DESK REVIEWS | 04.03. Characteristics of policies and plans for dementia

DESK REVIEW | 04.03. Characteristics of policies and plans for dementia

There is no national policy or plan for dementia in India. As a result, this section will include several policies and programmes that are relevant to persons with dementia.

Yes, particularly action step 2: ‘Advocacy of human rights for people with dementia and their caregivers’ (Ministry of Health Republic of Indonesia, 2015a, p.5).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

The Alzheimer’s and other dementias Action Plan (Gutiérrez-Robledo & Arrieta-Cruz, 2014) is in line with a human rights-based approach.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

Yes, this plan emphasised equity of diagnostic and care services through equal improvement in knowledge of all healthcare workers and non-health workers through education and trainings in all levels of care with emphasis on primary care (Ministry of Health Republic of Indonesia, 2015a).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Yes, the plan emphasises community empowerment and intergenerational approach for dementia care coordination (Ministry of Health Republic of Indonesia, 2015a).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Yes, chapter 5 of the dementia national strategy document is dedicated on discussing intersectoral stakeholders relevant to the policy.

The Alzheimer’s and other dementias Action Plan (Gutiérrez-Robledo & Arrieta-Cruz, 2014) includes multisectoral collaboration and it considers the participation of public health agencies, civil society, and industry.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

Yes.

It is also important to say that the health policies on ageing in Brazil so far have prioritized a longitudinal approach, not focusing on specific diseases but on people’s functionality.

Although it does not mention universal health coverage, it does describe the need to improve access to quality services, with timely diagnosis and treatment, as well as long-term care in the later stages of the disease.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

The documents focus on keeping people as independent as possible, on implementing strategies to prevent diseases, and on adopting a person-centred care to promote quality of life and well-being (Brazilian Ministry of Health, 2018e; United Nations, 2018).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

United Nations. (2018). Transforming Our World: The 2030 Agenda for Sustainable Development. In A New Era in Global Health. https://doi.org/10.1891/9780826190123.ap02

 

India is a signatory to the Sustainable Development Goals (SDGs). The 3rd goal focuses on improving health and wellbeing of people of all ages (Sustainable Development Solutions Network, n.d.). As part of the health goal, target 3.4 asks countries by 2030 to reduce premature mortality from NCDs by one third “through prevention, treatment, and promotion of mental health and well-being” (Sustainable Development Solutions Network, n.d.). However, in India there is no national dementia policy and, as a result, these aspects of the SDGs are not reflected in a dementia specific plan. Although, programmes/acts such as the National Programme for Control of Cancer, Diabetes, Cardiovascular Diseases, Diabetes and Stroke (NPCDCS) (addressing risk factors for dementia) (MoHFW, 2017b) and the Mental Healthcare Act (National Mental Health Programme, 2017) complement the goals of the SDGs.

References:

Ministry of Health and Family Welfare. (2017b). National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS).

National Mental Health Programme. (2017). National Mental Health Programme. Available from: https://www.nhp.gov.in/national-mental-health-programme_pg

Sustainable Development Solutions Network. (n.d.). Indicators and a Monitoring Framework: Launching a data revolution for the Sustainable Development Goals. Available from: https://indicators.report/targets/3-4/

 

The national plan reflects some aspects of the sustainable development goals, particularly goal number 3 (good health and wellbeing), 4 (quality education), 11 (sustainable communities), and 17 (partnerships for the goals), although these may not be explicitly stated (Ministry of Health Republic of Indonesia, 2015b). In 2015, the United Nations declared the prevention and treatment of non-communicable diseases (NCDs) and the promotion of physical and mental health and well-being with behavioural, developmental, and neurological disorders as one of their key goals in achieving sustainable development (United Nations, 2015). Indonesia’s national plan addressed the challenges of a growing ageing population and increasing number of people living with dementia through seven action steps.

 References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

United Nations. (2015). Goal 3: Ensure healthy lives and promote well-being for all at all ages. https://www.un.org/sustainabledevelopment/health/

Although not openly mentioned, the plan appears to refer to Goal 3 which refers to ensuring healthy lives and promote well-being for all at all ages.

The Law Project number 4364/2020 entitled “The National Policy for Integrated Care for People Living with Alzheimer’s Disease and other Dementias” recognizes people living with dementia and their carers and tries to provide psychological, social, and clinical support for these persons. In the “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” (Brazilian Ministry of Health, 2018e) dementia is recognised as a threat to independent life, strongly impacting on people, family, and carer’s quality of life.

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

 

People with dementia and their family carers are recognised in all action plans. However, the second action plan, advocacy on human rights for people with dementia and their carers specifically call for their recognition as part of its achievement indicators, which include protection of people with dementia through existing regulations and formation of support group for people with dementia and their carers.

The other action plans advise on development of a guidebook and a training programme to educate carers and people with dementia about dementia as well as the planning of financial strategies and improvement of services (including implementation of standards for older people, an effective referral system, and an increase in the quantity and quality of day and home care) (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

People with dementia are recognised in the following lines of action (Gutiérrez-Robledo & Arrieta-Cruz, 2014):

  1. Educational programs on the rights of people at the end of life, including topics such as testaments and advance directives.
  2. Legal, social, and financial assistance to prevent abuse, violence, or neglect in the care of the person with dementia.
  3. Financial support, especially for people with limited economic resources.

The family of the person with dementia is recognised in the following lines of action:

  1. To develop a model of training, evaluation, and care for primary caregivers and family members.
  2. To promote family guidance for better care and management of their family members affected by dementia.
  3. To create programs and training for family members and health personnel in palliative care.
  4. To establish facilities for the family primary caregiver.
  5. To develop psychological and spiritual support programs.
  6. To subsidise or low-cost programmes for funeral and purchase of essential medicines in palliative care at home (e.g., for pain control).
  7. To create respite care units for primary caregivers.
References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

It is stated in the Older People’s Statute that mistreatment and abuse towards any older person (with and without dementia) is not acceptable and will be treated under the penalty of law (Presidency of Republic of Brazil, 2003).

References:

Presidency of Republic of Brazil. (2003). Estatuto do Idoso. Presidency of Republic of Brazil; National Congress of Brazil’s Information System. http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm

 

The National Policy on Older Persons (NPOP, 1999) confirms the commitment of the government to the well-being of elderly people by recognising important rights including the need to protect them against abuse and exploitation (Government of India, 2014). There is also the Maintenance and Welfare of Parents and Senior Citizens Act (2007), which places the responsibility on children or relatives to take care of the elderly and highlights that neglect or abandonment of elderly people is a punishable offence by law (Ministry of Law and Justice, 2007).

References:

Government of India. (2014). Theme of International Day of Older Persons-‘Leaving No One Behind: Promoting a Society for All” echoes Sab ka Saath Sab ka Vikas.

Ministry of Law and Justice. (2007). Maintenance and welfare of parents and senior citizens Act. Government of India.

The national dementia policy/plan has not directly addressed the issue of mistreatment and abuse of people with dementia and its prevention. However, the national plan lists existing regulations that serve to protect older people from abuse as one of the indicators for the second action step (advocacy of human rights for people with dementia and their carers) (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The plan considers the need to promote the fight against discrimination in all spheres, as well as to inform vulnerable older adults about their rights, and mechanisms for access to services in case they become victims of mistreatment or discrimination, as well as to provide legal, social, and financial assistance to prevent abuse, violence or negligence in the care of the person with dementia.

Yes. Nowadays, the care pathway in Brazil focuses on older people’s multidimensional assessment in the context of healthy ageing. Healthcare is not only centred on the absence of disease, but is focused on the maintenance of independence, avoidance of functional capacity loss, and promotion of good quality of life (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

 

The dedicatory of the plan presents a recommendation for a humanistic, compassionate, person-centred, and quality-of-care approach; however, this concept is not developed throughout the full text.

At policy level, yes. Community healthcare agents and primary healthcare staff should conduct a multidimensional assessment and, from that, identify what the person is able to do independently and what help is needed. This is part of the integral care for older people, that considers clinical, psychosocial, and functional aspects of a person’s life. As one of the aims of the multidimensional assessment is to keep people’s independence, it is expected that support regarding the maintenance of an active role in the community is provided. It is important to state that all older persons can receive education regarding the maintenance of an active role in the community, regardless of having dementia (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

The national strategic plan aims to ensure that older people stay healthy and productive and therefore can continue to support the nation’s social system and economy. This is encouraged through a life-cycle perspective, which emphasises prevention by encouraging and supporting people in reducing risks of dementia to maintain healthy and active brains (Ministry of Health Republic of Indonesia, 2015b). Indicator 1.9 in the fourth action step, outlines the aim that an increased proportion of older people with physical or cognitive limitations should still be able to take part in physical, social, and spiritual activities (Ministry of Health Republic of Indonesia, 2015b). However, this seems to support the underlying aim of diagnosing more people at an earlier stage, as the plan does not describe in detail people with dementia could be supported in maintaining an active role in the community as the disease progresses.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

An active role of the people with dementia is not mentioned in the plan.

Probably yes (policy level), but there is no evidence that this occurs in practice. Not only people living with dementia, but older people in general as part of the multidimensional assessment which aims to keep people clinically, psychosocially, and functionally independent (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

 

Although not explicitly stated, this is mainly addressed in the fourth action step (early diagnosis and management). These are the indicators which support people with dementia in maintaining self-management:

  • Indicator 1.5 all referral facilities should have neurorestoration service (rehabilitation based on neuroscience principles). This serves as a mean to help the person with dementia maintain their independence.
  • Indicators 1.6 and 1.7 refer to the increased number and quality of day care and home care services. This will support people who are no longer in good health and need assistance in staying active and in performing daily activities of living.
  • Indicator 1.9 increased proportion of older people with disability (physical or cognitive) who can continue participating in physical, social, and spiritual activities. This serves as a secondary prevention effort.
  • Indicators 2.1 and 2.2 refer to the presence of a guideline on dementia care and training for caregivers (Ministry of Health Republic of Indonesia, 2015b).
References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

 

There’s no special emphasis on it.

This should happen (stated in policy), but there is no evidence that this occurs in practice. Not only people living with dementia, but all older people, as part of the integral healthcare orientation document and the multidimensional assessment for older people (Brazilian Ministry of Health, 2018e). However, we could not find information about how many older adults on average have this assessment completed routinely throughout the country, nor there is information about how this is managed when the person with dementia can no longer express his/her wishes. There is not a clear guidance about how this should be done, so it depends on the willingness of the clinician involved in the care provided.

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

 

The national dementia policy has not discussed this issue explicitly (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

It is not specifically mentioned in the document.

The National Policy for Older People’s Health (Brazilian Ministry of Health, 2006b) recognises the need for a high quality workforce with sufficient knowledge to take care of older people. The government, through its Federal, State, and Municipal levels provide training to professionals working at primary care level so that they can recognise people with cognitive impairment and refer them to adequate, more specialised, and integrated care units (Informal Source, 2019). Indicators of quality assurance include e.g., how many older adults have had a routine geriatric assessment completed and how many people living with dementia have been diagnosed, etc. However, this information is not available, or is not open for consultation.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

The policy document sets national targets as indicators of standardised, good quality of care. Examples of such targets are the initiation of a national training centre in cognitive health and dementia treatment, the development of standard operational procedure of older people’s care (to be implemented in all healthcare facilities), the implementation of an instrument for the screening of cognitive impairment and diagnosis of dementia among people at risk of developing it, the initiation of a referral system for people with dementia embedded in all primary healthcare facilities (alongside with screening, diagnosing and counselling), neurorestoration care in all referred healthcare facilities and ultimately supporting the development of long term care insurance (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

There is a specific strategy focusing on ensuring access to quality services, and it is centred on the following lines of action:

  1. The availability of human, material, and financial resources in accordance with the number of dementia patients at the three levels of health care.
  2. To improve the quality of geriatric, neurological and psychiatric care to achieve comprehensive medical management in advanced stages of the disease.
  3. To strengthen care at the community and family level with a comprehensive ambulatory, non-hospital vision for long-term care of dementia patients through specific rehabilitation programs.
  4. To establish, grow, maintain, and regulate day centres as an alternative for the comprehensive management of patients with dementia in the early stages of the disease.
  5. To destine the third level of attention to the study and management of difficult cases for an adequate differential and final diagnosis.

Yes. The need for multidisciplinary healthcare teams with sufficient knowledge about older people is mentioned as a challenge to be overcome in the National Policy for Older People’s Health and in the Law Project 4364/2020 (Brazilian Federal Congress, 2020; Brazilian Ministry of Health, 2006). However, the long-term care workforce is not specifically mentioned.

References:

Brazilian Federal Congress. (2020). Projeto de Lei do Senado 4364, de 2020. https://www25.senado.leg.br/web/atividade/materias/-/materia/144381

Brazilian Ministry of Health. (2006). Política Nacional de Saúde da Pessoa Idosa. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

The health and long-term care workforces are represented especially in the fifth action step: establishing a system to strengthen professional and sustainable human resources. This is described in their indicators, particularly:

  • ‘Indicator 1.1 All medical and nursing schools are expected to include older people’s cognitive health in their curriculum.
  • Indicator 1.2 Doctors and other healthcare workers who are trained in dementia management are present in all Puskesmas, hospitals, and senior homes.
  • Indicator 1.3 There are healthcare workers who have been trained to be trainers for dementia management’ (Ministry of Health Republic of Indonesia, 2015a, p.22).

The Long-term care workforce appears to be represented by the Ministry of Social Affairs in the same action step. The plan describes the need to develop a strategy to ensure health care workers understand the role of care partners in dementia care coordination. The indicators are:

  • ‘Indicator 2.1 There are regular meetings of all healthcare workers and care partners involved in dementia management
  • Indicator 2.2 There is a dementia care coordination’ (Ministry of Health Republic of Indonesia, 2015a, p.22)
References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

The health and long-term care workforce is represented in the National Plan through two strategies, the first one aims at training adequate and specific human resources through the following lines of action:

  1. To increase the number of specialists to provide care for dementia patients, in accordance with the needs of the country.
  2. To implement permanent training programs to update health professionals and non-professional personnel.
  3. To include topics on aging during undergraduate and graduate training for all health professionals, with emphasis on dementia.
  4. To promote human resource training strategies, taking advantage of new information technologies and inter-institutional collaboration.
  5. To create scholarships for the training of non-medical health professionals specialised in the care of the elderly with dementia.
  6. To promote family guidance for better care and management of family members affected by dementia.

The second strategy is aimed specifically at long-term care in the last stages of the disease, focussing on the need for programs or services for comprehensive palliative care at home.

The documents do not specify key actors. Based on the policies outlined above, we assume that the Ministry of Health is a key actor.

The plan describes the main stakeholders/key actors as:

  • the National Commission on Older People,
  • the government (through the Coordinating Ministry for Human Development and Cultural Affairs),
  • community involvement (Ministry of Health Republic of Indonesia, 2015b).
References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

There is no description of key actors or the definition of their roles.

Yes. The “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” is a document that supports integrated care in the Brazilian Unified Health System – SUS. This document explains that the government provides a “healthcare notebook” for older people, in which each older person should have her health information recorded. Based on this information, the person then becomes subject to a multidimensional assessment which considers physical, psychological, and emotional aspects of a person’s life in order to offer quality healthcare to each individual person. Based on these two tools, a “Person-Centered Therapeutic Plan” (Programa Terapeutico Singular – PTS) is tailored according to the needs and personal situation of each patient aiming at delivering integrated care, education, and better quality of life (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

The policy document states the target to implement standard operational procedures across all healthcare facilities. Furthermore, the document emphasises the standardization of instruments, the value of screening, diagnosis, and treatment of people with dementia in primary healthcare facilities and through appropriate referral to secondary and tertiary healthcare facilities. Secondary and tertiary healthcare services are expected to provide integrated geriatric services and neurorestoration services (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

It emphasises the need for an integrated care model involving all levels of the national health system, as well as the development of a training, evaluation and care model for primary caregivers and family members. On the other hand, the document aims at generating an inter-institutional network for the updating and feedback of personnel dedicated to the care of the person with dementia.

As the existing policies were developed to meet the needs of older people in Brazil (regardless of having dementia) they are broad in scope and incorporate other aspects of care, such as general healthcare (Brazilian Ministry of Health, 2006b). Mental health care is available through the National Policy for Primary Care (Política de Nacional de Atenção Básica) for all people of all ages. People who have been identified to be in need of mental health support may be sent to the Centres of Psychosocial Attention (Centro de Atenção Psicosocial – CASP) where they receive specialised care (Brazilian Ministry of Health, 2012, 2018e). People living with dementia might follow this route; however, these individuals are most often involved in the health system through the primary healthcare units, rather than through the mental health services.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

The policy outlines that efforts to achieve healthy and productive brains must be supported through balanced nutrition, physical activities, and cognitive, spiritual and social stimulations. The efforts should be supported by families, society, and the environment. These efforts are supposed to create a healthy lifestyle that reduces risk factors and reduces the risk of developing cognitive impairment in older people (Ministry of Health Republic of Indonesia, 2015b). The policy did not explicitly state the intersection with mental health care.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

It outlines the interface with other aspects of care with regards to the prevention and promotion of mental health with a life-course perspective. This involves considering known risk factors, and encouraging active and healthy ageing, which could help preventing, or at least delaying, the onset of dementia and other conditions.

It attempts to recognise common barriers to access. The National Policy for Primary Care document recognises that in some geographical areas of Brazil services are difficult to access. Therefore, some healthcare teams provide care for people living in regions with difficult access to services, such as rural, riverside, and Amazon rainforest (Brazilian Ministry of Health, 2012). Despite its challenges, in theory, such teams should have access to transportation (by car or by boat) so that such communities could be visited by healthcare providers. Older people’s policies mention the integration and coordination with other areas (intersectoral approach) to overcome some of these challenges. As healthcare is a right of every person in Brazil, it is implied that the government must actively identify strategies to overcome eventual barriers of access.

References:

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

We could not identify any information on barriers to access and how these could be overcome.

No potential barriers to access are described.

In Brazil, there is the Unified Health System (SUS), and the concept of equity is already incorporated in the government healthcare policies, being one of the three main principles of SUS. The National Healthcare Policy for Older People incorporates equity and universality in the sense that healthcare is offered to all persons aged 60 years and over regardless of whether they have dementia (Brazilian Ministry of Health, 2006b). However, although all people in Brazil are offered the same right of accessing care through the SUS (funded by public sector), people who are better off tend to use healthcare services provided by the private sector through out-of-pocket payments or healthcare insurances. So, there is a selection bias among people who use SUS. But even those using the public services, face different realities depending on where they live because the quality of and access to health services may vary according to neighbourhoods and cities. The SUS principles include universality and equity, but this is different in the different parts of the country.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

Equity is incorporated in the policy by upholding the national law on health, which ensures that all people have equal access to healthcare, as the national dementia plan operates within the universal healthcare system. The strategic plan emphasises the availability of standardized care for all older people across healthcare facilities. This includes public access to screening, diagnosis, and treatment. In addition, rights of the workforce alongside with patients’ rights are mentioned (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Although it is not directly mentioned, the plan not only refers to equity through awareness raising, but it also aims to emphasise that dementia is a public health problem that can affect anyone, and that generates profound changes in the lives of those who live with it. This includes promoting the fight against discrimination, informing people about their rights and services available to them, should they become victims of abuse or discrimination, recognising the role of caregivers as partners, and incorporating civil organisations to broaden the dissemination.

The National Healthcare Policy for Older People outlines the importance of immunization campaigns, prevention programs for chronic non-communicable diseases, and educational programs on healthy lifestyle (Brazilian Ministry of Health, 2006b). According to the National Policy of Primary Care healthcare-community agents are responsible for visiting people from their community on a regular basis. These visits aim, among other objectives, to assess the health of people and to guide them towards disease prevention and risk reduction (Brazilian Ministry of Health, 2012). It is relevant to note that this policy includes people of all ages, not only older people.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

Risk reduction and prevention for dementia is addressed in part through the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) (MoHFW, 2017b). While the NPCDCS does not specifically mention dementia, it addresses risk factors and co-morbid conditions in persons with dementia. This could involve screening for risk factors and promoting healthy behaviours to reduce the risk of dementia.

References:

Ministry of Health and Family Welfare. (2017b). National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS).

 

The policy states that dementia prevention can be achieved through a reduction of risk factors of degenerative diseases and the enhancement of factors supportive to achieve healthy and productive brain. These targets are also covered in the first action plan, which focuses on public awareness campaigns. These programmes are coordinated jointly by the Ministry of Home Affairs, the Ministry of Health, and actors, such as public and private companies, governmental and non-governmental organizations with the goal to intensify campaigns and education in schools, among families, and across society (and including the workforce) (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Three lines of action are developed around prevention and risk reduction:

  1. Considering dementia as a relevant public health problem.
  2. Strengthen preventive campaigns against diabetes, obesity, hypertension, and physical inactivity to reduce risk factors associated with dementia.
  3. Promote mental health care at all stages of human development.

No. Sustainability is not addressed explicitly.

Sustainability is not explicitly addressed in the national plan.

A continuous evaluation is proposed through the creation of an advisory group to evaluate the relevance and sustainability of the proposed actions, the mechanisms to execute them, and the generation of evaluation tools to measure the impact of the implemented actions. However, although there is institutional leadership, the group has not been officially formed.

The National Dementia Policy was created by a group that comprised a doctor, politicians, and others. The law created in the municipality of São Paulo was developed by a group composed of healthcare professionals, communication professionals, politicians etc. These professionals generally give expert inputs, the politicians write the law and are responsible for legislative procedures. The creation or development of some policies may be discussed in commissions composed of parliamentarians and civil society representatives.

Multi-disciplinary stakeholders were involved in developing the policy, which included clinicians, academics, carer, NGO, and other stakeholders. NGOs with international outlook have a focus on aligning the national policy with international goals (for example, early diagnosis is also a priority in Indonesia’s national strategic plan). A monitoring report on the policy has not yet been published but the document suggests that monitoring and evaluation should be conducted by all stakeholders including central and local governments, Komisi Lanjut Usia, the involved universities, professional organizations, and NGOs (Ministry of Health Republic of Indonesia, 2015b). There are tangible outcome indicators for each of the action steps in the policy (Ministry of Health Republic of Indonesia, 2015a, pp.25-35).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The actions in the plan are being led by national health institutes as well as by civil associations.

There are no monitoring targets specified in the policy documents. In terms of monitoring, there are health and social indicators available in the Brazilian Information Systems that may be used to support the monitoring of policies (such as mortality rate, number of live births, number of hospitalizations, many data stratified by sex, age etc.). For instance, some academic publications make use of these indicators to show advances or setbacks in the healthcare system. Another example is an article that shows positive impact of the Family Health Strategy program on mortality from heart and cerebrovascular diseases (Rasella et al., 2014).

References:

Rasella, D., Harhay, M. O., Pamponet, M. L., Aquino, R., & Barreto, M. L. (2014). Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: A nationwide analysis of longitudinal data. BMJ, 349. https://doi.org/10.1136/bmj.g4014

The document does not mention specific timeline/milestones. There are no instruments mentioned to monitor (Ministry of Health Republic of Indonesia, 2015b) and yet, no national evidence of evaluations linked to the national policy have been published.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Although progress has been made, no monitoring mechanisms have been established.

The National Policy for Older People’s Health stated in 2006 that some local, state, and municipal managers’ experiences were important for the establishment of the policy. However, no details about specific experiences and names of these managers were mentioned in the document (Fernandes & Soares, 2012).

References:

Fernandes, M. T. de O., & Soares, S. M. (2012). O desenvolvimento de políticas públicas de atenção ao idoso no Brasil. Revista Da Escola de Enfermagem Da USP, 46(6), 1494–1502. https://doi.org/10.1590/S0080-62342012000600029

 

The Ministry of Health is the primary stakeholder in creating the national strategic plan. The roles of the other key stakeholders are outlined for each action steps.

Overview of stakeholders involved in the seven action steps

Action step Stakeholders
1. “Campaign on Public Awareness and Promotion of Healthy Lifestyles Min. Health

Min. Home Affairs

Min. Population and Family Planning (BKKBN)

2. Advocacy of human rights for people with dementia and their caregivers Min. Home Affairs (leader)

Min. Health

 

3. Ensuring access and information of quality services Min. Social Affairs

Coordinating Ministry for Human Development and Cultural Affairs

Min. Population and Family Planning

4. Implementation of early detection, diagnosis and holistic management of cognitive disorders and dementia Min. Health

Min. Home Affairs

Min. Social Affairs

Min. Population and Family Planning

5. Establishment of System to Reinforce professional and sustainable human resources Min. Education and Culture

Min. Social Affairs

Min. Health

Min. Population and Family Planning

Min. Finance

BPJS

6. Establishment of System to Reinforce Cognitive Health Programs as main factor to increase literacy of nation based on life course approach Min. Health

Min. Population and Family Planning

Min. Home Affairs

Min. Social Affairs

7. Implementation and Application of Research on cognition and dementia” Health Research and Development (Litbangkes) of Min. Health

Indonesian Academy of Sciences (AIPI)

Indonesian Institute of Sciences (LIPI)

Min. Higher Education

Other research institutes

 

Source: (Ministry of Health Republic of Indonesia, 2015a, pp.18-25).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Their expectations were to better organise healthcare services for older people (Fernandes & Soares, 2012).

References:

Fernandes, M. T. de O., & Soares, S. M. (2012). O desenvolvimento de políticas públicas de atenção ao idoso no Brasil. Revista Da Escola de Enfermagem Da USP, 46(6), 1494–1502. https://doi.org/10.1590/S0080-62342012000600029