“Hard as it is to acknowledge, Smitty’s reaction to death was pretty typical. It hurts too much to see a stranger die, let alone someone you love and respect. Most folks would prefer just to ride away, leave the dead to do their dying, and only afterwards think on the good times.” C.A. Tedeschi
In the previous article, the problems confronting the elderly regarding access to healthcare and other complexities were outlined. I recognise that this is not a situation for the present day elderly, but one that will confront us all based on the data from Ghana’s recent population and housing census. My position is that the current situation where people are left to their own devices is untenable and needs reformation. In coming to this conclusion I ask, ‘Is there is a system to be reformed in the first place’?
I ask this question because, for many who constitute the elderly, their care requirements in the strictest sense should not come under the provision of health care at the primary, secondary or tertiary care level only but often comes under the realms of adult social care. Adult social care refers to a system of support designed to maintain and promote the independence and well-being of disabled and older people. It aims to keep the elderly well and to decrease the likelihood of debilitation, loneliness and ill-health in advanced years. Such a system proactively assesses the care and needs of the elderly and aims to keep them well in their home environment for as long as possible.
This system ultimately decreases the cost of health care as the likelihood of the aged being unwell and hospitalised is decreased and their reliance on prescribed medication is minimised. However, such systems must be well thought through, designed and financed either by the end-user (the elderly or their family) or paid for through insurance schemes or as a public service through government budgetary spending. Learnings from other countries suggest that without a guaranteed funding stream, social care is never a priority.
Unfortunately, as a country, our approach to social care has at a minimum, emphasised the care of the employed as per the sector Ministry of Employment and Social Welfare in past governments and currently the placement of the Department of Social Welfare under the Ministry of Gender, Children and Social Protection. A careful look at the website of the Ministry or that of the Department of Social Welfare suggests that there is little emphasis on adult social care. Our checks indicate that there is no specific policy that covers adult social care, though there are laws and Acts of Parliament that make mention of aspects of the risks the elderly face. Also, there is no system in place that ensures that the rights of the elderly are respected. I’m of the view that this lack of policy which translates into a lack of focused leadership is at the heart of why the elderly are being let down. This situation must be reversed and urgently.
In reversing this, consultation with all stakeholders especially those in the health sector and the finance ministry as well as civil society and non-governmental organisations with interest in the care of the elderly to identify the key challenges must take place. A cost-benefit analysis will then have to be undertaken to ascertain what added value committing public funds to this sector will bring. It will also be important if the private sector is encouraged to have social enterprises that invest in the provision of adult social care.
This analysis must not only look at the current population of Ghanaians above the age of 65-years but factor in the projected annual population growth rate of 2.1% to determine the elderly care requirements of the country leading up to 2030 when the country is expected to achieve Universal Health Coverage (UHC). According to the World Health Organisation (WHO), UHC is achieved when “All individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course.” Thus, without sorting out the social care needs of the elderly and ensuring that they are accessible and affordable, Ghana may struggle to reach this component of the United Nations Sustainable Development Goals.
Following this analysis, there would need to be the setting up of an adult social care system that will factor in the breakdown of the extended family social safety net. It may be an option to rely on community health and social care cadres who are trained in the assessment of the elderly, helping with the concordance with their prescribed medication, identifying recreational activities that can occupy their times and ensure that if they have pensions and other income these are utilised to their benefit and not exploited. This could result in sustainable job creation for many trained nursing assistants and community health nurses who currently struggle to find jobs after graduation.
There may also need to be a conversation around elderly care insurance and whether this could be included as a component of the National Health Insurance Scheme (NHIS) or will have to be funded privately. We hold this view because the current scope of the NHIS cannot remedy the situation many find themselves confronted with during old age. Also, even though the elderly have access to the NHIS free of premium, the census data suggest that a significant number are still without health insurance. Key of the reasons why this tends to happen is the lack of funds to register or renew their membership. Though this situation requires urgent redress, we are also mindful that 100% enrolment of the elderly would come with financial implications for the scheme.
Though improving the quality of social care for the elderly will increase their quality of life and keep them well for longer, ultimately the conversation around the end of life will have to be had. This conversation will have to be had in a manner that preserves the dignity of the senior citizen at a time when ideally, their mental capacity is not impaired, and while ensuring that the fear of death is not allowed to cloud the situation. Such a conversation will have to include the family and in some instances close friends or guardians.
This is an aspect of social care that is delicate in our society as many are in denial when their mortality stares them in the face. This is further compounded when the family is also unaccepting of the inevitable. Social caregivers will therefore have to be armed with the requisite counselling skills that ensure that the fears of all involved are allayed. They would have to discuss in detail the process of palliative care and all the options available.
This will also require that the pharmaceutical supply chain has adequate stocks of medication that will be required at each stage and geriatric practitioners can judge correctly the extent of pain if any and other discomforts the patient may be experiencing. Correct judgements will have to be made on the route through which medication must be administered to ensure the intent of pain management (absence of pain) is achieved. This will require that caregivers and family members are trained to identify discomfort even when patients have not indicated, and adjust medication (if trained), or seek help.
We cannot continue to ignore this problem and allow the continual neglect of many who have at different times played a role in the service of our country. Neither can we leave the dead to do their dying, and only afterwards think on the good times. If we do, our generation would have no moral justification when our rights are neglected by the generation that succeeds us and we are left to our own devices as we do our dying. Adult social care is about the preservation of human dignity and thus far, we seem to be missing the point.
By Kwame Sarpong Asiedu (PhD)
The writer is a pharmacist by profession, and a Democracy and Governance Fellow (Health) at CDD-Ghana.