministry of Health and Family Welfare, there might be a lack of trust between the two ministries. In the same way when Ministry of Health and Family Welfare will work at the center of a network that provides health care to ‘disabled’ elderly people, Ministry of Social Welfare will again think that their jurisdiction is being taken away ( as providing service to disabled people was a concern of MoSW too) and there may arise lack of trust. Besides that, inter-ministerial conflict due to different factions and other differences may arise too. Moving on from inter-ministerial relations to the relations between public and private actors, if the relation is not reciprocative, then the performance of the network will suffer too. For example, if the bureaucracy does not view the activities of the NGOs in a good light and tension exists in their relationship, then service provision will not be done smoothly as NGOs play a pivotal role in providing many services. If the bureaucracy sees the NGOs as competition and as a threat to their power, then this is an obvious indicator of lack of trust between the two parties.

Again, distribution of power in the network matters in order to ensure the smooth performance of the network. If the power is too centralized, local bodies that are supposed to provide health care in districts,upazilas, and unions may not find enough autonomy to apply their discretion in times of need. Again, if the voices of all the stakeholders are not heard, then the network might miss out on valuable relevant input and thus underperform due to lack of information.

If there is lack of managerial competence from the bureaucracy’s part, then a huge network like this involving many actors cannot be coordinated properly. There may arise lack of accountability, lack of conflict management when the bureaucracy is not competent enough to run the network.

Another key problem that is relevant in our country for service delivery network is the ratio of clients to resources. Whether we have enough resources to cater to the elderly population is an important issue and as such, the controlling of resources in accordance to the number of clients will be an important issue in this network’s management.

When service delivery networks are intended for providing health services like mental health counseling, the patients prefer a network that is stable. Networks are different from bureaucracy in the sense that they are more flexible, however, this very flexibility disrupts the stability that mental health patients look for. So, it must be ensured that the network is managed in such a way that changes are not made so frequently that it destabilizes the network.

GROUP-1

AZIZUN NAHAR LIMA

BYZID BOSTAMI

MOHAMMAD HOSSAIN

FAIRUSE AKTER

ALOKA AHMED OISHY

LUDMILA KHAN