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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.15 no.spe Ribeirão Preto Sept./Oct. 2007

http://dx.doi.org/10.1590/S0104-11692007000700006 

ORIGINAL ARTICLE

 

The economic survival of long stay institutions for impoverished aged people

 

 

Marion CreutzbergI; Lúcia Hisako Takase GonçalvesII; Emil Albert SobottkaIII

IEnfermeira, Doutor em Gerontologia Biomédica , Professor Adjunto, Vice–Diretor da Faculdade de Enfermagem, Nutrição e Fisioterapia, da Pontifícia Universidade Católica do Rio Grande do Sul, Brasil, e-mail: marionc@pucrs.br
IIEnfermeira, Doutor em Enfermagem, Professor Titular do Departamento de Enfermagem, da Universidade Federal de Santa Catarina, Brasil, e-mail: ltakase@brturbo.com.br
IIISociólogo, Doutor em Sociologia, Professor Adjunto da Faculdade de Filosofia e Ciências Humanas, da Pontifícia Universidade Católica do Rio Grande do Sul, Brasil, e-mail: sobottka@pucrs.br

 

 


ABSTRACT

OBJECTIVE: Identify structural couplings of Retirement Institutions for the Aged (RIA) with the economic system, in order to maintain those institutions that shelter the poor aged in the Brazilian context.
METHOD: Qualitative, exploratory-descriptive study. The data collection was carried out through interviews with seven leading people and eight aged people, analysis of communication of 52 non-profit Brazilian RIAs, both public and private. The content analysis was performed based on the Niklas Luhmann's Systems Theory.
RESULTS: It was verified that in face of the aged scarce resources, a considerable share of the maintenance costs are supported by the institutions themselves, whose search for resources is done by leaders, team, the aged and communities.
CONCLUSIONS: The excessive involvement of these institutions in the elaboration of programs for searching funds can harm the performance of their essential function which is to care for the poor aged.

Descriptors: homes for the aged; aged; geriatrics aging; systems theory; poverty


 

 

INTRODUCTION

In Brazil, impoverished elderly who face the need to turn to a Long Stay Institution for Aged People (LSIAP), have private and public nonprofit institutions as alternatives. Factors like the inexistence and impossibility of affording the costs of alternatives before institutionalization, as well as the few vacancies in nonprofit institutions create a market of (lack of) care to impoverished elderly, and the appearance of often irregular facilities with iatrogenic characteristics, a shocking reality of total abandonment, negligence, violence and abuse(1-3). From the perspective of the necessary qualification of elderly care facilities, the object of this study was determined: the maintenance and survival of LSIAP for impoverished elderly, in the Brazilian context.

Among other functions, LSIAPs should attend elderly "without family ties or conditions to provide their own subsistence, so as to fulfill their needs regarding housing, nutrition, health and social living" or shelter "dependent and/or independent elderly in a condition of social vulnerability"(4). In order to carry out this function, LSIAPs should be organized from an economic viewpoint, becoming involved with economic system operations. This system is focused on the lack of resources, as well as their distribution and the guarantee of fulfilling social system needs. Meeting the needs of aged people living in nonprofit LSIAPs is, for these institutions, a real and constant problem, since they attend low-income people. Thus, LSIAPs are responsible for the large majority of resources needed to maintain the elderly. Hence, institutions have to constantly assure themselves with certain elements to eliminate scarcity(5) and guarantee the care they propose.

 

OBJECTIVE

To identify the structural connections of a Long Stay Institution for Aged People with the economic system in order to maintain institutions that shelter impoverished elderly, in the Brazilian context, observing communications and resonances at the LSIAP.

 

METHOD

This is a qualitative, exploratory-descriptive study, focused on LSIAPs in the Brazilian context, in the urban area, with residents without condition to provide their own subsistence or coming from low-income families. The study comprised institutions regularly recognized as nonprofit LSIAPs, either public or private.

Data collection was carried out by means of interviews, following a script with guiding questions, with seven administrative professionals from different LSIAP internal subsystems and eight elderly residents from three LSIAPs in the metropolitan region of Porto Alegre. In addition, communications produced by 52 LSIAPs and broadcast by the media were observed. These communications expressed the view that organizations had of themselves and social environment expectations.

Data analysis of the observations were based on Niklas Luhmann's(5) functional analysis method. It is an updated formulation of Systems Theory, with applications to social and cultural phenomena, using an interdisciplinary approach. For Luhmann, organized social systems like LSIAPs, can be analyzed by their internal processes and their interdependences with other systems and organizations. These systems are autopoietic and their decisions have a permanent structural connection, through communications, with their surroundings, and can thus stimulate resonances in the systems involved. The data obtained from the transcriptions of the interviews and LSIAP communications was subject to Content Analysis(6). Meaning units, identified in the Content Analysis process, were coded using the letter E for elderly, A for administrators, and LSIAP for institutions, followed by an identification number.

The study was approved by the Review Board at the Pontifical Catholic University of Rio Grande do Sul (PUCRS). LSIAP administrators and resident elderly provided written consent. In addition, the organizations' identities were preserved, concerning the data obtained from LSIAP communications.

 

DATA PRESENTATION AND ANALYSIS

The need for LSIAPs to find ways to supply the economic need of the elderly they shelter is noticed in the elderly' statement:

Here we pay half our salary, which is a minimum salary [U$190]. We can't afford paying U$380 or U$500 every month (E3).

Considering that retirement is the main income source for impoverished elderly(7), the statement evidences the vulnerability institutionalized elderly may be facing, since they do not have conditions to supply their own maintenance cost in these places. The structural connections between LSIAPs and the economic system, in the search to maintain these organizations through the compensation of the scarcity of elderly people's resources, were identified and organized in three categories: "Economic resources for LSIAP maintenance", "Sources of economic resources", "Resources, alternative sources and strategies".

Economic resources for LSIAP maintenance

LSIAPs' relationship with the economic system is that of a debtor, and there is no other way of becoming debt-free than by paying the financial commitments. The economic system has no influence on making or denying payments. For this matter, there are self-regulating programs, which originated from the supply and demand relationship in the market dynamics(5), which converge to determine the maintenance costs of elderly in LSIAPs, as were referenced by the communications.

Our monthly cost today, considering the money we receive and spend, including all our donations, if a fixed price were to be set, it would have to be between U$300.00 and U$350.00, monthly (A4).

The cost of an elderly today for us ranges from U$275.00 to U$300.00 (A3).

Today, an elderly costs, apart from the donations, U$210.00 per month (LSIAP3).

According to the facility's administration, maintaining each elderly person's costs, on the average, U$500.00 (LSIAP52).

An elderly person's monthly cost is determined by all the resources needed to maintain the elderly in the institution, which ranges from food supplies and hygiene material to paying the staff and taxes, as described below. It should be emphasized that the description does not aim to be thorough, but, rather, to identify the indicatives of the dimension of responsibilities with the economic system.

Eating is a daily resource that must be available at the LSIAP, in the quality and quantity appropriate for their residents. In most organizations, meals are processed at the institution. Therefore, they purchase every supply item, perishable and imperishable.

We receive many donations, but not every donation we receive supplies the elderly's needs - so there are expenses with meat, vegetable, and fruit that they need (A2).

Hygiene products are indispensable. These include soap, shampoo, tooth paste and tooth brushes, in addition to geriatric diapers for people with urinary and/or intestinal incontinence, which are very common in these facilities.

We have to buy geriatric diapers, we have elderly in bed (A2).

Just regarding geriatric diapers, there is a need of up to 80 per day (LSIAP3).

Moreover, some people regard geriatric diapers as a luxury item. Nurses have fought real battles to guarantee this item, which, despite generating high costs, gives comfort, especially to elderly, but also provides for the quality and optimization of the staff looking after the elderly with such a need. Environmental hygiene products and laundry items also total a significant monthly toll, and need to be guaranteed so as to maintain environmental safety.

Medications are a high health care cost, especially those not obtained from the Health Secretariat. The institution's commitment in guaranteeing access to therapy, even if that meant having to buy the drug, was evidenced.

Every month, the organization has an expense of twelve thousand Reais only with drugs (LSIAP1).

The staff payroll represents a high percentage of the LSIAPs' monthly expenses, despite the exemption from the employers' legislation duty.

We have many employees, today there are fifty-nine workers, just in nursing we have thirty employees […]. That is one of the highest expenses, our payroll. Actually, we could use even more employees (D3).

The weight of the payroll on the monthly budget is referred to as the explanation for the small number of employees and their low salaries.

...caregivers are paid minimum salaries (LSIAP12).

Regarding water, electricity and gas bills, as well as taxes, there are no such possibilities of exemption, although the LSIAPs have already pursued them.

Because institutions have expenses, they are fixed expenses without exemptions, we pay electricity and water bills, we pay taxes (A6).

The taxes on our electricity bill are similar to those of an industry, who produces and sells something for profit (A3).

It is emphasized that part of philanthropic entities, as well as LSIAPs, might not be included in every type of exemption, since they are only given to entities that meet the requirements by the Instituto Nacional do Seguro Social (INSS) [National Social Security Institute], which include having the Certificado de Entidade Beneficente de Assistência Social (CEAS) [Certification of Social Care Beneficent Entity], given by the Conselho Nacional de Assistência Social (CNAS) [National Social Care Council], in which only 64% of all philanthropic entities were registered in 2004(1).

LSIAPs use a lot of equipment, especially those for self-care, which are generally expensive to buy and maintain.

Type of donations needed: beds, stretchers, bathing chairs, wheel chairs and orthopedic products (LSIAP9).

One of the institution's worst problems was the lack and poor conditions of the wheel chairs (LSIAP26).

Costs with continuous building maintenance, as well as the need for reforms and adjustments, founded on legislation, despite being indispensable, are not the priority. Moreover, in public LSIAPs, this aspect requires long and sometimes unsuccessful negotiations.

Part of the maintenance, very little, is done by the Municipality (A7).

We are always waiting. In fact, our home, with all this time of existence, we try to offer elderly everything they need, with quality, but we don't have the material to reform the building, to paint the rooms, to replace the wood frames, which are infested with termites, the tiles, reform bathrooms, since there are old bathrooms. There is a need for maintenance, changing equipment because of the high use, for example, there are forty people using the same shower once a day (A3).

Due to these needs and the lack of economic resources to meet them, most LSIAPs still do not comply with the standards. This was confirmed by authors(8-10) who studied the structures of different LSIAPs in terms of the legislation, especially Law 810/89(11). Despite the irregularity still present in LSIAPs, literature points at a slow and gradual change in this respect(8-9, 12). Communications referring to constructions reflect the adaptation to legal standards, and also to comply with the elderly's diverse needs, as well as the humanization in the facilities.

The junina fest (folkloric festival in June) coincided with the completion of the revitalization reform that assigned the city's institution the condition of a model in the country's Southern region (LSIAP22).

Installing surround sound in every room in the institution (LSIAP2).

Building a porch so it's easier for elderly to get some sun on the second floor (LSIAP2).

As some administrators well stated, physical area, furniture, equipment, and leisure materials are not secondary. They have an indirect influence on quality of life, and thus determine a higher or lower risk of fractures, for example, or social isolation.

In addition to trying to also include the structure part, providing elderly with adjustments so they can move around, so they have some space that meets their needs (A2).

Having a more comfortable chair to sit on, I think that is what's missing (A1).

In this sense, studies(1,13) have found that the lack of equipments in LSIAPs results in a reduced participation of the elderly in several activities, like watching TV, listening to the radio and to music, either individually or collectively.

Sources of economic resources

In the observation, it was evidenced that public grants and community donations were the sources of resources for LSIAP management.

Generally, nonprofit LSIAPs absorb part or all of the elderly' retirement pay as their form of contributing to the institution's maintenance. This is referred to in literature(10), as well as by the interviewed administrators.

We have a partnership with the elderly who pass us the benefit they receive so we can afford these expenses (D3).

Though this is understood by the elderly, they express a sensation of spoliation. With the Elderly Statute, the possibility of maintaining part of the elderly' income in the LSIAP was legitimized, as long as it is guaranteed that elderly will keep a percentage(14). Literature emphasizes that institutionalized elderly who do not manage their income are not "able to give their opinion about the services"(12) and, for instance, this situation makes it difficult to establish links with reality and remain updated on monetary values. Some of the LSIAP residents do not receive any retirement. They possibly represent the group of extremely impoverished elderly(7). For these cases, LSIAPs forward an application for the Continuous Care Benefit, but only after they complete 65 years of age.

Public LSIAPs are mostly maintained by the municipality's budget. Other LSIAPs recognized and acknowledged as nonprofit organizations usually receive some kind of public grant as a resource. The referred communications express this possibility:

We have a federal grant that is passed to the municipality, of U$20.00 per independent elderly and U$30.00 per dependent elderly. It is a small grant, but it helps us (A2).

Federal and State partnerships are the main resources for maintaining social work (LSIAP2).

LSIAPs sadly express that, in addition to being scarce, public resources are frequently received late. In some situations, public grants are passed to specific projects to expand or reform facilities, purchase equipment and other, approved in government organs. Together, the elderly's income passed to LSIAPs and the public grants do not reach the total need for resources to meet financial commitments:

It is a philanthropic organization maintained with Federal and Municipal grants and residents' benefits, which represent 50% of the monthly budget (LSIAP12).

In this sense, nonprofit LSIAPs strongly depend on donations from the community.

Private nonprofit LSIAPs face many more difficulties to meet their monthly budget, since most resources come from donations and partnerships, or, as they say:

... it is what we have to search for outside (A3).

Donations from the community include those made by individuals, groups and companies. The various individual and group donors are important to maintain the institutions and are constantly encouraged and called to solidarity:

We have the community and we have partners, collaborators, a great amount of contributing partners (A3).

Partnerships with companies require agility in forwarding projects that, sometimes, are not approved. Special emphasis is given to Governmental and Non-Governmental companies from different economic sectors, industry, commerce and services, as well as third sector organizations. The administrator comments:

Today, the search for partnerships is one of the key points. The institution's nurse is paid by a health company. Today we have several partnerships, some companies who pass us the money to use in some project. These partners don't want to simply give us the money, they want to see where and how that money is being used. Some even determine objectives, they supervise, give instructions (A6).

Partnerships with companies are the most disputed by LSIAPs and, as a result of social responsibility programs, possibilities have increased over the last years. With the implementation of social actions, companies, in addition to responding to a new culture based on ethics, understand that they can increase employee productivity and commitment. Moreover, they can guarantee that they will receive greater recognition in the community and market(15). A company chooses a certain LSIAP, depending on the institution's stimuli and respective resonances in the environment, favoring the structural connection with this sector of the economic system. Besides, it is also suggested that support is established based on market and marketing interests, which are very well weighed, so that this partnership can become stronger. Therefore, selection is done through a sense determined by the company and, if the partnership does not respond to the company's expectations, it is abandoned. Philanthropic and care institutions are the largest receivers of resources from companies' social responsibility. Administrators expressed that the sector's participation is still limited.

Alternative sources and strategies

LSIAPs create a wide range of ways to gather funding. One of the resonances of the structural connection with the economic system over the institution is the creation of internal programs to guarantee resources in order to overcome internal and external contingencies as well as economic conditionings. Hence, alternatives are created, strategies are implemented, and internal LSIAP subsystems are encouraged to overcome poverty conditions.

Among the many creative alternatives found by LSIAPs, they make holiday cards, garage sales, parties, beneficent bazaar and show, as well as raffles. Exemplifying:

So we have other alternatives, we have our fairs, which take place four times a year (A3).

They participate in monthly parties at the institution, where the main purpose is to allocate money for improvements. (LSIAP14).

Financial investments and rents are sources stated by the LSIAPs, in addition to partnerships with service rendering companies, who offer their services as an alternative resource. Less common resources also make a difference:

The group [of industry employees] decided to reform the chairs, every Saturday morning, traditionally dedicated to the 5S. The group was also committed to doing the preventive maintenance of the institution's chairs (LSIAP26).

The service aims to avoid animal and vegetable products to enter Brazilian territory. (…) An institution for aged people is included in the list of organizations benefited with merchandise collected [apprehended] at the inspection service (LSIAP44).

One of the reported forms was tax collection on invoices, a program in some States, whose main purpose was to increase revenue. The institutions, despite recognizing the benefit, state some controversies:

It is a good think but it causes some work, we are being supervisors for the government. We have to type so many invoices, one by one, in the system … to receive around one or two thousand reais every three months to supervise for the government… And we also have to account for what we do with that money, we have to send the invoices, prove it (D3).

LSIAPs selected this specific offer as communication for the institution, but understand that its resonance within the system generates a burden, which they are subject to due to the economic conditionings.

These alternatives in the search for resources demonstrate that LSIAPs expect some other system to understand, process and make use of the information they put in the environment, and then provide favorable feedback to this resonance that the communication caused(5). Administrators emphasize the fact that depending on donations is not so simple. Donors should work according to the institution's needs, which states that:

... any charity is not enough (A6).

Therefore, there is a concern for people to know about what happens, that they try to discover how the LSIAP works and what its real needs are, thus collaborating with its adequate function in providing elderly with integral care. In this sense, in addition to being available to offer information directly at the institution, LSIAPs diffuse information within the community, in a specific and detailed way, informing about their needs through fliers, institutional websites and journalistic reports. They also inform the ways people can contribute. The diversity of possibilities was observed, in the sense of facilitating the involvement of different social groups:

Contributions can be made monthly, quarterly, biannually, yearly or sporadically in the following bank accounts (LSIAP3).

It was observed that donors are not permanent. Hence, there is a constant need for obtaining new partners. In addition, LSIAP complexity and new demands to respond to society's expectations require the broadening of resource sources(3). Since the main motivation for partnership and contribution is solidarity, it should be positively explored, accompanied by clarifications and a new view regarding LSIAPs, seeking solidarity with senior citizens. Hence, through reports showing the institution, the organizations guarantee communication as well as the renewal of donors. In fact, many actions are only possible thanks to the solidarity of the community, people, groups, companies and education institutions.

Aware that their own maintenance depends mostly on the institution, resident elderly follow, closely, actions of seeking and receiving donations:

They make donations, the community comes to visit and brings donations (E3).

Professional teams should also be involved in the process of obtaining resources. However, the concern in guaranteeing resources is so large that it ends up being criticized even by the institution's professionals. They understand that the priority given to obtaining funding and saving puts planning the necessary investments for the elderly's wellbeing in the second place:

I see that this institution is too concerned about obtaining funding. Because I know it's important, I know it's important for the support (A1).

I see that elderly, their needs are left aside, I think they deserve at least more comfort (A1).

It was observed that giving priority to investment in elderly's wellbeing depends on the management's perspective on elderly needs, from a geriatric point of view(3,12).

 

FINAL CONSIDERATIONS

In view of the impoverishment of elderly living in nonprofit LSIAPs, public or private, it was observed that there are innumerable requirements for these institutions' structural connection with the economic system: on the one hand, determining the needs of LSIAP internal subsystems, nursing care, nutrition, leisure and wellbeing, among others; on the other hand, the needs resulting from the partial social systems, such as work legislation and the Standards for Elderly Care Service Functioning. The economic system conditions the payment processes which, consequently, when selected as information by the LSIAPs, determine the institutions' involvement in the constant search for resource sources.

Elderly, supported by the Elderly Statute, expressed the desire to receive and manage part of their income. This aspect from the internal subsystem should be taken into consideration by LSIAPs when making decisions about using these resources, which also contribute to maintaining the institutions. Impoverished elderly, in view of hospitalization, become vulnerable to the spoliation of their few resources.

Receiving public grants depends on successful communication in the structural connections between the LSIAP and the political partial social system. Among the donations from the community, partnerships with companies are much welcomed and their expansion is determined by the constant encouragement of the LSIAP in the environment. Resources from alternative sources equally represent resonances in the surroundings, based on information delivered by the LSIAP, which should change the culture that any donation is suitable to overcome poverty.

It is essential to continuously outline internal programs with a view to making communications understood in the surroundings and revert into financial resources for the LSIAP. However, the efforts to ensure these results should not add risks or put programs of integral care to elderly in the second place. The needs evidenced by subsystems responsible for direct care cannot be ignored and demand new investments or budget adjustments. Plans regarding both the guarantee of sustainability and investment in function quality reinforce the evident need to develop new management models for LSIAPs that shelter impoverished elderly, founded on geriatric principles.

 

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Recebido em: 6.5.2007
Aprovado em: 24.8.2007

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