Towards A Care Society


Towards A Care Society

Solita Sarwono *)
Santo Koesoebjono **)

 The global outlook has changed during the second half of the 20th century. New nation-states have been born, earlier associations are dissolved and new alliances are concluded. Progress in transportation and communication technologies are instrumental for frequent and rising flows of people, capital and goods across boundaries. Relationships between and within countries and regions are shifting towards interdependence. Societal develop­ment is linked with developments across bor­ders.

Disparities in political, economic and social situation are at the root of great international population moves towards areas of real or perceived afflu­ence. These structural imbalances have not improved and factors which induced migration in the past are still at play and have been rein­forced (Tapinos, 1994). These growing flows are conducive to the re-emergence and rise of diseases and epide­mics. Divergence and convergence of the development of various features are prevailing concurrently at global and local levels as illustrated by the trend of indicators such as income per capita, fertility, life expectancy and infant mortal­ity, access to health care and family planning services, clean water and electricity.

Changes in the demographic pattern of populations are continuing. Inter­ventions on the dynamics of popula­tion i.e., births, deaths and migra­tion, are progressing at national and international level. Policies and plans of action are formulated to accomodate issues related to population trend as part of the develop­ment progr

The first section of this paper reviews the demographic trend during the second half of the 20th century particularly focussed on life expectancy and infant mortality, and ageing of populati­ons. The second section summarizes the objec­tives of the Alma Ata Declaration and the shifitng health policies and strategies. The last section maps out a reflection on the consequences of leng­thening of longevity and ageing of population which lead to the need of care.

 1. Lengthening of average life span and ageing

In the past decades mortality has declined and consequently life expect­ancy has increased. In 1960-65 the expecta­tion of life for both sexes combined was around 70 years in devel­oped countries and over 47 years in develop­ing countries (Table A). During the past 25 years the longevity has improved consider­ably and it reaches around 79 years in developed coun­tries and 61 years in develop­ing coun­tries for both sexes com­bined. The lengthe­ning of the life span has taken place among males and females whereby women live longer than men. However, the pace of advance­ment has been uneven and large diver­gences are prevailing between and within countries. A relevant number of African coun­tries has a longevity around 50 years while at the same time some developing countries already achieved a longev­ity around or even higher than the average life expect­ancy of developed countries. A continued lengthening of the average life span and a reduction of dispari­ties between devel­oped and develop­ing coun­tries are expected in the coming period. The United Nations’ long-range population projections estimate an ultimate life expectancy at birth of 84.7 years for both sexes in 2045-50 (82.5 years for men and 87.5 years for women) (UN, 1992).

Altho­ugh infant mortality has declined consider­ably from 136 per 1,000 live births in 1960 to 76 per 1,000 in 1990 in developing countries, this rate is still five times higher than that for devel­oped countries (15 per 1,000 in 1990) (Table A). Infant mortality is considered an indicator of development since it is associated with the life expectancy. In countries where the expectation of life is high, the level of infant mortality is usually low and the reverse, high infant mortality is attended by low life expectancy (Figure A). Mortality among children under five dropped from 135 per 1,000 live births in 1975 to 96 per 1,000 in 1990 (varying between 11 per 1,000 in industrial­ized countries to 175 per 1,000 in Sub-Sahara Africa) (World Bank, 1993). This level is, however, still higher than the target set at the 1990 World Summit for Children which is the reduction of the child mortality to a level of 70 per 1,000 births during the 1990s (World Bank, 1993).

In the nineties population growth and demographic changes, inclu­ding increasing urbanization, pose direct threat to health when, as a result of poverty, they are rapid and uncontrolled. Two demographic pressures likely to have the greatest implications for the people’s health status are popula­tion ageing and urbani­zation (WHO, 1990). The young adults are continually moving to the cities, leaving behind the elderly population, often severing the traditional social support structures for the aged. WHO estimates that in developing countries the proportion of populations living in urban areas will rise to nearly 40 % by the end of the decade, compared with 75 % for developed countries. By that time 18 cities in the Third World will have populations greater than 10 million most of whom will be living in poverty (WHO, 1990:4).

Population ageing is procee­ding steadily in industrialized countries. The low-fertility-low-mortality demo­graphic régime in most indus­trialized coun­tries is responsible for the trend of popula­tion ageing (UN, 1993a). Some newly indus­trializing countries are already facing ageing of the population and its consequences such as labour shortage (e.g., Republic of Korea and Singapore). Great disparat­ies in age structure between countries are prevail­ing since the process of ageing is divergent. The proportion of children under 15 years is lower in industrialized countries than in deve-  l­oping countries. On the other hand, the proportion of elderly persons aged 65 years and older is higher in industrialized countries as compared with that in developing countries (Table B and Fig. 1). Most coun­tries in Africa still have a young popula­tion whereas coun­tries in Europe and Northern America have an old age dis­tribution.

Although population ageing in developing countries is not yet as serious as in industrialized coun­tries, developing coun­tries will house the great share of elderly persons. The share of senior persons living in developing countries is rising from 56.2 per cent of the total number of aged persons in 1990 (i.e. 325.7 million) to 69.7 per cent in 2025 (809.3 million) (UN, 1994). As development progresses developing countries will also be confronted with the consequences of an ageing population. In 2025 almost one out of five persons living in devel­oped coun­tries will be 65 years or older. By that time 8 per cent of the population in developing countries will be at ages 65 years or over. This is equal to the level of developed countries in the 1960s (Table B).

 2. Health for all

The strategy for coping with diseases and health problems started with curative approach, meaning, treating diseases and illnesses that are already occurred on an individual and manifested in various symptoms. Medical scientists then made numerous studies to understand the etiology and onset of diseases and developed therapy and medicine for each disease. However, combating the disease alone is not sufficient. One must also be able to prevent the disease from occuring and spreading, contaminating other people. This idea of disease prevention was realized two centu­ries ago (1798) when the first vaccine was discovered by a British physician Edward Jenner and proved to be effective for preventing smallpox.

Further development in medical sciences results in the discovery and production of more vaccines that can protect people from being infected with certain diseases. Vaccination programmes were developed and applied at national, regional as well as global levels. With the worldwide success of vaccination programmes the role of preventive medicine gained importance. Preventive methods other than immunization were also explored. Along with immuniza­tion programmes, health education campaigns were developed to raise the people’s awareness of the importance of maintaining a good health status and that vaccination is an important means to prevent illness. The general health strategy was then shifted from cure only to cure and prevention.

Being aware that prevention is better than cure, the WHO has put an emphasis on preventive measures in its global health strategy. These preventive efforts are to be made not only by medical personnel but also by the people themselves, i.e. the community at large. This approach is known as Primary Health Care (PHC) strategy was declared at the Alma Ata conference in 1978 as the mechanism for achieving the goal of Health for All by the Year 2000. In this declaration PHC was defined as “the essential health care based on practical, scientifically sound and socially accepted methods and technology, made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afforrd to maintain at every stage of their development in the spirit of self-reliance and self-deter­mination” (WHO, 1978:2). PHC forms an integral part of a coun­try’s health system. Apart from the overall responsibility of govern­ments for the health of their people, individuals, families and communities will assume a great responsibility for their own health and welfare, includ­ing self-care (Koesoebjono-Sarwono, 1993).

Rapid population growth increases the demand for health services. Yet health budgets for developing countries, where population growth rate is high, will not increase proportionately, and even existing health budgets do not provide total coverage with PHC services (WHO, 1990:4). In industrialized countries health expenditure counted for 9.2 % of the GNP in 1990 as compared with 4.7 % in developing countries and 8.1 % for the whole world. In industrialized countries as much as US $ 1,860 per person was spent for health expenditures whereas in developing countries the amount was $ 41 per person (World Bank, 1993:52, 211). Looking at these facts, drama­ti­cally altered strategies for finan­cing and organizing health care are essential.

Considering the persistent disparities within and between coun­tries, the PHC strategy is added with another element, equity, which incorporates the idea of universal coverage and care according to the need (WHO, 1990:8). Equity can be described as full and equal access for all people to income, resources and social services, including health services. By narrowing the gaps in health status between the highest and lowest income groups, it is expected that distribution of material benefits can be made more equitable and therefore resulting in a higher degree of self-reliance.

To reach equity, solidarity is needed. Solidarity can be achie­ved, if not encouraged, through favourable national and internati­onal political, economic, social and cultural environment. Government’s and public as well as private organizations ought to cooperate to meet the basic human needs of all people including the poor and vulnarable groups. In the field of health develop­ment, solidarity can be promoted through inter-sectoral coopera­tion within one country and international cooperation between coun­tries to ensure universal access to basic health services. Solidarity can be activated through community participation in the improvement of the people’s health and community action at individual and community levels. Intergroup solidarity is instru­mental for the creation and provision of services for all people and equity enhances a sense of solidarity between peoples within a country and between countries. Mutual interrelationship between equity and solidarity is contributory to promoting equality in the people’s health status. Equity and solidarity are the latest trend recommended by WHO as the key components in developing global strategies of the 1990s to ensure the achievement of the targets of Health for All by the Year 2000 (WHO, 1994).

 3. Preparing for a care society

The lengthening of the life span is not necesarily be accom­panied by improvements in the quality of life (World Bank, 1993; INSERM, 1994). Pro­gress in medical science and technology gives the opportunity for active functioning in daily life to individu­als who otherwise would not be able to do so, for instan­ce the disabled and elderly persons. In other words those who survive but become disabled persons, might have died should they live a few decades earlier, when the average life span was lower and medical technology was still underdeveloped. The growing number of elderly persons which is the conse­quence of an ageing popula­tion, will be accompanied by an increase in the numbers of elderly disabled since the level of disability rises as from the age 50 to 54 years (Yu, 1991). These people also need (health) care. The relevance of disability can be illustrated by the 1988 figures from the United Kingdom. The prevalence of disability rises steadily from 38 per 1,000 for children aged 5-9 years to 79 per 1,000 at ages 45-49 years and 205 per 1,000 at ages 60-64 (Pickin and St. Leger, 1993).

Changes in disease pattern is associated with changes in age structure of a popula­tion. As health improves with the passage of time, the distribution of deaths is shifting from the younger ages to the middle and elderly age-groups. The general pattern shows that in high mortality countries the impact of health improvements is taking place mostly among young children. The trend declining of infant mortality is relevant for the rise of longevity until it reaches a level af around 65 or 70 years. Beyond this level a further gain of average life span is conse­quence of the decrease of mortal­ity at middle and higher ages (Koesoe­bjono et al., 1989; Vallin, 1992). By contrast, in industrialized countries more than two-third of deaths occurred at ages 65 years and over and only 3 per cent was at ages under 5 years. In develop­ing coun­tries just over a quarter of all deaths took place among senior citizens and more than one-third among children under five years (UN, 1993:41).

Changes in disease pattern is associated with changes in age structure of a popula­tion. As health improves with the passage of time, the distribution of deaths is shifting from the younger ages to the middle and elderly age-groups. The general pattern shows that in high mortality countries the impact of health improvements is taking place mostly among young children. The trend declining of infant mortality is relevant for the rise of longevity until it reaches a level af around 65 or 70 years. Beyond this level a further gain of average life span is conse­quence of the decrease of mortal­ity at middle and higher ages (Koesoe­bjono et al., 1989; Vallin, 1992). By contrast, in industrialized countries more than two-third of deaths occurred at ages 65 years and over and only 3 per cent was at ages under 5 years. In develop­ing coun­tries just over a quarter of all deaths took place among senior citizens and more than one-third among children under five years (UN, 1993:41).

The declining mortality at young ages is the result of the reduction of communicable diseases such as infectious, parasitic and respiratory diseases. Once mortality at these ages has been reduced, the focus of health improve­ment is shifted to the middle and higher ages, among whom non-communi­cable diseases such as cardiovascular diseases and cancer are gaining importance. The epidemiological transi­tion shows that infec­tious diseases are being replaced by non-com­municable diseases as major causes of deaths. In other words, the length­en­ing of the average life span is at the start due to the fall of communi­cable diseases at younger ages. A further decrease of mortality means focusing health efforts on control­ling diseases other than communi­cable diseases, which are less responsive to measures. This transi­tion is linked to changes in life-style, environ­ment and to the trend towards an ageing popula­tion (WHO, 1991).

The process of shifting mortality and disability pattern from young to older ages is proceeding in present-day develop­ing countries. However, while still struggling with communicable diseases as the prime cause of high mortality among children under the age of five, many of these countries are also experien­c­ing similar disease pattern occurring in more developed coun­tries. These countries are facing the double burden of communica­ble disease and nutrient defi­ciency as well as “disease of afflu­ence” of the more advanced societies. Moreover, tropical diseases are showing a disturbing re-emergence and the AIDS pandemic continues spreading.

Given the shift in demographic structures and disease patterns it can be assumed that the emphasis of global health strategy needs to be shifted as well. Preventive and curative measures will remain important but care services will get an increasingly important role. Care services here include care for the sick, aged, physically and mentally handicapped and disabled. Centres for training, therapy and revalidation as well as institutions for old people and the handicapped will have to be developed. Consequently, health budget is to allocate greater funds for establishing infrastructures, medical technology, apparatus and appliances, and for providing trained personnel in the field of care (nurses, physiotherapists, speech therapists, social wor­kers, etc.).

Complementing the government’s efforts, care services should also be provided­ by the community itself. The community can establish care institu­tions and provide all kinds of activities aimed at helping the aged and disabled to better function in the society. Voluntary as well as paid services will enhace this care service. Care begins at home. Therefore individuals and families can contribute in this service. Care comprises more than just medical care as people experience and react differently to illnesses. Illness is frequently accompanied by symptoms of anxiety and distress which require comfort and personal attention from the care taker. For that prupose, training programmes are needed to equip the individu­als and families with the basic knowledge and skills to help the sick/homebound, aged or disabled family members. It is evident that health education and information will become the core of the care-society (Koizumi, 1985). Comprehensi­ve health infor­mation will make people better prepared to care for themselves, their family and others.

The idea of involving individuals, families and community groups in provid­ing care for the disabled and aged is in congruence with the essence of PHC, which suggests the community members to take responsibility for their own health and welfare, including self-care. Moreover, involving community members in providing care will promote the community’s self-reliance in this care-society.




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*)   Solita Sarwono, Public health educator and psychologist

**) Santo Koesoebjono, Economist-demographer


Publ. in Majalah Kesehatan Perkotaan, Tahun IV, 1997, No. 1, pp.37-44.



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