Country Diagnostic Study on Long-Term Care in Tonga

This publication presents findings of a study on the availability and provision of long-term care (LTC) in Tonga. It discusses the need for and supply of LTC in the country, including regulatory and policy frameworks, service provision, quality management, human resources, and financing. Analysis, conclusions, and recommendations for the development of LTC systems in Tonga are also included. Aiming to contribute to increasing the knowledge base on LTC policies, programs, and systems, this publication is one of six country diagnostic studies—the others on Indonesia, Mongolia, Sri Lanka, Thailand, and Viet Nam—prepared under the Asian Development Bank technical assistance 9111: Strengthening Developing Member Countries’ Capacity in Elderly Care.

Stakeholders working in aged care report that international agencies are more interested in youth programs. The government's policy focus is predominantly on the younger generation, despite the recent implementation of the Social Welfare Scheme for the Elderly. Care for older people has not received the necessary attention from policy makers, and this is at least partly due to the traditional view that aged care is a family obligation. However, without more aged care programs and budget support from the government and international agencies, the challenge of the older population will grow, while the lack of specific legislation to protect older people will leave them vulnerable to abuse.
service provision in tonga is limited to a national older persons home care program delivered by ma'a Fafine mo e Famili, an ngo, to 200 older persons. The Mango Tree Centre provides rehabilitation for up to 10 patients once a week. The main hospital is the primary health-care provider for older people, along with a few private clinics. The Naunau 'o e 'Alamaite Tonga Association (national disability organization) and the Red Cross also provide support. The national psychiatric unit does not have the appropriate facilities, but has to accept admissions of older people patients suffering from dementia and accommodate them with general mental health patients. The main hospital is not equipped for respite care for older people, but it often has to provide care when a family can no longer cope. There is no proper residential facility for older people, except for a small residential home used as a rest home for five homeless older people provided by the Loving Heart of Good Samaritan organization.
The government's main policy document is the Tonga Strategic Development Framework, 2015-2025, which identifies older people under "Organisational Outcome 2.7" as a priority group, alongside the disabled, young, and those considered vulnerable. 5 This framework, which guides policy decisions, requires government departments to include older people in their planning as a priority group. The Social Welfare Scheme for the Elderly is providing much-needed relief during the difficult economic conditions caused by the coronavirus disease  pandemic, and is popular. While tonga still lacks the legal framework required for LtC that could ensure that the dignity, freedom, and rights of older people are protected, the Prime minister launched the aged Care national strategic Plan, 2020-2024 on 11 august 2020, which was prepared under ta 9111: strengthening Developing member Countries' Capacity in elderly Care.
given the lack of a quality accreditation system for LtC, the standard of care provided by existing service providers cannot be measured. Training is an area of concern. A local training provider is needed to improve the skills of care workers and prepare family caregivers to provide appropriate and safe home care support. The national home care service provider has given care workers experience, but the workers do not receive accredited training or formal qualifications. xii executive summary the government is spending $1.6 million per year on the social Welfare scheme for the elderly. 6 This scheme, which received a budget of T$500,000 ($208,000) in 2019, provides home care services to up to 200 older persons, delivered by an NGO contracted by the government. Health care for older persons is included in the general pool of funding, but the exact amount cannot be quantified. However, estimates can be made based on the older population growth rate and health cost trends since 2010. This CDS estimates the annual cost for older people health care at $1.44 million. Health care is free and easily accessible to older people on the main island, Tongatapu, but not for those living on the remote islands due to lack of access.
Reflections from the key informant interviews and focus group discussions provided similar views on the following: (i) the establishment of older people centers in villages or regions for activities and care support; (ii) provision of older people activities on a regular basis, such as exercise, cultural events, and day trips; (iii) a training requirement for family caregivers and care workers; (iv) a public promotional campaign on the situation of older people and their need for appropriate care; (v) legal protection for older people; (vi) coordination of services for older people; (vii) policy development support for government agencies; and (viii) a dedicated government unit for older people.
The findings of the CDS and the feedback from the national consultation event with stakeholders showed support for the development of proper training for care workers and family caregivers to improve the quality of care being provided. An accredited quality management system will also support service providers, as well as protect older persons. A legal framework may be required to protect older persons from abuse and neglect, given the cases that have appeared in court.
Financing LtC could become a major issue in the future, based on this study's projections regarding the growing older population and rising cost of care. There are a number of options for funding LTC-for instance, from social welfare benefits and retirement funds-but planning needs to start now, as the cost of health and social service care for older persons is projected to rise significantly over the next 3 decades.
I. bACKGroUND 1.1 Introduction tongan people are proud of their culture, which includes the traditional duty of taking care of loved ones. Traditional norms and cultural responsibilities define how family members respect each other and protect the vulnerable in Tonga's hierarchical society. Older people in the community are the keepers of tradition and holders of historical records, so they are the cornerstone of Tongan society. Tongan traditional practices require adult children and younger members of the extended family to care for their parents and older people. However, this has been challenged by the migration abroad of adult children and young people for employment and educational opportunities. Increasingly, others from the extended family have to step in and provide care, and the number of older people who have no caregivers or access to formal care workers is increasing. The proportion of older people in the population is also increasing. For these reasons, it is important to develop policies and plans for long-term care (LTC) services for older people.
this country diagnostic study (CDs) aims to contribute to the building of an in-depth knowledge base on emerging LtC policies, programs, and systems. Therefore, the CDS sought to gather relevant data, review policies and plans, and explore the viewpoints on LTC for older people in Tonga and other countries, in order to provide an understanding of LTC in Tonga and build capacity for policy making and planning. The study drew on the experiences and opinions of older people and their families, and of stakeholders within the government, nongovernment organizations (NGOs), and the private sector.
the report begins with an examination of the need for care and the supply of care. This is followed by the findings regarding the state of LTC in Tonga based on five main areas: policy and governance, service provision, quality management, human resources, and financing. The report concludes with an analysis of the existing system and recommendations on how to improve it.

Definition of Long-term Care
The in the absence of a formal tongan definition of LtC, this report uses the definition provided by WHo.
A national consultation event for this study, which took place on 26 July 2017, adopted the WHO definition of LTC, and it was included in the Prime Minister's speech. The main goal of the LTC system is to maintain (or improve) the levels of functional ability in older people who have, or are at high risk of having, significant losses of capacity. This can be achieved in two ways: (i) optimizing the recipient's trajectory of intrinsic capacity; and (ii) compensating for a loss of capacity by providing the environmental support and care needed to maintain functional ability at a level that ensures well-being.

Country Context
the Kingdom of tonga is categorized as a "small island developing state." 2 Tonga's population of 99,600 in 2019 had fallen from 100,100 in 2018 due to the migration of seasonal workers to Australia and New Zealand. 3 Large-scale migration to the United States, Australia, and New Zealand in the 1960s resulted in more Tongans living abroad than in Tonga. 4 Around 70% of the population lives on the main island, Tongatapu, and the rest is spread out among the remote island groups of Vava'u, Ha'apai, 'Eua, and Niua.
tonga is a conservative Christian nation with strong cultural traditions and a hierarchical system. It is a constitutional monarchy, with the King as head of state and commander-in-chief of the armed forces. Parliament operates as a unicameral legislative assembly consisting of 26 elected members, including 17 peoples' representatives and 9 members selected from among the 33 hereditary nobles. The Prime Minister is elected by the Legislative Assembly and formally appointed by the King. Tonga experienced major sociopolitical changes in the early years of this century that led to political reforms, which, in turn, resulted in 2010 in the establishment of a democratic government for the first time, elected by commoners and nobility.
tonga's gross domestic product (gDP) in 2020 was $500 million and is expected to contract by 5.3% in 2021, and grow by 1.8% in 2022. Overall unemployment rate was 4.4% in 2020 with women unemployment rate higher at 3.7% compared with 2.6% for men. Laborers from rural areas participate in New Zealand's Recognised Seasonal Employer (RSE) scheme and the Australian Seasonal Work Programme (SWP), which are generating significant remittances for Tongan families. See Box for the latest available data on selected indicators for Tonga. tonga has a high Human Development index of 0.726, reflecting the country's high life expectancy and educational standards. 5 This compares to 0.725 in neighboring Samoa and 0.704 in the Marshall Islands. However, it is a concern that the proportion of the population living below the poverty line is 22.1%. This is higher than in Samoa, where 18.8% of the population lives below the basic needs poverty line. 6 Despite the Government of Tonga's efforts to deliver health, social, and education services to the outer islands, the inequality of opportunity and access to infrastructure there-including water, energy, communications, and transportremain a problem due to the islands' geographical remoteness.

5
United Nations Development Programme. 2020. Human Development Report 2020. New York. 6 Government of Samoa, Samoa Bureau of Statistics, and UNDP Pacific Centre. 2016. Samoa Hardship and Poverty Report: Analysis of the 2013/14 Household Income and Expenditure Survey. Apia. https://www.ws.undp.org/content/samoa/en/home/library/samoa-hardship-and -poverty-report.html.

research Design and Approach
A consultation meeting with key stakeholders took place in February 2017 before the conduct of the CDS, to identify country priorities and analyze the gaps in knowledge needed for planning LTC services.
In May and June 2017, the authors of this study undertook a literature review; analysis of secondary data; and a review of laws, policies, and regulations relating to aged care. They also conducted key informant interviews (KIIs) and focus group discussions (FGDs) with older people and caregivers ( Figure 1). The initial findings were presented to stakeholders at a national consultation event held in Nuku'alofa, Tonga, on 27 July 2017. Feedback and responses to the findings at the event have been incorporated into this report. the research approach was based on the Kakala Framework, which guided the collection and analysis of the data. 7 Kakala is the Tongan word for "garlands." The methodology reflects the different stages of making a garland, beginning with teu, which means "to prepare," i.e., to plan the arrangement of the flowers. Next is the toli, which means "to pick" the flowers. This is followed by tui, which means to weave or string the flowers into a garland. Luva is the gifting of the garland to the wearer during a special occasion. Malie is the appreciation shown by the recipient for the garland. Finally, mafana is the feeling of satisfaction with a job well done. These concepts also represent the different stages of this study's research, as provided in Table 1.

Literature review
as part of the CDs, the authors conducted a review of the literature to gauge the extent of the existing research and information on LtC in tonga. They started with an online search using variations of relevant terms such as "Tonga elderly care," "Tonga long-term care," "Pacific elderly care," "health of older people," and "social protection" on the PubMed and Google Scholar databases, as well as on the wider internet. They found no studies specifically on LTC for older people in Tonga. However, there were studies on health conditions, mortality, causes of death, and health promotion that have some relevance to LTC planning. And there were ample internal studies and reports on LTC as well as accounts of experiences in other countries that could be applied to Tonga's case. A search for studies on Tongan LTC abroad produced a few studies from the United States and New Zealand on the experiences of older person migrants from Tonga.
the authors also did a review of government surveys and reports produced by international bodies.

Key informant interviews
Key stakeholders were identified and interviewed, including health-care service providers (public, private, NGO, community group), various government agencies at the local and national levels, town officers, and village councils at the grassroots level. The "Talanoa Method" was used to engage stakeholders in discussions, as this method is more appropriate for communicating in a culturally appropriate manner. 8 Talanoa means "talking" or "conversing" between two parties. 9

Focus group Discussions
the FgDs were held with older people, their family members, and caregivers, using the talanoa method to delve into the levels of existing care and the sensitive issues around LTC. These discussions provided case studies, stakeholder opinions, and stories that were illustrative of the LTC situation in Tonga.

ethical Considerations
the FgDs were conducted with small groups, which in tongan culture are more suitable for discussions on sensitive topics. The facilitators provided potential participants with a clear written explanation of the purposes of the study and the organizations involved. Informed written consent from all the participants was obtained, including permission to record the discussions. The participants were assured that the discussions would be kept confidential and that all identifying information would be removed from transcripts and notes. With their consent, referral to appropriate health or social welfare services was arranged by the facilitators for participants who had revealed problems. The population of Tongatapu is increasing rapidly due to inward migration from the outer islands for employment opportunities and education. The majority of the population in all the islands lives in rural areas (77%). The population growth rate has been -0.5%, but the total population is projected to grow to 140,000 by 2050. 10 tonga is starting to experience population aging. In 2017, 8.8% of the population (9,035) was estimated to be 60 years and older, with 4.8% of the population in the "young old" group (60-69 years), 2.8% in the "middle old" group (70-79 years), and 1.1% in the "oldest-old" (80+ years) group. 11 The proportion of older people is higher in the outer islands than on Tongatapu. Only 29% of older people live in the urban area of Nuku'alofa, with the rest living in rural areas. Older people in urban areas are closer to health services, and can therefore access support more easily than those in rural areas and outer islands.
Pacific neighbors have similar statistics for those aged 60 and above, such as Samoa (8.1%) and Fiji (9.6%). Tonga has a lower proportion of older citizens than some other countries in the region, such as New Zealand, where 20.8% of the population is estimated to be aged 60 or older.
Projections from the 2016 census indicate that the pace of aging in tonga will accelerate over time, with women living longer than men. 12 It is projected that, by 2033, 10% of the population will be 60 years or older, and will rise to 13% by 2050.   In 2017, life expectancy at birth in Tonga was estimated to be 70.2 years for men and 76.2 years for women. Table 2 and Figure 2 highlight the actual and projected percentages of older people in total population by age group from 1990 to 2025, and the 2017 age and sex distribution projections based on the 2016 national census of population and housing.  older persons with no children or small families often have no close relation to serve as caregiver, and sometimes they have to rely on distant relations or neighbors. Of all the households in Tonga, 6.4% consist of one person, while 9.1% consist of a husband and wife only. 14 The older people living alone often experience extreme poverty, and some are bedridden. Care workers have reported many cases of highest need in rural areas and the remote islands.

intergenerational relationships
older persons may play a role in raising their grandchildren while the parents work, locally or abroad.
Service provider stakeholders at the CDS consultations raised concerns about the effects this practice may have on the older people, especially when the older people were physically unwell and poor. They felt that these duties affected the quality of life of the older people. More work was required to facilitate the transfer of cultural knowledge from grandparents to grandchildren as a method of building stronger intergenerational relationships. A study on the roles of grandparents in the Tongan community in Hawaii was more positive, finding that grandparents held essential roles as carers, teachers, and creators and preservers of cultural customs and traditions, with relationships with their grandchildren reflecting unconditional love. 15 During the key informant interviews (KIIs), however, older people and family caregivers noted a growing distance between grandchildren and grandparents. Similarly, during the national consultation event, one of the older speakers, Ahio, said that older people wished to build stronger relationships with Tongan youth. The caring of grandchildren by grandparents could thus have positive outcomes for both, through knowledge sharing and the fostering of stronger values. See Appendix 1 for the highlights of the KIIs and FGDs.

employment and Poverty
the 2016 census identified 3,857 (42.7%) older persons who were no longer in the workforce because they had either retired or were no longer able to continue working. The majority (68%) resided in rural areas, while 32% resided in urban centers ( Figure 3).
There are no data available on poverty in Tonga that is disaggregated based on age and sex, but responses from participants at the national consultation event, as well as during KIIs, indicated that poverty was common among older people, especially in rural areas and on the remote islands. nationally, about 22.5% of the population lives below the national poverty line. 16 Only 1% of older Tongans receive employment-related pension; 55.7% of men over the age of 65 and 29.2% of women over the age of 65 have paid jobs (footnote 13).
the wealth gap between rural and urban households is significant. Figure 4 highlights this contrast. Around 33% of the urban population is in the highest wealth quintile, compared with only 16% for rural residents. 17 In 2015, the Gini index, a measure of income inequality, was 37.6 for Tonga, which was higher than the score for Fiji   the global financial crisis of 2007-2008 strongly affected the economy and reduced the traditional social safety net provided by remittances. The worst affected were the vulnerable groups, including older people, who relied on remittances from family members working in Australia, New Zealand, and the United States. KIIs and feedback from the national consultation event indicated that economic shocks or natural disasters hit older people harder than the rest of the community due to their physical limitations and vulnerability.
3.1.5 Living Conditions most older people live in the family home or with relatives, so the supply of housing is not a major concern for them in tonga. At least 69% of all households owned their own home, while 5% paid rent, and 24% lived rent-free (footnote 13). However, some family homes were not older people-friendly, as access can be difficult.
No agency coordinates housing in Tonga, so the provision of appropriate housing is left to each individual family. Some homes observed during the study were in disrepair and unfit for habitation, their lack of upkeep due to poverty.
only 67% of all households have access to clean drinking water from a rainwater tank, while 25% source their water from a neighbor's tank and the rest use the village water supply. 19 The lack of access to clean water was a concern for older persons, who feared disease: in tongatapu, 93% of households had electric power for light, compared with 74% in Ha'apai. People in the Niua island groups had no access to a reliable electricity supply. Around 40% of households in the island groups relied on kerosene or benzene and 57% on solar power for their main lighting source (footnote 13). Older people interviewed for this study had experienced periods without electricity due to financial problems. In the case of the remote islands, older people may have no access to power, so they cooked on open wood fires. This was difficult because they had to collect the wood from their farms and were exposed to air pollution. In Tongatapu, 60% of the households cooked with gas.
tongatapu and Vava'u each has a waste collection system that covers 46% of households, mainly in their urban areas, while the other outer islands have no waste collection systems. Access to mobile phones was 90%, except for the Niua island groups, where it was 61% of households (footnote 13).
Public facilities and transport are not age-friendly because of access problems. The Ministry of Infrastructure, which controls public facilities and transportation, is considering incorporating age-friendly and disability-friendly policies so that any future public facilities will have to provide appropriate access and safety measures. 3.1.6 Health and Disability noncommunicable diseases are the major cause of morbidity and premature mortality in the Kingdom, and have become one of the main challenges for Tonga's health system.
tongan men have the highest rate of obesity in the world, followed by samoans; Tongan women have the second-highest rate of obesity, after Samoan women. 20 Lin et al. (2016) reported on the prevalence of type 2 diabetes and obesity in Tonga between 1973 and 2012. 21 Diabetes prevalence among those aged 25-64 years increased from 5. 2% in 1973 to 19% in 2012 (14.8% in men; 21.7% in women), and was projected to reach 22.3% in 2020. Obesity prevalence increased from 56% to 70.2%, and it was projected that by 2020, 64.5% of men and a staggering 80.5% of women would be obese. Obesity is associated with other health problems, and has health and cost implications for long-term care (LTC) services. Moving heavy and immobile older people to provide care, such as washing and toilet use, can be hazardous for family caregivers and formal care workers, who may need to work in pairs or to have adapted beds and mechanical hoists available.
as of 2012, the deaths of about 60% of men and 58% of women were attributed to cardiovascular disease and diabetes. 22 Carter et al. (2012) reviewed causes of deaths from medical certificates between 2001 and 2008, and found a rise in age-specific mortality from a range of noncommunicable diseases, especially diabetes, lung cancer, and cardiovascular diseases in those under 64 years of age. 23 in 2012, prevalence of hypertension among those aged between 45 and 64 years was 47.5%. 24 International studies have shown that the prevalence of hypertension increases with age, and is often responsible for chronic kidney disease among the oldest-old. 25 Since the incidence of noncommunicable diseases increases with age, it is likely that in Tonga, as elsewhere, these are the most common conditions affecting the quality of life and mortality for older age groups. The lack of data on older people is an indication of a lack of awareness about the significance of such data.
These issues have serious implications for the health of older people and the need for LTC in the future (Table 5). Figure 5 shows the numbers of older persons estimated to be affected by disability, by age group and setting. Disabilities are more common in the 75+ age group, so the numbers for that group are greater, even though the proportion of older people who are aged 75 years and older is small. Vision and walking disabilities are the most common, with similar patterns among all the older age groups.    across all older persons in tonga aged 65+, about two-thirds do not have any difficulty with vision. However, 26% have some difficulty, and 7% have a lot of difficulty or are unable to see. Figure 6 shows that the proportion of those with a lot of difficulty or inability to see increases with age, as expected.
Compared with difficulties with vision, the proportion of older persons in tonga aged 65+ with hearing difficulties is lower as highlighted in Figure 7. About 16% of the total older persons population has either some difficulty, and 5.5% a lot of difficulty or inability to hear. At older ages, the proportion of any difficulty increases, with about 10% of those aged 75+ having a lot of difficulty or inability to hear, a proportion similar to severe vision difficulties at this age.   about 17% of older persons in tonga aged 65+ have a lot of difficulty or are unable to walk or climb, with an age gradient as expected (Table 5). About 9% have a lot of difficulty or are unable to self-care, with the proportion low at 3.5% among the younger age group of 65-69, increasing to 6% among those aged 70-74 and considerably higher at 15% among those aged 75+.
the proportion of older persons in tonga aged 65+ who have a lot of difficulty remembering or concentrating is about 5%, with the proportion lowest among those aged 65-69 at about 1%, and rising with age to nearly 9% among those aged 75 years and older. In comparison, the proportions with difficulty in communicating in the usual language are lower, with about 3% of the total population of older adults having a lot of difficulty or inability (Table 6).

influences on Current Cohort of older People
During the 1960s and 1970s, many tongans emigrated to australia, new Zealand, and the united states for employment opportunities. In the mid-1980s, New Zealand offered visa-free travel that was taken up by many Tongan citizens, causing a spike in migration. Mass migration has continued since, with the younger generation also moving abroad for employment opportunities. Older people in the outer islands are migrating to the main island with their children for better opportunities.

Case studies reflecting Demand for Care
The following case studies were selected from KIIs and focus group discussions (FGDs) to present the range of needs and environment that older people experience, and to highlight the issues they face on a daily basis. Names, ages, and places have been changed to protect the identities of families. Also see Appendix 1 for the summary of reflections from the KIIs and FGDs.

advocacy
there are currently no agencies in tonga that advocate for older people, as there are in New Zealand, such as Aged Concern or the Citizens Advice Bureau. Public debate about LTC is limited because of cultural sensitivities. One result of the national consultation event associated with this study was the recommendation for a public education campaign, so that the public, government officials, and decision-makers could change their attitudes toward care for older people. Stakeholders held the view that more attention has to be given to the situation of older people, including their care needs. They said that the government and churches need to know that this is a growing problem and that the culture and values of the people are changing. Participating nongovernment organizations (NGOs) recommended partnering with the government to conduct public awareness campaigns to change the attitudes of the public toward older people and LTC, similar to the tobacco prevention campaign carried out by Tonga's Ministry of Health.
"Ageism is an issue, and a public campaign should target this negative attitude towards long-term care." -Elder representative at the national consultation event

Case 1: Care in Poverty
Living situation Seini, 72, lives with her son and daughter-in-law in a poor urban neighborhood. She lives in a small shack behind her son and daughter-in-law's house. The bathroom and toilet facilities are located outside the building. The family lives below the poverty line.

Basic and instrumental activities of Daily Living
Seini is physically immobile, so she relies on her daughter-in-law to help with her activities of daily living, including, for example, standing up from a seated position, eating, and washing; and with her instrumental activities of daily living, such as shopping, cooking, and handling money. After carrying out her caregiving tasks, the daughter-in-law returns to her normal household activities of weaving, cooking, and cleaning. Seini's son is employed and earns T$180 ($80) every 2 weeks.

support systems
The mother belongs to the Free Wesleyan Church, one of the largest churches in Tonga, while the son and daughterin-law are members of the local Gospel Church. Even though the mother is immobile, she still fulfills all her church kavenga (obligations), such as misinale (yearly church offering) and li kuata (quarterly church offering). The mother also contributes to village kavenga. She receives a monthly visit from the church reverend, but gets no other support from any other agency or relatives.

Health Problems
immobility. Seini relies on her son and daughter-in-law for care because she has lost all feeling in her lower body and is bedridden.
infections. The lack of hygienic resources in the home causes infections. At times, the daughter-in-law is overwhelmed with the household tasks, as well as caring for Seini.
Lack of nutrition. Due to its limited income, the family does not have enough food or nutritious meals for Seini. Often, the family only has enough money for one meal a day.
severe pain. The son and daughter-in-law are not trained in caregiving, so they do not know how to move Seini in such a way as to avoid pain and bedsores. Sometimes, they unintentionally hurt Seini when trying to move her to a more comfortable position.

Conclusion
The level of care provided for the mother is inadequate and is reducing her quality of life. The family is doing the best it can within the capabilities and financial resources it has, but Seini's health is worsening.
In the absence of external help, the family is struggling. The daily caregiving tasks are difficult, and as there is no external help, the situation will only get worse. The family continues to meet the church kavenga for the mother, despite not being able to afford it, so this is an extra burden. Both the son and the daughter-in-law need training on how to better care for their Seini, as well as access to medical knowledge and support with regard to preventing pain and infections.
This case highlights the lack of long-term care for elders and the plight of many families, especially the poor, who do not have the financial resources to provide care for their elders.

Living situation
Mele is 78 years old, and was encouraged by her family to return from the United States to live with her daughter and her daughter's three children in Tonga.

Difficulties with activities of Daily Living
Mele is starting to experience the onset of dementia, and her daughter assists her with both basic and instrumental activities of daily living. However, the daughter also works to support her own three school-age children, and does the cooking while her children clean the house. The daughter's weekly wage of T$160 (about $71) plus Mele's monthly T$65 (about $29) social welfare payments are the family's only sources of income.

Physical and Financial abuse
Mele knows about her social welfare payment, but has never received it. She complains to visitors about not receiving it, and about not being able to make decisions on what it should be used for. This has caused a rift between Mele and her daughter. Mele has also complained about being physically beaten and verbally abused.
She would often leave the house for walks just to avoid a confrontation, until someone would lead her back home. One day, a neighbor witnessed the daughter beating Mele in the shower, and called the police.

reporting abuse
After receiving the report concerning the daughter's abusive behavior, a police officer visited the home to investigate. After speaking to Mele and the daughter, the officer left without taking any further action. The daughter was angry at Mele for attracting police attention, so she assaulted her again, causing injury to her face and body. This case highlights the lack of elder abuse reporting processes, which means that elders are vulnerable to abuse without any sort of protection.

Conclusion
Family caregivers need training, while government needs to develop legislation to protect elders and to ensure that reporting systems are in place to protect them from all forms of abuse. Sugden et al. (2017) found that a mass media anti-tobacco campaign using adapted materials from developed countries had been effective. 26 The authors shared practical steps for adapting the campaign to also strengthen health literacy, change attitudes, support enforcement strategies, and set an agenda for policy changes in Tonga.
A similar strategy would also be useful for the LTC issue as a means of creating public awareness about the problems facing older people in general, and of changing attitudes toward caregiving.

supply of Care
in tonga, it is traditional for families to care for older people, and the majority of care provision is through family carers. Some families with an older person to provide care for may opt to have working-age adults remain in the workforce, and to therefore leave caregiving duties to grandchildren or relatives. Families with the means to do so may opt to hire private care workers. The cost for private care workers is still relatively low, between T$3 and T$5 per hour, according to interviews with stakeholders. There is some provision of home care through national older persons home care program, but formal care is otherwise very limited.

impact of migration
internal migration of working-age adults from the outer islands to tongatapu is reducing the number of family caregivers. In addition, New Zealand's Recognised Seasonal Employer (RSE) scheme and Australia's Seasonal Worker Programme (SWP) recruit a total of about 6,000 workers from Tonga, 27 mostly from the country's rural and remote regions, for short-term employment. The RSE disrupts the care of some of the older relatives of these seasonal workers, but the contracts are short-term, with the workers returning after at most 7 months. Similarly, under the SWP, the workers are away for only 6 months. The more lasting impact comes from overseas migration for longer-term opportunities. In 2013 alone, at least 5,436 (5.3% of the total population) migrated overseas on a permanent basis. 28 Older family members are often left behind in lonely and sometimes vulnerable situations, especially if they are physically impaired. Increasingly, relatives from the extended family have to step in and provide care. This can work, but it sometimes creates extra difficulty for the caregivers and the older persons with complex needs. The social and cultural changes of a modernized Tonga, along with the coronavirus disease (COVID-19) epidemic, makes it even more important to provide services that will support the efforts of communities and families to care for the older persons.
"Loneliness is the worst problem at my age.

other Domains in Care ecosystem
Health-care system. tonga has a universal health-care system that is free to all citizens, but is not equipped to handle LtC for older people. There is a dual system of medicine-traditional Tongan medicine (faito'o fakatonga) and Western medicine (faito'o fakapalangi). Traditional medicine use is more prevalent in the rural areas and remote islands. The national hospital is based in Nuku'alofa, and is the main hub for emergencies, surgery, primary care, and dental services for the people of Tongatapu. Rural areas are serviced by 14 community health centers based in the main regional villages. The remote islands are supported by three community hospitals based on the island of 'Eua and in the Vava'u and Ha'apai island groups. The location of community 27 The RSE recruits Pacific workers for short-term employment in New Zealand in the horticultural and agricultural industries (fruit picking).
The scheme provides economic benefits for the Pacific nations through remittances while filling a need for seasonal workers in New Zealand. health centers means that most people can access health services within a 1-hour walk. The majority of healthcare services are provided by government, but there is a small number of private health-care providers, including general practice clinics, pharmacies, and traditional healers. Outpatient contact rates are low, but the annual hospitalization rate is relatively high at 10%, due to patients bypassing the lower-level services in favor of hospitals. The Tonga Household Survey showed that expenditure by households on health care is very low, about $575 or 0.002% of total household expenditure. The main health-care burden for Tonga is noncommunicable diseases, which make up four of the five leading causes of mortality. Details of Tonga's health-care facilities and services are given in Appendix 2.
Health promotion. The Ministry of Health's initiatives to promote good health are implemented by the Tonga Health Trust, and target the general population with information on diabetes, smoking, family planning, typhoid, and nutrition; but there are no health promotions targeted specifically at people who are middle-aged or older. The ministry has the potential to deliver older people-specific services, which should address such topics as preparation for healthy aging, avoiding exposure to cooking smoke, and pelvic floor exercises for preventing or managing incontinence, in addition to the usual health messages about nutrition, physical exercise, the dangers of smoking, and the need to reduce alcohol intake.
social welfare services. the ngo sector delivers social services for older people and disabled citizens under contract to the Social Protection and Disability Unit of the Ministry of Internal Affairs. In 2017-2018, the government budget for vulnerable people, including social protection projects for older people, amounted to $6.65 million. The government's vision for social protection and disability for 2017-2030, as stated in the Budget Statement 2017-2018, is "to maintain a Tonga where vulnerable person hardships and difficulties are reduced with social protection schemes, social policies and social programmes aiming to improve quality of life by 2030" (footnote 30). The strategy is to ensure increasing institutional care and more support services, with a special focus on strengthening social protection and poverty-alleviation programs for village communities. NGOs also provide some support for older people, such as food, equipment, funds, and rehabilitation. There are only a few NGOs working with older people, so this is an area that needs further development.

Policy and Legal Framework
3.3.1 Policy Landscape the government's main policy instrument is the tonga strategic Development Framework 2015-2025 (tsDF), which has guided policy decisions and project implementation since 2015. All government agencies follow the TSDF, and projects must align with its vision, pillars, and outcomes. To achieve the TSDF vision, seven national outcomes are identified that aim to contribute to a more inclusive, sustainable, and developmentfocused nation that is fairer to all: (i) a more inclusive, sustainable, and dynamic knowledge-based economy; (ii) more inclusive, sustainable, and balanced urban and rural development across island groups; (iii) more inclusive, sustainable, and empowering human development with gender equality; (iv) more inclusive, sustainable, and responsive good governance, with law and order; (v) a more inclusive, sustainable, and successful provision and maintenance of infrastructure and technology; (vi) a more inclusive, sustainable, and effective land administration and environmental management, and resilience to climate and risk; and (vii) more inclusive, sustainable, and consistent advancement of Tonga's external interests, security, and sovereignty.
There are 29 organizational outcomes supporting the national outcomes, grouped as three institutional and two input pillars of development: (i) economic institutions, (ii) social institutions, (iii) political institutions, (iv) infrastructure and technology inputs, and (v) natural resource and environment inputs.
Regarding the second institutional pillar, social institutions, Organisational Outcome 2.7 is "Better care and support for vulnerable people that ensures that the elderly, the young, disabled and others with particular needs continue to be supported and protected despite shrinking extended families and other changing social institutions." 29 This pillar provides the direction for government programs that aim to support older people as a vulnerable group.

the tonga strategic Development Framework Vision
"A more progressive Tonga supporting a higher quality of life for all." -Tonga Strategic Development Framework (2015) 3

.3.2 stakeholder Landscape
In 2017, the Prime Minister of Tonga also headed the Ministry of Internal Affairs, which coordinated all government services and support for senior citizens.
"I want to convey our full support to provide better care services for older people throughout the Kingdom. We have started our assistance by increasing the social welfare benefits for older people in the 2017-2018 budget. The government is aware of the problems experienced by older people and their families struggling to provide home care support in order to meet our cultural responsibilities." -Prime Minister Samiuela 'Akilisi Pōhiva, national consultation event, 27 July 2017 Table 7 summarizes the policies related to the care of older persons. The main coordination agency for government-sponsored services is the Social Protection and Disability Unit, within the Ministry of Internal Affairs. The unit works alongside the National Retirement and Benefit Fund, as well as with social service providers.
the ministry of Health is responsible for universal health care for all citizens, including older people. It does not have a specific policy for older people, and according to the key informant interviews (KIIs) with the leadership, the government is considering how to provide better access to hospitals for older people.
The community health clinics are attached to the main hospital, Vaiola Hospital, in Nuku'alofa, and they can provide outreach mobile services to older people who cannot travel from rural areas to the capital. The government has identified noncommunicable diseases as one of its main target areas for the Ministry of Health's key performance measures. It has also implemented a second set of reforms using taxation to combat high-fat and high-sugar foods as part of an effort to curb the rise in noncommunicable diseases. 30 Feedback from the interviews with health officials indicate that older people are not specifically targeted by these programs, despite the fact they have the highest prevalence of hypertension and diabetes.  the social Protection and Disability unit coordinates the publicly funded services. Coordination is one component of social protection for the older persons. The other three -health, financial, and social servicesmake up the key support mechanisms for aged care. A formalized system is required to pull the stakeholders together under a common banner, and it was recommended at the national consultation event that a national strategic plan for the aged care sector needs to be developed to provide guidance for all stakeholders on care provision.

Legislation
The National Retirement Benefits Scheme Act 2010 is the only Tongan legislation that is specifically aimed at older people.
Recognizing the problems of poverty experienced by older persons, the government launched, on 1 September 2012, a Social Welfare Scheme for the Elderly under the National Retirement Benefits Scheme Act 2010, with the Ministry of Finance as the lead agency.
The government directly funded the Social Welfare Scheme for the Elderly at a cost of T$1.4 million ($582,000), which provided T$65 ($27) per month for citizens aged 75 years and above. 31 This decision was groundbreaking for a small developing island state, especially one with a small population base and tight revenue streams. The policy rationale was sound and based on a growing problem among vulnerable older people. Tonga is the only small developing island state in the Pacific that has introduced such a program. In the 2017 financial year, the government announced a lowering of the eligibility age from 75 to 70 years, due to the hardship and poverty among older people. The government expects the numbers of older and severely disabled recipients to increase due to the growing number of people affected by noncommunicable diseases, unless more effort is focused on healthier lifestyles. 32 At the end of June 2018, there were 4,105 eligible older people receiving the social welfare benefit, costing T$3.8 million ($1.6 million). 33

Legal Protection from abuse and neglect
Like most other Pacific nations, tonga does not have any laws specifically to protect older people and no formal system for reporting abuse. New Zealand, for example, has the Protection of Personal and Property Rights Act 1988, which allows vulnerable people to appoint one or more representatives to have enduring power of attorney. The act also allows the courts to appoint a person as a welfare guardian for the vulnerable. In the NGO stakeholder interviews and at the national consultation event, many participants mentioned that there were increasing numbers of unreported cases of older people abuse and neglect, especially within families living in poverty or living in rural areas. They felt that there should be separate laws to protect vulnerable groups, especially the older persons, and a formal abuse reporting process.
"We have laws for animals, laws for driving, laws for swearing, and pretty much laws for everything and anything except laws to protect us older people from being abused and left to fend for ourselves when we are old!" -81-year-old resident of Hahake District NGO stakeholders also mentioned that, sometimes, a caregiver is emotionally abused by the older people they care for, or is unable to have sufficient time off to look after his or her own needs. Moreover, some carers have been admitted to the hospital due to injuries caused by the heavy lifting of older people. support for caregivers is important in its own right, and is a way to reduce the stress they endure that might otherwise result in their mistreating the older people under their care.
KIIs with officials from the relevant ministries, including the ministers, indicate that care for older people is considered to be part of the universal social services already provided by the government, so no dedicated legislation is being planned for long-term care (LtC). The respondents understood the need for legislation specifically to protect older people and enforce standards for LTC, but nothing has yet been done.
"The sector needs direction and guidance, so we recommend developing a national strategic plan with strategies that NGOs and government agencies can follow in order to provide proper care for our elders now and into the future." -National consultation group feedback

Perspectives on the increasing Demand for aged Care services
The different perspectives of older persons, their families, and other stakeholders that emerged from the KIIs and focus group discussions (FGDs) conducted for this study are summarized in Table 8.

Questions responses
What is driving the demand for care?
The drivers for demand are • growing older population, • poverty, • cases of abuse and neglect of older people, • lack of support services for older people, and • the breakdown in traditional caregiving for elderly parents due to work opportunities and migration.
Who should be responsible for care services?
• Traditional Tongan culture dictates that adult children and other family members are responsible for the care of their elderly. However, the impacts of emigration, the cash economy, and employment opportunities are challenging that tradition. • Most families want to retain the responsibility for caring for their older members, but they want support from the government in the form of training and advice on caring for them. • Families that are struggling to care for older relatives would prefer that the government take on the responsibility for care services. • Government leaders believe that the responsibility for care rests with each family, in order to maintain local tradition. Government's role would be to provide support services, training, and funding. • The resources required for rest homes and residential facilities, including their personnel, are beyond the government's financial capacity. • NGOs are willing to provide rest homes or residential facilities, given their observations at the grassroots level. Frontline staff members believe that there are acute cases of older people requiring residential support and care. NGOs believe that they have the skills, so the government could partner with them to provide care for the aged. • Private sector representatives have expressed an interest in the future of residential facilities for older people. Participants at the national consultation event conducted for this study discussed the potential of smaller rest homes that could house fewer than six older people, similar to the Good Samaritan House, as they would be easier to fund and manage.
continued on next page 3.4 service Provision Figure 8 shows the elements of the tongan older persons care support system based on the findings of this study. The toulekeleka (elderly person), at the center of the diagram, is supported directly by the family, which includes a wife or husband, adult children, and extended family. They all live within the kolo (village), which is linked to the fonua (nation), because the family has traditional and cultural obligations to both. In the same circle is the church, whose influence is directly felt by all family members. The outer circle represents key support services. Most of the older persons in Tonga continue to rely on family, church, and village for their well-being.
In July 2012, the Asian Development Bank implemented a project with financing from the Japan Fund for Poverty Reduction amounting to T$300,000 ($125,000) per year to design home care services for older persons. 34 The project was known as the Tonga Social Service Pilot (TSSP), and it targeted 140 older persons aged 65 years and over in rural and remote villages in Tongatapu and Ha'apai. The pilot has since been rolled out as the national aged care service by the Ma'a Fafine mo e Famili organization, serving 190 older persons with the highest needs based on their assessments. The total annual cost of the home care service is T$500,000 ($208,000), funded directly by the government through the Ministry of Internal Affairs. 35 Other services that support the older persons are limited to a few NGOs and the national health system. Older people in outer island communities struggle to access much-needed services, and are thus at risk when they are unwell or disabled. There are no dementia-specific support services for the older persons and their families, and this is a major concern in terms of service gaps for older people. There are no official data available about the unmet needs of older people. KIIs, FGDs, and discussions at the national consultation event highlighted a concern that the care needs of many older people were not being met.

Questions responses
What needs to be done? Stakeholders from all sectors agreed on the following points: • Aged care services are needed in Tonga.
• The standard of care needs to match international levels.
• A quality accreditation system is needed for future care providers.
• Training for family caregivers, as well as potential paid care workers, is necessary.
• There is a need for more age-specific services in the areas of health, legal assistance, housing, transport, public amenities, and social protection. • Sufficient resources need to be allocated to aged care services.
• Community centers for older people should be established in villages or regions, and they should offer activities. • Coordination services are essential.
Why are better LTC services needed?
Better LTC services are needed to • improve the quality of life for older people, • provide an environment that enables older persons to participate in all areas of society, and • prepare the nation for an increase in the elderly population. LTC = long-term care, NGO = nongovernment organization.
Source: Interviews with caregivers, older persons, and other key informants conducted for the Tonga country diagnostic study conducted by the Asian Development Bank. Table 9 presents an outline of the services provided, delivery model, and number of people served (where available) for every type of care service for the older persons.
3.4.1 Home Care Visits a tongan ngo, ma'a Fafine mo e Famili, has piloted a donor-funded and government-controlled home care support pilot program. However, the program is only scratching the surface of the care needs in the area it is covering: the main island, Tongatapu, and the Ha'apai island group. In 2017, the program was able to assist only 150 older people with high needs and disabled residents. The program has been evaluated and found to be effective, and the government has increased the budget allocation to roll it out nationwide. In 2019, the program was rolled out, targeting the older persons with the highest level of dependency, reaching 200 people.
The program does not have a formal arrangement with the main hospital, Vaiola Hospital, in Nuku'alofa, so there should be better coordination to ensure that the older persons with high needs can be referred for immediate assistance. The accessing of health care is left to each older person's family to arrange.
one of the requests from the older persons and their family caregivers was for health workers to conduct home visits to older people who are bedridden. The director of health pointed out during an interview that home visits were part of health workers' duties, and that they could accommodate the needs of older persons care. Participants in the national consultation event also aired their views on this matter, asking for more home visits by doctors and nurses to reduce the burden on the older persons and their families.  3.4.2 Lack of a system to Provide assistive Devices and incontinence supplies interviews with ngos and family caregivers identified a lack of assistive devices such as wheelchairs, commodes, walkers, and other support resources throughout tonga. Eyeglasses and hearing aids are hard for older people to obtain because they are not provided as part of the core health services. Those requiring eyeglasses or hearing aids typically wait until the arrival of international teams of volunteer hearing and eyesight specialists, who visit the Kingdom once or twice a year. They normally bring eyeglasses and hearing aids for those in need. In the meantime, older people with vision problems can try their luck with cheap eyeglasses sold at the local stores as a temporary solution, while those with hearing problems must wait for the international specialists. Incontinence supports such as diapers are expensive, and it is up to each family to acquire them.

Dementia and mental Health Problems
Currently, there are limited services available for persons with dementia. In some cases, families use the hospital, especially the psychiatric unit, as a respite facility when they can no longer cope with caring for their family member. The psychiatric unit has several full-time older patients in its care. These patients are bathed, fed, helped with toileting, helped with walking, and provided with medication. This care is provided on a temporary, respite basis. The psychiatric unit, and the hospital as a whole, is not equipped to provide LTC, so every effort is made to return patients to their families.
efforts are being made by the mental Health Directorate to establish a separate housing facility that would provide care and protection to persons with dementia and other conditions. The Vaiola Hospital Psychiatric Unit hopes to establish this facility to protect older patients, depending on government funding approval. Two older patients were recently confirmed to have died due to injuries from assaults at a hospital psychiatric ward. This situation was discussed at the national consultation event, with many NGO staff members and older persons advocates demanding urgent action by the government to build a separate ward for older people, to prevent further deaths and harm. This message has been passed directly to the Ministry of Internal Affairs.
"This is a national shame knowing older people with dementia are being housed at the psychiatric ward, which has caused two confirmed deaths by assault and various beatings by mental health patients. We demand action and that a ward for older people be built immediately!" -The head of a health-related NGO at the national consultation event There are no community-based services specifically supporting persons with dementia and their caregivers.

respite Care
there is no dedicated LtC respite center for temporary relief or for help in emergency situations. Families use the hospital or the hospital psychiatric unit when they have emergencies; but, clearly, this solution is inadequate, as these facilities do not provide services designed specifically for older people.

neglect and abandonment
Hospital health workers have had to look after older people patients abandoned by their families. Some older people are abandoned and receive no help or visitors from their families. Patients are required to bring bedding and other supplies when staying at a hospital, but some families think that it is the state's responsibility to care for older people. Health workers have witnessed family members abuse older family members and take their benefit payments without visiting them at the hospital. These cases put extra pressure on the health system and also highlight the breakdown in the cultural practice of looking after older people.
3.4.6 gender Considerations in the Provision of Care the interviews conducted for this study, as well as discussions at the national consultation event, identified the different care needs of men and women that have emerged as a result of tongan cultural practices.
Family provision of personal care and social care is typically undertaken by women and girls, which may affect school participation or engagement in the paid workforce. However, older women wanted to be cared for by women care workers only, and older men preferred men, especially if they required bathing support. Some family caregivers find it culturally inappropriate to bathe their parents but, as the only caregivers, they have to do it.
One law enforcement officer who was linked to an NGO talked about the need to consider the fact that women are at a greater risk of sexual abuse. There have been incidents in the past where this has occurred. There is also a need to bear in mind that men can be more difficult to care for if they become aggressive.
"We have had cases of older people being sexually assaulted, and the risk to older women is high, especially if they are also suffering [from] dementia." -Law enforcement officer at present, no official data have been collected on neglect and abuse cases involving older people. Participants at the national consultation event recommended that new laws be developed to protect older people from all forms of abuse and neglect.

residential Care
Stakeholders had interesting views on residential care homes. the majority believed that the place for older persons care is in the family home, and not at residential care homes. There seems to be a stigma attached to having "outsiders" care for parents, and this is even more pronounced if the parents are moved to residential care. This is regarded by some families as culturally wrong, and as something that brings shame to the family. However, there is a demand for residential home care facilities in some form. The government could start by providing a respite center, and then expand to a residential LTC home if there is enough demand and sufficient resources.
Representatives from the private sector were interested in the discussion, and have sought further dialogue. At the same time, wealthier people may prefer residential care-especially if the quality of care is of a high standard-given they can afford to pay for that service for themselves or their parents.
"Some families think the hospital provides a rest home facility for older people. We often get admissions of older people in severe physical and mental conditions, and the family simply [walks] away and [expects] the hospital staff to provide care! Our health system is not geared for that type of service." -Hospital health worker

Knowledge, attitudes, and Beliefs and Practices
The responses from KIIs and FGDs about the knowledge, attitudes, and beliefs and practices regarding LTC services are summarized in Table 10. There are potential opportunities for retirement homes within the next 5-10 years, including small group homes, similar to the Good Samaritan House, that cost less and are easier to set up at the community level.

Bureaucrats
They are aware of the need to have better care for older people, especially as the bureaucrats themselves will retire one day.
Many bureaucrats live with their own parents or grandparents, so they understand the level of care required.
They have a positive attitude toward the idea of developing more programs for older people, as many are looking after their parents or grandparents.
They prefer to hire caregivers to look after their parents if they are too busy working. Bureaucrats earning a good salary prefer to hire private caregivers to look after their elderly family members.

National
Nationally, there is an acknowledgment of the plight of older persons and the need for LTC, but there is still a lack of understanding about the extent of the problems around aged care in Tonga.
Many tend to think that older people are fine if they have family, but there are many older persons without the traditional safety net or support due to children moving away.
People have a positive attitude toward the idea of having more activities and events for older people.
There are people in the community who seem to think that it is the government's job to look after older people, and not their families' responsibility.
The most common belief is that older people should be looked after by their own children, which is the normal practice in Tonga.

Regional
In the rural areas and outer islands, there is a good understanding of the plight of older people and the need for LTC, as due to the level of poverty there and the lack of support.
There is a very positive attitude toward the idea of having more activities for older people delivered regionally.
It is considered paramount to maintain the connection between older persons and their families.
continued on next page Group Knowledge Attitudes beliefs and Practices Regional areas would like better coordination and dedicated centers for aged care.
Challenges include finance and finding skilled personnel to deliver LTC that will be sustainable in the long run.
There is support for activities that will promote knowledge transfer between older people and the young.

Families
Families understand the need for better care for their older members.
Families will play a lesser role due to the collapse of the traditional practices (i.e., changes in the role of women).
Traditionally, the home was the only place for women. This has changed, with women now working and being the main breadwinner in some cases.
Family members would often like to receive training to become better caregivers for their older relatives.
They are open to external support if it will provide quality care for their older members.
Families would welcome more activities and events to keep their older members happy.
Adult children want to keep their parents at home, to maintain tradition.
Some families welcome external care workers, while others prefer to do the caregiving themselves.

NGOs
The response of NGO leaders is similar to those of other NGO representatives. For instance, as one said: "I think the government does not see this as a priority. Even though there is a special division for disabilities within the Ministry of Internal Affairs, their function does not spell out anything specifically for older people." a NGO leaders recommended education for families that supported the view that external care workers can be helpful and professional. This will help change families' attitudes against care workers looking after older people.
There is a need for more education campaigns so that the general public, government officials, and decision-makers change their attitude toward aged care.
Stigma is one of the major obstacles. Families think that looking after their own older members is their own responsibility. Consequently, they do not want to let other people take on that responsibility, in the belief that giving up their role as sole caregivers might not be approved by society. LTC = long-term care, NGO = nongovernment organization.
a Key informant interview with the leader of an NGO in Nuku'alofa, 23 May 2017.
Sources: Key informant interviews and focus group discussions.

Long-term Care information system
there is no specific information system for LtC. Older patients in the Ministry of Health facilities have case records stored within the system. The Ma'a Fafine mo e Famili home care program uses a paper-based case management system. At the national consultation event, participants identified the need for the older persons to have personal health records, preferably in a system similar to that used in Samoa. These records could be shared with health-care and social welfare professionals.

Quality management and Innovation
Currently, there is no registration or accreditation process to become an LtC provider, and no quality management system or guidelines for minimum protocols with regard to care practice. Support for caregivers is not formalized, and there is no system in place to provide capacity building or training.
According to the original Design Document of the Tonga Social Service Pilot (TSSP), training would be provided for selected government employees in monitoring and evaluating progress over the life cycles of pilot projects. 36 Monitoring and evaluations are conducted every 6 months and are administered by the Social Protection and Disability Unit, under the Ministry of Internal Affairs. The unit contracted an external provider, the Tongan Women's Crisis Centre, to undertake a formal evaluation of the government-funded Ma'a Fafine mo e Famili home care pilot program, in accordance with the TSSP. The evaluation was based on interviews with care workers, caregivers, and older people, and on observations of the evaluators themselves. The data were analyzed and written in a report by the senior evaluators for consideration by the Ministry of Internal Affairs.
The national consultation event recommended the establishment of a formal LTC quality-management system and the designation of training as a top priority.

Human resources
Formal LtC for older persons is a new concept in tonga, and qualified personnel are scarce. Internationally, Tongan caregivers are known to work in Australia, New Zealand, and the United States. Training and education will be critical for the LTC system in Tonga, however. A sector-wide workforce development plan is needed as part of the national strategic plan.
the Kiis highlighted the desire of family caregivers for formal training to be provided by government.
No support is in place for informal providers and families, but there is a need and demand from families for training. Given Tonga's high unemployment rate, there is a potential supply of people who could be trained as care workers.
nurses and doctors have not been trained in providing care for older persons. During their KIIs, health professionals expressed frustration with families who "dump" older person relatives with dementia or health problems on their hospitals. Interviews with NGO and government stakeholders identified the training of care workers and family caregivers as challenges that needed to be addressed. The national consultation event also highlighted the lack of experience and skills among health professionals and NGOs when it comes to LTC for older persons. Staff skilled in the delivery and management of LTC are required in order to provide a service that is effective. Family carers also highlight their view that they need training. Workers who could be trained to become care workers include primary health-care professionals, health promotion officers, social workers, and teachers. Feedback from participants at the national consultation event identified the need for a government agency dedicated to older persons care training that could become the coordination point; it could also undertake monitoring and evaluation of the sector while leaving service delivery to NGOs.
"We need quality training for care workers and family caregivers provided by specialist training organizations in the field of long-term care. This is what government could do, while NGOs focus on service delivery." -Service provider leader at the national consultation event Table 11 outlines the roles, tasks, and qualifications needed for the LTC sector.  ma'a Fafine mo e Famili employs 73 women care workers, aged 30-50 years, providing care to 200 older people and others with disabilities. They receive on-the-job training, but do not have formal qualifications. They have job descriptions, but are not accredited. They earn T$4.50 per hour, similar to that of junior public servants with limited qualifications. The workers say that they enjoy their role, and the turnover of staff is low. They are very passionate about their roles because of the positive impact they have on their older clients.
the good samaritan House residential facility has one manager and two women volunteer caregivers-without formal qualifications, job descriptions, or accreditation-for the facility's five residents. The Mango Tree Centre has four volunteers (two men and two women), including a qualified physiotherapist, and serves 10-12 older people.
informal care workers hired by individual households to look after an older person earn t$3.00 per hour. Working conditions are difficult, as carers also clean rooms, prepare meals, wash clothes, wash and bathe the client, and keep the client company for the day. The conditions can be challenging, with some of the homes in poor condition. 3.6.1 Workforce management management of the workforce is the responsibility of each private service provider, ngo, or government agency. When family members seeking support contact the Ma'a Fafine mo e Famili home care center, the manager and team supervisor assess the older person and allocate a care worker. All older and disabled persons are registered. The manager makes monthly on-site visits to observe the performance of the care workers, and reports on the status and quality of the services delivered. The national manager is considering options regarding accredited training programs for care workers in the future.

need for Coordination of services
responses from Kiis with care workers, family caregivers, and older person participants identified a need for the coordination of care, with calls for a government agency that would have a specific role focusing on LTC for the older persons. At present, the Ministry of Internal Affairs is the coordinating agency for all vulnerable groups, including the disabled, poor, unemployed, socially disadvantaged, and older people. The ministry has a Social Protection and Disability Unit, which is currently responsible for old-age and disability care. The unit is small, with a team of four working under a deputy secretary. The KIIs suggested that the unit does not have the personnel to adequately support the initiatives required for LTC. At the national consultation event, participants recommended the establishment of a dedicated agency with appropriate resources.

Financing
3.7.1 tongan economy and national Budget the gross domestic product (gDP) of tonga grew steadily in the 1990s; however, from the mid-2000s, the economy has faced high debt levels, low private sector investment, and the impact of civil disturbances in 2006 and the global financial crisis in the years that followed. 37 GDP growth has remained below 4% since 2015, and was forecasted to be 0.2% in 2018. The economy is based on subsistence farming, a small but growing tourism sector, and an underdeveloped fishing industry. Farmers grow cash crops for export to Asia on a small scale, with squash, kava, and other niche produce replacing the traditional copra and banana products. The nation's main source of foreign income is remittances from Tongans living abroad. Tonga has the fourth-highest percentage of GDP from remittances globally, and is the most remittance-dependent country in the Pacific, with remittances accounting for 27.9% of its GDP, compared with Samoa's 17.6% and Tuvalu's 10.7%. 38 the short-term hiring of tongan laborers by new Zealand and australian farmers under the seasonal employment scheme is boosting remittances and supporting hundreds of poor families throughout the Kingdom. The high rate of remittances reflects the close contact maintained by Tongans who migrate overseas. This is a cultural phenomenon that distinguishes the Tongan people from the rest of the Pacific, in terms of the amount of financial support and resources sent back to Tonga to help remaining family members.
the public sector is dominant in social services, with 3,710 employees, while the private sector remains underdeveloped and lacking investment opportunities. The government has initiated a number of economic and public sector reform programs since the early 2000s to improve public services, encourage private sector-led growth, and modernize the taxation system. 39 the government's budget for 2020 was estimated at $152 million, with 60% sourced from taxation and other domestic income and 40% from in-kind contributions and donor aid. scheme, employees contributed 5% to the fund, matched by 5% from the employer. After the first 5 years, the employers' contribution increased to 7.5% while the employees' contribution remains at 5%. By 2016, the NRBF had registered 574 employers with 9,596 employees, of which 3,710 were public servants. It is estimated that 28% of the labor force are registered in the scheme. All public and private sector employees, including employees of NGOs, are covered under this scheme unless they have an exemption enabling them to implement their own retirement savings scheme. The growth in employee membership is significant, as it indicates the importance of preparing for retirement. Those participating in the retirement savings scheme could, on an individual basis, use their pension for LTC if required.

social Welfare scheme for older Persons
in 2018, a total of 4,105 older people aged 70 and above were eligible to claim benefits under the social Welfare scheme for the elderly (Figure 10). The eligibility age has since been lowered to 70, and payments have increased from T$65 ($27) per month to T$71.28 ($30) for those aged 70-75 years, T$76.39 ($32) per month for those aged 76-79 years, and to T$81.49 ($34) per month for those aged 80 years or older. In 2018, the government paid out a total of T$3.8 million ($1.6 million) to eligible older people. Most of the benefits were paid out in Tongatapu, followed by Vava'u, Ha'apai, and the smaller outer islands. 40 Any older person citizens who receive retirement payments are not eligible to receive social welfare payments.
In the interviews conducted for this study, older tongans said that they were grateful for the social welfare payments under this scheme. they also said that, even though the payments were modest and not sufficient to pay for external LtC support, they had a significant impact on those with no other source of income. Still, older people suggested that the benefit level needs to increase to keep up with rising prices. For older persons with mobility issues, sometimes the payment has to be drawn by caregivers, and some older people expressed concern that the benefit could become part of the normal household budget rather than being reserved for their own needs.

affordability of Long-term
Care services the costs of the existing home care program and the incomes of older people aged 60 and above can be used to model the cost of home-based LtC services. Table 13 highlights the likely incomes of older people aged 60 and above, sourced from the records of either retirement funds or social welfare benefits. The average monthly social welfare benefit payment is based on the age group to which the recipient belongs, while the average monthly retirement payment is based   on a lump sum paid out over a set period-for example, 5 years. The average monthly LTC expenditure is taken from the hourly wage of Ma'a Fafine mo e Famili organization care workers, which is $2.10 per hour.
a service providing 16 hours per month of home care for older persons will cost each client $33.60 (table 13). This is a significant component of an older persons' income.
In Table 13  as part of this country diagnostic study (CDs), the authors did a projection of the costs of health care and social support for older people from 2017 to 2050, using population data from the 2011 Census, Ministry of Health budget data, and financial information from the Social Welfare Scheme for the Elderly. Table 14 shows the projections of health and social welfare costs of support for older persons care, estimated at $2.79 million in 2017. By using the health budget percentage changes from 1997 to 2007 and from 2007 to 2017, the authors of this study could spot trends in the costs and likely budget changes. Based on the shifts from year to year, they were able to estimate the likely social welfare and health costs for Tonga by 2033 and 2050. As a result of this analysis, they found that the Ministry of Health budget is likely to rise significantly due to population growth and the impact of noncommunicable diseases. This will push the budget up to at least $48 million by 2033, and to $95 million by 2050. Based on this model, the authors estimated that the number of older patients in the health system will grow in proportion to their size in the population. A conservative estimate, based on the growth of the older persons population, suggested that Tonga's health budget for older patients was projected to increase from $1.4 million in 2017 to about $16 million by 2033, and then to $40 million by 2050. The projections for social welfare costs were based on the assumption that governments would address the needs of older people by increasing benefit payments nationally to reduce poverty. This policy has proven to be popular, and so is likely to continue. Current government expenditure on older people represents 1% of the total annual budget. However, this is projected to increase to 10% by 2033 and 12% by 2050. These increases will have major policy implications for future governments in Tonga.

Projected Costs for older Persons Care
A model of cost projections for older persons care services, with three scenarios based on different levels of need for support, is shown in Table 15. This model assumes that 10% of older people (aged 60 and over), using the total older population of 8,881 in 2017, require care, and that the average hourly wage of a care worker is $2.10. The three scenarios are defined as follows: • low level of support, for which the government provides an average of 4 hours of home care per week, 52 weeks a year, for an annual total of 208 hours; • medium level of support, for which the government provides an average of 8 hours of home care per week, 52 weeks a year, for an annual total of 416 hours; and • high level of support, for which the government provides an average of 16 hours of home care per week, 52 weeks a year, for an annual total of 832 hours.   1. It is assumed here that 10% of the total older persons population, which was 8,881 in 2017, required some level of care support, so the number used was 888. 2. The cost of care was calculated based on the assumption that the hourly wage for caregiver services was $2.10.
Source: Authors' estimates based on interviews with caregivers and representatives of civil society organizations.
The scenarios presented in Tables 15 and 16 highlight the financial demands of providing older persons care, and the fact that the cost is dependent on the number of care hours provided. The social welfare benefits and retirement earnings for older people may not cover adequate care, so other forms of funding may be needed in order to provide a sustainable and affordable service.

Policy implications
the preceding analysis provides some incentive for policy makers to establish an older persons care system in tonga, not only to support older people, but also to ease the overloaded acute care system, a problem highlighted during the interviews and at the national consultation event. As shown in Table 16, the cost ranges between a low level of care, at $387,878 per year, and a maximum level of care, at over $1.55 million.
It would be helpful for policy makers if the percentage of older people who are in the hospital system for reasons other than acute conditions were quantified. However, that information is not available in Tonga.

Projection Limitations
Important information on the drivers of health and social care costs-such as trends affecting disabilities, the availability of informal and formal support, older persons care take-up rates, and other indicators-has been excluded due to the unavailability of data. The financial projections included in this report aim only to present potential scenarios based on the limited information available to the researchers at the time of the investigation. More accurate projections would require more data that are not yet available.

Funding Considerations in tonga
An appropriate funding system for Tonga must • promote equity by supporting the older persons who cannot afford LTC; • be efficient, targeting resources to those in need; • keep costs within the budget; • gain broad acceptance; • be flexible, with services tailored to the needs of the older persons in various situations; • provide support to family caregivers; and • promote the integration of medical and social services.
Decisions about the financing mix for aged care must take into consideration risk-pooling and ensure that families are not pushed into poverty or kept in poverty because of care provision needs.
With the use of social insurance schemes limited in Tonga, revenue raising for expanding aged care is likely to come from the national budget as the home care scheme is currently funded. Key decisions for the Government of Tonga to determine aged care financing relate to (i) Population coverage and who receives services. What will be the eligibility for care services based on care needs, and will there be age criteria to access care services? (ii) Service coverage. What services can be provided? What services would not be covered by public financing? (iii) Financial coverage. Will services be universal or means-tested based on levels of personal income and assets? Will there be any co-payment for services?
The Projected Costs for Aged Care model in Section 3.7.6 above can be used to model some of the financial implications for these key decisions.

sWot Analysis of the Current older Persons
Care system Table 17 presents an analysis of the strengths, weaknesses, opportunities, and threats (SWOT) of the current system of caring for the dependent older persons. The SWOT analysis was based on findings from the CDS, gap analysis, and on the responses and highlighted issues at the national consultation event. Sources: Interviews with key informants and review of secondary data.

Current Debates on the Development of an older Persons Care system
"The government is committed to aged care, and we see NGOs as our partner in developing a system that is sustainable and effective." -Government representative at the national consultation event the national consultation event confirmed the commitment of stakeholders to working together to provide proper care for the older persons. Leaders from government and NGOs agreed that there was a need for better coordination and collaboration, in order to reform the current older persons care system and to integrate and coordinate health, social services, and NGO services. This would enable the provision of seamless services to older people. There is also increasing recognition that a benefit of having a strategic plan would be a sense of direction on integration, as well as the encouragement of closer relationships between NGOs and government departments. There is also a recognition of the need for a formal monitoring and evaluation process to protect older people by means of accredited quality systems in older persons' homes and residential facilities.
addressing issues related to financing and funding will remain a challenge. But there are opportunities for mixed approaches, with smaller nursing homes and communities collaborating to provide services. The interviews conducted for this study, as well as discussions during the national consultation event, highlighted such priorities as international financial assistance to the government for short-term policy support, the training of specialists, establishment of village centers, and coordination, as well as the importance of adequate funding for NGO providers, so they can have the proper resources and trained staff they need to deliver quality older persons care. This would require a review of the current services, as a first step toward reconfiguring them, and the identification of the best ways to fund services from government revenues and foreign aid. Financing older persons care will require donor agency support, but there are also opportunities in the private sector. One positive prospect: older Tongans living overseas may consider returning to Tonga if quality care and support became available.
the social Welfare scheme for the elderly has been popular, and there is some pressure to further increase monthly payments. The government has signaled its long-term intentions to support highly dependent older persons by raising their monthly benefits, and it may consider additional policies such as making more equipment and resources available. This has now become a political issue for members of Parliament with electoral bases in rural and remote areas.
Public awareness campaign. Older persons care is a new concept, as the care needs of older persons have not been recognized as a serious problem, despite the evidence from this CDS and the national consultation event, which identified the serious situation of the vulnerable older persons in Tonga. Similar recommendations emerged from the CDS and the associated national consultation event, including the idea of launching a public awareness campaign to highlight the problems experienced by older people with functional limitations. Such a campaign would resonate with the core of Tongan society and attract serious attention to the issue of older persons care. Currently, the public has a relaxed attitude toward older people, and "ageism" is evident when discussions are held about national priorities. A public awareness campaign would increase public knowledge of the needs of the older persons, and garner support for the government's efforts to improve the aged care system.
A public awareness campaign could employ a mix of media: (i) radio programs-Leaders of relevant NGOs and other advocates of the older persons could talk about experiences of older persons care throughout the Kingdom. This is a very popular type of program for Tongan communities, and could have special appeal for those with older parents and grandparents in rural and remote areas. (ii) tV programs-They could feature profiles of older people who agreed to share their stories in public. This is quite a common way to create awareness, often used in the health sector. The programming could also feature interviews with NGO leaders and care workers. (iii) newspapers-Stories on older persons care in popular newspapers could include interviews with NGO leaders and care workers.
The following needs and priorities were also identified through the KIIs, FGDs, and at the national consultation event: (i) policy and regulatory development support for the government's efforts to prepare agencies for older persons care; (ii) a formal coordination agency for older persons care; (iii) community centers for older citizens in villages to provide activities, resources, and support; (iv) activity programs, resources, assistive devices, and support for home modifications; (v) respite care services; and (vi) residential care homes constructed by 2025-2030. v. CoNCLUsIoNs AND reCommeNDAtIoNs T he older persons are the keepers of the memory of tonga's long and illustrious history, so their importance to tongan culture is immeasurable. Tongan culture and customs refer to the older persons as the koloa mahu'inga, or most precious family possession. Their memories need to be shared, and the younger generation must be reminded about the value of those memories. The following poem by the late Ma'umatapule describes the importance of taking care of the older persons, who represent Tonga's heritage.
Although there is a strong Tongan tradition of caring for older people within the family, migration out of the country for job opportunities and the growth of the older persons population have created a clear need for care services for older people who have difficulties with ADL and IADL; who lack emotional support; or are at risk of poverty, neglect, and abuse. I long for my voice, still to be heard throughout Tonga.
You and I are still riding the tranquil wave of the sacred shore.
Let us not slacken or relinquish this precious heritage, but let us hold fast to it, for it is still our grand display of sweet-smelling flowers, to waft abroad and throughout Tonga, at all times.
We give thanks, our spiritual heritage is represented by the four golden waistbands: to fix and preserve among Tongans our love and harmony and Christianity.
Oh, blessings of blessings, we still inhabit a land rich in peacefulness and tranquility.
What is it that would ever cause us to challenge each other, to wrangle and fight, using cleverness with a hard shell.
Let us use wisdom with a soft shell, so we can journey steadfastly in a safe and secure land.
This will be like a rich display of many flowers whose beauty and sweetness will extend to countries abroad, in the Pacific, to Europe.
And they will admire our sense of duty, our unity, and our being bound together with one sennit rope.
Poem by the late Ma'umatapule, written at his residence in 1998.
Nima Tapu, Royal Undertaker and Punake (Shumway, 1990s) there is now a window of opportunity to prepare tonga for the growing number of senior citizens. Older persons care has the potential to become a significant sector, and research has highlighted the importance of building local provider capacity, as well as developing quality support systems for older persons. If there are no formal older persons care services, more older people will be admitted to hospitals, which will find it difficult to discharge them without support. The result will be blocked hospital beds and financial costs to the healthcare system. The older people in Tonga also deserve to live with respect, dignity, and company, and have a good quality of life. The government and stakeholders need to work together on a more coordinated approach to older persons care, and to give it a higher priority. This will require a new policy direction, so more resources can be allocated to relevant projects and initiatives.
For the development of a sustainable and equitable older persons care system that will meet the needs of current and future Tongan senior citizens and their families, the authors of this study offer the following recommendations for new policies in various areas.

Aged Care Policy and organization
aged Care national strategic Plan, 2020-2024. On 11 August 2020, the Prime Minister launched the Aged Care National Strategic Plan, 2020-2024. However, Tonga still lacks the legal framework required for LTC that could ensure that the dignity, freedom, and rights of older people are protected.
Legal framework and policy development. The government needs financial support to develop a regulatory framework and policies regarding older persons care. The older persons care legal frameworks of other countries should be reviewed; and relevant government departments should be provided training on older persons care policy making.
Law on the protection of older people. A law on older persons abuse should be proposed, or the government should consider setting up a system to protect older people from abuse-an idea that was highlighted during the interviews and the national consultation event. If the strategy is to have the older persons cared for in their own homes, then they should be protected from any form of abuse, especially by their own caregivers and other family members.
organization for policies and programs. To facilitate an effective development and implementation of policies and programs for older people in Tonga, dedicated organizational units should be set up as follows: (i) A new government agency should be established to coordinate and direct care services for older people. This would include the services provided by the Ministry of Health, the Social Protection and Disability Unit (under the Ministry of Internal Affairs), and NGOs, so that they can integrate their services in order to provide seamless support for older persons. (ii) A dedicated government unit should be established to focus specifically on older persons, given the vulnerability of this population and the future implications of its growth. This unit could become a division, responsible for coordination, policy making, and operational functions regarding older persons, including the older persons care system. (iii) To facilitate coordination, the possibility of an interministerial committee on aging with a secretariat housed under the Ministry of Internal Affairs (as the Prime Minister is the head of this ministry) should be explored. There are similar interministerial committees on aging in many Asian countries, with the responsibility for policy coordination and monitoring.

Aged Care services
Community-level activities and services. Older persons, their families, and service providers believe it is best to care for old people among their families and communities, and that a long-term care (LTC) system should support this approach with home care services and regular social activities at community centers for older people who live in villages. Religious and intergenerational activities are especially important to senior citizens. To enable older people to "age in place," there is a need for affordable assistive devices such as mobile lifting equipment, wheelchairs, walking frames, and incontinence support and supplies. Home modifications and respite care services may also be needed. Older persons in need of care who live alone and lack family caregivers could live in small group homes with a trained resident care worker. Local village councils could play a large role in making this happen.
respondents at the national consultation event supported the idea of establishing "elders' clubs" or "elders' associations" in communities. These facilities have proven successful in Sri Lanka and many other countries, so when the idea was presented at the national consultation event, it generated positive feedback and support, as this would be a vehicle for facilitating more active lives for older persons.
support for informal caregivers. Older persons care provision in Tonga is very limited, and is mainly provided by informal caregivers at home. The national strategic plan should consider how to best support informal and family caregivers, taking into account training programs, information services, respite services, and coordinated support from the health and social sectors. The government should also evaluate the provision of financial supports via the social pension or caregiver allowances.
services for older persons with dementia. There is an urgent need to develop services for people with dementia, whether by establishing residential centers with each a special unit for people with advanced dementia, or by ensuring that health-care and social service staff and families are trained to care for people with dementia. A suggestion from the national consultation event was for a geriatric ward to be developed at the main hospital for dementia patients who cannot be cared for at home. However, the appropriateness of this option should be carefully considered, as hospital care can be expensive. Complex care needs and people with advanced dementia may require institutional care support if the family is unable to safely and adequately provide for the older person. Dementia awareness should be part of the public awareness campaigns.
Prevention of need for older persons care (healthy aging). A life-course approach to healthy aging is necessary for reducing the likelihood that care services will be needed in older age. As there is a high and increasing level of noncommunicable diseases in Tonga, it is important to invest more in health promotion and to work at the community level to promote physical activity and healthy nutrition.

research.
A nationally representative survey is needed to gather quantitative data about older persons, their ability to carry out ADL, their health conditions, and their financial circumstances. Research is also needed on the knowledge, attitudes, and beliefs and practices of older persons and their caregivers.
Private sector. Discussions with representatives of the private sector highlighted the sector's keenness to be involved in older persons care from a commercial as well as cultural responsibility angle. The private sector can play a role in driving the older persons care information system, residential care facilities for those with dementia, research, financing, health promotion to reduce the need for older persons care, advocacy, and awareness raising. There is also the opportunity for government to explore public-private-people partnership models for these initiatives.

Aged Care Human resources
training of care workers. Training courses for care workers and family caregivers need to be developed with a local tertiary provider. This would lift the level of care for older persons and provide opportunities for Tongan care workers locally and overseas. Training should include the identification and prevention of neglect, abandonment, and abuse of senior citizens. The EASY-Care assessment tool-designed for assessing the physical, mental, and social functioning and unmet health and social needs of older people in community settings or primary care-has been trialed and found acceptable in Tonga. 41 telecare. There are possibilities in using technology for telecare or telehealth, especially for the outer islands and rural areas. Mobile phone coverage reaches all areas of the Kingdom. Internet coverage is improving and may present further opportunities for health care. This is worth further investigation.

Aged Care Quality
Quality accreditation system. Due to the lack of older persons care expertise, it is important to develop an accreditation system for future providers of aged care.
older persons care information system. Two key activities to make the use of older persons care information more efficient are • developing an integrated e-health information system for individuals (i.e., an information system for sharing records confidentially between health and social workers), and • developing a system for routine data collection by village councils.

Aged Care Finance
Financing. A plan for financing older persons care services, including staffing and supplies, needs to be developed as part of the government's strategic plan for LTC. This could include government allocations, social welfare benefits, retiree pensions, and contributions from remittances.
Budgetary and staffing limitations. The Social Protection and Disability Unit, under the Ministry of Internal Affairs, is responsible for all the vulnerable groups in the population, including older people and the disabled. However, the unit only has two staff members, a deputy chief executive officer, and a small operational budget. Due to staffing and budgetary limitations, any new projects, including those related to older persons care, should consider providing short-term operational support in terms of staff and resources.

Aged Care Public education
advocacy and awareness raising. Tongan culture strongly supports the notion that adult children are responsible for caring for their aged parents. Receiving help from an external care worker could be construed as a neglect of the children's responsibilities to their parents and could attract ridicule from others in the community. However, the country diagnostic study (CDS) and responses at the national consultation event clearly identify significant issues of aged care that need to be discussed in the public arena. A public debate is needed to create an awareness of the needs of older persons and how to provide better care for them.
role of older people who need older persons care. Older people who need LTC should play a central role in their own care. This "person-centered care" is an important principle for an older persons care system, ensuring that the opinions, preferences, values, and needs of older people and their families are understood and integrated into the system design. This would include person-centered assessment and care planning, user groups, satisfaction surveys, and the provision place and method of choice.
role of healthy older people. Older people with no care needs or with only limited care needs can also be involved as volunteers or paid workers in the planning, delivery, and monitoring of services to dependent older people. Many older people are caregivers for their spouses, siblings, friends, and older-old parents. Older person participants at the national consultation event reflected on their experience in caring for their parents and grandparents. Given their extensive experience in caregiving, the older person participants are a potential resource that should also be included in the service delivery model.  • System needed to provide better LTC for older persons • Support for accreditation system • Support for local training that has international accreditation

APPeNDIX 1 reFLeCtIoNs From KeY INFormANt INtervIeWs AND FoCUs GroUP DIsCUssIoNs
• No quality management system • Need for a system to be developed and provided locally     Section 2 of the New Zealand Crimes Act 1961 identifies the elderly person as a vulnerable adult who must be protected. The act places the duty for care on those living with elderly people, and specifies the following obligations: At home (Crimes Act 1961, ss.151, 195, 195A): • Anyone who is over 18 and who is aware that abuse of a vulnerable adult is occurring in the household they live in, or are a member of the family (whether or not they live there), must take reasonable steps to protect that vulnerable adult from death, serious harm, or sexual assault.
• Caregivers of vulnerable adults must ensure that all the care recipients' basic needs are met and take reasonable steps to protect the care recipient from injury.
In care and residential facilities: • All staff members of any hospital, institution, or residence (such as a rest home) must ensure that a vulnerable adult does not suffer injury, ill health, or any mental disorder due to a major departure from reasonable standards of care.
• If they become aware that a vulnerable adult is being abused, they must take reasonable steps to protect that vulnerable adult from death, serious harm, or sexual assault, or, if they are responsible for the vulnerable adult, injury.
In practical terms, this means that household members and hospital staff must report any serious abuse of vulnerable adults.
The maximum penalty for not taking reasonable steps to protect a vulnerable adult from injury is 10 years in prison. dementia A loss of brain function that affects mental function related to memory impairment, and low level of consciousness and executive function. The most common form of dementia is Alzheimer's disease (National Institute on Aging. What Is Dementia? Symptoms, Types, and Diagnosis).
demographic dividend Refers to a period-usually 20-30 years-when fertility rates fall due to significant reductions in child and infant mortality rates. The proportion of nonproductive dependents reduces and is often accompanied by an extension in average life expectancy that increases the portion of the population that is in the working-age group (A. A. M. Shohag. 2015 Disability may be a cause of dependency, but many disabilities can be managed without frequent human help.
Dependency can be categorized on a scale or in categories with a very small amount of people being considered totally dependent.
dependency ratio The ratio of dependent people (older persons and children) to working-age people (aged 15-64). May be split into old-age dependency ratios and child dependency ratios (B. Mirkin and M. B. Weinberger. 2001. The Demography of Population Ageing).
disability Disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations (WHO definition).
eligibility Entitlement of an individual to access the programs or services funded directly or indirectly by the government. Often determined on the basis of income or severity of dependency. environment All the factors in the extrinsic world that form the context of an individual's life; these include home, communities, and the broader society; within these environments are a range of factors, including the built environment, people and their relationships, attitudes and values, health and social policies, and systems and services (WHO 2015).
environmental hazards Hazards associated with one's living environment, in and outside the home. Hazards may be objective (real, observable) e.g., lack of electricity; or subjective (simply based on perception) e.g., anticipation of risk such as high crime rate in the neighborhood.
evidence based Professional practice that is based on a theoretical body of knowledge, empirically evaluated, and is known to be beneficial and effective for the client.
filial piety The virtue of respect for one's father, elders, and ancestors. In the care context, it relates to the obligation of children to care for their parents, directly and indirectly (through material means).
formal care The divide between formal care and informal care differs between countries.
Generally it is determined based on whether the individuals providing care are paid or unpaid, trained or untrained, and/or organized or unorganized.
Formal care can take place in the home (home help, home care, home nursing), the community (adult day care, respite care), or in residential care (nursing home, residential care home, hospice care).
See: informal care functional ability The health-related attributes that enable people to be and to do what they have reason to value; it is made up of the intrinsic capacity of the individual, relevant environmental characteristics, and the interactions between the individual and these characteristics (WHO 2015).
functioning An umbrella term for body functions, body structures, activities, and participation; it denotes the positive aspects of the interaction between an individual (with a health condition) and that individual's contextual factors (environmental and personal factors) (WHO 2015).
health literacy The skills and information to allow people to better manage and improve their health.
healthy aging The development and maintenance of optimal mental, social, and physical well-being and function in older adults. This is most likely to be achieved when communities are safe, promote health and well-being, and use health services and community programs to prevent or minimize disease (New Mexico Department of Health. Healthy Aging).
Alternatives: active aging healthy life expectancy The average number of years that a person can expect to live in "full health," excluding the years lived in less than full health due to disease and/or injury (WHO definition).

home-and communitybased care
Services that support older persons continue to live in their own homes and communities (National Institute on Aging. Activities that support independence but are not fundamental to survival; including housework, meal preparation, shopping, accounting, medication management, and transportation. integrated care A concept bringing together inputs, delivery, management, and organization of services related to diagnosis, treatment, care, rehabilitation, and health promotion. Reflects a concern to improve patient experience and achieve greater efficiency and value from health delivery systems (O. Gröne (2015): Long-term care is "the activities undertaken by others to ensure that people with or at risk of a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity." out-of-pocket expenditure Payments for goods or services that include (i) direct payments, such as payments for goods or services that are not covered by any form of insurance; (ii) cost sharing, which is a provision of health insurance or third-party payment that requires the individual who is covered to pay part of the cost of the health care received; and (iii) informal payments, such as unofficial payments for goods and services, that should be fully funded from pooled revenue (WHO 2015).
palliative care An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual (WHO definition).
pay-as-you-go A financing model where contributions (through social insurance or specific tax) are collected and then used to pay for current expenditure rather than saved for future expenditure (i.e., not fully funded schemes).
person-centered approach An approach to care that consciously adopts the perspectives of individuals, families, and communities, and sees them as participants as well as beneficiaries of health care and long-term care systems that respond to their needs and preferences in humane and holistic ways; ensuring that people-centered care is delivered requires that people have the education and support they need to make decisions and participate in their own care; it is organized around the health needs and expectations of people rather than diseases (WHO 2015).
personal care Assistance that helps an older person to remain independent. May be provided formally or informally and may be related to (i) activities of daily living; eating, mobility, dressing, grooming, bathing, or personal hygiene; (ii) medication; distribution of medication, administration of medication, or monitoring of medication use; (iii) maintenance or management of the cash resources or other properties of a resident or person in care; or (iv) monitoring of food intake or of adherence to therapeutic diets. rehabilitation A set of measures aimed at individuals who have experienced or are likely to experience disability to assist them in achieving and maintaining optimal functioning when interacting with their environments (WHO 2015).
residential care Refers to a wide range of housing options aimed at older persons; including nursing and care facilities (other than hospitals) and senior housing. Typically for older persons with care needs who require frequent personal care or close access to support.
In some countries, the term residential care is used to cover institutions that essentially provide shelter to people without the economic means or family support to live independently.
See: assisted living resilience The ability to maintain or improve a level of functional ability in the face of adversity through resistance, recovery, or adaptation (WHO 2015). self-care (or selfmanagement) Activities carried out by individuals to promote, maintain, treat, and care for themselves, as well as to engage in making decisions about their health (WHO 2015).
social care Assistance with the activities of daily living (such as personal care, maintaining the home) (WHO 2015).
social pension Noncontributory cash income given to older persons by the government. May be universal (cash income given to all older persons, regardless of their socioeconomic status) or means-tested (solely for the poor and are conditional on the level of income). Some countries use alternate terms such as "old age allowance" or "social assistance," reserving the term "pension" for civil servant pensions and contributory schemes.
transitional care Refers to the coordination and continuity of care during a movement from one care setting to another or to the home.
universal design Broad-spectrum ideas for producing buildings, products, and environments that are inherently accessible to older persons, and to people with and without disabilities. Principles of universal designs are equitable use, flexibility in use, simple and intuitive, perceptible information, tolerance for error, low physical effort, and size and space for approach and use (National Disability Authority.

What is Universal Design).
Alternative: inclusive design