Inclusive, Enabling Communities

Inclusive, Enabling Communities
Learning Brief


Neighbourhood Old Age Homes - STTOP

Housing and Health Care for the Elderly

Category: Inclusive, Enabling Communities | Older persons | 21 June, 2012 - 15:00

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Housing and Health Care for the Elderly

1. Introduction

In October 2009 STTOP was created by a group of sector organisations who recognised that unless they came together to collectively address the manifold issues that faced them, the older persons’ sector in the Western Cape, would continue to remain a poorly resourced and neglected backwater largely ignored by funding agencies (local and international) and the wider South African public. Since then, STTOP has met regularly on a monthly basis to discuss how best to address key sector issues.

This Briefing Paper is a concrete outcome of these monthly meetings. It has been developed to provide the Executive Leadership of the Departments of Health and Social Development with a picture of the issues faced by service providers and recommendations on how these issues can be addressed in an effective, feasible and systematic manner.

South Africa is a country of many cultures and great diversity. It is also a country that has a rapidly ageing population. The birth rate is falling and more people are living to a greater age. Family structures are changing and older persons can no longer rely on their children for care and support. Older persons in South Africa, although a vulnerable group, are not regarded as a priority. According to the report submitted to the UN Secretary on the situation of older persons in South Africa (April 2011), the present generation of older persons are those most affected by the countries troubled past. Since the birth of democracy in 1994, many changes have taken place but not all of these have made any real difference to the lives on older persons. Even though government has recognised through legislation that the rights of older persons require protection and promotion, the general perception of older persons is that they are frail and a burden on family and society. Therefore the valuable contribution of older persons to society is not adequately recognised. All older persons, whether healthy or frail, deserve to be treated with respect and dignity and to have their rights upheld.

In 2006 the Older Persons Act was placed on the statute book as a result of considerable effort on the part the government and civil society. The central themes of this Act were the clear obligations placed on all spheres of government to promote: 

  • ‘ active aging in the community’
  • quality of life, the dignity and well-being of older persons
  • prevention of abuse of older persons

How these obligations are realised within the Western Cape depends crucially on the willingness of the provincial government to:

  • ensure that across all departments policies, budgets and programmes are aligned to address these obligations
  • enter into a productive partnership with sector organizations(since it is sector organizations that give concrete expression to provincial policies and programmes)

From STTOP’s point of view the most significant and immediate outcome of the meeting of August 22, 2011 would be an agreement as to how this productive partnership could be most effectively structured and how it should function so that it can add value to the provincial government’s policies and programmes for older persons.

2. What are the key building blocks necessary to promote active ageing in the community?

Depending on who is consulted, opinions vary as to what are the key building blocks that are needed to promote active aging in the community. It is the view of STTOP that there are three fundamental building blocks – access to:

  • a state pension
  • safe and affordable housing
  • appropriate health care 

Since the provision of pensions is a national competence this briefing paper will not deal this issue.

3. Access to safe and affordable housing

According to statistics there are approximately 200,000 social pensioners living in the Western Cape. Of that number the Provincial Government provides funding to organisations to help house 10,000 social pensioners, principally in residential care settings. Some in government might argue that not all social pensioners would require funding support from the provincial government. The unanswered question is how many social pensioners are able to live decently on a state pension of R1 140 a month without requiring access to safe and affordable housing? In the absence of definitive evidence the financial reality of living on a state pension would strongly indicate that very few social pensioners would not require access to safe and affordable housing.

It is good to place on public record the fact that two well established housing models exist in the Province and are the direct means whereby social pensioners are able to obtain safe and affordable housing. Where else in this province or indeed in the country is there an alternative and viable housing programme that charges social pensioners no more than 30%of their pension income to live in secure accommodation (including the payment of municipal utilities)? These modest charges for rent and utilities are achieved because the houses provided by these two models are for fit older persons who live in ordinary houses on ordinary streets in ordinary communities. These community homes run independently, with residents sharing rooms, costs and daily household chores.

In essence these two community housing models eliminate the need for costly staff structures to run and support these community homes and have provided this type of cost-effective housing for the past 27 years. In other words these two community housing models gave concrete expression to the notion of “active aging in the community” a full two decades before the notion was embedded in legislation in 2006. Moreover they are in effect a poverty elimination measure; for once an individual enters such housing they are enabled to live with dignity and financial security on the basis of having a state pension.

One significant structural constraint prevents the wholesale expansion of these two community-housing models is seed capital- to either buy an existing property or to buy land to build on that land. Existing NGOs don’t have the ‘collective muscle’ to persuade large institutions and individual donors (both local and international) to provide the necessary seed capital to establish more community- based houses. Consequently the housing stock of such ‘community homes’ in the Province is very small indeed.    

3.1 Recommendations

It is therefore recommended that the Provincial Department of Social Development: 

  • commits to providing a per capita subsidy by March 2013 to existing sector organisations providing community-based housing for fit social pensioners (on the understanding that the organisations concerned will not charge more than 30% of an individual’s pension to provide such housing)
  • commits to providing a per capita subsidy by March 2014 to other sector organisations that want to provide community- based housing for fit social pensioners (on the understanding that the organisations concerned will not charge more than 30% of an individual’s pension to provide such housing)
  •  enters into discussions with STTOP to determine how the Provincial Government could help in promoting the concept of community-based housing to donors (both local and international)

4. A Provincial policy that promotes the development of a stock of safe and affordable housing for social pensioners

Given the enormity of the need for safe and cost-effective housing for social pensioners within the Province it is critically important that the provincial government undertakes a thorough review of its social housing policy and the funding allocations supporting this policy. For example it is our understanding that the present policy caters for individuals and families with a minimum monthly income of at least R 3000 a month. This effectively excludes all social pensioners from benefiting from such housing.

Secondly housing initiatives that qualify for funding are required to provide as a minimum discrete housing units; each unit [however small] needs to have its’ own bathroom and kitchen. Thus existing policy makes no provision for the notion of communal living where bathrooms and kitchens are shared amenities. On both counts community- based housing models such as those developed by Abbeyfield South Africa and NOAH would not qualify for financial assistance despite the fact they are cost effective responses to the social housing needs of economically vulnerable older persons.

It is our understanding that the Department of Human Settlements has a “Special Housing Needs Programme” and one of the groups that could theoretically benefit from this programme would be older persons. It is also our understanding that this programme makes available a housing subsidy of R 70 000 for each individual who qualifies. It would seem that such programme could potentially provide a source of funding for community-based housing.

Another initiative that would increase the stock of community-based housing would be to place a clear legal obligation on developers when tendering for ownership of public land there should be the requirement that at least 8% [the estimated percentage of older persons living within the Western Cape] of the social housing component of the proposed development should be specifically set aside for community-based housing for social pensioners. 

A further way to make inroads in addressing the critical housing shortage for social pensioners is to deal with the major obstacle to achieving security of tenure. The need for non-institutional community based homes for social pensioners living in urban and rural poor communities is significant, but access to land in order to build, even for an agreed period of time, is virtually impossible. Community-based housing initiatives within vulnerable communities should not be viewed as isolated housing projects but rather as catalysts for integrated community upgrading projects where, through partnerships, sector organisations can add value to projects already present in communities such as crèches, soup kitchens and community centres. The provision of additional housing stock will reduce the overcrowding in family households and potentially reduce the danger of abuse. However this type of community development cannot happen without securing the necessary land in vulnerable communities within the Province. 

It has been suggested that another way to increase the stock of community-based housing would be to convert vacant provincial buildings [e.g. vacant schools] for this purpose. The costs associated with converting and then the ongoing maintenance of such buildings needs to be carefully interrogated given the fact that sector organizations do not have ready or immediate access to large sums of money to invest in capital projects. If that was the case the stock of housing for community-based housing would be much larger than it is at present. Moreover issues such as duration of leaseholds and municipal rates and taxes need to be clarified and resolved so that the conversion of vacant provincial buildings becomes a distinct and viable financial possibility.

4.1 Recommendations 

It is therefore recommended that the Provincial Department of Human Settlements:

  • reviews (in consultation with relevant sector organisations) its housing policy for older persons and reports on the content of this review for public discussion by March 2012
  • creates  by March 2012 a  binding legal framework requiring that tenders for public land include an obligation that 8% of social housing that is to be built in compliance with the legal framework be for social pensioners
  • ensures that all such community-based housing for social pensioners created via social housing and special needs housing initiatives are vested in independent trusts to ensure that the buildings are secured and  not “sold off” to the detriment of future social pensioners
  • gives careful consideration to granting each year for a six year period, starting 2012, three plots of land in poor urban and rural communities to be used for the  building of community-based houses for social pensioners

It is therefore recommended that the Provincial Department of Public Works: 

  • be asked to investigate, report  and publish their findings by March 2012 regarding the financial and long term feasibility of vacant provincial buildings being used on a long term tenancy basis, to house fit social pensioners and other vulnerable groups (such as people living with mental and or physical disability)

5 Residential Care

There comes a time in the lives of older persons when (however active they have been) require professional care and support. In this country this care and support is provided at assisted living and residential care facilities. The responsibility for the care of mentally and or physically frail older persons (those with or without a social pension) has historically been delegated by the State to registered NGOs and leading providers of such care in the Province are the ACVV, BADISA,  CPOA and the G.H. Starck Centre. 

The services provided by NGOs are subsidised by the State, subject to NGOs meeting specified performance levels. Failure to achieve these performance levels carries financial and other penalties. The fundamental problem of the current subsidy arrangement is that it only covers a small part of the actual costs of providing frail care. For instance linked to this subsidy arrangement are regulations that lay down minimum staffing levels as well as the requirement to employ certain numbers of nursing and care staff. Yet the full costs of employing staff are carried by the organisations concerned. By way of illustration the average ‘subsidy gap’ for a residential facility providing care for 50 persons is R 1 746 per person per month which adds up to a yearly deficit of R 1 047 600!

In the same vein there are regulations covering minimum standards for the building of frail care facilities. Once again organisations are expected to build such facilities without any financial support from the State. The consequence of this regulatory environment is to place organisations in the invidious position of being required by law to assume a range of staffing, building and ongoing maintenance costs without sufficient financial support from the State to meet these costs. It should be of little surprise that from time to time incidences of inadequate care, neglect and abuse are reported. The public narrative around the reporting of such incidences is to assign most blame to the organisations concerned, with little attempt to recognise that the regulatory environment and the subsidy framework are manifestly complicit in the occurrence of these incidents. This manifest complicity of the state in these incidents is further underscored by the decision of the Provincial Department of Health to refuse to provide or subsidise the costs of incontinence products for mentally frail and incontinent older persons.   

There needs to be the recognition on the part of the Provincial Government that residential care for poor frail older persons is under real financial threat within the Province and as a consequence vulnerable older persons are potentially at severe risk of negligence and abuse.

5.1 Recommendations 

It is therefore recommended that the Provincial Government: 

  • acknowledges that residential care is essential to maintaining the dignity and wellbeing of those frail and vulnerable older persons who cannot be cared for by their families and communities
  • completes by March 2012, a comprehensive ‘costing exercise’ of residential care within the Province using the minimum ‘Norms and Standards’ (as per the Older Persons ACT of 2006 and associated regulations) to bench mark these costs
  • uses the results of the costing exercise to start to address the funding gap for residential care, starting with the 2012/2013 funding cycle
  • commits the Provincial Department of Health to setting aside adequate funding for assisted living and residential care facilities to help meet the costs associated with providing medical and nursing care in residential facilities by April 2012 

6 Access to appropriate healthcare

Access to appropriate health care is one of the key issues that determine whether or not an older person can remain active within their community. It is not an exaggeration to say that unless older persons have access to appropriate healthcare the value of other service provision is seriously compromised. Currently healthcare provided to older persons in the public sector is very unsatisfactory. The marginalisation of older persons is typified by the virtual absence of expertise in geriatric care( including the absence of appropriate education, awareness and clinical skills programmes especially in mental health). Anecdotal evidence points to a picture of a systematic failure of the provincial health services to provide caring, competent and comprehensive care for older persons. Central to this failure to provide appropriate healthcare is the weak management and poor clinical care in evidence at many of the province’s community health centres, secondary and tertiary institutions.

STTOP recognizes that the provincial government faces serious financial and personnel difficulties in wanting to turn around the provincial health services. Moreover this turn around of the health services will at best take, many years to be achieved. With this in mind STTOP wishes to propose a number of recommendations directed at improving health care delivery to older persons within the Province.

 6.1 Recommendations

 It is recommended that the Provincial Department of Health:

establishes an operationally robust, efficient and effective older persons’ programme within the department that has the necessary executive authority to spearhead efforts to improve service delivery to older persons throughout the Province

  •  introduces a triage system for older persons at all public health facilities to reduce the long waiting periods
  • introduces  a booked appointment system for older persons at all public health facilities
  • establishes ‘partnerships in health’ between itself and service providers ( see Appendix One for further details)
  • financially recognizes the vital role that such ‘partnerships in health’ could play in delivering cost effective PHC to social pensioners (as well as reducing the clinical load on the provincial public health services)
  • institutes an ongoing in-service skills development programme on the health care needs of older persons for all clinical nurse practitioners, allied health care professionals, social workers and general practitioners  working within the public health service to ensure it is able to provide adequate health care for older persons.
  • institutes a comprehensive review( including international policies and guidelines) for the  evaluation of psycho-geriatric policy and service delivery by August 2012.  
  • Use by  September 2012  the findings from this review to implement an evidence based incremental improvement in the provision of psycho- geriatric services within the Province

7.  Budget allocations for Older Persons   


It would be helpful to know the parameters used by the Provincial Government to arrive at the global sum allocated to the Older Persons Programme each financial year. In addition it would also the useful to learn how budget allocations are arrived at to subsidise sector activities.

7.1 Recommendations

It is therefore recommended that the Provincial Department of Social Development: 

  • as from 2012 it formally invites service providers to participate in the deliberations that determine the budget priorities for the Older Persons’ Programme for each budget year
  • mandates the Older Persons’ Programme to provide an annual  ‘budget briefing’ to inform sector organisations about the budget priorities of the Programme for the current and  the two subsequent financial years 

8 Administrative Issues

It is common cause that the Registry Section of the Department of Social Development is not ‘fit for purpose’. It has been the frequent experience of sector organisations that when using the registry for submission of important documentation, this documentation is either mislaid or lost. The first time an organisation is aware their documentation has not been received by the Older Persons' Programme is the receipt of a hostile letter threatening the organisations concerned with financial sanction. 

Another source of concern to sector organisations is the complexity of the ‘TPA’ documentation that is needed to be completed in order to be compliant to qualify for financial subsidies. Sector organisations fully recognise the importance of providing the required information so that the Provincial Government can be confident that the money allocated is used for the purposes for which it was granted. However it is contended that the documentation can be drawn up in a more ‘user friendly’ fashion.

8.1 Recommendations

It is therefore recommended that the Department of Social Development:

  • introduces a proper tracking system within the Registry Section as a matter of priority so that the officials who accept and sign for documentation are held to account if such documentation is mislaid or lost
  • establishes a working group to substantially revise the ‘TPA’ documentation before the next submission period to make this documentation more ‘user friendly’ for service providers 

9 Research

The availability of credible and recent research work concerning the ‘lived experience’ of older persons in the Western Cape is central to the development and implementation of effective policies and to the funding priorities for the sector.

9.1. Recommendations 

It is therefore recommended that the Department of Social Development and the Department of Health:

  • strengthens and capacitates the research section within these two departments so they  become accessible research and information assets for organisations and individuals working within the sector
  •  recognises the value of credible sector research by establishing  as of 2012/2013 budget cycle an annual ring-fenced research budget of 1% of the budget allocations for older persons in each department to commission  and publish relevant research from credible research practitioners
  • entrenches the practice within the departments of using relevant research to actively inform provincial policy, funding frameworks and meaningful programme development     

10. Older Persons living in the rural areas of the Province

Apart from the ACVV, STTOP membership, is predominately made up of organisations working within the environs of greater Cape Town and as such does not have direct experience of rendering services for rural older persons. Notwithstanding this lack of direct service provision to older persons living the rural areas of the Province, STTOP contends, that the issues facing older persons in the rural areas are not fundamentally different to those of their urban counterparts. The surmise is however that in all likelihood the key issues outlined in this paper are probably of a greater magnitude since socio- economic opportunities and service provision are generally(state, NGO and private) much more limited in scope and quality.  STTOP believes that this surmise would be largely confirmed by information provided by participants at the two ‘Older Persons’ Summits’ arranged by the Department of Social Development in George and Hermanus last year (2010).   

10.1 Recommendations

It is therefore recommended that the Older Persons’ Programme of the Department of Social Development:

  • circulates within six months the ‘findings’ of these two summits to the  participating organisations and interested parties
  • outlines how these ‘summit findings’ will impact on current or future policy and funding of services to older persons particularly those living in the rural areas of the province
  • establishes Older Persons’ Reference Groups as soon as is feasible (comprising departmental officials and sector partners) to meet on a quarterly basis in designated rural localities of the Province to begin to address the needs of older persons living in rural areas of the Province            

Conclusion

Since October 2009 STTOP’s has:

  • established a part time office,
  • engaged in active efforts to raise funds for operational costs
  • met regularly on a monthly basis to discuss how best to address key sector issues  

The authors of this Paper are very conscious that the Provincial Government is faced with many demands upon its financial resources and that the requirements of the older persons’ sector needs to be set against other sectors. Indeed the recommendations of this Paper have been framed in such a way that they take careful cognisance of the resource constraints facing the Provincial Government. Notwithstanding these competing demands it is intellectually and politically dishonest to use the lack of financial resources as a reason for not starting to seriously address the issues outlined in this Paper.

It is STTOP’s considered position that it would like to enter into a strategic partnership with the Provincial Government so that collectively the sector can be transformed from a poorly resourced backwater into one where best practice, sustainability and innovation are not the exception but the norm. This is an extraordinary goal but STTOP believes that the older persons of this Province who are the focus of our concern and services deserve nothing less. It is in a spirit of goodwill, goal focused collective engagement that this Briefing Paper is submitted for consideration by the Executive Leadership of the Provincial Government of the Western Cape.       


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