Grey matter: ageing in developing countries
2012; Elsevier BV; Volume: 379; Issue: 9823 Linguagem: Inglês
10.1016/s0140-6736(12)60541-8
ISSN1474-547X
Autores Tópico(s)Global Health Care Issues
ResumoThe proportion of older people is increasing in almost every country of the world but, by 2050, most will live in developing nations. Are they prepared for the demographic shift? Priya Shetty reports.The developing world is going grey. By 2050, one in five people in poor nations will be over 60 years old. Falling fertility rates, and increased life expectancy from improvements in health care, especially in Asia, has led to a rapidly ageing population. In part, this reflects a worldwide trend—in the next 5 years, for the first time ever, the number of people aged 65 years and older will outnumber children younger than 5 years of age.But we are set to witness a seismic demographic shift of ageing to the developing world. By 2050, 80% of the 2 billion elderly people on this planet will live in the developing world (table, figure). Countries in Asia are set to see some of the biggest rises—by 2050, one in four Asians will be older than 60 years of age. Yet even countries in sub-Saharan Africa, where fertility and mortality (both of which keep a population young) are still high, “the number of people aged over 60 is set to triple from 53 million in 2009 to 150 million by 2050”, says Sebastiana Kalula, director of the International Longevity Centre, University of Cape Town, South Africa.TableThe speed of population ageing in selected countriesYear in which 7% of population is aged 60 years and olderYear in which 14% of population is aged 60 years and olderNumber of years required to double the elderly share from 7% to 14%China2001202726Japan1970199424Republic of Korea2000202121Indonesia2019204223Malaysia2018204628Philippines2026205125Singapore1999201718Thailand2011203120Mexico2016203822France18641979115Germany1932197240Sweden1887197285United Kingdom1929197647Copyright: Population Ageing and Development, UNFPA. Open table in a new tab The health systems of many developing countries have over the past two decades been engaged in a precarious juggling act, trying to balance the fight against the existing burden of infectious diseases with the growing epidemic of chronic diseases such as heart disease and diabetes. For many in low-resource countries, longevity comes with a cruel twist. An increasingly ageing population is bringing a new tide of illness associated with old age, such as dementia and Alzheimer's disease.Clearly, the problems of old age are not confined to the developing world. In even the richest countries, elderly people must face ailing health, and the fact that they may not be physically independent, but many developed countries have policies in place for their care, even though these are far from perfect. Yet, blindsided by battling diseases in youth and middle age, many developing countries are simply unprepared for the fact that in just two decades, they will have a large number of people whose health needs will not be adequately met.This looming threat to the health and wellbeing of millions is starting to stir the global health community. WHO has devoted this year's World Health Day (April 7) to ageing, especially in low-resource countries, with an emphasis on improving the quality of life, as well as health, of older people. In line with this notion of healthy ageing, Anand Grover, the UN Special Rapporteur on the Right to Health, submitted a report last September on the importance of a rights-based approach to health care of older people to the Human Rights Council in Geneva, which called for countries to work towards “active and dignified ageing, which is planned and supported just like any other stage of the individual's life course”.Ageing should have been on the global health agenda long ago, says, Jose Guzman, chief of the Population and Development Branch, UN Population Fund (UNFPA), but instead there has been a massive disconnect between the Millennium Development Goals (MDGs) and ageing, he says. Arguably, the MDGs were defined before the 2002 Madrid Plan of Action on Ageing, which UN members signed to galvanise policy making to anticipate the needs of the ageing population, but even in post-MDG discussions, “ageing is not there”.This message is also taking a long time to filter through to countries, says Kalula. Despite signing up to the Madrid plan, “ageing does not feature highly on sub-Saharan governments' policy agendas”, she says.Karen Hardee, a social demographer and a senior visiting fellow at the Population Reference Bureau, Washington, DC, USA, recalls living in China in the 1970s. Demographers had warned China of the ageing crisis they would face, she says, but the country fully believed that by the time the population aged substantially, they would be rich enough to take care of their older citizens. “Fast forward 30 years, and a leading Chinese demographer on ageing says ‘China has no idea how it's going to pay for its elderly. So, no, countries are not prepared.’”Hardee, who is an expert in maternal and reproductive health, was in Afghanistan recently, reviewing gender policy for the ministry of health, and says that “ageing is just not in there”. Tight resources obviously play a big part, and conflict-ridden countries especially feel that “that's a problem we'll have to deal with later down the line”, says Hardee.Even when plans have been put in place, they are largely inadequate. In 1999, India set up a National Policy on Older Persons to ensure financial security for this group, under which people aged 65 years or older, and below the poverty line, are eligible for a monthly pension. However, Tannistha Samanta, who researches ageing at the Indian Institute of Technology, Gujarat, India, says a major criticism of the scheme is that it uses unrealistically low poverty lines, which means that “many people who deserve assistance are left out”. In addition, the amount of the pension—just Rs200 or US$4 a month—is too low to meet the basic needs of older people.Developing countries are fast running out of time to implement adequate policy solutions to cope with their ageing populations, however, and the cracks are already starting to show.A root cause for the seeming nonchalance with which governments of developing countries are responding to the ageing crisis seems to be the assumption that in countries in Africa, Asia, and Latin America, where family units are still fairly cohesive compared with the USA or Europe, families, rather than governments, can—and should—shoulder the burden of care for older people. This view is true to some extent, says Kalula. “African people have traditionally enjoyed strong community and family support networks in which older people were well looked after in multigenerational, extended family households.”Samanta agrees that “it is well known that many developing countries are characterised by filial piety and a strong sense of obligation towards parents”.But increasingly in developing countries, this filial responsibility is not just culturally expected, it is often legally mandated, she says. For instance, India's 2007 Maintenance and Welfare of Parents and Senior Citizens Act, requires that adult children who neglect their parents, either by refusing to make provisions for their care, or by inadequately caring for them in their homes, can be jailed for up to 3 months or a fine of Rs5000 (about US$110) or both. Tribunals have been set up so that older people can take their own children to court to demand maintenance of up to Rs10 000 (about $220) a month. Similar laws exist in Singapore and China.Though Samanta acknowledges that these laws can seem draconian, she says there could be an argument for them given “the severe lack of institutional support in terms of social security and pension schemes, as well as government funded elderly infrastructure such as old age homes and geriatric clinics”.Cultural nuances also come into play. In countries where people expect their children to look after them, the evidence is that they do better when living with their families. “Demographic and sociological literature from the developing world including China, Taiwan, Egypt, and Tunisia have consistently demonstrated that older people fare better in terms of health when they live with their children in multigenerational families than when they live on their own”, says Samanta, adding that her research in India confirms these findings.There is a problem with this model, however. First, it does not take into account the capacity of family carers. “If the elderly person is chronically ill and requires specialised care, this can be a significant drain on families' financial resources”, says Samanta. It also does not take into account women's role in contemporary society. “In India, where women are typically expected to be primary caregivers, paid employment can be particularly challenging for women who have to now struggle to balance both work and family lives.”China's one-child policy, meanwhile, means that there's only one individual per family to take on the responsibilty of looking after both parents, points out UNFPA's Jose Guzman.Second, the same economic progress that is leading to better life expectancies is also leading to increased urbanisation and migration. By 2030, Asia and Africa are projected to double their urban populations from 1·7 billion in 2000 to 3·4 billion in 2030, according to the UNFPA. Increasing urbanisation means that people who live several hundred miles away from their parents simply cannot provide care, says Hardee, and increased migration to other countries over the past few decades means that the younger generation may not even live in the same country as their parents. “Developing world governments may be living in a bit of a fantasy if they think all families can look after their elderly”, she says.The trend for grandparent carers is making the situation even harder, says Kalula. An uncertain employment environment means that people are more likely to migrate for work, or work much longer hours, which can mean that they leave their children in the care of their grandparents. This means that rather than enjoying their retirement, or being cared for, “older people have increasingly become care providers. Older women in particular are becoming overwhelmed with care responsibilities, and concern for their well-being and vulnerability is increasing.”This gender dimension is a crucial one. According to the UNFPA, there will be a massive spike in the number of people who are aged 80 years or older—from 86 million in 2005 to 402 million in 2050. By 2050, most of these 80-year-olds will live in the developing world, and most of these will be women. Women live longer than men worldwide, and this gender bias is not specific to low-income countries, but in developing nations, they can have less autonomy and less financial independence than in more developed nations.According to data from Irudaya Rajan, Center for Development Studies, Trivandrum, and his colleagues, 61% of elderly women, compared with 45% of elderly men, are fully dependent on others for basics such as food, clothing, and health care, says Samanta.Despite these warning signs, ageing simply does not feature in women's health, says Karen Hardee. Much of the world, especially the USA, is still “battling for reproductive rights and contraceptive access”.That the burden of elderly care weighs heavily on families is true the world over, says John Haaga, at the National Institute on Aging, Bethesda, MA, USA. “The idea that rich countries don't rely on family support, and developing countries do, is quite misleading”, he says. Haaga adds that “families are the main providers of care for the disabled elderly everywhere. The nursing home population in the US has actually declined as a percentage of the elderly for some years now.”The difference being that in developed countries, many people have pension plans that allow them to finance their old age, and not have to rely solely on their families or on the state. Governments that depend on families to care for the elderly ignores the “growing crisis of long-term care outside hospitals”, says Haaga. In China, for example, “the long-term care needs in China are a big concern and they really need improved but affordable models of home health services, and eventually, residential care as well.”Ageing issues will affect women more than men in the future, say expertsView Large Image Copyright © 2012 AP Zackary Canepari/PanosThe complacency towards ageing in developing countries is reflected in how health systems cater to older people, says Guzman. “In Chile, there are only about six geriatricians in the whole country.” Health-care professionals in countries that have not traditionally had to deal with ageing will also need to change their perspectives, he says, so that doctors do not dismiss age-related disease as “normal and just part of life”.Developing countries will need to devise health policies for long-term care, and fast, says Haaga. “The countries now rapidly ageing have a brief window of opportunity to get these policies right for a new population age structure. They should learn from [rich countries] mainly what not to do. Fortunately, there is a lot of policy experimentation going on so there is no reason to believe they will not manage ageing at a rapid pace.”“We need to create societies with a social protection system that allows people to contribute during their working life and have a pension at the end of that life. If we don't have that, it doesn't matter what type of family support you have.” The proportion of older people is increasing in almost every country of the world but, by 2050, most will live in developing nations. Are they prepared for the demographic shift? Priya Shetty reports. The developing world is going grey. By 2050, one in five people in poor nations will be over 60 years old. Falling fertility rates, and increased life expectancy from improvements in health care, especially in Asia, has led to a rapidly ageing population. In part, this reflects a worldwide trend—in the next 5 years, for the first time ever, the number of people aged 65 years and older will outnumber children younger than 5 years of age. But we are set to witness a seismic demographic shift of ageing to the developing world. By 2050, 80% of the 2 billion elderly people on this planet will live in the developing world (table, figure). Countries in Asia are set to see some of the biggest rises—by 2050, one in four Asians will be older than 60 years of age. Yet even countries in sub-Saharan Africa, where fertility and mortality (both of which keep a population young) are still high, “the number of people aged over 60 is set to triple from 53 million in 2009 to 150 million by 2050”, says Sebastiana Kalula, director of the International Longevity Centre, University of Cape Town, South Africa. Copyright: Population Ageing and Development, UNFPA. The health systems of many developing countries have over the past two decades been engaged in a precarious juggling act, trying to balance the fight against the existing burden of infectious diseases with the growing epidemic of chronic diseases such as heart disease and diabetes. For many in low-resource countries, longevity comes with a cruel twist. An increasingly ageing population is bringing a new tide of illness associated with old age, such as dementia and Alzheimer's disease. Clearly, the problems of old age are not confined to the developing world. In even the richest countries, elderly people must face ailing health, and the fact that they may not be physically independent, but many developed countries have policies in place for their care, even though these are far from perfect. Yet, blindsided by battling diseases in youth and middle age, many developing countries are simply unprepared for the fact that in just two decades, they will have a large number of people whose health needs will not be adequately met. This looming threat to the health and wellbeing of millions is starting to stir the global health community. WHO has devoted this year's World Health Day (April 7) to ageing, especially in low-resource countries, with an emphasis on improving the quality of life, as well as health, of older people. In line with this notion of healthy ageing, Anand Grover, the UN Special Rapporteur on the Right to Health, submitted a report last September on the importance of a rights-based approach to health care of older people to the Human Rights Council in Geneva, which called for countries to work towards “active and dignified ageing, which is planned and supported just like any other stage of the individual's life course”. Ageing should have been on the global health agenda long ago, says, Jose Guzman, chief of the Population and Development Branch, UN Population Fund (UNFPA), but instead there has been a massive disconnect between the Millennium Development Goals (MDGs) and ageing, he says. Arguably, the MDGs were defined before the 2002 Madrid Plan of Action on Ageing, which UN members signed to galvanise policy making to anticipate the needs of the ageing population, but even in post-MDG discussions, “ageing is not there”. This message is also taking a long time to filter through to countries, says Kalula. Despite signing up to the Madrid plan, “ageing does not feature highly on sub-Saharan governments' policy agendas”, she says. Karen Hardee, a social demographer and a senior visiting fellow at the Population Reference Bureau, Washington, DC, USA, recalls living in China in the 1970s. Demographers had warned China of the ageing crisis they would face, she says, but the country fully believed that by the time the population aged substantially, they would be rich enough to take care of their older citizens. “Fast forward 30 years, and a leading Chinese demographer on ageing says ‘China has no idea how it's going to pay for its elderly. So, no, countries are not prepared.’” Hardee, who is an expert in maternal and reproductive health, was in Afghanistan recently, reviewing gender policy for the ministry of health, and says that “ageing is just not in there”. Tight resources obviously play a big part, and conflict-ridden countries especially feel that “that's a problem we'll have to deal with later down the line”, says Hardee. Even when plans have been put in place, they are largely inadequate. In 1999, India set up a National Policy on Older Persons to ensure financial security for this group, under which people aged 65 years or older, and below the poverty line, are eligible for a monthly pension. However, Tannistha Samanta, who researches ageing at the Indian Institute of Technology, Gujarat, India, says a major criticism of the scheme is that it uses unrealistically low poverty lines, which means that “many people who deserve assistance are left out”. In addition, the amount of the pension—just Rs200 or US$4 a month—is too low to meet the basic needs of older people. Developing countries are fast running out of time to implement adequate policy solutions to cope with their ageing populations, however, and the cracks are already starting to show. A root cause for the seeming nonchalance with which governments of developing countries are responding to the ageing crisis seems to be the assumption that in countries in Africa, Asia, and Latin America, where family units are still fairly cohesive compared with the USA or Europe, families, rather than governments, can—and should—shoulder the burden of care for older people. This view is true to some extent, says Kalula. “African people have traditionally enjoyed strong community and family support networks in which older people were well looked after in multigenerational, extended family households.” Samanta agrees that “it is well known that many developing countries are characterised by filial piety and a strong sense of obligation towards parents”. But increasingly in developing countries, this filial responsibility is not just culturally expected, it is often legally mandated, she says. For instance, India's 2007 Maintenance and Welfare of Parents and Senior Citizens Act, requires that adult children who neglect their parents, either by refusing to make provisions for their care, or by inadequately caring for them in their homes, can be jailed for up to 3 months or a fine of Rs5000 (about US$110) or both. Tribunals have been set up so that older people can take their own children to court to demand maintenance of up to Rs10 000 (about $220) a month. Similar laws exist in Singapore and China. Though Samanta acknowledges that these laws can seem draconian, she says there could be an argument for them given “the severe lack of institutional support in terms of social security and pension schemes, as well as government funded elderly infrastructure such as old age homes and geriatric clinics”. Cultural nuances also come into play. In countries where people expect their children to look after them, the evidence is that they do better when living with their families. “Demographic and sociological literature from the developing world including China, Taiwan, Egypt, and Tunisia have consistently demonstrated that older people fare better in terms of health when they live with their children in multigenerational families than when they live on their own”, says Samanta, adding that her research in India confirms these findings. There is a problem with this model, however. First, it does not take into account the capacity of family carers. “If the elderly person is chronically ill and requires specialised care, this can be a significant drain on families' financial resources”, says Samanta. It also does not take into account women's role in contemporary society. “In India, where women are typically expected to be primary caregivers, paid employment can be particularly challenging for women who have to now struggle to balance both work and family lives.” China's one-child policy, meanwhile, means that there's only one individual per family to take on the responsibilty of looking after both parents, points out UNFPA's Jose Guzman. Second, the same economic progress that is leading to better life expectancies is also leading to increased urbanisation and migration. By 2030, Asia and Africa are projected to double their urban populations from 1·7 billion in 2000 to 3·4 billion in 2030, according to the UNFPA. Increasing urbanisation means that people who live several hundred miles away from their parents simply cannot provide care, says Hardee, and increased migration to other countries over the past few decades means that the younger generation may not even live in the same country as their parents. “Developing world governments may be living in a bit of a fantasy if they think all families can look after their elderly”, she says. The trend for grandparent carers is making the situation even harder, says Kalula. An uncertain employment environment means that people are more likely to migrate for work, or work much longer hours, which can mean that they leave their children in the care of their grandparents. This means that rather than enjoying their retirement, or being cared for, “older people have increasingly become care providers. Older women in particular are becoming overwhelmed with care responsibilities, and concern for their well-being and vulnerability is increasing.” This gender dimension is a crucial one. According to the UNFPA, there will be a massive spike in the number of people who are aged 80 years or older—from 86 million in 2005 to 402 million in 2050. By 2050, most of these 80-year-olds will live in the developing world, and most of these will be women. Women live longer than men worldwide, and this gender bias is not specific to low-income countries, but in developing nations, they can have less autonomy and less financial independence than in more developed nations. According to data from Irudaya Rajan, Center for Development Studies, Trivandrum, and his colleagues, 61% of elderly women, compared with 45% of elderly men, are fully dependent on others for basics such as food, clothing, and health care, says Samanta. Despite these warning signs, ageing simply does not feature in women's health, says Karen Hardee. Much of the world, especially the USA, is still “battling for reproductive rights and contraceptive access”. That the burden of elderly care weighs heavily on families is true the world over, says John Haaga, at the National Institute on Aging, Bethesda, MA, USA. “The idea that rich countries don't rely on family support, and developing countries do, is quite misleading”, he says. Haaga adds that “families are the main providers of care for the disabled elderly everywhere. The nursing home population in the US has actually declined as a percentage of the elderly for some years now.” The difference being that in developed countries, many people have pension plans that allow them to finance their old age, and not have to rely solely on their families or on the state. Governments that depend on families to care for the elderly ignores the “growing crisis of long-term care outside hospitals”, says Haaga. In China, for example, “the long-term care needs in China are a big concern and they really need improved but affordable models of home health services, and eventually, residential care as well.” The complacency towards ageing in developing countries is reflected in how health systems cater to older people, says Guzman. “In Chile, there are only about six geriatricians in the whole country.” Health-care professionals in countries that have not traditionally had to deal with ageing will also need to change their perspectives, he says, so that doctors do not dismiss age-related disease as “normal and just part of life”. Developing countries will need to devise health policies for long-term care, and fast, says Haaga. “The countries now rapidly ageing have a brief window of opportunity to get these policies right for a new population age structure. They should learn from [rich countries] mainly what not to do. Fortunately, there is a lot of policy experimentation going on so there is no reason to believe they will not manage ageing at a rapid pace.” “We need to create societies with a social protection system that allows people to contribute during their working life and have a pension at the end of that life. If we don't have that, it doesn't matter what type of family support you have.” Ageing well: a global priorityApril 7 is World Health Day , the theme of which is ageing. Globally, we are getting older. 5 years from now, for the first time in history, the number of people aged 65 years and older will outnumber children younger than 5 years. Advances in medicine, socioeconomic development, and declining fertility have all contributed to this demographic shift, and countries need to adapt to this change in a positive and inclusive way. Full-Text PDF
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