COUNTRY REPORT

Suriname

SOUTH AMERICA

FOCUS GROUP DISCUSSIONS ON THE AGEING POPULATION Paramaribo, 9 June 2004 The Inter-Disciplinary Team Intra II Suriname

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FOREWORD The Inter-Disciplinary Team is pleased to present the country report Suriname, with the findings of the focus group discussions, held with fourteen groups of providers and senior citizens, in and outside of Paramaribo. This report, together with the previously prepared Country Profile, is part of the activities to introduce INTRA II in Suriname. The INTRA I project (Integrated Response of Health Care Systems to Rapid Population Ageing) was launched in 2001, and implemented in six rapidly ageing developing countries – (Botswana, Chile, Jamaica, Korea Lebanon and Thailand) - all characterized by a common demographic feature - increasing life expectancy at birth and decreasing fertility rates. The overall aim of INTRA I was to examine the health system role and response to ageing with a particular focus on Primary Health Care (PHC). This was achieved through three main objectives: • • •

the development of a knowledge base that would assist developing countries in guiding future actions and policies towards integrated health care systems; building of inter-disciplinary teams in each of the countries to address and lead debates about health systems transformation; and using the evidence to develop a "comprehensive" health care strategy that would further health promotion and prevention interventions at the PHC level.

The lessons learned from INTRA I indicated the need to further explore the relationship between the provision, or the lack, of “integrated health services" and the health of the elderly population and well being. The follow-up project, INTRA II, proposes to explore these relationships further, by examining relevant factors that influence the organization, management, and delivery of integrated health services within the PHC system. Moreover, this project should lead to a better understanding of the supportive role of communitybased care as a means to improve access and utilization of services and to identify factors that may either lead to an accelerated functional decline or the compression of disability as individuals age. As a result of this visit, PAHO-Suriname was requested to coordinate the implementation of the project, while the general coordination of the project was delegated to the Ministry of Social Affairs and Housing. The Inter-Disciplinary Team was appointed to guide the introduction of the project. The team, recognizing the complexity involved in the planning, organization and implementation of the focus groups, and interpretation of the transcripts of the focus group meetings, hopes that it has met the expectations of all stakeholders in this endeavor, and that this report gives an idea of how the care and services available to the senior citizens in Suriname is perceived by the two main parties: the providers and the users of care for the senior citizens. The team wishes to thank all persons and institutions for their contribution to the finalization of this report. Prim Ritoe Coordinator – Suriname

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Table of contents I. EXECUTIVE SUMMARY .............................................................................................................................1 Needs and sources of care .......................................................................................................................................1 Coordination/collaboration of care .........................................................................................................................2 Continuity of care ....................................................................................................................................................3 Key issues.............................................................................................................................................................3 II. METHODOLOGY..........................................................................................................................................5 The mechanics .........................................................................................................................................................5 III.

USE OF THE ANALYSIS GRID............................................................................................................24

A. Information based on the perceptions of PHC professionals .....................................................................24 Satisfaction.............................................................................................................................................................25 Needs ......................................................................................................................................................................25 Needs not cared for ................................................................................................................................................26 Sources of care.......................................................................................................................................................27 Collaboration/Coordination...................................................................................................................................28 Continuity of care ..................................................................................................................................................30 How to improve continuity of care ........................................................................................................................31 Who is responsible for providing follow up /continuity of care to the elderly within and outside the clinic ......31 Special training required .......................................................................................................................................32 B. Information based on the perception of 50+ PHC frequent users..............................................................32 Satisfaction.............................................................................................................................................................33 Main health related needs......................................................................................................................................33 Needs not cared for ................................................................................................................................................34 Sources of care.......................................................................................................................................................35 Collaboration/Coordination...................................................................................................................................36 How to improve coordination between staff..........................................................................................................37 What facilitates/hinders .........................................................................................................................................38 Continuity of care ..................................................................................................................................................38 How to improve continuity of care ........................................................................................................................39 How to improve treatment......................................................................................................................................39 C. Intra-group Comparison ..............................................................................................................................40 Satisfaction.............................................................................................................................................................40 Health related needs ..............................................................................................................................................40 Collaboration/coordination ...................................................................................................................................41 Continuity of care ..................................................................................................................................................42 IV. 1. 2. 3.

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SUMMARY ..............................................................................................................................................43 Needs and Sources of Care ..........................................................................................................................43 Coordination/collaboration..........................................................................................................................44 Continuity of Care ........................................................................................................................................46

I.

EXECUTIVE SUMMARY

The overall scope of this study is to provide in-depth information on the current provisions of health and social services for older persons (50+) and assess how they could be potentially improved to face the current challenges of rapid ageing of the population, economic pressure and social change. The specific aim of the focus group studies is to assess the current situation and the potential for integration in primary health care (PHC). The concept of integration is operationalized here as collaboration/coordination and continuity of care. A total of fourteen focus group meetings (six with service providers and eight with elderly groups) were held in Paramaribo and in the Districts of Wanica and Saramacca. These meetings resulted in a comprehensive overview, according to these groups, of how the care and services for the elderly population in Suriname is perceived. Needs and sources of care Both parties interviewed agree that there is need for a well structured and functioning system for the provision of care and services to the elderly population. The Government has the central role in making these services available, while the health clinic is the place where the majority of the services should be made available. The family setting is a crucial environment where the wellbeing of the elderly population is guarded in many families. There are complaints however, that with the changes over time, the family value and the meaning of family support is diminishing. The role of children in supporting their parents in their old age is also disappearing. The children have their problems of their own to survive and look for their own family. Alternatives for (professional) home care are very limited. Only those who can afford it, can “buy” a place in a home for the elderly or a day care facility for the elderly. There are three main institutions identified by the providers that can be distinguished, when looking at the sources of care for the elderly: • The Primary Health Care Center as the source responsible for the services for the elderly. Specifically, it is mentioned for health education, preventive care, home care, monitoring of chronic diseases, adequate medication, and availability of medications, health guidance and monitoring of the diet. • The Government, specifically for housing, transportation to and from the health clinic, mobility support, easy accesibility of medications, finances to pay for health care and social guidance. • The family is mentioned as the source for recreation, nursing care, housing and transportation to and from the clinic. There are some shared responsibilities between family and government (housing, transportation) and between family and PHC Centre (home care). According to the elderly groups, there are three main institutions that can be distinguished, when looking at the sources of care for the elderly: • The Primary Health Care Center as the source responsible for the services for the elderly. Specifically, it is mentioned for access to medication, screening for diseases, free public

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health care, preventive care, health education, home care, help with bathing, dressing and washing and for general consultation. There are shared responsibilities with the Government and the family, in helping with independent living, and with the family in preventive care, home care and help with bathing, dressing and washing. The family is the source for paying for health care (together with the Government), attention/company, social and moral support, love/affection and family support. The Government is seen as the responsible authority, specifically for housing, transportation to and from the health clinic, mobility support, easy accesibility of medications, finances to pay for health care and social guidance. The Government is also mentioned as the responsible source for help with independent living. The elderly homes are mentioned as the only source for elderly day care.

Coordination/collaboration of care According to the providers the current situation regarding coordination between professionals within the PHC centre is adequate. Weekly planning meetings are being held and planning and budgeting is done together. Their concept of an ideal situation is planning together and good collaboration/coordination between professionals. The group suggests that the introduction of a system of appointments would be better to provide quality care. Receiving the elderly on special days might be an option. Home visits would also lighten the burden in the clinic, if transportation is available. A pharmacy with basic medications in the clinic would also help the elderly to reduce waiting and travel time. The main barriers to improvement are identified as lack of managers at the clinics, lack of personnel and absence of good internal organization. Their concept of an ideal situation is a good collaboration between the centers and other professional organizations. The professionals should try to work together as much as possible. This collaboration can be improved for better accessibility of services for elderly outside the PHC centre. The elderly groups say that there seem to be some sort of cooperation between professionals because it’s reflected when they need to substitute each other. The cooperation outside of the centers doesn’t seem to be very good because referring isn’t done very easily and communication between physicians doesn’t seem to be very common. The communication between the different professionals can be improved by having meetings together, but they have very little time for this. As regards the quality of care, the group finds that “some doctors have the prescription ready for the patients, only by hearing the name of the patient. Those who pay out of pocket, are treated better. The cooperation will be good if everyone change their work method. They need to learn how to treat the sick and how to talk to them”. At some clinics, the patient forgets everything when he/she sees the doctor. There is a need for treatment but seeing the physician makes them forget everything.

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Continuity of care The current situation with regard to continuity of care within the PHC centre is described by the providers as not guaranteed and not so good. Much has to be done yet. There is no transportation available for home visits. For quality care, the group finds that there should be certain criteria met, to provide quality service. “If these basics are in place, then we can look at organization, for example, the clinic doesn’t have adequate equipment and many things are yet to be done”. The concept of an ideal situation is described as ongoing health care, guaranteed care and assured continuity of services. The factors facilitating change are mentioned as a clear prepared plan, sufficient human resources, a basic plan of action, info in the media and good salaries for health workers. The barriers to change are lack of human resource. The elderly group finds that every time they go to the doctor, they see another face and should tell them their story again and again. The pharmacists don’t provide the quantity of medication prescribed, so continuity of care is disrupted. Most of the elderly say they don’t know how to use the medication prescribed. This is seen as another reason that hinders continuation of care. To solve this problem, the elderly suggest that there has to be a center where they can count on transportation for the sick. The group proposes that the government should prepare a basic plan addressing this problem and everybody should stick to it. According to the group, leaders are needed who don’t think of themselves and their pocket. They should think of the users and make the services better for them. It seems as “a lot of things that are to be done in the field of health have something to do with politics, and if that is so, we will not be able to say that health care is guaranteed. Leaders need to be trained and they need to learn how they should work with so little things that are available to work with”. Key issues

When addressing the health related needs of the elderly, there seems to be a number of significant issues where both the providers and the users agree on, such as: • The supply of medications is not guaranteed. • Transportation for the elderly to and from the clinic is a major issue. • The care for the elderly should get more financial input. • The elderly need more help in, for example, logistics. It would be good if the elderly could go to one office to do all their business. • Money is the key factor to good health and health seeking behavior. • The Old-age Pension should also be adjusted to today’s needs. The seniors cannot afford a newspaper daily. • The procedure to obtain a social-medical card should be simplified. • People need a daycare center for elderly, where they can also get information on health, etc... There are insufficient elderly homes where these seniors can go to. Some people are financially not strong so they cannot afford home-care for the elderly. There are, however, a number of issues that are not addressed by the providers, but are mentioned as significant health related needs by the elderly. These are:

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General consultation is mentioned by the groups as their greatest need and health education, as an important aspect to good health. Other issues to be addressed in order for the elderly to enjoy good health are mentioned, such as help with independent living, attention/company/need to be loved/family support, elderly day care/ ADL’s, home care, social and moral support, preventive care and screening for diseases.

Both sides agree that education/information about the problems which the person might face is needed. Health education should be more aggressive and information should be made available on medical, social and welfare issues. The providers mention other needs not cared for, like the in-affordability of certain supporting goods such as a walking racks, prosthesis, etc. The diet of the elderly is also seen as a neglected item, as well as recreation possibilities, prevention or regular care for people with chronic diseases and the costly services of home care. The elderly, on the other hand, mention as needs not cared for, that are related to social aspects such as listening to them, giving them love, and providing them company to address their loneliness. The support from their children is seen as a duty of the children towards their parents.

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II.

METHODOLOGY

This chapter gives an overview of the groups in the focus group discussions and a summary of the main findings out of these meetings. The mechanics A team of five interviewers/facilitators was formed to coordinate all activities pertaining to the planning and conducting of the focus groups. The requirements were discussed and the potential persons for each group identified. Permission was requested and received from the Regional Health Services1 office to make use of some of their facilities. The Director of the Regional Health Services notified the different centers of this particular activity, after which the recruitment was started according to the INTRA guidelines (persons had to be 50+, frequent users of PHC and present with at least one chronic condition). This criterion was closely followed as much as possible, but adjustments had to be made in certain cases. Recruitment was initially done through the PHC centers, but persons outside of the centers had to assist with the recruitment, because of the short time in which the groups had to be brought together. Table 1. Overview of the focus groups and their characteristic

Group 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Gender Female Combined Combined Female Combined Combined Combined Male Male Combined Female Combined Females Combined

Age

55+ 50-64 50-64 54+ 52+ 65+ 65+ 65+

Socio-economic Low High Low High Low High High Low High Low Low Low High High

Type P/ Physicians and nurses P/ Nurses and Physicians P / Nurses P / Nurses P/ Social workers/ Nurses P/ Doctors E E E E E E E E

Geographic Rural Central Central Central Central Central Central Central Central Central/ Rural Rural Rural Central Central

E- Elderly / P- Professionals

A tape recorder was used for most of the groups to record the discussion, while notes were taken. All persons were, as much as possible, arranged in a circle, with or without a table, depending on the location. Confidentiality was guaranteed. The participants were assured that their names and names of any other individual or organization they mentioned, would be anonymous in any reports on the study. They were also told that no one other than the research team would have access to the tapes, and that after transcription the tapes would be destroyed. Refreshments were served to all the groups before and at the end of the sessions. 1

The Regional Health Services (RGD) is the semi-private institution to provide primary health care to the population in the coastal area.

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Following are the details of the groups. Please note that the professionals were not asked to fill in Annex 4 – Participants Information. Group 1 Characteristics Recruitment

Location of meeting Participation Duration Date Time Additional information

Females - Low SE - Physicians and nurses - Rural

The activity was explained to the coordinator of social services at the clinics. Both clinics, (Uitkijk and Leiding) would take part, but after the appointments were cancelled a few times by the doctor at Uitkijk, the clinic at Koewarasan was asked to participate. The social worker assisted in recruiting the people needed. The doctor at the Leiding clinic requested that interns at the clinic join the focus group which was also done. The participation was optimal and the interaction between the participants was great. RGD Clinic – Leiding (peri-urban) Ten persons were invited, seven took part The interview took 1 ½ hour, exclusive of the introduction 15 April 2004 12 p.m. At the beginning of the interview, all issues to be discussed were stated to make sure that the participants knew in what context they needed to answer. The doctors at the clinic were the group met, were very friendly and hospitable which added to the positive result of this activity. It should be noted that the doctors were willing to give up their free time for this interview. At the time of the interview there was an electricity problem so the discussion couldn’t be taped. Because of this, the reactions and issues discussed were summarized.

Summary of discussions in group 1 This group of female physicians and nurses express that they do everything to guarantee satisfaction of their clients. They are ware that a lot more needs to be done for the senor citizens, but that limited resources (especially human resources) prevent them from doing so. The clinics are full every day, creating a huge burden on the staff. They find that the supply of medications can take very long, leaving patients waiting for their medications. In some cases patients don’t comply with doctor’s orders. Transportation for the elderly to and from the clinic is a major issue. As regards the coordination of the services, this group reports that collaboration between other professionals is reasonable, however, at times knowledge about the structure within the health care is needed, before quality collaboration can be reached. Internal meetings are needed to plan together and for good decision making. The collaboration in the clinics is adequate.

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This group mentions that the continuation of care at the centers is not guaranteed, both from local and national level. As possible solutions this group mentions sufficient resources (human) to take care of the clients, fewer patients to see per day and provision of transportation for the elderly to and from the clinic. Care should be ongoing. A clear plan should be made by the managements of the health care services including the big problem which is human resource. Special trainings should be offered to assist professionals to improve their skills in management. It is also needed that workers at the different centers work in a much more pleasant way. Group 2 Characteristics Recruitment Location of meeting Participation Duration

Date Time Additional information

Combined – High SE Status - Physicians and nurses - Central level Participants in this group were recruited at two health centers in Paramaribo. The participants came together at the Military Hospital 6 professionals were invited; 1 didn’t show up at the meeting, so 5 persons participated. This group lasted 1 hour and 20 minutes, exclusive of the introduction. Two of the participants couldn’t stay too long because of other appointments. 08 April 2004 9 a.m. Refreshments were served.

Summary of discussions in group 2 This group is a combined group of male and female physicians and nurses, on central level. The group agrees that the quality of care in the different areas is not what it should be There are other branches where the senior citizens are not well taken care of. A specific problem mentioned was the procedure to obtain a social-medical card. Waiting time is also a significant problem for the elderly. The lack of medicines is also mentioned as a problem. Patients have to wait the whole day or come back the next day to receive their prescriptions. The old-age pension is not sufficient fore the elderly to meet the ends or to pay the taxi to the doctor. This also affects their help seeking behavior. As regards coordination of services, the group finds that much has to be done yet. It takes a while to receive the results of tests. There is no transportation available for home visits. For quality care, the group finds that there should be certain criteria met to give quality service. “If these basics are in place, then we can look at organization, for example, the clinic doesn’t have adequate equipment, many things are yet to be done”. The group reports that there should come a basic plan for continued care, in which health care should be the basic part. There should be a group to put together such a plan for the elderly care.

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Information should be provided through the media about how to take care of oneself. For continuity of care they also need more staff and transportation facilities. Training for the care providers is a must. The financial factor is one of the main reasons but there need to be workers in this field. There should be more care centers and more facilities towards the needs of the elderly. The group suggests that the introduction of a system of appointments would be better to provide quality care. Receiving the elderly on special days might be an option. Home visits would also lighten the burden in the clinic, if transportation is available. A pharmacy with basic medications in the clinic would also help the elderly to reduce waiting and travel time. The elderly need company, personal help to assist them in their daily activities. “Individual organizations should work on their internal organization....then will the communication and the cooperation improve. A work group should be put together to set out a plan of survives for the elderly. Advice from the elderly is also needed because they are the persons that are confronted with all the problems”. Group 3 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

Combined – Low SE Status – Nurses – Central level Participants were recruited at two homes for senior citizens and a hospital in Paramaribo In a large room at one of the senior citizen’s homes Eight nurses were invited but 6 could take part The interview was 1 hour long, excluding the introduction 08 April 2004 11 a.m. The nurses didn’t seem to be very excited about taking part. It seemed to be a forced exercise.

Summary of discussions in group 3 Group three is a combined group of nurses and physicians at central level, in a low socioeconomic area. This group finds that quality of the care for seniors is not adequate. Money is a key factor in this. The old-age pension is not sufficient. There are insufficient elderly homes where these seniors can go to. The government should take care of this. There is nothing done on prevention, nor is there regular care for people with chronic diseases. If you don’t have money you will not be able to pay the doctor. “When it comes to care for chronic diseases, money makes the difference. If an elderly goes to the doctor he or she gets a prescription but is not helped, because, who will assist the person in taking the medicines when he goes home?“ Many seniors have only been through primary school. Most of them cannot read the instructions for medications. They need somebody to assist them. Transportation is another problem needing attention.

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The collaboration with other centers is not always needed, so it’s often absent. The group finds that the infrastructure doesn’t encourage collaboration. The collaboration between the staff can also be improved but isn’t too bad. The collaboration with professionals outside the PHC is reasonable. “We have a good communication line with other organizations outside of our system and assist patients also when they need to get help at one of these organizations. To do this effectively, we need enough and adequate staff”. The group suggests that health care can be improved, by increasing AOV, the Old-age Pension for persons over 60 years of age. The seniors should get more attention and the group that works with them should be financially better appreciated. The persons who take care of the elderly should be paid better so that more people will want to do that job, what will help solving the problem of insufficient caretakers for the elderly. Continuity of services can be improved by working with motivated staff, by appreciating the staff better, because many health workers are very dissatisfied about their salaries, for example. “Actually, the government is responsible for the continuation of any service within the health sector, but they keep saying that they can’t do too much because there is no money”. Group 4 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

Professionals - nurses Participants in this group were recruited through two health centers in Paramaribo. The participants came together at the Health Center at the Heerenstraat. Nine professional were recruited, 3 didn’t show up at the meeting. This group lasted 1 hour and 30 min. and was the first one done. 28 April 2004 12 p.m. None

Summary of discussions in group 4 According to this group, the care is not adequate in all areas. The most pressing needs of the elderly are housing and finances. In general there is nothing that is being done in the field of prevention for the elderly. They are being left on their own. De elderly should get more attention There is no health education for this group. Only a small group is fortunate to have access to the existing home care services. The group also finds that the children can’t handle taking care of their parents. The family band isn’t there anymore and that is the cause of these situations. “The senior citizens in Suriname in comparing with those in other countries like to stay at home, in their familiar surroundings, instead of going outdoors. Because, if someone is not willing, you can’t force the person”.

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The group reports that they work great together with other daycare centers and homes for senior citizens. “If we are planning an activity, we inform the other organizations so that their members can also take part”. There is no set structure or guidance towards the elderly. “Per individual you try to be of help when there is a need. This is unfinished work and as the experience shows, you often face walls that prevent you from getting any further. The organizations of which you believed to get help from, stand also powerless”. Money is mentioned as one of the barriers. The care providers need adequate training. The person should know how to deal with the elderly persons. To assure continuity of care we have to make sure that the personnel needed is available. Human resources are very important in this and should be the main area to be invested in. The group suggests that an organization should ‘stand up’ for these people. But if there was money, the person could be taken care of in his or her own surrounding. “It has to be made a must for everybody to safe money for their old day. There should be organizations that monitor this and make sure that everyone does it so their old day will be a smooth one”. There should be care centers where people can be taken care of for a payable price. And where they can do physically fitness exercises in groups, go out a little when needed, etc. To help the senior citizens, the government should make available busses that would drive on particular days and set times, so the senior citizens who would want to go out or go to town would be able to take these busses. This would surely stimulate the senior citizens to make use of such a facility to go and enjoy themselves and they can also be asked what they are interested in. The group suggest that self-control should be stimulated under the elderly and an assessment should be made under the elderly to know what their needs are. What would really be ideally is an elderly daycare system, similar to those for children in different neighborhoods, because nearly everybody works and there is no one at home to be with the elderly. The elderly will be able to visit a daycare centre for a small payment. Group 5 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

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Social workers/ Nurses The participants were recruited at 2 health clinics in Paramaribo The participants met at the Health Center at the Dr. Sophie Redmondstraat Six persons were invited, six persons participated The interview was 1 ½ hours long 21 April 2004 12 p.m. --

Summary of discussions in group 5 This group finds that the elderly need good education. They go to the pharmacy, get the medication and then go back to the health care center to ask how it should be used. Their diet has to be checked. It is often not been taken into consideration. They often do not earn enough, so that they cannot buy enough food, which results in decline in their health. “Sometimes they need help but they do not admit it. They want to do their things by themselves. They are pigheaded. They do not easily admit that they need help”. The group says that the sad thing in Suriname is that this group is being forgotten, as regards recreation. Many elderly can not pay the amount requested by the private sector. Care at home costs a lot of money and not everyone can afford it. If someone is ready to go to such a home, there is often a long waiting list. There should be a center where they can walk to for information or education via television, so they can live longer. The group thinks that the main issue is the attitude of those younger than 50. “We have a different attitude towards older ones. If they realize that the person cannot take care of his or herself he becomes a burden. And that needs to be changed”. As regards cooperation in care, the group thinks that there is not much cooperation, only if such a person has to be referred for further treatment. There is no cooperation between the clinics. This can be increased by more interaction, but it can be a problem when staff don’t see the need. This group says that most of the time the children of these elderly have their daily duties, reason why they have little time for the elderly. “I think that if they can afford it, they can hire someone to help and guide the elderly, who cooks for her every day and washes their clothes and by turns we good and do the chores”. The group finds that the most responsible group concerning continuation and care in the centers and outside of the centers would be the social workers who should have the main duties, together with the health care and nursing staff. The family and the children also have an important role in this. As main issues are mentioned the financial aspects. The group thinks that transportation should be given attention. It would be a good future plan if the government would be responsible for special busses for elderly where they can aboard easier. This transportation for the elderly should be free of charge. The group also mentions that the elderly should be given a preferential treatment in offices by a special line for this group, so that they can be helped as quickly as possible. Providing food parcels would help the elderly with their food, such as bread, milk, cheese etc. As specific actions to improve the situation, the group mentions the availability of daycare centers for the senior citizens with sufficiently trained staff to help keep this group busy. An increase of the Old-age Pension (A.O.V) would help the elderly to make ends meet. Another suggestion is that a senior citizens clinic should be established where elderly can ask questions and voice their complaints. There has to be a team that assists them with love and patience.

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Group 6 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

Professionals – Physicians The participants were recruited at 2 medical centers. RGD Clinic – Headquarters 6 doctors were invited but 5 participated and were joined by 2 assistants. The interview lasted for around 1 hour, exclusive of the introduction. 14 April 2004 1 p.m. The participants showed little or no interest in the subject. The moderator felt as though the participants were not very serious about the matters presented.

Summary of discussions in group 6 The group finds that you can’t be entirely satisfied with the quality of care. But they don’t say it is bad either. Medication, and other resources, such as prosthesis, a walk-rack etc, are not so easy to get. You can, however get those at the revalidation center. But it’s is not easy to get one and it costs a lot and not everyone can afford it. Some people are financially not strong so they can’t afford homecare for the elderly. The care for the elderly should get more financial input. The elderly need more help in, for example, logistics. They need to go to certain places to get things in order. It would be great if the elderly could go to one office to do all their business. As the most important need of the elderly the group thinks they need a place where they can come together to have contact with each other and play games for recreation. They also need to go on outings together. People need a daycare center for elderly, where they can also get information on health, etc. In the preventive care the group mentions that education/information about the problems which the person might face is needed. For many elderly, it’s not easy getting through the month. The financial need is the greatest at this time. The group suggests increasing of the Old-age Pension. The amount should be representative for this time. As regards cooperation/collaboration within departments, the group finds that at the clinic there is collaboration between the doctors and the nurses and the patients who are being helped. The collaboration between the different professional groups can be better. It’s so, that some groups should report back to the family doctor or general practitioner concerning the patient, but it doesn’t happen. As regards collaboration outside of the primary health care, there should be some kind of collaboration and this should happen from a central point. Different services should be joined and it should be made easier for the seniors to get help. Certain days can be reserved for

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treatment of the elderly. That will also help that seniors don’t go on the road too often. Money and human resources would be an important factor in approving these services. For continuity of health care the group thinks that it is important to invest in human resources. It’s presently not guaranteed that there are enough workers that will stay at the PHC centers, but the government seems to have other priorities. They should plan now and make sure that health care is guaranteed. The physicians are to be responsible for continuation of care and beyond the centers the responsibility is for the government. Group 7 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information Nr 1 2 3 4 5 6

Age 58 68 74 55 73 59

Elderly Combined – 55+ - High SE status - Central level The participants were recruited by a nurse attached to one of the PHC clinics. At the home of one of the participants. Ten persons were recruited but only 6 took part. Two came after the interview was done, while the two others didn’t show up. 11/2 hour, exclusive of the introduction. 21 April 2004 2 p.m. --

Complaints Diabetes Have often blood in urine Hypertension Well Well Hypertension

Gender M M F F F F

Marital Status M W W M M M

Summary of discussions in Group 7 The group said they were not at all satisfied with the healthcare and services. According to this group, public healthcare should be free of charge to the elderly. The fact that they have to pay the doctor, and for additional services, not withstanding the fact that they have a social medical card, does not have their approval. Some don’t even have a social medical card; neither do they have children to take care of them. Health education should be more aggressive and information should be made available on medical, social and welfare issues. If something happens, they should know where to go and to whom to appeal for help. Preventive care should focus on education on frequent occurring illnesses in the elderly. This education could be done by special trained workers. The VPSI2 has a special target group and these people work in district organizations and communities, but is has to happen on a large scale. 2

VPSI is the private umbrella organization ”Association of Private Social Institutions”

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The group says that they don’t need the ‘calpol’ speeches3 from the physicians. They need quality medication that they can request from family in Holland to send for them. The AOV should also be adjusted to today's needs. Housing is a problematic issue. Easy accessible daycare centers are needed. Transportation should be made available for the elderly to move freely. Something has to be arranged so that those with a wheelchair can be transported. You have elderly that are lonely and they need some distraction. To get away from that lonely feeling people have to visit them. The elderly should not wait long in lines for services. In order to improve the services, the group says that fieldworkers have to be trained to go to the people. “If I say that the transportation needs changing, I will say so, because I will benefit from it; but they have to go to the people and find out what they need”. “To solve this problem, there has to be a center where you can count on transportation for the sick; cars that can easily transport those in a wheelchair or in a bed, especially if the person cannot sit. Important is that you must be able to count on it. Then this will be a great improvement”. According to the group, it seems that there is no corporation/collaboration/communication between the doctors and the different centers, because at times nurses tell you one thing while the physicians tell you another thing “so I think they start to sort out things internally first and then get out. Internal meetings might help them solve this”. “Those (the physicians) are a special breed within our society. Those are the boys that study with our money and when they take their seat they also try to ‘pick’ from us”. Group 8 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

3

Elderly Males – 50-64 yrs – Low SE status- Central level The participants were recruited by a volunteer. Most of the participants belong to a Christian church and seemed quite religious. At the home of one of the participants. Ten persons were invited and ten persons took part. The interview was 2 hours long, exclusive of the introduction. 18 April 2004 9 a.m. After the interview, the participants stayed talking about issues that were raised. A few felt that some participants were too ‘religious’ and did as though they didn’t suffer from anything or even though that they lied about their physical conditions.

Calpol® is the locally available Paracetamol, that is considered the “wonder pill” against all complaints. The patients complain that many physicians prescribe this, before listening to the patient, in order to quickly move to the next patient.

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Nr 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Age 55 60 63 52 60 63 57 60 56 59

Complaints Diabetes Heart Trouble Hypertension Arthritis Heart Trouble Hypertension Well Diabetes Arthritis Hypertension

Gender M M M M M M M M M M

Marital Status M D N W D M M M M D

Summary of discussions in group 8 This group also finds that the services are not to satisfaction. “Because, if you talk to the doctor, before you talk to him, he starts writing (the prescription). And he starts giving you medicines from January till December, starting from 60 years till you’re maybe 100”. “The doctor keeps giving me suppositories and if I tell him that they don’t help he asks if I would like to have an injection which costs SRD 5,- 4 because it’s not covered by the state health insurance....” Some of the doctors are very unfriendly too. The nurses come to work with their anger from home and then you’re treated very sarcastic and need to sit for along time. So for a little paper (prescription) you need to wait the whole day. The group says that older persons also need to feel loved. To them this is one of the greatest needs. Appointments at the specialist may take the whole day. A new appointment will take two months. Some places you have to pay a bribe to the nurse in order not to wait too long. The pharmacists don’t provide the quantity of medication prescribed. But you can buy it for cash. Sometimes you don’t know how to use the medication. “At times we see the doctor as God but their personality is far from being so. They just want your money and then they treat you as an animal. They have time for people with money. People should show some love towards you because that heals too”. One main barrier is that the elevator in the clinic is not functioning for years. Especially those with heart problems need to take the steps to get to the cardiologist. As regards continuity of care, the group says that every time they go to the doctor, they see another face and should tell them their story again and again.

4

1 SRD (Surinamese Dollar) equals US$ 0.37

15

Group 9 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information Nr. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Age 65 63 55 64 60 63 63 64 60 62

Elderly Males – 50 – 64 yr - High SE status – Central level Participants were recruited during a church club meeting for elderly at a Pentecostal church. Class room near the church Nine persons were invited but ten came and participated. The interview was 1 ¾ hour, exclusive of the introduction. 19 April 2004 5 p.m. ---

Complaints Diabetes/ Heart Trouble Hypertension Heart trouble Hypertension Arthritis Heart trouble Diabetes Diabetes Hypertension Heart trouble

Gender M M M M M M M M M M

Marital Status M D W W D W M M D M

Summary of discussions in group 9 According to this group, you are healthy under the normal circumstances: no high blood pressure and no diabetes. You are healthy when you wake up and feel good and are able to work. Being healthy is being able to do a lot during the day, for example sporting, relax, walk in the garden etc. As regards the treatment they get, the group says that when you are old, you’re no good anymore. They need more help with things they need to do home, because actually they don’t have to go so often to doctor as they do now. The main obstacles for seeing a doctor are the long waiting hours, the fact that the doctor comes late and that the clinic is packed. Sometimes while waiting to be seen by the doctor, other people who can pay or have an appointment with the doctor are seen first. The letter of referral to the specialist is only valid for one month and two referrals. Making a telephone call to the doctor also counts as one referral. As regards cooperation or collaboration within the centers, the group says that there seem to be some sort of cooperation between professionals because it is reflected when they need to substitute each other. The cooperation outside of the centers doesn’t seem to be very good, because referring isn’t done very easily and communication between physicians don’t seem to be very common. The communication between the different professionals can be improved by having meetings together, but they have very little time for this.

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According to the group, the nurses should care more about their patients. When you’re already sick you feel even worse if they treat you bad. You become more ill than you already are… Some people, who have problems at home, take these problems to work. And that’s why some people are mistreated. The waiting time in the clinic and for your prescriptions is also a problem for this group. Sometimes they have to wait for two days before they get their medication. And sometimes they don’t have it, so they send you somewhere else or to a private owned pharmacy to get it. This takes time and money, which they don’t have. But when you pay for medication, you get the best and you get it fast. The group proposes to apply one standard of treatment and care, regardless of who pays and where you are from. As regards continuity of care, the group experiences this as a problem because there are constantly different people attending you, so every time you need to start the process anew. The group proposes that the government should prepare a basic plan addressing this problem and everybody should stick to it. Group 10 Characteristics Recruitment

Location of meeting Participation Duration Date Time Additional information

Nr. 1. 2. 3. 4. 5. 6. 7. 8.

17

Age 75 73 57 59 69 54 80 83

Elderly Combined – 54+ - Low SE Status– Central level A volunteer in the city recruited this group. The volunteer heard about these activities and assisted in recruiting people to participate in a focus group discussion. The home of one of the participants was used. Ten persons were invited but only 8 participated. The other two cancelled just before the interview started. This group lasted 1 hour and 30 minutes, exclusive of the introduction. Date: 20 April 2004 5 p.m. During the introduction people wanted details about the study which took up much time. The participants expressed their concerns about this study just being yet another study, and said that they hoped that this would be the beginning of better care towards the elderly.

Complaints Well Hypertension Diabetic Hypertension Well Well Diabetic Well

Gender F M F M M M F F

Marital Status M N M M F M W W

Summary of discussions in group 10 This group is not satisfied by the care, “because if you’ve past 50 or 60 you are not counted by society or by the youth”. “Youths are on the foreground and elderly on the background”. The greatest need according to this group is for people to listen to seniors. It is not right for the elderly to pay the full price of their prescriptions. They find that this group is being discriminated because of their age. The waiting time to be seen by a specialist is also very long. Health education should be improved. Not everyone reads the newspapers. If the seniors get their pension allowance, they can’t afford to pay SRD 1 for a newspaper daily. Some seniors can’t watch the TV because of their bad eyesight or just because their TV isn’t working and they can’t replace it because they don’t have the money to do so. It happens that the senior homes or care centers are too crowded and the costs of these homes are too high for the ‘small man’. The group thinks that there is collaboration between care takers when it comes to the elderly. They are not sure if there is any collaboration outside of the hospital. They believe that the services at the centers should be expanded. This will eliminate having to go to so many places for care. According to the group, a computerized system is needed where the data of patients is stored and accessible to the person you are referred to. This will make it much easier because your information will be at hand. The group is not happy with the income from the Old-age Pension (AOV) because everything is so expensive. Some medicines are not available on the card, except for when you want to pay cash for it. The AOV should be increased. The transportation problem is mentioned as a barrier for the elderly to move. The identification of the busses is not clear. By the time they can read the bus number, it is too late to stop the bus. The government should make sure that the identification of the buses is clear. Group 11 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

18

Females – 52+ - Low SE status --- Elderly ---Rural level This group was recruited through the regional health clinic in district Saramacca. The discussion took place at the home of one of the participants. Eleven persons were invited but 6 actually took part in the discussion The group lasted 1 ½ hours, exclusive of the introduction. 08 April 2004 10 a.m. This group was planned for three times and at all the previous appointments most people didn’t show up. After the person who recruited tried it for the third time, people showed up but didn’t loosen up. Quite often there were long breaks between responses and it could be felt that the participants wanted to make sure that they don’t say what they thought should not be said. It must further be noted that the participants didn’t approve the use of the tape recorder. Notes had to be made by the moderator.

Nr. 1. 2. 3. 4. 5. 6.

Age 52 57 71 63 65 67

Complaints Diabetic Diabetic Heart problems/ Diabetic/ Hypertension Diabetic Diabetic Hypertension/Heart problems

Gender F F F F F F

Marital Status W M M D M W

Summary of discussions in group 11 The group is not satisfied with the care and services for the elderly. They find that they are not always treated in a proper manner. The doctor does not have sufficient time for the patients because he works up to 10:00 o’clock, and there are other people waiting to see him. The care is not good, because you cannot say what you want. In fact he should listen to what you have to tell him. Sometimes the doctor shouts at the people. They need to change. They have to know how to deal with people. The group finds that they should get proper medication so that they can get well. Sometimes they have to pay for the medications they have been prescribed. These medications would not be supplied free of charge and the elderly don’t have the money to pay for that. It happens that some medications re not available in one pharmacy, so they have to walk around all pharmacies to find it. Transportation facilities and the bus fare need to be addressed. The children are not always available to take care of them. “The children don’t even have time. Others don’t even watch you. They only want your social-security check. It becomes obvious that the elderly prefer to remain in their own environment, and get some help as needed”. A bus for people of 60 yrs and older to and from the doctor would be a good thing. The group thinks that the communication between the doctors can be improved. They can maybe have monthly planning meetings to talk about different things. The Minister of Health should not move the physicians all the time, only if they are not good. He is the one responsible now and he should ensure that it stays so. According to the group, leaders are needed who don’t think of themselves and their pocket. They should think of the users and make the services better for them. It seems as a lot of things that are to be done in the field of health, have something to do with politics and, if that is so, we will not be able to say that health care is guaranteed. Leaders need to be trained and they need to learn how they should work with so little things that are available to work with. Group 12 Characteristics Recruitment

Location of meeting

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Combined, 65+ --- Low SE status, Rural level The participants were recruited by a relative of the moderator who lives close to a clinic which is often visited by the elderly in the neighborhood. At the home of one of the participants

Participation Duration Date Time Additional information

Nr. 1. 2. 3. 4. 5. 6. 7.

20

Age 95 85 60 80 68 66 80

Twelve persons were invited but 7 actually took part in the discussion. The group lasted 1 ¾ hours, exclusive of the introduction 12 April 2004 5 p.m. The participations sat in a circle while the host could sit in his own favorite spot in this house (at least on the balcony). Usually people who pass by, tend to drop in to have a little talk with the old man. They feel at home here, hence the choice for this house. The participants were drinking something since some of the interviewees had left home since 8:00 in the morning and the weather was not the best. Attention had been paid to the fact that many of the senior citizens often have to use less salt or sugar, or they might not use it at all. This attention to detail was appreciated by the group. The confidential nature of this exercise was emphasized to the interviewees in order to ensure obtaining the greatest involvement possible since there is an obvious fear evident by these people. They received the letter by the coordinator of this activity which was regarded as very precious, which can be deduced from the fact that one of the members of the group asked for his/her letter after the meeting had ended. After the “Declaration of Consent” was presented to the group in full once more, we could begin officially. The session was conducted in “Sranang” in order to make it clear for everyone. Some of the questions had to be adjusted to suit the educational level of the interviewees. Of the eight participants, seven of them were Negroes, since the citizens of that area are predominantly negroes. Therefore, they were the ones that were willing to participate in the interview. It was interesting to note that in the responses the participants gave open and honest answers (compared to participants of other groups) and did not seem to have any feeling of trepidation towards the staff at the doctor’s clinic. This was different in the case of group no. 11 that was interviewed, in which case the participants were working for a certain company where they had a designated physician, and thus were not brave to say everything in case there was no confidentiality.

Complaints Arthritis Diabetic Prostate Problems Arthritis / Hypertension Heart problems Diabetic Hypertension / Diabetic

Gender Marital Status

Summary of discussions in group 12 The group finds that the care for the adults needs to be better than it is at the moment. There are a lot of complaints about the doctor, the medication and the treatment. Going back to the clinic to get the prescription is an extra burden for them. “I receive medication and have to collect them the next day”. The group thinks that after you receive a prescription you should get the medication within ½ hour time. The biggest problem for them is worrying. “When you worry you get high blood pressure”. They need education on how to live a healthy life. Even training on how to go about with worrying is fine because that can result in a rise in the blood sugar level and in your blood pressure. These illnesses are related to worrying. The more you worry the higher they get. A raise in the financial support that the adults get can help them to worry less. They can’t make ends meet with what they get - money causes problems. The group complains that they don’t get support from their children or relatives. Everyone feels the pressure, not only the parents, but also the children, because everything is expensive. “As long as the government does not step in I doubt that the elderly will get help. The children can give some support but not regularly. The children will tell us that they can help sometimes but not all the time”. “You will have to pay something for your house to be cleaned. No one will do that free of charge. Everyone is trying to make a living. If there is an organization and they register the people, it would be good. If they have to wait on the family they will die at home. That is true. So there must be an organization that provides help not someone who comes once a while. The person will go where he or she can earn”. The need for transportation for the elderly is expressed. These should be adapted to the mobility of the elderly. Sometimes you cannot step into the bus because of a sick knee or you get dizzy (‘car sick’). A reduced fare for the elderly would help a lot too. The procedure for applying for a social-medical card is an issue. Social services gives a card but you have to wait very long for it to be processed and you must have a good relationship with those people, otherwise you will not be helped. The supply of medication is often disrupted. They have to go and find their medication, which is very time and money consuming. As regards the quality of care, the group finds that some doctors have the prescription ready for the patients, only by hearing the name of the patient. Those who pay are treated better. There is a lot of discrimination. The cooperation will be good if everyone does their part (change their work method) They need to learn how to treat the sick and how to talk to them. At some clinics the patient forgets everything when he sees the doctor. There is a need for treatment but seeing the physician makes them forget everything. The collaboration between the clinics and the doctors needs improvement. If the doctor does not treat the patient right, the patient needs to go to another doctor or the doctor has to be replaced.

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Some doctors are very nice and sometimes they speak very nice. But you have others who may think or say “Woman are you here for again” Some do not address you properly. If you go to a nurse and you feel comfortable with her that will improve your health. The nurse has to be friendly at all times. The group agrees that over the years, continuity of care has been provided. In order to improve their health, the group mentions the way the doctor treats you, getting the medication on time, that the government provides transportation, home care (provided by the government) and that the doctor should visit those who cannot go the clinic at home. Group 13 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

Nr. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Age 72 80 75 75 78 72 68 76 80

Elderly Female 65+ - High SE Status – Central level The participants of the group were recruited through a social worker at a day care center for elderly. The discussion was held at the center. Ten persons were invited but nine persons participated. The interview was 1 ¾ hour long, exclusive of the introduction. 07 April 2004 10 a.m. Most of the seniors visit the center often and were willing to be part of this activity. Even though some where not too old, it seemed that it wasn’t too easy for the participants to concentrate very long. After a while they seemed to be tired. This group began the session with the song “Klein Vogellijn”, with guitar accompanied of the interviewer.

Complaints Hypertension Hypertension Arthritis Hypertension Hypertension Nerves disorder Heart trouble Diabetes Hypertension / Heart trouble

Gender F F F F F F F F F

Marital Status M N N W M W W W M

Summary of discussions in group 13 One of the reasons for not going to the doctor is the problem with the medications. Sometimes they do have the medicine, but as long as you don’t present some money, you can’t have it. It’s not right, they should stop that. Another complaint is that you have to wait to long to see the doctor. Transportation is also one of the barriers. Not everybody can afford a taxicab. The group says that they are satisfied with the quality of care and service they get from the doctor. The only problem here is the availability of medication and money needed to get these medications. 22

The income from Old Age Pension is not enough to pay the water and the electricity bill That care should be available whenever we need it. So far it was always available to us and we hope that it stays so. That is why leaders or the government should put more money in health care. We don’t have any more money. As regards the coordination within the RGD centers, the group says that the office is well setup and they think the clinics coordinate well. The staff is always on time If the doctor is on leave, his assistant can help because the information is recorded and available to the assistant. Group 14 Characteristics Recruitment Location of meeting Participation Duration Date Time Additional information

Nr. 1. 2. 3. 4. 5. 6. 7.

Age 89 79 85 74 75 84 74

Elderly Combined 65+ High SE – Central level The participants of the group were recruited through a social worker at a day care center for elderly. The discussion was held at the center Ten persons were invited but only seven participated. The interview was 1 1/5 hour long, exclusive of the introduction. 07 April 2004 12 p.m. This group began the interview by singing the well-known song “In ’t groene dal” accompanied on the guitar by the interviewer.

Complaints Well Well Heart Trouble Well Hypertension Hypertension / Diabetes Hypertension / Diabetes

Gender M M F F M F M

Marital Status M M W N N W M

Summary of discussions in Group 14 The reasons the group mentions for not going to the doctor are problems of transportation and nighttime. Not everybody can afford a taxi. In the cooperation/collaboration within the health centers they miss social workers. It would be good if the social workers are also included, so they can assist more. There’s always room for improvement in anything, but to communicate more with each other, more time is needed and they will not stay at work too late. The group recommends for approving the health care, that the government makes sure that the continuity of health care is being guaranteed. The Minister should make sure that people are trained to manage the different centers to make sure that continuity is guaranteed. The health workers also need to be motivated for them to stay.

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III.

USE OF THE ANALYSIS GRID.

The specific aim of the focus group study is to assess current situation and the potential for integration in PHC. The concept of integration is operationalized here as collaboration/ coordination and continuity of care. The following dimensions/objectives have been defined reflecting the overall scope of the study: Needs and sources of care • To define the health-related needs of 50yr+ PHC users • To define the different sources of care potentially available to them Collaboration/Co-ordination • To describe the current degree of collaboration and co-ordination between the various components of PHC and their interface with other areas of care provisions (secondary and tertiary care; LTC; social welfare; NGO sector) • To ascertain the potential for increased collaboration/co-ordination • To establish the factors which facilitate collaboration/co-ordination • To establish the factors which act as barriers to collaboration/co-ordination Continuity of care • To describe current practices that ensure continuity of care • To ascertain the potential for increased continuity of care • To establish the factors which facilitate continuity of care • To establish the factors which act as barriers to continuity of care The above objectives had to be met through a synthesis of data obtained from three separate streams. Each stream represents a different perspective, thus a different source and process of data collection, as described in section under "field work". In each case, the objectives had to be used directly to structure the analysis of data The data for this report was obtained from three complementary sources of information: A. Information on the administrative structure and policy regarding PHC based on documentation and interviews with informed persons. Details are described in the INTRA II Country Profile for Suriname. B. Information based on the perceptions of PHC professionals. C. Information based on the perceptions of PHC regular users (50 yrs+). A.

Information based on the perceptions of PHC professionals

A series of six focus groups with PHC professionals (physicians, nurses, social workers/others) were conducted. Focus groups were composed so as to be as homogenous as possible. For each category, two groups were organized, one composed of staff working in a district with a relatively high socio-economic level, and the other staff working in a district with a relatively low socio-economic level. The groups are summarized in the table below.

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Group 1 2 3 4 5 6

Professional Group Physicians Physicians Nurses Nurses Social workers/other Social workers/other

Socio-economic level of district High Low High Low High Low

Each group represented a different socio-economic setting. The focus group discussion was structured according to the study objectives and the analysis grids. Following is a report of the results from these focus group discussions with the providers. Satisfaction The group of providers express that they do everything to guarantee satisfaction of their clients. “You can’t say that you can be entirely satisfied with the quality of care. But you can’t say it is bad either”. They are aware that a lot more needs to be done for the senor citizens, but that limited resources (especially human resources) prevent them from doing so. The clinics are full, every day, creating a huge burden on the staff. The majority of the groups of the providers mention that the quality of the care for seniors is not adequate. The quality of care in the different areas, like in nursing homes, elderly homes and in the family setting etc., is not what it should be. There are other branches where the senior citizens are not well taken care of, like housing, transportation and pensions. Needs The group of providers find that the supply of medications can take very long, leaving patients waiting for their medications. In some cases patients don’t comply with doctors orders. Transportation for the elderly to and from the clinic is a major issue, especially when the patient has to come back to the pharmacy to collect their prescription. “Not everybody can afford a taxi”. The care for the elderly should get more financial input. The elderly need more help in, for example, logistics. They need to go to certain places to get things in order. It would be great if the elderly could go to one office to do all their business. Money is the key factor to good health and health seeking behavior. The old age pension is not sufficient to cover the daily needs, and certainly not the medical costs. For many elderly, it’s not easy getting through the month. The financial need is the greatest at this time. The group suggests increasing of the Old-age Pension (AOV) money. The amount should be representative for this time. A specific problem mentioned was the procedure to obtain a social-medical card. The elderly person, applying for a card or needing renewal of the card, has to go through a number of offices and procedures, demanding time, effort and money from the elderly. The procedure should be simplified.

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Waiting time is also a significant problem for the elderly. In the existing system there are no preferences for the elderly coming to the clinic. As the most important need of the elderly the group thinks they need a place where they can come together to have contact with each other and play games, have some recreation. They also need to go on outings together. People need a daycare center for elderly, where they can also get information on health, etc. There are insufficient elderly homes where these seniors can go to. Some people are financially not strong so they can’t afford home-care for the elderly. The group makes the following suggestions towards improvement: 1. Provide the clinic with the basic medications. 2. Perhaps government can provide the elderly with special services in the public transportation, like a reduced fare and special accessible buses. 3. The government should take care of the need for elderly homes. Needs not cared for Sometimes the elderly need help but they do not admit it. “They want to do their things by themselves. They are pigheaded. They do not easily admit that they need help”. Medication, and other resources, such as prosthesis, a walk-rack etc, are not so easy to get. “You can, however get those at the revalidation center. But it’s is not easy to get and it costs a lot and not everyone can afford it “. In the preventive care, the group mentions that education/ information about the problems which the person might face is needed. “They go to the pharmacy, get the medication and then go back to the health care center to question as to how it should be used”. The diet of the elderly is often not been taken into consideration. They often do not earn enough so that they cannot buy enough food which result in decline in their health. Health education would help them very much. In general, there is nothing that is being done in the field of prevention for the elderly, according to the providers. They are being left on their own. De elderly should get more attention. There is no health education for this group The providers mention that there is nothing done on prevention, nor is there regular care for people with chronic diseases. “If you don’t have money you will not be able to pay the doctor”. When it comes to care for chronic diseases, money makes the difference. Only a small group is fortunate to have access to the existing home care services “If an elderly goes to the doctor he or she gets a prescription but is not helped because who will assist the person in taking the medicines when he goes home?” Many seniors have only been through primary school. Most of them cannot read the instructions for medications; they need somebody to assist them. The group says that the sad thing in Suriname is that this group is being forgotten where recreation is concerned. Many elderly can not pay the amount requested by the private sector. Care at home costs a lot of money and not everyone can afford it. If someone is ready to go in such a home there is often a long waiting list.

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The group of providers suggest that: 1. There should be a center where they can walk to for information, or education via television, so they can live longer. 2. Health care can be improved by increasing the Old-Age Pension. The seniors should get more attention and the group that works with them should be appreciated financially better. 3. The persons who take care of seniors should be paid better so that more people will want to do that job what will help solving the problem of a lack of care providers. Sources of care According to the providers, there are three main institutions that can be distinguished, when looking at the sources of care for the elderly (Table 2). • The Primary Health Care Center is mentioned 10 times as the source responsible for the services for the elderly. Specifically it is mentioned for health education, preventive care, home care, monitoring of chronic diseases, adequate medication, and availability of medications, health guidance and monitoring of diet. • The Government is mentioned 6 times, specifically for housing, transportation to and from the health clinic, mobility support, easy accesibility of medications, finances to pay for health care and social guidance . • The family is mentioned as the source for recreation, nursing care, housing and transportation to and from the clinic. There are some shared responsibilities between family and government (housing, transportation) and between family and PHC Centre (home care) Table 2: Sources of care as mentioned by the providers groups

Care 1. Recreation (5) (6) 2. Nursing care (4) 3. Housing (3) 4. Transportation to and from the health clinics (1)(2)(5) 5. Mobility support (6) 6. Transportation to and from the health centers 7. Easy accesibility of medications (2) 8. Finances to pay for health care (3) (4) 9. Social guidance (2) 10. Health education (5) 11. Preventive care (4) 12. Home care (4) (5) (6) 13. Monitoring of chronic diseases (3) 14. Adequate medication (1)(2) 15. Availabliblity of medications 16. Health Guidance (5) 17. Monitoring of diet (5)

Source Family 2 x Private 1 x Family Family + Government Family 1x Government 3x Government and Home Care Government Government Government 2x Family 1x Ministry of Social Affairs PHC PHC PHC 3x Family 3 x PHC Centre PHC Centre PHC Centre PHC Centre PHC Centre

The numbers in brackets in the “Care” column indicate the group that mentioned this. The number of times the sources were mentioned, are given in the “source” column.

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Collaboration/Coordination According to the providers ,the current situation regarding coordination between professionals within the PHC centre is adequate. Weekly planning meetings are being held and planning and budgeting is done together. Their concept of an ideal situation is planning together and good collaboration/coordination between professionals. The group suggests that the introduction of a system of appointments would be better to provide quality care. Receiving the elderly on special days might be an option. Home visits would also lighten the burden in the clinic, if transportation is available. A pharmacy with basic medications in the clinic would also help the elderly to reduce waiting and travel time. Internal meetings are needed to plan together and good decision making. Continuity of services can be improved by working with motivated staff. By appreciating the staff more because many health workers are very dissatisfied about their salaries for example. The collaboration between the different professional groups can be better. It’s so that some groups should report back to the family doctor or general practitioner concerning the patient, but it doesn’t happen. The factors that facilitate the change are mentioned as: • Plan more efficiently • Good internal organization • Enough/ adequate staff • Team meetings. The main barriers to change are: • Lack of managers at the clinics. • Lack of personnel • Absence of good internal organization The current situation regarding coordination between professionals outside the PHC centre is, according to the providers, reasonable, existing to a certain extent. In this matter, the opinions of the care providers are divided. One part says that the collaboration with professionals outside the PHC is reasonable. The group reports that they work great together with other daycare centers and homes for senior citizens. “If we are planning an activity, we inform the other organizations so that their members can also take part”. “We have a good communication line with other organizations outside of our system and assist patients also when they need to get help at one of these organizations. To do this, we need enough/ adequate staff”. The other part says that the collaboration with other centers is not always needed so it’s often absent. The group finds that the infrastructure does not encourage collaboration. They think that the there is not much cooperation, except when the person has to be referred for further treatment. Between the clinics there is no such cooperation. This can be increased by more interaction but it can be a problem when staff doesn’t see the need.

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However, at times knowledge about the structure within the health care is needed before quality collaboration can be reached Their concept of an ideal situation is a good collaboration between the centers and other professional organizations. The professionals should try to work together as much as possible. This collaboration can be improved for better accessibility of services for elderly outside the PHC centre. The elderly need company, personal help to assist them in their daily activities. Individual organizations should work on their internal organization....then will the communication and the cooperation improve. The group thinks that the main issue is the attitude of those younger than 50. We have a different attitude towards older ones. If they realize that the person cannot take care of his or herself he becomes a burden. And that needs to be changed. There is no set structure or guidance towards the elderly. Per individual you try to be of help when there is a need. This is unfinished work and as the experience shows, you often face walls that prevent you in getting any further. Money is mentioned as one of the barriers. The providers make a number of suggestions towards improvement: • An organization should stand up for these people. • It has to be made a must for everybody to safe money for their old day. There should be organizations that monitor this and make sure that everyone does it so their old day will be a smooth one. • There should be care centers where people can be taken care of against an affordable price, and where they can do physically fitness exercises in groups, go out a little when needed, etc. • To help the senior citizens, the government should make available busses that would drive on particular days and set times so the senior citizens who would want to go out or go to town would be able to take these busses. This would surely stimulate the senior citizens to make use of such a facility to go and enjoy themselves and they can also be asked what they are interested in. • Self-control should be stimulated under the elderly and an assessment should be made under the elderly to know what their needs are. • What would really be ideally is an elderly daycare similar to those for children in different neighborhoods because nearly everybody works and there is no one at home to be with the elderly. The elderly will be able to visit a daycare for a small payment. • There should be some kind of collaboration and this should happen from a central point. Different services should be joined and it should be made easier for the seniors to get help. Certain days can be reserved for treatment of the elderly. That will also help that seniors don’t go on the road too often. Money and man power would be an important factor in approving these services. • A work group should be put together to set out a plan of survives for the elderly. Advice from the elderly is also needed because they are the persons that are confronted with all the problems.

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The factors facilitating this change are, according to the providers, meetings on planning and decision making. The needed structures hereto need to be set up. The Government should produce a plan in which the different health professionals are included. The barriers identified are • Not enough knowledge about structures within the health care. • Existing infrastructure – which excludes coordination between professionals outside PHC centre. • Lack of finances • An infrastructure which doesn’t seem to work • Time • Lack of Human Resources Continuity of care Following are interpretations from the group of providers, of what is understood by “Continuity of care” • Care which is ongoing • Service guarantee in absence of a certain person • Delivering of ongoing services • Assurances of the continuation of care • Ongoing care • Assurance that services continue. The current situation with regard to continuity of care within the PHC centre is described by the providers as not guaranteed and not too good. The concept of an ideal situation is described as ongoing health car, guaranteed care and assured continuity of services. The factors facilitating change are mentioned as a clear prepared plan, sufficient human resources, a basic plan of action, info in the media and good salaries for health workers. The barriers to change are lack of human resource. The continuity of care with agencies outside the PHC centre is described as not guaranteed. Only one group mentions that it is adequate. The concept of an ideal situation is described as planning together. The main factor facilitating change is a basic plan of action of the government. The main barrier to change is the lack of finances. The main responsible institution for continuation of care within the PHC is, according to the providers, the Director of the Regional Health Services (RGD). The RGD is a semi-private organization, responsible for the provision of primary health care in the coastal area of Suriname. In an ideal situation, the RGD would collaborate with social workers and all general practitioners. The main barrier is the lack of finances. The main responsible for continuation of care outside the PHC centre are the Director and the Minister of Health. In an ideal situation these would work together with the youth to educate them on how to prepare for their old age. The main problem is the lack of finances.

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How to improve continuity of care As regards coordination of services, the group of providers finds that much has to be done yet. There is no transportation available for home visits. For quality care the group finds that there should be certain criteria met to give quality service. If these basics are in place, then we can look at organization, for example, the clinic doesn’t have adequate equipment and many things are yet to be done. In their discussions, the providers mention a number of possible solutions, such as: • Sufficient resources (human and financial) to take care of the clients, fewer patients to see per day and provision of transportation for the elderly to and from the clinic. To assure continuity of care we have to make sure that the personnel needed is available. Human resources are very important in this and should be the main area in which need to be invested. • Care should be ongoing. A clear plan should be made by the managements of the health care services including the big problem which is human resource. • It’s also needed that workers at the different centers work in a much more pleasant way. • There should be a basic plan for continued care, in which health care should be the basic part. There should be a group to put together such a plan for the elderly care in this country. • Information should be provided through the media about how to take care of oneself. • Availability of daycare centers for the senior citizens with sufficiently trained staff to help keep this group busy. • An increase of the Old-age Pension would help the elderly to make ends meet. • A senior citizens clinic should be established where elderly can ask questions and voice their complaints. There has to be a team that assists them with love and patience. Who is responsible for providing follow up /continuity of care to the elderly within and outside the clinic The providers say that actually the government is responsible for the continuation of any service within the health sector but they keep saying that they can’t do too much because there is no money. One group of providers finds that the most responsible concerning continuation and care in the centers and outside of the centers would be the social workers who should have the main duties, together with the healthcare and nursing staff. The family and the children also have an important role in this, but the children can’t handle taking care of their parents. The family band isn’t there anymore and that is then the cause of these situations. According to the providers, the senior citizens in Suriname, in comparing with those in other countries, like to stay at home in their familiar surroundings, instead of going outdoors. Because if someone is not willing, you can’t force the person. This group says that most of the time the children of these elderly have their daily duties, reason why they have little time for the elderly. “I think that if they can afford it they can hire someone to help and guide the elderly, who cooks for her every day and washes their clothes and by turns we go and do chores”. It’s presently not guaranteed that there re enough workers that will stay at the PHC centers but

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the government seems to have other priorities. They should plan now and make sure that health care is guaranteed. The physicians are to be responsible for continuation of care and beyond the centers the responsibility is for the government. As main issues are mentioned the financial aspect. The group thinks that the government should give special attention to the transportation problem of the elderly. It would be a good future plan if the government would be responsible for special busses for elderly where they can aboard easier. This transportation for the elderly should be free of charge. The providers also mention that the elderly should be given a preferential treatment in government offices and other public places. A special line must be created for this group so that they can be helped as quickly as possible. Providing food parcels would help the elderly with their food such as bread, milk, cheese etc. Special training required The providers identify the following training needs to improve continuity of care: • Management training for professionals • Training for workers at the ‘homes for the elderly’ • Training for managers on managing human resources • Training focusing on elderly care. The providers mention that the care providers at all levels need adequate training. The person should know how to deal with the elderly persons. Special trainings should also be offered to assist professionals to improve their skills in management.

B.

Information based on the perception of 50+ PHC frequent users

A series of eight focus groups were conducted with older persons 50+ frequenting a PHC centre 3 or more times in the last 6 months for at least one or more chronic conditions. The groups were selected as homogenous as possible, structured by gender (Female/Male); age (50 – 65 yrs/65 yr. +) and socio-economic status (SES) of the group. As with the PHC providers, the focus group was structured according to the study objectives and the analysis grids. Following is a report of the results from these focus group discussions with the providers. According to this group, you are healthy under the normal circumstances: no high blood pressure and no diabetes. You are healthy when you wake up and feel good and are able to work. Being healthy is being able to do a lot during the day, for example sporting, relax, walk in the garden etc. As regards the treatment they get, the group says that when you are old, you’re no good anymore. They need more help with things they need to do at home, because actually they don’t have to go so often to doctor as they do now.

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Satisfaction Asked about their level of satisfaction with the care and services provided to them, all the groups expressed that they were not at all satisfied with the healthcare and services. “Because if you talk to the doctor, before you talk to him, he starts writing (the prescription). And he starts giving you medicines from January till December, starting from 60 years till you’re maybe 100”. “The doctor keeps giving me suppositories and if I tell him that they don’t help, he asks if I would like to have an injection which costs SRD 5,- because it’s not covered by the state health insurance....” The elderly say that there are a lot of complaints about the doctor, the medication and the treatment. Going back to the clinic to get the prescription is an extra burden for them. After they have submitted the prescription, they have to collect them the next day. The group thinks that after they submit their prescription they should get the medication within ½ hour time. According to this group, public healthcare should be free of charge to the elderly. The fact that they have to pay the doctor and for additional services, not withstanding the fact that they have a social medical card, does not have their approval. The main problem for them is worrying. “When you worry you get high blood pressure”. They worry about the availability of medication and money needed to get these medications. The income from Old Age Pension is not enough to pay the water and the electricity bill. Some other expressions from the groups are: • Some of the doctors are very unfriendly too. Sometimes the doctor shouts at the people. They need to change. They have to know how to deal with people. • The nurses come to work with their anger from home and then you’re treated very sarcastic and need to sit for along time. So for a little paper (prescription) you need to wait the whole day. • “Because if you’ve past 50 or 60 you are not counted by society nor by the youth”. • “Youths are on the foreground and elderly on the background”. • The doctor does not have sufficient time for the patients because he works up to 10:00 o’clock, and there are other people waiting to see him. • The care is not good, because you cannot say what you want. In fact he should listen to what you have to tell him. Main health related needs The elderly say that basic care should be available whenever they need it. “So far it was always available to us and we hope that it stays so. That is why leaders or the government should put more money in health care. We don’t have any more money” The groups report that they should get proper medication so that they can get well. Sometimes they have to pay for the medications they have been prescribed, when these are not provided by their social card. It happens that some medications are not available in one pharmacy so, they have to walk around all pharmacies to find it. Transportation facilities and the bus fare need to be addressed. The elderly express that public health should be free to the elderly.

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General consultation is mentioned by six of the 8 groups as their greatest need, followed by enough finances to pay for health care (5 groups) and health education, as an important aspect to good health (4 groups). This should be provided by the PHC clinics. Other issues to be addressed in order for the elderly to enjoy good health are mentioned: • Help with independent living • Attention/company/need to be loved/family support • Elderly day care/ADL’s • Home care • Social and moral support • Preventive care • Screening for diseases Needs not cared for One of the greatest needs according to the elderly is for people to listen to seniors. One group says that they don’t need the ‘calpol’ speeches from the physicians. They need quality medication that they can request from family in Holland to send for them. The group says that older persons also need to feel loved. To them this is one of the greatest needs. Some places you have to pay a bribe to the nurse in order not to wait too long. The group complains that they don’t get support from their children or relatives. “The children don’t even have time. They only want your social-security check. It becomes obvious that the elderly prefer to remain in their own environment, and get some help as needed”. Everyone feels the pressure, the parents but also the children because everything is expensive. “As long as the government does not step in I doubt that the elderly will get help”. The children can give some support but not regularly. “The children will tell us that they can help sometimes but not all the time”. Some other needs not addresses are summarized here: • The elderly say that they are being discriminated because of their age. The main obstacles for seeing a doctor are the long waiting hours, the fact that the doctor comes late and that the clinic is packed. Sometimes, while waiting to be seen by the doctor, other people who can pay or have an appointment with the doctor, are received first. Appointments at the specialist may take the whole day. A new appointment will take 2 months. The letter of referral to the specialist is only valid for 1 month and 2 referrals. Making a telephone cal to the doctor also counts as one referral. • Housing is a problematic issue. Easy accessible daycare centers are needed. It happens that the senior homes or care centers are too crowded and the costs of these homes are too high for the ‘small man’ • Some don’t even have a social medical card, neither do they have children to take care of them. The procedure for applying for a social-medical card is an issue. Social services gives a card but you have to wait very long for it to be processed and you must have a good relationship with those people otherwise you will not be helped. • Health education should be more aggressive and information should be made available on medical, social and welfare issues. Preventive care should focus on education on frequent 34

•

•

•

• •

occurring illnesses in the elderly. If something happens, they should know where to go and by whom to appeal for help. The elderly need education on how to live a healthy life. Even a training on how to cope with worrying is fine because worrying can result in a diabetes and in high blood pressure. These illnesses are related to worrying. The more you worry the higher they get. A raise in the financial support that the adults get can help them to worry less. They can’t make ends meet with what they get. Not everyone reads the newspapers. The seniors can’t afford to pay SRD 1 for a newspaper daily. Some seniors can’t watch the TV because of their bad eyesight or just because their TV isn’t working and they can’t replace it because they don’t have the money to do so. The Old-age Pension should also be adjusted to today’s needs. You will have to pay something for your house to be cleaned. No one will do that free of charge. Everyone is trying to make a living. If there is an organization and they register the people it would be good. If they have to wait for the family they will die at home. Transportation should be made available for the elderly to move freely. A bus for people of 60 yrs and older to and from the doctor would be a good thing. These should be adapted to the mobility of the elderly. Sometimes you cannot step into the bus because of a sick knee or you get dizzy (‘car sick’). A reduced fare for the elderly would help too. You have elderly that are lonely and they need some distraction. To get away from that lonely feeling, people have to visit them. So there must be an organization that provides help not someone who comes once a while. It is not right for the elderly to pay the full price of their prescriptions. The supply of medication is often disrupted. They have to go and find their medication, which is very time and money consuming. Sometimes they do have the medicine in the pharmacy, but as long as you don’t present some money, you can’t have it. It’s not right, they should stop that.

Sources of care According to the elderly groups, there are three main institutions that can be distinguished, when looking at the sources of care for the elderly (Table 3). • The Primary Health Care Center is mentioned 19 times as the source responsible for the services for the elderly. Specifically it is mentioned for access to medication, screening for diseases, free public health care, preventive care, health education, home care, help with bathing, dressing and washing and for general consultation. There are shared responsibilities with the gvernment and the family, in helping with independent living, and with the family in preventive care, home care and help with bathing, dressing and washing. • The family is mentioned 9 times as the source for paying for health care (together with the Government), attention/company, social and moral support, love/affection and family support. • Government is mentioned 6 times, specifically for housing, transportation to and from the health clinic, mobility support, easy accesibility of medications, finances to pay for health care and social guidance . • The government is also mentioned as the responsible source for help with independent living. The Elderly homes are mentioned as the only source for elderly day care.

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Table 3: Sources of care as mentioned by the users groups

Care 1. Elderly day care 7 2. Finances to pay for health care 9,10,12,13,14 3. Attention/ Company 7 4. Social and Moral support 10 5. Need to be loved /Family Support 8,12 6. Help with independent living 7,12 7. Free access to medication 11 8. Adequate availability of medication 11 9. Screening for diseases11, 13 10. Free public health care 7 11. Preventive care 10, 12 12.Health education 7, 9, 10, 12 13 Fast access to medication 12 14. Home care 8,9,10 15. Help with bathing, dressing and washing 11 16. General consultation 8,9,11,12,13,14,

Sources Elderly Homes Family 5x Government 5x Family Family Family 2x Government 1x, PHC 2 x Family 2 x PHC PHC PHC PHC PHC 2 x Family 1 x PHC 4x PHC Centre PHC Centre 1 x Family 3 x PHC, Family PHC 6x

The numbers in brackets in the “Care” column indicate the group that mentioned this. The number of times the sources were mentioned, are given in the “source” column.

Collaboration/Coordination As regards cooperation or collaboration within the centers, the group says that there seem to be some sort of cooperation between professionals because it’s reflected when they need to substitute each other. The cooperation outside of the centers doesn’t seem to be very good because referring isn’t done very easily and communication between physicians does not seem to be very common. The communication between the different professionals can be improved by having meetings together but they have very little time for this. With regard to the quality of care, the group finds that some doctors have the prescription ready for the patients, only by hearing the name of the patient. Those who pay are treated better. “There is a lot of discrimination”. The cooperation will be good if everyone does their part (change their work method. They need to learn how to treat the sick and how to talk to them. At some clinics the patient forgets everything when he sees the doctor. There is a need for treatment but seeing the physician makes them forget everything. As regards the coordination within the RGD centers, the group says that the office is well setup and they think the clinics coordinate well. The staff is always on time If the doctor is on leave, his assistant can help because the information is recorded and available to the assistant. In the cooperation/collaboration within the health centers they miss social workers. It would be good if the social workers are also included so they can assist more. There’s always room for improvement in anything but to communicate more with each other, more time is needed and they will not stay at work too late.

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Their concept of an ideal situation is that information regarding services at the centres should be the same, regardless of who provides it. The coordination will guarantee adequate substitution of personnel when needed. The services at the health centres can be expanded so elderly won’t need to go to many different locations for care. Planning should be made with the elderly in mind. Good coordination and collaboration between physicians, nurses and social workers is a crucial precondition. The factors enabling the change are identified as: • Regular staff meeting • Enough adequate trained physicians and nurses • Finances for expansion of services • Better Communication • Work plan from management that includes physicians, nurses and social workers, promoting coordination and collaboration. The barriers to change are identified as: • Change of personnel • Undocumented protocols • Low salaries resulting in great number of health professionals leaving. • Lack of finances for the health sector. • Incapable or unwilling professionals. • Time available As regards the coordination between professionals outside the PHC centre, the elderly say that cooperation doesn’t always seems to be good because referrals from the centre to other specialists seem to be very difficult. Two groups say that the coordination between centre and specialists seems to be good. The ideal situation is described by the elderly as one with a good communication between physicians and specialists. It should have a good referral system. The coordination can be improved by having a computerized system for the different health centres to make referring easier. The enabling factors to change are identified as a structural plan of communication between professionals and proper infrastructure that will facilitate easy referrals. The factors hindering this change are identified as lack of finances, adequate professionals, and limited time and money for setting up good infrastructure. How to improve coordination between staff According to the group, the nurses should care more about their patients. “When you’re already sick you feel even worse if they treat you bad. You become more ill than you already are. Some people, who have problems at home, take these problems to work. And that’s why some people are mistreated”. The waiting time in the clinic and for their prescriptions is also a problem for this group. Sometimes they have to wait for two days before they get their medication. And when the medication is not in stock, they are sent somewhere else or to a private owned pharmacy to get it. 37

This takes time and money, which they don’t have. But patients who pay for their medications get the best and get it fast. The group proposes to apply one standard of treatment and care, regardless of who pays and where you are from. They believe that the services at the centers should be expanded. This will eliminate having to go to so many places for care. The group thinks that the communication between the doctors can be improved. They can maybe have monthly planning meetings to talk about different things. The Minister of Health should not move the physicians all the time, only if they are not good. He is the one responsible now and he should ensure that it stays so. What facilitates/hinders In order to improve the services, the group says that fieldworkers have to be trained to go to the people. “If I say that the transportation needs changing I will say so because I will benefit from it; but they have to go to the people and find out what they need”. One main barrier is that the elevator in the clinic is not functioning for years. Especially those with heart problems need to take the steps to get to the cardiologist. Some doctors are very nice and sometimes they speak very nice. But you have others who may think or say “Woman, what are you here for again” Some do not address you well. If you go to a nurse and you feel comfortable with her, then that will improve your health. The nurse has to be friendly at all times. Continuity of care Following are interpretations from the group of service users, of what is understood by “Continuity of care” • Not stopping of the services offered presently • not moving of health workers • Availability of care when needed’ According to the group it seems that there is no corporation/collaboration/communication between the doctors and the different centers, “because at times nurses tell you one thing while the physicians tell you another thing “so I think they start to sort out things internally first and then get out. Internal meetings might help them solve this”. “Those (the physicians are a special breed within our society. Those are the boys that study with our money and when they take their seat they also try to ‘pick’ from us”. “At times we see the doctor as God but their personality is far from being so. They just want your money and then they treat you as an animal. They have time for people with money. People should show some love towards you because that heals to”. As regards continuity of care, the group says that every time they go to the doctor, they see another face and should tell them their story again and again. The pharmacists don’t provide the quantity of medication prescribed. But you can buy it for cash. Sometimes you don’t know how to use the medication.

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As regards continuity of care, the group experiences this as a problem because there are constantly different people attending to you so every time you need to start the process a new. How to improve continuity of care To solve this problem there has to be a center where you can count on transportation for the sick. Cars that can easily transport those in a wheelchair or in a bed, especially if the person cannot sit. Important is that you must be able to count on it. Then this will be a great improvement”. The group proposes that the government should prepare a basic plan addressing this problem and everybody should stick to it. According to the group, leaders are needed who don’t think of themselves and their pocket. They should think of the users and make the services better for them. It seems as a lot of things that are to be done in the field of health have something to do with politics and if that is so we will not be able to say that health care is guaranteed. Leaders need to be trained and they need to learn how they should work with so little things that are available to work with. The group recommends for approving the health care that the government makes sure that the continuity of health care is being guaranteed. The Minister should make sure that people are trained to manage the different centers to make sure that continuity is guaranteed. The health workers also need to be motivated for them to stay. How to improve treatment In order to improve their health, the group mentions the way the doctor treats you, getting the medication on time, that the government provides transportation, home care’ (provided by the government and that the doctor should visit those who cannot go the clinic at home. The factors that would facilitate this change are identified as • The government should set-up a plan for continuity to which people stick to. • Insurance for young people which will take care of their medical expenses in old age. • Enough adequate health workers. • Elderly friendly planning The hindering factors are identified as: • Low salaries causing professionals to leave • Lack of adequate, capable, trained personnel and willing professionals. • Unwillingness of young people to make savings towards care during their old days. • Lack of finances The transportation problem is mentioned as a barrier for the elderly to move. The identification of the busses is not clear. By the time they can read the bus number, it is too late to stop the bus. The government should make sure that the identification is clear.

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C.

Intra-group Comparison

The following brings together the views of the provider-groups and the user-groups, in order to compare their views and interpretation of the situation. The views are compared in order to detect discrepancies or similarities in the perceptions. Satisfaction Looking at the perception of satisfaction with the services provided to the elderly, it is noted that the providers agree that the quality of the care for seniors is not adequate. A lot more needs to be done for the senor citizens, but limited resources (especially human resources prevent them from doing so. The users (elderly express that they are not satisfied with the healthcare and services. They have to pay the doctor and for additional services. The care is not good, because they are not being listened to. Some of the doctors and nurses are very unfriendly. The doctor works until 10:00 o’clock, so there is not sufficient time spent with the patients. Health related needs When addressing the health related needs of the elderly, there seems to be a number of significant issues where both the providers and the users agree on, such as: • The supply of medications is not guaranteed • Transportation for the elderly to and from the clinic is a major issue • The care for the elderly should get more financial input • The elderly need more help in, for example, logistics. It would be great if the elderly could go to one office to do all their business • Money is the key factor to good health and health seeking behavior. • The Old-age Pension should also be adjusted to today’s needs. The seniors can’t afford a newspaper daily. • The procedure to obtain a social-medical card should be simplified. • People need a daycare center for elderly, where they can also get information on health, etc... There are insufficient elderly homes where these seniors can go to. Some people are financially not strong so they can’t afford home-care for the elderly. There are, however, a number of issues that are not addressed by the providers, but are mentioned as significant health related needs. These are: • General consultation is mentioned by the groups as their greatest need and health education, as an important aspect to good health. • Other issues to be addressed in order for the elderly to enjoy good health are mentioned, such as: • Help with independent living • Attention/company/need to be loved/family support • Elderly day care/ ADL’s • Home care • Social and moral support

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• •

Preventive care Screening for diseases

Both sides agree that education/ information about the problems which the person might face is needed. Health education should be more aggressive and information should be made available on medical, social and welfare issues. The providers mention other needs not cared for, like the in-affordability of certain supporting goods such as a walk rack, prosthesis, etc. The diet of the elderly is also seen as a neglected item, as well as recreation possibilities, prevention or regular care for people with chronic diseases and the costly services of home care. The elderly, on the other hand, mention as needs not cared for, that are related to social aspects such as listening to them, giving them love, and providing them company to address their loneliness. The support from their children is seen as a duty of the children towards their parents. One significant point made by the elderly is that it can take more than 2 months before they can have an appointment with a medical specialist. A visit to the specialist may take the whole day. Those who can, sometimes bribe the administrative staff, in order to be served with priority. For a referral to the specialist, one needs a letter of referral. This letter is valid for one month or 2 visits only. Renewal of a referral letter brings with it extra costs and efforts. Collaboration/coordination As regards the collaboration/coordination between the health and service providers in and outside the clinic, both sides express that there is some level of collaboration/ coordination. According to the providers, weekly planning meetings are being held and planning and budgeting is done together. Their concept of an ideal situation is planning together and good collaboration/coordination between them. Internal meetings are needed to plan together and good decision making. But the elderly think that communication between physicians doesn’t seem to be very common. They suggest that the communication between the different professionals can be improved by having meetings together but they have very little time for this. Planning should be made with the elderly in mind. Good coordination and collaboration between physicians, nurses and social workers is a crucial precondition. The care/service providers need to learn how to treat the sick and how to talk to them. In the cooperation / collaboration within the health centers they miss social workers. Both sides have somewhat the same views on what the facilitating circumstances and the barriers are towards adequate coordination and collaboration. The providers make a number of suggestions towards improvement, which are more or less in the same line with what the elderly think as to contribute towards improvement. They add to these that the care providers should care more about their patients and apply one standard of treatment and care, regardless of who pays and where the patient comes from. Services at the centers should be expanded. This will eliminate having to go to so many places for care and related services.

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Both sides see more or less the same facilitating factors and barriers, situated in the area of resources and structures, like a national plan and protocols. Continuity of care The interpretation of “Continuity of care” is more or less the same with the providers as well the elderly. Both sides express that the current situation with regard to continuity of care within the PHC centre is not guaranteed and not good. There is no corporation/ collaboration/ communication between the doctors and the different centers. The providers elaborate more on the needed infrastructure for continuity of care (like a clear plan, sufficient resources, etc and the role of the government in this. The Ministry of Health is seen as the major responsible institution to secure continuity of care. The elderly, on the other hand, place more emphasis on the “continuation of care” by the same providers and the love and affection shown by these. The quality of the services is one aspect (medical, pharmaceutical and daily care contributing to the quality of care. There also are some similarities between both groups on how the continuity of care can be improved: • A basic plan • Transportation • Sufficient resources (human and financial • Short waiting hours • Pleasant working conditions • Health education and information • Availability of elderly care facilities • Increase of the Old-Age Pension The elderly add to this the need for leaders who don’t think of themselves and their pocket, the training of leaders, how they should work with so little things that are available to work with and training in the management of the different centers to make sure that continuity is guaranteed. The role of their children and family is also stressed as contributors to continuity of care. As regards the training needs, we also see similarities between the providers and the elderly, mentioning: • Training for workers at the ‘homes for the elderly’ • Training for managers on managing human resources • Training focusing on elderly care. The providers mention that the care providers at all levels need adequate training. The person should know how to deal with the elderly persons. Special trainings should also be offered to assist professionals to improve their skills in management.

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IV.

SUMMARY

1.

Needs and Sources of Care

Attention/ Company Availabliblity of medications: free, adequate, quick Elderly day care Family support Finances Free public health care General consultation Health education Health Guidance Help towards independent living Home care Housing Mobility support Monitoring of chronic diseases Monitoring of diet Need to be loved Nursing care Preventive care Recreation Screening for diseases Social and Moral support Social guidance Transportation to and from the health clinics

Lacking from children, family, relatives. Prescription ready next day long waiting lines, pay out of pocket Insufficient; Not accesible for most elderly Not available Old Age Pension not sufficient to survive Might remove barrier for health seeking behaviour Should be available at PHC clinic Needed for general guidance ,diet, medication, healthy lifestyles Needed for general guidance ,diet, medication, healthy lifestyles Lacking, or too expensive Not available. Not affordable Not adequate Lacking, or too expensive. Transportation also a problem Should be availabele at PHC clinic Should be availabele at PHC clinic Family, chuldren and health/service providers should show more love Insufficient, not affordable for most Lacking. PHC Center should be providing comprehensve care Lacking, expensive, transportation problem Should be availabele at PHC clinic Not available Not available Difficult, expensive,

2.

Coordination/collaboration

Group 1 Coordination within PHC centre Coordination outside PHC centre

Current situation described Adequate Reasonable

Group 2 Coordination within PHC centre

Current situation described Partial collaboration exists.

Coordination outside PHC centre Group 3 Coordination within PHC centre Coordination outside PHC centre

Partially Current situation described Weekly planning meetings are being held. Is not always needed/ often absent

Group 4 Coordination within PHC centre Coordination outside PHC centre

Current situation described Exists to a certain extent

Group 5 Coordination within PHC centre Coordination outside PHC centre

Current situation described Little coordination / Limited Collaboration only during referrals Current situation described Coordination exists. Planning and budgeting is done together. Can be improved Current situation described Coordination doesn’t seem to exist because the nurses give different information regarding issues -

Group 6 Coordination within PHC centre Coordination outside PHC centre Group 7 Coordination within PHC centre Coordination outside PHC centre

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Concept of Ideal situation Planning together An good collaboration between the canters and other professional organizations Concept of Ideal situation Good collaboration/ coordination between professionals Concept of Ideal situation Professionals should try to work together as much as possible. Concept of Ideal situation Can be improved for better accessibility of services for elderly outside the PHC centre. Concept of Ideal situation Good coordination and collaboration between professionals Concept of Ideal situation -

Concept of Ideal situation Information regarding services at the centres should be the same regardless of who gives it. -

Group 8 Coordination within PHC centre Coordination outside PHC centre Group 9 Coordination within PHC centre Coordination outside PHC centre Group 10 Coordination within PHC centre

Coordination outside PHC centre

Group 11 Coordination within PHC centre Coordination outside PHC centre Group 12 Coordination within PHC centre Coordination outside PHC centre Group 13 Coordination within PHC centre Coordination outside PHC centre Group 14 Coordination within PHC centre

Coordination outside PHC centre

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Current situation described Collaboration seem to be quite well (between centre and specialists) Current situation described Coordination is reflected in adequate substitution during absence of a physician or nurse. Cooperation is not always good because referrals to other specialists seem to be very difficult Current situation described Seems to be good but there is always room for improvement.

Concept of Ideal situation Good communication between physicians and specialists. Concept of Ideal situation Coordination that will guarantee adequate substitution of personnel when needed. Good referral system

Concept of Ideal situation The services at the health centres can be expanded so elderly won’t need to go to many different locations for care. Coordination seems to be good. Coordination can be improved by having a computerised system for the different health centres to make referring easier. Current situation described Concept of Ideal situation Coordination seems not to be what it should. Current situation described Concept of Ideal situation Current situation described Concept of Ideal situation The centres seem to be well set-up and planning Planning should be made with the elderly in seem to be good. Staff is always on time. mind. Current situation described Concept of Ideal situation There seems to be a good coordination between Good coordination and collaboration between nurses and physicians however the social services physicians, nurses and social workers. are not always included. -

3.

Continuity of Care

Group 1 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 2 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 3 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 4 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 5 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 6 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 7 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 8 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 9 Continuity of care within the PHC centre

Current situation described Continuity not guaranteed Adequate Current situation described Not too good Current situation described Continuity Not assured. Continuity Not assured. Current situation described Not guaranteed Current situation described Current situation described Current situation described Current situation described Not adequate. Doctors are changed often Current situation described Not adequate – doctors are changed often

Continuity of care outside PHC centre

-

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Concept of Ideal situation Ongoing health care Planning together Concept of Ideal situation Care guaranteed Concept of Ideal situation Assured continuity of services Concept of Ideal situation Care should be assured Concept of Ideal situation Concept of Ideal situation Concept of Ideal situation Concept of Ideal situation Patients should see one doctor for as much as possible Concept of Ideal situation Patients should see one doctor for as much as possible -

Group 10 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 11 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 12 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 13 Continuity of care within the PHC centre Continuity of care outside PHC centre Group 14 Continuity of care within the PHC centre Continuity of care outside PHC centre

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Current situation described Continuity seems to be guaranteed Current situation described Lack of proper communication Current situation described Continuity seems to be guaranteed. Health care was always provided when needed Current situation described Continuity exist because the services are being used by them at the present time Current situation described Continuity seems to be guaranteed. Health care was always provided when needed

Concept of Ideal situation Guaranteed service Concept of Ideal situation Good communication Concept of Ideal situation Guaranteed service in the future Concept of Ideal situation Continuity with the focus more on elderly needs Concept of Ideal situation Guaranteed service in the future -