An evidence-based policy prescription for an aging population.

In this paper, the authors provide a policy prescription for Canada's aging population. They question the appropriateness of predictions about the lack of sustainability of our healthcare system. The authors note that aging per se will only have a modest impact on future healthcare costs, and that other factors such as increased medical interventions, changes in technology and increases in overall service use will be the main cost drivers. They argue that, to increase value for money, government should validate, as a priority, integrated systems of care delivery for older adults and recognize such systems as a major component of Canada's healthcare system, along with hospitals, primary care and public/population health. They also note a range of mechanisms to enhance such systems going forward. The authors present data and policy commentary on the following topics: ageism, healthy communities, prevention, unpaid caregivers and integrated systems of care delivery.

Paradigm shift: shaping policy to meet the needs of our aging population.

The extent to which our aging population impacts the health system is, as Chappell and Hollander suggest, dependent on (1) how that system is defined and organized and (2) our attitudes as a society to aging and the elderly. The Canadian Home Care Association supports the policy prescription described by Chappell and Hollander and believes that a paradigm shift from a reactive and episodic system to one that is proactive and supportive is required. This article expands upon the lead essay by further discussing the role of home care and the need for its integration into the healthcare system. And the article concludes by asserting that we must change our attitude toward aging by improving our understanding of and attention to the needs of older adults.

Politics of a policy for aging in Canada.

Canada's health and social care system is paralyzed by our decentralized federalist governing structure. Public policy change, such as that suggested by Chappell and Hollander, will require a new political paradigm that recognizes the need for a multi-sectoral, co-operative approach to integrated systems of care delivery. The federal government must provide the necessary leadership, and the provinces and territories must show the political will to co-operate if Canada is to embrace the challenges of an aging population.

Is it time to implement a value-for-money approach in healthcare of the elderly?

This commentary addresses several issues raised by Chappell and Hollander in their review of policy issues that should be addressed to improve care for the elderly in Canada. First, the author takes some issue with the suggestion that the continuing care system needs to be re-validated. The data seem to indicate that the issue is not re-validation of the system but, rather, operational reform of the current system. Thus, the recommendation to focus on improving integrated care for seniors, which is a process measure, is a very timely one. Then the author raises the question of recommending a value-for-money approach to care of the elderly. Although fraught with problems and a lack of data, increasing numbers of researchers and others are suggesting that there is a need to question how we are spending scarce resources. A value-for-money policy would contribute evidence about the most effective use of services for older people.

Stumbling over iron rice bowls: the quest for integrated continuing care for the elderly.

Chappell and Hollander "offer an evidence-based policy prescription to meet the challenges …[of] an aging society." The fallacies of apocalyptic demography are briskly dismissed; their message is that decades of solid evidence support the critical importance of an integrated system of continuing care for the chronically ill elderly, both health services and home support. But the paper loses focus with discussions of "ageism", the compression of morbidity, and healthy communities. The authors might have explored why (as they argue) public policy has retreated from their prescription in recent decades. That prescription would require either a re-allocation of resources (incomes) away from politically well-entrenched interests, or simply more money. Neither appears currently promising.

Population pressures, system-level inertia and healthy aging policy revisited.

Chappell and Hollander provide support for a set of policy directives formulated for an aging population. An integrated continuum of care model is the fulcrum of the policy prescription, given evidence-based support for its cost-effectiveness; improved quality of care and quality of life; and the success of similar models found in Denmark, Japan and other countries. This commentary addresses the underlying assumptions of these policy recommendations, identifies the major barriers to their implementation and suggests solutions. Improving our understanding of the dynamics of population aging as it relates to health and healthcare use is a necessary requirement to reaching the aims set out by the authors.

Why the elderly could bankrupt Canada and how demographic imperatives will force the redesign of acute care service delivery.

Canada's aging population poses a significant challenge for the existing healthcare system. While individuals 65 and older accounted for 13.7% of the population in 2005, they accounted for 60% of all acute care service spending. This paper further illustrates how the heterogeneity of the older population and its impact on patterns of healthcare use demonstrate the failings of our current care systems. Our outdated acute care models frequently disadvantage the system's highest users, who are often characterized by factors such as poly-morbidity, functional impairment and social frailty. Understanding how implementing innovative models that challenge deeply ingrained ways of providing care has proven to be a significant challenge, this paper highlights one hospital's mission to transform current traditional paradigms of care by developing and implementing an elder-friendly hospital integrated service delivery model. This hospital aims to demonstrate wide-ranging benefits of this model that can contribute toward optimizing the outcomes of hospitalization for older adults and the system as a whole. The establishment of a national agency that could support the development of a national aging strategy to promote best practice dissemination and implementation could also ensure that the significant health, social and economic benefits that better care models can realize could be more easily achieved.

Chicken little? Why the healthcare sky does not have to fall.

If the healthcare sky is falling, it is because we have not yet grasped the opportunity to do better. Here we comment on three points in Chappell and Hollander's lead article. First, rather than looking to new federal-provincial mechanisms, which do not currently appear on the political agenda, we propose that federal and provincial governments honour their current commitments, including an extension of the 2004 First Ministers' agreement, set to expire in 2013-2014, that flows federal healthcare dollars to the provinces. Second, we concur that small things (e.g., transportation and medication management) matter in big health systems. Access to a full range of services in integrated systems of care permits cost-effective "downward substitution" instead of more costly, and often inappropriate "upward substitution" to hospital and institutional care. Finally, given the current political climate of fiscal constraint, it is helpful to consider the lessons of successful local initiatives such as supportive housing, which can integrate care "from the ground up" including essential primary and preventive care. Rather than seeing an aging population as the harbinger of healthcare doom, we suggest seeing it as a motivator to rethink, refresh and innovate.

Effective treatment of chronic disease--key to the future of our health system.

In this paper, Chappell and Hollander's argument to recognize continuing care as a major component of the healthcare system is applauded. Further justification for looking at prevention and effective treatment of complex, multiple chronic diseases is offered. Finally, the concept of ageism as an important policy issue is further explored.

Integrated care for the frail elderly.

Chronic disease management initiatives have thus far focused on single disease entities. The challenge of an aging population is the occurrence of multiple diseases, complicated by geriatric syndromes, in the same person. The term frailty is used to denote such persons, who are more vulnerable to poor health outcomes when challenged by a health stressor. In this paper, it is argued that frailty is a chronic condition and thus requires a chronic disease management approach. Hospital-based and community interventions for managing frail seniors are discussed, with a focus on enhancing primary care, and with appropriate and targeted support from geriatric specialists in the form of capacity building as well as direct clinical service. Finally, a model for integrating individual geriatric interventions into a broader system is proposed.

How we move beyond a policy prescription to action.

In response to "Evidence-Based Policy Prescription for an Aging Population," by Chappell and Hollander, this paper proposes that efforts be made to execute strategies to build the political momentum and public support necessary for concrete action toward achieving the recommended policies. It also suggests the implementation of knowledge translation strategies to assist in disseminating and integrating existing successful programs across the wider health system. Finally, this paper proposes a concerted and robust mobilization of forces in order to move from evidence-based agenda setting into active policy implementation. A key element of this transition involves placing greater emphasis on interest group activation and public policy deliberation. Such a focus would enable consensus between policy makers, decision-makers, interest groups and the public, garnering the political traction necessary to allow for the implementation of healthy public policy that best serves the needs of an aging population.

Countdown to 2015: tracking donor assistance to maternal, newborn, and child health.

BACKGROUND: Timely reliable data on aid flows to maternal, newborn, and child health are essential for assessing the adequacy of current levels of funding, and to promote accountability among donors for attainment of the Millennium Development Goals (MDGs) for child and maternal health. We provide global estimates of official development assistance (ODA) to maternal, newborn, and child health in 2003 and 2004, drawing on data reported by high-income donor countries and aid agencies to the Organisation for Economic Development and Cooperation. METHODS: ODA was tracked on a project-by-project basis to 150 developing countries. We applied a standard definition of maternal, newborn, and child health across donors, and included not only funds specific to these areas, but also integrated health funds and disease-specific funds allocated on a proportional distribution basis, using appropriate factors. FINDINGS: Donor spending on activities related to maternal, newborn, and child health was estimated to be US1990 million dollars in 2004, representing just 2% of gross aid disbursements to developing countries. The 60 priority low-income countries that account for most child and newborn deaths received 1363 million dollars, or 3.1 dollars per child. Across recipient countries, there is a positive association between mortality and ODA per head, although at any given rate of mortality for children aged younger than 5 years or maternal mortality, there is significant variation in the amount of ODA per person received by developing countries. INTERPRETATION: The current level of ODA to maternal, newborn, and child health is inadequate to provide more than a small portion of the total resources needed to reach the MDGs for child and maternal health. If commitments are to be honoured, global aid flows will need to increase sharply during the next 5 years. The challenge will be to ensure a sufficient share of these new funds is channelled effectively towards the scaling up of key maternal, newborn, and child health interventions in high priority countries.

Cost effectiveness analysis of strategies for child health in developing countries.

OBJECTIVE: To determine the costs and effectiveness of selected child health interventions-namely, case management of pneumonia, oral rehydration therapy, supplementation or fortification of staple foods with vitamin A or zinc, provision of supplementary food with counselling on nutrition, and immunisation against measles. DESIGN: Cost effectiveness analysis. DATA SOURCES: Efficacy data came from published systematic reviews and before and after evaluations of programmes. For resource inputs, quantities came from literature and expert opinion, and prices from the World Health Organization Choosing Interventions that are Cost Effective (WHO-CHOICE) database, RESULTS: Cost effectiveness ratios clustered in three groups, with fortification with zinc or vitamin A as the most cost effective intervention, and provision of supplementary food and counselling on nutrition as the least cost effective. Between these were oral rehydration therapy, case management of pneumonia, vitamin A or zinc supplementation, and measles immunisation. CONCLUSIONS: On the grounds of cost effectiveness, micronutrients and measles immunisation should be provided routinely to all children, in addition to oral rehydration therapy and case management of pneumonia for those who are sick. The challenge of malnutrition is not well addressed by existing interventions.

Scaling up integrated management of childhood illness to the national level: achievements and challenges in Peru.

This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru's 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience.