Health status and service needs of older persons: a policy framework.
Position paper prepared for the UNFPA technical meeting on Population Ageing, Brussels, October 1998.
Margaret Grieco, Professor of Organisation and Development Management, the Business School, University of North London.
Abstract
Ageing is an issue for the developing world. And the health needs of older persons, and associated costs of health provision, pose a very real challenge to societies whose economic resources are severely constrained. Within this emerging relationship between ageing and development, the gender composition of an ageing world is striking: an ageing world is increasingly a female world and a world where the lifetime inferior access of women to resources cumulates in high levels of female poverty and poor health status. This position paper explores policy actions which can be taken to better the health status of older persons, most particularly women. Some actions relate to those stages of the life cycle which proceed older person status: ensuring an appropriate diet for child bearing women result in a healthier older stock. Some actions relate to the older person status itself: creating social environments which integrate older persons can prevent the disorientation which occurs with social marginalisation and reduce health problems and health costs. The paper explores the evidence on the relationship between social policy and the health of older persons and draws upon this evidence to make concrete suggestions in the anticipation of the International Year of the Older Person 1999.
1.Introduction: Ageing is a development issue: the challenge to development agencies.
Ageing is an issue for the developing world (Apt, 1995) And the health needs of older persons, and associated costs of health provision, pose a very real challenge to societies whose economic resources are severely constrained (World Bank, 1994). The World Health Organisation Ageing and Health web site, a relatively new and important development, opens with the following statements:
‘In 1993, 200 million of the world's total of 356 million persons over 65 were in developing countries. By 2020 seven of the ten countries with the largest elderly populations will be in the developing world........
The majority of elderly people are women, often in ill health and vulnerable as they are particularly poor and more likely than men to be widowed.......
Traditional forms of support are being eroded by the modernization process.’............
The health needs of older persons have consequences for social service provision in addition to the more readily identifiable demands for medical services and drugs. Similarly the social circumstances of older persons impact upon their health: where older persons are marginalised and distanced from social and economic resources, their health suffers. The resource constraints experienced by older persons, and their consequent impact on the health of this section of society, is particularly pronounced in the modern, developing world.
The pace and patterns of ageing in developing countries are without precedent. Neither the demographic processes nor the social context have parallels in the experience of the developed countries. (WHO Ageing and Health web site)
A first need in respect of meeting the requirements of an ageing developing world is that of readily accessible information on the details of local context. The WHO Ageing and Health web sites provides us with a very good set of grand numbers which give us a sense of the size of the new emerging client base of older persons in the developing world: precise information on local age and health patterns is much more difficult to access. Yet in order to service the needs of older persons in the developing world it is precisely the detail on local needs and patterns that we require. Variability by area in exposure to disease and availability of nutrients and character of diet by area are factors which impact upon the health of older persons. Similarly, social customs around entitlement to food share or access to health resources are also subject to local variations.
Historically, collecting, managing and manipulating detailed local data sets and providing global access to these same data sets was an impossibility. In the new information age, there are marked opportunities to develop and create data and information tools which permit the ready monitoring of local patterns and the variations in the health circumstance of older persons in the developing world as between areas.
In the developing world, there is no such comparable dynamic yet present. Many of the key development and aid agencies have not yet developed an appropriate awareness of the ageing crisis emerging in the developing world. Agencies such as the World Bank do not yet have a points person responsible for attending to any form of ageing agenda. In the absence of significant research into the health status of older persons in the developing world, there is not surprisingly a policy vacuum and as a consequence of this policy vacuum little or no operational work is being conducted on ageing and development issues, health or otherwise, by the key development agencies.
In order to achieve the level of local detail on ageing and health status necessary for operational activities by the development agencies, in combination with the governments, private sector operators, NGOs and community level organisation of developing countries, the orientation of the main development agencies towards the collection of the relevant data must first change . A first step forward could be an audit of the data collection practices of lead agencies in respect of ageing and health data.
Not only has ageing and health been bypassed in the current development agenda but gender considerations have been largely ignored. The WHO Ageing and Health web site draws explicit attention to the gender dimension:
The fundamental differences in the impact of the gender dimensions on the demographic transition are often neglected. In the past, fertility limitation came about in concert with economic development and the education of women. In the field of family planning, development agencies have until recently under-estimated the need for parallel social and economic measures that benefit women. In view of the fact that the majority of older persons are female, it is crucial that ageing policies reflect this situation, informing and empowering adult women who will increasingly constitute the majority of older persons in most of the developing world. (WHO Ageing and Health web site)
Had gender considerations been better integrated into the operational work of the developing agencies, ageing and health issues would have rapidly become more apparent. Not only do women live longer than men but their cumulative life circumstances mean they live longer at a lower standard of living than do men. High quality social analysis and use of better survey protocols by the development agencies would have drawn stronger attention to gender issues and in this process ageing and health issues would also have been better addressed. After Beijing, there has been substantial policy discussion around the significance of gender in the development agenda but as of yet this policy discussion remains largely untranslated into data collection processes and operational activities . Quality gender audits of development agency activities would reveal this gap and help create the necessary pressure for data collection and operational budgets in this area. The building pressure for improved operational performance by development agencies and governments on gender which is the outcome of Beijing may very well have positive consequences for the inclusion of Ageing and Health on the development agenda, most particularly in respect of older women.
Focusing on gender, it quickly becomes transparent that the life time cumulative disadvantages in access to all forms of resource experienced by women as compared with men have consequences for health and wellbeing. WHO has already recognised the importance of understanding the health status of older persons in terms of their cumulative life time experience. Some of the health problems of older persons can only be prevented by attending to negative experiences detrimental to health earlier in life.
WHO: The purpose of the programme (Ageing and Health) is to promote health and well-being throughout the lifespan, thus ensuring the attainment of the highest possible level of quality of life for as long as possible, for the largest possible number of older people. In order for this to be achieved, WHO will be required to advance the state of knowledge about health care in old age and gerontology through special training and research efforts, with special emphasis on the unprecedented fast ageing of developing country societies in the context of prevailing poverty and continuing demands arising from unsolved problems related to communicable diseases. Within this framework, ageing is perceived by Ageing and Health as a development issue urgently requiring action and policies.
(WHO Ageing and Health web site)
Taking our lead from the WHO approach sketched above, within the developing world, promoting health and well being throughout the life span requires us to consider gender as a central issue. Consider for example the impact of headloading goods or bad child birth practices on the cumulative health of African women. Currently, over eighty per cent of the rural transport burden of Africa is carried upon the heads of women: promoting life time health and well being for Africa and its ageing population will necessarily require engaging with the existing gender division of labour to ensure that the transport burden is more equitably distributed between the genders. Similarly, promoting life time health and well being for African women necessarily requires that reproductive health issues be addressed.
For the developing world, research into the specific health needs of older persons is a necessary priority and that this research be location sensitive is equally critical. Identifying the specific health needs of older persons is a necessary step on the path to identifying cures, solutions and adjustments which meet these needs. The illnesses which threaten the health of older persons in the southern world, such as malaria, are not shared with the northern hemisphere with the consequence that the resources for health research into the specific needs of the older persons of the developing world are scant. The dynamic which disattends to the health needs of older cohorts in the population is exacerbated in relation to the southern hemisphere.
Relatively little is known about ageing compared to other life phases. This is largely due to the fact that research has neglected cohort differences in both health and the factors that protect or damage it, contributing to pathological models of ageing.
(WHO Ageing and Health web site)
Within the developed world, older persons have a greater range of resources available to them with which to build their social environment for health and wellbeing: within the developing world, older persons have a restricted range of economic and financial resources available to them. In this context, sustaining and creating social arrangements which are intergenerational and incorporate intergenerational reciprocity and exchange of services is vital. Development agencies have done little to develop such intergenerational arrangements: indeed many of the measures introduced by the development agencies have had very much the opposite effect. Intergenerational schemes which lend resources to communities through the services of older persons are a possibility: organising aid so that it endows the old and not simply the young should be an explicit component of any development policy framework. Ensuring that resources are directed in such a way as not to discriminate against the old can greatly reduce social marginalisation and social vulnerability: it is a measure which, if adopted, is capable of moving the dynamics around aging and health in the developing world into a direction comparable with that of ‘gray power’ in the north.
In constructing a policy framework for addressing the aging and health needs of the developing world, it is necessary to recast the discussion of ‘supported living’ arrangements which has attended the emergence of the ‘old-old ’ in the developed world
In already aged societies the fastest growing population group is the oldest old with particularly high demands for social and health services (WHO Aging and Health web site)
The old and old-old of the developing world are unlikely to be housed in separate accommodation: the range of services and technologies which have been designed to support older people in living on their own is unlikely to arrive to any degree in the third world. However, there are policy issues which are related and can be regarded as ‘supported living’ considerations. Infrastructure deficiencies in many parts of the developing world results in household members, most particularly women, having to carry the burden of water, fuel, household provisions into the home and the removal of refuse and excrement away from the home to dump sites. In this context, older persons who can no longer carry these burdens frequently face the prospect of marginalisation. Measures taken to improve infrastructure reduce the carrying load of household members with benefits to health and improvements in the social exchange position of older persons within families: thus infrastructure improvements such as that conducted by the Oranji community in Karachi can be viewed as ‘supported living’ measures. Development agencies can be encouraged towards viewing and evaluating infrastructure design and provision in terms of its contribution to Ageing and Health. Despite the obvious relationship between disease and poor infrastructure, the larger part of development agency focus on infrastructure has been on highway communications rather sanitation . A useful step to highlight these concerns would be the adoption of an infrastructure audit which measured the investment in sanitation as compared with road developments in the third world.
2. Investing in the older person: a cumulative perspective.
The focus on developing intergenerational programs promoted by the most progressive of the development aid agencies reflects on the whole a concern with safety nets rather than with an investment perspective.
In April 1995, WHO launched a new programme on Ageing and Health. It replaces the previous programme on Health of the Elderly (1979-95) and incorporates the following perspectives:
Undoubtedly older persons in much of the developing world are increasingly becoming marginalised, with clear health consequences. and the need for safety nets and the promotion of intergenerational project and development design is indeed a wise path to take, however, there is a need for a much more radical approach in terms of meeting the challenge of the scale of growth in the numbers of older persons.
Recognising that women’s life time adverse circumstances has consequences for their health in their older years, a more radical approach would begin to investigate the prospect of developing health clubs for older women which combined enterprise, microfinance and investment in good health practice. Such clubs could be involved by development agencies and governments in organising local level community infrastructure projects for example. Creating an incentive structure through well designed development operations which enabled older women to contribute to their communities welfare could have very real and positive consequences for both their health and social location within their communities. With this type of paradigm or approach, the emphasis is no longer on safety net financing which is not sustainable in the long term but rather is upon enhancing the social capital of older women within their communities and in a context where they could create the opportunities for clean and safe water and sanitation.
One clear implication of the new WHO approach is that it is important to reach the younger population and change its negative behaviours in order to improve the health status of cohorts of older persons in the future. This raises the important issues of changing dietary allocations within households to ensure that women get the necessary nutrients and food stocks especially in their child bearing years in order to prevent calcium deficiencies and other similar conditions. Developing a life time approach to health in many developing countries can not be easily accomplished without major challenge to the existing organisation of access to household resources. To mount such a challenge, major thought must be given to outreach approaches.
A life time approach to ageing and health necessarily requires the involvement of the community to be effective and the creation of appropriate incentive structures for a change in behaviour must be carefully considered. Our suggestion of health clubs with a microfinance and infrastructure development component for older women gives a new idea on ways of approaching a more successful and appropriate outreach model than those formalistic consultations with local communities generally engaged in by the development agencies.
In order to have a successful outreach program or practice on life time health, training local community members in health practice and the ways in which such practice can assist in achieving better social and economic wellbeing is critical. In the same way that we discussed the potential for detailed local data collection and for global accessibility to that data in the first section of this paper as being critical to the identification of appropriate measures for servicing the health needs of any particular population of older persons, so in terms of investing in life time health approaches it is important that rural communities in the developing world have ready access to global knowledge on health developments which affect them or are relevant to their situation. Local areas do not have the resources to develop the full set of appropriate knowledge to their circumstances locally, however, the knowledge developed elsewhere on the basis of the scientific research of their area is important to them. Consider the constant transformations in strains of malaria with the consequence that drugs which previously worked in combating the disease are no longer effective. Keeping track of what is happening in this fast moving domain is imperative for health and welfare of Africa’s rural population. Western researchers now use new technology extensively to collect current information on the pattern of change around malaria and its treatment: it seems sensible that we begin to investigate ways of moving information in the opposite direction within the same modes.
Given the low income base of much of the developing world and the predictions that such a low income base will persist well into the future, it is important that life time health approaches are not seen in terms of the voluntaristic activities of individuals. Within the developed world, much of the focus is upon persuading individuals to take responsibility for their own health and welfare and is not placed upon the changing of social relationships and structures. The healthy exercise programs for older persons at the University of Western Ontario in Canada provide an example of the more voluntaristic approach, with it should be noted very good outreach approaches and understandings. For the developing world, resources to invest in the health of older persons are very constrained which requires a careful consideration of effective and appropriate programs or measures for adoption. The development of an inventory of approaches, projects or measures which have been carefully thought through and converted into tool kits or packages available to operational task managers in the development agencies would greatly assist the take up of the ageing issue. Currently there are few evaluatory or concrete guidelines available for such managers on these issues: the consequence is that lack of familiarity results in a very much hands off the issue culture.
In developing such an inventory, participatory protocols can be built in - there is no need why a set of tools on how to approach funding or investing in older persons’ health and wellbeing operations would close out participatory activity. Indeed our example of older women’s health clubs gives an idea on how the detailing of a good practice and the participation of the local community in the exact design of that practice can be integrated. Perhaps within this meeting we can begin to consider and identify an inventory or set of approaches which would move the health status of older persons in the developing world forward on the highly constrained budgets available. The creation of a workable inventory might actually assist in gaining increased budget for this type of activity: by raising its visibility in operational terms, its budget priority status can be improved.
3. Removing the bias in investing in older persons health: lowering the costs of provision.
As the numbers of older persons grow then there is a change in the demographic basis for investment: changes in the demographic base create the opportunity for changing rules of the game. The focus of many commentators to date on this demographic groundswell has been on the extent to which the arrival of enlarged cohorts of older persons stretches the financial boundaries of insurance and medical provision within the high income world. So far the concern has been on the cost of providing treatment but the new demographics may remove the bias in searching for cures for older persons ailments.
As more older persons share a condition so the pressure to find a resolution increases: indeed going to the admirable lists of Age and Health Web sites put together by the American Association of Retired Persons it is clear these dynamics have already begun. Concern with Alzheimer’s disease and Parkinson’s disease have growing visibility: what was previously hidden and rarely discussed is now a matter of routine Internet research for many who would have in a prior age sat in fear waiting for specialist opinion. The interaction between growing numbers of older persons and the user friendliness and highly reduced cost of information communication technologies has produced an effective advocacy community on older health issues within the United States. ‘Gray power’ in the health policy process is the other side of the expansion of ‘gray markets’.
Population aging represents a triumph of social development and public health. In addition, antibiotics and new medical technologies provide the means to prevent premature death caused by diseases in the middle-aged and young old. This is resulting in the survival of much larger populations to even older ages.
(WHO Aging and Health web site)
In the context of this new social movement and its growing knowledge of and research into its own health circumstance, the consumer will is present both to pressure for new treatments and to pressure for the reduction in their costs given the scale of the market.
In discussing the health status and service needs of older persons, the political and market dynamics of this new demography must be placed fairly and squarely in the middle of the equation. Research into vehicle design which best meets the needs of an older driving population has already made major moves to determine and accommodate the health status of older drivers (Axhausen and Grieco, 1991).
4. Context and condition: creating a positive health environment for older persons.
The thrust of WHO ageing and health approach is that the context and health condition of older persons are related and that there must be a major effort to create a positive health environment for older persons. By creating a culture of life time health and a positive health environment for older persons then the health costs to society can be greatly reduced. In our discussion here, we have suggested that ensuring life time health is not necessarily a low cost option. Indeed for many parts of developing society, a life time approach would require a major reorganisation of social and economic investment. Similarly, the creation of a positive health environment for persons when they reach old age also has substantial investment costs.
It may very well be that the investment costs of life time health for vulnerable groups are as great or larger than the economic costs of limited health care provision for older persons in developing countries. It may be that the investment of resources in older persons to provide a positive context costs as much or more than the simple treatments provided by society to repair fundamental neglects.
This is not to argue against the context and condition argument, nor to argue against the benefits of a positive health environment as espoused in the WHO Ageing and Health proposal. It is simply to argue that in embracing the context and condition argument and the benefits of a positive health environment realism should be present about both costs and the energy required to see such policies are adopted given their financial implications.
Changing tack slightly, in developing a ‘positive health environment for older persons’ approach it is important that there be careful concern about the outreach implications of reaching the older persons themselves. Earlier we discussed the extent to which outreach had to ensure that the communities being targeted took on the program, in the absence of such measures projects fail.
Outreach approaches which have as their targets people in marginal or vulnerable positions have to consider how they will indeed get past those social boundaries that have resulted in the social exclusion and marginalisation of the targets they seek to reach. In bringing an educational message to older persons in the community, it will be important to recognise the extent to which such older persons have been distanced from the educational world. The education of older persons will typically have been in the distant past if at all for many parts of the developing world. A precise analysis of the ways in which older persons can be reached in the present with medical and health knowledge is necessary as they will typically not be part of any of the conventional links with the educational or official world. Once again the suggestion of developing health clubs anchored on older women makes sense. As we have already seen in developed countries, the activities of institutions like the AARP provide a very good road map for older persons to find the relevant medical information. Similarly we can find in Canada very good outreach programmes which assist in developing a context of healthy living for older persons - the third age outreach approach . Developing a policy for the developing world and delivering that policy in operational terms are very different matters and to date the sequence of appropriate outreach moves and infrastructure development necessary to the successful formulation of such programmes has not received an adequate debate. If we want a good test on the effectiveness of outreach policy in the context of health in Africa, the extent to which contraceptives remain in the loading bays of urban areas and fail to reach the rural user provides us with a very good indicator of that failure.
5. Conclusion: A lifetime perspective on health and the older person: steps towards an active future.
In order to move the lifetime perspective on health and the older person forward, WHO, UNFPA and a number of other agencies are now involved in raising awareness of the issue in the context of the advent of 1999, the International Year of Older Person: WHO has provided a very useful summary of the key components of the life time approach:
Life Course Perspective Health in old age is determined by the patterns of living, exposures and opportunities for health protection over the life course. The patterns of living that enhance health are formed in early life and are not easily changed. Furthermore, the most frequently occurring ageing-related diseases - such as cardiovascular diseases and cancer - are long-term disease processes.
Cohort Perspective Valid and meaningful approaches to cohort analysis, necessary for scientifically sound research on ageing, are especially crucial for understanding the consequences of rapid social change. Relatively little is known about ageing compared to other life phases. This is largely due to the fact that research has neglected cohort differences in both health and the factors that protect or damage it, contributing to pathological models of ageing.
Health Promoting Perspective Pathogenic approaches cannot meet the challenges of global ageing outlined above. Statistical correlations relating age and disease/disability tend to result in a focus on ageing as problematic and the aged as ill, leading many to believe that the changing age distributions will only cause problems. Such pessimism is unwarranted and inhibits the development of effective health policy and services. Longitudinal studies have shown that physical and mental status can improve in successive older cohorts. The programme's challenge is to understand and promote the factors that keep people healthy, with a focus on both personal and external resources.
Cultural Perspective An effective life course perspective must be embedded in a cultural perspective. Patterns of daily living are learned in cultural settings that shape values and goals. Peer group pressures, together with traditions, spirituality and religious values of society, habits of charity, duties of children and extended families, are among the major influences shaping and maintaining ways of living. They are clearly defined and need to be considered when interventions aimed at improving well-being in older age are planned. Health programmes must contribute towards a positive view of ageing.
Gender Perspective In order to be effective, health research and programmes need to recognize gender differences in both health and ways of living. Men die earlier, while women experience greater burdens of morbidity and disability. Women constitute the majority of care givers; supporting them is a key health policy challenge.
Inter-generational Perspective Ageing is a matter for both those who are already old and those approaching old age. One major social transformation that accompanies population ageing is the restructuring of inter-generational relationships. Policies with an inter-generational perspective are needed if new roles are to be developed for older people. Strategies to maintain cohesion between the generations are required if inter-generational conflict over competition for resources is to be avoided.
Ethical Perspective As populations age, a range of ethical considerations come to the fore. They are linked to inequities, allocation of resources, choice of interventions, undue hastening or delaying of death, and a range of dilemmas linked to long-term care provision and the human rights of poor, disabled or demented elderly. WHO must support Member States in clarifying these complex issues, through advocacy and upholding the rights of all older people.
The task now must be to convert these categories into inventories of actions which can be taken at the operational level and to use these inventories to persuade the major operational agencies such as the World Bank that the adoption of such moves is critical if the ageing of the developing world is to be prevented from transforming into a crisis.
The discussion in the literature is of the need to develop and design broad initiatives to address the challenges at hand.
At this point, the World Health Organization can exert crucial influence to increase awareness and design broad initiatives to address the challenges at hand. The design of the WHO Ageing and Health Programme, and the concept of ageing on which it builds provide a framework for an effective WHO response to population ageing worldwide.
(WHO Ageing and Health web site)
The view presented here challenges the suggestion that it is broad initiatives which are indeed needed. Broad initiatives rarely get implemented and typically remain at the level of policy rhetoric. The major failure in development has been in terms of the translation of policy initiatives into operational action. The suggestion which has been made here is that new technologies enable the ready organisation of detailed local data into appropriate local action plans which can integrated through the use of new technologies to achieve the same effects as broad initiatives. Furthermore, energy placed upon converting the already available broad outlines of action into more specific inventories of possible operations will increase the likelihood of measures moving from the policy table into the operational field. Once again with a well organised ICT approach - and the WHO Ageing and Health web site represents the beginning of such an option - inventories can be combined, adjusted, converted, reorganised, transferred, transformed and translated. ICT can provide a flexibility on initiatives that was previously not conceivable. The Smart micro finance arrangements of Swaziland could be linked with other programs and projects anywhere in the world: the ability to manage risk between a pool of remote rural locations has never previously existed. But it does now and it should inform the way in which we do business around raising the resources and action necessary for improving the health and well being of older persons in the developing world.
From a demographic perspective the view of ageing as a crisis must be rejected: ageing has a lead time of decades rather than years and provides societies with the opportunity to prepare themselves through appropriate policies and programmes for an ageing population. The real crisis of ageing is the personal crisis of day-to-day existence - a present reality faced by many older individuals and their carers. Health policies must respond to both dimensions: increasing quality of life of both present and future cohorts of elderly populations.
(WHO Ageing and Health web site)
References and background reading
Apt, N.A. (1995) Coping with old age in a changing Africa. Avebury:
Aldershot.
Apt, N.A. (1998) 'Education and the girl child' in Apt, N.A., Agyemang-Mensah, N. and Grieco, M.S. Maintaining the momentum of Beijing - the contribution of African gender NGOs. University of North London Voices in Development Management series, Avebury Press: Aldershot
Apt, N.A., Koomson, J., Williams, N. and Grieco, M.S. (1996) 'Family,
finance and doorstep trading: the social and economic wellbeing of
Ghana's elderly female traders', Southern African Journal of Gerontology.
Axhausen, K. and Grieco, M.S., 1991, 'The older driver: emergent trends in the European policy environment'. VTIrapport 372A 3 pp 185-201.
Cheung, P. and Vasoo, S., 1992, 'Ageing population in Singapore : a case study.' in Ageing in east and south east Asia. Edited by David R. Phillips. London: Edward Arnold .
Chi, I. and Lee, J.J., 1989, A health survey of the elderly in Hong Kong. UHK research paper no 14 Department of social work and social administration.
Ebrahim, S. and Kalache, A. Epidemiology in Old Age British Medical Journal Publishers, London, 1996
Grieco, M.S., 1992, Breaking the ice: the contribution of new transport
information technologies to improving the quality of life of the elderly
in a cold climate. Report commissioned by the Prefecture of Niigata,
Japan .
Grieco, M.S.,1996, 'Older people's role in development' in In spite of
poverty: The older population builds towards its future. AARP:
Washington, D.C.
International Conference on Population and Development, Cairo, Egypt, 5-13 September 1994
Kalache, A. and Sen, K. Ageing in Developing Countries. In: Pathy, M.S. (ed) Principles and Practice of Geriatric Medicine 3rd Edition John Wiley and Sons Ltd, 1998
Okpala, D.C.I. (1977) 'Received concepts and theories in African studies and urban management strategies: a critique', Urban Studies, Vol 24 No 2
pp 137-150
Overseas Development Agency (1994) Gender issues in Ghana: a review. Prepared by BRIDGE, Institute of Development Studies: Sussex.
University of North London Development Management : Senior Sense - 1998
The World Bank World Development Report 1993: Investing in Health Oxford University Press, New York, 1993
World Bank (1994)) Averting the old age crisis: policies to protect the old and promote growth. World Bank: Washington D.C.
.The World Bank World Development Report 1992: Development and the Environment Oxford University Press, New York, 1992
The World Bank Adult Health in Brazil: Adjusting to New Challenges World Bank Report No. 7807-BR, 14 November 1989
World Health Organization Women, Aging and Health Achieving health across the life span prepared by Ruth Bonita for the Global Commission on Women's Health under the guidance of the Ageing and Health Programme World Health Organization, Geneva, 1996 WHO/HPR/AHE/HPD/96.1
Healthy policy aspects of aging Report of the World Health Organization World Assembly on Aging, Vienna, 26 July-6 August 1982 United Nations, 1982 A/CONF.113/9
World Health Organization The uses of epidemiology in the study of the elderly WHO Technical Report Series No.706 World Health Organization, Geneva, 1984
WHO Ageing and Health Program, (1998) Web site: Ageing and Health
Appendices
Appendix 1 :
Epidemiological dimensions Both in the developed and the developing world, ischaemic heart and cerebrovascular diseases are the main causes of death in old age, followed by neoplasms and then respiratory diseases, largely pneumonias. Rates increase steeply with age, although neoplastic diseases are less frequent in the very old age group. There are however some differences in degree; in developing countries, infectious and parasitic diseases still kill at the oldest ages, cerebrovascular diseases are more important than ischaemic heart disease and the group of other heart diseases are also prominent, as are injuries, compared to developed countries. Too much attention should perhaps not be paid to causes of death at the oldest ages, partly because these are inaccurate or lacking even under the best circumstances and partly because of the prevalence of multiple pathology. What is important is the fact that the last years of life are frequently accompanied by an increase in disability and sickness, although measurements of longevity do not necessarily indicate the burden of disease. There is an urgent need to measure functional status in order to provide information for service priorities, planning and evaluation and particularly to explore the potential for healthy ageing and independence despite reduced functional status. To do this, the notion of disability-free life expectancy or active life expectancy (also called healthy life expectancy) that has been developed needs further exploration.
(WHO Ageing and Health web site)
Appendix 2:
In already aged societies the fastest growing population group is the oldest old with particularly high demands for social and health services.
The process of population ageing commenced earlier in Europe and 18 of the 20 countries with the highest percentages of elderly are in that region the others are Japan and the United States) with 13.2-17.9% of their population already over 65. However, the most rapid changes are now seen in some of the developing countries with predicted increases of 200-400% in their elderly populations during the next 30 years. In developed countries, already with older populations, the increase will be of the order of 30-140% depending on the country. The least developed nations will start their spurt in growth of their older population early in the next century. Elderly people themselves are growing older, increasing the numbers and proportions of the very old. The fastest growing population in most countries of the world is of the oldest old, 80 years and above. In 1993, they constituted 16% of all the older population over 65 - 22% in developed countries and 12% in developing countries. These proportions will increase during the next 30 years to over 30% in the "oldest" countries.
(WHO Ageing and Health web site)
The dominant paradigm in development has been one of investing in the young and most employable, whether as a consequence of health or as a consequence of social definitions such as gender. The growing focus on the ageing of high income societies has given rise to a shift in the ruling paradigm of the developed world: increasingly ideas such as life long learning and investments in technology for the learning needs of older persons have begun to gain ground (and click on ‘senior sense’). Research into the employment qualities of older persons has begun to feature at international gerontology/ ageing meetings and conferences. The imminent prospect of large numbers of older persons in the developing world has begun to stimulate research into the development of social safety nets to protect these growing cohorts from the extremes of poverty and illhealth. The dominant development paradigm for the developing world has not yet moved towards the investment perspective we begin to see in the northern hemisphere.
Back to Senior Sense.