Active Aging - A Policy Framework

7/29/2019 Active Aging - A Policy Framework

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ACTIVEAGEING:APOLICYFRAMEWORK

WHO/NMH/NPH/02.8

DISTR.:GENERALORIG.:ENGLISH

ActiveAgeingAPolicyFramework

WorldHealthOrganization

NoncommunicableDiseasesandMentalHealthCluster

NoncommunicableDiseasePreventionandHealthPromotionDepartment

AgeingandLifeCourse


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ThisPolicyFrameworkisintendedtoinform

discussionandtheformulationofactionplans

thatpromotehealthyandactiveageing.Itwas

developedbyWHOsAgeingandLifeCourse

ProgrammeasacontributiontotheSecond

UnitedNationsWorldAssemblyonAgeing,

heldinApril2002,inMadrid,Spain.The

preliminaryversion,publishedin2001entitled

HealthandAgeing:ADiscussionPaper,was

translatedintoFrenchandSpanishandwidely

circulatedforfeedbackthroughout2001

(includingatspecialworkshopsheldinBrazil,

Canada,theNetherlands,SpainandtheUnited

Kingdom).InJanuary2002,anexpertgroup

meetingwasconvenedattheWHOCentrefor

HealthDevelopment(WKC)inKobe ,Japan,

with29participantsfrom21countries.De-

tailedcommentsandrecommendationsfrom

thismeeting,aswellasthosereceivedthrough

thepreviousconsultationprocess,werecom-

piledtocompletethisfinalversion.

Acomplementarymonographentitled

ActiveAgeing:From EvidencetoActionis

beingpreparedincollaborationwiththeInter-

nationalAssociationofGerontology(IAG)and

willbeavailableathttp://www.who.int/hpr/

ageingwheremoreinformationaboutageing

fromalifecourseperspectiveisalsoprovided.

AcontributionoftheWorldHealthOrganizationtothe

SecondUnitedNationsWorldAssemblyonAgeing,

Madrid, Spain,April 2002.


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Contents

Intro duction 5

1 . Global Ageing: A Tr iumph and a Challen ge 6

TheDemographicRevolution 6

RapidPopulationAgeinginDevelopingCountries 9

2. Active Ageing: The Con cept and Rationale 1 2

WhatisActiveAgeing? 12

ALifeCourseApproachtoActiveAgeing 14

ActiveAgeingPoliciesandProgrammes 16

3. The Deter min ants of Active Ageing: Under standing the Evidence 1 9

Cross-CuttingDeterminants:CultureandGender 20

DeterminantsRelatedtoHealthandSocialServiceSystems 21

BehaviouralDeterminants 22

DeterminantsRelatedtoPersonalFactors 26

DeterminantsRelatedtothePhysicalEnvironment 27

DeterminantsRelatedtotheSocialEnvironment 28

EconomicDeterminants 30

4. Challen ges of an Ageing Population 33

Challenge1:TheDoub leBurdenofDisease 33

Challenge2:IncreasedRiskofDisability 34

Challenge3:ProvidingCareforAgeingPopulations 37

Challenge4:TheFeminizationofAgeing 39

Challenge5:EthicsandInequities 40

Challenge6:TheEconomicsofanAgeingPopulation 42

Challenge7:ForgingaNewParadigm 43

5. The Policy Respon se 45IntersectoralAction 46

KeyPolicyProposals 46

1.Health 47

2.Participation 51

3.Security 52

WHOandAgeing 54

InternationalCollaboration 55

Conclusion 55

6. Referen ces 57


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Thisbooklet usestheUn itedNationsstandardofage 60todescribe olderpeop le.Thismayseemyounginthedevelopedworldand inthosedevelop ing countrieswheremajorgainsinlifeexpectancyhave alreadyoccurred .However,whateverage isused with indifferentcon-texts,itisimportant to acknowledgethatchronolog icalage isnotaprec isemarkerforthechangesthataccompanyage ing .Therearedramaticvariationsinhealth status,participation and levelsofindependenceamongolderpeopleofthesame age .Decision-makersneedto taketh isintoaccountwhendesign ing po liciesand programmesfortheirolderpopulations.Enact ing broadsocialpo liciesbased on chronolog icalage alonecanbe discriminatoryand counterproductive to we llbe ing inolderage .

HowOldisOlder?

Thehandsyouseeinthebackgrounddesignofthispaperarecelebratingtheworldwide

triumphofpopulationageing.Ifyoufanthepagesquickly,youwillseethemapplaudingthe

importantcontributionthatolderpeoplemaketooursocieties,aswellasthecriticalgainsin

publichealthandstandardsoflivingthathaveallowedpeopletolivelongerinalmostallparts

oftheworld.

ThistextandthepreliminaryversionofthepaperweredraftedbyPeggyEdwards,aHealth

CanadaconsultantbasedforsixmonthsatWHO,undertheguidanceofWHOsAgeingandLife

CourseProgramme.ThesupportfromHealthCanadaatallphasesoftheprojectisgratefully

acknowledged.


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Introduction

Populationageingraisesmanyfundamental

questionsforpolicy-makers.Howdowehelp

peopleremainindependentandactiveasthey

age?Howcanwestrengthenhealthpromo-

tionandpreventionpolicies,especiallythose

directedtoolderpeople?Aspeopleareliving

longer,howcanthequalityoflifeinoldage

beimproved?Willlargenumbersofolder

peoplebankruptourhealthcareandsocial

securitysystems?Howdowebestbalancethe

roleofthefamilyandthestatewhenitcomes

tocaringforpeoplewhoneedassistance,as

theygrowolder?Howdoweacknowledge

andsupportthemajorrolethatpeopleplayas

theyageincaringforothers?

Thispaperisdesignedtoaddresstheseques-

tionsandotherconcernsaboutpopulation

ageing.Ittargetsgovernmentdecision-mak-

ersatalllevels,thenongovernmentalsec-

torandtheprivatesector,allofwhomare

responsiblefortheformulationofpoliciesand

programmesonageing.Itapproacheshealth

fromabroadperspectiveandacknowledges

thefactthathealthcanonlybecreatedand

sustainedthroughtheparticipationofmultiple

sectors.Itsuggeststhathealthprovidersand

professionalsmusttakealeadifweareto

achievethegoalthathealthyolderpersonsre-

mainaresourcetotheirfamilies, communities

andeconomies,asstatedintheWHOBrasilia

DeclarationonAgeingandHealthin1996.

Part1describestherapidworldwide

growthofthepopulationoverage60,espe-

ciallyindevelopingcountries.

Part2explorestheconceptandrationale

foractiveageingasagoalforpolicyand

programmeformulation.

Part3summarizestheevidenceabout

thefactorsthatdeterminewhetherornot

individualsandpopulationswillenjoya

positivequalityoflifeastheyage.

Part4discussessevenkeychallengesas-

sociatedwithanageingpopulationforgov-

ernments,thenongovernmental,academicandprivatesectors.

Part5providesapolicyframeworkfor

activeageingandconcretesuggestionsfor

keypolicyproposals.Theseareintended

toserveasabaselineforthedevelopment

ofmorespecificactionstepsatregional,

nationalandlocallevelsinkeepingwith

theactionplanadoptedbythe2002Second

UnitedNationsWorldAssemblyonAgeing.


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1.GlobalAgeing:ATriumphandaChallenge

Populationageingisoneofhumanitys

greatesttriumphs.Itisalsooneofourgreat-

estchallenges.Asweenterthe21stcentury,

globalageingwillputincreasedeconomic

andsocialdemandsonallcountries.Atthe

sametime,olderpeopleareaprecious,often-

ignoredresourcethatmakesanimportant

contributiontothefabricofoursocieties.

TheWorldHealthOrganizationarguesthat

countriescanaffordtogetoldifgovernments,

internationalorganizationsandcivilsociety

enactactiveageingpoliciesandprogrammes

thatenhancethehealth,participationand

securityofoldercitizens.Thetimetoplanand

toactisnow.

In all countries, and in developing

countries in particular, measures to

help older people remain healthy

and active are a necessity, not a

luxury.

Thesepoliciesandprogrammesshou ldbe

basedontherights,needs,preferencesand

capacitiesofolderpeople.Theyalsoneedto

embracealifecourseperspectivethatrecog-

nizestheimportantinfluenceofearlierlife

experiencesonthewayindividualsage.

The Demograph ic Revolution

Worldwide,theproportionofpeopleage

60andoverisgrowingfasterthananyother

agegroup.Between1970and2025,agrowth

inolderpersonsofsome694millionor

223percentisexpected.In2025,therewillbe

atotalofabout1.2billionpeopleovertheage

of60.By2050therewillbe2billionwith

80percentofthemlivingindeveloping

countries.

Agecompositionthatis,theproportionate

numbersofchildren,youngadults,middle-

agedadultsandolderadultsinanygiven

countryisanimportantelementforpolicy-

makerstotakeintoaccount.Population

ageingreferstoadeclineintheproportionof

childrenandyoungpeopleandanincrease

intheproportionofpeopleage60andover.

Aspopulationsage,thetriangularpopulation

pyramidof2002willbereplacedwithamore

cylinder-likestructurein2025(seeFigure1).

Populationageingisfirstandforemostasuccessstoryforpublichealthpolicies

aswellassocialandeconomicdevelopment.

GroHarlemBrundtland,Director-General,WorldHealthOrganization,1999


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Decreasingfertilityratesandincreasing

longevitywillensurethecontinuedgreying

oftheworldspopulation,despitesetbacks

inlifeexpectancyinsomeAfricancountries

(duetoAIDS)andinsomenewlyindepen-

dentstates(duetoincreaseddeathscaused

bycardiovasculardiseaseandviolence).Sharp

decreasesinfertilityratesarebeingobserved

throughouttheworld.Itisestimatedthatby

2025,120countrieswillhavereachedtotal

fertilityratesbelowreplacementlevel(aver-

agefertilityrateof2.1childrenperwoman),a

substantialincreasecomparedto1975,when

just22countrieshadatotalfertilityratebelow

orequaltothereplacementlevel.Thecurrent

figureis70countries.

Untilnow,populationageinghasbeenmostly

associatedwiththemoredevelopedregions

oftheworld.Forexample,currentlynineof

thetencountrieswithmorethantenmillion

inhabitantsandthelargestproportionofolder

peopleareinEurope(seeTable1).Little

changeintherankingisexpectedby2025

whenpeopleage60andoverwillmakeup

aboutone-thirdofthepopulationincountries

likeJapan,GermanyandItaly,closelyfol-

lowedbyotherEuropeancountries

(seeTable1).

Astheproportionofchildrenandyoungpeopledeclinesandtheproportionofpeopleage60andoverincreases,thetriangularpopulationpyramidof2002willbereplacedwithamorecylinder-likestructurein2025.


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Table1.Countrieswithmorethan10millioninhabitants(in2002)withthehighestproportionofpersonsaboveage60

2002 2025

Ita ly 24 .5% Japan 35.1%

Japan 24.3% Ita ly 34 .0%

Germany 24.0% Germany 33.2%

Greece 23 .9% Greece 31 .6%

Be lg iu m 22.3% Spain 31 .4%

Spain 22 .1% Belg ium 31.2%

Portuga l 21 .1% Un ite dKing do m 29.4%

Un ite dKin gd om 20.8% Netherlands 29 .4%

Ukraine 20.7% France 28 .7%

France 20 .5% Canada 27.9%

Source:UN,2001

Whatislessknownisthespeedandsignifi-

canceofpopulationageinginlessdeveloped

regions.Already,mostolderpeoplearound

70percentliveindevelopingcountries(see

Table2).Thesenumberswillcontinuetorise

atarapidpace.

Table2.Absolutenumbersofpersons(inmillions)above60yearsofageincountrieswithatotalpopulationapproachingorabove100millioninhabitants(in2002)

2002 2025

Ch ina 134.2 China 287.5

Ind ia 81 .0 Ind ia 168.5

UnitedStatesofAmerica 46 .9 Un itedStatesofAmerica 86 .1

Japan 31.0 Japan 43.5

RussianFederat ion 26.2 Indonesia 35 .0

Indonesia 17 .1 Brazil 33 .4

Brazil 14 .1 RussianFederation 32.7

Pak istan 8.6 Pakistan 18.3

Mexico 7.3 Bang ladesh 17 .7

Bang lad esh 7.2 Mexico 17 .6

Niger ia 5.7 N iger ia 11 .4Source:UN,2001

Inallcountries,especiallyindevelopedones,

theolderpopulationitselfisalsoageing.

Peopleovertheageof80currentlynumber

some69million,themajorityofwhomlive

inmoredevelopedregions.Althoughpeople

overtheageof80makeupaboutonepercent


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oftheworldspopulationandthreepercentof

thepopulationindevelopedregions,thisage

groupisthefastestgrowingsegmentofthe

olderpopulation.

Inbothdevelopedanddevelopingcountries,

theageingofthepopulationraisesconcerns

aboutwhetherornotashrinkinglabour

forcewillbeabletosupportthatpartofthe

populationwhoarecommonlybelievedtobe

dependentonothers(i.e.,childrenandolder

people).

Theold-agedependencyratio(i.e.,thetotal

populationage60andoverdividedbythe

populationage15to60seeTable3)ispri-

marilyusedbyeconomistsandactuarieswho

forecastthefinancialimplicationsofpension

policies.However,itisalsousefulforthose

concernedwiththemanagementandplanning

ofcaringservices.

Old-agedependencyratiosare

changingquicklythroughoutthe

world.InJapanforexample,there

are currently39peopleover

age 60forevery100intheage

group1560.In2025thisnumber

willincreaseto66.

However,mostoftheolderpeopleinall

countriescontinuetobeavitalresourceto

theirfamiliesandcommunities.Manycon-

tinuetoworkinboththeformalandinfor-

mallaboursectors.Thus,asanindicatorfor

forecastingpopulationneeds,thedependency

ratioisoflimiteduse.Moresophisticated

indicesareneededtomoreaccuratelyreflect

dependency,ratherthanfalselycategorizing

individualsthatcontinuetobefullyableand

independent.

Atthesametime,activeageingpoliciesand

programmesareneededtoenablepeopleto

continuetoworkaccordingtotheircapaci-

tiesandpreferencesastheygrowolder,and

topreventordelaydisabilitiesandchronic

diseasesthatarecostlytoindividuals,families

andthehealthcaresystem.Thisisdiscussed

furtherinthesectiononwork(page31)and

inChallenge2:IncreasedRiskofDisability

(page34)andChallenge6:theEconomicsof

anAgeingPopulation(page42).

Table3.Oldagedependencyratioforselectedcountries/regions

2002 2025

Japan 0.39 Japan 0.66

NorthAmerica 0.26 NorthAmerica 0.44

European

Un ion

0.36 Euro pea n

Un ion

0.56

Source:UN,2001

Rapid Population Ageing in

Develop ing Countries

In2002,almost400millionpeopleaged60

andoverlivedinthedevelopingworld.By

2025,thiswillhaveincreasedtoapproximately

840millionrepresenting70percentofallolder

peopleworldwide.(seeFigure2).Intermsof

regions,overhalfoftheworldsolderpeople

liveinAsia.Asiasshareoftheworldsold-

estpeoplewillcontinuetoincreasethemost

whileEuropesshareasaproportionofthe

globalolderpopulationwilldecreasethemost

overthenexttwodecades(seeFigure3).


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Comparedtothedevelopedworld,socio-

economicdevelopmentindevelopingcoun-

trieshasoftennotkeptpacewiththerapid

speedofpopulationageing.Forexample,

whileittook115yearsfortheproportionof

olderpeopleinFrancetodoublefrom7to

14percent,itwilltakeChinaonly27years

toachievethesameincrease.Inmostofthe

developedworld,populationageingwasa

gradualprocessfollowingsteadysocio-eco-

nomicgrowthoverseveraldecadesandgener-

ations.Indevelopingcountries,theprocessis

beingcompressedintotwoorthreedecades.

Thus,whiledevelopedcountriesgrewaffluent

beforetheybecameold,developingcountries

aregettingoldbeforeasubstantialincreasein

wealthoccurs(KalacheandKeller,2000).

Rapidageingindevelopingcountriesis

accompaniedbydramaticchangesinfam-

ilystructuresandroles,aswellasinlabour

patternsandmigration.Urbanization,the

migrationofyoungpeopletocitiesinsearch

ofjobs,smallerfamiliesandmorewomen

enteringtheformalworkforcemeanthatfewer

peopleareavailabletocareforolderpeople

whentheyneedassistance.


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2.ActiveAgeing:TheConceptandRationale

Ifageingistobeapositiveexperience,

longerlifemustbeaccompaniedbycontinu-

ingopportunitiesforhealth,participationand

security.TheWorldHealthOrganizationhas

adoptedthetermactiveageingtoexpress

theprocessforachievingthisvision.

What is Active Agein g?

Activeageingistheprocessof

optimizingopportunitiesforhealth,

participationandsecurityinorder

toenhancequalityoflifeaspeople

age.

Activeageingappliestobothindividualsand

populationgroups.Itallowspeopletorealize

theirpotentialforphysical,social,andmental

wellbeingthroughoutthelifecourseandto

participateinsocietyaccordingtotheirneeds,

desiresandcapacities,whileprovidingthem

withadequateprotection,securityandcare

whentheyrequireassistance.

Thewordactivereferstocontinuingpartici-

pationinsocial,economic,cultural,spiritual

andcivicaffairs,notjusttheabilitytobe

physicallyactiveortoparticipateinthelabour

force.Olderpeoplewhoretirefromwork

andthosewhoareillorlivewithdisabilities

canremainactivecontributorstotheirfami-

lies,peers,communitiesandnations.Active

ageingaimstoextendhealthylifeexpectancy

andqualityoflifeforallpeopleastheyage,

includingthosewhoarefrail,disabledandin

needofcare.

Healthreferstophysical,mentalandsocial

wellbeingasexpressedintheWHOdefinition

ofhealth.Thus,inanactiveageingframe-

work,policiesandprogrammesthatpromote

mentalhealthandsocialconnectionsare

asimportantasthosethatimprovephysical

healthstatus.

Maintainingautonomyandindependenceas

onegrowsolderisakeygoalforbothindi-

vidualsandpolicymakers(seeboxondefini-

tions).Moreover,ageingtakesplacewithin

thecontextofothersfriends,workassoci-

ates,neighboursandfamilymembers.Thisis

whyinterdependenceaswellasintergenera-

tionalsolidarity(two-waygivingandreceiv-

ingbetweenindividualsaswellasolderand

youngergenerations)areimportanttenetsof

activeageing.Yesterdayschildistodaysadult

andtomorrowsgrandmotherorgrandfather.

Thequalityoflifetheywillenjoyasgrandpar-

entsdependsontherisksandopportunities

theyexperiencedthroughoutthelifecourse,

aswellasthemannerinwhichsucceeding

generationsprovidemutualaidandsupport

whenneeded.


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Somekeydefinitions

Autonomyistheperceivedab il ityto contro l,

co p ew ithan dmakep ersonaldecisionsaboutho wonelivesonaday-to -day basis,accord ingto oneso wnru lesan dprefer-ences.

Independenceiscommon lyunderstoodastheab il ityto p er for mfunctionsre latedtodailylivingi.e.thecapacityoflivingindependentlyinthecommun ityw ithnoand/orli tt lehelpfro mothers.

Qualityoflifeis anind ivid ualsperceptionofh isorherpositioninlifeinthecontextofthecultureandva luesyste mwheretheylive ,an dinre lat ionto theirgoals,expecta -tions,standardsandconcerns. Itisabroadrangingconcept,incorporatin ginaco m-p lexway apersonsp hysicalhealth,psycho log icalstate,leve lofindependence,social

re lat ionsh ips,p ersonalb eliefsandre lat ionsh iptosalientfeaturesintheenvironment.(WH O,1994).Aspeop leage,theirquali tyoflifeislargelydeterm inedbytheirab il ity to mainta inautonomyan dindependence.

Healthylifeexpectancyiscommon lyusedasasynonymfor d isab ili ty-fre elifeexpec-ta ncy.Whilelifeexpecta ncyat b irt hremainsanimportantmeasureofp o p ulat ionageing,howlongpeop lecanexpecttolivew ithoutd isab il itiesisesp eciallyimportant toanageingp o p ulat ion.

Withtheexce ptionofautonomywh ichisnotoriouslyd ifficultto measure,alloftheaboveconce ptshavebeenelaboratedbyattemptstomeasurethedegreeofd if-ficu ltyano ld erp ersonhasinp er for m ingactivitiesre latedto dailyliving (ADLs) andinstrumentalactivitiesofdailyliving (IA DLs).ADLsinclude,forexample,bath ing,eat ing,usingtheto iletandwalkingacrosstheroom . IA DLsincludeactivitiessuchasshop-p in g,houseworkandmealpreparation.Recently,anumberofva lidated,moreho listicmeasuresofhealth-re latedqualityoflifehavebeendevelo p e d.Th eseind icesneedtobesharedandadaptedforuseinavarietyofculturesandsett ings.

Thetermactiveageingwasadoptedbythe

WorldHealthOrganizationinthelate1990s.It

ismeanttoconveyamoreinclusivemessage

thanhealthyageingandtorecognizethefac-

torsinadditiontohealthcarethataffecthow

individualsandpopulationsage(Kalacheand

Kickbusch,1997).

Theactiveageingapproachisbasedonthe

recognitionofthehumanrightsofolder

peopleandtheUnitedNationsPrinciplesof

independence,participation,dignity,careand

self-fulfillment.Itshiftsstrategicplanningaway

fromaneeds-basedapproach(whichas-

sumesthatolderpeoplearepassivetargets)to

arights-basedapproachthatrecognizesthe

rightsofpeopletoequalityofopportunityand

treatmentinallaspectsoflifeastheygrow

older.Itsupportstheirresponsibilitytoexer-

cisetheirparticipationinthepoliticalprocess

andotheraspectsofcommunitylife.


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A Life Course Appr oach to Active

Agein g

Alifecourseperspectiveonageingrecognizes

thatolderpeoplearenotonehomogeneous

groupandthatindividualdiversitytendsto

increasewithage.Interventionsthatcreate

supportiveenvironmentsandfosterhealthy

choicesareimportantatallstagesoflife(see

Figure4).

Asindividualsage,noncommunicablediseases

(NCDs)becometheleadingcausesofmorbid-

ity,disabilityandmortalityinallregionsof

theworld,includingindevelopingcountries,

asshowninFigures5and6.NCDs,which

areessentiallydiseasesoflaterlife,arecostly

toindividuals,familiesandthepublicpurse.

ButmanyNCDsarepreventableorcanbe

postponed.Failingtopreventormanagethe

growthofNCDsappropriatelywillresultin

enormoushumanandsocialcoststhatwillab-

sorbadisproportionateamountofresources,

whichcouldhavebeenusedtoaddressthe

healthproblemsofotheragegroups.

*Changesintheenvironmentcanlowerthedisabilitythreshold, thusdecreasingthenumberofdisabledpeopleinagivencom-munity.

Functionalcapacity(suchasventilatorycapacity,muscularstrength, andcardiovascularoutput)increasesinchildhoodandpeaksinearlyadulthood, eventuallyfollowedbyadecline.Therateofdecline,however, islargelydeterminedbyfactorsrelatedtoadultlifestylesuchassmoking, alcoholconsumption, levelsofphysicalactivityanddietaswellasexternalandenvironmen-talfactors.Thegradientofdeclinemaybecomesosteepastoresultinprematuredisability.However, theaccelerationindeclinecanbeinfluencedandmaybereversibleatanyagethroughindividualandpublicpolicymeasures.


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Majorchronicconditionsaffectingolderpeopleworldwide Cardiovascu lard iseases

(suchascoronaryheartd isease)

Hypertension

Stroke

D iabetes

Ca ncer

Chronicobstructivep ulmonaryd isease

Muscu loske leta lcond itions(suchasarthritisan dosteoporosis)

Mentalhealthcond itions(mostlydement iaan ddepression)

Blindnessandvisualim pairment

Note:Thecausesofdisabilityinolderagearesimilarforwomenandmenalthoughwomenaremorelikelytoreportmusculoskeletalproblems.

Source:WHO,1998a

Intheearlyyears,communicablediseases,

maternalandperinatalcond itionsandnu-

tritionaldeficienciesarethemajorcausesof

deathanddisease.Inlaterchildhood,ado-

lescenceandyoungadulthood,injuriesand

noncommunicablecond itionsbegintoassume

amuchgreaterrole.Bymidlife(age45)and

inthelateryears,NCDsareresponsiblefor

thevastmajorityofdeathsanddiseases(see

Figures5and6).Researchisincreasingly

showingthattheoriginsofriskforchronic

cond itions,suchasdiabetesandheartdisease,

begininearlychildhoodorevenearlier.This

riskissubsequentlyshapedandmodifiedby

factors,suchassocio-economicstatusand

experiencesacrossthewholelifespan.The

riskofdevelopingNCDscontinuestoincrease

asindividualsage.Butitistobaccouse,lack

ofphysicalactivity,inadequatedietandother

establishedadultriskfactorswhichwillput

individualsatrelativelygreaterriskofdevelop-

ingNCDsatolderages(seeFigure7).Thus,

itisimportanttoaddresstherisksofnoncom-

municablediseasefromearlylifetolatelife,

i.e.throughoutthelifecourse.

Activ e Agein g Policies an dProgrammes

Anactiveageingapproachtopolicyand

programmedevelopmenthasthepotentialto

addressmanyofthechallengesofbothindi-

vidualandpopulationageing.Whenhealth,

labourmarket,employment,educationand

socialpoliciessupportactiveageingtherewill

potentiallybe:

fewerprematuredeathsinthehighlypro-

ductivestagesoflife

fewerdisabilitiesassociatedwithchronic

diseasesinolderage

morepeopleenjoyingapositivequalityof

lifeastheygrowolder

morepeopleparticipatingactivelyasthey

ageinthesocial,cultural,economicand

politicalaspectsofsociety,inpaidand

unpaidrolesandindomestic,familyand

communitylife

lowercostsrelatedtomedicaltreatment

andcareservices.


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Activeageingpoliciesandprogrammesrec-

ognizetheneedtoencourageandbalance

personalresponsibility(self-care),age-friendly

environmentsandintergenerationalsolidarity.

Individualsandfamiliesneedtoplanandpre-

pareforolderage,andmakepersonalefforts

toadoptpositivepersonalhealthpracticesat

allstagesoflife.Atthesametimesupport-

iveenvironmentsarerequiredtomakethe

healthychoicestheeasychoices.

Therearegoodeconomicreasonsforenacting

policiesandprogrammesthatpromoteactive

ageingintermsofincreasedparticipationand

reducedcostsincare.Peoplewhoremain

healthyastheyagefacefewerimpediments

tocontinuedwork.Thecurrenttrendtoward

earlyretirementinindustrialisedcountriesis

largelytheresultofpublicpoliciesthathave

encouragedearlywithdrawalfromthelabour

force.Aspopulationsage,therewillbe

increasingpressuresforsuchpoliciesto

changeparticularlyifmoreandmoreindi-

vidualsreacholdageingoodhealth,i.e.are

fitforwork.Thiswouldhelptooffsetthe

risingcostsinpensionsandincomesecurity

schemesaswellasthoserelatedtomedical

andsocialcarecosts.

Withregardtorisingpublicexpenditures

form

edica

lcar

e,a

va

ila

bledata

incr

ea

singlyindicatethatoldageitselfisnotassociated

withincreasedmedicalspending.Rather,itis

disabilityandpoorhealthoftenassociated

witholdagethatarecostly.Aspeopleage

inbetterhealth,medicalspendingmaynot

increaseasrapidly.


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Policymakersneedtolookatthefullpicture

andconsiderthesavingsachievedbydeclines

indisabilityrates.IntheUSAforexample,

suchdeclinesmightlowermedicalspend ing

byabout20percentoverthenext50years

(Cutler,2001).Between1982and1994,inthe

USA,thesavingsinnursinghomecostsalone

wereestimatedtoexceed$17billion(Singer

andManton,1998).Moreover,ifincreased

numbersofhealthyolderpeoplewereto

extendtheirparticipationintheworkforce

(througheitherfullorpart-timeemployment),

theircontributiontopublicrevenueswould

continuouslyincrease.Finally,itisoftenless

costlytopreventdiseasethantotreatit.For

example,ithasbeenestimatedthataone-dol-

larinvestmentinmeasurestoencouragemod-

eratephysicalactivityleadstoacostsavingof

$3.2inmedicalcosts(U.S.CentersforDisease

Control,1999).


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Activeageingdependsonavarietyofinflu-

encesordeterminantsthatsurroundindivid-

uals,familiesandnations.Understandingthe

evidencewehaveaboutthesedeterminants

helpsusdesignpoliciesandprogrammesthat

work.

Thefollowingsectionsummarizeswhatwe

knowabouthowthebroaddeterminantsof

healthaffecttheprocessofageing.These

determinantsapplytothehealthofallage

groups,althoughtheemphasishereisonthe

healthandqualityoflifeofolderpersons.At

thispoint,itisnotpossibletoattributedirect

causationtoanyonedeterminant;however,

thesubstantialbodyofevidenceonwhat

determineshealthsuggeststhatallofthese

factors(andtheinterplaybetweenthem)are

goodpredictorsofhowwellbothindividuals

andpopulationsage.Moreresearchisneeded

toclarifyandspecifytheroleofeachdeter-

minant,aswellastheinteractionbetween

determinants,intheactiveageingprocess.We

alsoneedtobetterunderstandthepathways

thatexplainhowthesebroaddeterminants

actuallyaffecthealthandwellbeing.

Moreover,itishelpfultoconsidertheinflu-

enceofvariousdeterminantsoverthelife

coursesoastotakeadvantageoftransitions

andwindowsofopportunityforenhancing

health,participationandsecurityatdifferent

stages.Forexample,thereisevidencethat

stimulationandsecureattachmentsininfancy

influenceanindividualsabilitytolearnand

3.TheDeterminantsofActiveAgeing:UnderstandingtheEvidence


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PAGE20

getalongwithothersthroughoutallofthe

laterstagesoflife.Employment,whichisa

determinantthroughoutadultlifegreatlyinflu-

encesone sfinancialreadinessforoldage.Ac-cesstohighquality,dignifiedlong-termcareis

particularlyimportantinlaterlife.Often,asis

thecasewithexposuretopollution,theyoung

andtheoldarethemostvulnerablepopula-

tiongroups.

Cross-Cutting Determinants: Culture

and Gender

Cultureisacross-cuttingdeterminantwithinthe

frameworkforunderstandingactiveageing.

Culture, w hich surr ounds all indi-

viduals and p op ulation s, sh ap es th e

way in which we age because it in flu-

ences all of the other deter minants

of active ageing.

Culturalvaluesandtraditionsdeterminetoa

largeextenthowagivensocietyviewsolder

peopleandtheageingprocess.Whensocieties

aremorelikelytoattributesymptomsofdis-

easetotheageingprocess,theyarelesslikely

toprovideprevention,earlydetectionand

appropriatetreatmentservices.Cultureisa

keyfactorinwhetherornotco-residencywith

youngergenerationsisthepreferredwayof

living.Forexample,inmostAsiancountries,

theculturalnormistovalueextendedfami-

liesandtolivetogetherinmultigenerational

households.Culturalfactorsalsoinfluence

health-seekingbehaviours.Forexample,at-

titudestowardsmokingaregraduallychanging

inarangeofcountries.

Thereisenormousculturaldiversityandcom-

plexitywithincountriesandamongcountries

andregionsoftheworld.Forexample,diverse

ethnicitiesbringavarietyofvalues,attitudes

andtraditionstothemainstreamculturewithin

acountry.Policiesandprogrammesneedto

respectcurrentculturesandtraditionswhile

de-bunkingoutdatedstereotypesandmisinfor-

mation.Moreover,therearecriticaluniversal

valuesthattranscendculture,suchasethics

andhumanrights.

Gender is a lens thr ough wh ich to

consider the approp riateness of vari-

ous policy options and how they will

affect the well being of both men

and women.

Inmanysocieties,girlsandwomenhave

lowersocialstatusandlessaccesstonutri-

tiousfoods,education,meaningfulworkand

healthservices.Womenstraditionalroleas

familycaregiversmayalsocontributetotheir

increasedpovertyandillhealthinolderage.

Somewomenareforcedtogiveuppaidem-

ploymenttocarryouttheircaregivingrespon-

sibilities.Othersneverhaveaccesstopaid

employmentbecausetheyworkfull-timein

unpaidcaregivingroles,lookingafterchildren,

olderparents,spouseswhoareillandgrand-

children.Atthesametime,boysandmenare

morelikelytosufferdebilitatinginjuriesor

deathduetoviolence,occupationalhazards,

andsuicide.Theyalsoengageinmorerisk-

takingbehaviourssuchassmoking,alcoho l

anddrugconsumptionandunnecessaryexpo-

suretotheriskofinjury.


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PAGE21


Determinants Related to Health and

Social Serv ice Systems

To p r omo te active ageing, healthsystems n eed to take a life course

per sp ectiv e th at fo cuses o n health

pr om otio n, disease pr ev en tio n an d

equitable access to quality pr imar y

health care an d long-term care.

Healthandsocialservicesneedtobeinte-

grat

ed,coor

dinat

eda

ndcost

-effect

ive.Ther

emustbenoagediscriminationintheprovision

ofservicesandserviceprovidersneedtotreat

peopleofallageswithdignityandrespect.

HealthPromotionandDiseasePrevention

Healthpromotionistheprocessofenabling

peopletotakecontroloverandtoimprove

theirhealth.Diseasepreventionincludesthe

preventionandmanagementofthecond itions

thatareparticularlycommonasindividuals

age:noncommunicablediseasesandinjuries.

Preventionrefersbothtoprimarypreven-

tion(e.g.avoidanceoftobaccouse)aswell

assecondaryprevention(e.g.screeningfor

theearlydetectionofchronicdiseases),or

tertiaryprevention,e.g.appropriateclini-

calmanagementofdiseases.Allcontributeto

r

educing

t

heri

skofdisa

biliti

es.Disea

sepr

e-

ventionstrategieswhichmayalsoaddress

infectiousdiseasessavemoneyatanyage.

Forexample,vaccinatingolderadultsagainst

influenzasavesanestimated$30to$60in

treatmentcostsper$1spentonvaccines(U.S.

DepartmentofHealthandHumanServices,

1999).

CurativeServices

Despitebesteffortsinhealthpromotionand

diseaseprevention,peopleareatincreasing

riskofdevelopingdiseasesastheyage.Thus

accesstocurativeservicesbecomesindispens-

able.Asthevastmajorityofolderpersons

inanygivencountryliveinthecommunity,

mostcurativeservicesmustbeofferedbythe

primaryhealthcaresector.Thissectorisbest

equ ippedto.makereferralstothesecondary

andtertiarylevelsofcarewheremostacute

andemergencycareisalsoprovided .

Ultimately,theworldwideshiftintheglobal

burdenofdiseasetowardchronicdiseases

requiresashiftfromafinditandfixitmodel

toacoordinatedandcomprehensivecontin-

uumofcare.Thiswillrequireareorientation

inhealthsystemsthatarecurrentlyorganized

aroundacute,episodicexperiencesofdis-

ease.Thepresentacutecaremode lsofhealth

servicedeliveryareinadequatetoaddressthehealthneedsofrapidlyageingpopulations

(WHO,2001).

Asthepopulationages,thedemandwillcon-

tinuetoriseformedicationsthatareusedto

delayandtreatchronicdiseases,alleviatepain

andimprovequalityoflife.Thiscallsfora

renewedefforttoincreaseaffordableaccessto

essentialsafemedicationsandtobetterensure

theappropriate,cost-effectiveuseofcurrent

andnewdrugs.Partnersinthiseffortneedto

includegovernments,healthprofessionals,the

pharmaceuticalindustry,traditionalhealers,

employersandorganizationsrepresenting

olderpeople.


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PAGE22

Long-termcare

Long-termcareisdefinedbyWHOasthe

systemofactivitiesundertakenbyinformal

caregivers(family,friendsand/orneighbours)

and/orprofessionals(healthandsocialser-

vices)toensurethatapersonwhoisnotfully

capableofself-carecanmaintainthehighest

possiblequalityoflife,accordingtohisor

herindividualpreferences,withthegreatest

possibledegreeofindependence,autonomy,

participation,personalfulfillmentandhuman

dignity(WHO,2000b).

Thus,long-termcareincludesbothinformal

andformalsupportsystems.Thelattermay

includeabroadrangeofcommunityservices

(e.g.,publichealth,primarycare,homecare,

rehabilitationservicesandpalliativecare)as

wellasinstitutionalcareinnursinghomesand

hospices.Italsoreferstotreatmentsthathalt

orreversethecourseofdiseaseanddisability.

MentalHealthServices

Mentalhealthservices,whichplayacrucial

roleinactiveageing,shou ldbeanintegral

partoflong-termcare.Particularattention

needstobepaidtotheunder-diagnosisof

mentalillness(especiallydepression)and

tosuicideratesamongolderpeople(WHO,

2001a).

Behavioural Determinants

The adoption of healthy lifestyles

and actively participating in ones

own care ar e impor tant at all stages

of the life course. One of the my ths

of ageing is that it is too late to adop t

such lifestyles in the later year s. On

the contrary , engaging in appr opr i-

ate physical activity, healthy eating,

not smokin g and using alcohol and

medications wisely in older age can

prev en t disease an d f un ctional de-

cline, extend longevity and en hance

on es quality of life.

TobaccoUse

Smokingisthemostimportantmodifiable

riskfactorforNCDsforyoungandoldalike

andamajorpreventablecauseofpremature

death.Smokingnotonlyincreasestherisk

fordiseasessuchaslungcancer,itisalso

negativelyrelatedtofactorsthatmaylead

toimportantlossesinfunctionalcapacity.

Forexample,smokingacceleratestherateof

declineofbonedensity,muscularstrengthand

respiratoryfunction.Researchontheeffects

ofsmokingrevealednotjustthatsmokingisa

riskfactorforalargeandincreasingnumber

ofdiseasesbutalsothatitsilleffectsarecu-

mulativeandlonglasting.Theriskofcontract-

ingatleastoneofthediseasesassociatedwith

smokingincreaseswiththedurationandthe

amountofexposure.


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24/60

PAGE24

activityandareorganizedandledbyolder

peoplethemselves.Professionaladvicetogo

fromdoingnothingtodoingsomethingand

physicalrehabilitationprogrammesthathelpolderpeoplerecoverfrommobilityproblems

arebotheffectiveandcost-efficient.

Intheleastdevelopedcountries,theoppo-

siteproblemmayoccur.Inthesecountries,

individualsareoftenengagedinstrenuous

physicalworkandchoresthatmayhasten

disabilities,causeinjuriesandaggravateprevi-

ouscond itions,especiallyastheyapproach

oldage.Thismayincludeheavycaregiving

responsibilitiesforillanddyingrelatives.

Healthpromotioneffortsintheseareasshou ld

bedirectedatprovidingrelieffromrepetitive,

strenuoustasksandmakingadjustmentsto

unsafephysicalmovementsatworkthatwill

decreaseinjuriesandpain.Olderpeoplewho

regularlyengageinvigorousphysicalwork

needopportunitiesforrestandrecreation.

HealthyEating

Eatingandfoodsecurityproblemsatallages

includebothunder-nutrition(mostly,butnot

exclusively,intheleastdevelopedcountries)

andexcessenergyintake.Inolderpeople,

malnutritioncanbecausedbylimitedaccess

tofood,socioeconomichardships,alackof

informationandknowledgeaboutnutrition,

poorfoodchoices(e.g.,eatinghighfatfoods),

diseaseandtheuseofmedications,toothloss,

socialisolation,cognitiveorphysicaldisabili-

tiesthatinhibitone sabilitytobuyfoodsand

preparethem,emergencysituationsandalack

ofphysicalactivity.

Excessenergyintakegreatlyincreasestherisk

forobesity,chronicdiseasesanddisabilitiesas

peoplegrowolder.

Diets high in (saturated) fat and

salt, low in fr uits and vegetables and

providing in suffi cient amoun ts offibr e and vitamins combined with

sedentarism, are m ajor r isks factors

for chr onic conditions like diabetes,

cardiovascular disease, high blood

pressure, obesity , ar th r itis an d some

cancers.

InsufficientcalciumandvitaminDisassoci-

atedwithalossofbonedensityinolderage

andconsequentlyanincreaseinpainful,costly

anddeb ilitatingbonefractures,especiallyin

olderwomen.Inpopulationswithhighfrac-

tureincidence,riskcanbedecreasedthrough

ensuringadequatecalciumandvitaminD

intake.

OralHealth

Poororalhealthprimarilydentalcaries,

periodontaldiseases,toothlossandoralcan-

cercauseothersystemichealthproblems.

Theycreateafinancialburdenforindividuals

andsocietyandcanreduceself-confidence

andqualityoflife.Studiesshowthatpoor

oralhealthisassociatedwithmalnutritionand

thereforeincreasedrisksforvariousnoncom-

municablediseases.Oralhealthpromotion

andcavitypreventionprogrammesdesigned

toencouragepeopletokeeptheirnatural

teethneedtobeginearlyinlifeandcontinue

overthelifecourse.Becauseofthepainand

reducedqualityoflifeassociatedwithoral

healthproblems,basicdentaltreatmentservic-

esandaccessibilitytodenturesarerequired.


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PAGE25


Alcohol

Whileolderpeopletendtodrinklessthan

youngerpeople,metabolismchangesthat

accompanyageingincreasetheirsuscepti-

bilitytoalcohol-relateddiseases,including

malnutritionandliver,gastricandpancreatic

diseases.Olderpeoplealsohavegreaterrisks

foralcoho l-relatedfallsandinjuries,aswellas

thepotentialhazardsassociatedwithmixing

alcoho landmedications.Treatmentservices

foralcoho lproblemsshouldbeavailableto

olderpeopleaswellasyoungerpeople.

AccordingtoarecentWHOreviewofthe

literature,thereisevidencethatalcoho luseat

verylowlevels(uptoonedrinkaday)may

offersomeformofprotectionagainstcoronary

heartdiseaseandstrokeforpeopleage45and

over.However,intermsofoverallexcessmor-

tality,theadverseeffectsofdrinkingoutweigh

anyprotectionagainstcoronaryheartdisease,

eveninhighriskpopulations(Jerniganetal.,2000).

Medications

Becauseolderpeopleoftenhavechronic

healthproblems,theyaremorelikelythan

youngerpeopletoneedandusemedications

traditional,over-the-counterandprescribed.

Inmostcountries,olderpeoplewithlow

incomeshavelittleornoaccesstoinsuranceformedications.Asaresult,manygowithout

orspendaninappropriatelylargepartoftheir

meagerincomesondrugs.

Incontrast,medicationsaresometimesover-

prescribedtoolderpeople(especiallytoolder

women)whohaveinsuranceorthemeans

topayforthesedrugs.Adversedrug-related

reactionsandfallsassociatedwithmedication

use(especiallysleepingpillsandtranqu ilizers)

aresignificantcausesofpersonalsufferingand

costlypreventablehospitaladmissions(Gur-

witzandAvorn,1991).

Iatrogenesishealthproblemsthatare

inducedbydiagnosesortreatmentscaused

bytheuseofdrugsiscommoninoldage,

duetotheinteractionofdrugs,inadequate

dosagesandahigherfrequencyofunpredict-

ablereactionsthroughunknownmechanisms.

Withtheadventofmanynewtherapies,there

isanincreasingneedtoestablishsystemsfor

preventingadversedrugreactionsandfor

informingbothhealthprofessionalsandthe

ageingpublicabouttherisksandbenefitsof

moderntherapies.

Adherence

Accesstoneededmedicationsisinsufficientin

itselfunlessadherencetolong-termtherapy

forageing-relatedchronicillnessesishigh.

Adherenceincludestheadoptionandmain-

tenanceofawiderangeofbehaviours(e.g.,

healthydiet,physicalactivity,notsmoking),

aswellastakingmedicationsasdirectedby

ahealthprofessional.Itisestimatedthatin

developedcountriesadherencetolong-term

therapyaveragesonly50percent.Indevelop-

ingcountriestheratesareevenlower.Such

pooradherenceseverelycompromisesthe

effectivenessoftreatmentsandhasdramatic

qualityoflifeandeconomicimplicationsfor

publichealth.Populationhealthoutcomespre-

dictedbytreatmentefficacydatacanonlybe

achievedifadherenceinformationisprovided

toallhealthprofessionalsandplanners.With-

outasystemthataddressestheinfluenceson

adherence,advancesinbiomedicaltechno l-


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PAGE26

ogywillfailtorealizetheirpotentialtoreduce

theburdenofchronicdisease(Dipollinaand

Sabate,2002).

Determ inan ts Related to Person al

Factors

BiologyandGenetics

Biologyandgeneticsgreatlyinfluencehowa

personages.Ageingisasetofbiologicalpro-

cessesthataregeneticallydetermined.Ageing

canbedefinedasaprogressive,generalized

impairmentoffunctionresultinginalossof

adaptativeresponsetoastressandinagrow-

ingriskofage-associateddisease(Kirkwood ,

1996).Inotherwords,themainreasonwhy

olderpersonsgetsickmorefrequentlythan

youngerpersonsisthat,duetotheirlonger

lives,theyhavebeenexposedtoexternal,

behavioural,andenvironmentalfactorsthat

causediseaseforalongertimethantheir

youngercounterparts(Gray,1996).

While genesmaybeinvolvedinthe

causationofdisease,formany

diseasesthe causeisenvironmental

andexternaltoagreaterdegree

thanitisgeneticandinternal.

Itshouldalsobenotedthatthereisevidence

inhumanpopulationsthatlongevitytends

toruninfamilies.But,allthingsconsidered,

thereisgeneralagreementthatthelifelong

trajectoryofhealthanddiseaseforanindi-

vidualistheresultofacombinationofgenet-

ics,environment,lifestyle,nutrition,andtoan

importantextent,chance(Kirkwood,1996).

Therefore,theinfluenceofgeneticsonthe

developmentofchroniccond itionssuchas

diabetes,heartdisease,AlzheimersDisease

andcertaincancersvariesgreatlyamongindi-viduals.Formanypeople,lifestylebehaviours

suchasnotsmoking,personalcopingskills

andanetworkofclosekinandfriendscan

effectivelymodifytheinfluenceofheredityon

functionaldeclineandtheonsetofdisease.

PsychologicalFactors

Psychologicalfactorsincludingintelligence

andcognitivecapacity(forexample,theabilitytosolveproblemsandadapttochangeand

loss)arestrongpredictorsofactiveageingand

longevity(Smitsetal.,1999).Duringnormal

ageing,somecognitivecapacities(including

learningspeedandmemory)naturallyde-

clinewithage.However,theselossescanbe

compensatedbygainsinwisdom,knowledge

andexperience.Often,declinesincognitive

functioningaretriggeredbydisuse(lackofpractice),illness(suchasdepression),behav-

iouralfactors(suchastheuseofalcoho land

medications),psychologicalfactors(suchas

lackofmotivation,lowexpectationsandlack

ofconfidence),andsocialfactors(suchas

lonelinessandisolation),ratherthanageing

perse.

Otherpsychologicalfactorsthatareacquired

acrossthelifecoursegreatlyinfluencethe

wayinwhichpeopleage.Self-efficacy(the

beliefpeoplehaveintheircapacitytoexert

controlovertheirlives)islinkedtopersonal

behaviourchoicesasoneagesandtoprepara-

tionforretirement.Copingstylesdetermine

howwellpeopleadapttothetransitions(such

asretirement)andcrisesofageing(suchas

bereavementandtheonsetofillness).


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PAGE27


Menandwomenwhoprepareforoldageand

areadaptabletochangemakeabetteradjust-

menttolifeafterage60.Mostpeopleremain

resilientastheyageand,onthewhole,older

peopledonotvarysignificantlyfromyounger

peopleintheirabilitytocope.

Determ inan ts Related to the Phy sical

Environment

PhysicalEnvironments

Physicalenvironmentsthatareagefriendly

canmakethedifferencebetweenindepen-

denceanddependenceforallindividualsbut

areofparticularimportanceforthosegrow-

ingolder.Forexample,olderpeoplewho

liveinanunsafeenvironmentorareaswith

multiplephysicalbarriersarelesslikelytoget

outandthereforemorepronetoisolation,

depression,reducedfitnessandincreased

mobilityproblems.

Specificattentionmustbegiventoolderpeo-plewholiveinruralareas(some60percent

worldwide)wherediseasepatternsmaybe

differentduetoenvironmentalcond itionsand

alackofavailablesupportservices.Urbaniza-

tionandthemigrationofyoungerpeoplein

searchofjobsmayleaveolderpeopleisolated

inruralareaswithlittlemeansofsupportand

littleornoaccesstohealthandsocialservices.

Accessibleandaffordablepublictransporta-

tionservicesareneededinbothruraland

urbanareassothatpeopleofallagescanfully

participateinfamilyandcommunitylife.This

isespeciallyimportantforolderpersonswho

havemobilityproblems.

Hazardsinthephysicalenvironmentcanlead

todebilitatingandpainfulinjuriesamong

olderpeople.Injuriesfromfalls,firesandtraf-

ficcollisionsarethemostcommon.

Safe Housing

Safe,adequatehousingandneighbourhoods

areessentialtothewellbeingofyoungand

old.Forolderpeople,location,including

proximitytofamilymembers,servicesand

transportationcanmeanthedifferencebe-

tweenpositivesocialinteractionandisolation.

Buildingcodesneedtotakethehealthand

safetyneedsofolderpeopleintoaccount.

Householdhazardsthatincreasetheriskof

fallingneedtoberemediedorremoved.

Worldwide,thereisanincreasingtrendforolderpeopletolivealoneespeciallyunat-

tachedolderwomenwhoaremainlywidows

andareoftenpoor,evenindevelopedcoun-

tries.Othersmaybeforcedtoliveinarrange-

mentsthatarenotoftheirchoice,suchaswith

relativesinalreadycrowdedhouseholds.In

manydevelopingcountries,theproportionof

olderpeoplelivinginslumsandshantytowns

isrisingquicklyasmany,whomovedtothecitieslongago,havebecomelong-termslum-

dwellers,whileotherolderpeoplemigrateto

citiestojoinyoungerfamilymemberswho

havealreadymovedthere.Olderpeopleliving

inthesesettlementsareathighriskforsocial

isolationandpoorhealth.

Intimesofcrisisandconflict,displacedolder

peopleareparticularlyvulnerable.Oftenthey

areunabletowalktorefugeecamps.Even

iftheymakeittocamps,itmaybehardto

obtainshelterandfood,especiallyforolder

womenandolderpersonswithdisabilities

whoexperiencelowsocialstatusandmultiple

otherbarriers.


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PAGE28

Falls

Fallsamongolderpeoplearealargeand

increasingcauseofinjury,treatmentcostsand

death.Environmentalhazardsthatincrease

therisksoffallingincludepoorlighting,slip-

peryorirregularwalkingsurfacesandalack

ofsupportivehandrails.Mostoften,these

fallsoccurinthehomeenvironmentandare

preventable.

Theconsequencesofinjuriessustainedinold-

eragearemoreseverethanamongyounger

people.Forinjuriesofthesameseverity,olderpeopleexperiencemoredisability,longerhos-

pitalstays,extendedperiodsofrehabilitation,

ahigherriskofsubsequentdependencyanda

higherriskofdying.

The greatmajorityofinjuriesare

preventable;however,thetraditional

viewofinjuriesasaccidentshas

resultedinhistoricalneglectofthis

areainpublichealth.

CleanWater,CleanAirandSafeFoods

Cleanwater,cleanairandaccesstosafefoods

areparticularlyimportantforthemostvulner-

ablepopulationgroups,i.e.childrenandolder

persons,andforthosewhohavechronicill-

nessesandcompromisedimmunesystems.

Determ inan ts Related to the Social

Environment

Socialsupport,opportunitiesforeducation

andlifelonglearning,peace,andprotection

fromviolenceandabusearekeyfactorsin

thesocialenvironmentthatenhancehealth,

participationandsecurityaspeopleage.Lone-

liness,socialisolation,illiteracyandalack

ofeducation,abuseandexposuretoconflict

situationsgreatlyincreaseolderpeoplesrisks

fordisabilitiesandearlydeath.

SocialSupport

Inadequatesocialsupportisassociatednot

onlywithanincreaseinmortality,morbidity

andpsychologicaldistressbutadecreasein

overallgeneralhealthandwellbeing.Disrup-

tionofpersonalties,lone linessandconflictual

interactionsaremajorsourcesofstress,while

supportivesocialconnectionsandintimatere-

lationsarevitalsourcesofemotionalstrength(GirondaandLubben,inpress).InJapan,for

example,olderpeoplewhoreportedalack

ofsocialcontactwere1.5timesmorelikely

todieinthenextthreeyearsthanwerethose

withhighersocialsupport(Sugiswawaetal,

1994).

Olderpeoplearemorelikelytolosefamily

membersandfriendsandtobemorevulner-

abletolone liness,socialisolationandthe

availabilityofasmallersocialpool.Social

isolationandlone linessinoldagearelinked

toadeclineinbothphysicalandmental

wellbeing.Inmostsocieties,menareless

likelythanwomentohavesupportivesocial

networks.However,insomecultures,older

womenwhoarewidowedaresystematically

excludedfrommainstreamsocietyoreven

rejectedbytheircommunity.

Decision-makers,nongovernmentalorganiza-

tions,privateindustryandhealthandsocial

serviceprofessionalscanhelpfostersocial

networksforageingpeoplebysupportingtra-

ditionalsocietiesandcommunitygroupsrun

byolderpeople,voluntarism,neighbourhood

helping,peermentoringandvisiting,family

caregivers,intergenerationalprogrammesand

outreachservices.


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PAGE29


ViolenceandAbuse

Olderpeoplewhoarefrailorlivealonemay

feelparticularlyvulnerabletocrimessuchas

theftandassault.Acommonformofviolence

againstolderpeople(especiallyagainstolder

women)iselderabusecommittedbyfamily

membersandinstitutionalcaregiverswho

arewellknowntothevictims.Elderabuse

occursinfamiliesatalleconomiclevels.It

islikelytoescalateinsocietiesexperiencing

economicupheavalandsocialdisorganization

whenoverallcrimeandexploitationtendsto

increase.

AccordingtotheInternational

NetworkforthePreventionofElder

Abuse,elderabuseisasingleor

repeatedact,orlackofappropriate

actionoccurring withinanyrela-

tionshipwherethereisanexpecta-

tionoftrustwhichcausesharmor

distresstoanolderperson(Action

onElderAbuse 1995).

Elderabuseincludesphysical,sexual,psycho-

logicalandfinancialabuseaswellasneglect.

Olderpeoplethemselvesperceiveabuseas

includingthefollowingsocietalfactors:neglect

(socialexclusionandabandonment),violation

(human,legalandmedicalrights)anddepriva-

tion(choices,decisions,status,financesand

respect)(WHO/INPEA2002).Elderabuseis

aviolationofhumanrightsandasignificant

causeofinjury,illness,lostproductivity,isola-

tionanddespair.Typically,itisunderreported

inallcultures.

Confrontingandreducingelderabuserequires

amultisectoral,multidisciplinaryapproachin-

volvingjusticeofficials,lawenforcementoffi-

cers,healthandsocialserviceworkers,labour

leaders,spiritualleaders,faithinstitutions,

advocacyorganizationsandolderpeople

themselves.Sustainedeffortstoincreasepublic

awarenessoftheproblemandtoshiftvalues

thatperpetuategenderinequitiesandageist

attitudesarealsorequired.

EducationandLiteracy

Lowlevelsofeducationandilliteracyareas-sociatedwithincreasedrisksfordisabilityand

deathamongpeopleastheyage,aswellas

withhigherratesofunemployment.Education

inearlylifecombinedwithopportunitiesfor

lifelonglearningcanhelppeopledevelopthe

skillsandconfidencetheyneedtoadaptand

stayindependent,astheygrowolder.

Studieshaveshownthatemploymentprob-

lemsofolderworkersareoftenrootedintheir

relativelylowliteracyskills,notinageingper

se.Ifpeoplearetoremainengagedinmean-

ingfulandproductiveactivitiesastheygrow

older,thereisaneedforcontinuoustraining

intheworkplaceandlifelonglearningoppor-

tunitiesinthecommunity(OECD,1998).

Likeyoungerpeople,oldercitizensneedtrain-

inginnewtechno logies,especiallyinagricul-

tureandelectroniccommunication.Self-direct-

edlearning,increasedpracticeandphysical

adjustments(suchastheuseoflargeprint)

cancompensateforreductionsinvisualacuity,

hearingandshort-termmemory.Olderpeople

cananddoremaincreativeandflexible.Inter-

generationallearningbridgesagedifferences,

enhancesthetransmissionofculturalvalues

andpromotestheworthofallages.Studies

haveshownthatyoungpeoplewholearnwith


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PAGE30

olderpeoplehavemorepositiveandrealistic

attitudesabouttheoldergeneration.

Unfortunately,therecontinuetobestriking

disparitiesinliteracyratesbetweenmenand

women.In1995intheleastdevelopedcoun-

tries,31percentofadultwomenwereilliterate

comparedto20percentofadultmen(WHO,

1998a).

Econo mic Determ inan ts

Threeaspectsoftheeconomicenvironment

ha

veapart

icular

lysignifica

nteffec

ton

a

ct

iveageing:income,workandsocialprotection.

Income

Activeageingpoliciesneedtointersectwith

broaderschemestoreducepovertyatallages.

Whilepoorpeopleofallagesfaceanin-

creasedriskofillhealthanddisabilities,older

peopleareparticularlyvulnerable.Manyolder

people espec

ially

t

hosewhoar

efemal

e,live

aloneorinruralareas donothavereliableor

sufficientincomes.Thisseriouslyaffectstheir

accesstonutritiousfoods,adequatehousing

andhealthcare.Infact,studieshaveshown

thatolderpeoplewithlowincomesareone-

thirdaslikelytohavehighlevelsoffunction-

ingasthosewithhighincomes(Guralnickand

Kaplan,1989).

Themostvulnerableareolderwomenand

menwhohavenoassets,littleornosavings,

nopensionsorsocialsecuritypaymentsor

whoarepartoffamilieswithloworuncertain

incomes.Particularly,thosewithoutchildren

orfamilymembersoftenfaceanuncertain

futureandareathighriskforhomelessness

anddestitution.

SocialProtection

Inallcountriesoftheworld,familiesprovide

themajorityofsupportforolderpeoplewho

requirehelp.However,associetiesdevelop

andthetraditionofgenerationslivingtogether

beginstodecline,countriesareincreasingly

calledontodevelopmechanismsthatpro-

videsocialprotectionforolderpeoplewho

areunabletoearnalivingandarealoneand

vulnerable.Indevelopingcountries,older

peoplewhoneedassistancetendtorelyon

familysupport,informalservicetransfersand

personalsavings.Socialinsuranceprogrammes

inthesesettingsareminimalandinsome

casesredistributeincometominoritiesinthe

populationwhoarelessinneed.However,in

countriessuchasSouthAfricaandNamibia,

whichhaveanationaloldagepension,these

benefitsareamajorsourceofincomefor

manypoorfamiliesaswellastheolderadults

wholiveinthesefamilies.Themoneyfrom

thesesmallpensionsisusedtopurchasefood

forthehousehold,tosendchildrentoschoo l,

toinvestinfarmingtechno logiesandtoen-

suresurvivalformanyurbanpoorfamilies.

Indevelopedcountries,socialsecurity

measurescanincludeold-agepensions,

occupationalpensionschemes,voluntary

savingsincentives,compulsorysavingsfunds

andinsuranceprogrammesfordisability,

sickness,long-termcareandunemployment.

Inrecentyears,policyreformshavefavoured

amulti-pillaredapproachthatmixesstate

andprivatesupportforoldagesecurityand

encouragesworkinglongerandgradual

retirement(OECD,1998).


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PAGE31


Work

Throughouttheworld,ifmorepeople

wouldenjoyopportunitiesfordignified

work(properlyremunerated,inadequate

environments,protectedagainstthehazards)

earlierinlife,peoplewouldreacholdage

abletoparticipateintheworkforce.Thus,the

wholesocietywouldbenefit.Inallpartsofthe

world,thereisanincreasingrecognitionof

theneedtosupporttheactiveandproductive

contributionthatolderpeoplecananddo

makeinformalwork,informalwork,unpaid

activitiesinthehomeandinvoluntary

occupations.

Indevelopedcountries,thepotentialgain

ofencouragingolderpeopletowork

longerisnotbeingfullyrealized.Butwhen

unemploymentishigh,thereisoftena

tendencytoseereducingthenumberofolder

workersasawaytocreatejobsforyounger

people.However,experiencehasshownthat

theuseofearlyretirementtofreeupnewjobs

fortheunemployedhasnotbeenaneffective

solution(OECD,1998).

Inlessdevelopedcountries,olderpeopleare

bynecessitymorelikelytoremaineconomically

activeintooldage(seeFigure9).However,

industrialization,adoptionofnewtechnologies

andlabourmarketmobilityisthreatening

muchofthetraditionalworkofolderpeople,

particularlyinruralareas.Developmentprojects

needtoensurethatolderpeopleareeligiblefor

creditschemesandfullparticipationinincome-

generatingopportunities.


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PAGE32

Concentratingonlyon workinthe

formallabourmarkettendstoig-

norethevaluable contributionthatolderpeoplemakein workinthe

informalsector(e.g.,smallscale,

self-employedactivitiesanddomes-

tic work)andunpaidworkinthe

home.

Inbo thdevelopinganddevelopedcou n-

tries,olderpeopleoftentakeprimerespon -

sibili tyforho useholdmanagemen tand

childcaresothatyoungeradu ltscanwork

ou tside thehome.

Inallcountries,skilledandexperiencedolder

peopleactasvolunteersinschoo ls,commu-

nities,religiousinstitutions,businessesand

healthandpoliticalorganizations.Voluntary

workbenefitsolderpeoplebyincreasing

socialcontactsandpsychologicalwellbeing

whilemakingasignificantcontributiontotheir

communitiesandnations.


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PAGE33


Thechallengesofpopulationageingare

global,nationalandlocal.Meetingthesechal-

lengeswillrequireinnovativeplanningand

substantivepolicyreformsindevelopedcoun-

triesandincountriesintransition.Develop-

ingcountries,mostofwhomdonotyethave

comprehensivepoliciesonageing,facethe

biggestchallenges.

Challenge 1: The Double Burden

of Disease

Asnationsindustrialize,changingpatternsof

livingandworkingareinevitablyaccompanied

byashiftindiseasepatterns.Thesechanges

impactdevelopingcountriesmost.Evenas

thesecountriescontinuetostrugglewithinfec-

tiousdiseases,malnutritionandcomplications

fromchildbirth,theyarefacedwiththerapid

growthofnoncommunicablediseases(NCDs).

Thisdoubleburdenofdiseasestrainsalready

scarceresourcestothelimit.

TheshiftfromcommunicabletoNCDsisfast

occurringinmostofthedevelopingworld,

wherechronicillnessessuchasheartdisease,

canceranddepressionarequicklybecomingtheleadingcausesofmorbidityanddisabil-

ity.Thistrendwillescalateoverthenextfew

decades.In1990,51percentoftheglobal

burdenofdiseaseindevelopingandnewly

industrializedcountrieswascausedbyNCDs,

mentalhealthdisordersandinjuries.By2020,

theburdenofthesediseaseswillrisetoap-

proximately78percent(SeeFigure10).

By2020,over70percentoftheglobalburdenofdiseaseindevelopingandnewlyindustrializedcountrieswillbecausedbynoncommunicablediseases,mentalhealthdisordersandinjuries.

4.ChallengesofanAgeingPopulation


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PAGE34

Thereisnoquestionthatpolicymakersand

donorsmustcontinuetoputresourcesto-

wardthecontrolanderadicationofinfectious

diseases.Butitisalsocriticaltoputpolicies,

programmesandintersectoralpartnerships

intoplacethatcanhelptohaltthemassive

expansionofchronicNCDs.Whilenotneces-

sarilyeasytoimplement,thosethatfocuson

communitydevelopment,healthpromotion,

diseasepreventionandincreasingparticipa-

tionareoftenthemosteffectiveincontrol-

lingtheburdenofdisease.Furthermoreother

long-termpoliciesthattargetmalnutritionand

povertywillhelptoreducebothchroniccom-

municableandnoncommunicablediseases.

Supportforrelevantresearchismost

urgentlyneededforlessdevelopedcountries.

Currently,lowandmiddle-incomecountries

have85percentoftheworldspopulationand

92percentofthediseaseburden,butonly

10per

centoft

heworl

d

shealt

hr

esear

chspending(WHO,2000).

HIV/AIDSandolderpeopleInAfricaan dotherdevelop ingre g ions,HIV/ AIDShashadmultip leim pactsonolderpeop le,intermsoflivingw iththed iseasethemselves,car ingforotherswhoareinfect-edan dta kingontheparent ingro lew ithorphansofAIDS.Th isimpacthasbeenlargely

ignoredtodate.

Infact,

mostdataonHIVandAIDSinfectionratesareonlyco mp iledu pto age49 . Improved dataco llection (w ithoutageli m ita tions) thathelpsusbetterunderstandtheim pactofHIV/ AIDSono ld erpeop leisurgentlyneeded.HIV/ AIDSinfor-mat ion,ed ucat ionan dpreventionactivitiesaswellastreatmentser vicesshou ldap p lytoallages.

Numerousstud ieshavefoundthatmostadultch ildrenw ithAIDSreturnhometod ie.Wives,mothers,aunts,siste rs,siste rs-in-lawandgrandmotherstakeontheb ulkofthecare.Then,inmanycases,thesewomentakeonthecareoftheorphanedch ildren.Governments,nongovernmentalorgan iza tionsandpr ivatein dustryneedto addressthefinancial,socialandtra in ingneedsofolderpeop lewhocareforfam ilymembersandne ighbourswhoareinfecte dandra isechildsur vivo rs,so meofwhomthemse lvesarealsoinfecte d (WH O,2002).

Challenge 2: Increased Risk of

Disability

Inbothdevelopinganddevelopedcountries,

chronicdiseasesaresignificantandcostly

causesofdisabilityandreducedqualityoflife.

Anolderpersonsindependenceisthreatened

whenphysicalormentaldisabilitiesmakeitdif-

ficulttocarryouttheactivitiesofdailyliving.

Astheygrowolder,peoplewithdisabilities

arelikelytoencounteradditionalbarriersrelat-

edtotheageingprocess.Forexample,mobil-

ityproblemsduetopoliomyelitisinchildhood

maybeconsiderablyaggravatedlaterinlife.

Nowthatmanyyoungpeoplewithintellectual

disabilitiessurviveatmucholderagesandlive

beyondtheirparents,thisspecialgroupalso

requirescarefulattentionfrompolicymakers.

Manypeopledevelopdisabilitiesinlaterlife

relatedtothewearandtearofageing(e.g.,

art

hriti

s)ort

heonsetofa

chr

onicd

isea

se,


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PAGE35


whichcouldhavebeenpreventedinthefirst

place(e.g.,lungcancer,diabetesandperiph-

eralvasculardisease)oradegenerativeillness

(e.g.,dementia).Thelikelihoodofexperienc-ingseriouscognitiveandphysicaldisabilities

dramaticallyincreasesinveryoldage.Signifi-

cantly,adultsovertheageof80arethefastest

growingagegroupworldwide.

Butdisabilitiesassociatedwithageingandthe

onsetofchronicdiseasecanbeprevented

ordelayed.Forexample,asmentionedon

page18,therehasbeenasignificantdecline

overthelast20yearsinage-specificdisability

ratesintheU.S.A(seeFigure11),England,

Swedenandotherdevelopedcountries.

Figure10showstheactualdeclineindisabili-

tiesamongolderAmericansbetween1982

and1999comparedtotheprojectednumbers

ifratesofdisabilityhadremainedstableover

thattimeperiod.

Someofthisdeclineislikelyduetoincreased

educationlevels,improvedstandardsofliv-

ingandbetterhealthintheearlyyears.The

adoptionofpositivelifestylebehavioursis

alsoafactor.Asalreadymentioned,choosing

nottosmokeandmakingmodestincreasesin

physicalactivitylevelscansignificantlyreduce

one sriskforheartdiseaseandotherillnesses.

Supportivechangesinthecommunityare

alsoimportant,bothintermsofpreventing

disabilitiesandreducingtherestrictionsthat

peoplewithdisabilitiesoftenface.Inaddition,

impressiveprogressinthemanagementof

chroniccond itionshasbeenobserved,includ-

ingnewtechniquesforearlydiagnosisand

treatment,aswellaslong-termmanagement

ofchronicdiseases,suchashypertensionand

arthritis.Recentstudieshavealsoemphasized

thattheincreasinguseofaidsfromsimple

personalaids,suchascanes,walkers,hand-

rails,totechnologiesaimedatthepopulation

asawhole,suchastelephonesmayreduce


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PAGE36

dependenceamongdisabledpeople.Inthe

USAtheuseofsuchaidsbydependentolder

peopleincreasedfrom76percentin1984to

over90percentin1999(Cutler,2001).

VisionandHearing

Othercommonage-relateddisabilitiesinclude

visionandhearinglosses.Worldwide,there

arecurrently180millionpeoplewithvisual

disability,upto45millionofwhomareblind.

Mostoftheseareolderpeople,asvisualim-

pairmentandblindnessincreasesharplywith

age.Overall,approximatelyfourpercentofpersonsaged60yearsandabovearethought

tobeblind,and60percentofthemlivein

Sub-SaharanAfrica,ChinaandIndia.Thema-

jorage-relatedcausesofblindnessandvisual

disabilityincludecataracts(nearly50percent

ofallblindness),glaucoma,maculardegenera-

tionanddiabeticretinopathy(WHO,1997).

Thereisanurgentneedforpoliciesandpro-

grammesdesignedtopreventvisualimpair-

mentandtoincreaseappropriateeyecare

services,particularlyindevelopingcountries.

Inallcountries,correctivelensesandcataract

surgeryshouldbeaccessibleandaffordable

forolderpeoplewhoneedthem.

Hearingimpairmentleadstooneofthemost

widespreaddisabilities,particularlyinolder

people.Itisestimatedthatworldwideover

50percentofpeopleaged65yearsandover

havesomedegreeofhearingloss(WHO,

2002a).Hearinglosscancausedifficultieswith

communication.This,inturncanleadtofrus-

tration,lowself-esteem,withdrawalandsocial

isolation(Pal,1974,Wilson,1999).

Policiesandprogrammesneedtobeinplace

toreduceandeventuallyeliminateavoidable

hearingimpairmentandtohelppeoplewith

hearinglossobtainhearingaids.Hearingloss

maybepreventedbyavoidingexposureto

excessivenoiseandtheuseofpotentially

damagingdrugsandbyearlytreatmentofdis-

easesleadingtohearingloss,suchasmiddle

earinfections,diabetesandpossiblyhyperten-

sion.Hearinglosscansometimesbetreated,

especiallyifthecauseisintheearcanalor

middleear.Mostoften,however,thedisability

isreducedbyamplificationofsounds,usually

byusingahearingaid.

AnEnablingEnvironment

Aspopulationsaroundtheworldlivelonger,

policiesandprogrammesthathelpprevent

andreducetheburdenofdisabilityinold

ageareurgentlyneededinbothdeveloping

anddevelopedcountries.Oneusefulwayto

lookatdecision-makinginthisareaistothinkaboutenablementinsteadofdisablement.Dis-

ablingprocessesincreasetheneedsofolder

peopleandleadtoisolationanddependence.

Enablingprocessesrestorefunctionand

expandtheparticipationofolderpeopleinall

aspectsofsociety.

Avarietyofsectorscanenactage-friendly

policiesthatpreventdisabilityandenable

thosewhohavedisabilitiestofullyparticipate

incommunitylife.Herearesomeexamplesof

enablingprogrammes,environmentsandpoli-

ciesinavarietyofsectors:

barrier-freeworkplaces,flexiblework

hours,modifiedworkenvironmentsand

part-timeworkforpeoplewhoexperience

disabilitiesastheyageorarerequiredto

careforotherswithdisabilities(private

industryandemployers)


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PAGE37


well-litstreetsforsafewalking,accessible

publictoiletsandtrafficlightsthatgive

peoplemoretimetocrossthestreet(local

governments)

exerciseprogrammesthathelpolder

peoplemaintaintheirmobilityorrecover

thelegstrengththeyneedtobemobile

(recreationservicesandnongovernmental

agencies)

life-longlearningandliteracyprogrammes

(educationsectorandnongovernmental

organizations)

hearingaidsorinstructioninsignlanguage

thatenablesolderpeoplewhoarehardof

hearingtocontinuetocommunicatewith

others(socialservicesandnongovernmen-

talorganizations)

barrier-freeaccesstohealthcentres,reha-

bilitationprogrammesandcost-effective

proceduressuchascataractsurgeryandhip

replacements(healthsector)

creditschemesandaccesstosmallbusi-

nessanddevelopmentopportunitiessothat

olderpeoplecancontinuetoearnaliving

(governmentsandinternationalagencies).

Changingtheattitudesofhealthandsocial

ser

vicep

r

ovide

r

sisp

aramoun

tt

oensuri

ngt

hat

theirpracticesenableandempowerindividu-

alstoremainasautonomousandindependent

aspossibleforaslongaspossible.Profession-

alcaregiversneedtorespectolderpeoples

dignityatalltimesandtobecarefultoavoid

prematureinterventionsthatmayunintention-

allyinducethelossofindependence.

Researchersneedtobetterdefineandstan-

dardizethetoolsusedtoassessabilityand

disabilityandtoprovidepolicymakerswith

additionalevidenceonkeyenablingprocesses

inthebroaderenvironment,aswellasinmed-

icineandhealth.Carefulattentionneedstobe

paidtogenderdifferencesintheseanalyses.

Challen ge 3: Pr oviding Care for

Agein g Populations

Aspopulationsage,oneofthegreatestchal-

lengesinhealthpolicyistostrikeabalance

amongsupportforself-care(peoplelook-ingafterthemselves),informalsupport(care

fromfamilymembersandfriends)andformal

care(healthandsocialservices).Formalcare

includesbothprimaryhealthcare(delivered

mostlyatthecommunitylevel)andinstitution-

alcare(eitherinhospitalsornursinghomes).

Whileitisclearthatmostofthecareindividu-

alsneedisprovidedbythemselvesortheir

informalcaregivers,mostcountriesallottheir

financialresourcesinversely,i.e.,thegreatest

shareofexpenditureisoninstitutionalcare.

Allovertheworld,familymembers,friends

andneighbours(mostofwhomarewomen)

providethebulkofsupportandcaretoolder

adultsthatneedassistance.Somepolicymak-

ersfearthatprovidingmoreformalcareser-

viceswilllessent

heinvolvem

entoff

amilies.

Studiesshowthatthisisnotthecase.When

appropriateformalservicesareprovided,

informalcareremainsthekeypartner(WHO,

2000c).Ofconcernthougharerecentdemo-

graphictrendsinalargenumberofcountries

indicatingtheincreaseintheproportionof

childlesswomen,changesindivorceandmar-

riagepatternsandtheoverallmuchsmaller

num

berofchild

renoffu

turecoho

rtsofolde

r

people,allcontributingtoashrinkingpoolof

familysupport(Wolf,2001).


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PAGE38

Formalcarethroughhealthandsocialservice

systemsneedstobeequallyaccessibletoall.

Inmanycountriesolderpeoplewhoarepoor

andwholiveinruralareashavelimitedor

noaccesstoneededhealthcare.Adeclinein

publicsupportforprimaryhealthcareservices

inmanyareashasputincreasedfinancialand

intergenerationalstrainonolderpeopleand

theirfamilies.

Mostolderpersonsinneedofcarepreferto

becaredforintheirownhomes.Butcare-

givers(whoareoftenolderpeople)mustbe

supportediftheyaretocontinuetoprovide

carewithoutbecomingillthemselves.Above

all,theyneedtobewellinformedaboutthe

conditiontheyarefacedwithandhowitis

likelytoprogress,andabouthowtoobtain

thesupportservicesthatareavailable.Visiting

nurses,homecare,peersupportprogrammes,

rehabilitationservices,theprovisionof

assistivedevices(rangingfrombasicdevices

suchasahearingaidtomoresophisticated

ones,suchasanelectronicalarmsystem),

respitecareandadultdaycareareallimpor-tantservicesthatenableinformalcaregiversto

continuetoprovidecaretoindividualswho

requirehelp,whatevertheirage.Otherforms

ofsupportincludetraining,incomesecurity

(e.g.,socialsecuritycoverageandpensions),

helpwithhousingadjustmentsthatenable

familiestolookafterpeoplewhoaredisabled

anddisbursementstohelpcovercaringcosts.

Astheproportionofolderpeopleincreasesin

allcountries,livingathomeintoveryoldage

withhelpfromfamilymemberswillbecome

increasinglycommon.Homecareandcom-

munityservicestoassistinformalcaregivers

needtobeavailabletoall,notjusttothose

whoknowaboutthemorcanaffordtopay

forthem.

Sexratiosforpopulationsage60andoverreflectthelargerproportionofwomenthanmeninallregionsoftheworld,particularlyinthemoredevelopedregions.


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PAGE39


Professionalcaregiversalsoneedtraining

andpracticeinenablingmode lsofcarethat

recognizeolderpeoplesstrengthsandem-

powerthemtomaintainevensmallmeasures

ofindependencewhentheyareillorfrail.

Paternalisticordisrespectfulattitudesbypro-

fessionalscanhaveadevastatingeffectonthe

self-esteemandindependenceofolderpeople

whorequireservices.

Informationandeducationaboutactiveage-

ingneedstobeincorporatedintocurricula

andtrainingprogrammesforallhealth,social

serviceandrecreationworkersaswellascity

plannersandarchitects.Basicprinciplesand

approachesinold-agecareshou ldbemanda-

toryinthetrainingofallmedicalandnursing

studentsaswellasotherhealthprofessions.

Challenge 4: The Feminization of

Agein g

Womenlivelongerthanmenalmostevery-

where.Thisisreflectedinthehigherratioof

womenversusmeninolderagegroups.For

example,in2002,therewere678menfor

every1,000womenaged60plusinEurope.

Inlessdevelopedregions,therewere879men

per1,000women(SeeFigure12).Women

makeupapproximatelytwo-thirdsofthe

populationoverage75incountriessuchas

BrazilandSouthAfrica.Whilewomenhave

theadvantageinlengthoflife,theyaremore

likelythanmentoexperiencedomesticvio-

lenceanddiscriminationinaccesstoeduca-

tion,income,food ,meaningfulwork,health

care,inheritances,socialsecuritymeasuresand

politicalpower.Thesecumulativedisadvan-

tagesmeanthatwomenaremorelikelythan

Incontrasttothepyramidform,theJapanesepopulationstructurehaschangedduetopopulationageingtowardsaconeshape.By2025,theshapewillbesimilartoanup-side-downpyramid,withpersonsage80andoveraccountingforthelarg-estpopulationgroup.Thefeminizationofoldageishighlyvisible.


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PAGE40

mentobepoorandtosufferdisabilitiesin

olderage.Becauseoftheirsecond-classstatus,

thehealthofolderwomenisoftenneglected

orignored.Inaddition,manywomenhave

lowornoincomesbecauseofyearsspentin

unpaidcaregivingroles.Theprovisionoffam-

ilycareisoftenachievedatthedetrimentof

femalecaregiverseconomicsecurityandgood

healthinlaterlife.

Womenarealsomorelikelythanmentolive

toveryoldagewhendisabilitiesandmultiple

healthproblemsaremorecommon.Atage

80andover,theworldaverageisbelow600

menforevery1,000women.Inthemore

developedregionswomenage80andover

outnumbermenbymorethantwotoone(see

theexampleofJapaninFigure13).

Becauseofwomenslongerlifeexpectancy

andthetendencyofmentomarryyounger

womenandtoremarryiftheirspousesdie,

femalewidowsdramaticallyoutnumbermale

widowersinallcountries.Forexample,inthe

EasternEuropeancountriesineconomictran-

sitionover70percentofwomenage70and

overarewidows(Botev,1999).

Olderwomenwhoarealonearehighly

vulnerabletopovertyandsocialisolation.In

somecultures,degradinganddestructiveat-

titudesandpracticesaroundburialrightsandinheritancemayrobwidowsoftheirproperty

andpossessions,theirhealthandindepen-

denceand,insomecases,theirverylives.

Challen ge 5: Ethics an d Inequities

Aspopulationsage,arangeofethicalcon-

siderationscomestothefore.Theyareoften

linkedtoagediscriminationinresourceal-

location,issuesrelatedtotheendoflifeanda

hostofdilemmaslinkedtolong-termcareand

thehumanrightsofpooranddisabledolder

citizens.Scientificadvancementsandmodern

medicinehaveledtomanyethicalquestions

relatedtogeneticresearchandmanipulation,

biotechnology,stemcellresearchandtheuse

oftechno logytosustainlifewhilecompromis-

ingqualityoflife.Inallcultures,consumers

needtobefullyinformedaboutfalseclaims

ofanti-ageingproductsandprogrammesthat

areineffectiveorharmful.Theyneedprotec-

tionfromfraudulentmarketingandfinancing

schemes,especiallyastheygrowolder.

Societiesthatvaluesocialjusticemuststriveto

ensurethatallpoliciesandpracticesuphold

andguaranteetherightsofallpeople,re-

gardlessofage.Advocacyandethicaldeci-

sion-makingmustbecentralstrategiesinall

programmes,practices,policiesandresearch

onageing.

Olderageoftenexacerbatesotherpre-existing

inequalitiesbasedonrace,ethnicityorgender.

Whilewomenareuniversallydisadvantaged

intermsofpoverty,menhaveshorterlifeexpectanciesinmostcountries.Theexclusion

andimpoverishmentofolderwomenandmen

isoftenaproductofstructuralinequitiesin

bothdevelopinganddevelopedcountries.In-

equalitiesexperiencedinearlierlifeinaccess

toeducation,employmentandhealthcare,as

wellasthosebasedongenderandracehave

acriticalbearingonstatusandwellbeingin

oldage.Forolderpeoplewhoarepoor,theconsequencesoftheseearlierexperiences


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PAGE41


areworsenedthroughfurtherexclusionfrom

healthservices,creditschemes,income-gener-

atingactivitiesanddecision-making.Inequities

incareoccurwhensmallandcomparatively

welloffportionsoftheageingpopulation,

particularlythoseindevelopingcountries,

consumeadisproportionatelyhighamountof

publicresourcesfortheircare.

Inmanycases,themeansforolderpeopleto

achievedignityandindependence,receive

careandparticipateincivicaffairsarevery

limited.Theseconditionsareoftenworsefor

olderpeoplelivinginruralareas,incountries

intransitionandinsituationsofconflictor

humanitariandisasters.

Inallregionsoftheworld,relativewealthand

poverty,gender,ownershipofassets,accessto

workandcontrolofresourcesarekeyfactors

insocioeconomicstatus.RecentWorldBank

datarevealthatinmanydevelopingcountries

welloverhalfofthepopulationlivesonless

thantwopurchasingpowerparity(PPP)dol-larsperday(seeTable4).

Itiswellknownthatsocioeconomicstatus

andhealthareintimatelyrelated.Witheach

stepupthesocioeconomicladder,peoplelive

longer,healthierlives(Wilkinson,1996).Inre-

centyears,thegapbetweenrichandpoorand

subsequentinequalitiesinhealthstatushas

beenincreasingincountriesinallpartsofthe

world(Lynchetal,2000).Failuretoaddress

thisproblemwillhaveseriousconsequences

fortheglobaleconomyandsocialorder,as

wellasforindividualsocietiesandpeopleof

allages.

Table4.Percentageofthepopulationbelowinternationalpovertylinesincountrieswithapopulationapproachingorabove100millionintheyear2000Countries Popu lation

(millions)#Percentagewith


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PAGE42

Challenge 6: The Economics of an

Agein g Population

Perhapsmorethananythingelse,policymak-

ersfearthatrapidpopulationageingwilllead

toanunmanageableexplosioninhealthcare

andsocialsecuritycosts.Whilethereisno

doubtthatageingpopulationswillincrease

demandsintheseareas,thereisalsoevidence

thatinnovation,cooperationfromallsectors,

planningaheadandmakingevidence-based,

culturally-appropriatepolicychoiceswill

enablecountriestosuccessfullymanagethe

economicsofanageingpopulation.

Researchincountrieswithagedpopulations

hasshownthatageingperseisnotlikelyto

leadtohealthcarecoststhatarespiralingout

ofcontrol,fortworeasons.

First,accordingtoOECDdata,themajor

causesofescalatinghealthcarecostsare

relatedtocircumstancesthatareunrelatedtothedemographicageingofagivenpopulation.

Inefficienciesincaredelivery,buildingtoo

manyhospitals,paymentsystemsthatencour-

agelonghospitalstays,excessivenumbers

ofmedicalinterventionsandtheinappropri-

ateuseofhighcosttechno logiesarethekey

factorsinescalationsinhealthcarecosts.For

example,intheUnitedStatesandotherOECD

countries,newtechno logiesweresometimesrapidlyintroducedandusedwherealternative

andlessexpensiveproceduresalreadyexisted,

andforwhichthemarginaleffectivenesswas

relativelylow(JacobzoneandOxley,2002).

Thereappearstobeconsiderablescopefor

policymakerstoaddresstheseissuesand

improvetheeffectivenessofhealthcare.

Second,thecostsoflong-termcarecanbe

managedifpoliciesandprogrammesaddress

preventionandtheroleofinformalcare.Poli-

ciesandhealthpromotionprogrammesthat

preventchronicdiseasesandlessenthedegree

ofdisabilityamongoldercitizensenable

themtoliveindependentlylonger.Another

majorfactoristhecapacityandwillingness

offamiliestoprovidecareandsupportfor

olderfamilymembers.Thiswilldependtoa

largeextentontheratesoffemaleparticipa-

tioninthelabourforceandonworkplaceand

publicpoliciesthatrecognizeandsupportthe

caregivingrole.

Inmanycountries,thebulkofspendingison

curativemedicine.Careforchronicconditions

leadstoanimprovedqualityoflife;however,

itisalwayspreferableifthoseconditionscould

bepreventedordelayeduntilverylateinlife.

Decisionmakersneedtoevaluatewhethersuch

outcomescanbeachievedthroughpoliciesthataddressthebroaddeterminantsofactiveage-

ing,suchasinterventionstopreventinjuries,

improvedietsandphysicalactivity,increase

literacyorincreaseemployment.

Ultimately,theleveloffund ingallocatedto

thehealthsystemisasocialandpolitical

choicewithnouniversallyapplicableanswer.

However,theWHOsuggeststhatitisbetter

tomakepre-paymentsonhealthcareasmuch

aspossible,whetherintheformofinsurance,

taxesorsocialsecurity.Theprincipleoffair

financingensuresequityofaccessregardless

ofage,sexorethnicityandthatthefinancial

burdenis

Active Aging - A Policy Framework

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