Health, ageing and public policies in European Union.


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Health, ageing and public policies in European Union.

  1. 1. Directorate-General for Research WORKING PAPER HEALTH, AGEING AND PUBLIC POLICY Social Affairs Series
  2. 2. Health, Ageing and Public PoliciesThe original working paper is available in EN.Author: José Antonio Camacho CondeSupervisor: Lothar Bauer Division for Employment and Social Affairs Directorate-General for Research Tel.: + (352) 4300 22575The opinions expressed is this working paper are those of the author and do not necessarily representthe official position of the European Parliament.Manuscript completed in June de 2001. 3
  3. 3. Health, Ageing and Public Policies CONTENTS1. INTRODUCTION………………..……………...……………………..........................................62. DEVELOPMENT OF PUBLIC HEALTH POLICY IN THE COMMUNITY ……...............73. LAW CONCERNED.......................................................................................................................93.1.Decisions.........................................................................................................................................93.2.Resolutions....................................................................................................................................114. CHALLENGES FOR AN EUROPEAN AGEING.…………..................................................134.1. Health and Social Service Systems..............................................................................................134.2. Social Protection...........................................................................................................................144.3. Feminization of Ageing................................................................................................................154.4. The Challenge of Dementia..........................................................................................................164.5. Prevention and Care......................................................................................................................174.6. Violence and Abuse......................................................................................................................175. PUBLIC POLICIES IN AGEING...............................................................................................185.1. Intersectorial Policy Objectives....................................................................................................185.2. Policies for the Future...................................................................................................................226. PROGRAMMES AND PROJECTS IN EUROPEAN COMMUNITY....................................286.1. Health Programmes......................................................................................................................286.1.1. Health Programme 1999............................................................................................................296.1.2. Health Programme 2000............................................................................................................306.1.3. Health Programme 2001............................................................................................................316.2. Elderly Programmes.....................................................................................................................316.3. Health and Ageing Projects: Alzheimers Disease.......................................................................326.4. European Crisis in the Financing of Alzheimers Projects...........................................................337. CONCLUSION………...…………..…………………………….................................................34BIBLIOGRAPHY...…………………………..……………………….............................................35ANNEXES …..…………….………………………………………..................................................38 4
  4. 4. Health, Ageing and Public PoliciesAnnex I: Decision No 372/1999/EC of the European Parliament and of the Council of 8 February1999 adopting a programme of Community action on injury prevention in the framework for actionin the field of public health (1999 to 2003).........................................................................................39Annex II: Decision No 1295/1999/EC of the European Parliament and of the Council of 2April 1999 adopting a programme of Community action on rare diseases within the framework foraction in the field of public health (1999 to 2003)..............................................................................44Annex III: Decision No 521/2001/EC of the European Parliament and of the Council of 26 February2001 extending certain programmes of Community action in the field of public health adopted byDecisions No 645/96/EC, No 646/96/EC, No 647/96/EC, No 102/97/EC, No 1400/97/EC and No1296/1999/EC and amending those Decisions....................................................................................49Annex IV: Council Resolution of 8 June 1999 on the future Community action in the field of publichealth...................................................................................................................................................57Annex V: Council resolution of 18 November 1999 on the promotion of mental health...................59Annex VI: European Parliament Resolution of 17 April 1996 on Alzheimers disease and theprevention of disorders of the cognitive functions in the elderly........................................................61Annex VII: European Parliament Resolution of 11/03/98 on Alzheimers disease............................63 5
  5. 5. Health, Ageing and Public Policies1. INTRODUCTIONThe EU Treaty provided a major impetus by introducing a specific article on public health intothe EC Treaty - Article 129 (now renumbered Article 152). However, since most power in thissector remains in the hands of the Member States, the Communitys role is subsidiary andmainly involves supporting the efforts of the Member States and helping them formulate andimplement coordinated objectives and strategies. The Treaty of Amsterdam is designed toimprove matters by amending the wording of Article 152 (ex Article 129) of the EC Treaty.Originally the Treaty of Rome did not contain any formal legal basis for measures in the field ofpublic health. However, since 1997, a Council of the Ministers of Health began to meet on anoccasional basis. These meetings resulted in acts such as "decisions of the Member Statesmeeting within the Council" or non-binding resolutions. Following the signature of the SingleEuropean Act, instruments of this kind - whose legal impact is sometimes uncertain - began toproliferate. Public health was finally enshrined in the Treaty on European Union with theinsertion of a "Public Health" title, which opened the way to formal cooperation betweenMember States in this area. In parallel, Article 3 raised health protection to the rank of aCommunity objective.Since then Community measures have focused on horizontal initiatives providing forinformation, education, surveillance and training in the field of health, the drafting by theEuropean Commission of reports on the state of health in the European Community and theintegration of health protection requirements into the Community policies. Moreover, globalmultiannual programmes have been mounted in priority areas such as cancer, drug addiction,AIDS and transmissible diseases.Community action has also assumed other forms, for example in the fields of transmissiblediseases, blood and tobacco and - in the context of completing the Single Market - through theadoption of legislation on veterinary and phytosanitary controls, or again, in the field ofbiotechnology, through the funding of research work.As far as general health trends are concerned, it would appear that the population of the EUenjoys excellent health. Nevertheless, the following serious problems remain:- high levels of premature death (one fifth of all deaths occur before the age of 65) fromdisorders related to particular lifestyles, such as alcohol abuse, drug consumption and smoking;- new risk factors linked to the emergence of new diseases, e.g. variant CJD and diseasestransmitted from the food chain;- the reappearance of infectious diseases such as tuberculosis, exacerbated by drug resistance;- an increase in age-related diseases (e.g., Alzheimers disease).In the next 20 years Europe will be one of the areas of the world with the most pronouncedageing trends. In 2025, the share of the above 60 age group in Europe and Japan will be around30% compared to 255 in North America. Projections show also that others countries, like Chinawill be confronted with similar demographic ageing trends 20 years later. Finally, populationgrowth in North America will continue to be relatively strong and the ageing trend will remainweaker than in Europe. 6
  6. 6. Health, Ageing and Public PoliciesEurope is entering into period of accelerating population ageing. However, the existingevidence shows that the regions of the EU are unevenly affected by demographic trends. Thisasymetrical demographic impact adds to an already diversified regional environment.The phenomenon will extend to the majority of EU regions, which will see their populationstagnating or declining before 2015. The younger generation, the 0-24 age group, representing31% of population in 1995, will be reduced to 27% in 2015, a decline of 11 millions. In someregions in Germany, Italy, Spain and France the younger generation will represent less than 25per cent. The retired generation (65+) will increase, significantly and unevenly, throughoutEurope. In some regions of France, Italy and Spain the 80+ generation will represent between 7and 9 per cent of population (compared with 3,9 per cent as an average 1995).In most cases the speed of ageing process will increase after 2010. This will become clearer inthe 5 year period between 2010. The number of people aged 65 and over will then increase by asmuch as 19% (Finland) or 17% (Netherlands), against an average of 7,6% 7 out of 15 countrieswill have increases over 10%.Ageing is clearly a major public policy issue in Europe. The growing acceptance of a need toprotect the rights and freedoms of elderly people and to secure both their full inclusion withinsociety and a right to equality of opportunity is manifest in recent legislative and constitutionaldevelopments within a number of Member States.In addition, the Commission adopted a Communication on "Towards a Europe for all Ages -Promoting Prosperity and Intergenerational Solidarity"1 in May 1999 which sets out theimplications of ageing of population in employment, social protection, health and social servicesand proposes a strategy for effective policy responses in these fields, based on strengthening co-operation amongst all actors and solidarity and equity between generations.The adoption of the Amsterdam Treaty and Agenda 2000 has provided both a platform andfurther political momentum for the strengthening of age policies at European level.2. DEVELOPMENT OF PUBLIC HEALTH POLICY IN THE COMMUNITYThe Community can now adopt measures aimed at ensuring (rather than merely contributing to)a high level of human health protection. To stimulate a broad debate on the overall direction ofthe future Community public health policy in order to be able to put forward concrete proposalsonce the Treaty of Amsterdam has been ratified.The new Article 152 (ex Article 129) of the EC Treaty has a wider scope than before. Amongthe areas of cooperation between Member States, the new Article lists not only diseases andmajor health scourges but also, more generally, all causes of danger to human health, as well asthe general objective of improving health.The Council may also adopt measures setting high quality and safety standards for organs andsubstances of human origin, blood and blood derivatives. Veterinary and plant-health measures1 Commission of the European Communities. Communication from the Commission to the UN International Yearof Older Persons. Towards a Europe for All Ages: Promoting Prosperity and Interganerational Solidarity, Brussels21.05.1999 COM(1999) 7
  7. 7. Health, Ageing and Public Policiesdirectly aimed at protecting public health are now adopted under the codecision procedure . Thisis a new departure, as the European Parliament previously only had a right to be consulted onthe adoption of health measures linked to agriculture.The Community strategy on public health is in need of fundamental revision in order to be ableto cope with a number of major developments, such as new health threats, the increasingpressures on health systems, the enlargement of the Community and the new provisions of theTreaty of Amsterdam.In recent decades, the health of the Community population has improved dramatically, as shownby the fact that life expectancy at birth has risen by five years since 1970. While there is everyreason to welcome this development, it must not be allowed to hide the fact that there are stillserious health problems in the Community: • one person in every five still dies prematurely (before the age of 65) from avoidable diseases, particularly relating to lifestyle, or as a result of accidents; • new risks to health are emerging, especially from communicable diseases; • there are still wide variations in health status from one socio-economic stratum to another; • the ageing of the population is giving rise to a substantial increase in diseases related to old age, such as Alzheimers disease.Community public health policy must take account of both the prospects of enlargement and theworld context. Of course, the cooperation with international organisations, such as the WorldHealth Organisation (WHO), is also necessary to address threats to health at the global level.Although health issues have featured in the Treaties since the beginnings of the construction ofEurope, it is only since the ratification of the Treaty of Maastricht that the Community has beenable to implement a genuine public health strategy: five specific action programmes (cancer,AIDS, drug dependence, health promotion and health monitoring) have been adopted and threeothers proposed (rare diseases, injuries, pollution-related diseases) alongside other initiatives(reports on the state of health in the European Community, recommendations on the safety ofblood products, etc.). In addition, a number of other Community policies have an impact onhealth.The Commission has drawn the following conclusions from the experience gained inimplementing the 1993 framework of action: • the approach involving distinct action programmes has made it possible to overcome the differences between Member States as regards the order of priorities; • on the other hand, it has led in practice to a considerable administrative burden, a lack of flexibility, a dispersion of financial resources and difficulties of coordination between the programmes.In the last two years, several developments, such as the "mad cow" crisis, have contributed to anew awareness of the importance of health policy at Community level. The extension of thelegal basis of the Communitys public health activities in the Amsterdam Treaty reflects thisgrowing interest. 8
  8. 8. Health, Ageing and Public PoliciesIn order to meet this demand, the Commission considers that the future Community policyshould comprise three strands of action: • improving information for the development of public health: building on the activities and outputs of the programme on health monitoring, a structured and comprehensive Community system should be developed for collecting, analysing and disseminating information on general trends in the populations health status and health determinants and on developments concerning health systems; • reacting rapidly to threats to health: this involves creating Community surveillance, early warning and rapid reaction mechanisms to meet the threats to health which might arise at any time (the proposal to create a European network for communicable disease surveillance and control is already contributing to this objective); • tackling health determinants through health promotion and disease prevention: this third strand comprises actions aimed at strengthening individuals ability to improve their health, including social, economic and environmental conditions, and the many activities linked to prevention (vaccination, screening, etc.).Implementation of these three strands would facilitate compliance with the provisions of theTreaty regarding the incorporation of health requirements in all Community policies.3. LAW CONCERNED3.1. Decisions- Decision No 645/96/EC of European Parliament and of Council of 29 March 1996 adopting aprogramme of Community action on health promotion, information, education and trainingwithin the framework for action in the field of public (1996 to 2000)2The objetive of this programme was to contribute towards ensuring a high level of healthprotection and comprised actions aimed at: encouraging the health promotion approach inMember States health policies by lending support to various cooperation measures (exchangesof experience, pilot projects, networks, etc.); encouraging the adoption of healthly lifestyles andbehaviour; promoting awareness of risk factors and health-enhancing aspects; encouragingintersectorial and multidisciplinary approaches to health promotion, taking account of the socio-economic factors and the physical environment necessary for the health of individual and thecommunity, especially for disadvantaged groups.- Decision No 646/96/EC of the European Parliament and of the Council of 29 March 1996adopting an action plan to combat cancer within the framework for action in the field of publichealth (1996 to 2000)3- Decision No 647/96/EC of the European Parliament and of the Council of 29 March 1996adopting a programme of Community action on the prevention of AIDS and certain othercommunicable diseases within the framework for action in the field of public health (1996 to2000)42 OJL 95, 16.4.1996, p.1.3 OJ L 95, 16.4.1996, p. 9.4 OJL 95, 16.4.1996, p. 16. 9
  9. 9. Health, Ageing and Public Policies- Decision No 1400/97/EC of the European Parliament and the Council of 30 June 1997adopting a programme of Community action on health monitoring within the framework foraction in the field of public health (1997 to 2001)5.- Decision No 372/1999/EC of the European Parliament and of the Council of 8 February 1999adopting a programme of Community action on injury prevention in the framework for action inthe field of public health (1999 to 2003)6.A programme of Community action on injury prevention, hereinafter referre to as "thisprogramme", is hereby adopted for the period from 1 January 1999 to 31 December 2003 in theframework for action in the field of public health. The aim of this programme shall be tocontribute to public health activities which seek to reduce the incidence of injures, particularlyinjuries caused by home and leisure accidents, by promoting: the epidemiological monitoring ofinjuries by means of a Community system for the collection of data and the exchange ofinformation on injuries based on strengthening and improving on the achievements of theformer EHLASS system; information exchanges on the use of those data to contibute to thedefinition of priorities and better prevention strategies.- Decision No 1295/1999/EC of the European Parliament and of the Council of 29 April 1999adopting a programme of Community action on rare diseases within the framework for action inthe field of public health (1999 to 2003)7.A programme of Community action on rare diseases, incluiding genetic diseases, hereinafterreferred to as "this programme", is adopted for the period from 1 January 1999 to 31 December2003 within the framework for action in the field of public health. The aim of this programme isto contribute, in coordination with other Community measures, towards ensuring a high level ofhealth protection in relation to rare diseases by improving knowledge, for example by promotingthe setting-up of a coherent and complementary European information network on rare diseases,and facilitating access to information about these diseases, in particular for health professionals,researchers and those affected directly or indirectly by these diseases, by encouraging andstrengthening transnational cooperation between voluntary and professional support groups forthose concerned, and by ensuring optimum handling of clusters and by promoting thesurveillance of rare diseases.- Decision No 1296/1999/EC of the European Parliament and of the Council of 29 April 1999adopting a programme of Community action on pollution-related diseases in the context of theframework for action in the field of public health (1999 to 2001)8.- Decision No 521/2001/EC of the European Parliament and of the Council of 26 February 2001extending certain programmes of Community action in the field of public health adopted byDecisions No 645/96/EC, No 646/96/EC, No 647/96/EC, No 102/97/EC, No 1400/97/EC andNo 1296/1999/EC and amending those Decisions9.A number of programmes of Community action within the framework for action in the field ofpublic health expired at the end of 2000:5 OJL 193, 22.7.1997, p. 1.6 C.f. Annex I: Decision No 372/1999/EC (OJ L 46, 20.2.1999, p. 1.)7 C.f. Annex II: Decision No 1295/1999/EC (OJ L 155, 22.6.1999, p. 1.)8 OJ L 155, 22.6.1999, p. 7.9 Annex III: Decision No 521/2001/EC (OJ L 079, 17.03.2001, p. 1.) 10
  10. 10. Health, Ageing and Public Policies- the programme of Community action on health promotion, information, education andtraining, adopted by Decision No 645/96/EC of the European Parliament and of the Council10,- the action plan to combat cancer, adopted by Decision No 646/96/EC of the EuropeanParliament and of the Council11,- the programme of Community action on the prevention of AIDS and certain othercommunicable diseases, adopted by Decision No 647/96/EC of the European Parliament and ofthe Council12,- the programme of Community action on the prevention of drug dependence, adopted byDecision No 102/97/EC of the European Parliament and of the Council13.The following expire at the end of 2001:- the programme of Community action on health monitoring, adopted by Decision No1400/97/EC of the European Parliament and of the Council14,- the programme of Community action on pollution-related diseases, adopted by Decision No1296/1999/EC of the European Parliament and of the Council15.In its Resolution of 8 June 1999 on the future Community action in the field of public health16,the Council stressed the need for continuity of Community action in the field of public health inthe light of the perspective of expiry of existing programmes.In its Communication of 15 April 1998 to the European Parliament, the Council, the Economicand Social Committee and the Committee of the Regions on the development of public healthpolicy in the European Community, the Commission indicated that existing public healthprogrammes will be coming to an end from the end of year 2000 onwards and stressed that thereis a need to ensure that there is no vacuum in Community policy in this important field. Thesubsequent debate on that communication resulted in a consensus among the Communityinstitutions in favour of developing a new health strategy with an overall public healthprogramme of action.While a new strategy and proposals for a new, overall, public health programme are beingconsidered, the present programmes in the public health area should be extended until the end of2002 in order to avoid any interruption in the Community action concerned. For theprogrammes which are due to expire on 31 December 2000, provision should be made for atwo-year extension over two successive years for the period from 1 January 2001 to 31December 2001 and for the period from 1 January 2002 to 31 December 2002, respectively, andfor the annual division of the financial framework implementing the programmes in question.- Proposal for a decision of the European Parliament and of the Council adopting a programmeof Community action in the field of public health (2001-2006).The overall aim of the public health programme should be to make a contribution towards theattainment of a high level of health protection by directing action towards improving public10 OJ L 95, 16.4.1996, p. 1.11 OJ L 95, 16.4.1996, p. 9.12 OJ L 95, 16.4.1996, p. 16.13 OJ L 19, 22.1.1997, p. 25.14 OJ L 193, 22.7.1997, p. 1.15 OJ L 155, 22.6.1999, p. 7.16 OJ C 200, 15.7.1999, p. 1. 11
  11. 11. Health, Ageing and Public Policieshealth, preventing human illness and diseases, and obviating sources of danger to health. Actionshould be guided by the need to prevent premature death, increase life expectancy withoutdisability or sickness, promote quality of life and physical and mental well-being, and minimisethe economic and social consequences of ill health, thus reducing health inequalities. Achievingthis aim, and the general objectives of the programme requires effective cooperation of theMember States, their full commitment in the implementation of Community actions, and theinvolvement of actors in the health field as well as the public at large.In accordance with the principles of subsidiarity and proportionality set out in Article 5 of theTreaty, Community action on matters which do not fall within the exclusive competence of theCommunity, such as public health, should be undertaken only if and insofar as, by reason of itsscale or effects, its objective can be better achieved by the Community. The objectives of theprogramme cannot be sufficiently accomplished by the Member States because of thecomplexity, transnational character and lack of complete control at Member State level over thefactors affecting health status and health systems. The programme will enable the Community tocontribute towards fulfilling its Treaty obligations in the field of public health while fullyrespecting the responsibilities of the Member States for the organisation and delivery of healthservices and health care. This Decision does not go beyond what is necessary to achieve thoseobjectives.The measures under the programme underpin the health strategy of the Community and willyield Community added value by responding to needs in health policy and health systemsarising out of conditions and structures established through Community action in other fields, byaddressing new developments, new threats and new problems for which the Community wouldbe in a better position to act to protect its people, by bringing together activities undertaken inrelative isolation and with limited impact at national level and by complementing them in orderto achieve positive results for the people of the Community, and by contributing to thestrengthening of solidarity and cohesion in the Community.The programme should last six years in order to allow sufficient time to implement measures toachieve its objectives. It is essential that the Commission should ensure implementation of theprogramme in close cooperation with the Member States.3.2 Resolutions- Council Resolution of 8 June 1999 on future Community action in the field of public health17The Council reiterates its position concerning future action in the health field and emphasisesthe need for transparency in order to promote better knowledge and greater involvement on thepart of citizens.The Commission was preparing a series of documents relating to the public health sector: • a communication; • a proposal for a decision on an action plan;a proposal for a decision extending the Community action programmes due to end in 2000.- Council resolution of 18 November 1999 on the promoting of mental health18.17 C.f. Annex IV: Council Resolution of 8 June 1999 on future Community action in the field of public health (OJ C200, 15.07.1999) 12
  12. 12. Health, Ageing and Public Policies- Council Resolution of 18 November 1999 on ensuring health protection in all Communitypolicies and activities19.- European Parliament Resolution of 17 April 1996 on Alzheimers disease and the preventionof disorders of the cognitive functions in the elderly20.- European Parliament Resolution of 11 March 1998 on Alzheimers disease21.4. CHALLENGES OF AN EUROPEAN AGEING4.1. Health and Social Service Systems The state of health in the European Union is better than ever before. This is due to spectacularprogress made over the second half of this century in terms of medical research, health servicesprovision and living conditions. However, older people require more, and substantiabillydifferent, health and social services than younger people. The central challenge of the policymakers is ensure that the future health care policies will provide an adequate and cost effectivereponse to the changes brought about by demographic trends.The rising cost of health and care system and the need for structural reform constitute key issuesfor the present and the future of social protection sytems. Today the main focus of discussion onhealth and care policies can be resumed as follows:- how to balance quality and costs;- how to reduce persistent gaps in the equity of health care systems, improving health conditionsamong the most vulnerable age and income groups.The majority of older old age group (over 80 years) needing permanent assistance and care areattended to at home by their families, while the proportion of profesional services provided isstill rather low. In the future, families will be less and less able of assuming the increasing caretasks. The role of both formal and informal carers will be of incresing importance. Moreprofessional services like home nursing, old age assistance, old age apartments will be needed.The role of civil society in providing health and care services is also of particular importance.Older people require more, and substantially different, health and care services than youngerpeople. The following factors are typical of the morbility of older populations:- Higher incidence: older persons tend to fall ill more frequently.- Old age diseasescertain diseases like cancer, cardiovascular disease, physical disabilities andmental disorders are found primarily among the old age group.18 Annex V: Council resolution of 18 November 1999 on the promoting of mental health (OJ C 086, 24.03.2000, p.1.)19 OJ C 086, 24.03.2000, p. 3.20 C.f. Annex VI: European Parliament Resolution of 17 April 1996 on Alzheimers disease and the prevention ofdisorders of the cognitive functions in the elderly.21 C.f. Annex VII: European Parliament Resolution of 11 March 1998 on Alzheimers disease. 13
  13. 13. Health, Ageing and Public Policies- Chronicity: older people generally take a longer time to recover from desease and there is ahigher risk of diseases turning into chronic conditions. Dementia is a typical old age disease forwhich profesional care services are often needed.- Multi-morbility: older persons run a higher risk of suffering from several diseases andimpairments at the same time.Concerning the future, although predictions concerning the longer term remain highlyspeculative, the following developments may be expected for the next 10-15 years:- due to advances made in modern medicine, mortality rates will tend to decrease cannot bepredicted- the advances in medicine might have rather limited effects on chronic diseases and physicalimpairments among the very old age group.- the increasing importance of carersStatistics show that 30% of people over 65 have special needs. This percentage increasessignificantly after 75. The widely quoted survey in Germany (Schneekloth and Potthoff, 1993)shows that 72% of main carers of those in need nursing care (at all ages) are not employed, 5%are working at a low level, 7% are employed part time and 10% are in full employment.However, among carers aged 18-64, two thirds were in employment when caring began;subsequently, at least a quarter of these had reduced their working hours.Health systems need to take a life course perspective that focuses on health promotion, diseaseprevention, equitable access to primary care and a balanced approach to long-term care. Healthand social services need to be integrated, equitable and cost-effective.Long-term care includes both informal and formal support systems. The latter may include abroad range of community and public health, primary care, palliative care and rehabilitationservices as well as institutional care in supportive housing, nursing homes, hospices, etc. andtreatments to halt or reserve the course of disease and disability. Mental health services shouldbe an integral part of long-term care. The under-diagnosis of mental illness, particularly ofdepression in older people is increasingly recognized.One of the greatest challenges in health policy is to strike a balance among support for self-care(older people looking after themselves), informal support (family members and friends helpingto care for older people) and formal care (health and social services).Family members (mostly women) and neighbours provide the bulk of support and care to olderadults that need assistance. Some policy makers fear that providing formal care services willlessen the involvement of families. The research shows that this is not the case. Whenappropriate formal services are provided, informal care remains the key important partner(WHO, 1999).4.2. Social ProtectionIn all Member States, families provide the majority of support for older people who requirehelp. They are increasingly called on to develop mechanisms that provide social protection forolder people who are unable to earn a living are alone and vulnerable. Social protection 14
  14. 14. Health, Ageing and Public Policiesmeasures can include old age pensions, inkind services, occupational pensions schemes,mandated contribution programmes, savings incentives programmes, compulsory savings fundsand disability, health and unemployment insurance programmes.The operational and financial structures of publicly funded social protection sytems wereestablished decades ago. However, the basic needs to wich they respond remain important. Theeconomic and social conditions under which they operate have changed and will keep changingover the next years. Social protection systems will need to be adapted to:- The changing nature of work and the need to improve flexibility but also maintain security;- The change in gender balance in working life and the growing importance of gender issuesboth at work and the social protection;- The implications of demographic change on dependency ratios and the need to expand activityrates and employment opportunities;The increasing need for co-ordination within the European Union.Increasing the number of people in work can have the effect of stablilising or even reducing thedependency ratios of elderly, despite the increasing age of population. The decline of workingage population over the next decades may also contribute in fighting unemployment, if theappropriate policy adjustments take place in time.Finally, informal intergenerational solidarity may also play an increasing role. In consideringsocial protection reforms, policy markers should take into account all these dimensions. What isneedes is a good balance between long-term financial sustainability, intergenerational solidarityand equity between generations.4.3 Feminization of AgeingWomen live longer than men in almost all areas of the world. The variation between male andfemale life expectancy in the European Union has considerable consequences for old people. Inthe 60-64 year age group there are roughly the same numbers of men and women but increasingage, the imbalance between the sexes increases so that in the 80 to 84 year old group there aretwo women to every man and in the 90 to 94 year old group the ratio is three to one. The factthat there are many more elderly (and particularly very elderly) women in the population of theEuropean Union has significant implications for care, since elderly women tend to suffer higherlevels of disability than men of the same age (Martin, Meltzer & Elliot, 1988). Elderly womenare more likely to live alone, more likely to have low incomes and more likely to be widowedthan men (Dooghe, 1993). For example , in the Eastern European countries in economictransition over 70 percent of women age 70 and over are widows (Botev, 1999). Thesecumulative disadvantages mean that women are more likely than men to be poor and suffersocial isolation in older age.Womens traditional role as family caregivers may also contribute to their increased poverty andill health in older age. Some women are forced to give up paid employment to carry out theircaregiving responsabilities. Others never have access to paid employment because they workfull-time in unpaid caregiving roles, looking after children, older parents, spouses who are illand grandchildren. Thus, the provision of family care is often achieved at the detriment offemale caregivers economic security and good health in later life. 15
  15. 15. Health, Ageing and Public Policies4.4. The Challenge of DementiaIt appears that the number of old people affected by mental deterioration is increasing becausethe drop in mortality among the older elderly. As yet, there are no pharmacological treatmentsfor the various forms of dementia, but the research in this field is progressing. Research in manycountries shows that most of care of elderly people with dementia is undertaken by families anddementia represents perhaps the greatest source of stress for informal carers.Between 1990 and 2010, the number of dementia cases in the more developed countries isprojected to increase from 7.4 million to 10.2 (a 37% increase), the elderly population (aged65+) from 143 million to 185 million (a 30% increase) and the total population in thesecountries is projected to increase from 1,143 million to 1,213 million (a 6% increase). Becauseof the lack of prevalence data from the less developed countries, it is difficult to makeprojections of the future number of dementia cases. However, these countries are also ageingrapidly and are therefore expected to show an increase in dementia cases. Between 1990 and2010 the number of people aged 65 or over in the less developed countries is projected toincrease from 183 million to 325 million (a 78% increase)."In the mid 1990s the European Unions over 65 population represented about 15% of thepopulation. Given the demographics of the post-war generation boom, the situation will onlyintensify. By 2020 the over 65s will make up more than 20% of the total population22." Theprevalence of Alzheimers disease and other kinds of dementia is difficult to establish becausemany cases go undiagnosed. It is estimated, however, that as of the year 2000, approximatelyeight million people among European Union Member States will have Alzheimers disease,according to Alzheimer Europe. Since Alzheimers accounts for only half the cases of dementiaamong people over 65 years of age, total estimates for dementia in Europe are closer to 16million. It is estimated that Alzheimers disease alone strikes 1 in 20 over age 65, or 5 percent ofthe population. Taken together, dementia affects more than one-quarter aged 85 and over and athird to a half of those aged 90 and over. The incidence of all dementias rises with age, nearlydoubling every five years between the ages of 60 and 95, according to the 1991 EURODEMstudy of dementia in Europe (Hofman 1991). In the most recent EURODEM analysis, the studysamples showed an incidence rate of 2.5 per 1,000 person-years at 65 years of age, advancing to85.6 for those 90 years of age and older (Launer 1999).As the population ages and people live longer, the prevalence of Alzheimers disease and otherdementias is destined to grow. In 1990,older people comprised 15 percent of the population inItaly and Germany. By 2020, that percentage is projected to increase to nearly one-quarter of thepopulation, 22.5 percent in Germany and 23.6 percent in Italy (IBRD World Population). Thesituation is further complicated by a projected decline in the working age population.The data clearly indicates differences by country in the proportion of the elderly in thepopulation, ranging from 4.6 percent in Ireland to 7.2 percent in Germany and 8.0 percent inSweden. For all countries there will be an increase in absolute numbers of elderly. The mostrapid increases are expected in Italy, Luxembourg and The Netherlands, where the 75+population is projected to increase by two-thirds over the next two decades. The most rapidgrowth will take place in the 80+ group. Since women outlive men, a disproportionate part ofthese elderly will be women. (Rasmussen, 1999).22 Eurolink Age 1995 16
  16. 16. Health, Ageing and Public PoliciesGiven the demographics, it is clear that each country is facing monumental costs for supportservices and institutional care, and loss of productivity from those who bear the burden of carein the home, primarily women. In most countries, eighty percent of Alzheimers sufferers arecared for by unpaid, informal carers across most countries. However, these traditional supportsystems are severely challenged because of changing family patterns, and the declining ratiobetween older persons and available younger family carers. The prevailing trend is to shiftresponsibilities from public support policies back to the families, responsibilities for whichfamilies are unprepared (Rasmussen, 1999). Dementia is a rising tide and a neglected problemat the same time" (Hofman 1991).4.5. Prevention and careHealth has proved to be highly valued in different European population surveys. Maintaining theabilities of older people by preventing threats to health, or even challenging the ageing processitself, should be of fundamental concern. It is essential to develop strategies for prevention andearly diagnosis that are based on understanding the process of ageing from a physiological aswell as psychosocial perspective. The promotion of health is a great challenge for policy. One ofmyths of ageing is that it is too late to adopt healthly lifestyle behaviours in older age. On thecontrary, engaging in appropiate physical activity, healthly eating, not smoking and usingalcohol and medications wisely in older age can prevent disease and functional decline, extendlongetivity and enhance ones quality of life.In particular, it is important to remember that many carers will themselves be elderly andtherefore subject to the same health problems as elderly people in general. Many studies havetestified to the levels of stress experienced by informal carers as a result of looking after elderlyrelatives and has Evers has observed that "stress perceived" in matters of care is strongly shapedwhat is seen as "justified" or normal by carers. The same "objective stress" is felt verydifferently depending on the self-images of carers and what they perceive as their rights andduties, those of their spouses and likewise as the reponsabilities of the Welfare State (Evers,1992).4.6. Violence and AbuseOlder people are increasingly at risk for violence in times of war and conflict. In peacetime,older people who are frail or live alone may be particularly vulnerable to crimes commited bystrangers such theft, assault and break-and-enter. But the most common form of violence againstolder women) is "elder abuse" committed by family members or others (such as institutionalcaregivers) that are well known to the victims.According to the International Network for the Prevention of Elder Abuse, elder abuse is "asingle or repeated act, or lack of appropriate action occurring within any realtionship wherethere is a expectation of trust which causes harm or distress to an older person". It includesphsysical, sexual, psychological and financial abuse as well as neglect, and is notoriously under-reported in all cultures. It is a violation of human rights and a significant cause of injury, illness,lost productivity, isolation and despair.Domestic and societal violence against older people is an issue for justicie, public health andsocial development. Sustained efforts to increase public awareness of the problem and shiftvalues that perpetuate gender inequities and ageist attitudes are also required. 17
  17. 17. Health, Ageing and Public Policies5. PUBLIC POLICIES IN AGEINGThe ageing of population is a global phenomenon that demands international, national, regionaland local action. In an increasingly connected world, failure to deal with the demographicimperative and rapid changes in disease patterns in a rational way in any part of the world willhave socioeconomic and political consequences everywhere.A policy framework for active ageing is guided by the United Nations Principles for OlderPeople23. These are independence, participation, care, self-fulfillment and dignity. Policy actionaddressing the determinants of active ageing is required in three areas:- Health and independence. When the risk factors (both environmental and behavioural) forchronic diseases and functional decline are kept low and the protective factors are kept high,people enjoy both a longer quantity and quality of life. Older people will remain healthly andable to manage their own lives. Fewer older adults need costly medical treatment and careservices.- Productivity. Older people will continue to make a productive contribution to society in bothpaid and unpaid activities when labour market, employment, education, health and socialpolicies and programmes support their full participation in socioeconomic, cultural and spiritualactivities, according to their capacities, needs and preferences.- Protection. When policies and pro- grammes address the health, social, financial and physicalsecurity needs and rights of older people, older people are ensured of protection, dignity andcare in the event that they are no longer able to support and protect themselves. Families aresupported in their efforts to care for older loved ones.5.1 Intersectoral Policy ObjectivesAttaining the goal of active ageing will require action in a variety of sectors, including health,social services, education, employment and labour, finance, social security, housing,transportation, justice and rural and urban development. All policies need to supportintergenerational solidarity and include specific targets to reduce inequities between women andmen and among différent sub-groups within the older population. Particular attention needs tobe paid to, older people who are poor and marginalized, and those who live in rural areas.The World Health Organization suggests that we can afford to get old if countries, regions andinternational organizations enact "active ageing" polices and programmes that enhance thehealth, independence and productivity of older citizens. The time to plan and to act is now. In allcountries, but in developing countries in particular, measures to help older people remainhealthy and economically active are a necessity, not a luxury. The WHO has exposed the nextKey Policy Proposals:23 The United Nations General Assembly adopted these Principles for Older Persons on 16th December 1991 (ResolutionNo.46/91). 18
  18. 18. Health, Ageing and Public Policies1. Reduce the prevalence of risk factors associated with major diseases and increase theprevalence of factors that protect health and well-being through-out the life course.• Develop culturally-appropriate, population-based guidelines for physical activity for oldermen and women. Provide acces- sible, pleasant and affordable opportunities to be physicallyactive (e.g., safe walking areas and parks) and support peer leaders and groups that promoteregular, moderate physical activity for older people.• Develop culturally-appropriate, population-based guidelines for healthy eating for older menand women that can be used as education and policy tools. Support improved diets and healthyweights in older age through the provision of information (including information specific to thenutrition needs of older people), healthy food policies and interventions to improve oral healthamong older people.• Take comprehensive action at local, national and international levels to control the marketingand use of tobacco products and provide older people with help to quit smoking.• Determine the extent of misuse of alcohol, medications and other drugs by older people andput practices and policies in place to reduce misuse and inappropriate prescribing practices.• Provide incentives and training for health and social service professionals to counsel and guideolder people in positive self-care and healthy lifestyle practices.• Reduce risk for social isolation by supporting community empowerment and mutual aidgroups, traditional societies, peer outreach, neighbourhood visiting and family caregivers.• Capitalize on the strengths and abilities of older people while helping thern build self-efficacyand confidence, as well as coping and realistic goal-setting skills.• Recognize and support the importance of mental health and spirituality in older age.• Include older people in prevention and education efforts to reduce the spread of HIV/AIDS.2. Develop health and social service systents that emphasize health promotion, diseaseprevention and the provision of cost-effective, equitable and dignified long-term care.• Train health and social service workers in enabling models of primary health care and long-terrn care that recognize the strengths and contributions of older people.• Eliminate age discrimination in health and social service systems.• Reduce inequities in access to primary health care and long-term care in rural and isolatedareas, through the use of both high-tech (e.g., telemedicine) and low-tech solutions (e.g., supportto community-based outreach programmes).• Reduce inequities in access to care among older people who are poor by reducing oreliminating user fees and/or providing equitable insurance schemes for care.• Improve the coordination of primary health care and social services. 19
  19. 19. Health, Ageing and Public Policies• Provide a comprehensive approach to long-term care that stimulates collaboration between thepublic and private sectors and involves all levels of government, civil society and the not-for-profit sector. Support informal caregivers through initiatives such as training, respite care,pension credits, financial subsidies and home care nursing services.• Ensure high quality standards and stimulating environments in residential care facilities.Provide needed services to care for older people with dementia and other mental healthproblems as well as physical problems.• Ensure that all people have a right to death with dignity and one which respects their culturalvalues.• Endorse policies which enable people whenever possible to die in a place they themselvesdecide, surrounded by people of their own choosing and as free from distress and pain aspossible.• Support older healers who are knowledge-able about traditional and complementary medicinesand encourage their roles as teachers.3. Prevent and reduce the burden of excess disabilities, especially in marginalizedpopulations.• Set gender specific targets for improvements in health status among older people and in thereduction of disabilities and premature mortality.• Create "age-friendly" standards and environments that help prevent the onset or worsening ofdisabilities.• Support the continuing independence of people with disabilities by assisting with changes inthe environment, providing rehabilitation services and/or providing effective assistive devices(eg., corrective eyeglasses).• Prevent injuries by protecting older pedestrians in traffic, making walking safe, implementingfall prevention programmes, eliminating hazards in the home and providing safety advice.• Make effective, cost-efficient treatments that reduce disabilities ( such as cataract removal andhip replacements) more accessible to older people with low incomes.• Increase affordable access to essential safe medications among older people who need thembut cannot afford them.• Encourage the development of a range of housing options for older people that eliminatebarriers to independence and encourage full participation in community and family life.4. Enable the active parficipation of older people in aff aspects of society.• Include older people in the planning, implementation and evaluation of social developmentinitiatives, efforts to reduce poverty and in political processes that affect their rights. Ensure thatolder people have the same access to development grants, income-generation projects and creditas younger people do. 20
  20. 20. Health, Ageing and Public Policies• Enact labour market and etnployment policies and programmes that enable the participation ofolder people in meaningfül work at the same rate as other age groups, according to theirindividual needs, preferences and capacities (e.g., the elimination of age discrimination in thehiring and retention of older workers).• Support pension reforms that encourage productivity, a diverse system of pension schemesand more flexible retirement: options (e.g., gradual or partial retirement).• Provide greater flexibility in periods devoted to education, work and caregivingresponsibilities throughout the life course.• Recognize the contribution that older women and men make in unpaid work in the informalsector and in caregiving in the home.• Recognize the value of volunteering and expand opportunities for older people to participatein meaningful volunteer activities, especially those who want to volunteer but cannot because ofhealth or transportation restrictions.• Provide policies and programmes in education and training that support lifelong learning andskill development for older people, especially in information technologies and agriculture.• Provide intergenerational activities in schools and teach young people about active ageing.• Work with the media to provide realistic and positive images of active ageing, as well aseducational information for older people.5. Improve health and increase independence by providing protection to older people,particularly in difficult times.• Recognize the relevance of HIV/AIDS to older people and provide necessary financial andcaregiving support to older people who care for dying family members and orphanedgrandchildren.• Enforce occupational safety standards that protect older workers from injury and themodification of formal and informal work environments so that older workers can continue towork productively and safely.• Uphold older peoples right to maintain control over personal decision-making, even whenthey are frail.• Support the provision of a social safety net for older people who are poor and alone, as well associal protection initiatives that improve the quality of life.• Protect older consumers from unsafe medications and treatments.• Explicitly recognize older peoples right to and need for secure, appropriate shelter, especiallyin times of conflict and crisis. Provide housing assistance for older people when required(paying special attention to the circumstances of those who live alone) through rent subsidies,cooperative housing initiatives, support for housing renovations, etc. 21
  21. 21. Health, Ageing and Public Policies• Specifically recognize and act on the need to protect older people in emergency situations(e.g., by providing transportation to relief centres to those who cannot walk there). Recognizethe contribution that older people can make to recovery efforts in the aftermath of an emergencyand include them in recovery initiatives.• Recognize crimes committed against older people during war and bring the perpetrators totrial.• Enact legislation that protects widows from the theft of property and possessions and fromharmful practices such as health-threatening burial rituals and charges of witchcraft.• Recognize elder abuse (physical, psychological, financial and neglect) as a crime, andencourage the prosecution of offenders. Train law enforcement officers, health and socialservice providers, spiritual leaders, advocacy organizations and groups of older people torecognize and deal with elder abuse.• Increase awareness of the injustice of elder abuse (especially domestic violence against olderwomen and widows) through public information and awareness campaigns. Involve the mediaand young people, as well as older people in these efforts.6. Stimulate Research and Share Knowledge• Clarify and popularize the term "active ageing" through dialogue, discussion and debate in thepolitical area, public fora and media outlets such as radio and television programming.• Assist developing countries in collecting and analyzing pertinent information for policy-making on population ageing.• Publish more detailed analyses of the evidence related to the various determinants of activeageing and how they interact, the life course approach to understanding older age, and specific,successful policies and programmes that foster active ageing.• Involve older people in efforts to develop research agendas on active ageing, both as advisorsand as investigators.• Disseminate the results of reliable research efforts on ageing in ways that can be easilyunderstood and used by policy-makers, the media, seniors groups and the general public.5.2 Policies for the FutureIn terms of recognition of the role of -and policy to support- family carers, all Member States ofthe European Union have a very long way to go. The role is recognised to varying in thedifferent Member States of European Union. Clearly, what is expected of families in the futurewill depend to a large extent on existing ideology. One would not, for example, expect that inDenmark, where there has been an explicit assumption that families will not care for theirelderly relatives, there would be sudden change of policy towards family responsability(although it is assumed that spouses will provide care, and support is being developed for carersto some extent). In the same way, one would least expect a dramatic withdrawal of family carein countries such as greece, where such care has traditionally been taken for granted and in thosecountries where there is legal obliggation to care for elderly realtives. In Spain, while various 22
  22. 22. Health, Ageing and Public Policiespolicy documents may make it easier for families to care for their elderly relatives, there is nosingle policy whose direct aim is to help families with the needs and problems associated withcaring for elderly people. In Italy the economic advantages of family care for elderly people arerecognised by the government, but there is no overall policy for supporting them in their task.There is an urgent need for the govemments of the Member States to recognise just how muchthey currently depend on informal carers - many of whom are themselves elderly - and toconsider all possible options in making solid plans for the future. There is an urgent need forbetter information to allow planning for the future and in particular in order to be able to preparefor the large increase associated with the coming of the baby boom cohorts into old age.Further research is required in three specific areas:Provision of Basic Information on the Situation of Family Carers in the European UnionIn most of the Member States, there is a pressing need for nationally representative research onthe socio-demographic and socio-cultural characteristics of carers, their needs and the assistancethey provide to elderly people (Jani-Le Bris, 1993).Evaluation of the Effects of Policies and Initiatives to Support Family CarersOnce base level information bas been obtained, it will then be possible to undertake research toascertain the effect of initiatives and policies on the quality of life of elderly people and theircarers. Specific information is requested on:- the costs and effectiveness of public policies for the care of elderly people- the economic value of care provided by families and the economic costs incurred- the costs and effectiveness of specific service interventions including detailed analysis of the benefits/costs to carers- the acceptability and likely effects of financial incentives versus service provision for family carers (including the effects, of such incentives on the quality of family relationships).Research on Attitudes to Receipt of - and Provision of - Family CareIn many Member States there is a shortage of research on prefèrences for care among people ofall ages. It is important that such research be promoted, and that the results of such research beinterpreted within the existing sociocultural context. Comparative international research -particularly of a longitudinal nature - would be particularly fruitful.Presented below are four options which may be considered in approaching the issue of futurecare for elderly people. Family care is not, and should not be, the only option considered.1. Reducing Demand for Care: A Preventive ApproachOne strategy for the future could be an attempt to reduce the demand for care by focusing onimproving elderly peoples health and independence.Development of Preventive Health Care and Information ProgrammesEarly detection of eyesight, hearing and foot problems, and encouraging people to adopthealthier lifestyles could have considerable potential for reducing morbidity and increasing 23
  23. 23. Health, Ageing and Public Policiesmobility and independence in old age. Consideration would have to be given to inequalitiesamong the elderly population in terms of access to services and information.Housing StrategiesHousing policy can have very significant implications for elderly peoples ability to liveindependently; an OECD report published in 1990 notes that "housing policies are seen ascritical links in formulating integrated responses to the problems of long-term care" (OECD,1990b: 5). Elderly peoples housing is often inappropriate in terras of design and operating costsand in many countries there is a shortage of suitable housing - in particular, of small units ofaccommodation (OED, 1990a, 1990b). Granny flats, where an elderly person and a family canlive side-by-side, can enable elderly people to maintain their independence yet have help, athand (Tinker, 1991), while for elderly people witlf disabilities who, need more support than canbe provided in non-specialised housing, congregate or sheltered housing with extra care canprovide a satisfactory solution (Tinker, 1989).Bearing in mind the potential specialised housing can have for elderly peoples independence,attempts should be made to develop social and housing policy for elderly people in an integratedmanner, with special attention being given to the development of small, purpose-built orspecially- adapted living units.Development of "Assistive Technology"Mere are many technological devices - many of them comparatively simple and inexpensive -which have high potential for enabling elderly people to live independently in their own homes.Mobility aids, alarms, telephone links, etc., could all enhance disabled peoples ability to carefor themselves. Bearing in mind that there will be more very elderly people in the future, andthat willingness to use this technology is likely to increase, serious consideration should begiven to research and development in this area.Creating, Extending andlor Restructuring Home Care ServicesAt present, most home care services (even where they are available) tend to be inflexible, and toprovide standardised - rather than tailor-made - care. Attempts should be made to ensure thathome care services reach those most in need of them, and that they are able to respond in aflexible way to individual need.Services for IndependenceSome heath and social services which are aimed at maintaining or restoring independence in oldage can enhance elderly peoples ability to continue living in their own home. Healthexpenditure priorities for services such as physiotherapy, speech and occupational therapyshould be reviewed.Encouraging self-sufficiencyEncouraging elderly peoples self-help skills (e.g. teaching widowed people, who have alwaysrelied on their partrier to perform what they saw as gender- appropriate roles, how to do thosethings for themselves) and encouraging elderly people to, form groups to help one another - run telephone advice lines or provide assistance - would not only make people more 24
  24. 24. Health, Ageing and Public Policiesindependent but would capitalise on their skills and knowledge. Consideration should be givento the development of self-sufficiency training programmes for elderly people living alone orwith a disabled elderly parmer.Reallocation of ResourcesMere would appear to be considerable scope, in many countries, for moving resources fromacute care towards primary and long term care. Bearing in mind the increasing size of theelderly population in the European Union, consideration should be given to the possibility ofmoving health and social care resources from "curing" to "caringt.2. Stimulating Supply: Supporting CarersAt present, support of any kind for carers is poorly developed in Europe. There are few servicesdesigned specifically to meet their needs, little formal financial support to compensate thern fortheir input and few facilities to meet their emotional and training needs. Where communityservices are provided they are usually focused primarily on the needs of the elderly dependant,so that the abilities and needs of family members are considered of only secondary importance.A complementary approach to meeting the care needs of elderly people in the future could fécuson the development of flexible mixed welfare arrangements which would not only make it easierfor families to provide care for elderly relatives but would consider their needs alongside thoseof their dependants.Developing Family Based Policies for the ElderlyAssistance for family carers should form an integral part of the objectives and responsibilities ofservices and organisations looking after elderly people; Member States should be encouraged todevelop health and social policies for elderly people which take into account the needs of familycarers.Family Centred ServicesAt present, most health and social services provided for elderly people focus specifically on theneeds of the elderly person and providers frequently make assumptions concerning theavailability of family care. Consideration needs to be given to making health and social servicesprovision farnily-focused to the extent that need assessment is based on the needs of the farnilyas a whole, building on its strengths and supporting its weaknesses.Developing co-operation and co-ordination between différent care providers (includingprincipal carers)There is a need to ensure the co-ordination of care for individual elderly people, ensuringcomplete care coverage, reducing overlaps and taking into account both the prefèrences of thedependent person and the abilities and prefèrences of the farnily carer/s. Where one familymember is providing the majority of care, consideration should be given to encouraging inputfrom other available fanùly members. Consideration should be given to development of "keyworkers" for elderly dependants and their families, to co-ordinate care and ensure complete carecoverage, taking carer needs very much into account. 25
  25. 25. Health, Ageing and Public PoliciesProvision of Respite and Other Support ServicesFamilies are better able to tolerate the long-term stress of caring for a disabled elderly person -especially one sufféring some form of dementia or with heavy personal care assistance needs - ifthey are able to obtain periodic respite (Doty, 1986). The possibility of having a regular breakfrom caring was one of the needs most frequently mentioned by carers in the eleven EuropeanFoundation reports.Respite care can take many forms, including "granny sitting", day centres, temporary residentialcare, holiday stays for dependent people, temporary fostering (with another family member orsomeone unrelated to the elderly person).It is important that such alternative care arrangements should be highly visible and accessible;carers need reassurance that, should there come a time when they are unable to continue caring,alternative care will be available at short notice.There is a need to review respite care provisions and (where they exist) evaluate them in termsof costs and benefits to elderly people and carers; and for consideration to be given to the furtherdevelopment of such services - to be provided on a regular basis where required - toprevent the overburdening of carers. The provision of other services such as home nursing,home care, meal-provision and day-centres can be invaluable in supporting informal carers intheir tasks.Provision of Financial Supportfor CarersFamily carers are often financially disadvantaged in numerous ways, not only at the time of caregiving but also, frequently, later in life. Consideration should be given to the possibility ofproviding financial assistance in respect of :- recognition of the value of the work undertaken- realistic compensation for forféited employment opportunities (including pension entitlement cover for periods of care giving)- expenses connected with the dependant (e.g. medical and paramedical costs, purchase/rental of minor equipment and technical resources - e.g. wheelchairs, walking frames)- tax incentives for families taking elderly relatives into their home.Introduction of Flexible Employment ArrangementsAt present many women experience some degree of conflict between caring, care giving andpaid employment. There is a need for the development of measures which would give them areal choice between various options. At one level, they need to be able to decide whether toremain in employment, reduce or stop work; at another level they need to be assured of a greaterlevel of flexibility - where they choose to work - to combine their two roles. Considerationshould be given to:- the provision of alternative care arrangements for the dependent person to enable carers wishing to undertake paid employment to do so- the establishment of flexible working hours/job sharing for carers -- the establishment of paid leave for carers, with coverage of rights to pension and sickness benefits- guaranteed (or priority re-employment)- assured social insurance rights (to cover illness and old age) where it is necessary to reduce 26
  26. 26. Health, Ageing and Public Policies hours or give up work due to carer responsibilitiesProvision of Training and Information for CarersMost carers take on the job of caring for elderly dependants with no specialist knowledge ortraining. They have to learn as they go, frequently at considerable cost to their physical andpsychological health and at considerable economic expense. Special training in practical,psychological and emotional aspects of care can lead to improvements in their quality of life andgreater satisfaction in the situation and relationship to care (Jani-Le Bris, 1993a: 136).Apart from training programmes, information on the problems of old age needs to be providedin books, leaflets, television programmes, videos and local advice centres. Elderly people andtheir carers also need to be fully informed about the services and financial support available tothem. For choice to exist, people have to know what is available to them. There is a need forconsideration to be given to the review, evaluation and development of training programmes andinformation sources to family carers.Encouraging and Supporting the Creation of Associations of Carers (National and Local) andSupport GroupsAssociations of carers can assist carers by allowing them to articulate their common needs andexert pressure on Governments to meet these needs. Carer groups have been found to providevaluable support to family carers, especially where psychological support and information isprovided with some professional input. The development of carers associations (at national andlocal level) and carers support groups should therefore be encouraged.3. Alternative Approaches to Care in the CommunityThe options so far discussed focus, firstly, upon reducing demand for care among future elderlypopulations by improving health and independence and, secondly, upon providing adequatesupport to enable and encourage families to provide care for elderly relatives. A third way ofaddressing the issue of future care for elderly people is to attempt to think beyond existingstructures towards other ways in which care needs could be met.Alternative ways of meeting elderly peoples needs could include:- intergenerational housing schemes (as how has been developed in Spain).- "service exchanges" at which elderly people can pay for the assistance they need with their own time and skills, rather than money.- incentives for family members living apart to form family groups- "surrogate" families in which elderly people without relatives can live with families in exchange for payment for rent and care provided.4. A New Face for Institutional Care?It is important to recognise that the antipathy to institutional care which emerges so clearly fromthe literature on care prefèrences is based on individuals perceptions and experiences ofparticular forms of institutional care. The developrnent today of alternative forms of institutionalcare could alter the perceptions of tomorrows elderly people to the extent that they enterindividual consciousness as desirable and accessible options. 27
  27. 27. Health, Ageing and Public PoliciesWith greater awareness of individual rights, higher demands for a good quality of life and lesswillingness (or need) to accept what appears to be the only viable alternative, the face ofresidential care could change considerably. Many older people will continue to need (and someto prefer) residential care, even on todays design. Discussion of the ways in which it mightdevelop in the future should accompany consideration of other options.Inevitably, provision is all Member States is moving towards a welfare mix of providers andoptions for care. There is a need to strengthen the debate by moving from an either/or approachtowards a concern with balance and a consideration of the quality of life for both older peopleand their carers.6. PROGRAMMES AND PROJECTS IN EUROPEAN COMMUNITY6.1. Health ProgrammeThe Community action programme on Health Promotion aims at increasing the impact on healthby supporting health promotion activities. It contributes to guaranteeing a high level of humanhealth protection in the definition and the implementation of all policies in the Member Statesand in the Community. It empowers a health promotion approach by developing healthpromotion strategies and disseminating models of good practice.Through specific prevention and health promotion measures, the Health Promotion Programmeaims at improving the quality of relevant information. Attention will also be paid to improvinghealth messages in order to keep both health professionals and policy makers, in particular, upto date with any new ideas, know-how and techniques related to public health, prevention ofdiseases and the promotion of health.The Health Promotion Programme supports the development of strategic health promotionnetworks in creating and launching their initiatives. Once firmly established, the networks shallfmd other sources for fianding as bodies cannot be financially supported on a long-term. basis.The Commission has already taken a proactive role in establishing and supporting Europeannetworks which cover the following areas:Settings - health promotion in the workplace, schools and capital cities, Issues - the promotionof physical activities and mental health, Population groups - the elderly.Evaluation and quality assurance will be developed as an integral part of the programme. A mid-terin evaluation has been commissioned and will be carried out, which covers questions such aswhether the programme has attracted valid projects that can facilitate cooperation on regional,national, supra- and international level; and whether any sustainable networks have beenestablished which may provide the infrastructure for policy development.Inter-linkages with other relevant Community programmes will be strengthened, and therelevant partnerships developed with the private sector, NGOs (Non GovermnentalOrganisations), public bodies and international organisations.In accordance with the Commissions policy that enlargement is of prime importance, once thedecision of the Council on the participation of the applicant countries in the Public HealthProgrammes has come into force, the countries concernedwill be encouraged to, take part inhealth promotion activities. 28
  28. 28. Health, Ageing and Public PoliciesEUR 800 million have been allocated for the new Community public health action programme(2001-2006) which will replace the eight previous programmes. To bridge the gap between theend of the period of application of these programmes and the adoption of the newcomprehensive public health action programme, Mr Trakatellis, rapporteur for the new publichealth programme, has proposed the extension of several Community programmes on healthpromotion, information, education and training, the action plans to combat cancer, to preventAIDS and other communicable diseases, to prevent drug addiction (two-year programme), aswell as the programmes concerning health monitoring and pollution-related diseases (one yearprogramme).The Commission has identified three general objectives for its new comprehensive actionprogramme: 1. to improve health information by developing a full Internet health information system aimed at the public, health workers, health authorities and industry; 2. to improve rapid reaction capability with regard to serious health threats, such as major diseases and new risks, by establishing early warning mechanisms, by coordinating action amongst the competent national authorities and by taking grass-roots action; 3. to combat health determinants, i.e. basic factors which have an impact on health, via measures to promote health and prevent disease. Priority will be given to premature death and to disorders caused by major diseases such as cancer, cardiovascular diseases and mental illness, and key lifestyle-related risk factors will be examined (smoking, drug and alcohol consumption, stress, socio-economic and environmental factors).The Commission has also proposed that a European Health Forum be established to improvetransparency and the coordination of health policy at Community level. The Commissionsintention is to involve all those concerned with public health (health organisations, healthrepresentatives, volunteers, universities, etc.) and allow them to contribute to the framing ofhealth policy, thereby making it more open, transparent and better able to meet newrequirements thanks to a constant comparison between respective experiences and practices.6.1.1. Health Programme 1999In 1999 were sustained proposals for recommendations for a healthly diet and obtain anoverview of the situation in Europe.Account were taken of the results of the CommunityResearch Programmes concerning nutrition and health (BIOMED and FAIR).Attetion was given to the issue of bodyweight as a broad concept affecting the well-being ofpeople, as eating disorders and other problems related to body image.The European heart health initiative was focused on alliance building, on cross-bordercollaboration, information exchange, and the promotion of effective interventions and policies.The drafting of a Commission communication on alcohol and health was planned, based on areview made in the Member States. The preparations for a conference on alcohol and health,celebrated in the year 2000, was supported. The scientific, social, economic and politicaldimensions of the issue of alcohol and health were discussed. 29
  29. 29. Health, Ageing and Public PoliciesThe promotion of health-enhancing physical activity was continue by enlarging andstrengthening the network activities and by initiating the implementation of the strategies theyhad agreed upon.Emphasis was put on mental health and unemployment. In this connection the EuropeanNetwork for Mental Health promotion worked in close cooperation with the European networkof National Health Promotion Agencies, responsible for socially disadvantaged and excludedgroups, and with the European Network for Workplace Health Promotion. During that year anconference was hold in Finland on the promotion of mental health, in wich the Commissionplayed an active role.Health policy guidelines for successful ageing for the elderly and older people were developed,with a view to strengthening collaboration with other services, notably in the field of researchactivities concerning "the ageing of population" within the context of the 5th FrameworkProgramme on Technical Research and Development. The possibility of appointing a high levelgroup of experts in this area would be examined. 1999 was the "Year of Elderly".During that year other priority areas were focused on the continuation of projects on EuropeanMasters in the field of Public Health. Four training programmes on public health, healthpromotion, PH nutrition and gerontology were implemented. The glosary of Public HelathTechnical Termes, commenced in 1998, was´extended to all official languages of EuropeanUnion. The III European Summer School on Health Promotion and Public Health was hold inLuxembourg between June and July.6.1.2 Health Programme 2000Initiatives aiming at putting existing knowledge into practice to influence determinants ofhealth, were given priority. The development of infrastructures for health promotion in MemberStates and EEA countries was continued to be supported, with emphasis on capacity building inhealth promotion, incluiding means and methods for emplowerment and citizens participation inhealth development, as well as for the establishment of partnerships.The Health Promotion Programme was continued to concentrate on operating though three keypriority dimensions which are specific below: issues, population groups and settings.The development of the European Heart Health Initiative (EHHI) continued. The results of thisproject have been presented and discussed at a high profile conference for public health experts,health professionals and policy markers, during this year. The final results of the EuropeanComparative Alcohol Study (ECAS) are available since the end of this year.Health promotion policy guidelines for succesful ageing were developed based on the work of ahigh level group of experts in this area. Socially disavantaged and excluede groups will be apriority of the ENHPA and the Meagalopes Network. Attenion was given to activities for peoplewith chronic diseases or disabilities such as diabetes, epilepsy etc.The European Network of Healt promoting Schools (ENHPS) was continued to further developand systematically disseminate the healthy school concept, incluiding models of good practice,by taking into a account the advice of EVA II evaluation project as well as the recommndationsof the Commission report to the Council. Within the European Network of Workplace HealthPromotion (ENWHP) a thorough evaluation of identified models of good practice in workplace 30
  30. 30. Health, Ageing and Public Policieshealth promotion in all Member States have been undertaken. Health promotion in capital cities(megalopes) of Member States and EEA countries was further developed concrette activities andpolicy recommendations. Attention was focused on out-of-school youth, disadvantaged youngpeople, young families, and elderly people.Coordination with ENHPA will be encouraged in the area of disadvantaged groups. The field ofhealth promotion in health care settings was a priority area of activities in 2000. Beides,European Masters in Public Health Nutrition -had enrolled the first students in September1999- was evaluated in the end of this year. Enrolment for the European Masters in PublicHealth and the European Masters in Health Promotion was started in this year. The project todevelop European Masters in Gerontology was continued aiming at enrolling the first studentsin 2001.6.1.3. Health Programme 2001The year 2001 is a period of transition towards this new public health strategy. As aconsequence, projects funded under the extended health promotion programme have to showclear links with the activities foressen under the new programme of Community action in thefield of public health.Priorities corresponding to activities foreseen under strand 3 of the proposal for a Decision ofEuropean Parliament and the Council adopting a programme of Community action in the fieldof public health are: a) Tackling lifestyle-related health determinants in certain settings (schools, workplace,health care establishments) b) Tackling lifestyle-related health determinants for certain target groups (children andadolescents; elderly; migrants). Health promotion activities can address these concerns, both byreducing older peoples dependence on health, social and welfare services, as well as by helpingolder people to maintain good function, independence and social contacts. For this purpose,strategies and policies will be analysed with-promoting interventions for elderly people. c) Tackling single lifestyle-related health determinants through issue-based approach(mental health, physical activity, heart health, alcohol, nutrition, alcohol, musculo-skeletaldisorders d) Tackling health determinants through training.The project to develop European Masters in Gerontology have continued aiming at enrollingthe first students in 2001.The Commission services will support the organisation of the XVII World Conference of theInternational Union for Health Promotion and Eduaction (IUHPE) which is to take place in Parisin July 2001.6.2. Elderly ProgrammesSince 1984, the Community has carried out studies and seminars focussing on the contributionof elderly to economic and social life. The first action programme for the elderly, ran from 1January to 31 December 1993. It highlights how important it is to further the integration of theelderly in society through a targereted approach and to strengthen solidarity between thegenerations. 1993 was designated the European Year of Elderly and solidarity between the 31
  31. 31. Health, Ageing and Public Policiesgenerations. The Community introduced co-ordinated measures, like competitions and seminars,jointly with the Member States and local or regional authorities.The Commission has submitted a proposal for a second action programme (COM(95)0053)24but the proposal has not seen adopted by the Council owing to some Memeber States objetionsto the use of Article 308 as legal base. the same argument was used for not adopting the fourthpoverty programme.The elderly have also been taken into consideration in other programmes such as: povertyprogrammes, Helios, progrmammes to promote equality between men and women andprogrammes on behalf of the family.6.3. Health and Ageing Projects: Alzheimers DiseaseThe next projects received financing from the European Commission in 1997:- Les Statistiques hospitalieres: un instrument pour la surveillance de la maladie dAlzheimer etdes autres maladies neuro-degeneratives (Institut de Démographie - Université Catholique deLouvain).- Evaluation de la Qualite de vie dans la Maladie dAlzheimer (Université de Reims ChampagneArdenne).- Lawnet (Alzheimer Europe).- 8th Annual Meeting of Alzheimer Europe (Alzheimer Europe).- Synthesis of emerging data on the impact of Alzheimers disease, and on policy and servicesresponses across Europe (The Welsh Institute for Health and Social Care).- Early detection and psychological rehabilation to maintain quality of life in dementia - atraining package (Hull and Holderness Community Helath NHS Trust).- Remembering yesterday, caring today (European Reminiscence Network).- A trans-national comparison an evaluation of the role of institutional care for people withdementia (Alzheimer Scotland / Action of Dementia).- Qualifizierung und qualitätsverbesserung bei der pflege von Alzheimer patienten(Noorderpoort College).- Euro-Candid: European counselling and diagnosis in dementia (The Institute of Neurology).- Neurodegenerative erkrankungen bei migrantien in EU-Ländern-Prävalenzen undversorgungssituation (Wissenschaftliches Institut der Ärtze Deutschlands).- What needs do demented person have? What should care givers attach importance to? (TheDanish National Institute for Elderly Education).- Synthesis and dissemination of EC-Funded Alzheimers Project (Middlesex University HealthResearch Centre).- The interface between family care-givers and institutional care for people with Alzheimersdisease and related disorders: developing relevant training resources (University of Wales).- Remind (Research effort to maxime information on neurodegenerative diseases), (EuropeanInstitute of Womens Health).- Alzheimer brochure for children (Association Luxembourg Alzheimer).- Alzheimers disease and public health European conference (Fundación Alzheimer España).24 OJC 110, 02-05-1995, p. 53. 32
  32. 32. Health, Ageing and Public Policies- Study of the psychological relationship between professional caregivers (nurses andpshysiotherapists), demented patients and family caregivers: how to optimize it (FundaciónAlzheimer España).- Nutrition, maladie dAlzheimer et promotion de la santé-Education nutritionnelle et maladedAlzheimer (Chu Purpan-Casserladit Toulouse).- Alzheimer network with hospitals and shelter houses-Alzheimer network with doctors andhealth professionals (Hellenic Association of Gerontology and Geriatrics).- Prospective memory failures in dementia of the Alzheimer type (University of Aberdeen)- Dealing with cognitive and functional impairments through special stuctured exerciseprograms in patients with AD (Aristotelian University of Tessalonniki).- Concerted European Project on the Harmonisation of Common Psychometric instruments forthe diagnosis and evaluation of Alzheimers disease and related disorders (University Hospital ofMaastricht).In 1998 the number of projects to finance was enough lower :- Network facilitation and disemination of Alzheimers information and knowledge (MiddlesexUniversity).- Studying for care (Asociaicón de Familiares de Enfermos de Alzheimer de Álava).- Promoting of minority ethnic older persons with Alzheimers disease and related disorders(University of Bradford).- Remembering yesterday, caring today-A manual, a conference and a training programme onreminiscence for family carers (Age Exchange Theatre Trust).- Dementia: Just another disability (Glasgow City Council).- 9th Annual Meeting of Alzheimer Europe (Alzheimers Disease Society).- Alzheimer Europe Intranet (Alzheimer Europe).6.4 European Crisis of Alzheimers ProjectsAccording to Jeannot Krecke, chairman of Alzheimer Europe, at European level the dementia isnot recognized sufficiently and the financing of the important pilot projects is in a deep crisis.The article 152 of the Amsterdams Treaty limits the action of the European Union in the publichealth field to "improving public health, preventing human illness and diseases and obviatingsources of danger to human health". Consequently action programs have been adopted againstplagues for the health, as the AIDS or the cancer. However, dementia hasnt been settled downamong the priorities by the European institutions.Nevertheless, in the most recent years European Parliament has made several appeals toEuropean Commission to create a specific European Action Program for the Alzheimersdisease. Of course, since 1996 two resolutions have been adopted that recognized thatAlzheimers disease has become a growing threat and a genuinely European plague.Recently Karla Pejs, European Parliaments deputy and chairman of Alzheimers HollandAssociation proposed an amendment to the 2000 budget to assign EURO 2,5 million formeasures to improve the life quality of people who suffer from neurodegeneratives diseases andrelationed forms, and for the informal caregivers.In spite of the European Parliaments clear commitment, the European Commission has assignedthese funds for the health promotion general budget. This actions threatens seriously the futureof the European cooperation in the dementia field. 33