A/HRC/30/43 73. The Independent Expert emphasizes that the assistance provided by family members and communities cannot substitute for States’ obligations to promote and protect all human rights of older persons. She also notes the radical changes some societies are undergoing, such as changes in family patterns or lifestyles, as well as challenges related to migration and urbanization, which need to be taken into account. 74. The institutionalization of care, while it can be the result of an autonomous decision of a person as he or she becomes older, can often take the form of forced institutionalization and compulsory placements, especially when no other forms of care are available for the individual or when relatives are unable or unwilling to provide care. 17 When proper legal and institutional mechanisms and procedures are in place in care settings, thus ensuring freedom of choice and informed consent, older persons in need of care can lead a life with dignity. It is therefore crucial to ensure older persons’ autonomy, in particular when it comes to any decision-making affecting their care. 75. Flexible and open care institutions have been established in several countries in order to avoid such institutionalization, with free provision of medical home care, including administration of medication and infusions. Such services have improved the quality of life of older persons by enabling them to stay at home. 3. Quality control and accessibility 76. Ensuring quality control in care settings is one of the main challenges. It has been pointed out that the office hours of social and health-care services were often anti-social and to the disadvantage of older persons. For example, older persons are often required to arrive early in the morning and queue to receive a number that will correspond to their attendance. Such an approach results in long waits in uncomfortable and even inhumane conditions, with a lack of appropriate assistance that takes into account their specific needs. Associated with this, is the shortage of social and health-care professionals with formal education in geriatrics and gerontology, and with gender and disability-based expertise. 77. Most health-care undergraduate programmes do not include geriatric and gerontology in their curricula, with the result that health-care professionals are not fully trained to help and understand older persons. For older persons who do not have family or community support, having to rely exclusively on formal caregivers without such training or qualifications can make their lives particularly difficult. 78. The fragmentation of care also causes problems owing to the co-existence of many units that are not integrated into the network of services, and which results in hours spent in filling complicated forms to access both social and health-care services and facilities. It also results in poor quality service provision, inefficient use of available resources and low user satisfaction. This may often be due to the lack of coordination between the different levels and places of care, especially in hospitals. Consequently, older users experience a lack of continuity in care, together with a lack of consistency in the provision of services for meeting their needs. 79. Equitable access to health services is another challenge faced by many countries. Care facilities, goods and related services need to be made available, accessible, affordable and acceptable, and be of good quality for all older persons. There is a need to ensure that these all older persons have access to the same services irrespective of the type of care and the place of residence, including in urban, rural and remote areas. In this connection, older persons may require access to transportation, information and communication on carerelated programmes and facilities that meet their requirements and needs. 17 14 See E/2012/51, para. 25.