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ABSTRACT
This study examines
health care expenditure trends for developed
countries and the impact of changing demographics
on health expenditure. The characteristics of
the life of the elderly in relation to individual,
social and general changes facing the aged,
together with attitudes toward it, and major
components regarding elderly are explained.
Disease and burden of disease of ageing as central
to the areas of Health and Health Economics
is emphasized. The influential factors on the
growth of ageing, and policies and policymakers'
responsibilities in this respect, is analyzed.
An attempt was made
to discuss and analyze ageing and escalating
costs of long-term care of elderly in the context
of social problems. The quality of interactions
between elderly and community, attitudes toward
the elderly and its consequences, as well as
gaps between generations, were examined.
There is a need to reassessment
of views towards ageing, elderly health, and
their roles and functions in the family and
community. This approach may enable us to utilize
the effective potential of the elderly and use
their experience to resolve some existing conflicts
among genders and generations.
The ideas of scholars
either from other countries or Iran extracted
from literature, will be the starting point
of the present paper, since it may help to provide
a rather broad and comprehensive picture of
life, which ageing is considered as an important
part of. This picture, however, would demonstrate
the weak points of services provided and delivered
to the elderly in Iran, while for some developed
countries such as the USA, Canada, Germany,
and Japan per capita health expenditure has
increased fastest among those aged 65 and over.
Therefore, experiences
of health care expenditures on ageing among
developed countries could be applied for developing
countries such as Iran.
Key
Words: Ageing, Health Economics, Disease's
Theories, Health Expenditure.
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Introduction
Over
the next half-century the proportion of people aged
60-plus around the world is expected to more than
double, from 10 to 22 percent. For the purpose of
better understanding of ageing as part of our life,
a glance on the concept of life, which leads to aging
and ultimately to death, seems to be necessary.
There
are varieties of definitions presented by Literates,
Poets, and Philosophers for life. But life can be
defined as the evolving of human beings around the
axis of time in terms of appearance and form on one
hand and the replacement of periods of life successively,
in terms of content and quality, on the other.
It
is evident that the process of replacement takes place
in a way that no body experiences it in a very concrete
and tangible form. This is why Leo Tolstoy says that
"Ageing ambushes all of us", and some other
scholars calls the process as "Gray Zone problem"
in which there is no definite line between white and
black.
Physical
and social characteristics and values dominate human
beings during all courses of life, and aging, of course,
is not an exception. Physically there are changes
which take place in organisms: Bones become depreciated
and osteoporosis appears, muscles degenerate, fat
is redistributed and accumulated in specific parts
of body such as the waist, and attitudes restructure.
These
changes reduce vitality and compatibility of aged
people with sudden and somehow unpredictable circumstances
and make it difficult for the elderly to
readjust to new conditions. Therefore, health needs
of aged people are defined differently from those
of other age groups.
Ageing
is considered on one hand, as an inevitable phenomenon,
this is shown by the nonstop snow falls which sits
on our hair and eyebrow (Shamlou, 1998), and on the
other, is a financially burdensome social phenomenon.
There is still another view which believes that ageing
is an incurable illness. In an Old Persian text it
has been stated that "be merciful to the elderly
since it is an illness that nobody and no therapist
knows its cure except death", and there is a
hope for all ill people to be recovered except the
elderly who get worse every day until she/he dies
(Onsorolmaaly, 1986).
Development of Theories of Illness
It
is a fact that ageing is not an illness but a nonstop,
natural process which all human beings experience.
Aging, like other periods of life is a battle field
of health and illness, though the pattern of disease,
disabilities and sufferings are quite different from
previous periods of life.
A glance
on theories and transitions of illnesses may help
us to have a precise analysis on the elderly, and
its expanding ratio among more developed and even
developing countries.
In Pastor's time, as a result of his devoted work,
an external origin for disease, namely pathogens or
microorganisms, was discovered.
But
this great achievement, as the main cause of disease,
was not able to explain all features of illness and
their development, nor was it compatible with social
theories and views which define several causes for
a phenomenon.
Epidemiologists
criticized Pastor's approach or explanatory model
of disease since they believed that microorganisms
alone cannot develop illnesses. According to epidemiologic
theory of disease, microorganisms as agents need hosts
and an environment to be active and able to develop
disease. This is called the triangle theory of epidemiology.
This approach was recognized as useful in explanation
of illnesses, particularly in analysis of infectious
and communicable diseases (Locker, 1999).
But
nowadays, analysis of disease is not limited to these
factors. There is a broad network of social factors
affecting health and illness known as "social
determinants of health". In fact social aspects
of health and illness are bonded. This is in contrast
to previously explained theories with emphasis on
individual characteristics of health or illness. This
view on health issues has emerged in a period which
is called epidemiologic transition.
Chronic,
not easily preventable disease with no definite cure,
related to behavioural, economical, social, cultural
factors and life style are known as dominant patterns
of disease in this transition. Most disease affecting
the aged population belongs to epidemiological transition
pattern.
Similar
reasons have been reported as the main causes for
both population aging and chronic diseases. These
are as follows:
Major
reasons for growing chronic disease and population
aging:
- Increasing of health
services and preventive medicine.
- Decreasing fertility
and mortality rates over time, which is a starting
point for emerging aged populations.
- Development of medical
technology and more effective treatment of acute
illnesses, and
- Increased life expectancy
(Scott et al, 2003 ).
Such
a phenomenon leads burden of disease towards a chronic
state, which is neither easily preventable nor requires
less spending for recovery. It is worth noting that
developing countries suffer from burden of both communicable
diseases and non- communicable disease (Witter et
al, 2003).
Developing
countries face particularly serious challenges as
they attempt to improve the well-being of their populations,
achieve economic development objectives, and integrate
themselves with the global economy. Health care financing
is a particular concern for these countries, which
account for 84 percent of the world's population,
and 93 percent of its disease burden, but only 18
percent of its income and 11 percent of its health
expenditures. Imbalances between spending and the
disease burden will be exacerbated as a result of
the changing composition of illness toward non-communicable
disease and injuries, which by 2020 will account for
almost 80 percent of these countries' disease burdens,
compared with just 50 percent at present. These diseases
are more expensive to treat and harder to prevent
than the infectious diseases that were previously
the leading causes of illness and death (Schieber,
1997).
Moreover,
international aids for prevention and treatment of
these diseases may be essentially reduced.
Aged population, illness and medical expenditure
Although,
ageing is not considered as an illness, its economic
burden is very significant. The higher frequency of
disease such as hypertension, heart disease, diabetes,
cancer, respiratory, and musculo-skeletal deficiencies
are known as effective factors in it. Since demographic
transition has taken place earlier among European
industrialized countries, aged people have dominated
their population structure. It has been said that
about one-fourth of the Western Europe population
are 65 years old or more. It has also been reported
that about 8,500 people over 100 years old lived in
Japan in the late 1990s. The rate of growth of aged
population in this country has been calculated as
increasing 10 persons over 65 per birth. The rate
will reach 15 per birth in next 20 years (Scott et
al, 2003).
Table 1 indicates health expenditure for the elderly
among eight developed countries.
Table
1: Health spending for the elderly in eight
developed countries, 1993-1995
|
Country |
Percent
of Total Health Spending on the Elderly |
Ratio
of Health Spending for Persons Age 65 and Older
to Persons under Age 65 |
Estimated
Percent of GDP Spent on Health for the Elderly |
Percent
of GDP Spent on Health |
Health
Spending per Capita, 1997 |
|
Australia
(1994)
Canada
(1994)
France
(1993)
Germany
(1994)
Japan
(1995)
New
Zealand (1994)
United
Kingdom (1993)
United
States (1995)
|
35%
40
35
34
47
34
43
38
|
4
4.7
3
2.7
4.8
3.9
3.9
3.8
|
3.0%
3.6
3.4
3.5
3.4
2.5
2.8
5
|
8.3%
9.3
9.6
10.4
7.3
7.6
6.7
13.6
|
$5,348
6,764
4,717
4,993
5,258
3,870
3,612
12,090
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Source: John P.Geyman,
Health Care in America, 2002
Figure 1 shows
health care expenditures for the aged in the USA.
Figure 1: Health care expenditures for the age of
65 years until death, according to the type of health
service and age at death (USA)
Source: Geyman,
2002.
In the USA, 5 to 10 percent
of people over 65 years of age account for about two
thirds of annual health care expenses for this age
group. In other words, the elderly, 12% of total population,
has spent 36% of health care expenditure. It is said
that one third (33%) of hospital admissions and 44%
of total in-patient days belonged to the elderly.
In this country, Medicaid annually pays about 70,000
million for geriatric care expenditure of which 20%
is for physician visits, 40% for in-patient expenditure
and 20% is spent in nursing home. This expenditure
has an upward trend. If the current trend holds in
the United States, by 2050 government health care
spending will claim one-third of GDP ( Kotlikoff et
al., 2006).
By 2040 Medicaid's portion
of total spending on long - term care alone could
reach $ 125 billion. Moreover, long term care expenditure,
particularly in nursing homes is increasing more rapidly
than that of acute care among the elderly, parallel
to the increase of their ages. In fact aging is divided
into two categories, namely young aged (65-80) and
old aged (80 +). The highest health care expenditures
belongs to the latter.
Cumulative expenditure for
the ages 65 years to death were found to be about
$ 157,000 for persons dying at 80, $ 235,000 for persons
dying at 90, and $407,000 for persons at 101 and over,
years of age (Geyman, 2002).
The care of chronically ill
elderly patients with their dense concentration of
morbidity is complex and requires coordination with
a broad spectrum of public and private resources in
many instances. Unfortunately, however, much of this
care is fragment and uncoordinated.
Although physicians play an
essential and critical role in geriatric care, comprehensive
care necessarily requires a multidisciplinary team
approach.
Many other health professionals are actively involved
in care of the elderly including nurses, social workers,
pharmacists, dietitians, psychologists, physical therapists,
and occupational therapists. In managed care environments,
case management may be provided by a primary care
physician or nurse case manager. Table 2 shows total
health expenditure by region.
Table 2:
Health care expenditure of
ageing is known as direct and measurable costs. Aging,
also imposes indirect costs to either individuals,
families or communities. Lower age of retirement together
with increased life expectancy, adoption of policies
meeting compulsory retirement and womens participation
in labour market ( mainly due to low wages) bear a
higher burden on retirement funds. On the other hand,
early discharge of skilled and experienced workforces
from service and production markets, make organizations
vulnerable by losing human capital and at the same
time affect free home care for the elderly which is
delivered largely by women, resulting in free home
care provided, to be medicalized and marketized.
Another perspective on ageing
Some scholars of "positive
ageing" argue that "most aged people are
productive and provide more benefits to families and
communities, and they are not a burden to the others".
According to this group "degeneratives"
and "disabilities" among elderly even aged
over 75, are not a common but an exceptional phenomenon.
Most aged people are healthy and do practice preventive
activities much better than the younger population.
They also have potential to practice healthy behavior
and diet, exercise, and cease smoking and increase
their quality of life and life expectancies as well.
Studies indicate that a healthier
lifestyle, even if adopted in later years of life,
can increase life expectancy and decrease both disability
and health care costs (Bret, 1994; Lundy et al., 2001;
Stanhope et al., 2000).
It is now recognized that
many of the health risks of older adults can be reduced
by an active preventive program, including diet and
exercise. Falls can be reduced or prevented by physical
training; cardiovascular fitness can be maintained
by aerobic exercise, and weight training can limit
muscle loss and preserve strength (Kalache, 1999).
According to these experiences, WHO launched a plan
on "elderly health" in 1995, putting more
emphasis on promoting public health, and quality of
life particularly among the elderly and the healthy
process of aging.
Loneliness may be a main cause
of contracting or aggravating illness in the elderly.
Correlations have been found between depression rates
(as an outcome of loneliness) and attempt of suicide,
parallel to an increase in age. In Western Europe
the rate of attempting suicide increased among men
at the threshold of retirement.
This phenomenon takes place
among women when their children leave home, and their
motherhood roles are downgraded. These types of behaviors
are very dependent on cultural norms and values as
well as the social status of aged people in a given
community, and may not be true in any community over
time. Depression and aging do not necessarily support
each other. It can be said that even parallel to an
increase in age, depression rate begins to be decreased.
Moreover, depressed aged people react more positively
to anti-depression drugs, which help them to be treated
easily and conveniently
In fact, what makes the elderly
positive or negative is not merely human beings' natural
and biological characteristics, but the socio-cultural
context and values in which elderly is found.
Ageing for a human being is a bio-psycho-social phenomenon.
Different cultures value aging differently. For example,
aged people in China do not suffer from dementia and
on occasions they demonstrate high scores of intelligence.
Another problem related to
elderly life is the problem of their residency, with
or without their families. According to some studies
the elderly among Indians and Eskimos leave their
own tribes when they cannot either move with the others
or are compatible with tribal life. They leave to
die.
In advanced European countries
such as Denmark, Italy, and Australia, elderly residency
has been demonstrated as a major social problem. It
has been stated that elderly prefer to live in their
own homes and to keep and save their independency.
Living in nursing homes, even in a more modern and
well-equipped one such as that of Copenhagen, do not
satisfy the elderly, since they, particularly aged
women, strongly feel loneliness. In Italy nursing
homes are the last choice of aged people to live in.
This may be partly because of low quality services
delivered in nursing homes.
In Australia, the commonwealth
government allocated higher subsidies for nursing
homes services, which led to a growth of nursing homes.
But later studies demonstrated that only 20% out of
60% of aged people have had a daily bath, and 50%
of aged living in nursing homes are unnecessarily
put in wheelchairs resulting in loss of their physical
mobility. More importantly was that 80% of allocated
funds to nursing homes were utilized on only 4% of
elderly.
Demographic shifts and population
growth predicted, show only 18 percent of the observed
increases in health care expenditures in England and
Wales, compared to 68 percent, 44 percent and 34 percent
for Japan, Canada and Australia respectively. These
differential changes in costs for older age groups
over time invite future research into the driving
forces behind these costs (Seshamani et al., 2003).
It is important to bear in mind that changes in demographic
structure and in health status are only part of a
much wider set of influences on future health expenditure.
Demographic change will also affect the health care
workforce, which is typically one of the largest in
most developed countries (Grey, 2005).
In Iran, studies conducted
by welfare organizations demonstrate an escalating
trend of taking elderly to nursing homes. The trend
is also dominant among not very well to do families,
and different segments of the community, on the living
and residency of elderly with or without family in
nursing homes, after their children get married and
produce their own families (Mohseni, M, Pourreza,A.
et al , 2000; Teymoori et al., 2006).
Health care spending changes
over time because of changes in the age structure
of the population. Government health care expenditure
has grown much more rapidly than the economy.
Conclusion
Ageing as a multi-facet phenomenon,
is discussed from different points of view. Historically,
in human literature, it is described as a natural
phase of the human life span which mainly covers the
last segment of it. This period, essentially, is accompanied
by physical weakness, mental retardation, illness,
and hopelessness.
Today the aged population
is a great social, economic, and health concern around
the world, particularly for developed countries. In
fact, because of technological advancement, epidemiologic
transition and changes in patterns of diseases affecting
populations, changes in population pyramids, and development
of new theories of health and illness, aged care has
become a core policy issue for particularly welfare
states. The most striking issue of the elderly in
the health domain for governments is the cost of illness
and burden of disease, affecting them.
Different approaches have
been developed to analyze and demonstrate economic
consequences of aged care health services.
Apart from these approaches,
the social status of the elderly in different settings
was briefly pointed out. It is stressed today that
the elderly are a productive segment of population,
even though they do not actively participate in the
formal labor market. They can and do cope with their
health conditions and overcome the difficulties faced
as adult generations. They do need and prefer to live
independently and to be treated as independent individuals.
The aged population is, however,
growing rapidly and becoming the significant concern
of governments, national and international organizations
and NGOs, dealing with elderly problems. This is,
now, the major responsibility of governments to work
appropriately towards solving the problems of this
important segment of the human population.
In general, developing countries,
particularly low-income ones, tend to spend a much
lower share of their national income on health care.
For example, per capita health expenditure in sub-Saharan
Africa is over 50 times less than the average of such
expenditure in the developed world (World Bank, 2006).
Policies and practical experiences
of health care expenditure on ageing among developed
countries could be applied for developing countries
such as Iran.
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