Current State of Home Care

By Paneetha Ameresekere | Published: 2:00 AM Oct 25 2021

By Paneetha Ameresekere 

Legally, in-home care assistants in Sri Lanka do not require training, the ADB in a study titled ‘Country Diagnostic study on Long-Term Care (LTC) in Sri Lanka’ released on 8 July said. However, most agencies that supply home care assistants provide some kind of training or recruit trained people. Such training varies greatly because Sri Lanka has no standard curriculum or standardised qualification. 

Elder Rights Promotion Officers (ERPOs) must hold a Bachelor Degree. Currently, 100 ERPOs deliver services coordinated by the National Secretariat for Elders (NSE), at a ratio of about 1:25,000 older people or more. Although this limits the role they can play at an individual level, they can coordinate the work of social welfare officers who provide social protection to older persons. 

Elders Ignored 

ERPOs are not evenly distributed around the country, raising concerns about equity of service provision. Social service officers (i.e., social workers employed by the State Ministry of Primary Health Care, Epidemics and COVID Disease Control) work at the community level, but official duties focus on domains such as poverty and children. Expanding their scope to include elder issues is unlikely, due to the workload in the current scope of their work. 

Nurses 

Currently, Sri Lanka’s 17 national nurse-training schools produce roughly 2,500 nurses per year. The Diploma in Nursing is awarded at the end of a three-year training period. A Bachelor of Science (BS) Degree in nursing also provides entry into the service at a higher level (i.e., Sister). Armed with either qualification, a person can register with the Sri Lanka Medical Council to become a registered nurse.

A nurse must be registered to serve in a Government of Sri Lanka (GoSL) medical institution. In 2015, Sri Lanka had 202 nurses per 100,000 people. Some nursing courses now include community health nursing and geriatric nursing. Nurses training at the Kotelawala Defence University Faculty of Allied Health Services can include a comprehensive Community Health Nursing module in its curriculum. Despite some small community health nursing projects, larger-scale implementation has not happened due to the great shortage of nurses in hospitals. 

Many private institutes provide nurses training (but not a Bachelor Degree) that qualifies graduates to serve only in private medical institutions. The Private Health Sector Regulatory Council (PHSRC) provides some training to improve the quality of such nurses. To practice medicine in Sri Lanka, an individual is required to possess a Bachelor of Medicine, Bachelor of Surgery (MBBS) or Medical Doctor (MD) degree as well as registration by the Sri Lanka Medical Council, and must also demonstrate competency in clinical procedures in the capacity of medical officer. 

Currently, eight State universities and a lateral entry format for graduates from foreign universities produce about 1,500 medical interns biannually. Upon completing a oneyear internship, graduates are entitled to practice medicine by themselves. Sri Lanka currently has 87 medical officers per 100,000 people. The current cadre of medical officers can provide care to elders. Since there is strong interest in this field, it is possible to establish a cadre of doctors who specialise in geriatric medicine and care of older persons. 

Around 150 doctors provide medical care, mostly on a visiting basis, and 1,500 caregivers (including nurses, volunteers, trained and untrained attendants) provide care in eldercare homes. Each eldercare home has about five residents per caregiver and around 40 physiotherapists. An estimated 100 nurses, 800 trained attendants and 500 untrained attendants work for in-home nursing care services, caring for older persons and other people who need LTC. However, families may hire caregivers from in-home nursing care services, home care assistant services, or through other family connections. 

No data is available regarding the total number of trained and untrained caregivers who provide LTC for older persons. The Institute for Health Policy (IHP) Survey of eldercare providers estimates the monthly income of a caregiver hired from an in-home nursing care provider institution at Rs 30,000 – Rs 72,000 (US$200 – US$480).A caregiver’s daily rate depends on the services provided, the training of the caregiver and the in-home nursing care provider institute they are hired from. 

Currently, Sri Lanka has no national standard for evaluating care performance, career structure, and incentives that focus on LTC. Different professions and institutions use their own systems and methods to evaluate performance. No agency is formally responsible for developing an LTC workforce in Sri Lanka. However, the Postgraduate Institute of Medicine (PGIM), the NSE, the Ministry of Health (MOH) and the Sri Lanka Association of Geriatric Medicine (SLAGM) have taken the initiative in developing some of the eldercare workforce. 

In 2006, the NSE initiated a 3-week training programme for home care assistants on how to provide care for older patients. In 2015, the programme was developed into a National Vocational Qualification (NVQ) Level 2 qualification, which was conducted and appraised by the National Apprentice and Industrial Training Authority (NAITA). This NVQ 2 qualification was conducted jointly with the NSE and the Directorate for Youth, Elderly and Disabled Persons, Ministry of Health (YED MOH). 

Instruction was provided free of charge. The National Apprentice and Industrial Training Authority (NAITA) and NSE advertised the course and selected people for the training. The YED MOH provided the curriculum and instructors, particularly regarding health education. The programme included two weeks of practical training in the National Hospital of Sri Lanka. Since this NVQ 2 level programme began, it has trained about 20–25 people in each batch of students. 

Because trainees are women, there is a need to increase the male cadre. Upon completion, the trainee receives an NVQ 2 level certificate and is also listed on the NSE’s database of trained home care assistants. Currently, the NSE has about 100 trained home care assistants in its database. The NVQ 2 level qualification was introduced under the One Million Jobs programme and was identified as a way to improve women’s participation in the labour force and reduce female worker migration. 

However, low visibility is a major problem for this programme. Newspaper advertisements have not been successful in attracting people into the vocation. To counter this, the NSE plans to initiate a sticker campaign to increase visibility and attempt to reach their target audience. Trained caregivers can earn Rs 30,000– Rs 40,000 (US$200–US$250) per month and the NSE reports that the trained caregivers find employment. Retaining trained workers has also been a challenge. Some NGOs also conduct this sort of training programme, but with no formal curriculum or standards. 

It would be good to amalgamate these different programmes and introduce a standard curriculum and qualification at the national level, the ADB said. At present, there is no way to continuously assess caregivers’ performance and career development. The National Institute for Social Development offers a free 18-month part-time diploma course on gerontology and/or eldercare. 

The NSE facilitates this qualification for its ERPOs. In 2015, 37 ERPOs completed this training, which covers subjects such as social gerontology, aging society and culture, basic research methods, health and ageing, ayurvedic health and eldercare, mental health and counselling and case management and eldercare. It is possible to expand the role ERPOs play in providing social care for older people who require LTC. 

At present, family members who need LTC for their elders pay for these services themselves. However, data on out-of-pocket expenditure for LTC at the household level are not currently available. Sri Lanka has no systematic data on financial flows to LTC. The Sri Lanka Health Accounts (SLHA) compiled by the IHP do not track LTC expenditure. The IHP is improving its SLHA estimates to track LTC as part of this country diagnostic study (CDS).SLHA estimates comply with the new version of the international standard – System of Health Accounts. 

Health spending was 3.8 per cent of GDP in 2017, of which 1.6 per cent was accounted for by public health expenditure and 2.2 per cent by other financing. The government finances most social services, while non-profit sector and private donation financing is limited. NGOs and charities are financed by international NGOs, donors, private donations from the public, and private corporations. Families currently bear most LTC costs. Services provided by family members are considered unpaid household production. Residential care homes are financed by the nonprofit sector and fees are paid by the resident or covered by charitable donations. In-home nursing care services are financed by out-of-pocket payments. 

(Next Monday:LTC an Investment)

By Paneetha Ameresekere | Published: 2:00 AM Oct 25 2021

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