Health Care Services for the Elderly in the Middle East

Author A. ABYAD, MD, PhD, MBA, MPH, AGSF

Abstract

Middle Eastern countries have certain cultural, social and economic characteristics in common with similar aspirations. The percentage of elderly in the Middle East is expected to increase with improvement of health care delivery in the area. The region, like other developing countries, needs to define the policies and programs that will reduce the burden of aging populations on society and its economy. There is a need to ensure the availability of health and social services for older persons and promote their continuing participation in a socially and economically productive life. In particular there is a need to facilitate family provision of support, to increase employment opportunities for the elderly, to establish or expand public pension systems, to prepare health care systems, to develop the infrastructure for elderly care, to shift to prevention and to encourage home health care. Policymakers in the developing world need to invest soon in formal systems of old-age support to be able to meet these challenges in the coming decades

Background

The world's elderly population is quickly growing, both in its absolute numbers and in its percentage relative to the younger population. It is currently estimated that more than half (58%) of all people who are 65 years and older live in developing nations. The world's older population experiences a net increase of 1.2 million each month, 80 percent of which occur in Third World nations ^(1,2,3). It is projected that by the year 2025, the total elderly population will reach 976 million with 72% living in developing regions ^(2,3,4).

And populations are aging even faster in the developing world, as fertility rates there have declined more rapidly and more recently than in the developed world ⁽⁵⁾. Asia and Latin America and the Caribbean are the world's fastest aging regions, with the percent of elderly in both regions projected to double between 2000 and 2030⁽⁶⁾.

Also, as in the west, the growth rate is fastest for the oldest old, those most likely to have chronic diseases and to be in need of health services. It is apparent that the problems of the frail elderly and development of geriatric programs and understanding of geriatric principles are international problems ⁽⁷⁾. The Middle East will develop rapidly aging populations within the next few decades. The less developed countries in the area which have much lower levels of economic development and access to adequate health care than more developed countries, will be hard-pressed to meet the challenges of more elderly people, especially as traditional family support systems for the elderly are breaking down. Policymakers in the developing world need to invest soon in formal systems of old-age support to be able to meet these challenges in the coming decades

The Region is passing through the "Health Transition Phase," which is characterised by an unprecedented increase in both number and proportion of adults and elderly persons. Since the elderly are at high risk for disease and disability, this population aging will place urgent demands on developing-country health care systems, most of which are ill-prepared for such demands.
Chronic disease now makes up almost one-half of the world's burden of disease, creating a double burden of disease when coupled with those infectious diseases that are still the major cause of ill health in developing countries⁽⁸⁾. The challenge for developing countries is to reorient health sectors toward managing chronic diseases and the special needs of the elderly. Policymakers must take two steps: Shift health-sector priorities to include a chronic-disease prevention approach; and invest in formal systems of old-age support

More specifically, these countries should institute prevention planning and programming to delay the onset of chronic diseases, enhance care for the chronic diseases that plague elderly populations, and improve the functioning and daily life for the expanding elderly population ^(9-13).

Socioeconomic and Political Factors

Middle-Eastern culture ensures respect for the elderly and values highly the natural bonds of affection between all members of the family. The eldest members are a source of spiritual blessing, religious faith, wisdom and love. Despite the general feeling among most people in the region that sending an elderly parent to a nursing home violates our sense of sacred duty towards them, many individuals and groups are faced with situations, where they have no other alternative. It is clear that the majority of elderly in nursing and psychiatric homes are there owing to circumstances where their families cannot possibly look after them. Among such groups are those whose families are abroad, unmarried women, old people whose families cannot support them financially, and those who suffer from diseases where professional care is needed. Morbidity patterns have changed and lead to prolonged states of chronic disease, dependency and loss of autonomy for growing numbers of elderly in the region ^(9-13).

Elderly people in the area receive social and economic support from the informal sources of extended kin networks, and particularly from their own children. With smaller families being the trend, this will lead to fewer potentially supportive children available. Studies from developed countries reveal that where children are in a position to help their aged parents, the majority of them do so. However, traditional patterns of family responsibility will diminish with economic development^(9-13). Young city dwellers may become more preoccupied with the future of their children than with the difficulties of their parents. Women, who traditionally bear the main responsibilities for providing family care, enter the labor force for reasons of personal choice and economic necessity and are no longer available to care for aged relatives^(9-13).

Governments of the area are still assuming that families will take care of their own elderly. The changing economic and shifting migration patterns lead to the projection that the provision of long-term care will be an important part of health care planning ^(1,9-13). Government is unwilling to make major commitments to elderly health ^(9-13). There is little incentive to direct limited resources in order to add an additional few years of life. There are conflicts between the needs of large population groups and the purchasing power of a more limited elite. The role of private sector is very important. Given the fragile finances of the government, the private sector has a greater role to play in the insurance of health care.

The Development of health care and social services for the elderly in the Middle-East

The Advances in medical technology are propelling a longevity and wellness revolution. The numbers of elderly in the region are increasing or growing at a much faster rate, than the elderly in more developed countries. Over the next ten years, the number of people needing long-term care services will increase. Health care systems in the region have ignored the needs of the elderly. There are only sporadic programs that take care of the elderly, mainly initiated by the community or within the private sector.
The countries in his region can be divided into the following groups:

1. Countries typified by substantial capital, rapid development, and a small indigenous population, such as Saudi Arabia, Kuwait, and most
   Persian Gulf states
2. Countries with less capital, more people, a quantitatively larger medical infrastructure, and more trained medical personnel, such as Egypt,
   Israel, and Algeria.
3. 3. Countries whose extensive medical service plans have been halted or greatly decreased in scope because of civil strife or war, such as Iraq, Lebanon, and Iran ⁽¹⁴⁾.
   

Population aging presents major challenges for the Middle East. Most countries in the area are facing the following

· Strain on informal support systems.
· Pressure on health care systems.
· Shrinking productivity and increasing demand for pensions.
· Increasingly feminized older populations.

To offset the impact of the demographic shift and other changes on the traditional system, policymakers in the region must invest in the systems that would encourage and facilitate the elderly to work longer, save more, and rely on public pension and health care programs to meet their needs fully ⁽¹⁵⁾. Below are some policy measures that could help the region deal with population aging ⁽¹⁶⁾.

Facilitate family provision of support. Programs to assist families in caring for the elderly include providing tax incentives for elder care and increasing day care and home nursing services ⁽¹⁷⁾. Creating public housing options for multigenerational living also encourages such living arrangements and might facilitate family care for the elderly.

Increase employment opportunities for the elderly. Greater workforce retention levels would help elderly individuals save more for retirement; they would also bolster the fiscal viability of public pension and health care programs. Work disincentives and labor market impediments to the elderly (such as low mandatory retirement ages) should be eliminated. Increasing both flexible and part-time employment options as well as expanding educational programs for older workers are also essential.

Establish or expand public pension systems. Most developing countries have pension coverage that is restricted to small segments of the workforce, such as those working for government or large companies. Public pension programs, most of which also cover some disability insurance, provide an economic safety net and also allow risk pooling to mitigate the cost of becoming disabled, making poor investments, and outliving one's savings.

However, providing wide coverage in developing countries requires political stability and may be administratively challenging, particularly in places with high proportions of agricultural, self-employed, and informal-sector workers (18). These programs also must be designed with enough capacity to incorporate the expanding ratio of elderly to working-age populations.
Prepare health care systems. As in the case of pension coverage, insurance programs for the elderly in most developing countries cover only a small minority of that population. Without universal access to even basic health care in many developing countries, securing the care to address chronic conditions for the elderly is often lower priority.

Develop the infrastructure for Elderly care. There is a pressing priority for the provision of facilities including medical, psychiatric and rehabilitative services for early diagnosis and treatment of illness, to alleviate problems that could lead to long-term debilitating conditions in old age. It is important to achieve a balance of care between community and institutional services, both for humanitarian and economic reasons. Given the growth of the aging population in the region, especially the oldest with expected multiple chronic illnesses, the need for intermittent or continuous long term care services will undoubtedly grow, including nursing facilities and home or community-based long term care.

Shift to Prevention. Projections made by the World Health Organization (WHO) suggest that, by 2015, deaths from chronic diseases, such as cancer, hypertension, cardiovascular diseases, and diabetes, will increase by 17 percent, from 35 million to 41 million ⁽¹⁹⁾. But few Middle Eastern countries have implemented primary prevention programs to encourage those healthy lifestyle choices that would mitigate chronic diseases or delay their onset. Rarely do developing countries have the appropriate medicines or adequate clinical care necessary to treat these diseases.
Delaying the onset of disability through prevention approaches can both alleviate the growing demand for health care and, more importantly, improve the quality of life for the elderly.

Disability significantly affects quality of life in old age. Types of disability frequently considered among the elderly include limitations in general functioning (such as walking or climbing stairs); managing a home; and personal care. In addition to being consequences of the normal aging process, disabilities are also often caused by chronic diseases. And population aging also increases the prevalence of mental health problems, especially dementia, which results in disability by limiting the ability to live independently. WHO projects that Africa, Asia, and Latin America will have more than 55 million people with senile dementia in 2020 ⁽²⁰⁾.

Home Care. Caring for the elderly in a way that addresses disability and maintains good quality of life has become a global challenge. Informal care-often provided by spouses, adult children, and other family members - accounts for most of the care the elderly currently receive in developing countries. Care provided at home is often considered the preference of the elderly and, from a policy standpoint, is essential for managing the cost of long-term care. However, despite the increasing demand for home-based care due to population aging, decreasing fertility rates means that future cohorts of elderly will have smaller networks of potential family caregivers.

The need for public policies to address the demand for caregivers is one of the priority issues for long-term care and a guiding principle for WHO's 2000 publication Towards and International Consensus on Policy for Long-Term Care of the Ageing⁽²¹⁾. In it, WHO urges developing countries need to urgently train more professional caregivers to focus on elder care in order to meet current and future demand.

According to WHO, future care-giving for the elderly will also require models of both formal and informal care and systems for supporting caregivers ⁽²²⁾. Although formal long-term care programs are vastly underdeveloped in poor countries, they will be essential for complementing the informal support system and sustaining the major role that family caregivers currently play.

Conclusion

While developing countries can learn from the policy successes and failures of developed countries, adopting these policies in a short time frame and at much lower levels of economic development has never been attempted. Addressing the health care and economic needs of increasing numbers of elderly will also require balancing these needs with those of other populations as well as summoning the political will to support often very expensive programs. But the opportunity for such investments will be available only for a few decades, and the cost of squandering this opportunity will be high.

Policies and health promotion programs that prevent chronic diseases and lessen the degree of disability among the elderly have the potential to reduce the impact of population aging on health care costs. Research shows increasing health care costs are attributable not just to population aging but also to inefficiencies in health care systems such as excessively long hospital stays, the number of medical interventions, and the use of high cost technologies ⁽²³⁾. Appropriate policies to address health care challenges for aging populations are crucial for developing countries if they are to simultaneously meet the health care needs of their elderly populations and continue their economic development.

The severely impaired and dependent aged will need a wide range of professional care, as will their families. In the process of creating adequate services, it is important to realise that home care and institutional services are complementary and multidirectional. Care of such patients, needs the shared responsibility of both families and professional service providers. Services can be alternately provided in the home, the community, or the institution. Health promotion and prevention should be a key factor in any program. Environmental planning should take into consideration the needs of the elderly. The role of those concerned with aging in Lebanon or the Middle East is to provide communities and concerned professionals with the knowledge and skills to solve their problems, not to import solutions from developed countries after other alternatives have been explored. Health promotion and prevention should be key factor in any program. Geriatric and gerontological information should be a part of the education of all health professionals. Environmental design of hospitals and clinics should take into consideration the needs of the elderly.

Table 1: Life Expectancy at birth for selected countries,
Human Development Report, 1996

Reference