Public Health in the 21st Century II

The challenge of ageing populations

DR REDDY: The last hundred years have seen a huge rise in life expectancy.That should be a cause for celebration for all interested in public health. However it also brings some concern about the health of aging populations. Indeed, when we are looking at the large number of people who are reaching the age of the elderly which is about 60 years or the very elderly which is about 80 years, then we have to regard it as an important area of public health action in the 21st Century. And therefore it’s not surprising that when we are really looking at what sustainable development should really look at as a goal then it is logical to think of a life course perspective which not only looks at the health of the newborn baby or the young child, but also of the elderly person. This life course approach can be spelt out through a goal which says achieve health and well-being at all ages. We expect this to happen through universal health coverage and also pro-health policies in all of the sectors which create a healthy society. But we must ensure that in the broad sweep of our health system and social development that persons who are elderly and in great need of public health attention are not marginalized. When we look at the world, we recognize that already there are a fairly large number of people in the category of the elderly and the very elderly. But these are mostly in the high income countries or in the middle income countries where the life expectancy has risen sharply over the last century. But we are going to see a different phenomenon over the next forty years when by 2050 while the high income countries would continue to have a fairly substantial proportion of the population in that elderly age group it is the low and middle income countries which are going to see the largest rise in the numbers of the aged and the elderly. In China, for example, between 1990 and 2050 we are going to be seeing a huge change in the demographic profile from a pyramidal age structure to a very cylindrical age structure where those who are in the middle age and in the elderly age groups are going to be dominating rather than the young. We also recognize that as we move along the number of persons aged about 60 years is going to be rising progressively in all parts of the world and particularly in the developing countries this is where the maximum rise is going to be witnessed over the next four decades. In the low and middle income countries by 2050, two billion people will be aged over 60, that’s the elderly. And 80% of them will be living in low and middle income countries. By 2050, 400 million persons will be over 80 years. That’s the very elderly and 100 million of them will be in China alone. Chile, China and Iran will have a greater proportion of old people or older people than the United States of America, so that is where the major presence of the aging populations is going to be. And when we look at what are the factors affecting population aging, clearly increasing global life expectancy is the principle propellant of this change. Life expectancy has increased globally on an average from 47 years between 1950 and ’55 to 65 years between 2000 and 2005, but by 2050 we expect to reach an average global life expectancy of 75 years. At the same time we are also seeing a decline in global fertility rates from a fertility ratio of about 5 in 1955 to ’55, we are likely to see this coming down to 2 by 2050. Early in the century we had already a major decline where the fertility rate had come down to 2.6 but when it reaches 2 then we are going to see a very large number of elderly people. At the same time we are also seeing that in the developed countries restrictions on immigration are also going to affect the age structure. Previously, in pursuit of accelerated economic development, high income countries invited a large number of young and productive immigrants. But now for a variety of security reasons and because of mounting xenophobia, there are crackdowns in immigration and that is again going to result in a closed door policy which will raise the age profile of the developed countries and restrict the number of young people in those populations. We also recognize that this has an impact on the dependency ratios. When a country has a larger number of people who are in the elderly age group or are children, they are going to be dependent on the working age population. When we look at the ratios of the dependents to the working age population in the high income countries because of declining birth rates and increasing life expectancy we have seen that already changing that there is a high dependency at the moment. But in the developing countries, where the birthrates have started falling only recently but aging has now started climbing as a major factor in altering the population age profile we are going to be seeing an increasing dependency ratio in countries like China. Countries like India are still fairly young in terms of their population profile, but even they by 2050 will see a much higher dependency ratio. And this has health consequences in terms of what happens to the health of the elderly as well as the nature of the support their society provides them. The demographic and the epidemiological transitions are closely linked in populations. Older people are likely to live longer but we have also to ensure that they live healthier. It is to be expected that as people age the number of cases of chronic illness and disabilities will rise. There will be increased spending on nursing, palliative care and end of life treatments and we require also long term care for irreversible conditions. All of this is going to be an important health system priority as we move along to a larger aging population in most countries. In terms of some of the other consequences there are challenges in elderly care in terms of provision of formal care as the living arrangements for the elderly are changing globally. What has happened in general over the last fifty to sixty years is that unlike homecare which used to be the norm prior to that, people have moved to institutional care and now in some of the high income countries, they’re also moving back to assisted homecare. But countries which are now facing the problem of health systems which are under resourced, but also the challenge of catering to the needs of the elderly will now have to look at how they can provide institutional or assisted homecare. And the whole area of social security also needs to be clearly addressed. Unfortunately we are also seeing a negative side of the societal response in terms of increasing neglect and abuse of the elderly.We have seen in several societies a greater abuse of the elderly which is partly because of poverty and lack of resources for care which results in neglect and the stress of having to provide care with low resources also pressures families into abuse. There is also poor  training and education of caregivers and there is job related stress in institutional care facilities where instead of empathetic care there is very indifferent attention or actual abuse. Therefore we really must look at what happens to the elderly and particularly poignant is the state of elderly who live alone. Because of the changing population structures, one in every seven persons in the elderly age group now lives alone. That means 90 million elderly people across the world live alone and this is much more true in case of woman then in case of men and particularly an elderly woman who is a widow is often without adequate family support and lives alone in penurious circumstances with very little attention even from the healthcare system. And when we look at long term care for the elderly, we have to look at different models like institutional care, formal homecare and informal care. In high income countries like Japan which has the largest proportion of the elderly population because of the longest life expectancy we have a very large proportion of the elderly population living with adult children, though this is also showing a declining trend. In the low and middle income countries about three-fourths of their elderly population in Asia and Africa and two-thirds in Latin America stay with their families. But that has been a tradition and a part of their culture. But that is rapidly changing with urbanization, with the growth of nuclear families, with migration of the working age children and therefore the probability of the elderly getting care in the family environment is now diminishing even in these countries. When we are looking at long term care for the elderly, insurance coverage or some form of coverage under a universal health coverage scheme is absolutely important for providing healthcare to the elderly. Whether it is a wide ranging insurance which particularly caters to the needs of the elderly or a universal health coverage system which is foolproof in terms of its attention to the needs of the elderly, we need to ensure that financial barriers do not arise in providing the needed care. All high income countries presently provide public insurance coverage for hospital and physician services to the elderly. However, even the best among them provide very poor coverage for drugs and long term care. And that can be a major impediment to good health among the elderly. So we are really looking at the need for long term care financing as well. Even in high income countries, public expenditure accounts for less than 1% of spending on long term care for the elderly. The United States and New Zealand have the highest proportion of private funding. Now if you happen to be a poor person living in those countries or if you happen to be a person living in a country without adequate sources and low per capita GDP, then long term care can become a major problem indeed. Now in terms of aging and the healthcare costs, while it is natural to associate that aging itself is driving up the healthcare cost, that’s not the major factor. Health costs will continue to rise in any case in the future because of other reasons. Changes in health seeking behavior, new medical technologies, rising wages of healthcare professionals, increasing cost of drugs, health insurance premiums rising, and inefficiencies in health service delivery. While healthcare costs are spiraling up, we need to ensure that the people who will pay the maximum price for that will not be the elderly and again, universal health coverage will have to provide adequate protection for that. So when we look at the sources of payment for healthcare services and what are the major contributors to that kind of payment which is not covered by insurance or sparsely covered by the insurance, then we recognize that prescription drugs and long term care facilities are the ones that have the maximum cost attached to them. And these are seldom adequately provided for in any insurance program. So we have to make a very careful planning for ensuring that prescription drugs as well as long term care are built into the system of universal health coverage so that the elderly do not suffer deprivation. There are obviously some solutions that we need to implement on a priority. We need to develop health policies with an increased focus on sustainable financing of long term services for the elderly. And we must ensure adequacy of healthcare personnel and these are not merely people who treat in a hospital for a medical emergency or a chronic condition. We are talking about rehabilitation personnel, we are talking about physiotherapy, we are talking about mental health counselors, a variety of medical social support systems and we must incentivize the existing workforce and also provide task shifting because the health systems of many of the low and middle income countries have a great shortage of human resources and we can not leave the care of the elderly only to very specialized categories who are anyway not available in large numbers. So we ought to really ensure that some of the frontline health workers and even laypersons are provided the requisite training for providing the kind of care that elderly need and giving them the support that will make their lives healthier and more comfortable. In terms of addressing the increasing need for home-based long term care as family structures undergo changes. Again, countries have to have some definitive planning for that just as families need to do that because we can’t allow people to go abandoned by families without care if the overall health system itself is inattentive to it. We need a better legal framework in support of the elderly and we must ensure that age discrimination is not a factor for employment of fit elderly in the labor markets. Really we ought to be looking at the possibility of using this gray power to the advantage of developing societies by using their intellect and experience to greater advantage in a variety of ways. And when we also look at policy we must ensure protective mechanisms against abuse and neglect. That’s also a critical element that we must actually ensure so that people in the elderly age group do not suffer unnecessarily. So we are really looking at developing a society which is much more caring in terms of addressing the needs of the elderly but we do not always have to presuppose that the elderly will inevitably be feeble and debilitated. If we adopt a healthy life course approach and build a health society where people can actually adopt healthy living habits and have an environment which supports the choice of healthy living habits across the life course, we will see many more elderly as fit and functioning rather than frail and feeble. But when they do need care and support we must also ensure that the health system in particular but the society as a whole springs to their support.

Pedro Pereira Leite

Researcher and professor. He had his PhD. on museology in 2011, with the title “Muss-amb-ike Homeland: The commitment on musicological process”, that was published in 2011. In 2012 he finishes a Post-PhD Research on "Biographical Glances: The intersubjectivity poetry on museology, at Lusófona University (Lisbon). Presently he is working in his Post PhD. Research about: “Global Heritages" with the aims to build a network on local cognizance and memory manager has a tool to build the will of action in 3 different communities, linked by past communed heritages.” He works at CES. He participates on different Research network, presented papers in national and international conferences, and had published books on research subjects.

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