International Compendium of Home Health Care

Home health care in Albania is provided under the general health care system of the state, usually in the form of consultations, check-ups, and procedures performed by a general practitioner. In 1993, physicians reportedly made about 450,000 medical visits, of which approximately 280,000 were in rural areas. Nurses and midwives also make home visits, usually to perform pediatric or geriatric care, to dress wounds or to administer medicines by injection. Also, emergency visits are made to the home in cases of acute disease or when the patient is homebound. While most home health care is provided by state-employed health workers, some home health services are now being offered by private organizations, which have been licensed within the past two years.

It is unknown what portion of the state budget is allocated to home health services or exactly how many individuals receive care in the home at this time.

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Antigua and Barbuda

Health care in Antigua and Barbuda is a function of the national government. Formal home care, a component of the Community Health Programmes, is administered by Public Health Nurses.

Home care services are provided mainly by informal caregivers, including members of the family, community and religious organizations. Traditionally, professional services, including medical, home help, social service and physical therapy visits, ahve been carried out and overseen by district doctors and nurses and welfare and community aides. A referral system had resulted in collaboration between the informal and the professional caregiver. However, there seems to be a growing need to develop appropraite policies so as to coordinate home care services. This seems to be of particular importance as there has been significant growth in the number of both independent professional caregivers and private for-profit agencies.

Health care is financed primarily by the government with additional donations from outside sources. Private agencies are paid by their clients.

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Australia

Historically home care traditionally has been provided by religious and charitable organizations. Government subsidies were not instituted until 1956. Today however, the majority of home care services presently being provided are paid for by the government. This set of circumstances results in part from a national study which concluded that about one-fourth of all nursing home residents could be cared for in the community if appropriate services existed. Thus the government introduced the Home and Community Care Program in 1985 to encourage the provision of a range of home care services. Since then, the home care community has increased by 197% in real terms. Few for-profit companies have successfully entered the market.

Also in the 1970's, the Australian Government introduced a Domiciliary Nursing Care Benefit (DNCB) which provides support for people who care for elderly or disabled person. In 1993, slightly more than 28,000 persons over the age of 60 were paid under DNCB.

A 1993 study estimated that 15.7% of the Australian population was over the age of 60. Of interest, when asked to prioritizing their home care needs, older persons stressed home maintenance, transportation, home help, mobility, health care, self-care, personal affairs and meal preparation.

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Belgium

Home care services in Belgium include nursing, home help, cleaning services, social work, home-delivered meals, job services and care coordination. Additional services continue to emerge, such as day care and family placement. Services are provided through public agencies, private non-profit organizations and informal caregivers.

Home nurses and home helpers are paid on a fee-for-service basis and clients are free to choose their providers, whether public or private. The national government provides for public health care, including home nursing and, in 1988, approximately 83% of all home nursing in Belgium was funded by it. The remaining portion was financed by out-of-pocket payments. Health education, planning and preventative services, including home help, home delivered meals, and social work, are supported by the regional governments and the communities. In 1989, 247 agencies provided home help services. Of these 62 were private non-profit organizations while the others were locally organized public agencies. About 27% of the elderly in Belgium receive help from a child living in a different home.

While Belgium does not have a uniform system of home care quality assurance, some initial steps are being taken. For example, home nurses and home helpers must use the same scale to assess a client's need for care. However, this data is not yet collected systematically.

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Home health care agencies, as the term is used in the United States, do not exist in Bermuda. Registered community nurses are provided by the Health Department and, in addition, there is a Private Duty Nurses Register which is in the for-profit sector.

Home health care is funded predominantly by the local government with some assistance form various charitable organizations. Patients Assistance league and Service, for example, is a registered charity that cares for cancer patients in their homes. Certain home health needs will be paid for by some private insurance companies.

The demand for home care services in Bermuda is increasing due in part to shortened hospital stays. Hospital social workers arrange for discharge using services such as Home Help and Meals-on-Wheels. The role of nurses has expanded substantially so that procedures formerly restricted to the hospital setting are performed in the home.

Other caregivers who provide home health care services include physicians, home resource aides, social workers and therapists of various types. Home care providers must be licensed of have attended specific courses, thereby assuring a certain standard of quality.

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Until approximately three years ago, little organized home care was available in Botswana. Any patient requiring nursing care was treated in the hospital as an inpatient. While arrangements could be made to have community health nurses make home visits, in practice there was little possibility of providing such home care due to staffing shortages. Patients requiring drugs or medical attention were required to go in person to a clinic or a hospital.

With the onset of AIDS in Botswana, and the growing reality that hospital services will not be able to provide all necessary degree of nursing services, the Ministry of Health is developing a national strategy for home-based care, defined as care given at the household level with family members acting as the principal caregivers. A few years ago a full-time home-based care coordinator was appointed to integrate home care into the primary health care system of Botswana. It will undertake needs assessment studies, pilot projects and arrange for the training of health staff and lay people. At present, less that 0.1% of the population receives professional home care services. These services are limited to home visits by trained nursing personnel to assess medical problems and prescribe medications of arrange for transfer to the hospital and instruct family caregivers. There are only three full-time home care nurses, although other nurses, employed by the government, may have some involvement in the provision of care.

The government finances home health care (best estimate: US $200,000 per annum). Emerging hospice programs depend on private funds or foreign aid organizations. At this time, the World Bank is supporting a study of possible models for home care. Nonetheless, significant improvements in the capability to provide home care will be limited by fiscal considerations and staffing constraints.

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Canada

In Canada, all residents have access to needed medical care on a prepaid basis. This includes medically necessary hospital services, physician services and certain surgical-dental procedures which are covered by insurance with no "out-of pocket" expense. Since 1990, the federal government has reduced the amount of money it provides to provincial governments for such services as health, education and welfare. As a result, both federal and local governments have initiated major health care reform initiatives in order to assure effective and efficient services. Most provinces see comprehensive home care services as a central component of health reform.

Coordinated Home Care Programs (CHCPs) provide a wide range of home care services, including visiting services on a volunteer basis, domestic help, and technologically sophisticated medical care by highly trained clinical professionals.

In Canada, there are many different administrative structures for deliver of CHCP services, but the two main types are hospital based and community based. The first targets clients who need comprehensive clinical care. Community-based care covers the widest range of clients. Of the over 400 CHCP's in Canada, only about 19 are affiliated with hospitals, with the rest are affiliated with community-based agencies. The majority of CHCP's are administrated by health departments and locally elected community health boards in each province, although a small number are run by hospitals or non-profit voluntary agencies.

Home care clients are usually charged a fee for non-clinical services such as homemaking, personal assistance and housecleaning, meals-on-wheels, transportation, supplies and equipment. These fees, sometimes called "use fees", are based on a sliding scale according to the client's income. No user fees are generally charged for professional home care services, such as nursing, Physiotherapy, occupational and speech therapy, counseling and case-management. These services are provided to eligible clients through CHCPs.

During the 1992-92 fiscal year, government expenditures on home care were approximately $1 billion while the overall health care expenditure for the same time period was $70 billion. Across Canada, provincial governments fund about 85% of the costs of CHCPs while the balance is funded by user fees and third party payers.

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China

China, with a population of about 1.2 billion persons, has a long history of providing care in the home. First utilized in rural areas, home care gradually developed in urban areas as an appropriate long-term option for frail elderly, the handicapped, and people with chronic diseases.

Today, most district and township hospitals have Home Medical Services Departments, and the larger hospitals have Prevention and Care Departments which are involved with home care services. Services include medical counseling, instruction on the use of drugs or treatments, maternal and child care, health management, rehabilitation and health education. Home care providers are predominately rural doctors an paramedics, other physicians and nurses. Approximately 2.27 million people are employed in the home health care industry.

Several sources contribute to the financing of home health care, including Free Medical Care, Labor Medical Insurance, Collective Funds and payments by private individuals. It is estimated that in 1993, approximately 2 billion yuan was spent on home care. Still, studies suggest that the population receiving formal home care services in 1993 was far less than the number of individuals needing such services.

White there is currently no system in place for quality assurance or assessment, the Ministry of Public Health plans to develop regulations and standards for assessing home health care services.

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Cook Islands

The Public Health Department, under the Ministry of Health, deals predominantly with health promotion and the prevention of disease in the Cook Islands. Within the Public Health Department, Public health nurses working in concern with others from the Ministry of Education and non-governmental organizations provide a team approach to health care. Nurses also work with the Ministry of Education to promote good health and disease prevention in the school system, visiting schools on a weekly basis.

Public health nurses provide care in the community and work to promote self-care and the early detection and prevention of disease. They are involved in family planning, pre-natal and post-natal care, the health care of infants and pre-school aged children and immunization program. Disable preschoolers and school-aged children attend special schools for the handicapped

The elderly and disabled are visited periodically by public health nurses and referred for treatment if necessary. The Ministry of Health is currently working, through community involvement efforts, to improve the health of the country as much as possible without use of sophisticated training.

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Cyprus

At present, no comprehensive health care system for the elderly exists. However, due to the aging of the population, and increasing number of "old people homes," operated by bathe the government and the private sector, have emerged.

Home care of the elderly is generally based on a family's ability to provide necessary assistance. Those who have no relatives may receive support from the state. Health visitors, paramedics, and government doctors may provide services for the elderly in rural areas.

The government of Cyprus has proposed a compulsory National Insurance Health plan for the entire population as well as reorganizing the health care system to emphasize the community health nurse.

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The Czech Republic

The Czech Republic has a long history of home nursing dating back to the mid-1920s when the Czech Red Cross provided services in Prague and other major cities. Beginning in 1952, home health services and social home help services were provided under a centralized system of care. Along with very dramatic political changes over the past few years there has been a substantial change in the provision of home care services. With the fall of communism in 1989, there has been a rapid growth of both private and state home health care agencies.

Home health services include acute and chronic skilled and basic nursing care, as well as rehabilitative services, transportation, and counseling. Social services encompass a different set of services including personal assistance, home help, homemaking and meal delivery. Estimates from different years suggest that perhaps as many as 2.5 million or more health that social home care visits are make annually. Coordination between health and social service sectors so as to provide effective delivery is beginning to be addressed at this time.

As in most nations, the majority of home care services are provided by the informal sector, especially family members and persons from voluntary and religious groups. Recently, the complementary use of formal home care services by persons receiving informal care has been noted.

At present, the health insurance system, based on a third party fee-for-service payment model is compulsory. Home health nursing services are reimbursed if provided by health professionals under contract to the insurance company and are approved by a physician. On the other hand, social services are financed by the Ministry of Welfare as well as by municipal and regional government agencies. Clients my make co-payments, the percentage determined by their income. Still, lack of adequate financing precludes the provision of service to those with limited incomes. Despite the recent increase in the number o providers.

Currently, the education and training of the home health professional is being given increasing attention in nursing schools. There is as yet little involvement in home care by general practitioners and very limited training at medical institutions. The concerns about quality assurance have been raised in the Czech Republic as will as in many other Countries.

In 1993, the Association of Home Care was created to collect data related to home care and to unite home care personnel. Additionally, the National Center of Home Care has recently come into existence.

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As the elderly are the biggest users of home care, Denmark offers a continuum of services for this age group, from nursing and rehabilitative care to food service and social activities. County governments are responsible for the provision of acute care, while municipalities are responsible for the delivery of health maintenance and long term care, whether provided in a nursing home or the individual's home. Thus, the primary source of funding for home health care is municipal taxes.

Service delivery is based on need. The municipal office for home help and social services assesses and elderly applicant and decides, in conjunction with the applicant, how much help is required. Approximately 17 percent of persons 64 and older receive home health care provided by nurses and home helpers at not cost to the recipient. However, the residents contribute to the payment for such services as meals-on-wheels, day care, rehabilitation, transportation, and medications. Informal care provided by family members usually consists of social visits.

Within the last five years, every county undertook a comprehensive restructuring of the basic social and health education programs in the fields of home care assistance and nursing. As a result, home helpers are now required to complete 12 months of training (2/3 practical, 1/3 theory) related the performance of activities of daily living and general nursing functions in private homes and institutions.

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Eritrea

Eritrea's thirty year struggle for independence ended in 1991, but the country was not recognized officially until two years later. As a result of years of strife, including war and severe drought, the economic and social situation in Eritrea has left its inhabitants with a low life expectancy (about 46 years), high infant and child mortality, and stunted growth in children due to poor nutrition, unsafe drinking water conditions and lack of adequate sanitation. There is only one doctor in Eritrea for every 28,000 persons. Therefore, Eritreans must rely on traditional informal home care provided by relatives of neighbors.

Many fighters during the war for independence, from the Eritrean People's Liberation Front (EPLF) were given basic medical training and are known as "barefoot doctors." These "doctors" began t treat people living in rural areas (80% of the population) as a means of providing health services. The EPLF also trained traditional midwives to improve their knowledge and skills.

Plans are being made by the new government to build hospitals, at least one in each of Eritrea's zones, as well as district clinics and village medical stations, especially in the rural areas where residents have little or no access to professional health services. Programs have been established to train people in basic medical skills as well as the principles of preventive and mother-child health. Pubic education efforts are being made to improve the knowledge of the general public about health and sanitation.

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Estonian Republic

The health care system that had been in place in the former Soviet Union Republic of Estonia is still in use. However, in 1992 Estonia restored its independence. At that time financing of the health care system was centralized and sick-funds were established to support medical service. Until that year, all medical services were available free of charge.

At present , three levels of medical care are available in Estonia. The primary level, consisting of family doctors, presently consumes about 20% of the health budget and is expected to increase to 40-50% of the whole in the near future. The secondary level, county hospitals, limited in scope, provide treatment for many usual medical problems. On the tertiary level, some hospitals provide highly specialized medical services.

Many small village hospitals, with 15 to 30 beds, have traditionally served those in need of long-term care and have performed many of the functions that hospices perform in Europe and the United States. It is planned to convert about 30 of these facilities to "care homes" or rehabilitation centers.

Any individual residing in the Estonian Republic may receive medical services in the home. Visits are provided by doctors, and in some cased by feldshers or medical assistants, at the primary level in the cities, towns and smaller villages. In 1993, more than 800,000 home visits were made by doctors, medical assistants, nurses and therapists. As part of Social Care, almost 300 caregivers work in Social Help Departments on Estonia, each visiting six to eight disabled and elders in their homes two to three times per week. They assist the resident with simple everyday procedures such as preparing food, delivering medications and cleaning the house. This service is funded entirely by the national government.

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At present, although there is no formal home care in Ethiopia, home visits are sometimes carried out by public or community health nurses during their training period or as a part of a public health project. Additionally, some evidence suggests that physicians, nurses and other health assistants do provide care in the home setting, either for free of for a fee. However, traditionally, care in the home has been provided by relatives, healers, spiritualists and other non-professionals.

Government policy in Ethiopia supports private medical practice, so home health care agencies may be established in the future.

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Fiji

Currently only three percent of persons living in Fiji are age 65 and over. However, declining fertility and mortality rates are expected to increase the percentage of the population which is elderly. In 1993, the Ministry of Health designed a national health care program for this group with the objective of improving the efficiency and effectiveness of continuing care in the community, including home health care. Some non-governmental organizations, such as the Help Age Center, currently provide home care but such services are limited to residents of urban areas and are only supplied upon request. There is a lack of both trained staff and funding. Home care is also provided by public health nurses but this is also don only at the request of the family of the physician.

In the villages and rural areas, home health care is normally provided by family members and relatives although public health nurses will render service during their visits to these communities when requested by the family.

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Finland

Home health care is a component of social welfare and health care provided by the national government and arranged regionally through the municipal health care centers. Health care services, including hospitalization, "non-specialist" care, nursing home and home care, are provided by community health centers in each municipality. There are currently about 220 health centers in Finland. Each center has a nurse to coordinate home health services, which are provided by physicians, nurses, and physical therapists. At present, women 75 years of age and older living alone are the predominant users of home health care services. Additionally the homes of the elderly may be modified so that they may live at home with ease. Home help services are also available to families and individuals who, due to illness, childbirth or age-related disabilities, are unable to manage with housework. Public health services are supplemented by services from non-profit groups and by the private sector, which has grown in recent years, especially in the areas of physical therapy and rehabilitation.

Pubic services are paid for primarily by local authorities ant the national government, which bases its subsidies on the age structure, level of unemployment and "financial capacity" of the municipality. However, based on their income, clients do pay some fees, totaling about 12% of social services expenditures in 1992. If not included in a monthly payment, a fee regulated by the Decree on Social and Health Care Fees is charged for the service. While the various social support services, such as home help, are not regulated by the Decree, their fees are set by the municipality. The state sickness insurance reimburses a portion of private doctor visits and medications. Overall, the patients' share of home health costs has been about 10%.

In 1993, the government passed the Act on the Status and Rights of Patients, which emphasized the patient's right to participate in his our her own health care. Finland is attempting to reform the structure of social welfare and health in order to reduce the need for hospitalization and institutional care and to make outpatient care more effective as well as economical.

Sources:

Ms. Syyne Martikainen Senior Advisor for Nursing Ministry of Social Affairs and Health Snellmaninkatu 4-6 00170 Helsinki, Finland

Mr. Pekka Pitkanen, Senior Planning Officer National Research and Development Center for Welfare and Health International Affairs Unit P.O. Box 20 00531 Helsinki, Finland

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France

France has a long tradition of providing home care to those who need it. As there is one physician for every 280 inhabitants in the country, doctors play a prominent role in the provision of services. This is true even in relatively remote locations.

In addition, over the past decade, there has been a national effort to shorten the duration of hospital stays. This has fostered the development of home care as has a recent consensus conference on day surgery. Furthermore, new legislation has facilitated the provision of medical care in the ambulatory setting.

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Federal Republic of Germany

The Federal Republic of Germany has statutory health insurance for all wage earners and salaried employees through health insurance fund. Also covered by this compulsory insurance are students, trainees and persons in "second chance education," pensioners, or retired persons, provided that they were already insured as compulsory members, disabled persons who are employed or taking part in a vocational training program, unemployed persons receiving benefits from the Federal Institute for Employment, and farmers. In order to keep health insurance affordable, co-payments are required for certain benefits such as hospitalization, in-patient preventative treatments and rehabilitation measures, drugs, bandages, and dentures. Children under the age of 18, as well as those with financial hardship are exempt from co-payments.

Home health care services are covered under the statutory health insurance. This includes home help and home nursing, at the time the insured is hospitalized, and home care for new mothers. As of January 1995, benefits for persons in sever need of care are covered by the statutory long-term care insurance. Private long-term care insurance is also available, but benefits must be equal to those provided by the social program of insurance for long-term care. Long-term care activities include such daily activities as hygiene (bathing, eat..), food preparation, assistance with mobility and transferring, and home help including shopping and cleaning, and will provide "around the clock" daily assistance when necessary.

In Germany, home care takes priority over institutional care. Ninety percent of those who need long-term care who live at home are cared for by family members. New laws focus on improving home car and relieving the caretakers. Visits by home care services are covered under the long-term care benefit. Also, a long-term care cash allowance may be issued in lieu of benefits in-kind. Respite care is available for caretakers for a period of time up to four weeks

Social insurance for longer-term care is financed by income-related contributions which are deducted directly from and employee's pay. For home care benefits, the uniform national contribution is equal to 1% of the gross wages until July 1996 when the rate will increase to 1.7% at which time it will cover institutional benefits as well.

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Guyana

The Home Based Nursing Service in Guyana provides comprehensive nursing services in the home. This privately run service was started in 1994 to provide nursing care in the home, including post-surgical follow-up, a well as counseling services for patients and their families. The service targets any patient in need of home care, including recovering patients, the chronically ill and the handicapped.

In addition to basic nursing visits to provide assessment and care, the service provides pre and post-natal care, and assistance with bathing, personal hygiene, diet planning, and companionship. A nurse may also accompany a patient to the hospital or assist those who need to leave Guyana in order to receive medical attention in another country.

All nurses on the Home Based Nursing Service must be registered with the General Nursing Council of Guyana and must be certified and experienced.

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Hungary

Home help services in Hungary were organized as early as the late 1960's, primarily to care for the elderly, patients with chronic conditions and the homebound. Typical services have included the provision of medications and meals, house cleaning, and assistance in maintaining personal hygiene. Professional caregivers and volunteers deliver these services. In addition, a group of nurse specialists perform nursing activities in the home setting under a doctor's orders.

Since 1993, each municipality has been required to meet local needs for home care, with contributions from the central budget based on the municipality's population size and number of inactive and unemployed persons.

In the past, health and social services in Hungary were considered a right of citizenship. In 1993, one in five Hungarians spent an average of 12.4 days in the hospital. It is believed that this policy promoted lengthy hospital stays and removed the responsibility of home care from the family. Therefore, the health care system is undergoing a reform whereby service delivery will be based on insurance coverage. The insured will receive, at no cost, preventative services, ambulatory care, inpatient care, obstetrical services, medical rehabilitation and rehabilitation of addiction, sanitarium care and ambulance transportation.

Efforts are being made to establish a separate home care and nursing service and to expand the insurance-based system of deliver to the non-profit agencies.

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Iceland

Icelandic law stipulates that elderly persons shall be supported in their homes for as long as possible and cared for in a nursing home when necessary. This law, together with the high cost of nursing home care and the desire of more and more elderly to remain at home, as resulted in an increase in home health services provided by physicians, nurses, nurses aides, physical therapists and homemakers. Because of the need to serve large geographic areas and sparse populations, it has been difficult to organize home care services in rural areas.

Home nursing is usually provided by community health centers while homemaker services are coordinated through the social services sector. The national health insurance finances home health care almost entirely while clients pay a small co-payment for homemaker services. It is planned to try to combine the health and social services and provide home care primarily through the community health centers. While the role of private home nursing is unclear, the number of private home care agencies is expected in increase. There is also a trend toward a hospital-based home nursing program.

Out of approximately 4,000 Icelanders who were estimated to require home care in 1993, about 88% received help from paid professionals. Others received support solely from family members. Usually there is a mixture of formal and informal support services.

As yet, there is no formal specialized training program for home nursing. However, and educational program culminating in licensure is currently being developed for homemakers.

Sources:

Palmi V. Johnson, M.D. Chief of Geriatrics Reykjavik City Hospital Associate Professor of Geriatrics University of Iceland, School of Medicine Reykjavik, Iceland

Torunn Olafsdottir, R.N. Chief of Nursing Seltjarnarnes Community Health Center Seltjarnarnesi Iceland

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Indonesia

Indonesia has a well-developed infrastructure for providing comprehensive primary health care. The system is made up of district health centers, headed by a medical doctor and staffed with between 8 to 15 nurses and other paramedical personnel, depending upon the region. These centers are supported by mobile health centers and midwives. Still, there may exist vulnerable persons, such as pregnant mothers, children under five years of age, and elders who, for whatever reason, are unable to receive care through the health centers. In such cases, the Community Health Nursing Service, which has been developed intensively since 1992, coordinates with the health centers to provide care through home nursing visits.

In addition to the community health nurses, home health care may be provided by extension workers, including village voluntary health workers. Due to limited numbers of professional staff, nurses often function as coordinators and provide training to the extension workers.

While it is estimated that 8 to 10 million people need nursing services, the current system serves about 600,000 vulnerable families. A phased plan is in place which aims to cover all those in need by the end of 1999. Extensive participation from the private sector is expected.

Home care is funded through the national development budget, as well as the autonomous government budgets at the provincial and district levels.

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Ireland

Community-based care, available locally or delivered to the client's home, has developed rapidly in Ireland and has become an option preferred by most recipients of institutional care. Growing community services also address the previously unmet needs of vulnerable groups, for example, the elderly.

The general practitioner and the public health nursing services lie at the core of the community care program in Ireland. General practitioners or community physicians make home visits when necessary. These services are provided free of charge to approximately 36% of the population over 65 years of age. Prescriptions are free to this population as well. General practitioners, not employed by the state, are paid on a captivation basis and are also free to conduct private practice. Home nursing care, paramedical services, home helps and meal delivery are examples of other available home care services.

The majority of funding for the community care is provided by the central government through the Department of Health. Additionally, voluntary providers, ranging in size from large national agencies to small local organizations, play a vital role in the provision of care in the community. Local health boards may fund a voluntary organization to provide a service rather than provide it themselves and some voluntary providers may raise their own funds.

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Israel

Between 1970 and 1990 the number of persons in Israel over the age of 75 increased by 90%. Many of these elders had significant impairments in their activities of daily living. During the same period, services for the elderly increased in range and scope, partly fueled by the implementation of the new Community Long-Term Care Insurance Law (CLTCI) which ensured that all severely disabled elderly receive some degree of support. The law specifically covers the provision of day care, personal care and homemaker services. The Social Security CLTCI Las has resulted in a significant amount of home care being provided for the disabled elderly.

Both professional and "non-professional" home care services are utilized. Professional home care encompasses medical, paramedical, and nursing care delivered in the home. It is provided through the four sick funds, or HMOs, which cover 95% of all Israeli citizens. These funds also provide full primary and hospital car.

Non-professional home are services include assistance with activities of daily living, personal care, and homemaking. Under the CLTCI law, these services are provided mainly through the Social Security Administration. In addition to formal providers, informal caregivers continue to be an important source of care for the elderly due to a strong commitment by the Israeli family to keep family members at home.

The financial responsibility for formal home care services is shared by the government and by both public and voluntary agencies. The Ministry of Labor and Social Welfare, which oversees the Social Security Administration, funds the majority of personal care for the frail elderly. A very low percentage of personal care services is funded privately, primarily through out-of-pocket contributions. In 1990, 46% of all government long-term care financing was allocated to community care, up from 8% a decade earlier. Also in 1990, the government financed 85% of all home health care, as compared too only 41% of institutional care.

The government has taken steps to assure the quality of services delivered. Primarily, the CLTCI law requires all publicly funded service providers to be certified and licensed. Additionally, the Social Security Administration implemented a "basic training" program for providers to teach skills not offered by any formal degree programs and to encourage professionalism.

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Jamaica

Traditionally, Jamaican families provide home care, with assistance from other members of the community when it is needed. However, as women join the workforce and younger family members move to urban areas in search of economic opportunities, the elderly are increasingly being left without the traditional sources of support, resulting in the growing need for formal home care services.

Currently, personal and support care is available for vulnerable groups, for example, infants, children, the physically and mentally disabled, and the chronically and terminally ill. The provision of care is based on age, physical and mental abilities, and health status. Services are provided by approximately 188 day care centers, 46 children's homes and 49 geriatric homes. Utilization data indicate that approximately 1300 children reside in homes and 6000 use services offered by day care centers. An additional 300 persons live in geriatric homes. Additionally a Visiting Nurse Service and a Community Health Aide Service assist clients in their homes. Caregivers are employees of Jamaica's public primary health care system. These providers include nurses and midwives, enrolled nurses (LPNs) and nurses aides, as well as physicians and physical therapists.

At present, out-of-pocket payments by clients of their families finance home care services. However, some health insurance companies are beginning to include home care in their coverage.

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Japan

Although historically home care has been provided by the family, the increasing number of women working outside of the home and the migration of young people to urban areas make this traditional form of care difficult to maintain. Formal home care services have been viewed as a supplement to care provided by family members.

Home care services in Japan are segmented into medical care, human services, and public health. Medical care, delivered by physicians and hospital-based vision nurses, is provided by the private sector but financed on a fee-for-service basis through the universal social insurance program. This plan does require some co-payments by patients. Human services, including home help, are provided by the local or municipal government with funding provided through a national government program. There are out-of-pocket expenses for clients determined by a sliding scale according to household income. Public health care, fully financed by the national government, covers home visits by public health nurses and other health professionals. These services are mainly delivered through health centers nationwide, which employ about 13,000 public health nurses who make home visits.

With the increasing number of elderly, the need for home care is growing. However, at present there are too few human resources, particularly care managers, community nurses, and social workers to satisfy the need. Private ventures have been limited by government regulations and the social imperative to maintain equality in service provision. White some for-profit provider organizations do exist, they are financed solely by client payments and the amount of service they provide is not large.

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Jordan

The Ministry of Health and the Armed Forces Health Care Services provide the majority of health services in Jordan, supplemented by private hospitals and clinics and international charitable organizations, such as the United Nations Relief and Work Agency. However the government neither provides nor reimburses home care services.

Home health care is financed solely by patients who request such services. They are provided by professional caregivers, primarily licensed practical nurses, who receive informal training and on-site experience, and a limited number of registered nurses. These providers are employed by home care agencies. The range of services provided by home health agencies has greatly expanded in recent years, from skilled nursing to respiratory care, physiotherapy and palliative care. Additionally, home care nurses participate in discharge planning, and patient, family and community education. Physicians are not involved in home hare.

Recruiting qualified nurses to perform home care services has been a challenge. Agencies have taken steps to improve this situation such as providing higher salaries than hospitals and providing transportation.

The Jordanian Nursing and Midwifery Council (JNMC) licensed 18 agencies to provide home health services, but of these, only 11 remain open.

Source:

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Kenya

Home care in Kenya is directed toward two population, those with cancer who are terminally ill and persons with AIDS. Nairobi Hospice, a charitable organization which relies primarily on donations, provides home care to approximately 70-100 cancer patients, including some no longer living in Nairobi.

Home care for patients with AIDS is provided by a variety of volunteer organizations, non-governmental organizations and study projects. Some providers include the Kenya Red Cross, Norwegian Church Aid, Christian Health Association of Kenya, Association of People Living with AIDS in Kenya, Know AIDS Society, and AIDS Community Based Outreach Services. Nairobi Hospice and other organizations, which provide care in the home to the terminally ill and patients with AIDS, offer visits by nurses, doctors, social workers and volunteers. In addition they offer counseling services for patients and their families.

Several factors limit the growth of home care in Kenya, including insufficient funds, a dearth of training facilities, and a shortage of drugs such as morphine. Additionally, there is no national policy on the management of terminal illness such as AIDS and cancer.

However, Nairobi Hospice plans to expand its services in Nairobi and to encourage the development of other hospices in other parts of the country. Also, it is hoped that an increase awareness of AIDS and AIDS-related illnesses will lead to an increase in the number of home care programs available in the country.

Sources:

J.J. Huges Nairobi Hospice P.O. Box 74818 Nairobi

Pauline M. Mwololo STD/AIDS Control Programme Ministry of Health P.O. Box 30016 Nairobi

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Kuwait

Traditionally, the needs of the elderly in Kuwait are met by their families in their own homes. While home health care services do exist, they are limited in scope and availability. Primary health care centers supported by the Ministry of Health and employing doctors, nurses, and social workers, provide services for post-natal care and post-surgical care when, for example, the patient is unable to visit a health center. They also provide care in cases of certain diseases, such as diabetes, or in an emergency. However, shortages of health services staff and transportation often make it difficult to provide even these limited services. Social services too are provided under very limited circumstances.

Source:

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Lithuania

The health care system in Lituania is currently being reformed so as to be similar to that of developed countries. The Ministry of Health is responsible for the national health care system of Lithuania, and all medical institutions report directly to that office. Health centers, out-patient clinics, in-patient medical services, and other components of the medical system operate under the jurisdiction of the municipalities. Primary health care is rendered primarily in outpatient clinics an there are some private practices. In 1990, more than 26 million visits (or seven visits per person) were made to out-patient settings. In addition, physicians made 475,800 home visits that same year.

Health policy development is directed toward improving the nation's health through disease prevention and the formation of social and economic structures that are conducive to a healthier lifestyle.

Source:

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Luxembourg

The elderly in Luxembourg have an array of home and community-based services available to them, including health care, homemaking, home-delivered meals, adult day care centers, alarm transmitters, and home adaptation. Home health services are prescribed by and delivered in collaboration with the treating physician. Home health care is provided by two large organizations, the Hellef doheem (help at home) and the Luxembourg Red Cross, as well as by two non-profit associations which provide home nursing and help at home, and two inter-municipal cooperatives which provide only home nursing services. The Ministry of Health subsidizes the large organizations and has contributed to the formation of the other associations in order to promote the availability of services nationwide.

Home nursing services are largely used by the elderly, although home nursing is available for anyone who needs it. All home care nurses are state registered nurses although there is no special education required to become a community home health nurse.

Only one of the six provider organizations operates within a give region of the country, except in the city of Luxembourg where the two largest operate. Two categories of home nursing services are recognized. The first category includes technical nursing skills, such as injections and would care, and must be prescribed by a treating physician. The second category includes such services as personal hygiene assistance, assistance with medications, and psychological and social counseling. Clients may contact a provider organization directly to receive this type of care, without a physician referral.

While Social Security reimburses for some medical treatment, it does not reimburse for home help services. Some contribution from the patient is required for these services, however, a "care allocation" or care grant may be allowed if major care is required.

Day centers for the elderly and patients with Alzheimer's Disease provide activities for the participants and brief respite for the caregivers. Alarm "transmitters" send a help signal to the patient's family, friend, or physician via the telephone in case of a fall or other health problem which may immobilize the patient. The adaptation of housing allows frail elderly to remain in their homes more safely.

Sources:

Paul Moes Responsible Officer/Elderly Ministry of Health 1, Rue di Plebiscite L-2341 Luxembourg

Fernand Bley Deput Director Croix-Rouge Luxembourgeoise Boite postale 404 L-2014 Luxembourg

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Macedonia

As a result of demographic and social changes in Macedonia, the elderly population, especially those suffering from chronic disease, the terminally ill and other disabled individuals have experienced significant changes in their care needs. It is currently estimated that ten thousand elderly or handicapped are in need of home health care services. According to some studies, more than 20.5% of elders are dependent on someone else in order to satisfy very basic needs.

For most recipients, home health care is provided through health homes, medical centers and specialized gerontology hospices. Professional care is provided by the Health and Social Office. Professionals engaged in home care delivery include physicians, nurses, physiotherapists, social workers and psychologists. An individual's need for care is determined by dependence on others, ability to communicate and need for medical or other services.

Geriatric departments within the Geriatric Institute and Clinic for Neurologic and Psychiatric Diseases teach health workers how to care for clients at home. On average, the Geriatric Institute provides medical or rehabilitative home services to approximately 3.488 clients per year.

The Ministry of Health reimburses individuals who are insured for the health care services received. Social services are paid for by the Ministry of Labor and Social Policy. Uninsured persons pay for their care personally as so recipients of non-professional care.

Source:

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Malaysia

The population of Malaysia is generally young. In 1990 it was estimated that 37% of the population was 15 years of age or younger, while less than 5% of the population was over the age of 65. However, the number of elderly is expected to increase rapidly in the future. Additionally, the rapid industrialization of the country has led to an increase in the number of women working outside the home. In light of these trends, the home health care industry is expected to grow and professional caregivers are entering the field as it develops as an industry.

Currently, services are provided by doctors, nurses, physiotherapists, and lay volunteers, mostly in urban areas. The government, recognizing a trend, has encouraged the establishment of a home nursing service. Additionally, the government assists the private development of hospice organizations and cooperated with non-governmental organizations which provide home health care services, counseling, physiotherapy, and rehabilitation. Religious groups also support the provision of home care services.

The government and private organizations provide welfare aid for individuals in need of home care. The elderly and handicapped may also take income tax deductions for medical services received. Additionally, the government allows a significant number of foreign maids to work in Malaysia, many of whom become involved in the care of the elderly and the handicapped in the homes in which they work.

Sources:

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Malta

In Malta, the Department of Health, under the Ministry for Home Affairs and Social Development, oversees hospital care, community health care and public health services. Community health services encompass a wide range of programs including those directed to the needs of children, women, families and persons with specific medical and psychiatric problems. Other available community services are those of a general practitioner as well as domiciliary nursing and midwifery care. A health visiting and domiciliary service is provided to elders and disabled persons who cannot look after themselves so that they may continue to live in their own homes.

Beginning in 1980, the community care services, including the general practitioner services, were offered free of charge to the entire population of Malta. The government is gradually establishing free comprehensive health and medical care for the whole population, including hospitalization and community care. Domiciliary nursing and midwife services are available day or night. The general practitioner services are also provided 24 hours per day.

There are presently 8 government health center that serve different localities. In addition to general practitioner and nursing services they offer programs for immunization, speech therapy, dental services, pre- and post-natal clinics, Well Baby, Family Welfare, Diabetic, Pediatric, physiotherapy, pediatric, ophthalmologic and psychiatric clinics.

Source:

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Federated States of Micronesia

There are currently only two health programs in Micronesia which might be viewed as home health care. The Mental Health Outreach program provides treatment and medication in the homes of clients. Additionally, the Special Education Related Services Assistance Program provides educational therapy in client's home. This second program falls under the jurisdiction of the Department of Education.

Source:

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Republic of Moldova

Health care in the Republic of Moldova is performed by sector physicians, nurses, therapists and charity nurses. Due to the impact of recent socio-economic conditions, medical assistance in the home is not a high priority in Moldova. Medical workers make weekly visits to children up to the first year of life. After the first year, children receive visits in the home when necessary.

At present, particular attention is being paid to promoting healthy living by informing the public of the health risks associated with smoking and alcohol consumption, and by stressing disease prevention, especially in children.

Source:

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Myanmar

Home health care in Myanmar is traditionally provided by women, who generally teach health care practices to their families.

Therefore, Myanmar has launched a training program for women based on the outcome of a study which assessed women's knowledge of self-care as well as their attitudes and practices. This learning module for self-care contains chapters on hygiene and sanitation, nutrition, immunization, pre- and post- natal care, delivery and breast feeding, child care, family care, AIDS, and common health problems and diseases. The program is taught to women in the community by health personnel and members of non-governmental organizations. The intended result of this program is the adoption of healthier lifestyles by all members of the community.

It is generally recognized, by both health care professionals and individuals in the community, that self-care at home, or home health care, is not only essential to primary health care, but necessary for the future development of the health care system in the country.

Source:

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The Netherlands

Formal home care service in the Netherlands supplement informal care provided by family and friends. The Dutch system of home health care includes home help, community health care and maternity care, and a broad range of services from nursing care to housekeeping for the chronic and terminally ill as well as for mothers and infants. Maternity care is very important because the majority of Dutch births take place in the home.

Home help is available to every individual, regardless of age, income or family structure; however the elderly are the predominant users. Typical home help services include housekeeping, meal preparation, and personal care.

Home nursing, parent and child care, and health education are provided by community health associations. To promote health education, the community associations also organize informative meetings on nutrition, sleeping problems and other health related subjects.

The amount of home care has been increasing because of the aging of the population as well as the growing number of people living in single households. Additionally, the government has encouraged the use of home care to decrease the length of costly hospital stays and postpone admissions to nursing homes and other institutions. Clients seem to prefer home care as well.

A large majority of home care workers are part-time employees. 130,000 workers are employed in the industry, providing 300,000 households with home help, 800,000 clients with community health care services, and 150,000 families with maternity care. The work of the community health care associations, along with home help, is funded mainly through the AWBZ (General Act for Specialist Medical Care) and through the membership dues of the members of the associations. Maternity care is funded through the Sick Fund Act and through private insurance. In addition, clients make a contribution based upon their level of income.

In 1990, the Dutch National Association for Home Care was formed by the merger of the Central Home Help Council and the national Community Health Care Association. Its aims are to protect the interests of its members and to develop home care policy. A separate national commission addresses complaints made by clients about home care organizations and makes recommendations to providers and clients.

Source:

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Nicaragua

Nicaragua has no formal system of home health care perhaps in part because it has a young population. In 1990, 47.9% of the population was under the age of 15. Health care, including mental health care, is providing by the Ministry of Health. Six "day hospitals" in the city of Managua provide counseling and occupational therapy. Social services, which in Nicaragua includes homes for the aged, are provided by an institutional called Inssbi.

In the entire country, there are 21 elder homes or nursing homes. Most of these homes are dependent upon the national government for funding, with supplemental funding coming from local governments and volunteer organizations. A few are privately financed.

Source:

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Norway

Health care and social services for the elderly are planned and operated through the municipal governments, as directed by the Acts of Health and Social Services. While informal caregivers, such as family members. play an important role in home care in Norway, available professional services include home help, community home nursing, meal delivery and caretakers services, day care and activity centers, and respite services for the families. Additionally, many municipalities are able to offer an alarm, connect to a health center or nursing home, in the event of an emergency. Over the past ten to fifteen years, home care has grown, with the highest rate of growth in community home nursing.

While there is still a significant level of institutional care in Norway, increasingly the institutions have been retained for the very needy, while home care services have become a viable alternative for those who are less dependent.

Health and social services are financed by local taxes and state programs. Out-of-pocket payments by the users of home care make up approximately 10% of the total expenditures. Recently, with the support of state funding, efforts have been made to increase volunteerism in health care of the elderly.

Source:

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Panama

Home care services in Panama are provided by private nursing groups and for-profit agencies. As the Ministry of Health endeavors to provide coverage for that portion of the population not covered by social security or by private insurance, the future of home health care in the country is uncertain. Presently, less than 1% of the population receives professional home care services and only 2% of the population of Panama receives informal care. (non-paid caregiver), although home health care services have seen an increase in recent years due to increased demand, high cost of hospitalization.

Source:

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Peru

Traditionally, the elderly in Peru live at home and are cared for by relatives, or they are placed in private institutions. Wealthy families may hire aids to assist with the care of the elderly person, but this happens in only a few cases.

The Sociedad de Beneficencia de Lima is the oldest and largest institution in Peru, providing care for more than 2,500 persons in 20 community homes or shelters, most of which are located in Lima. Religious charitable organizations also provide care for about 1,000 people in lodgings around the country. These institutions do not receive any government assistance in terms of funding and therefore rely on other forms of income and private donations.

Some small private institutions, or "academias," exist which employ home care and health aides, but these employees primarily care for infants rather than the elderly.

Source:

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Poland

Home care services in Poland are directed toward palliative care for terminally ill cancer patients. The Voluntary Movement (VHM) was developed in Poland during the 1980's. Caregivers, including doctors and nurses are unpaid, and in addition there are lay-volunteers. Hospice training is provided for doctors and nurses in the United Kingdom, with travel and accommodations being funded by the Polish Hospices Fund-UK.

A Palliative Care Service (PCS), organized by the National Health Service (NHS) and which took an interdisciplinary approach to the care of cancer patients, was developed at the University Ontological Centre in the city of Poznan in the late 1980's. The NHS sponsors 5 more PCS programs. The service offers educational programs to doctors, nurses, pharmacists, theology students and volunteers. It is planned to implement the educational programs in the curricula of other medical and nursing schools. This team approach, consisting of a home care unit, a pain clinic, a seven-bed ward and a bereavement service, allows for the provision of 24-hour/7-day per week care. The teams are largely supported by volunteer efforts. In 1993, the Poznan PCS home care team care for 1,000 patients.

The PCS contributed to the development of more than 50 palliative care home services. Other hospices are run by religious and charitable organizations. Poland hopes to develop palliative home care teams in communities in every region of Poland, which will consist of licensed professionals and be supported by family members and volunteers.

Since 1993, local government funds aided by charitable fundraising has financed home care. A national council for palliative and hospice care has developed standards for care.

Source:

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The Russian Federation

In the former U.S.S.R., hospitals at home (HH) operated in several cities during the 1960's, providing skilled care for patients after discharge from the hospital. This service was initially developed for psychiatric patients. HH patients were visited by a doctor or nurse on a daily basis, sometimes several times per day. Patients were evaluated for HH care on the basis of their health condition, living conditions, potential for care by family members and their financial situation. Patients underwent laboratory and diagnostic procedures using transported equipment, when necessary. The hospital at home program was later adopted for therapeutic, neurological, gynecological, and pediatric patients.

In the 1970s and 80s, the concept of hospitals at home tapered off and many programs closed due to lack of funding and regulations. However, a recent re-emergence of the concept of HH has been realized in the Russian Federation, with 553 hospitals at home serving over 173,000 patients in 1993. Services provided range from post-operative care to the care of patients with cardio-vascular and respiratory diseases, using intravenous drugs, physical exercise and other rehabilitation procedures.

Research from the late 1960s indicated that HH could provide treatment efficiently for a longer duration and at a lower cost.

Source:

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Saint Kitts-Nevis

In Saint Christopher (Saint Kitts) and Nevis, the majority of home health care is provided by private organizations, churches and voluntary organizations. District public health nurses visit homes on a regular basis to provide assistance to persons who are unable to attend regular clinics. The public nurses fall under the jurisdiction of the Ministry of Health.

Not unlike many other developing countries, there is a recognized need for increasing the availability of home health care in St. Kitts, especially in light of increasing life expectancy.

Source:

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Saint Lucia

Both the government and private industry provide health care services in St. Lucia. Currently, five agencies employing 50 professional staff, including physicians, nurses, home health aides and other therapists, provide home care in St. Lucia. It is estimated that 5,000 people are in need of professional health care services, while only 209 receive such services at this time.

The government has realized the need to increase services for the elderly as people are living longer and more of the population is migrating to the cities. Non-governmental organizations have been encouraged to establish residential homes and day care centers. However, families are also encouraged to care for their elderly at home.

Source:

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Seychelles

In Seychelles, life expectancy has seen much improvement, thereby increasing the number of elderly within the population. Because this trend is expected to continue, efforts are being made to allow elders to continue to live in their communities and to be an active part of the community.

Primary health care covers home care for the elderly, in addition to support and counseling for the family caregivers. Home visiting nurse dress wounds and administer medications in addition to discussing preventative measures with patients. Visiting nurses also provide health education and counseling. The medical staff of the Primary Health Care Service generally visit the elderly once every three months, although a doctor may visit more often if there is a special need. Elders may also receive social services from Home Help Carers, who assist them in their own homes. Seychelles also has several residential homes for the elderly. There are two hospitals and the elderly are admitted when they have an acute condition or require rehabilitative care.

Grants are provided for the maintenance of private homes owned by the elderly, and for improving the safety of the home environment by adding, for example, ramps and banisters. Social services provides wheelchairs, walking sticks, and funds funerals for those elderly who have no relatives or who have difficulty with the financing of the funeral. Social Security provides a pension for elderly residents aged 63 and older.

While the elderly in Seychelles receive a substantial amount of care provided by the government, the majority of the care provided is from their families. Traditionally, elderly members of families in Seychelles remain in the homes of their children and grandchildren. It is suggested that family life education prepares families to accept their aged members and make this an easy transition by preparing the home environment so that the elderly can continue to remain at home. Only those who are markedly frail are moved to another residence.

Source:

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Singapore

The Ministry of Health (MOH) and the Home Nursing Foundation (HNF), a voluntary organization, provide extensive home nursing care by trained nurses. There are also for-profit nursing agencies in Singapore that perform home care services. Physicians provide medical care mainly on a private basis, although in 1993, a voluntary home medical service was established.

Approximately 93% of home nursing financed by the government, with the Home Nursing Foundation making up the remaining seven percent. In 1993, the government spent approximately $1.2 million on home nursing, but only 2% of Singapore's elderly received such care from the MOH and HNF. Private medical practitioners and nursing agencies are paid by their clients and utilization and expenditures for these private services are difficult to estimate.

At present, only a limited amount of home care is provided by therapists and social workers due to personnel shortages. Singapore anticipates that the need home health care agencies to increase as well.

Source:

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Republic of Slovenia

Prior to 1990, Slovenia's health care system was administered through a complex, decentralized system organized by the national government but managed through individual communities. Individuals were covered for almost any type of service without having to make a significant fiscal contribution.

New legislation adopted in 1992 introduced both centralized national insurance and voluntary health insurance as well as private practice. The basic primary health services are covered by the compulsory health insurance. However, individuals may purchase additional not purchase the voluntary insurance will be charged a fee for the additional service provided.

Primary health care activities are funded and operate locally in community health centers. These offer the basic medical and dental services, as well as preventative services, health education, home nursing services, ambulance, transportation and pharmacy services. Secondary and tertiary levels of health care exist within hospitals in each of the nine health regions in Slovenia. Organizations at the tertiary level include institutes and clinics which provide advanced level treatment and conduct educational and research activities.

Source:

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Spain

Spain is currently undergoing a political transition from a centralized government to 15 autonomous regional governments, each controlling its own health and social services. Because this process is not yet completed, it is difficult to obtain accurate data. However, it is clear that there is a high demand for home care which is not being met by available services. It is estimated that about 1% of the elderly receive formal home care services at this time by the government. Others need rely on informal support. Home care has traditionally been provided by informal networks and the introduction of formal providers is quite recent.

The national health service finances all health care, provided free of charge to all residents of Spain. Home social services, financed jointly by the Ministry of Social Affairs, the regional ministries of Social Welfare and the municipalities, provide primary care social services, including social work, home aide, maels-on-wheels, and tele-alarm services. Volunteers and not-for-profit groups such as the Red Cross, play an important role in providing social home care services. Home visits by general practitioners and nurses for primary care is financed by the Public Health Service.

Although private professional agencies have begun developing rapidly in the recent past, little data is available.

Source:

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Republic of Sudan

Home health is a traditional part of the Sudanese way of life. Immediate and extended family, neighbors and friends offer social, financial and physical support to an ill person and his or her family during a period of need. Approximately 40% of the population in the Sudan do not access to formal health care. Therefore, society places great importance on home health care. A person who fails to provide care or support when needed can easily become an outcast in the eyes of Sudanese society as a result.

Families and friends often visit ill person in their homes, and in addition to offering moral support they may provide food and money as well as help with household chores. It is not unusual for women to leave their homes to care for a daughter or sister who is pregnant or has just given birth. Families also assist in caring for each others' sick children. Sometimes assistance simply means preparing a nourishing meal. During times of illness, often traditional home remedies are prepared. When a condition becomes worse, help may be sought from more professional health care services, or from a traditional healer. Most of the nursing care that is available in the Sudan is provided in the home, especially to persons recovering from an acute condition, or suffering from a chronic illness or severe malnutrition. In general, with the exception of expert medical care, most of the health care offered in the Sudan is provided by family members.

Source:

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Kingdom of Swaziland

The Swaziland Hospice at Home was established in 1990 and is currently the only health care organization in Swaziland that specializes in care for the terminally ill. Severely understaffed and without many resources, including reliable transportation and adequate security, only three trained nurses visit families throughout the entire Kingdom of Swaziland, providing pain relief, nursing care and emotional support to patients and their families.

The number of persons requiring home based care has grown substantially, especially in light of the dramatic increase in the number of patients suffering from terminal AIDS (18.5% of the population is HIV positive). In an effort to expand the service and increase accessibility for rural populations, Swaziland Hospice at Home plans to decentralize, in addition to providing training for health care workers and rural community groups. This effort will allow for greater frequency of home visits and better pain control, and will reduce the burden on the already inadequate hospital facilities in the country.

However, due to scarce resources, Swaziland Hospice at Home must rely on charitable contributions alone for its funding. Patients and their families are asked to contribute if they are able.

Source:

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Sweden

Care of the elderly has undergone significant change over the past ten years to fifteen years, from an emphasis on institutional care to a focus in independent living, even when extensive care is required. In January of 1992, Sweden reorganized its services for the elderly and disabled, turning the responsibility for health services, including specialized housing for the elderly, disabled and those suffering from dementia, over to municipalities, which already provide social services. Oversight of local nursing homes and home medical care for anyone living in one of the special residences or in ordinary housing also became the responsibility of the municipalities.

Home care services include home nursing (after the reforms) as well as assistance with homemaking, shopping and personal hygiene Personnel who participate in home care included district nurses and nursing assistants, occupational therapists and physiotherapists. In 1993, the municipalities provided home care services to about three percent of the national population. Over half of the recipients were 80 years of age or older.

Home care is financed through local taxation. The combined cost of social and medical home care is estimated to have tripled since 1985.

Source:

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Switzerland

Switzerland is divided into 26 cantons, each of which is responsible for providing health and social services to its citizens. As a result, Switzerland has 26 health care systems, which differ in terms of health care delivery, reimbursement, and policy. However, one commonality is the trend toward limiting health care expenditures by reducing hospitalizations and nursing home growth while encouraging the development of home health care.

Current home care services include nursing care and family and household aid, as well as home-delivered meals, safety installations, day care, physical therapy, chiropody and transportation. The predominately not-for-profit home health agencies receive large pubic subsidies. Clients pay a portion of their costs, usually in proportion to their incomes. In general, health insurance reimburses for acute but not chronic care, and does not cover a household or family aid.

Source:

Rued Gilgen, M.D. Stadtspital Waid CH-8037 Zurich Switzerland

Jean-Noel Du Pasquier Me-Ti, S.A. rue Vatier 16 CH-1227 Carouge Switzerland

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Syria

Home health care of the elderly and handicapped is the responsibility of the family, based on the traditions of the country's religion and culture. Approximately 95% of Syria's elderly population receive informal home care from family members, who learn to render basic medical services such as taking blood pressure or dressing wounds, in addition to providing total daily care (bathing, feeding, dressing). friends and neighbors assist in providing informal care. If a physician or a nurse is needed, the family pays for this service. In the unlikely event that a person does not have any family, a non-profit or government-run home will likely provide health care. These homes are supported by the Syrian government.

There is a plan in place to build more homes for the elderly and handicapped in each province.

Source:

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Tanzania

Many of the health concerns in Tanzania are similar to those of much of Sub-Sahara Africa. Parasitic diseases, nutritional deficiencies and a high rate of difficulties surrounding pregnancy, childbirth and infancy.

Home care in the country is directed to a great extent to home deliveries. About half of all births take place in that setting. There are about 32,000 birth attendants who carry out these deliveries, many of whom are specially trained for this purpose. They are paid "in kind".

Most care in the home is carried out by relatives of the patients, especially women. Village communities virtually always offer assistance to those who are ill and their family although with the migration of many individuals to the cities there is a concern that these relationships are being lost. Most persons with AIDS are treated at home. There are some non-governmental organizations and public health care programmes which provide home care, especially for those with AIDS, tuberculosis, leprosy, maternal care and psychiatric needs. At times a traditional healer is consulted for whose services payment may be in the form of cash, a goat, chicken or perhaps a period of work.

A system of cost-sharing has been introduced although children below the age of five years and pregnant women are still provided care fee of charge at the district hospitals.

Source:

Dr Ali Mzige Principal Secretary Ministry of Health The United republic of Tanzania P.O. Box 9083 Dar Es Salaam Tanzania

Prof. I.A. Ntulia Chief Medical Officer Ministry of Health The United republic of Tanzania P.O. Box 9083 Dar Es Salaam Tanzania

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Thailand

Home health care in Thailand operates as a n extension of the hospital. A "health team" comprised of doctors, nurses, social workers, physiotherapists, pharmacist, nutritionists and dentists leaves the hospital at least once every week to provide care to people at home. This project called "Health Care begins at Home," is designed to empower the people of Thailand to actively participate in their own health care. The health teams serve not just the elderly, but anyone with health problems. Each hospital's center for "Good Health Begins at Home" acts as a liaison between the health team and the patients and their families after the patient is discharged from the hospital. The goals of the project are to decrease the number of inpatient stays and outpatient visits, reduce the length of hospital stays, and lower health care expenditures.

The project is currently being carried out by at least 85 of the 93 regional and provincial hospitals in urban areas and approximately 20 percent of community hospitals in rural areas. Informal caregivers and volunteers play an important role in providing additional care in the rural areas. Future home care in rural areas will target persons with AIDS and related illnesses.

Home health is funded by the national government health budget, distributed through the Rural Health and Nursing division of the Ministry of Public Health.

Source:

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Trinidad and Tobago

Trinidad and Tobago does not have a formal home care delivery system. In general, the elderly are cared for in the home by relatives or paid help, most likely aides or nursing assistants. Affluent families may elect to hire a trained private nurse. Two or three private agencies keep a list of nurses, assistants and aides who desire this type of work.

The number of nursing homes for the elderly has increased, but these homes are not accredited or administered by the government.

Source:

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Tuvalu

The Polynesians who inhabit the 9 atoll islands of Tuvala take pride in tradition. The elderly of Tuvala are cared for by their families and the community. There is no formal home care or hospice care in the country.

Medical care, including hospitalization, is provided by the government. When an elderly person needs hospitalization, his or her caretaker (children) may stay with him or her in the hospital.

Statistics indicate growth in the prevalence of chronic conditions such as hypertension, obesity, diabetes and terminal illness. As a result, the health Division has introduced an educational preventative program called "Fitness for Health," which includes such activities as walking, dancing, organized sports and weight watching.

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Home care is the fastest growing component of the health care system in the United States. Presently there are about 15,000 home care agencies of varying types. They represent approximately $25 billion of about $900 billion dollars spent on health in the country. Some agencies are proprietary, other are hospital based and some are in the public health sector. The enactment of the Medicare legislation of 1965 was a major stimulus for the growth of this industry over the past thirty years as upwards of half of all home care recipients are 65 years of age and over and therefore Medicare-eligible.

At the present time the home care system offers an exceptionally wide rang of services addressing the needs of acutely and chronically ill persons of all ages. As hospital length of stay has declined over the past five to ten years the need for home care services immediately following an in-hospital stay for virtually all age groups has expanded substantially. In addition the older population is enlarging both in absolute numbers and as a percentage of the whole thereby resulting in an increased demand for home services of the more chronic variety. There is also an enlarging need for home care services for infants and children with chronic disease and, of course, for those of all ages with such chronic illnesses as AIDS. Rehabilitative, psychiatric and subspecialty services, such as ventilator care, are now routine in many parts of the country.

Between two and three percent of the population receives formal home care services although that number may well be quite different in the near future. The health care system in the United States is experiencing dramatic and rapidly evolving change with the introduction of health maintenance organizations (HMOs) and similar delivery systems replacing the for-fee-service private practice style of medicine as well as legislative efforts to control overall health care costs. In all likelihood some or all of these changes will have a significant impact on the type and quantity of home care services offered and delivered in the future.

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Vietnam

Vietnam has an extensive health care delivery system with 10 teaching hospital, 676 district hospitals, 2219 clinics, 104 dispensaries and 9205 commune health centers. Home care is a function of the health centers which are staffed by 33,577 health workers, including pharmacists, nurses, physicians, assistant physicians and traditional healers. They provide some service in the home setting including the administration of injections and the taking of a resident's blood pressure. These centers are also responsible for advising families about safe drinking water, waste disposal and disease prevention, especially malaria control and HIV control. Private practitioners and Red Cross members may also participate in home care.

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Zimbabwe

Recently a Home-based Subcommittee has been formed under the national AIDS Control Programme and home care programmes have been established in all provinces of the country. This effort flows from a series of pilot projects. At present the most important constraint in expanding these services is a shortage of resources.

The history of this programme is of interest. Between 1988 and 1993 the first Medium Term Plan identified home care as one of the most important components of care required to address the growing epidemic of HIV/AIDS. By the end of this period there were more than forty-five community home-based care projects. Furthermore since then, some guidelines for establishing such programmes have been developed and widely distributed. Some support for persons with AIDS has been provided by the Department of Social welfare.

the second Medium Term Plan will be focused on the most effective means of providing care given the limited resources available. Particular attention will also be given to quality of care issues. In addition, at the national level representatives from the Department of Social welfare and the Ministry of Health and Child Welfare as well as persons from the private sector will work with non-governmental organizations, religious groups and support groups of those with HIV/AIDS to oversee the care plan. They are specifically directed to expand services, intensify preventive health measures with respect to HIV/AIDS, strengthen outreach programmes, improve efficiency, and plan for the provision of social support for those afflicted. They intend to increase the capacity of all groups involved, improve co-ordination, and fight the stigma associated with HIV/AIDS. Specific targets have been set with specific dates for the implementation of these objectives.

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WHHO News | Compendium Introduction