Aging , Disability and economic loss 

An estimated 15 percent of the global population has one or more disability with persons with disabilities being the largest minority group in the world. Being at a state of disability prevents individuals from functioning and participating within their environments. This also includes inability to become contributors to a country’s economy, through gainful employment. According to the United Nation More than 46 per cent of older persons that is those aged 60 years and above have disabilities With  more than 250 million older people experience moderate to severe disability. Higher disability rates among older people are a direct effect of lifespan of disease i:e  any diseases that could occur from birth that could give rise to disability, injury, and chronic illness  such as vascular (blood) disease and non communicable diseases that is predominantly influenced by an unhealthy life style. Thus  it is urged by the United Nations for countries to facilitate discourse that will lead to policy change conducive towards the growing aging population of the globe. 

 In Sri Lanka according to the prevailing statistics the population above the age of 60 years was at  2.5 million in 2012 comprising of  12.5% of the total population.  A forecast is made  that Sri Lanka would have elderly population nearing to 3.6 million by 2021, which would be an estimated 16.7% of the total population and by 2041, one-quarter of the population would  be  the elderly. 

Both the acute and the rehabilitative care within the health sector needs to be prepared to prevent and to manage the complications arising from an increasing aging population of the country, without which a double deprivation to the country’s economy can be expected in losing out on productive labor force due to disability and incurring additional costs to the economy in having to spend on health and rehabilitative care of the  aged population who are no longer able to contribute to the economy.   

The Global strategy and action plan on ageing and health

The World Health Organization in recognition of the growing aging population and the need for promoting healthy ageing in building systems to meet the needs of older adults has endorsed investments made for the aging population.  The investments are viewed as sound investments in a future where older people have the freedom to be and do what they value.

Last year at the sixty ninth World Health assembly “Multisectoral action for a life course approach to healthy ageing: global strategy and plan of action on ageing and health” (Document A69/17) and a related resolution (WHA69.3) were adopted. The Document is two fold concentrating on the following areas from 2016- 2020.

‘Firstly a five years of evidence-based action to maximize functional ability that reaches every person; and by 2020, establish evidence and partnerships necessary to support a Decade of Healthy Ageing from 2020 to 2030.’ 

Specifically the Strategy focuses on five strategic objectives i:e commitment to action on Healthy Ageing in every country, developing age-friendly environments;  health systems to the needs of older populations; developing sustainable and equitable systems for providing long-term care (home, communities, institutions); and improving measurement, monitoring and research on Healthy Ageing.

Source http://www.who.int/ageing/global-strategy/en/

The United Nations World Health Organization has also pointed out that as people age, their health needs tend to become more complex with a general trend towards declining capacity and increasing the likelihood of having one or more chronic diseases. In many parts of the world health  services are often being designed to cure acute conditions or symptoms and tend to manage health issues in disconnected and fragmented ways having lack of coordination across care providers, settings and time. 

Thus it is pointed out that Health systems need to be transformed so that they can ensure affordable access to evidence-based medical interventions that respond to the needs of older people and can help prevent care dependency later in life.

Japan and the aged

At present Japan is categorized to out weigh all other countries in the globe in its aged population. According to statistics developed in 2014 an estimated, 33.0% of the Japanese population is above the age of 60, whilst  25.9 percent  are aged 65 or above, 12.5 percent are aged 75 or above.^[2]People aged 65 and older in Japan make up fifth of its total population. One third of Japan’s population is expected to be the elderly by the ear 2050. 

Faced with a dire fiscal pressure having a zero return through the economic boom resulting in a sluggish economy, More burden to this equation was added through the rapid aging and low birth rate of  Japan’s s population.  Yet the Health care system in Japan has risen to the occasion by introducing schemes that are open to improvements

As one of the leading industrialized countries Japan has prepared and is pioneering well in health investments made for the elderly in comparision with many  other industrialized counterparts. In the year 2000 ; seventeen years ago Japan introduced the long term care insurance, through which many elderly in the country today benefits.  

According to an article published in the New England Journal of Medicine in 2015 ‘In addition to improving health outcomes, Japan’s social insurance system has made incremental improvements in equity through cross-subsidies and tax transfers, which contributed to income redistribution in addition to risk pooling.’ Similar to what many countries have practiced Japan has increased the health coverage population group by population group, with  policies designed for different groups with differing levels of coverage (both in terms of benefits and funding). However this has created disparities and problems of fairness. According to the article the Government action and new social policy were required in order to reduce these inequities. Japan’s single reimbursement fee schedule (for all physicians and patients) and single benefit package for all social insurance programs created a foundation for equity in access. The Japanese government then increased equity by changing the copayment policies for the various insurance programs, reducing benefits for employees of private companies (by increasing their copayment rates), and increasing benefits for the elderly and non–employment-based insurance plans (by reducing their copayment rates).

At present Japan however is in need of further reforms and consolidations to fully address the magnitude of the crisis. Yet early planning and pro-activeness to address the predicament along with the openness shown to adapt and reform the existing health care frameworks have helped Japan’s economy to sustain. 

Age friendly city in Sri Lanka 

In the rural city of Welawaya Sri Lanka the first age friendly city endorsed by the WHO was built making it the first in the region. An initiative done by the Uva Provincial Council with the support of the Ministry of Social Services and the Ministry of Health. Elder’s Committees and Disabled Peoples’ Organizations remain as the key stakeholders of the project.

Speaking to Ceylon FT the pioneer of the project  member of the Uva provincial councilor and Attorney at Law Mr. Senarath Attanayaka stated that the Sri Lankan society and the those making policies needs to be more aware  about the conducive changes that needs to take place in favor of the growing  elderly population in Sri Lanka. Devoid of which significant population of the country will not be able to contribute positively to the economy due to the lack of accessibility.  

“ Accessibility is key for any individual to make the contribution they are capable of making. Physically accessible public places, systems and structures are both needed for persons with disabilities as well as for the growing aging population in this country. The presence of accessible infrastructure has a direct impact to one’s health and level of functioning. The project in Welawaya stands as a model for the rest of the country to adopt both within the rural and urban setting as our demographics change in having an increased number of elderly: ” 

Any area that affects to the positive state of being in an individual contributes directly to Health. Having age friendly cities give more access to senior citizen to contribute productively to their environments that in turn prevents the effects of disability as well as in having the opportunity to contribute to the labor force. This also prevents many of the potential economic losses a country could face with a growing aging population. 

Rehabilitative servicers and productivity of the elderly 

At present the rehabilitative care available in the country is progressing to match the demand that currently prevails. Although the professions of physiotherapy, occupational therapy and Speech therapy are available in the country in many rural and urban settings the influx of patients have contributed to professionals spreading themselves thin to offer quality servicers.   With an expected increase in the number of geriatrics in the population, specific investments should be made in the country to train professionals who are versed in providing services for the elderly population.  Increase in geriatric medical practioners as well as rehabilitative service providers specialized in providing servicers for the aging population should be a priority both in the health sector and within the medical education fields in Sri Lanka. 

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Sri Lanka  is well known for it’s  health care structure indicative of outcomes that are seen as exemplary to the developing world. With 99% of all maternal deaths occurring in the developing world, the South Asian region accounts to the predominance of these. Sri Lanka’s closest neighbour India both on  geographical as well as on influential grounds,  has an estimated 300 maternal deaths per 100,000 births whilst in Sri Lanka it is less than 30 per 100,000 live births. A similar trend is also seen in infant mortality rate. These indicators illuminate  the long established healthcare structure of the country, that has prioritized training health professionals  towards serving the poorest and the most under resourced communities in the country.  It also stand as a testament to the long establish medical education of the country ensued solely by state investments. 

Investment disparity in acute and rehabilitative care for children

Nevertheless when skilled doctors in the country save lives at the birth of infants who have odd chances to live, there remains a dire lack in trained professionals monitoring and facilitating optimal child development. Infants who have faced complications before, during and after birth are at risk in achieving milestones in their  development. Some of the disabilities are presented on full scale later on in a child’s life due to medical professionals and parents missing out on early presenting signs. Many children in the country have been diagnosed with childhood developmental disabilities the effects of which could have been minimized or even reversed if early detection and treatment were provided. 

The most common conditions that call forth for investments made in child development are Learning Disability, Cerebral Palsey and Autism Spectrum Disorder (ASD)  All of these conditions have the ability  present better outcomes if detected early. Following early identification, intervention needs to be provided early enough within the period where a child’s brain is still developing where the brain is more responsive to stimulation. Thus systematic environmental exposures can change the outcomes of a child’s life if facilitated early enough, ideally before the age of five. 

Beyond mere living, making children contributors 

Yet in Sri Lanka it is still a farfetched reality to many at risk children  to be a part of an early intervention  program that could change their level of functioning for the rest of their lives. Despite the great strengths indicated by  the health system, adequate recognition and financial investments have not been made for the area of child development and rehabilitation.  The  government and other emerging main stream private health care systems at present focus mainly only on acute care pertaining to child health and much less on preventive and rehabilitative measures pertaining to childhood disabilities.  The current health structures have failed to recognize that following acute care a process involves in making a child functional, beyond mere living. 

High and rising prevalence 

According to global statistics about 15% of children aged 3 to 17 are diagnosed with a developmental disability. The presence of Autism have increased by 289.5% globally over the last decade. Prevalence of Attention Deficit Hyperactive disorder (ADHD) have by increased 33.0%.  Males children are seen to be having twice the prevalence of any Developmental Disorder than females and more specifically had higher prevalence of ADHD, autism, learning disabilities, stuttering/stammering. 

In Sri Lanka too there has been a rise in the presence of developmental disabilities in children with a recent study showing 1 in 93 children in Sri Lanka are affected by the disorder. However at present there also remains a significant gap in the amount of data available on these conditions with minimal research done despite its presence being seen evidently more within health and school settings. 

Minimal goal oriented investments made for child development

Dr. Samanmali Sumanasena, Consultant Peaditrician and Senior Lecturer at the Faculty of Medicine, University of Kelaniya, is a developmental peaditrician with many years of experience both within the hospital and academic setting of Sri Lanka. Speaking to Ceylon FT she stated that at present minimal planned, goal oriented investments are made by authorities towards facilitating optimal child development through early identification and intervention given to  developmental disorders.

“ Given the rate at which we encounter children  with developmental disabilities the country is likely to end up with a significant amount of the population being unable to contribute positively to the country within the next two decades, simply because we as a country failed to recognize the need to invest in child development.  We need to take immediate measures to reverse these outcomes of at risk children by investing within the education and heath care structures. Well trained professionals to identify and provide 360 degree treatment to these children are very important, without which these children will fall through the cracks and will be labeled as invalids and be highly dependant in the future.”

Comprising a high number of depandants who are unable to contribute to the developments of the country poses a critical thereat to a country’s economy. Thus the dire need for a national program that  would facilitate child development to all children at risk for disability and having a disability is currently seen as a critical investments the authorities should make. 

More Economically Developed Countries (MEDC) and Early Intervention investments

Many developed economies have singularly recognized the need for investments made in early intervention and thus are reaping the benefits of a more productive labor force that contribute to the economy overcoming and despite disabilities. Head Start is a program of the of the United States Department of Health and Human Services which provides comprehensive early childhood education, health, nutrition, and parent involvement services to low-income children and their families. Studies have shown that young children with multiple disabilities who are enrolled in this program have better outcomes in reading, writing and math scores.  The Return On Investment (ROI) of the Federally/Nationally funded Head Start program in the US ranges from USD 7-9 for every dollar invested.  

Recommendations have been made to the National Commission on Fiscal Responsibility and Budget Reform that budgetary allocations should be made and not cut for such programs. It is also reported that such programs  yields a higher rate of return to society than spending money on secondary education and job training programs. The European Union has also recognized and endorsed investments made in the like by the governments of countries in Europe.  Canada, Australia and the United Kingdom too have recognized and facilitated such programs as part of a national initiative. 

Parental investment in  spending time with children in play 

Investments made in children should be multifaceted starting from creating a home environment conducive towards a child’s development. Many parents have traded one-on one time with children with electronic devices such as televisions and phones, which has significantly affected the regression of a child’s overall development. This has also contributed to the increase of the severity of certain developmental disabilities.  Speaking further Dr. Sumanasena said that there is much that needs to be done by the child development authorities particularly in training professionals involved with children. 

“ Currently there is no screening available for babies and toddlers to detect developmental concerns. Many pre school teachers are absorbed into our education system with no or minimal qualifications and training on child development. Little do we realize that these are the individuals who will shape our children’s lives to the better or to the worse. This is very important because at this age a child’ s brain is still developing and there is much that can be changed and improved through the exposures a child gets through pre school. It is therefore critical  to have ongoing trainings for these professionals as they would be the ones who will be shaping the lives of the next generation.”

Minimal public infrastructure conducive for child development

Investments should also be  made in public infrastructure targeting early childhood development.  Facilities and schools designed in a way condusive to providing optimal brain stimulation for children should be a part of a national program. Other facilities such as themed parks, museums and other stimulatory environments needs to be build and be accessible for all children in this country. Including for children with disabilities. 

“ Awareness should be raised within all stakeholders on child development. Parents, doctors, teachers, health professionals  and all other professionals need to take action now, if we want citizens in this country who are well developed not just grown.” 

UNICEF has strongly emphasized that  ‘Evidence-based research and multi-country experiences provide a strong rationale for investing in Early Childhood Development (ECD), especially for children at risk of developmental delay or with a disability. Both the Convention on the Rights of the Child (CRC) and the Convention on the Rights of People with Disabilities (CRPD) state that all children with disabilities have the right to develop “to the maximum extent possible”.’   Sri Lanka at present having ratified the United Nations CRPD thus should take active measures to include these investments within its health care structures in viewing capital spent on child development a lucrative investment made in the country. 

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A longitudinal study done in the US that examined children aged 3- 17 that has received a diagnosis of a delay revealed that over 17% of children were given at some point given a diagnosis of a delay/ disability.  ADHD, Learning Disability and Speech and senses related delays were the most common. Although no official data is available in Sri Lanka currently on children facing developmental delays several preliminary studies show that with increased pre-natal, peri natal and postnatal complications elevates the risk  for children having delays. One study done as a developmental surveillance at the Colombo North Teaching hospital revealed that a direct impact of postnatal complications impacted cerebral palsey and other developmental disorders.  Maternal stress level, socio economic variants and now even a pandemic situation is likely to make children vulnerable for delays.  

Currently in Sri Lanka Island wide services are available initiated both by the government and the private sector to identify and treat early children with or at risk for a delay or a disability. However, the Covid – 19 pandemic situation posed a new challenge to all health care and educational professionals addressing delays presented in childhood.  This called forth for innovation and evidence based systems that would effectively address health, rehabilitative and educational needs of children with delays. Thus tele health systems in the form of tele therapy and tele consultations that provides online support directly to children and their caregivers towards their development currently is in operation.

Importance of Early Identification and ROI in child development in a pandemic.

Many developed economies have singularly recognized the need for investments made in early intervention and thus are reaping the benefits of a more productive labor force that contribute to the economy overcoming and despite disabilities. The Return On Investment (ROI) of the Federally/Nationally funded Head Start program in the US ranges from USD 7-9 for every dollar invested.  

In a pandemic, children with a delay or at risk for a delay remain highly vulnerable. If unaddressed these children have a high risk of having a disability that could limit their contribution as adults making them dependents. This poses a serious risk to any economy calling forth for proactive measures.  Hence investments made both at an institutional and at an individual level for children facing delays particularly at the time of the pandemic should remain a priority. 

Evidence of Tele health and Tele Therapy for children. 

Telehealth  has been used by pediatric clinicians for over a century,  in cases of emergency and monitoring use of telephone facilities were an important part of the over all pediatric practice. More advanced technologies such as video consultations are prevalent with its high usage happening since 2020 with the Covid 19  pandemic. 

According to a study done recently Telehealth presents the opportunity to bridge many divides including geographical and logistical challenges. It states that ‘many acute pediatric conditions can be managed safely and effectively through telehealth especially when remote physical exam equipment is used. Telehealth can also be especially useful in medical care of children with medical complexity. Traveling with medical equipment to multiple subspecialists can be incredibly challenging and often a similar quality visit can be conducted through telehealth in the comfort of a child’s home environment.’ 

Evidence suggests that the integration of telehealth into the pediatric patient centered medical home can enable families to gain convenience while maintaining the essential relationship with the health professional. 

Speech delay and tele therapy

A preliminary study conducted by Ceylon Speechie recently revealed that tele therapy in Speech and Language Therapy given through an online platform delivered in the form of parental training remained successful with children below the age of five. These results were even comparatively better than face to face consultations. Tele therapy improved the overall communication, speech and language skills of the all the children that were part of the study. The improvements were mainly identified to be due to the reduced stress levels of parents during tele health consultations, clinician being able to analyze child’s natural environment in reference to the treatment plan, easy accessibility of the service and high parental involvement. 

In a study published dating back to as 2017 a systematic review revealed both telehealth and in-person participants made significant and similar improvements when treatment effects were measured through outcomes in speech and language therapy given for school aged children. 

Findings previously before the Covid -19 pandemic showed there is limited but promising evidence to support telehealth for delivering speech-language pathology intervention services to school-age children. In 2021 these evidence is further backed by many researches with parents expressing  high levels of satisfaction with tele health programs given for delays that children faced. 

Way forward

Sri Lanka  is well known for its  health care structure indicative of outcomes that are seen as exemplary to the developing world. With 99% of all maternal deaths occurring in the developing world, the South Asian region accounts to the predominance of these. Sri Lanka’s closest neighbour India both on  geographical as well as on influential grounds,  has an estimated 300 maternal deaths per 100,000 births whilst in Sri Lanka it is less than 30 per 100,000 live births. A similar trend is also seen in infant mortality rate. These indicators illuminate  the long established healthcare structure of the country, that has prioritized training health professionals  towards serving the poorest and the most under resourced communities in the country.  It also stand as a testament to the long establish medical education of the country ensued solely by state investments. 

Nevertheless when skilled doctors in the country save lives at the birth of infants who have odd chances to live, there remains a dire lack in trained professionals monitoring and facilitating optimal child development. In Sri Lanka too there has been a rise in the presence of developmental disabilities in children with a recent study showing 1 in 93 children in Sri Lanka are affected by the disorder.

 Some of the disabilities are presented full blown later on in a child’s life due to medical professionals and parents missing out on early presenting signs. Many children in the country have been diagnosed with childhood developmental disabilities the effects of which could have been minimized or even reversed if early detection and treatment were provided. 

Within the new scenario of the pandemic use of tele health platforms both for tele therapy and other pediatric needs should be acknowledged and made use of optimally within this context.  

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