Comments on the White Paper for the Transformation of the Health System in South Africa

It is noted with acclaim that there is a Directorate in the national programme for Chronic Diseases, Disablement and Gerontology.

This association is wholly supportive of the District Health System and the development of a Primary Health Care System throughout the Republic of South Africa as described in the White Paper. Also we wish to stress the necessity for the development of services rendered in the community as an Outreach from Primary Health Care centres in view of the Dept of Welfare's Policy of limiting the intake to Old Age Homes to only the very frail elderly. (Table 3.2 on pp. 37 and 38)

Proposals towards protecting the interests of the elderly (e.g. 3.10.4 p51) are appreciated particularly as the costs of private hospitalisation are prohibitive for at least 90% of elderly people as has been found by research projects done for the association through the H.S.R.C.

Regulation of the private sector as regards hospitalisation and the cost of medicines is an extremely sensitive issue from the point of view of pensioners, widows, etc., whose resources are very limited due to inflation inter alia.

According to 17.5.1 of the White Paper, efforts will be made to attract paying patients to public hospitals. This is especially applauded by this association particularly the improvement of service in public hospitals, and regulatory measures to control the expansion of the private sector (P175). 17.5.1

Ch.4 Education and Training.
On page 61 regarding training of appropriate health professional personnel it is noted that rehabilitation personnel (Occupational and Physiotherapists) are tabled. This is particularly important as regards elderly and disabled people and it is noted that chronic disease managers are mentioned but surprisingly not geriatrics personnel - are we avoiding geriatrics in the planning?

4.5.1. p. 69 also avoids the use of the word "geriatric" and calls for the upgrading of chronic disease nurse-clinicians - it is hoped that the elderly population will benefit.
The charter for patients' rights mentioned in 4.3 on page 64 is particularly important for the planning for the elderly and it is well known that the numbers of old and very old people are rising very rapidly, especially the black elderly.

Ch.5 5.1.1 In implementation strategies a task force is a recommendation in Essential Health Research. This association is of the opinion that a geriatrician should be included, particularly now that geriatrics is registered by the Interim Medical Council as a defined speciality.

Ch.7 Nutrition
While this association notes the need for a nutrition implementation strategy in the RSA it should be emphasised that the elderly, and the growing numbers of old elderly particularly, are very vulnerable to malnutrition. This should be brought into sharp focus.

Although younger people are more vulnerable to Aids it should be noted that elderly grandparents are an important resource in looking after victims and their children in the family circle.

Ch.12 Mental Health and Substance Abuse, pages138,139
It is appreciated that psychogeriatric services are to be planned and special training developed for this service. Alzheimer's Disease and cerebo-vascular pathology are on the increase in the Republic of South Africa.

Ch.13 Oral Health
There is appropriate mention of the elderly in this chapter as a matter of priority.

Ch.15 Academic Health Service Complexes
Full support is given to the emphasis on peripheralisation of services with teaching involvement in the primary health care setting.
There is strong support for the transfer of excess "tertiary" beds to Peripheral hospitals (15.3.1b)

P.156 At the same time it must be recognised that the communication regarding patient care is severely lacking between health service providers in the various categories of service.

15.4 Curricula of academic Health Service complexes
Upgrading of Curricula, post-graduate education and re-orientation of teaching staff is supported with acclaim. It is however felt that there is a great lack of teachers and teaching resources in geriatrics for the whole geriatric team in the RSA. Now that Geriatrics is to be regarded as a subspeciality under medicine the way should be accelerated in overcoming these obstacles in the education of the geriatric team on all levels of service. There is currently only one professor of geriatrics in the RSA.
It is recommended that all faculties of medicine should include staff for service, teaching and research purposes and that teaching should extend into the peripheral services.

Ch.18 Health Promotion and Communication
This has previously been a neglected area.
Structures on National, Provincial and District level will be strongly supported especially to address the needs of priority groups among which are the elderly (18.1)
In implementation strategies (8.2.1b) supportive environments are mentioned but it should be emphasised that elimination of architectural barriers to the free movement of the disabled and elderly should be regarded as an important issue The A.R.P.& P. can play a useful role in promoting Health Education amongst its members.

Ch.19 Role of non-governmental organisations
Pages 189, 190 (19.2.2.e)
It is noted with acclamation that among the preferred NGOs for funding HOSPICE CARE is mentioned. This certainly is a very important extension of the Government's scope of activities.

Ch.20 International Health
The Principal of intersectoral and inter-departmental co-operation is strongly supported both nationally and internationally. This is especially important in the gerontological field where the activities of the Dept of Welfare and Population Development and National Health cannot be regarded as divisible issues. (20.1.1.(8) ii)
This Country can learn a great deal from countries such as the U.K. in its approach to policy making, education and services regarding the elderly - RSA is many
years behind in these resects. (20.1.1.)

Ch.21 Year 2000 Goals and Indicators.
The tables of goals, objectives and indicators are supported particularly as regards the needs of the elderly.(21.5) It must however, be emphasised that accessibility, availability and affordability of services for the aged need to be improved rapidly. It is stated that there is a long period of implementation. The numbers of elderly and old elderly are rapidly increasing and this association particularly requests that interim steps on improving services should be taken.
As regards DRUG POLICY (p.220) (21.18(c) affordability and rational drug use are of cardinal importance to elderly persons with limited resources (92% of them). The Control of medicine pricing and establishment of an Essential National Drug List is strongly supported by the ARP&P.

The "Elder Voice" Standing committee of the A.R.P.&P. strongly supports this document.
It would however, recommend that more specific finite detail and specific policy regarding our expanding elderly population be explored. In particular the length of time of implementation is a cause of great anxiety and methods of "Fast tracking" should be explored and implemented.

The ARP&P offers its services for consultation as an interested and informed body and for dissemination of Health Information amongst its members.

Dr L Tibbit