The Felt Need of Home-based Geriatric Care in Bangladesh

Aging is an emerging issue in Bangladesh, yet adequate infrastructures, policies, programs and services are not there to cater to the needs of the growing number of elderly persons in the country. Although aging is a personal concern in many ways, but coping with this demographic shift does not come down to individual effort only. Rather, it calls for a comprehensive approach– on the part of state, communities, institutions and organizations. As an institutional government welfare approach to geriatric nursing and care for this large population remains a costly proposition, and family is the first and foremost arena for addressing different issues of elderly persons, an education and training curriculumfacilitated community/family/home-based geriatric care system is recommended which may be more affordable, cost-saving, cost-effective, interactive, humane and inclusive. We have to prepare ourselves, to handle this emerging inevitable stage of the population, which we all, someday, will be a part of.


Introduction
Although aging is an emerging issue in Bangladesh, adequate programs and policies do not seem to have been formulated to cater to the needs of the growing number of elderly persons in the country.
If we look at the geriatric scenario of Bangladesh, we come across the following statistics and aspects: • Population aged 55-65 years and above, stands at 13% of total 160 million, the absolute number being about 21 million with a Male:Female ratio to be 20:21 [1]. • Elderly dependency ratio: 7.7% [1].
• Life expectancy at birth is 71.3 yrs for male while 75.6 yrs for female (2017 est.) [1]. Increased life expectancy has brought with it much higher rates of chronic diseases. Many people carry non-life-threatening chronic conditions such as arthritis, hearing and vision loss, mental illness, cardiovascular diseases that include hypertension, stroke, angina and myocardial infarction or heart attack; diabetes mellitus and its complications, cataract, cancers, arthritis, osteoporosis or skeletal fragility, obesity, enlargement of prostate in male, sleep disorder, change in behaviour, dementia, etc. with them into final years. Thus these conditions significantly affect a person's well-being and health care need [2]. • Arthritis is probably the number one condition affecting 50% of the people aged over 65 years and can lead to pain and lower quality of life for some of them. Heart diseases affect about 35% of men and 25% of women over 65 years of age. As age advances, high blood pressure and high cholesterol and diabetes mellitus increase the chances of stroke and coronary heart diseases. About 25% of people over 65 years of age are living with diabetes mellitus, which is epidemic throughout the globe. Diabetes is a risk for developing hypertension, stroke, coronary heart disease, kidney disease, eye problem and nerve problems. About 25% of people over 65 years of age may suffer and die from cancer e.g. Cancer of prostate, lungs, stomach, colon, breast and uterine cervix. Osteoporosis is another health problem of the elderly which can make them less mobile and potentially disabled following fall-a common occurrence among older people. Obesity is a risk factor for diabetes, hypertension, stroke, coronary heart disease and some cancers. Bladder control and incontinence are common with aging, which may be due to enlargement of prostate gland in male. Constipation is also common among them. Many elderly people do not have all natural teeth. This may hinder easy eating. They are also very much prone to flu and pneumonia [2]. • In the fiscal year 2017-18, number of government pensioners or pension beneficiary's stands at about 626,000 based on the government retirement age of 59 years [3].

Objectives
• To remind the young generation that everyone has to pass five stages in one's lifespan-infancy, childhood, adolescence, adulthood and old age and aging is a natural process. • To raise awareness. • To think ahead for a preparedness through advanced planning. • To share concepts and ideas.

Geriatric needs and issues
Emerging geriatric needs and issues are observed, which are not limited to, as the following:

Physical or Physiological
• Regulated Lifestyle. • Maintenance drugs for e.g. Hypertension, Diabetes, Prostate, Osteoporosis. • Physical disability requiring inclusive, accessible and enabling environment along with assistive devices.

Mental/Psychological
• Loneliness, particularly for widow/widower/divorced/ separated/confirmed bachelor. • Depression due to inability to take part in Social Happening. • Depression due to loss of leadership, authority and decision making power, thus loss of importance.

Social
Maladjustment with changing norms/pace of younger generation.

Economic
Around 6.4 million or 4 percent people of the country get poorer every year due to excessive costs of healthcare. About 50 million people are poor. They cannot pay for healthcare available in the private sector, while public healthcare facilities are inadequate [4].
Following costs are implied for old-age people: Cost of food, medicine, clothing, doctors' fee, diagnostic tests, hospitalization, surgery, accommodation with utilities, attendant's pay, transportation, recreation, communication (Telephone, internet, etc).
Financial assistance provided by the government: Some have pensions, Provident Fund on retirement, which does not seem enough for independent subsistence. According to newly introduced old age allowance the Government of Bangladesh (Old age allowance, Ministry of Social Welfare web page) took an initiative for paying a subsidy to the poor and vulnerable older persons by establishing Oldage Allowance Program (Boyoshko Bhata Karmashuchi) from the revenue budget in 1998. Beneficiary of the Old Age Allowances must have the age of 65 and above. Age limit is relaxable for the women recipients. A woman recipient is having the right to get the same allowance when they are 62 years old. In the financial year 2011-2012 the Bangladesh Government assigned 891 crore Taka. The overall legatee of this is 2.475 million. Beneficiaries are getting Tk. 400/-monthly per head (From January 2015) which is receivable in every 3 months. Old age allowance was 980.10 crore BDT for the fiscal year 2013-14 which was 10 percent additional than 2012-13 fiscal year. There were 24,75,000 beneficiaries among which 1202448 were female. The old age allowance strategy is enforced in the rural areas of all Upazila at union level and for all wards of the municipalities of the 64 districts of the country. The Ministry of Social Welfare of the government shoulders the authority of the strategy. A study conveys information that almost half of the beneficiaries of the government-sponsored Old Age Allowance consume their full receipt in buying medicines [5].

Asset-related/Legal
• Right to ownership of land and other tangible assets is there but right to possession easily denied by vestedinterest quarters and sometimes even by own offspring. • Loss of loan-worthiness due to loss of property.
• Loss of bank account signatory capacity because of trembling hands thus mismatching signature. • However, the recently formulated Parent Care Act 2013 of Bangladesh tries to ensure that the children have to take necessary steps to look after their parents for three years and provide them with maintenance. But it is not fully functional yet [5].

Special
None of the old homes in the country, whether run by the government or NGOs, offers places for disabled or invalid old citizens.

Institutional education and training
Considering the population, the knowledge provision in relation to aging population, is less than inadequate: • Masters in Gerontology, only in Dhaka University, the oldest and the largest university of the country. • A 100 mark course on geriatric nursing in the BSc and Diploma in Nursing at the Nursing Colleges and Institutes. an initiative where older women are progressively incorporated in education services for women and children through clinics located in urban and rural areas by taking a "life cycle approach" to health care. BAAIGM is furnishing health care and welfare of the elderly persons regardless of cast in collaboration with the Government of Bangladesh and other national and international organizations.

Scope of work/profession at facilities and otherwise
Recently it has started providing services at 34 locations. Its program will moderately be expanded to all the 64 districts [8]. • Mental Health Clinic: Some of the affluent families take the help of mental health clinics, which take care of their family elders against a handsome amount of money. • Parents' Lounge is a non-profit organization which is a recreational center in Chittagong for senior citizens run by volunteers and donors. Parents' Lounge-a totally free of cost happy pass time lounge for them. All the persons aged over 60 are welcome here. They are taken care of, have amusement arrangements and enjoy health care service also, totally free of cost, expenses borne by 60 donor members [10]. • Home-based: Most of the time, a person is brought from the home-village of the concerned family to give care to the old man/woman, to give bath and to take care of his/her defecation and urination; whereas ideally geriatric care means many others things, which remain unaddressed and ignored.

Social Response Marriage
Sometimes nature takes its own course to handle a situation. Likewise, marriage becomes a marriage of convenience to a great extent for both the parties concerned, in case of affluent rural elderly men. For an old man who is somewhat rich and/or widower, a younger woman or a widow or a divorcee is chosen for marriage to the old man which on one hand provides a safe, secure and socially acceptable shelter for the woman who was otherwise a burden for her family, and ensures on the other a round-the-clock caregiving to the old man through a legitimate relationship between the man and the woman.

Lodging-a social barter
Sometimes the age-old traditional way is also used to recruit an attendant against free food and Lodging in the rural areas.

Uneducated or less educated housemaid
Especially for the elderly women in rich rural families, a woman is brought from the neighborhood to spend time with her, to give bath and to take care of her defecation and urination.

Gender issues
Like any other sphere of life, gender issues play important roles here. An elderly male is given more respect, value and importance, thus a better and greater care, supposedly to take care of the inheritance of the properties. Compared to that, as an elderly female does not have a direct command on her husband's and even on her own properties, she gets less attention, care and respect. Moreover, there are instances that elderly widows have been thrown out of their own land.

Possibilities/Recommendations
• Inclusion of training on geriatric care in primary health care systems of the government. • Inclusion of Prime features of elderly people in the secondary or higher secondary textbook/curriculum. • Inclusion of Prime features of handling of elderly people in the curriculum of Scouts/Girl Guides, which will be prerequisite for earning particular badge.
• Certificate Course of 3/6 months to be regarded/ recognized as preference/requirement for getting jobs or promotion in jobs particularly for the Govt/Non-govt/ Private organizations. • A course on geriatric care may even be introduced in all public and private universities as a mandatory one, approved by University Grants Commission (UGC). • Provision of mandatory life insurance along with Provident Fund, Gratuity and other benefits.

Discussion and Conclusion
Elderly people provide us their experience/wisdom-not to reinvent the wheel to save time, money and efforts and not to commit the same mistake again.
They should have a happy and peaceful life as a return on their investment as an active and contributing life before they depart from this world. In many ways, aging is a personal concern, but coping with this demographic shift will not come down to individual effort. Rather, it's going to take a comprehensive approach-on the part of cities, communities, and companies-to make room for a population that still has much to offer, and that we all, someday, will be a part of discussed by Gorman [11].
It is evident that to feed the geriatric care need of the huge old age population we have now and we are going to have in near future in Bangladesh, it is almost impossible to deal with the issues in terms of infrastructure, human resource and systems afresh. Thus, being a developing country we have to work out strategies, which are culturally appropriate or adaptable, socially acceptable, technically achievable and economically viable. It seems time is ripe enough to think about developing a cadre of family-bound, family-born, familytrained and community-based geriatric nurses/caregivers so that home-based geriatric care can be provided by the members of the family of an old age person cost-effectively.