The multipillar system for health care financing: Thirteen good reasons for open capitalisation funds covering both pension and health care provisions
Fabio Pammolli e Nicola C. Salerno

Dance For Life
Hwa A. Lim

The Global Aging Preparedness Index: A New Tool for Assessing  How Well Prepared Countries are for Global Aging
Richard Jackson

Work in progress

Figure 1: Elderly (aged 60 and over), as a per cent of the population in 2007 and 2040

The developing world as a whole is still much younger, but it too is aging—with some countries traversing the entire demographic distance from young and growing to old and stagnant or declining at a breathtaking pace. By 2040, Brazil and Mexico will be nearly as old as the United States and China will be older. Meanwhile, South Korea will be vying with Germany, Italy, and Japan for the title of the country with the oldest population on earth.

The demographic transformation now sweeping the world promises to affect every dimension of economic, social, and political life. Perhaps most fatefully, it could throw into question the ability of societies to provide a decent standard of living for the old without imposing a crushing burden on the young.

Which countries are most prepared to meet the challenge? And which countries are the least prepared? The Global Aging Preparedness Index (or GAP Index), developed by the Center for Strategic and International Studies, provides the first comprehensive quantitative assessment of the progress that countries worldwide are making in preparing for global aging, and particularly the old-age dependency dimension of the challenge.

1. Purpose and Structure of the GAP Index

Ten or 15 years ago, global aging barely registered as a policy issue. Today, it has become the focus of growing concern worldwide. Many governments are beginning to debate and some have enacted major reforms.

Most of the concern, especially in the developed world, is focused on the rising fiscal cost of government benefit programs. Most developed countries have expensive pay-as-you-go public pension systems that were put in place or expanded back in the early postwar decades when workers were relatively abundant and retirees scarce, but which the steep decline in fertility and the steady rise in life expectancy are now rendering unsustainable. Graying also means paying much more for healthcare, because the elderly typically consume at least three times more per capita in medical services and at least ten times more in long-term care services than the non-elderly.

Meanwhile, in the developing world, governments are beginning to worry that societies may grow old before they grow rich. Many emerging markets are aging before they have had time to put in place the full social protections of a modern welfare State. In China, India, and Mexico, only a fraction of the workforce is earning a formal retirement benefit of any kind, and the majority of elders still depend heavily on the extended family for support. Yet the informal family networks on which elders depend are already under stress from the forces of modernization—and will soon come under intense new pressure as populations age and family size declines. Here the problem is not so much the growing burden on the young as the growing vulnerability of the old.

Yet despite the growing concern, there exists no satisfactory measure of how well countries are actually responding to the challenge. The purpose of the Global Aging Preparedness Index is to fill this gap. The GAP Index is based on projections of public benefit spending and household income by age through the year 2040. It covers 20 countries, including most major developed countries and a selection of economically important emerging markets for which adequate data were available.

In calculating the GAP Index, we use a current policy and current behavior baseline. The projections fully reflect the future impact of retirement policy reforms that have already been enacted but are being phased in over time. They also incorporate predictable “cohort effects” in rates of labor-force participation and pension receipt. The projections, however, do not anticipate additional policy or behavioral responses beyond those that are already in the pipeline. The GAP Index thus serves as a “stress test” of current retirement policies. Its purpose is not to forecast where countries will necessarily end up, but rather to show where they are heading on their current course.

The GAP Index consists of two subindices—a fiscal sustainability index and an income adequacy index. These subindices in turn are based on indicators grouped into distinct categories, each dealing with a different dimension of the challenge (see Figures 2 and 3).

On the fiscal side, the GAP Index includes three indicator categories: public burden, fiscal room, and benefit dependence. The public burden category measures the magnitude of each country’s projected public old-age dependency burden, including both State pensions and health benefits. The fiscal room category measures each country’s ability to accommodate the growth in its public old-age dependency burden by raising taxes, cutting other government spending, or borrowing. The benefit dependence category measures how dependent the elderly in each country are on public benefits, and thus how politically difficult it may be to enact cost-cutting reforms—or indeed, to follow through on reforms that have already been enacted but not yet phased in.

Figure 2: GAP Fiscal Sustainability Index

Figure 3: GAP Income Adequacy Index

On the adequacy side, there are also three indicator categories: total income, income vulnerability, and family support. The total income category measures the overall level of and trend in the living standard of the elderly relative to the non-elderly in each country. The income vulnerability category measures the relative level of and trend in the living standard of “middle income” elders in each country, a group that will be disproportionately affected by changes in the generosity of retirement income systems, as well as the extent of elderly poverty. The family support category measures the strength of informal family support networks, which play a crucial role in retirement security in many emerging markets and some developed countries.

Note that the GAP Index measures the performance of countries relative to each other rather than against some absolute standard of “preparedness”. We considered establishing such a standard, but concluded that any benchmark would be arbitrary. There is no real consensus within countries, much less across countries, on what constitutes an acceptable old-age benefit burden on workers or an acceptable living standard for retirees. Yet almost everyone would agree that the lower the burden on workers is and the higher the relative living standard of retirees is, the more prepared the country is.

Richard Jackson: CSIS (Center for Strategic and International Studies), Washington
1 The demographic projections cited in this article are from the United Nation’s World Population Prospects: The 2008 Revision (New York: UN Population Division, 2009). They refer to the UN’s “constant fertility variant”, except for India, where they refer to the “medium variant”.

]]> http://eng.newwelfare.org/2011/07/17/the-global-aging-preparedness-index-a-new-tool-for-assessing-how-well-prepared-countries-are-for-global-aging/feed/ 0 http://eng.newwelfare.org/2011/05/01/dance-for-life/ http://eng.newwelfare.org/2011/05/01/dance-for-life/#comments Sun, 01 May 2011 12:04:10 +0000 Hwa A. Lim http://eng.newwelfare.org/?p=920 If you can walk, you can dance.
If you can talk, you can sing.
— A saying in Zimbabwe

Fit For Life
“Dance for life” can mean dance for the duration of life, or it can mean dance for the health of life. The two are actually interrelated: to be able to dance, one has to stay relatively healthy; to be healthy, one may want to dance.

Fun or not, fit or not, small starts can yield big dividends, health-wise. A good walking program may improve overall measures of physical health as much as 15% in just three months. Since the human body after age 25 experiences, on average, about a 1% falloff in fitness for every additional year of life, the numbers are simple arithmetic to crunch—that is a 15-year functional rejuvenation.²
The good news is that medical opinion is uniting around the message that getting fit for life can be quick and need not involve a gym or running shoes. The U.S. government’s dietary guidelines were updated in 2005 with its most explicit recommendations to date on exercise. The public has been advised to get 30 minutes per day of moderate-intensity physical activity on most days of the week; 60 minutes per day if they are trying to control their weight; and up to 90 minutes per day to maintain weight loss.
A rough guide for “moderate,” according to Harold Kohl, the lead epidemiologist at the Physical Activity and Health Branch of the U.S. Centers for Disease Control and Prevention (CDC), is walking at about 3 to 3.5 miles per hour. If you cannot maintain a conversation and the heart is beating rapidly, then you have probably crossed into “vigorous” physical activity. “Moderate” can be something as simple as group dance lessons ubiquitous in Asian public parks from Singapore to Beijing, or in most senior centers in the U.S.
fIf time is an issue, U.S. government guidelines suggest that there are still significant health benefits to be gained if the 30 to 60 minutes of exercise is broken up into 10- or 15-minute segments throughout the day. Also, do not choose sports that are seasonal, expensive or solitary—each one is a handy excuse for not sticking with the workout program. Dancing, for example, is not seasonal, solitary, nor expensive, and is a lot of fun.
Yet only 33% of Americans say they do get a moderate 30 minutes at least five days a week, and they are bucking a trend. The U.S. government statistics show that between 1977 and 1995, trips made by walking declined 40%, and walking to school fell 60%. To put the whole thing in perspective, the department of health and exercise science of the University of Tennessee studied a group of Old Order Amish, a religious sect that shuns cars and other modern conveniences. Using pedometers, researchers found that average Amish men take 18,425 steps a day and average Amish women 14,196 steps. A typical American, by contrast, takes only about 5,000 steps.

In Shape And Out of Shape
In a culture that makes a fetish of slimness, the idea of being fat and happy raises eyebrows; the idea of being fat and fit isnothing short of apostasy. With 30% of American adults considered obese, some 200 million Europeans overweight and countless millions worldwide on some sort of diet—usually unsuccessfully—at any one time, that is, “globesity” is an epidemic, perhaps we ought to be asking ourselves whether we are going about things all wrong. There is nothing easier than falling out of shape in this age of instant entertainment on big flat-screen TV; cell phones, iPods, iPhones and BlackBerrys a touch away; an arsenal of remotes within easy reach; conveniences of pizza deliveries to the door, fast food chains, all-you-can-eat buffets… With all these conveniences and comfort, climbing out of the couch and getting back into condition is a trickier proposition.

NEAT
NEAT stands for “NonExercise Activity Thermogenesis” and it is essential for successful weight loss. Basically, it is the extra stuff one does, physically, all day long that adds up. One should make a point to add more “neat” into one’s day so that one can zap another 500 calories! A few ideas include:³
• Do crunches in bed: One could burn about 20 calories in under 5 minutes just by drawing one’s knees to the chest 25 to 50 times, plus it strengthens one’s abs and gets one’s blood pumping.
• Dance around while getting dressed: One could turn up the radio or listen to upbeat music on an iPod while doing all the morning rituals—an hour of hip shaking can burn about 55 calories.
• Stand up! One should not sit when one can be on one’s feet—to burn about 40% more calories. So just take a stand—when one is on the phone, watching kids at the playground, making small talk at a party.
• augh: One should watch something that is consistently funny. That could burn about 40 calories if one guffaws for 10 to 15 minutes straight.
• Walk, pace, jog down the hall: In other words, MOVE! Doing little bits of activity all day—taking the stairs to use the restroom on another floor at work, doing an extra lap around the grocery store—can help one burn an additional 375 calories a day!
In fact, everyday activities do add up as well:

Table 1. Move a little, and lose a lot.

Exercise for Weight Control

People who exercise regularly give many reasons for why they do what they do, regardless of life and occupation’s demands.

They say exercise can improve their health, mood, strength, stamina, or even take them away from their daily chores. But for many, whether they admit it or not, the desire to lose or control weight to stay in shape is a major motivation.
But when one diets without exercising, one loses both muscle and fat, which is counterproductive because muscle loss significantly lowers the basic metabolic rate—the number of calories the body uses at rest.

Table 2. Exercise burns calories, offsetting the calorie intake and helping lose weight. Heavier people need more energy to move, using more calories per activity. 1 kg = 2.2 lbs; 54 kg = 120 lbs; 82 kg = 180 lbs. The weight used in this article is 154 lbs, about the average of these two weights.

Weight-bearing activities that work against gravity—aerobic activities like walking, running, cross-country skiing, dancing, skating and stair-climbing—use proportionately more calories at a given level of effort than swimming, cycling or water aerobics. The more muscle groups are involved in the activities, such as in vigorous or competitive dancing, the more calories one is likely to burn. That is why working out against gravity uses more calories than non-weight-bearing activities. In comparison, because activities like swimming put less stress on weight-bearing joints, many people can do them for longer periods, making up for the lower caloric burn. In addition, the buoyancy in swimming can help the overweight initially as they get into the routine of exercising.
If one engages in resistance exercises—working out with weights or on machines that strengthen various muscle groups—one may gain several pounds of muscle that partly offset the loss of body fat. In other words, one may lose fewer pounds than if one expends the same number of calories on an aerobic activity like brisk walking or swimming, but one will be stronger and better toned. With greater muscle mass, one’s basic metabolic rate will rise and one will burn more calories all day and night. And since muscle holds less water and takes up less room than the equivalent weight of fat, by shedding fat and gaining muscle one can lose inches and sizes without losing actual pounds on the scale. Jack Wilmore, an exercise physiologist at Texas A&M University, calculated that the average amount of muscle that men gained after a serious 12-week weight-lifting program was 2 kilograms, or 4.4 pounds. That added muscle would increase the metabolic rate by 24 calories a day.⁴

But one should keep in mind that the time spent doing resistance exercise burns fewer calories than if the same time is spent on aerobic activities. How skilled one is at the chosen activity also influences the calories burned. Those less skilled, such as unskilled dancers, make unnecessary movements or have to work harder at the activity, using more calories an hour than those who perform it efficiently. That may sound like it is an advantage to be unskilled, but there is a significant downside: Those with less skill tend to tire faster and thus spend less time at the activity. They are also more prone to overuse injuries; they probably would not enjoy doing the activity as much, giving them a good excuse to quit. Another factor in caloric burn is the increased number of calories the body uses after a workout. Both aerobic and resistance exercises raise energy expenditure over the next 12 to 24 hours, but the range is great—from 10 to 150 calories, depending on the type of activity and how long and vigorously it was done. Though it does not sound like much, it can add up over the long run.

Exercise for All
The older one gets, the more one has to deal with creaky and painful joints. But the benefits of exercise—from lower blood pressure to improved mood—are just too great to pass up. So most people who want to remain active eventually learn to accommodate their aging bodies by changing sports or exercise routines.
There are, however, a few rules of thumb to keep in mind. Recent studies have taught exercise physiologist a lot about which combinations of physical activities work best at different ages. But the same physiologists also warn that one should not get so hung up on the new advice that one abandons the old routines. Herbert Löllgen, professor of sports medicine and cardiology at Bochum University, Germany, says, “Swimming, hiking, bowling and calisthenics are particularly advisable.
But even the smallest units of exercise mount up over the day.”
Whatever the age, do spice up the routine with variety to avoid both boredom and injury. The effects of physical exercise on mortality and morbidity, even in old age, can be compared to expensive medication. But what is even more important is preserving independence and quality of life. There are several excellent sports that one may use as hobby exercises. Examples are badminton, swimming, hiking or dancing. Take for example, badminton, which has a false wimpy perception because of the backyard version of the real sport, is really one of those few skilled sports that one can play from the age of six to the age of seventy, and even offering more intense workout than other racquet sports like racquetball and tennis.⁵
Dancing, which can double as a hobby, is an outstanding form of social and exercise activity whose intensity can be adjusted accordingly to suit one’s age and flexibility. It is one of the few forms of exercise that on a social dance floor, the dancer gets to meet new people, dance different dances to a variety of songs, that is, no monotony. In fact, it does not feel like exercising at all; it feels like fun. Using one’s hobby as a form of exercise has another advantage: one not only enjoys the “exercise” more, but one is also not likely to find a handy excuse for not sticking with the “workout program.”
Fitness activities can be divided into three broadly categories. On top of the list is cardiovascular exercise—anything that makes the heart beat faster. No matter one’s age, unless one has a truly unstable condition, getting the heart rate up several times a week is really important. The other two types are strength training and stability (balance) exercise. These two come into greater play as one gets older. One does not necessarily have to separate the exercise for each category.
Indeed, some of the best physical routines, like dancing, tai chi or rock climbing, combine two or more approaches. But expect to change the mix as one move through the decades of one’s life.

Dr. Hwa A. Lim: Ph.D., MBA, MA [USA] ; B.Sc. (Hons), ARCS [UK]. e-mail: hal@ahsaworld.org
This article is based on a chapter in a forthcoming book in Hal’s series of “Yours” books: Hwa A. Lim, Healthfully Yours: Diets, diseases, fountain of
youth, and longevity, (2011, eBook), and references therein.
2 Jeffrey Kluger, “Couch potatoes, arise”, Time, 165(23), August 8, 2005, pp. 52–53.
3 Liz Vaccariello, “5 Neat and easy ways to burn calories all day, every day!” Prevention, June 27, 2009.
4 Gina Kolata, “Does exercise really keep us healthy?” The New York Times, January 8, 2008.

]]> http://eng.newwelfare.org/2011/05/01/dance-for-life/feed/ 0 http://eng.newwelfare.org/2011/04/16/the-multipillar-system-for-health-care-financing-thirteen-good-reasons-for-open-capitalisation-funds-covering-both-pension-and-health-care-provisions/ http://eng.newwelfare.org/2011/04/16/the-multipillar-system-for-health-care-financing-thirteen-good-reasons-for-open-capitalisation-funds-covering-both-pension-and-health-care-provisions/#comments Sat, 16 Apr 2011 14:57:01 +0000 Fabio Pammolli e Nicola C. Salerno http://eng.newwelfare.org/?p=902 CeRM recommendation for creating a new tool, the Open Welfare Funds: open funds based on real capitalisation of contributions, dedicated to both pension and health care provisions, and linked to collective insurance coverage against major health risks (first among them being lack of self-sufficiency).

F. Pammolli, N. C. Salerno (CeRM, Rome)

Abstract
Within welfare systems, health care is the expenditure that poses the most urgent problems for long term sustainability. Without policy interventions and structural reforms, its physiological tendency towards increases over Gdp will inevitably result in restrictions on access and the cutting off of demand for services.
This position paper highlights the need to renew the current health care financing scheme. This scheme cannot remain fully charged to the working income of active people (distribution or pay-as-you-go), if we want to avoid depressive effects on employment, investments and productivity. Such effects, besides hampering economic growth, would have a negative impact on health care itself, with resources becoming increasingly scarce with respect to needs. The financing scheme must become multipillar, with pay-as-you-go being complemented by a private channel based on the real capitalisation of contributions. This channel would be capable of allocating savings, supporting productive investments and generating resources to be dedicated to health care.
The desirable structuring and concrete functioning of the private pillar are less clear and remain under discussion. This position paper puts forward an operational proposal: the open capitalisation fund for welfare should offer both pension and health care provisions through real accumulation of contributions on individual accounts, and should be linked to collective insurance coverage against major risks and lack of self-sufficiency.
This tool presents numerous positive characteristics, compared to the public pay-as-you-go monopillar as well as to a multipillar system in which the private component consists exclusively or mainly of insurance contracts.
An open and conclusive debate is necessary.

Italy is one of the countries that will age the most in Europe. In 2007 the dependency ratio (the ratio between non versus working age people is 51.5 percent, against 48.6 in the Eu-25 and 49 in the Eu-15. This gap is likely to increase. In 2050 the ratio will be 86.8 percent, against 77.1 in the Eu-15 according to the Eurostat central demographic scenario, and 94.3 percent against 83.1 in the Eu-15 according to the most intense aging scenario. Besides the many changes in the organisation of the economy and of society caused by this profound reshaping of the demographic pyramid, disproportionate flows of resources between generations will emerge, particularly as far as the financing of pension and health care systems is concerned.

1. Inadequacy of the monopillar pay-as-you-go system
In Italy, pensions and health care are financed almost entirely on a pay-as-you-go basis, that means through resources taken yearly from the incomes of workers.
Considering the long term projections for pension expenditure (Ecofin) and health care (Oecd), together with Eurostat demographic projections, in 2050 every citizen of working age will have to contribute an amount equal to 50 percent of per capita GDP (today it is 30).
Even in the optimistic hypothesis of achieving the labour market goals set at the Lisbon and Stockholm European Councils, the burden on every employed person would exceed 70 percent of per capita GDP. If instead the employment rates were to remain as they are today, this burden would be much heavier, close to 100 percent, as for every employed person there would be 1.5 persons (children and the elderly) to be supported (today 0.85).
These huge disproportions will take place, to different extents, in all industrialized countries, and are bound to produce distorting effects on labour markets, investments and production. Pay-as-you go financing schemes can no longer rely on the so-called Aaron’s theorem, which, given a young and growing population, states that yearly contributions paid by all working people were the best possible solution for both transferring resources across generations (for pensions) and sustaining universalistic provisions (for health care systems).

2. The development of the complementary capitalisation pillar
In order to rebalance the pay-as-you-go scheme, for both pensions and health care, it is necessary to develop a complementary pillar based on real capitalisation, that provides resources for facing future expenditures through the accumulation, supported by tax relief, of long term investments on individual accounts.
In Italy, the debate on the limits of pay-as-you-go schemes has focused almost exclusively on pensions. For these, even though the private pillar still displays an insufficient dimension and its normative framework is far from complete, a certain awareness of the problem has been reached. For health care, on the contrary, it seems there is still a long road ahead, even if multipillar diversification appears more necessary than it does for pensions.
In Italy, while public pension expenditure is slowly stabilising over GDP in the long run, public health care expenditure, without policy correction, could double or more than double its incidence (from approximately 6.8 percent of Gdp to 15-16). In the mid-long term, the dynamics of the two items will bring two different problems: for pensions a problem of social sustainability, if the employment rates fail to close the gaps with respect to the EU Partners, working life will not be lengthened and the private pillar will not manage to integrate sufficiently; while for health care a real and true financial problem, that is unbearable pressure on the public budget will result.
The development of the private pillar would also bring positive effects in terms of incentives to work, productivity, and the lengthening of active life, from the moment that, boosted by tax relief, the single adherent’s savings would accumulate to his advantage only, with his rights to the fruits thereof guaranteed. From this point of view, the private pillar in health care would reinforce the virtuous properties of the rules of notional capitalisation calculation introduced by the “Dini” pensions reform of 1995.

3. A proposal: open capitalisation funds for welfare In order to promote the development of a financing channel based on real accumulation, it would appear useful to reflect on the possibility of a convergence of the two complementary covers: the pension one and that for health care, for both acute and long term care provisions. This is a subject that concerns above all the funds (pension and health care) that through simplification, standardisation and critical mass have great potential for lowering administrative and managing costs.
With greater convergence between pension and health care aims, it would be possible to borrow the actual pension funds structure directly, completing and perfecting it. More specifically, the three goals – pensions, acute health care and long term care – could refer to the same legal subject, identifiable as , operating through the real accumulation of contributions on members’ individual accounts, and linked to collective insurance coverage against major health risks and lack of self-sufficiency.
Incidentally, current Italian legislation already allows pension funds to pursue aims of a health/socio-health nature by disinvesting a predefined percentage of accumulated capital, or by using a percentage of member’s contributions to buy an insurance policy against major critical events, and in particular the lack of self-sufficiency.

]]> http://eng.newwelfare.org/2011/04/16/the-multipillar-system-for-health-care-financing-thirteen-good-reasons-for-open-capitalisation-funds-covering-both-pension-and-health-care-provisions/feed/ 0 http://eng.newwelfare.org/2010/10/30/paper-no-15-october-2010-welfare-for-wealth/ http://eng.newwelfare.org/2010/10/30/paper-no-15-october-2010-welfare-for-wealth/#comments Sat, 30 Oct 2010 16:08:20 +0000 Administrator http://eng.newwelfare.org/?p=891

Content Summary

Editorial

The Elderly between the Needs for Care and Active Ageing
Tiziana Tesauro and Luca Pianelli

Aging of the Elderly: An Intragenerational Funding Approach to Long-term Care
Susan St. John and Yung-Ping Chen

Costs of Political Intermediation and Sustainability of the European Social Model in Health Care: the Dutch Example
Giulio Ercolessi

Sustainability and Adequacy of Pensions in EU countries: Synthesis from a Cross-national Perspective
Asghar Zaidi

A Comparative Analysis of Welfare Systems and the Health and Social Sector: Evidence from 16 European Countries
Gabriella Pappadà

Dementia and Diagnosis — The Discrepancies in Response across Europe
Sally-Marie Bamford

The Evolution of Clinical Engineering and the Development of Digital and Molecular Medicine: Cultural and Economic Effects
Diego Bravar

Securing Decent Pensions for Nurses: Gaining Insights into the Issues at Stake for an ‘Atypical’ Workforce
Hedva Sarfati

The Post-Socialist Transition and Care for Older People in Slovenia
Valentina Hlebec

Document: Strengthening Older Persons’ Rights

Download this paper in Acrobat Pdf format.

For your library buy the printed version!

2. Why is Demographic Ageing Important?

Population ageing is one of humanity’s greatest triumphs. It is also one of our greatest challenges and places increasing economic and social demands on all countries.
Worldwide, the proportion of people aged 60 years and over is growing and will continue to grow faster than any other age group due to declining fertility and rising longevity.
The number of older people over 60 years is expected to increase from about 600 million in 2000 to over 2 billion in 2050. This increase will be greatest and the most rapid in developing countries, where the number of older people is expected to triple during the next 40 years.
By 2050, over 80 per cent of older people worldwide will be living in developing countries.
At the same time, the number of ‘older old’ persons (here defined as 80 years and over) in the developed world will reach unprecedented levels.²
Older people need adequate income support as they age, opportunities to engage in decent employment should they wish to remain active, and access to appropriate health and social services, including long-term care. The higher number of women living into very old age also presents a major challenge for policy-makers.
The lack of policies to address these issues is condemning millions of older people to a life of poverty instead of recognising the active economic and social contributions they can make to their families, communities and society as a whole.

3. Putting older People’s rights into Context

What Are Human Rights?
Human rights are the rights people are entitled to simply because they are human beings, irrespective of age, citizenship, nationality, race, ethnicity, language, gender, sexuality or abilities.
When these inherent rights are respected, people are able to live with dignity and equality, free from discrimination. Human rights are universal, widely accepted and central to our understanding of humanity. The concept of human rights has developed over time and has its origins in a wide range of philosophical, moral, religious and political traditions. There is no single historical narrative charting the evolution of rights to the understanding we have of them today. This is what gives them their universal relevance.
What Are older People’s Rights?
The Universal Declaration on Human Rights states in Article 1 that ‘all human beings are born free and equal in dignity and rights’. This equality does not change with age: older men and women have the same rights as people younger than themselves.
The rights of older people are embedded yet not specific in international human rights conventions on economic, social, civil, cultural and political rights. Examples include the right to equal protection before the law, the right to own property, the right to education, the right to work and the right to participate in government.
Some rights may have more relevance in older age than at other times in life, e.g. the right to social security in the form of a pension.
Sometimes a right that may have been respected when someone is young may not be well protected in older age, e.g. the right to access appropriate health and social care services.

Why is it Important to Promote and Protect the Rights of older People?
Human rights change people’s lives. Protecting older people’s rights will help to enable them to lead dignified, secure lives, as equal members of society.
Discrimination against any group in society is unacceptable. With rapid population ageing, the prevalence of age discrimination escalates and so does the imperative to address the fundamental causes of discrimination. Treating older people with respect and on an equal basis with younger people creates the conditions that enable all people in society to participate in and contribute to their own development. It is important to remember that today’s younger adults are tomorrow’s older people.

What Is the Connection between Ageism, Age Discrimination and older People’s Rights?
Ageism is the stereotyping of, prejudice against, or discrimination against a person because of their age. Age discrimination is when someone is treated differently because of their age.
Ageism and age discrimination can result in violations of older men’s and women’s rights.They continue to be tolerated at all levels of society: by individuals and institutions; through local, provincial and national policies; as well as in the business sector.
It is important to remember that older people are not a homogenous group. Older men and women age differently and the discrimination that they experience is often multi-dimensional, based not only on age but on other factors, such as gender, ethnic origin, where they live, disability, poverty, sexuality or literacy levels.

How Are older People’s rights Violated?
The rights of older people are violated in a number of different ways, including: Older people’s right to freedom from discrimination, older men and women are often denied access to services, jobs or treated without respect because of their age and other factors such as gender or disability.
Older people’s right to freedom from violence
Older men and women are often subjected to abuse including verbal, sexual, psychological and financial abuse.

Older people’s right to social security
Many older people do not have financial protection such as pensions and other forms of social security. Lack of a secure minimum income can make older people and their families fall into poverty.

Older people’s right to health
Older people may not receive appropriate health and social care because of their age. Treatment can be denied and older people can receive poor or insufficient service.

Older people’s right to work
Sometimes older people are deemed ‘unemployable’ because of their age — this is a violation of a person’s rights in the workplace, everyone has the right to free choice of employment. Furthermore, older people may also be forced to stop working because of mandatory retirement ages.

Older people’s right to property and inheritance rights
In many parts of the world, inheritance laws, both statutory and customary, deny women of all ages the right to own or inherit property when their husband is deceased. Family members often force widows off their land or seize their property which is a violation of their right to equality of ownership, management and the disposition of property.

* This document on the “Rights of Older People” as been provided to us by Susan Paul, President, Global Action on Aging, 777 Un Plaza, Suite 6J, New York, NY 10017 US, E-mail: list.serv@globalaging.org – www.globalaging.org. This publication was produced collaboratively by nine organisations (their names and sites are provided at the end of the document).
1 The Universal Declaration of Human Rights, established in 1948, is now recognised as customary law that is binding on every country in the world. The UN has compiled translations of the Universal Declaration on Human Rights in over 300 languages and dialects: www.ohchr.org/EN/UDHR/Pages/SearchByLang.aspx .
2 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: the 2008 Revision: esa.un.org/unpp/ .

]]> http://eng.newwelfare.org/2010/10/26/strengthening-older-people%e2%80%99s-rights-towards-a-united-nations-convention/feed/ 0 http://eng.newwelfare.org/2010/10/20/the-post-socialist-transition-and-care-for-older-people-in-slovenia-2/ http://eng.newwelfare.org/2010/10/20/the-post-socialist-transition-and-care-for-older-people-in-slovenia-2/#comments Wed, 20 Oct 2010 12:59:34 +0000 Valentina Hlebec http://eng.newwelfare.org/?p=856 Abstract
The complex set of social changes in Central and Eastern European countries (CEE) which include the transformation of political, economic and welfare systems is generally named “the transition period”. In Slovenia these changes started in 1991 with the country attaining independence and continued with thorough changes to the welfare system. Together with the transformation of the welfare system, new forms of care for older people such as home care services were introduced. In this paper we present the welfare system reforms relevant to older people and the consequent development of their care in two main areas: institutional care as well as the development of social services for older people living at home.

1. Introduction
The Slovenian welfare system today is the outcome of a series of gradual changes over the last 20 years. However, its origins can be traced to the 1950s and the development of the Yugoslav welfare system (see Kolarič, 1990 and 1992; Kolarič et al., 2009). The state socialist welfare system was based on the compulsory payment of contributions by employees and enterprises to cover risks of income loss (including old age) and all contributions for education, childcare, care for older people etc. The system had three components, namely: the public sector, the informal sector and the “gray” sector. In the public sector, a well developed and regionally dispersed network of public (state) organisations and institutions provided formally organised professional services, including numerous institutions for the care of older people (old people’s homes). The second sector — the informal sector — provided services that were lacking in the public sector. These were provided by members of close and extended families, friends and neighbours. This voluntary and unpaid provision of services, largely based on strong value orientations, normative expectations and emotional closeness within informal networks (Filipovič Hrast and Hlebec 2008 and 2009; Hlebec and Filipovič Hrast 2009; Hlebec 2009), was ignored by the state and therefore not supported by policy measures. The gray sector (Kolarič 1990 and 1992; Kolarič et al., 2009) comprised employees in public institutions and organisations who were offering services for direct (illegal) payment. The gray supply of services was tolerated by the state as it compensated for the lack of services in the public sector. Part of the third sector also comprised voluntary organisations and associations which were financially supported by the state. This part of the system was not well developed before the transition period.
Therefore, care for older people before the transition period was based on the public provision of institutional care and on informal care provided mostly by family members (Nagode et al., 2004). That is why it is important to continually observe both: (1) the development of institutional care; and (2) the development of policy measures and services for older people living at home and for their carers.
The change of the political system in 1991 was accompanied by changes in the economic system as well as gradual changes in the welfare system. Among changes to employment policy, family policy, disability and old age pension policy, health care policy, educational policy and housing policy (Kolarič et al., 2009), the old age pension reforms and health care reform had the greatest impact on care for older people. There were also several specific acts and programmes related to care of older people which we will review later.
Two pension system reforms took place in 1992 and 1999 (Kolarič et al., 2009). Changes in the pension system, although gradual, increased the retirement age, reduced differences in requirements for men and women (the full pensionable age for men is 63 and 61 for women) and emphasised the relationship between benefits and contributions. A three-pillar system of pension financing was also introduced. A new reform is in the pipeline and the proposed changes further increase the retirement age and are aimed at the pension system’s long-term financial sustainability.
The pension system changes have had an effect on the retirement age which is slowly rising, as shown in Figure 1 below.

Figure 1: Average age of new pension beneficiaries (without survivors and widower’s pensioners) under general and special regulations, by years, situation in December

Sources: Zavod za pokojninsko in invalidsko zavarovanje Slovenije, 2010; The Pension and Disability Insurance Institute of Slovenia, 2004.

However, other changes relating to the pension system reform have had a negative impact on the lives of older people, especially those who are the most vulnerable — the very oldest. The income position of retired people was improving from 1983 to 1993, although the poverty incidence of people aged 60+ was considerably above the national average (see Stropnik et al., 2003: 62-64). While the economic situation of older people was improving until 2001, their economic situation has deteriorated since 2001 as shown by Kump and Stropnik (2009; Stropnik et al., 2010) in their analysis of the economic status of older people after the pension reforms. The biggest decrease in the economic situation occurred for those aged 75+, who also faced a decrease in their absolute (not only relative) income. As emphasised by those authors, elderly women, especially women in a single household, and people living in pensioner households are in a particularly low income position. The authors relate these changes directly to the impact of the pension reforms.
Changes to the health care system were introduced by the health insurance reform of the 1990s (Kolarič et al., 2009). Basic (compulsory) health insurance (CHI) still covers almost the entire Slovenian population and therefore the health security system is accessible to all. However, several services, medicines etc. require additional voluntary health insurance (Stropnik et al., 2003). Some researchers (e.g., Javornik, 2006) claim that the growing social and economic inequalities as a result of the transition have had a greater effect on differences in health and overall wellbeing than the health security system itself. Moreover the health system and social welfare system are only slowly responding to demographic changes and the intensive ageing of the population. The long-term care system is still quite fragmented and systemic, while related policy changes are still a challenge for the near future.
Apart from overall changes to the welfare system after the transition, other policy measures were developed that relate directly to the care of older people. These measures and their consequences are presented in the following paragraphs.
The Pension and Disability Insurance Act (PDIA) prescribes means-tested transfers among the elderly such as a pension income supplement which is available to pensioners with low incomes and an incomplete contribution period. It is granted to old-age pensioners, disability pensioners and recipients of a survivor pension. 1999 also saw the introduction of a national pension granted to people who do not receive any pension and satisfy a number of conditions. In addition, assistance and attendance allowance beneficiaries are mostly given to pensioners.
The Health Care and Health Insurance Act (1992) offers an opportunity for family members to take care of a close family member. They are eligible for wage compensation for 7 days, exceptionally for 14 days, but only for people who are living in the same household. The National Health Care Programme in the Republic of Slovenia — Health for All by 2004, emphasised home care services. Although a long-term care insurance act was proposed in 2006, it is still to be passed.
The Social Security Act (MDDSZ, 2006a; Amendment to the Social Security Act, 1992) defines services for social prevention, and services meant to eliminate social distress and difficulties (first social aid, personal help, help to the family, institutional care, guidance, protection and employment under special conditions, help to workers in enterprises, institutions and other employers). One measure related to care for older people is the possibility for a family member to become a family attendant with the right to partial payment for lost income at the minimum wage level or to a proportional part of payment for lost income in the case of part-time work.
The programme for the development of care for older people in social protection in Slovenia (Program razvoja varstva starejših oseb na področju socialnega varstva v Sloveniji do leta 2005, MDDSZ, 1997) emphasised the development of institutional care and the development of services in the community.
The strategy of care for the elderly till 2010 (MDDSZ, 2006b) supports: the enlargement of capacity for care at old people’s homes; the granting of concessions to and encouragement of public-private partnerships; upgrading of the capacity network for day care; the distribution of home help services; the distribution of the sheltered housing system; the distribution of the remote help system provider so that the public access contractor network is ensured and covers the whole country. Support for family members who take care of elderly family members was also encouraged.
The National Social Protection Strategy of 2005 and the Resolution on the National Social Protection Programme 2006-2010 define new forms of mobile assistance, day care centres, care in a family other than the birth family and care in sheltered housing for the elderly. In addition, two programmes tackle social exclusion and poverty: the National Programme on the Fight against Poverty and Social Exclusion (MoLFSA 2000) and the National Action Plan on Social Inclusion 2004-2006.
As mentioned, care for older people before the transition period was based on the public provision of institutional care coupled with informal care provided mostly by family members. Policy measures since 1991 have targeted both the development of institutional care and support for older people living at home and their carers. Therefore, we focus the main part of this paper on trends already emerging in the development of: (1) institutional care; and (2) services for older people living at home.

Valentina Hlebec: Faculty of Social Sciences, University of Ljubljana, Slovenia. Kardeljeva pl. 5, 1000 Ljubljana – valentina.hlebec@fdv.uni-lj.si .

]]> http://eng.newwelfare.org/2010/10/20/the-post-socialist-transition-and-care-for-older-people-in-slovenia-2/feed/ 0 http://eng.newwelfare.org/2010/10/15/securing-decent-pensions-for-nurses-gaining-insights-into-the-issues-at-stake-for-an-%e2%80%98atypical%e2%80%99-workforce/ http://eng.newwelfare.org/2010/10/15/securing-decent-pensions-for-nurses-gaining-insights-into-the-issues-at-stake-for-an-%e2%80%98atypical%e2%80%99-workforce/#comments Fri, 15 Oct 2010 13:53:55 +0000 Hedva Sarfati http://eng.newwelfare.org/?p=849 Abstract

Securing pension coverage and adequacy for nurses raises several basic challenges and policy implications for pension systems, for individual nurses, nurses’ professional associations and health care trade unions. In several countries, nurses are exposed to poverty in old-age due to their ‘atypical’ career path: many leave the profession early, work part-time, have discontinued careers, and retire early. Their pay is sometimes low and the calculation of their pension benefits does not take account of various hardship bonuses. As a result, their pensions may fall short of guaranteeing a decent living standard. Moreover, recent pension reforms (both public and private schemes) tend to reduce benefits, extend the period of contribution, and shift the risk of benefit adequacy to the nurses themselves. This article draws principally on a recent monograph by the author carried out for the International Council of Nurses (ICN).

1. Introduction

The primary objective of pension schemes is to prevent old age poverty. This supposes the existence of pension schemes that are affordable for individuals and society and financially sound enough to be sustainable over the foreseeable future, despite the current antagonistic economic, societal, demographic and labour market context.
Over the past three decades, major changes have occurred in these four groups factors, which will be outlined below. They have generated growing concerns about the extent of pension coverage of the population, the adequacy of income replacement in retirement, and the financial sustainability of existing pension schemes in the advanced economies. These changes have been taking place against the backdrop, first, of growing public deficits and debts (increasingly evident and acute since 2007 following the financial markets meltdown); and second, the substantial and constantly growing increase in social expenditures in the wake of demographic ageing. (Expenditure on social protection in EU-27 accounts on average for between a quarter and a third of GDP. Social benefits for old-age and survivors are by far the highest item in this expenditure, close to 46% on average, and growing steadily since 2000 by 3.4% per year. It is followed by sickness benefits and health care, close to 20% on average. (EUROSTAT 2008a).
These concerns have, over the past two decades, brought the issue of pension reforms to the forefront of the political agenda worldwide, but more particularly in the industrialised countries. The main thrust of the planned and/or implemented pension reforms is to cap social expenditure to reign in, if not reduce, rising public deficits by limiting the generosity of the welfare state by transferring the risks to employers, to pension funds and, increasingly, to the individual wage earners. They also tend to increase the legal retirement age, increase the period of social contributions and expect employers to retain older workers and employees to delay retirement.
The highly controversial debate over pension reform, however, rarely touched the problem of coverage of the growing numbers of people with short or discontinued careers. These are ill-defined categories of ‘flexible’, ‘non-standard’ or ‘atypical’ workers, for which limited labour market statistics are available nationally, and even more so internationally. They roughly include: (i) part-time work – with different numbers of working hours, sometimes less than 15 hours per week, sometimes more than 20 hours per week; they may be quasi permanent with a pro rata coverage of social and employment protection or short term, with minimal or no protection; (ii) temporary work — which may include fixed term contracts, spanning several years or a few months, and contracts through temporary employment agencies, of diverse duration and extent of social and employment protection; (iii) self-employed – with either very high or very low earnings (viz. the so-called ‘mini jobs’ or ‘solo’ self-employment); (iv) seasonal and casual work; and (v) people working in the informal sector (which, is relatively widespread even in some advanced countries where it involves between 7 and 30 % of the workforce). OECD and EU statistics do provide data on part-time employment generally, but without a breakdown of the extent of hours worked. Data on total hours worked, on the other hand, do not provide insights into the distribution among non-standard workers. One study on social protection coverage of this category only offers a few general comments on coverage of persons in ‘marginal employment’ and ‘solo self-employment’ in six EU countries (Schulze Buschoff & Protsch 2008), while another international one focuses on the informal sector and migrant workers (van Ginneken 2010).
The concern about ‘atypical’ workers is due to the fact that their social protection rights may be significantly curtailed, particularly as regards pension coverage and even more so adequacy of income replacement (this of course also applies to employment protection rights and to unemployment benefits). This issue has already been underlined in 2003 by the EU Task force on employment, chaired by Wim Kok, whose report called on EU Member States and social partners “to examine the degree of security in non-standard contract” to help prevent the emergence of a two-tier labour market where “insiders” benefit from high levels of employment protection, while an increasing number of “outsiders” are recruited under alternative forms of contracts with lower protection” (European Commission 2003:7).
Indeed, where the level and duration of cash benefits payments are linked to the length of past employment record, the amount of contributions paid and previous earnings, atypical workers may be at significant disadvantage compared to ‘standard’ full-time, full career workers. Even in the few countries where universal basic public pension schemes exist for all residents, the qualifying period of residence is rather long (40 years in Denmark, 50 years in the Netherlands), or the level of benefits below poverty line (for example in the UK (Ginn 2002). Moreover where remuneration is low (sometimes reflecting part-time employment), it may disqualify many ‘atypical’ workers from access to supplementary pension schemes to improve their retirement income (e.g. in UK and, until recently, Switzerland).
The latest ILO data shows the relatively low pension coverage worldwide – nearly 40% of the population of working age is legally covered by contributory mandatory old-age pension schemes. Arguably, this average hides a widely diverse regional situation. North America and Western Europe legal coverage is almost twice as high, though somewhat lower in Central and Eastern Europe (73%, 70% and 62% respectively). More importantly, when considering the effective coverage¹ of the compulsory old-age pension, the percentages slightly decline to 72% in North America and 65% in Western Europe, but to 48% in Central and Eastern Europe. By comparison, the percentages drop from 58% to 28% in Latin America and the Caribbean, from 38% to 18% in the Middle East, from 28% to 19%, in Asia and the Pacific, and from 14% to just 4% in Sub-Saharan Africa (ILO, WSSR 2010, pp. 49-50, Figure 4.1). This leaves quite a substantial number of non-protected people, presumably many among whom are in atypical jobs. Unsurprisingly, the ILO concludes that “Incomplete coverage is a widespread phenomenon; it is seen not only in developing countries but in industrialized countries too. Given the fact that a large proportion of pension schemes provide benefits on an earnings-related basis, some groups with incomplete past work records tend to fall behind. Notably hard-hit groups include women (as discussed above), low-skilled workers and ethnic minorities.”(Ibid: 59).
Atypical work status is common among women in advanced economies, and is associated with child rearing and caring for older relatives. It explains the strong gender dimension of poverty in old age (Sarfati 2004). A further aggravating factor is the fact that atypical workers are usually not covered by unemployment insurance — which in several industrialized countries pays pension contributions (credits) during unemployment. This of course affects the limited level of income replacement where they have pension coverage. In high income countries, nearly 70% of the labour force is covered by law for some type of unemployment protection scheme, the percentage drops to 40% in upper-middle income countries and less than 20% in lower-middle-income countries. However, as with pensions, the effective level of coverage is substantially lower, even in high income countries, dropping to less than 40% of all unemployed, though many among them may qualify for general social assistance (ILO, 2010:.70-71). Moreover, coverage of atypical workers varies widely even within this group of countries, with high coverage above or close to 80% in Luxembourg, Denmark, Sweden and Finland, about 60% in the Netherlands, Spain and France, but lower in other EU-15 countries. (Leschke 2007 and 2009).
Given the difficulty in assessing the exact social protection situation of this growing ‘atypical’ workforce, the author felt that looking at one occupational group – nurses — provides interesting insights for the policy implications of ensuring provision of coverage and decent pension benefits in ageing societies where a ‘permanent austerity welfare State’ is plausible for the foreseeable future (to paraphrase Paul Pierson: 2001) for the following main two reasons:
First, nurses cumulate several characteristics of an ‘atypical’ workforce as regards pension coverage and adequacy. Nurses seem to be a well established professional group in great demand, but they tend to have short and discontinued careers, work part-time and retire early. While in most advanced countries nurses, at least in public and private hospitals, are covered by statutory public pension schemes (‘pay-as-you-go’ PAYG) and also have, in several countries, access to employer occupational pension schemes, they may still be exposed to poverty in old age, as will be shown in this article. Among developing economies, few countries have adequate pension systems to support retired nurses, although ‘emerging economies’ do have basic public schemes and some have either already developed or are in the process of developing supplementary pensions schemes.
Second, the nursing profession is ageing — with some 40% of presently employed nurses in advanced economies expected to retire in the coming decade. There is a risk of a nursing shortage, because the highly demanding conditions of work and, in several countries, the relatively low pay, do not attract sufficient numbers of younger persons into the profession. There is therefore a concern that the growing demand for adequate staffing in institutional and community long-term care for the ageing population will not be met. Providing adequate pensions may improve hiring (besides, perhaps, offering rare job openings in a deteriorating labour market).
Though a substantial proportion of nursing personnel are employed in public hospitals, rather limited information is available about their pension coverage. The Geneva-based International Council of Nurses, representing registered nurses worldwide, has therefore asked the author to undertake a comparative study on this issue on which much of this article is based.²
The article starts with a description of the context in which pension reforms take place, reviewing successively the changing societal and labour market profiles, demography, gender and the effects of the financial crisis. It follows with a brief summary of selected findings of the ICN monograph on the pension coverage and adequacy situation of nurses in several countries and concludes with some policy implications.

2. The Context of Pension Reforms

2.1 Societal and Labour Market Changes

Major societal and labour market changes have generated new risks, calling into question the basic parameters that underpinned the post-1945 European welfare State, namely a stable and full-time employment (mostly) of the male breadwinner and the (traditional) family. These include (Sarfati 2002):
•    Changes in the family status and composition, with a dramatic incidence of divorce, single parenthood and single-person households (associated with poverty and social exclusion).
•    Massive access of women to education and paid work accompanied by demands for equal opportunities in both areas, which require an affordable provision of child care and care for elderly dependents and a more balanced division of labour in the family.
•    Delayed labour market entry as a result of extended education, high youth unemployment and early labour market exit, which had been encouraged in earlier recessions and has only slightly declined in response to reversing incentives for pre-retirement.
•    Low employment rates of young and older workers, as well as women of all age groups, despite their massive entry into the labour market since 1945 and their higher employment rates during the economic expansion of the past decade.
•    Rapid expansion of “atypical” or “non-standard”, often precarious, jobs — which increasingly tend to be the main source of job creation.
•    Significant, though fluctuating peaks of unemployment in OECD countries from the mid-1970s to mid- or late 1990s, and again in the current recession which wiped out most previous job gains (most spectacularly in Ireland, Spain and the US) though the safety net limited the crunch in Western Europe (Sarfati 2002).
•    These changes obviously tend to shrink the size of the active population and therefore limit the potential for a dynamic labour force, which is indispensable for maintaining the Welfare State.

Hedva Sarfati: ISSA consultant on Labour market and welfare reforms Geneva Former ILO Director, Industrial Relations and Labour Administration Department, E-mail hsarfati@iprolink.ch .
1 To give an idea of the magnitude and limits of legal and effective social protection coverage worldwide: “Only one-third of countries globally (inhabited by 28 per cent of the global population) have comprehensive social protection systems covering all branches of social security (plus social assistance) as defined in ILO Convention No. 102 and R.67. However, most of these social security systems cover only those in formal employment as wage or salary workers, and such workers constitute less then half of the economically active population globally — but over 70 per cent in countries with comprehensive social security systems. Taking into account those who are not economically active, it is estimated that only about 20 per cent of the world’s working-age population (and their families) have effective access to such comprehensive social protection systems.” (ILO 2010: 51).
2 Sarfati, Hedva: Decent pensions for nurses, International Council of Nurses/ International Centre for Human Resources  in  Nursing, Geneva, 90 pp. www.ichrn.com/publications/policyresearch/ICHRN-Pensions.pdf .

]]> http://eng.newwelfare.org/2010/10/15/securing-decent-pensions-for-nurses-gaining-insights-into-the-issues-at-stake-for-an-%e2%80%98atypical%e2%80%99-workforce/feed/ 0 http://eng.newwelfare.org/2010/10/12/the-evolution-of-clinical-engineering-and-the-development-of-digital-and-molecular-medicine-cultural-and-economic-effects/ http://eng.newwelfare.org/2010/10/12/the-evolution-of-clinical-engineering-and-the-development-of-digital-and-molecular-medicine-cultural-and-economic-effects/#comments Tue, 12 Oct 2010 12:37:51 +0000 Diego Bravar http://eng.newwelfare.org/?p=829 Abstract
Improving the quality of social and healthcare services; positively influencing population’s health and quality of life; controlling and restructuring health expenditure in the technology sector. These are the daily challenges faced by the engineers and technicians who work within the twenty companies of the ITAL TBS Group. The Group, with headquarters in Trieste (Italy) but now established (with permanent organizational structures) in nine European countries, has chosen to pursue a strategy aimed at promoting a new generation of clinical engineering: this involves professional skills not only targeted at safe, efficient and effective management of technologies in medical and biomedical engineering, but also information technology and genetic engineering and, more generally, anything that falls under the banner of “life sciences”. The path leading to this goal (which will enable further growth of the company’s activities, services and consequently the value of its production) is a local and international scientific and cultural project that aims to resolve critical issues concerning the evolution of medicine (as increasingly costly and advanced technologies permeate services for social healthcare nationwide and in the industrialized world).

1. Clinical Engineering Services: International and Italian Contexts

1.1 The Market for Medical Equipment

A typical hospital in an industrialised country contains several thousand biomedical instruments for diagnosis, therapy and rehabilitation. Replacement costs are between 30 and 50 million Euros, a figure that could be as much as an order of magnitude or two lower in developing and underdeveloped countries (being directly proportional to gross national product in these locations). In developed countries such equipment should normally be under ten years old on average: as a consequence, a typical hospital should spend 3 to 5 million euros on new biomedical equipment as well as other medical equipment (reagents, radiographic films, prostheses, disability aids, etc.) in one year, for a total cost of at least 15-25 million euros.
Figure 1 illustrates that expenditure on medical equipment in industrialized countries (such as the USA, Sweden and Italy) is at least $100 per person, one order of magnitude greater than in developing countries (such as Argentina, Iran or Mongolia) and two orders of magnitude greater than in underdeveloped countries (such as Ethiopia and Bangladesh).
The graph below shows a clear correlation between expenditure per head on medical devices, and several economic parameters for the relevant countries (GNP/head and average annual health expenditure per head).

Figure 1: Expenditure for medical equipment compared to healthcare costs per head and the GNP per capita

1.2 Role of the clinical engineer and quantification of Clinical Engineering Services

In most countries the main task of clinical engineers and biomedical equipment technicians is to provide integrated management of biomedical equipment, which is just one component of the total market for medical devices (equal to 10-20% of this market according to Bostrom U. and others, 1993).
The attempt to arrive at an internationally recognised definition, based on precise and recognized criteria, of the roles and skills of the Clinical Engineer in managing biomedical equipment and medical devices in general has continued for more than 30 years. The International Federation for Medical and Biological Engineering (IFMBE) set up the “Working Group for Clinical Engineering” in 1979, which became the “Specialized Division in Clinical Engineering” (CED) in 1985.
CED’s work led to a precise definition of Clinical Engineering as well as a detailed specification of the role and areas of competence for the profession, which include the prudent, appropriate and economic use of technology in health systems. The CED has for a number of years promoted conferences and seminars as well as the continual analysis and monitoring of the worldwide growth in numbers of clinical engineers.
Data collected at the start of the 1990s from a sample of 28 developed and developing countries with a total population of around one billion, revealed that approximately two thousand clinical engineers were then employed in the hospital systems under examination.
At that time Italy was one of the countries in which Clinical Engineering was relatively uncommon, with one Clinical Engineer for every 8,300 hospital beds compared to the international average of one for every 3,500 beds. Furthermore, the presence of Clinical Engineering services in our country was limited to 5% of hospitals, while the figure was 95% in the USA and Northern Europe.
The international definition of clinical engineering had already been drawn up in 1992 by the IFMBE: “The Clinical Engineer has areas of competence covering the prudent, appropriate and economic use of technology relating to biomedical engineering applications in healthcare systems, and is supported in this work by biomedical equipment technicians.”
The areas of competence of the clinical engineer, as defined by IFMBE in 1992, were as follows:
•    to analyse the technologies available on the market;
•    to plan the replacement of obsolete equipment;
•    to provide technical consultancy on acquisitions and ensure the correct installation and testing of biomedical equipment;
•    to manage the maintenance of biomedical equipment and ensure its safety and effectiveness, making use of the hospital system’s internal maintenance facilities and maintenance contracts drawn up with producers or service companies;
•    to prevent dangerous situations, through the acquisition of equipment compliant with national and international standards, and through the dissemination of information and international reports on defects in equipment available on the market;
•    to lend direct support to medical staff using complex technology to perform clinical procedures and to coordinate the activities of health services support technicians modifying equipment or medical devices to improve their performance or safety;
•    to develop software programs and hardware interfaces between biomedical instruments and hospital information systems;
•    to organize educational sessions on biomedical technologies for the Clinical Engineering, medical, paramedical and administrative staff of health facilities;
•    to determine optimal technological solutions for resolving clinical problems with the possible development of prototypes of equipment or medical devices, and to run clinical trials on any such prototypes prior to their industrial production.
The specification of the biomedical equipment technician role quoted below was drawn up in the USA by the International Certification Commission (ICC, 1993): “The biomedical equipment technician is a person who is familiar with the functioning of biomedical equipment and the physiological conditions that it tests, and is competent to operate such equipment in a safe and practical manner. His/her responsibilities may include the installation, inspection, preventive maintenance, safety checks and repair of biomedical equipment. He/she may also be required to help operate biomedical equipment or to ensure correct functioning and periodically test and verify its performance”.
The roles of the clinical engineer and biomedical equipment technician in industrialised countries may differ significantly from those in developing or underdeveloped countries, since the presence of biomedical equipment – and hence the activities of these professionals in their respective hospital facilities – is closely linked to the economic strength of individual countries.
The prime indicators of the extent to which economic strength governs the organisation of such services are the gross national product per capita and healthcare spending per head, which are closely linked to the value and quantity of biomedical equipment in hospitals.
A study carried out in Germany by W. Irnich in 1989 suggested an organizational model for economically advanced countries, specifying that one biomedical equipment technician per 80-100 beds and one clinical engineer for each 5-6 technicians would serve as a correct and adequate number for clinical engineering services (CES). A similar Italian study by L. Mariani the same year recommended figures similar to those by Irnich but suggested an initial level of service could include one technician for every 200 beds and one clinical engineer for every 700 beds.
The Italian Association of Clinical Engineering (AIIC) was already attempting in 1994 to classify what a service should provide, analysing a set of indicators such as technology (e.g. quantity of autonomously functioning equipment), structure (e.g. number of hospital facilities) and organisation (e.g. number of purchasing administrators). The diverse methodologies used to determine the correct sizing of CE services are summarized in the table below.

Table 1: Sizing a CE service

Clinical engineer training began in Italy in the 1990s with the introduction of the first degree courses in biomedical and/or clinical engineering and specialised Masters degrees in leading Italian universities and specialist Schools. By 2007 there were over 300 clinical engineers working in Italy of whom 57% in the North, 20% in Central Italy and 23% in the South (Italian Association of Clinical Engineers, 2007).
In order to assess the need for clinical engineers and biomedical equipment technicians in Italy, the Ministry of Health analysed a representative sample of NHSs (local health units) or hospitals (comprising 16% of all Italian facilities).
The resulting projection is illustrated in the following table, which distinguishes technicians working internally from those in companies that outsource Clinical Engineering services.

Table 2: Estimated number of clinical engineers and biomedical equipment technicians needed in Italy for internal services and outsourced services

A similar result was found using expenditure on outsourced Clinical Engineering services (60 million euros in the cluster examined) as the reference parameter instead of bed numbers. This approach based on expenditure (or production value) also made it possible to estimate the number of personnel already employed in the Clinical Engineering sector in Italy, by extrapolating the figures to the total market for outsourced Clinical Engineering services for 2007 (a market which was monitored by the Industrial Association ANIE at the time). With the Association reporting that the entire Italian market for the maintenance of biomedical equipment was worth around 400 million euros that year (of which 230 were directly allocated to manufacturing companies and 170 allocated to outsourced Clinical Engineering services operating in collaboration with internal Clinical Engineering Services), it was possible to estimate not only the national requirements for clinical engineers (652) and biomedical equipment technicians (2,091) but also the number of clinical engineers (277) and biomedical equipment technicians (888) already operating.

Table 3: Estimated number of clinical engineers and biomedical equipment technicians required and already present in Italy

By projecting the detailed data of the first NHS sample onto the second, which refers to the entirety of outsourced Clinical Engineering Services, it was possible to categorize the figures for the same year showing the (estimated) respective numbers of technicians employed both internally and by companies outsourcing Clinical Engineering Services for the management of biomedical equipment.

Table 4: Subdivision between clinical engineers and biomedical equipment technicians needed for internal and outsourced services (Italy)

With regard to Clinical Engineers, these estimates are broadly confirmed by the membership figures of the Italian Association of Clinical Engineers (AIIC, 2007), given that around 10% of clinical engineers had not taken up membership in the Association.

Table 5: Clinical engineering by category according to the AIIC

Diego Bravar:Chairman and Managing Director of ITAL TBS, Trieste – Italy.

]]> http://eng.newwelfare.org/2010/10/12/the-evolution-of-clinical-engineering-and-the-development-of-digital-and-molecular-medicine-cultural-and-economic-effects/feed/ 0 http://eng.newwelfare.org/2010/10/11/dementia-and-diagnosis-%e2%80%94-the-discrepancies-in-response-across-europe/ http://eng.newwelfare.org/2010/10/11/dementia-and-diagnosis-%e2%80%94-the-discrepancies-in-response-across-europe/#comments Mon, 11 Oct 2010 09:36:01 +0000 Sally-Marie Bamford http://eng.newwelfare.org/?p=819 1. Introduction
The inexorable growth of our ageing population has led to a rise in the global prevalence of dementia syndrome. The word dementia, coming from the Latin de meaning “apart” and mens from the genitive mentis meaning “mind”, is a descriptive term, describing the pattern of symptoms of brain disorder which involve the progressive damage and eventual death of brain cells. The result is the devastating loss of cognitive and intellectual functions that is often accompanied by changes in psychological and emotional states such as depression, agitation, aggression and apathy.
As a result of our success in increasing longevity, we are now paradoxically facing what one British Minister described, as a “Tsunami” of dementia.¹ It is estimated that in 2006, 7.3 million Europeans (across the 27 Member States) between 30 and 99 years of age had some form of dementia. Within this group, more women (4.9 million) than men (2.4 million) are affected. It is expected that by 2050 the number of people with dementia in the EU will have grown to 15 million. Every 24 seconds a new case of dementia arises in Europe with individuals and families left counting the cost.
According to the available epidemiological data, across the EU fewer than 50% of people with dementia receive a diagnosis. However the number of people affected is probably significantly higher.² The vast majority of people with dementia similarly do not receive a specialist diagnosis in terms of identifying the specific type of dementia, be it Alzheimer’s disease, Vascular dementia and mixed dementia (which is a mixture of Alzheimer’s disease and dementia) or the rarer types of Lewy body dementia, dementia in Parkinson’s disease and Frontotemporal dementia.
This paper will explore why there are variations in the diagnosis of dementia across the continuum of care in different EU Member States and consider what the reasons may be for the differences in approach. It will also consider the dynamics which have led certain EU Member States to become perceived leaders in the field of diagnosis. The later part of the paper will explore the respective merits of different policy interventions in the field of dementia diagnosis and will argue that early diagnosis constitutes good value for the public purse.

2. Dementia and Diagnosis

It is critical to understand that dementia is not part of the normal ageing process. While dementia is predominately a disorder of later life, it can affect people of all ages. The vast majority of people with dementia either do not receive a specialist diagnosis at any time in their illness, or do so only late in the disorder, or at a time of crisis. This has profound repercussions for the individual’s access to treatment and care.
The conceptualisation and stigma attached to dementia in societies affects diagnosis rates in many different ways. For many individuals and families across Europe a lack of awareness surrounding the condition proves to be a major barrier to people seeking help and receiving an accurate diagnosis and referral. Research by the Alzheimer’s Society in 2002, entitled ‘Feeling the Pulse’ found that on average people in the UK wait up to three years before reporting symptoms of dementia. A lack of recognition of the symptoms of dementia, the severity of symptoms, and denial and fear were also identified as significant barriers to early diagnosis.³
Widespread ignorance, prejudice and stigma surrounding dementia must also be considered a significant barrier to early diagnosis, impacting not only the attitudes and behaviour of the general public, but also their treatment by clinical professionals. In Belgium for example there is an ongoing national debate on dementia and euthanasia, with one view emerging that suffering from dementia reflects an undignified existence.⁴ This affects the referral rates by GPs in Belgium and the disclosure of the diagnosis. In 2004 the individual was told of his or her diagnosis in only 44% to 55% of cases.⁵
It has also been argued that for many GP’s there are sometimes perverse incentives not to diagnose linked to the stigma and discrimination they associate with dementia.⁶ They may assume for example that the individual may not want their cognitive impairment labelled as dementia, believing a diagnosis will have implications for independence and lifestyle choice of the individual. This could have an impact for example in terms of driving.
However the relationship between dementia and stigma should not be over-emphasised, the health and social care funding systems of Member States also play a significant role. In Spain and Portugal for example, physicians were found to be particularly resistant to providing a diagnosis. This was not accountable to stigma or prejudice though, but rather the anomalies of their respective social care systems. In Portugal avoidance of the dementia label is related to resources, for a diagnosis of dementia may preclude access to nursing home care.⁷
In many European Member States dementia remains inextricably linked to the process of ageing. Across Europe as a whole, 58% of carers identify the symptoms of dementia as a normal part of the ageing process.⁸ Higher diagnosis rates can be found in countries where the ‘normal ageing’ explanation is challenged. This has been attributed in particular to the campaigning activities of national Alzheimer’s charities for example in the UK and Netherlands.⁹ It is important to note rates of diagnosis are dependent on several factors. The range of different systems, for example memory clinics or specialist old age psychiatry services and who carries out the diagnosis and treatment are also hugely influential.

Sally-Marie Bamford: Senior Researcher, ILC-UK, 11 Tufton Street, Westminster, London SW1P 3QB – www.ilcuk.org.uk/ .
1 Phil Hope MP, (July 2009) National Dementia Research Summit.
2 European Commission (July 2009) Communication on a European Initiative on Alzheimer’s disease and other dementias.
3 Alzheimer’s Society (2002) Feeling the Pulse.
4 Vernooij-Dassen M (2005 Recognition and diagnosis of dementia across Europe: from awareness to stigma in International Journal of Geriatric Psychiatry.
5 Lepeleire de (2004) Disclosing the diagnosis of dementia: the performance of Flemish general practitioners.
6 Professor IIiffe, (2009) Dementia dinner and debate, House of Lords.
7 Iliffe S, De Lepeleire J, Van Hout H, Kenny G, Lewis A, Vernooij-Dassen M; DIADEM Group. (2005) Understanding obstacles to the recognition of and response to dementia in different European countries: a modified focus group approach using multinational, multi-disciplinary expert groups. Ageing and Mental Health, Volume 9, Number 1, January 2005, pp. 1-6(6).
8 Bond, J, Stave, C. Sganga, A.; O’connell, B.Stanley, R. L. Inequalities in dementia care across Europe: key findings of the Facing Dementia Survey, International Journal of Clinical Practice, Volume 59, Supplement 146, March 2005, pp. 8-14(7), Blackwell Publishing.
9 Vernooij-Dassen MJ, Moniz-Cook ED, Woods RT, De Lepeleire J, Leuschner A, Zanetti O, de Rotrou J, Kenny G, Franco M, Peters V, Iliffe S. Factors affecting timely recognition and diagnosis of dementia across Europe: from awareness to stigma. Int J Geriatr Psychiatry. 2005;20: 377-386.
10 Lustman, F (2009) House of Lords dinner debate on dementia.

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