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ACTIVE AGEING:A POLICY FRAMEWORK !
Contents
Introduction
1.
5
Global Ageing: A Triumph and a Challenge
6
The Demographic Revolution
6
Rapid Population Ageing in Developing Countries
9
2.
Active Ageing: The Concept and Rationale
12
What is “Active Ageing”?
12
A Life Course Approach to Active Ageing
14
Active Ageing Policies and Programmes
16
3.
The Determinants of Active Ageing: Understanding the Evidence
19
Cross-Cutting Determinants: Culture and Gender
20
Determinants Related to Health and Social Sendee Systems
21
Behavioural Determinants
22
Determinants Related to Personal Factors
26
Determinants Related to the Physical Environment
27
Determinants Related to the Social Environment
28
Economic Determinants
30
4.
Challenges of an Ageing Population
33
Challenge 1: The Double Burden of Disease
33
Challenge 2: Increased Risk of Disability
34
Challenge 3: Providing Care for Ageing Populations
37
Challenge 4: The Feminization of Ageing
39
Challenge 5: Ethics and Inequities
40
Challenge 6: The Economics of an Ageing Population
42
Challenge 7: Forging a New Paradigm
43
5.
The Policy Response
45
Intersectoral Action
46
Key Policy Proposals
46
1.
Health
47
2.
Participation
51
3.
Security
52
WHO and Ageing
54
International Collaboration
55
Conclusion
55
6.
References
57
PAGE 3
How Old is Older?
........
.
-
This booklet uses the United Nations standard of age 60 to describe "older" people.This may
seem young in the developed world and in those developing countries where major gains in
life expectancy have already occurred. However, whatever age is used within different con
texts, it is important to acknowledge that chronological age is not a precise marker for the
changes that accompany ageing.There are dramatic variations in health status, participation
and levels of independence among older people of the same age. Decision-makers need to
take this into account when designing policies and programmes for their "older" populations.
Enacting broad social policies based on chronological age alone can be discriminatory and
counterproductive to well being in older age.
The hands you see in the background design of this paper are celebrating the worldwide
triumph of population ageing. If you fan the pages quickly, you will see them applauding the
important contribution that older people make to our societies, as well as the critical gains in
public health and standards of living that have allowed people to live longer in almost all parts
of the world.
This text and the preliminary version of the paper were drafted by Peggy Edwards, a Health
Canada consultant based for six months at WHO, under the guidance of WHO's Ageing and Life
Course Programme. The support from Health Canada at all phases of the project is gratefully
acknowledged.
PAGE 4
ACTIVE AGEING: A POLICY FRAMEWORK i
Introduction
Population ageing raises many fundamental
and economies, as stated in the WHO Brasilia
questions for policy-makers. How do we help
Declaration on Ageing and Health in 1996.
people remain independent and active as they
age? How can we strengthen health promo
tion and prevention policies, especially those
directed to older people? As people are living
longer, how can the quality of life in old age
• Part 1 describes the rapid worldwide
growth of the population over age 60, espe
cially in developing countries.
• Part 2 explores the concept and rationale
be improved? Will large numbers of older
for “active ageing” as a goal for policy and
people bankrupt our health care and social
programme formulation.
security systems? How do we best balance the
role of the family and the stale when it comes
• Part 3 summarizes the evidence about
to caring for people who need assistance, as
the factors that determine whether or not
they grow older? How do we acknowledge
individuals and populations will enjoy a
and support the major role that people play as
positive quality of life as they age.
they age in caring for others?
• Part 4 discusses seven key challenges as
This paper is designed to address these ques
sociated with an ageing population for gov
tions and other concerns about population
ernments, the nongovernmental, academic
ageing. It targets government decision-mak
and private sectors.
ers at all levels, the nongovernmental sec
tor and the private sector, all of w hom are
responsible for the formulation of policies and
programmes on ageing. It approaches health
from a broad perspective and acknowledges
the fact that health can only be created and
sustained through the participation of multiple
sectors. It suggests that health providers and
• Part 5 provides a policy framework for
active ageing and concrete suggestions for
key policy proposals. These are intended
to serve as a baseline for the development
of more specific action steps at regional.
national and local levels in keeping with
the action plan adopted by the 2002 Second
United Nations World Assembly on Ageing.
professionals must take a lead if we are to
achieve the goal that healthy older persons re
main a resource to theirfamilies, communities
PAGE 5
1. Global Ageing:
A Triumph and a Challenge
Population ageing is first andforemost a success storyfor public health policies
as well as social and economic development. ...
Gro Harlem Brundtland, Director-General. World Health Organization. 1999
Population ageing is one of humanity’s
embrace a life course perspective that recog
greatest triumphs. It is also one of our great
nizes the important influence of earlier life
est challenges. As we enter the 21st century,
experiences on the way individuals age.
global ageing will put increased economic
and social demands on all countries. At the
The Demographic Revolution
same time, older people are a precious, often-
Worldwide, the proportion of people age
ignored resource that makes an important
60 and over is growing faster than any other
contribution to the fabric of our societies.
age group. Between 1970 and 2025, a growth
The World Health Organization argues that
countries can afford to get old if governments.
international organizations and civil society
enact “active ageing" policies and programmes
that enhance the health, participation and
security of older citizens. The time to plan and
to act is now.
in older persons of some 694 million or
223 percent is expected. In 2025, there will be
a total of about 1.2 billion people over the age
of 60. By 2050 there will be 2 billion with
80 percent of them living in developing
countries.
Age composition - that is, the proportionate
numbers of children, young adults, middle-
In all countries, and in developing
countries in particular, measures to
help older people remain healthy
and active are a necessity, not a
luxury.
aged adults and older adults in any given
country - is an important element for policy
makers to take into account. Population
ageing refers to a decline in the proportion of
children and young people and an increase
in the proportion of people age 60 and over.
As populations age, the triangular population
These policies and programmes should be
pyramid of 2002 will be replaced with a more
based on the rights, needs, preferences and
cylinder-like structure in 2025 (see Figure 1).
capacities of older people. They also need to
I PAGE 6
ACTIVE AGEING: A POLICY FRAMEWORK
Decreasing fertility rates and increasing
Until now. population ageing has been mostly
longevity will ensure the continued “greying”
associated with the more developed regions
of the world’s population, despite setbacks
of the world. For example, currently nine of
in life expectancy in some African countries
the ten countries with more than ten million
(due to AIDS) and in some newly indepen
inhabitants and the largest proportion of older
dent states (due to increased deaths caused
people are in Europe (see Table 1). Little
by cardiovascular disease and violence). Sharp
change in the ranking is expected by 2025
decreases in fertility rates are being observed
when people age 60 and over will make up
throughout the world. It is estimated that by
about one-third of the population in countries
2025, 120 countries will have reached total
like Japan. Germany and Italy, closely fol
fertility rates below replacement level (aver
lowed by other European countries
age fertility rate of 2.1 children per woman), a
(see Table 1).
substantial increase compared to 1975, when
just 22 countries had a total fertility rate below
or equal to the replacement level. The current
figure is 70 countries.
As the proportion of children and young people declines and the proportion ofpeople age 60 and over increases, the
triangular population pyramid of2002 will be replaced with a more cylinder-like structure in 2025.
PAGE 7 ;
Table 1. Countries with more than 10 million inhabitants (in 2002) with the
highest proportion of persons above age 60
2002
2025
Italy
24.5%
Japan
35.1%
Japan
24.3%
Italy
34.0%
Germany
24.0%
Germany
33.2%
Greece
23.9%
Greece
31.6%
Belgium
22.3%
Spain
31.4%
Spain
22.1%
Belgium
31.2%
Portugal
21.1%
United Kingdom
29.4%
United Kingdom
20.8%
Netherlands
29.4%
Ukraine
20.7%
France
28.7%
France
20.5%
Canada
27.9%
Source:UN,2001
What is less known is the speed and signifi
In all countries, especially in developed ones,
cance of population ageing in less developed
the older population itself is also ageing.
regions. Already, most older people - around
People over the age of 80 currently number
70 percent - live in developing countries (see
some 69 million, the majority of whom live
Table 2). These numbers will continue to rise
in more developed regions. Although people
at a rapid pace.
over the age of 80 make up about one percent
Table 2. Absolute numbers of persons (in millions) above 60 years of age in countries
with a total population approaching or above 100 million inhabitants (in 2002)
2002
134.2
China
287.5
India
81.0
India
168.5
United States of America
46.9
United States of America
86.1
Japan
31.0
Japan
43.5
Russian Federation
26.2
Indonesia
35.0
Indonesia
17.1
Brazil
33.4
Brazil
14.1
Russian Federation
32.7
Pakistan
8.6
Pakistan
18.3
Mexico
7.3
Bangladesh
17.7
Bangladesh
7.2
Mexico
17.6
Nigeria
5.7
Nigeria
11.4
Source: UN, 2001
PAGE 8
2025
China
ACTIVE AGEINGtA POLICY FRAMEWORK
of the world’s population and three percent of
individuals that continue to be fully able and
the population in developed regions, this age
independent.
group is the fastest growing segment of the
older population.
At the same time, active ageing policies and
programmes are needed to enable people to
In both developed and developing countries,
continue to work according to their capaci
the ageing of the population raises concerns
ties and preferences as they grow older, and
about whether or not a shrinking labour
to prevent or delay disabilities and chronic
force will be able to support that part of the
diseases that are costly to individuals, families
population who are commonly believed to be
and the health care system. This is discussed
dependent on others (i.e.. children and older
further in the section on work (page 3D and
people).
in Challenge 2: Increased Risk of Disability
(page 34) and Challenge 6: the Economics of
The old-age dependency ratio (i.e.. the total
an Ageing Population (page 42).
population age 60 and over divided by the
population age 15 to 60 - see Table 3) is pri
marily used by economists and actuaries who
Table 3. Old age dependency ratio for selected
countries / regions
forecast the financial implications of pension
2002
policies. However, it is also useful for those
concerned with the management and planning
of caring services.
Old-age dependency ratios are
changing quickly throughout the
world. In Japan for example, there
are currently 39 people over
age 60for every 100 in the age
group 15-60. In 2025 this number
will increase to 66.
2025
Japan
0.39
Japan
0.66
North America
0.26
North America
0.44
European
Union
0.36
European
Union
0.56
Source: UN. 2001
Rapid Population Ageing in
Developing Countries
In 2002, almost -iOO million people aged 60
and over lived in the developing world. By
2025, this will have increased to approximately
840 million representing 70 percent of all older
However, most of the older people in all
countries continue to be a vital resource to
their families and communities. Many con
tinue to work in both the formal and infor
mal labour sectors. Thus, as an indicator for
forecasting population needs, the dependency
ratio is of limited use. More sophisticated
people worldwide, (see Figure 2). In terms of
regions, over half of the world's older people
live in Asia. Asia’s share of the world's old
est people will continue to increase the most
while Europe’s share as a proponion of the
global older population will decrease the most
over the next two decades (see Figure 3).
indices are needed to more accurately reflect
“dependency”, rather than falsely categorizing
PAGE 9
Figure 2. The numbers of people over age 60 in less and more developed regions,
1970,2000 and 2025
PAGE 10
Compared to the developed world, socio
before they became old, developing countries
economic development in developing coun
are getting old before a substantial increase in
tries has often not kept pace with the rapid
wealth occurs (Kalache and Keller, 2000).
speed of population ageing. For example,
while it took 115 years for the proportion of
older people in France to double from 7 to
14 percent, it will take China only 27 years
to achieve the same increase. In most of the
developed world, population ageing was a
gradual process following steady socio-eco
nomic growth over several decades and gener
ations. In developing countries, the process is
being compressed into two or three decades.
Thus, while developed countries grew affluent
Rapid ageing in developing countries is
accompanied by dramatic changes in fam
ily structures and roles, as well as in labour
patterns and migration. Urbanization, the
migration of young people to cities in search
of jobs, smaller families and more women
entering the formal workforce mean that fewer
people are available to care for older people
when they need assistance.
The Concept and Rationale
If ageing is to be a positive experience,
ageing aims to extend healthy life expectancy
longer life must be accompanied by continu
and quality of life for all people as they age,
ing opportunities for health, participation and
including those who are frail, disabled and in
security. The World Health Organization has
need of care.
adopted the term "active ageing" to express
the process for achieving this vision.
What is “Active Ageing”?
"Health" refers to physical, mental and social
well being as expressed in the WHO definition
of health. Thus, in an active ageing frame
work, policies and programmes that promote
Active ageing is the process of
optimizing opportunities for health,
participation and security in order
to enhance quality of life as people
age.
mental health and social connections are
as important as those that improve physical
health status.
Maintaining autonomy and independence as
one grows older is a key goal for both indi
viduals and policy makers (see box on defini
Active ageing applies to both individuals and
tions). Moreover, ageing takes place within
population groups. It allows people to realize
the context of others - friends, work associ
their potential for physical, social, and mental
ates, neighbours and family members. This is
well being throughout the life course and to
why interdependence as wre!l as intergenera-
participate in society according to their needs,
tional solidarity (two-way giving and receiv
desires and capacities, while providing them
ing between individuals as well as older and
with adequate protection, security and care
younger generations) are important tenets of
when they require assistance.
active ageing. Yesterday's child is today’s adult
The word “active" refers to continuing partici
pation in social, economic, cultural, spiritual
and civic affairs, not just the ability to be
physically active or to participate in the labour
force. Older people who retire from work
and those who are ill or live with disabilities
can remain active contributors to their fami
lies, peers, communities and nations. Active
PAGE 12
and tomorrow's grandmother or grandfather.
The quality of life they will enjoy as grandpar
ents depends on the risks and opportunities
they experienced throughout the life course,
as well as the manner in which succeeding
generations provide mutual aid and support
when needed.
ACTIVE AGEING:A POLICY FRAMEWORK
Some key definitions
Autonomy is the perceived ability to control, cope with and make personal decisions
about how one lives on a day-to-day basis, according to one's own rules and prefer
ences.
Independence is commonly understood as the ability to perform functions related to
daily living - i.e.the capacity of living independently in the community with no and/or
little help from others.
Quality of life is "an individual's perception of his or her position in life in the context
of the culture and value system where they live, and in relation to their goals, expecta
tions, standards and concerns. It is a broad ranging concept, incorporating in a com
plex way a person's physical health, psychological state, level of independence, social
relationships, personal beliefs and relationship to salient features in the environment."
(WHO, 1994). As people age, their quality of life is largely determined by their ability to
maintain autonomy and independence.
Healthy life expectancy is commonly used as a synonym for "disability-free life expectancy'IWhile life expectancy at birth remains an important measure of population
ageing, how long people can expect to live without disabilities is especially important
to an ageing population.
With the exception of autonomy which is notoriously difficult to measure, all of the
above concepts have been elaborated by attempts to measure the degree of dif
ficulty an older person has in performing activities related to daily living (ADLs) and
instrumental activities of daily living (lADLs). ADLs include, for example, bathing, eating,
using the toilet and walking across the room. lADLs include activities such as shop
ping, housework and meal preparation. Recently, a number of validated, more holistic
measures of health-related quality of life have been developed.These indices need to
be shared and adapted for use in a variety of cultures and settings.
The term “active ageing" was adopted by the
self-fulfillment. It shifts strategic planning away
World Health Organization in the late 1990s. It
from a “needs-based" approach (which as
is meant to convey a more inclusive message
sumes that older people are passive targets) to
than “healthy ageing" and to recognize the fac
a “rights- based’ approach that recognizes the
tors in addition to health care that affect how
rights of people to equality of opportunity and
individuals and populations age (Kalache and
treatment in all aspects of life as drey grow
Kickbusch, 1997).
older. It supports their responsibility to exer
cise their participation in the political process
The active ageing approach is based on the
and other aspects of community life.
recognition of the human rights of older
people and the United Nations Principles of
independence, participation, dignity, care and
PAGE 13
A Life Course Approach to Active
Ageing
A life course perspective on ageing recognizes
dial older people are not one homogeneous
group and that individual diversity tends to
increase with age. Interventions that create
supportive environments and foster healthy
choices are important at all stages of life (see
the world, including in developing countries,
as shown in Figures 5 and 6. NCDs, which
are essentially diseases of later life, are costly
to individuals, families and the public purse.
But many NCDs are preventable or can be
postponed. Failing to prevent or manage the
growth of NCDs appropriately will result in
enormous human and social costs that will ab
sorb a disproportionate amount of resources,
Figure 4).
which could have been used to address the
As individuals age, noncommunicable diseases
health problems of other age groups.
(NCDs) become the leading causes of morbid
ity, disability and mortality in all regions of
Figure 4. Maintaining functional capacity over the life course
Adult Life
Early Life
Older Age
Growth and
i
Maintaining highest
•
Maintaining independence and
development
:
possible level of function
i
preventing disability
•
:
Rehabilitation and ensuring
the quality of life
Age
Source: Kalache and Kickbusch, 1997
'Changes in the environment can lower the disability threshold, thus decreasing the number of disabled people in a given com
munity.
Functional capacity (such as ventilatory capacity, muscular strength, and cardiovascular output) increases in childhood and
peaks in early adulthood, eventually followed by a decline. The rate of decline, however, is largely determined by factors related to
adult lifestyle - such as smoking, alcohol consumption, levels of physical activity and diet - as well as external and environmen
tal factors. The gradient of decline may become so steep as to result in premature disability. However, the acceleration in decline
can be influenced and may be reversible at any age through individual and public policy measures.
| PAGE 14
ACTIVE AGEING: A POLICY FRAMEWORK
Figure 5. Leading causes of death, both sexes, 1998, low- and middle-income
countries by age
0-4 years
5-14 years
15-44 years
45-59 years
>60 years
Noncommunicable conditions
Injuries
(^2) Communicable diseases, maternal and perinatal conditions and nutritional deficiencies
Source: World Health Report 1999 Database
PAGE 15
factors, such as socio-economic status and
Major chronic conditions affecting
older people worldwide
experiences across the whole life span. The
risk of developing NCDs continues to increase
as individuals age. But it is tobacco use, lack
• Cardiovascular diseases
(such as coronary heart disease)
• Hypertension
of physical activity, inadequate diet and other
established adult risk factors which will put
individuals at relatively greater risk of develop
• Stroke
ing NCDs at older ages (see Figure 7). Thus,
• Diabetes
it is important to address the risks of noncom
• Cancer
municable disease from early life to late life,
• Chronic obstructive pulmonary
disease
• Musculoskeletal conditions
(such as arthritis and osteoporosis)
• Mental health conditions
(mostly dementia and depression)
• Blindness and visual impairment
i.e. throughout the life course.
Active Ageing Policies and
Programmes
An active ageing approach to policy and
programme development has the potential to
address many of the challenges of both indi
vidual and population ageing. When health,
Note:The causes of disability in older age are similar for
labour market, employment, education and
women and men although women are more likely to report
social policies support active ageing there will
musculoskeletal problems.
Source:WHO, 1998a
In the early years, communicable diseases,
maternal and perinatal conditions and nu
tritional deficiencies are the major causes of
death and disease. In later childhood, ado
potentially be:
• fewer premature deaths in the highly pro
ductive stages of life
• fewer disabilities associated with chronic
diseases in older age
lescence and young adulthood, injuries and
noncommunicable conditions begin to assume
a much greater role. By midlife (age 45) and
in the later years, NCDs are responsible for
the vast majority of deaths and diseases (see
Figures 5 and 6). Research is increasingly
showing that the origins of risk for chronic
conditions, such as diabetes and heart disease,
• more people enjoying a positive quality of
life as they grow older
• more people participating actively as they
age in the social, cultural, economic and
political aspects of society, in paid and
unpaid roles and in domestic, family and
community life
begin in early childhood or even earlier. This
risk is subsequently shaped and modified by
• lower costs related to medical treatment
and care services.
PAGE 16
ACTIVE AGEING: A POLICY FRAMEWORK
Active ageing policies and programmes rec
largely the result of public policies that have
ognize the need to encourage and balance
encouraged early withdrawal from the labour
personal responsibility (self-care), age-friendly
force. As populations age, there will be
environments and intergenerational solidarity.
increasing pressures for such policies to
Individuals and families need to plan and pre
change - particularly if more and more indi
pare for older age, and make personal efforts
viduals reach old age in good health, i.e. are
to adopt positive personal health practices at
"fit for work.” This would help to offset the
all stages of life. At the same time support
rising costs in pensions and income security
ive environments are required to "make the
schemes as well as those related to medical
healthy choices the easy choices.”
and social care costs.
There are good economic reasons for enacting
With regard to rising public expenditures
policies and programmes that promote active
for medical care, available data increasingly
ageing in terms of increased participation and
indicate that old age itself is not associated
reduced costs in care. People who remain
with increased medical spending. Rather, it is
healthy as they age face fewer impediments
disability and poor health - often associated
to continued work. The current trend toward
with old age - that are costly. As people age
early retirement in industrialised countries is
in better health, medical spending may not
increase as rapidly.
Figure 7. Scope for noncommunicable diseases prevention, a life course approach
PAGE 1 7
Policymakers need to look at the full picture
(through either full or part-time employment),
and consider the savings achieved by declines
their contribution to public revenues would
in disability rates. In the USA for example,
continuously increase. Finally, it is often less
such declines might lower medical spending
costly to prevent disease dian to treat it. For
by about 20 percent over the next 50 years
example, it has been estimated that a one-dol-
(Cutler, 2001). Between 1982 and 1994, in the
lar investment in measures to encourage mod
USA, the savings in nursing home costs alone
erate physical activity leads to a cost saving of
were estimated to exceed $17 billion (Singer
$3.2 in medical costs (U.S. Centers for Disease
and Manton, 1998). Moreover, if increased
Control. 1999).
numbers of healthy older people were to
extend their participation in the work force
PAGE 18
ACTIVE AGEING: A POLICY FRAMEWORK
3. The Determinants of Active Ageing:
Understanding the Evidence
Active ageing depends on a variety of influ
factors (and the interplay between them) are
ences or “determinants” that surround individ
good predictors of how well both individuals
uals, families and nations. Understanding the
and populations age. More research is needed
evidence we have about these determinants
to clarify and specify the role of each deter
helps us design policies and programmes that
minant, as well as the interaction between
work.
determinants, in the active ageing process. We
also need to better understand the pathways
The following section summarizes what we
know about how the broad determinants of
that explain how these broad determinants
actually affect health and well being.
health affect the process of ageing. These
determinants apply to the health of all age
Moreover, it is helpful to consider the influ
groups, although the emphasis here is on the
ence of various determinants over the life
health and quality of life of older persons. At
course so as to take advantage of transitions
this point, it is not possible to attribute direct
and “windows of opportunity” for enhancing
causation to any one determinant; however,
health, participation and security at different
the substantial body of evidence on what
stages. For example, there is evidence that
determines health suggests that all of these
stimulation and secure attachments in infancy
influence an individual's ability to learn and
PAGE 19
Policymakers need to look at the full picture
(through either full or part-time employment),
and consider the savings achieved by declines
their contribution to public revenues would
in disability rates. In the USA for example,
continuously increase. Finally, it is often less
such declines might lower medical spending
costly to prevent disease than to treat it. For
by about 20 percent over the next 50 years
example, it has been estimated that a one-dol-
(Cutler, 2001). Between 1982 and 1994, in the
lar investment in measures to encourage mod
USA, tire savings in nursing home costs alone
erate physical activity leads to a cost saving of
were estimated to exceed $17 billion (Singer
$3.2 in medical costs (U.S. Centers for Disease
and Manton, 1998). Moreover, if increased
Control, 1999).
numbers of healthy older people were to
extend tlieir participation in the work force
PAGE 18
ACTIVE AGEING: A POLICY FRAMEWORK
3. The Determinants of Active Ageing:
Understanding the Evidence
Active ageing depends on a variety of influ
factors (and the interplay between them) are
ences or “determinants" that surround individ
good predictors of how well both individuals
uals, families and nations. Understanding the
and populations age. More research is needed
evidence we have about these determinants
to clarify and specify the role of each deter
helps us design policies and programmes that
minant, as well as the interaction between
work.
determinants, in the active ageing process. We
also need to better understand the pathways
The following section summarizes what we
know about how the broad determinants of
that explain how these broad determinants
actually affect health and well being.
health affect the process of ageing. These
determinants apply to the health of all age
Moreover, it is helpful to consider the influ
groups, although the emphasis here is on the
ence of various determinants over the life
health and quality of life of older persons. At
course so as to take advantage of transitions
this point, it is not possible to attribute direct
and “windows of opportunity" for enhancing
causation to any one determinant; however,
health, participation and security at different
the substantial body of evidence on what
stages. For example, there is evidence that
determines health suggests that all of these
stimulation and secure attachments in infancy
influence an individual's ability to learn and
PAGE
gel along with others throughout all of the
There is enormous cultural diversity and com
later stages of life. Employment, which is a
plexity' within countries and among countries
determinant throughout adult life greatly influ
and regions of the world. For example, diverse
ences one’s financial readiness for old age. Ac
ethnicities bring a variety' of values, attitudes
cess to high quality, dignified long-term care is
and traditions to die mainstream culture within
particularly important in later life. Often, as is
a country'. Policies and programmes need to
the case with exposure to pollution, the young
respect current cultures and traditions while
and the old are the most vulnerable popula
de-bunking outdated stereotypes and misinfor
tion groups.
mation. Moreover, there are critical universal
values that transcend culture, such as ethics
Cross-Cutting Determinants: Culture
and Gender
Culture is a cross-cutting determinant within the
framework for understanding active ageing.
Culture, which surrounds all indi
viduals and populations, shapes the
way in which we age because it influ
ences all of the other determinants
of active ageing.
and human rights.
Gender is a ‘‘lens" through which to
consider the appropriateness of vari
ous policy' options and how they will
affect the well being of both men
and women.
In many societies, girls and women have
lower social status and less access to nutri
tious foods, education, meaningful work and
health services. Women's traditional role as
Cultural values and traditions determine to a
large extent how a given society' views older
people and the ageing process. When societies
are more likely to attribute symptoms of dis
ease to the ageing process, they are less likely
to provide prevention, early detection and
appropriate treatment services. Culture is a
key factor in whether or not co-residency with
younger generations is the preferred way of
living. For example, in most Asian countries,
the cultural norm is to value extended fami
lies and to live together in multigenerational
households. Cultural factors also influence
health-seeking behaviours. For example, at
titudes toward smoking are gradually changing
in a range of countries.
PAGE 20
family caregivers may also contribute to their
increased poverty and ill health in older age.
Some women are forced to give up paid em
ployment to carry' out their caregiving respon
sibilities. Others never have access to paid
employment because they work full-time in
unpaid caregiving roles, looking after children,
older parents, spouses who are ill and grand
children. At the same time, boys and men are
more likely to suffer debilitating injuries or
death due to violence, occupational hazards,
and suicide. They also engage in more risk
taking behaviours such as smoking, alcohol
and drug consumption and unnecessary expo
sure to the risk of injury’.
ACTIVE AGEINGrA POLICY FRAMEWORK
Determinants Related to Health and
Social Service Systems
Curative Services
Despite best efforts in health promotion and
disease prevention, people are at increasing
To promote active ageing, health
systems need to take a life course
perspective that focuses on health
promotion, disease prevention and
equitable access to quality primary
health care and long-term care.
risk of developing diseases as they age. Thus
access to curative services becomes indispens
able. As the vast majority of older persons
in any given country live in the community,
most curative services must be offered by tlie
primary' health care sector. This sector is best
equipped to. make referrals to the secondary'
Health and social services need to be inte
grated, coordinated and cost-effective. There
and tertiary levels of care where most acute
and emergency care is also provided.
must be no age discrimination in the provision
Ultimately, the worldwide shift in the global
of services and sendee providers need to treat
burden of disease toward chronic diseases
people of all ages with dignity and respect.
Health Promotion and Disease Prevention
Health promotion is the process of enabling
people to take control over and to improve
requires a shift from a "find it and fix it" model
to a coordinated and comprehensive contin
uum of care. This will require a reorientation
in health systems that are currently organized
around acute, episodic experiences of dis
their health. Disease prevention includes the
ease. The present acute care models of health
prevention and management of the conditions
service delivery' are inadequate to address the
that are particularly common as individuals
age: noncommunicable diseases and injuries.
health needs of rapidly ageing populations
(WHO, 2001).
Prevention refers both to “primary” preven
tion (e.g. avoidance of tobacco use) as well
As the population ages, the demand will con
as “secondary" prevention (e.g. screening for
tinue to rise for medications that are used to
the early detection of chronic diseases), or
delay and treat chronic diseases, alleviate pain
“tertiary" prevention, e.g. appropriate clini
and improve quality of life. This calls for a
cal management of diseases. All contribute to
renewed effort to increase affordable access to
reducing the risk of disabilities. Disease pre
essential safe medications and to better ensure
vention strategies - which may also address
the appropriate, cost-effective use of current
infectious diseases - save money at any age.
and new drugs. Partners in this effort need to
For example, vaccinating older adults against
include governments, health professionals, the
influenza saves an estimated $30 to $60 in
pharmaceutical industry, traditional healers,
treatment costs per $ 1 spent on vaccines (U.S.
employers and organizations representing
Department of Health and Human Services,
older people.
1999).
PAGE 21
Long-term care
Behavioural Determinants
Long-term care is defined by WHO as "the
system of activities undertaken by informal
caregivers (family, friends and/or neighbours)
and/or professionals (health and social ser
vices) to ensure that a person who is not fully
capable of self-care can maintain the highest
possible quality of life, according to his or
her individual preferences, with the greatest
possible degree of independence, autonomy,
participation, personal fulfillment and human
dignity" (WHO, 2000b).
Thus, long-term care includes both informal
and formal support systems. The latter may
The adoption of healthy lifestyles
and actively participating in one’s
own care are important at all stages
of the life course. One of the myths
of ageing is that it is too late to adopt
such lifestyles in the later years. On
the contrary’, engaging in appropri
ate physical activity, healthy eating,
not smoking and using alcohol and
medications wisely in older age can
prevent disease and functional de
cline, extend longevity and enhance
one’s quality of life.
include a broad range of community sendees
(e.g., public health, primary care, home care,
rehabilitation services and palliative care) as
Tobacco Use
well as institutional care in nursing homes and
Smoking is the most important modifiable
hospices. It also refers to treatments that halt
risk factor for NCDs for young and old alike
or reverse the course of disease and disability.
and a major preventable cause of premature
Mental Health Services
death. Smoking not only increases the risk
for diseases such as lung cancer, it is also
Menial health services, which play a crucial
negatively related to factors that may lead
role in active ageing, should be an integral
to important losses in functional capacity.
part of long-term care. Particular attention
For example, smoking accelerates the rate of
needs to be paid to the under-diagnosis of
decline of bone density, muscular strength and
mental illness (especially depression) and
respiratory function. Research on the effects
to suicide rates among older people (WHO.
of smoking revealed not just that smoking is a
2001a).
risk factor for a large and increasing number
of diseases but also that its ill effects are cu
mulative and long lasting. The risk of contract
ing at least one of the diseases associated with
smoking increases with the duration and the
amount of exposure.
PAGE 22
ACTIVE AGEINC : A POLICY FRAMEWORK
A critical message for young people should
percent and increase overall revenue by five
always be “If you want to grow older, don’t
percent. This increased revenue would be suf
smoke. Moreover, if you want to grow older
ficient to finance a package of essential health
and to increase your chance to age well, again
care services for one-third of China’s poorest
don’t smoke.”
citizens (World Bank, 1999).
The benefits of quitting are wide-ranging
Physical Activity
and apply to any age group. It is never too
Participation in regular, moderate physical
late to quit smoking. For instance, stroke risk
activity can delay functional declines. It can
decreases after two years of abstinence from
reduce the onset of chronic diseases in both
cigarette smoking and, after five years, it
healthy and chronically ill older people. For
becomes the same as that for individuals who
example, regular moderate physical activity
have never smoked. For other diseases, e.g.
reduces the risk of cardiac death by 20 to 25
lung cancer and obstructive pulmonary' dis
percent among people with established heart
ease, quitting decreases the risk but only very
disease (Merz and Forrester, 1997). It can also
slowly. Thus, current exposure is not a very
substantially reduce the severity of disabili
good indicator of current and future risks and
ties associated with heart disease and other
past exposure should be taken into account
chronic illnesses (U.S Preventive Services Task
as well; the effects of smoking are cumulative
Force. 1996). Active living improves mental
and long standing (Doll, 1999).
health and often promotes social contacts.
Smoking may interfere with the effect of
needed medications. Exposure to second-hand
smoke can also have a negative effect on older
people’s health, especially if they suffer from
asthma or other respiratory problems.
Being active can help older people remain as
independent as possible for the longest period
of time. It can also reduce the risk of falls.
There are thus important economic benefits
when older people are physically active.
Medical costs are substantially lower for older
Most smokers start young and are quickly
people who are active (WHO, 1998).
addicted to the nicotine in tobacco. Therefore.
efforts to prevent children and youth from
starting to smoke must be a primary strategy in
tobacco control. Al the same time, it is impor
tant to reduce the demand for tobacco among
adults (through comprehensive actions such
as taxation and restrictions on advertising) and
to help adults of all ages to quit. Studies have
shown that tobacco control is highly cost-ef
fective in low- and middle-income countries.
In China, for example, conservative estimates
suggest that a 10 percent increase in tobacco
Despite all of these benefits, high proportions
of older people in most countries lead seden
tary lives. Populations with low incomes, eth
nic minorities and older people with disabili
ties are the most likely to be inactive. Policies
and programmes should encourage inactive
people to become more active as they age and
to provide them with opportunities to do so. It
is particularly important to provide safe areas
for walking and to support culturally-appropriate community activities that stimulate physical
taxes would reduce consumption by five
PAGE 23
activity and are organized and led by older
people themselves. Professional advice to "go
from doing nothing to doing something" and
physical rehabilitation programmes that help
older people recover from mobility problems
are both effective and cost-efficient.
In the least developed countries, the oppo
site problem may occur. In these countries,
individuals are often engaged in strenuous
Diets high in (saturated) fat and
salt, low in fruits and vegetables and
providing insufficient amounts of
fibre and vitamins combined with
sedentarism, are major risks factors
for chronic conditions like diabetes,
cardiovascular disease, high blood
pressure, obesity', arthritis and some
cancers.
physical work and chores that may hasten
disabilities, cause injuries and aggravate previ
ous conditions, especially as they approach
Insufficient calcium and vitamin D is associ
old age. This may include heavy' caregiving
ated with a loss of bone density in older age
responsibilities for ill and dying relatives.
and consequently an increase in painful, costly
Health promotion efforts in these areas should
and debilitating bone fractures, especially in
be directed at providing relief from repetitive,
older women. In populations with high frac
strenuous tasks and making adjustments to
ture incidence, risk can be decreased through
unsafe physical movements at work that will
ensuring adequate calcium and vitamin D
decrease injuries and pain. Older people who
intake.
regularly engage in vigorous physical work
need opportunities for rest and recreation.
Oral Health
Poor oral health - primarily' dental caries,
Healthy Eating
periodontal diseases, tooth loss and oral can
Eating and food security problems at all ages
cer - cause other systemic health problems.
include both under-nutrition (mostly, but not
They create a financial burden for individuals
exclusively, in the least developed countries)
and society and can reduce self-confidence
and excess energy' intake. In older people,
and quality of life. Studies show that poor
malnutrition can be caused by limited access
oral health is associated with malnutrition and
to food, socioeconomic hardships, a lack of
therefore increased risks for various noncom
information and knowledge about nutrition,
municable diseases. Oral health promotion
poor food choices (e.g., eating high fat foods),
and cavity prevention programmes designed
disease and the use of medications, tooth loss,
to encourage people to keep their natural
social isolation, cognitive or physical disabili
teeth need to begin early in life and continue
ties that inhibit one’s ability to buy foods and
over the life course. Because of the pain and
prepare them, emergency' situations and a lack
reduced quality of life associated with oral
of physical activity.
health problems, basic dental treatment servic
es and accessibility to dentures are required.
Excess energy intake greatly increases the risk
for obesity, chronic diseases and disabilities as
people grow older.
PAGE 24
Alcohol
are significant causes of personal suffering and
While older people tend to drink less than
costly preventable hospital admissions (Gur-
younger people, metabolism changes that
witz and /Worn, 1991).
accompany ageing increase their suscepti
Iatrogenesis - health problems that are
bility to alcohol-related diseases, including
malnutrition and liver, gastric and pancreatic
diseases. Older people also have greater risks
for alcohol-related falls and injuries, as well as
the potential hazards associated with mixing
alcohol and medications. Treatment services
for alcohol problems should be available to
older people as well as younger people.
induced by diagnoses or treatments - caused
by the use of drugs is common in old age,
due to the interaction of drugs, inadequate
dosages and a higher frequency of unpredict
able reactions through unknown mechanisms.
With the advent of many new therapies, there
is an increasing need to establish systems for
preventing adverse drug reactions and for
According to a recent WHO review of the
informing both health professionals and the
literature, there is evidence that alcohol use at
ageing public about the risks and benefits of
very low levels (up to one drink a day) may
modern therapies.
offer some form of protection against coronary
Adherence
heart disease and stroke for people age 45 and
over. However, in terms of overall excess mor
tality, the adverse effects of drinking outweigh
any protection against coronary heart disease,
even in high risk populations (Jernigan et al.,
2000).
Access to needed medications is insufficient in
itself unless adherence to long-term therapy
for ageing-related chronic illnesses is high.
Adherence includes the adoption and main
tenance of a wide range of behaviours (e.g..
healthy diet, physical activity, not smoking),
Medications
as well as taking medications as directed by
Because older people often have chronic
a health professional. It is estimated that in
health problems, they are more likely than
developed countries adherence to long-term
younger people to need and use medications
therapy averages only 50 percent. In develop
- traditional, over-the-counter and prescribed.
ing countries the rates are even lower. Such
In most countries, older people with low
poor adherence severely compromises the
incomes have little or no access to insurance.
effectiveness of treatments and has dramatic
for medications. As a result, many go without
quality of life and economic implications for
or spend an inappropriately large pan of their
public health. Population health outcomes pre
meager incomes on drugs.
dicted by treatment efficacy data can only be
achieved if adherence information is provided
In contrast, medications are sometimes over
to all health professionals and planners. With
prescribed to older people (especially to older
out a system that addresses the inlluences on
women) who have insurance or the means
adherence, advances in biomedical technol
to pay for these drugs. Adverse drug-related
reactions and falls associated with medication
use (especially sleeping pills and tranquilizers)
ogy will fail to realize their potential to reduce
Therefore, the influence of genetics on the
the burden of chronic disease (Dtpollina and
development of chronic conditions such as
Sabate, 2002).
diabetes, heart disease. Alzheimer's Disease
and certain cancers varies greatly among indi
Determinants Related to Personal
Factors
such as not smoking, personal coping skills
Biology and Genetics
and a network of close kin and friends can
Biology and genetics greatly influence how a
person ages. Ageing is a set of biological pro
cesses that are genetically determined. Ageing
can be defined as a progressive, generalized
impairment of function resulting in a loss of
adaptative response to a stress and in a grow
ing risk of age-associated disease (Kirkwood.
1996). In other words, the main reason why
older persons get sick more frequently than
younger persons is that, due to their longer
lives, they have been exposed to external.
behavioural, and environmental factors that
cause disease for a longer time than their
younger counterparts (Gray, 1996).
viduals. For many people, lifestyle behaviours
effectively modify the influence of heredity on
functional decline and the onset of disease.
Psychological Factors
Psychological factors including intelligence
and cognitive capacity (for example, the ability
to solve problems and adapt to change and
loss) are strong predictors of active ageing and
longevity (Smits et al., 1999). During normal
ageing, some cognitive capacities (including
learning speed and memory) naturally de
cline with age. However, these losses can be
compensated by gains in wisdom, knowledge
and experience. Often, declines in cognitive
functioning are triggered by disuse (lack of
practice), illness (such as depression), behav
While genes may be involved in the
causation of disease, for many
diseases the catise is environmental
and external to a greater degree
than it is genetic and internal.
ioural factors (such as the use of alcohol and
medications), psychological factors (such as
lack of motivation, low expectations and lack
of confidence), and social factors (such as
loneliness and isolation), rather than ageing
per se.
It should also be noted that there is evidence
Other psychological factors that are acquired
in human populations that longevity tends
across the life course greatly influence the
to run in families. But, all things considered,
way in which people age. Self-efficacy (the
there is general agreement that the lifelong
belief people have in their capacity to exert
trajectory of health and disease for an indi
control over their lives) is linked to personal
vidual is the result of a combination of genet
behaviour choices as one ages and to prepara
ics, environment, lifestyle, nutrition, and to an
tion for retirement. Coping styles determine
important extent, chance (Kirkwood, 1996).
how well people adapt to the transitions (such
as retirement) and crises of ageing (such as
bereavement and the onset of illness).
PAGE 26
Men and women who prepare for old age and
Safe Housing
are adaptable to change make a better adjust
Safe, adequate housing and neighbourhoods
ment to life after age 60. Most people remain
are essential to the well being of young and
resilient as they age and, on the whole, older
old. For older people, location, including
people do not vary significantly from younger
proximity to family members, services and
people in their ability to cope.
transportation can mean the difference be
Determinants Related to the Physical
Environment
tween positive social interaction and isolation.
Building codes need to take the health and
safety needs of older people into account.
Physical Environments
Household hazards that increase the risk of
Physical environments that are age friendly
falling need to be remedied or removed.
can make the difference between indepen
dence and dependence for all individuals but
are of particular importance for those grow
ing older. For example, older people who
live in an unsafe environment or areas with
multiple physical barriers are less likely to get
out and therefore more prone to isolation,
depression, reduced fitness and increased
mobility problems.
Worldwide, there is an increasing trend for
older people to live alone - especially unat
tached older women who are mainly widows
and are often poor, even in developed coun
tries. Others may be forced to live in arrange
ments that are not of their choice, such as with
relatives in already crowded households. In
many developing countries, the proportion of
older people living in slums and shanty towns
Specific attention must be given to older peo
is rising quickly as many, who moved to the
ple who live in rural areas (some 60 percent
cities long ago. have become long-term slum
worldwide) where disease patterns may be
dwellers, while other older people migrate to
different due to environmental conditions and
cities to join younger family members who
a lack of available support services. Urbaniza
have already moved there. Older people living
tion and the migration of younger people in
in these settlements are at high risk for social
search of jobs may leave older people isolated
isolation and poor health.
in rural areas with little means of support and
little or no access to health and social services.
Accessible and affordable public transporta
In times of crisis and conflict, displaced older
people are particularly vulnerable. Often they
are unable to walk to refugee camps. Even
tion services are needed in both rural and
if they make it to camps, it may be hard to
urban areas so that people of all ages can fully
obtain shelter and food, especially for older
participate in family and community life. This
women and older persons with disabilities
is especially important for older persons who
who experience low social status and multiple
have mobility problems.
other barriers.
Hazards in the physical environment can lead
to debilitating and painful injuries among
older people. Injuries from falls, fires and traf
fic collisions are the most common.
Falls
of education, abuse and exposure to conflict
Falls among older people are a large and
situations greatly increase older people’s risks
increasing cause of injury, treatment costs and
for disabilities and early death.
death. Environmental hazards that increase
Social Support
the risks of falling include poor lighting, slip
pery or irregular walking surfaces and a lack
of supportive handrails. Most often, these
falls occur in the home environment and are
preventable.
Inadequate social support is associated not
only with an increase in mortality, morbidity
and psychological distress but a decrease in
overall general health and well being. Disrup
tion of personal ties, loneliness and conflictual
The consequences of injuries sustained in old
interactions are major sources of stress, while
er age are more severe than among younger
supportive social connections and intimate re
people. For injuries of the same severity, older
lations are vital sources of emotional strength
people experience more disability, longer hos
(Gironda and Lubben, in press). In Japan, for
pital stays, extended periods of rehabilitation.
example, older people who reported a lack
a higher risk of subsequent dependency and a
of social contact were 1.5 times more likely
higher risk of dying.
to die in the next three years than were those
with higher social support (Sugiswawa el al,
The great majority of injuries are
preventable; however, the traditional
view of injuries as “accidents” has
resulted in historical neglect of this
area in public health.
1994).
Older people are more likely to lose family
members and friends and to be more vulner
able to loneliness, social isolation and the
availability of a "smaller social pool”. Social
isolation and loneliness in old age are linked
Clean Water, Clean Air and Safe Foods
to a decline in both physical and mental
well being. In most societies, men are less
Clean water, clean air and access to safe foods
are particularly important for the most vulner
able population groups, i.e. children and older
persons, and for those who have chronic ill
nesses and compromised immune systems.
likely than women to have supportive social
networks. However, in some cultures, older
women who are widowed are systematically
excluded from mainstream society or even
rejected by their community.
Determinants Related to the Social
Environment
Decision-makers, nongovernmental organiza
Social support, opportunities for education
service professionals can help foster social
tions, private industry and health and social
and lifelong learning, peace, and protection
networks for ageing people by supporting tra
from violence and abuse are key factors in
ditional societies and community groups run
the social environment that enhance health,
by older people, voluntarism, neighbourhood
participation and security as people age. Lone
helping, peer mentoring and visiting, family
liness, social isolation, illiteracy and a lack
caregivers, intergenerational programmes and
outreach services.
PAGE 28
ACTIVE AGEING: A POLICY FRAMEWORK
Violence and Abuse
Confronting and reducing elder abuse requires
Older people who are frail or live alone may
a multisectoral, multidisciplinary approach in
feel particularly vulnerable to crimes such as
volving justice officials, law enforcement offi
theft and assault. A common form of violence
cers, health and social service workers, labour
against older people (especially against older
leaders, spiritual leaders, faith institutions.
women) is “elder abuse” committed by family
advocacy' organizations and older people
members and institutional caregivers who
themselves. Sustained efforts to increase public
are well known to the victims. Elder abuse
awareness of the problem and to shift values
occurs in families at all economic levels. It
that perpetuate gender inequities and ageist
is likely to escalate in societies experiencing
attitudes are also required.
economic upheaval and social disorganization
Education and Literacy
when overall crime and exploitation tends to
increase.
Low levels of education and illiteracy are as
sociated with increased risks for disability and
According to the International
Network for the Prevention of Elder
Abuse, elder abuse is “a single or
repeated act, or lack of appropriate
action occurring within any rela
tionship where there is an expecta
tion of trust which causes harm or
distress to an older person" (Action
on Elder Abuse 1995).
death among people as they age. as well as
with higher rates of unemployment. Education
in early life combined with opportunities for
lifelong learning can help people develop the
skills and confidence they need to adapt and
stay independent, as they grow older.
Studies have shown that employment prob
lems of older workers are often rooted in their
relatively low literacy skills, not in ageing per
se. If people are to remain engaged in mean
ingful and productive activities as they grow
Elder abuse includes physical, sexual, psycho
older, there is a need for continuous training
logical and financial abuse as well as neglect.
in the workplace and lifelong learning oppor
Older people themselves perceive abuse as
tunities in the community' (OECD. 1998).
including the following societal factors: neglect
(social exclusion and abandonment), violation
Like younger people, older citizens need train
(human, legal and medical rights) and depriva
ing in new technologies, especially in agricul
tion (choices, decisions, status, finances and
ture and electronic communication. Self-direct
respect) (WHO/INPEA 2002). Elder abuse is
ed learning, increased practice and physical
a violation of human rights and a significant
adjustments (such as the use of large print)
cause of injury, illness, lost productivity, isola
can compensate for reductions in visual acuity,
tion and despair. Typically, it is underreported
hearing and short-term memory. Older people
in all cultures.
can and do remain creative and flexible. Inter-
generational learning bridges age differences.
enhances the transmission of cultural values
and promotes the worth of all ages. Studies
have shown that young people who learn with
PAGE 29
older people have more positive and realistic
attitudes about the older generation.
Unfortunately, there continue to be striking
Social Protection
In all countries of the world, families provide
the majority of support for older people who
disparities in literacy rates between men and
require help. However, as societies develop
women. In 1995 in the least developed coun
and the tradition of generations living together
tries, 31 percent of adult women were illiterate
compared to 20 percent of adult men (WHO.
1998a).
begins to decline, countries are increasingly
called on to develop mechanisms that pro
vide social protection for older people who
are unable to earn a living and are alone and
Economic Determinants
Three aspects of the economic environment
have a particularly significant effect on active
ageing: income, work and social protection.
vulnerable. In developing countries, older
people who need assistance tend to rely on
family support, informal service transfers and
personal savings. Social insurance programmes
in these settings are minimal and in some
Income
Active ageing policies need to intersect with
broader schemes to reduce poverty at all ages.
While poor people of all ages face an in
creased risk of ill health and disabilities, older
people are particularly vulnerable. Many older
people especially those who are female, live
alone or in rural areas do not have reliable or
sufficient incomes. This seriously affects their
access to nutritious foods, adequate housing
and health care. In fact, studies have shown
population who are less in need. However, in
countries such as South Africa and Namibia,
which have a national old age pension, these
benefits are a major source of income for
many poor families as well as the older adults
who live in these families. The money from
these small pensions is used to purchase food
for the household, to send children to school,
to invest in farming technologies and to en
sure survival for many urban poor families.
that older people with low incomes are one-
In developed countries, social security
third as likely to have high levels of function
measures can include old-age pensions,
ing as those with high incomes (Guralnick and
occupational pension schemes, voluntary
Kaplan, 1989).
savings incentives, compulsory savings funds
The most vulnerable are older women and
men who have no assets, little or no savings,
no pensions or social security payments or
who are part of families with low or uncertain
incomes. Particularly, those without children
or family members often face an uncertain
future and are at high risk for homelessness
and destitution.
PAGE 30
cases redistribute income to minorities in the
and insurance programmes for disability,
sickness, long-term care and unemployment.
In recent years, policy reforms have favoured
a multi-pillared approach that mixes state
and private support for old age security and
encourages working longer and gradual
retirement (OECD, 1998).
Work
tendency to see reducing the number of older
Throughout the world, if more people
workers as a way to create jobs for younger
would enjoy opportunities for dignified
people. However, experience has shown that
work (properly remunerated, in adequate
the use of early retirement to free up new jobs
environments, protected against the hazards)
for the unemployed has not been an effective
earlier in life, people would reach old age
solution (OECD, 1998).
able to participate in the workforce. Thus, the
whole society would benefit. In all parts of the
world, there is an increasing recognition of
the need to support the active and productive
contribution that older people can and do
make in formal work, informal work, unpaid
activities in the home and in voluntary
occupations.
In less developed countries, older people are
by necessity more likely to remain economically
active into old age (see Figure 9). However,
industrialization, adoption of new technologies
and labour market mobility is threatening
much of the traditional work of older people,
particularly in rural areas. Development projects
need to ensure that older people are eligible for
In developed countries, the potential gain
credit schemes and full participation in income
of encouraging older people to work
generating opportunities.
longer is not being fully realized. But when
unemployment is high, there is often a
childcare so that younger adults can work
Concentrating only on work in the
formal labour market tends to ig
nore the valuable contribution that
older people make in work in the
informal sector (e.g., small scale,
self-employed activities and domes
tic work) and unpaid work in the
home.
outside the home.
In all countries, skilled and experienced older
people act as volunteers in schools, commu
nities, religious institutions, businesses and
health and political organizations. Voluntary
work benefits older people by increasing
social contacts and psychological well being
while making a significant contribution to their
communities and nations.
In both developing and developed coun
tries, older people often take prime respon
sibility for household management and
PAGE 32
ACTIVE AGEING: A POLICY FRAMEWORK
4. Challenges of an Ageing Population
The challenges of population ageing are
from childbirth, they are faced with the rapid
global, national and local. Meeting these chal
growth of noncommunicable diseases (NCDs).
lenges will require innovative planning and
This “double burden of disease" strains already
substantive policy reforms in developed coun
scarce resources to the limit.
tries and in countries in transition. Develop
ing countries, most of whom do not yet have
comprehensive policies on ageing, face the
The shift from communicable to NCDs is fast
occurring in most of the developing world,
where chronic illnesses such as heart disease.
biggest challenges.
cancer and depression are quickly becoming
Challenge 1: The Double Burden
of Disease
As nations industrialize, changing patterns of
living and working are inevitably accompanied
by a shift in disease patterns. These changes
impact developing countries most. Even as
these countries continue to struggle with infec
tious diseases, malnutrition and complications
the leading causes of morbidity and disabil
ity. This trend will escalate over the next few
decades. In 1990, 51 percent of the global
burden of disease in developing and newly
industrialized countries was caused by NCDs,
mental health disorders and injuries. By 2020.
the burden of these diseases will rise to ap
proximately 78 percent (See Figure 10).
Figure 10. Global burden of disease 1990 and 2020 contribution by disease group
in developing and newly industrialized countries
1990
H Communicable diseases
O Noncommunicable diseases
2020
Neuropsychiatric diseases
L-J Injuries
Source: Murray&Lopez, 1996
By 2020, over 70 percent of the global burden of disease in developing and newly industrialized countries will be caused by
noncommunicable diseases, mental health disorders and injuries.
PAGE 33
There is no question that policy makers and
donors must continue to put resources to
ward the control and eradication of infectious
diseases. But it is also critical to put policies,
programmes and intersectoral partnerships
into place that can help to halt the massive
expansion of chronic NCDs. While not neces
sarily easy to implement, those that focus on
community development, health promotion,
Challenge 2: Increased Risk of
Disability
In both developing and developed countries,
chronic diseases are significant and costly
causes of disability and reduced quality of life.
An older person’s independence is threatened
when physical or mental disabilities make it dif
ficult to cany7 out the activities of daily living.
disease prevention and increasing participa
As they grow older, people with disabilities
tion are often the most effective in control
are likely to encounter additional barriers relat
ling the burden of disease. Furthermore other
ed to the ageing process. For example, mobil
long-term policies that target malnutrition and
ity problems due to poliomyelitis in childhood
poverty will help to reduce both chronic com
may be considerably aggravated later in life.
municable and noncommunicable diseases.
Now that many young people with intellectual
Support for relevant research is most
urgently needed for less developed countries.
Currently, low and middle-income countries
have 85 percent of the world's population and
disabilities survive at much older ages and live
beyond their parents, this special group also
requires careful attention from policy makers.
Many people develop disabilities in later life
92 percent of the disease burden, but only
related to the wear and tear of ageing (e.g.,
10 percent of the world's health research
arthritis) or the onset of a chronic disease,
spending (WHO, 2000).
HIV/AIDS and older people
In Africa and other developing regions, HIV/AIDS has had multiple impacts on older
people, in terms of living with the disease themselves, caring for others who are infect
ed and taking on the parenting role with orphans of AIDS.This impact has been largely
ignored to date. In fact, most data on HIV and AIDS infection rates are only compiled
up to age 49. Improved data collection (without age limitations) that helps us better
understand the impact of HIV/AIDS on older people is urgently needed. HIV/AIDS infor
mation, education and prevention activities as well as treatment services should apply
to all ages.
Numerous studies have found that most adult children with AIDS return home to die.
Wives, mothers, aunts, sisters, sisters-in-law and grandmothers take on the bulk of the
care.Then, in many cases, these women take on the care of the orphaned children.
Governments, nongovernmental organizations and private industry need to address
the financial, social and training needs of older people who care for family members
and neighbours who are infected and raise child survivors, some of whom themselves
are also infected (WHO, 2002).
PAGE 34
ACTIVE AGEING: A POLICY FRAMEWORK
which could have been prevented in the first
Some of this decline is likely due to increased
place (e.g., lung cancer, diabetes and periph
education levels, improved standards of liv
eral vascular disease) or a degenerative illness
ing and better health in the early years. The
(e.g., dementia). The likelihood of experienc
adoption of positive lifestyle behaviours is
ing serious cognitive and physical disabilities
also a factor. As already mentioned, choosing
dramatically increases in very' old age. Signifi
not to smoke and making modest increases in
cantly, adults over the age of 80 are the fastest
physical activity levels can significantly reduce
growing age group worldwide.
one’s risk for heart disease and other illnesses.
i
Supportive changes in the community are
But disabilities associated with ageing and the
onset of chronic disease can be prevented
or delayed. For example, as mentioned on
page 18, there has been a significant decline
over the last 20 years in age-specific disability
rates in the U.S.A (see Figure 11), England,
Sweden and other developed countries.
also important, both in terms of preventing
disabilities and reducing the restrictions that
people with disabilities often face. In addition.
impressive progress in the management of
chronic conditions has been observed, includ
ing new techniques for early diagnosis and
treatment, as well as long-term management
Figure 10 shows the actual decline in disabili
of chronic diseases, such as hypertension and
ties among older Americans between 1982
arthritis. Recent studies have also emphasized
and 1999 compared to the projected numbers
that the increasing use of aids - from simple
if rates of disability had remained stable over
personal aids, such as canes, walkers, hand
that time period.
rails, to technologies aimed at the population
as a whole, such as telephones - may reduce
PAGE 35
dependence among disabled people. In the
Policies and programmes need to be in place
USA the use of such aids by dependent older
to reduce and eventually eliminate avoidable
people increased from 76 percent in 1984 to
hearing impairment and to help people with
over 90 percent in 1999 (Cutler, 2001).
hearing loss obtain hearing aids. Hearing loss
Vision and Hearing
may be prevented by avoiding exposure to
excessive noise and the use of potentially
Other common age-related disabilities include
damaging drugs and by early treatment of dis
vision and hearing losses. Worldwide, there
eases leading to hearing loss, such as middle
are currently 180 million people with visual
ear infections, diabetes and possibly hyperten
disability, up to 45 million of whom are blind.
sion. Hearing loss can sometimes be treated,
Most of these are older people, as visual im
especially if the cause is in the ear canal or
pairment and blindness increase sharply with
middle ear. Most often, however, the disability
age. Overall, approximately four percent of
is reduced by amplification of sounds, usually
persons aged 60 years and above are thought
by using a hearing aid.
to be blind, and 60 percent of them live in
Sub-Saharan Africa. China and India. The ma
An Enabling Environment
jor age-related causes of blindness and visual
As populations around the world live longer,
disability include cataracts (nearly 50 percent
policies and programmes that help prevent
of all blindness), glaucoma, macular degenera
and reduce the burden of disability in old
tion and diabetic retinopathy (WHO, 1997).
age are urgently needed in both developing
and developed countries. One useful way to
There is an urgent need for policies and pro
grammes designed to prevent visual impair
ment and to increase appropriate eye care
sendees, particularly in developing countries.
In all countries, corrective lenses and cataract
surgery should be accessible and affordable
for older people who need them.
Hearing impairment leads to one of the most
widespread disabilities, particularly in older
people. It is estimated that worldwide over
50 percent of people aged 65 years and over
have some degree of hearing loss (WHO,
2002a). Hearing loss can cause difficulties with
look at decision-making in this area is to think
about enablement instead of disablement. Dis
abling processes increase the needs of older
people and lead to isolation and dependence.
Enabling processes restore function and
expand the participation of older people in all
aspects of society.
A variety of sectors can enact "age-friendly"
policies that prevent disability and enable
those who have disabilities to fully participate
in community life. Here are some examples of
enabling programmes, environments and poli
cies in a variety of sectors:
communication. This, in turn can lead to frus
tration, low self-esteem, withdrawal and social
isolation (Pal, 1974, Wilson, 1999).
• barrier-free workplaces, flexible work
hours, modified work environments and
part-time work for people who experience
disabilities as they age or are required to
care for others with disabilities (private
industry and employers)
PAGE 36
ACTIVE AGEING: A POLICY FRAMEWORK
• well-lit streets for safe walking, accessible
Researchers need to better define and stan
public toilets and traffic lights that give
dardize the tools used to assess ability and
people more time to cross the street (local
disability and to provide policy makers with
governments)
additional evidence on key enabling processes
in the broader environment, as well as in med
• exercise programmes that help older
people maintain their mobility or recover
icine and health. Careful attention needs to be
paid to gender differences in these analyses.
the leg strength they need to be mobile
(recreation services and nongovernmental
agencies)
• life-long learning and literacy programmes
Challenge 3: Providing Care for
Ageing Populations
As populations age, one of the greatest chal
(education sector and nongovernmental
lenges in health policy' is to strike a balance
organizations)
among support for self-care (people look
ing after themselves), informal support (care
• hearing aids or instruction in sign language
from family members and friends) and formal
that enables older people who are hard of
care (health and social services). Formal care
hearing to continue to communicate with
includes both primary health care (delivered
others (social services and nongovernmen
mostly at the community level) and institution
tal organizations)
al care (either in hospitals or nursing homes).
• barrier-free access to health centres, reha
bilitation programmes and cost-effective
procedures such as cataract surgery and hip
replacements (health sector)
While it is clear that most of the care individu
als need is provided by themselves or their
informal caregivers, most countries allot their
financial resources inversely, i.e., the greatest
share of expenditure is on institutional care.
• credit schemes and access to small busi
ness and development opportunities so that
older people can continue to earn a living
(governments and international agencies).
All over the world, family members, friends
and neighbours (most of whom are women)
provide the bulk of support and care to older
adults that need assistance. Some policy mak
Changing the attitudes of health and social
ers fear that providing more formal care ser
service providers is paramount to ensuring that
vices will lessen the involvement of families.
their practices enable and empower individu
Studies show that this is not the case. When
als to remain as autonomous and independent
appropriate formal services are provided,
as possible for as long as possible. Profession
informal care remains the key partner (WHO.
al caregivers need to respect older people’s
2000c). Of concern though are recent demo
dignity at all times and to be careful to avoid
graphic trends in a large number of countries
premature interventions that may unintention
indicating the increase in the proponion of
ally induce the loss of independence.
childless women, changes in divorce and mar
riage patterns and the overall much smaller
number of children of future cohorts of older
people, all contributing to a shrinking pool of
family support (Wolf, 2001).
PAGE 37
Formal care through health and social sen ice
assistive devices (ranging from basic devices
systems needs to be equally accessible to all.
such as a hearing aid to more sophisticated
In many countries older people who are poor
ones, such as an electronic alarm system),
and who live in rural areas have limited or
respite care and adult day care are all impor
no access to needed health care. A decline in
tant services that enable informal caregivers to
public support for primary’ health care sen ices
continue to provide care to individuals who
in many areas has put increased financial and
require help, whatever their age. Other forms
intergenerational strain on older people and
of support include training, income security
their families.
(e.g., social security coverage and pensions),
help with housing adjustments that enable
Most older persons in need of care prefer to
be cared for in their own homes. But care
families to look after people who are disabled
and disbursements to help cover caring costs.
givers (who are often older people) must be
supported if they are to continue to provide
As the proportion of older people increases in
care without becoming ill themselves. Above
all countries, living at home into very old age
all, they need to be well informed about the
with help from family members will become
condition they are faced with and how it is
increasingly common. Home care and com
likely to progress, and about how to obtain
munity services to assist informal caregivers
the support sendees that are available. Visiting
need to be available to all, not just to those
nurses, home care, peer support programmes,
who know about them or can afford to pay
rehabilitation services, the provision of
for them.
Sex ratios for populations age 60 and over reflect the larger proportion of women than men in all regions of the world,
particularly in the more developed regions.
PAGE 38
ACTIVE AGEINGtA POLICY FRAMEWORK
Professional caregivers also need training
and practice in enabling models of care that
recognize older people's strengths and em
power them to maintain even small measures
of independence when they are ill or frail.
Paternalistic or disrespectful attitudes by pro
fessionals can have a devastating effect on the
self-esteem and independence of older people
who require sendees.
Challenge 4: The Feminization of
Ageing
Women live longer than men almost every
where. This is reflected in the higher ratio of
women versus men in older age groups. For
example, in 2002, there were 678 men for
every 1,000 women aged 60 plus in Europe.
In less developed regions, there were 879 men
per 1,000 women (See Figure 12). Women
Information and education about active age
make up approximately two-thirds of the
ing needs to be incorporated into curricula
population over age 75 in countries such as
and training programmes for all health, social
Brazil and South Africa. While women have
service and recreation workers as well as city
the advantage in length of life, they are more
planners and architects. Basic principles and
likely than men to experience domestic vio
approaches in old-age care should be manda
lence and discrimination in access to educa
tory in the training of all medical and nursing
tion. income, food, meaningful work, health
students as well as other health professions.
care, inheritances, social securin' measures and
political power. These cumulative disadvan
tages mean that women are more likely than
In contrast to the pyramid form, the Japanese population structure has changed due to population ageing towards a cone
shape. By 2025, the shape will be similar to an up-side-down pyramid, with persons age 80 and over accounting for the larg
est population group. The feminization of old age is highly visible.
PAGE 39
men io be poor and to suffer disabilities in
older age. Because of their second-class status,
the health of older women is often neglected
or ignored. In addition, many women have
low or no incomes because of years spent in
unpaid caregiving roles. The provision of fam
ily care is often achieved at the detriment of
female caregivers' economic security and good
health in later life.
Women are also more likely than men to live
Challenge 5: Ethics and Inequities
As populations age, a range of ethical con
siderations comes to the fore. They are often
linked to age discrimination in resource al
location, issues related to the end of life and a
host of dilemmas linked to long-term care and
the human rights of poor and disabled older
citizens. Scientific advancements and modern
medicine have led to many ethical questions
related to genetic research and manipulation,
to very' old age when disabilities and multiple
biotechnology', stem cell research and the use
health problems are more common. At age
of technology’ to sustain life while compromis
80 and over, the world average is below 600
ing quality of life. In all cultures, consumers
men for every 1,000 women. In the more
need to be fully informed about false claims
developed regions women age 80 and over
of "anti-ageing" products and programmes that
outnumber men by more than two to one (see
are ineffective or harmful. They need protec
the example of Japan in Figure 13).
tion from fraudulent marketing and financing
schemes, especially as they grow older.
Because of women's longer life expectancy
and the tendency of men to many younger
Societies that value social justice must strive to
women and to remarry' if their spouses die,
ensure that all policies and practices uphold
female widows dramatically outnumber male
and guarantee the rights of all people, re
widowers in all countries. For example, in the
gardless of age. Advocacy and ethical deci
Eastern European countries in economic tran
sion-making must be central strategies in all
sition over 70 percent of women age 70 and
programmes, practices, policies and research
over are widows (Botev, 1999).
on ageing.
Older women who are alone are highly
Older age often exacerbates other pre-existing
vulnerable to poverty and social isolation. In
inequalities based on race, ethnicity or gender.
some cultures, degrading and destructive at
While women are universally disadvantaged
titudes and practices around burial rights and
in terms of poverty, men have shorter life
inheritance may rob widows of their property'
expectancies in most countries. The exclusion
and possessions, their health and indepen
and impoverishment of older women and men
dence and, in some cases, their very’ lives.
is often a product of structural inequities in
both developing and developed countries. In
equalities experienced in earlier life in access
to education, employment and health care, as
well as those based on gender and race have
a critical bearing on status and well being in
old age. For older people who are poor, the
consequences of these earlier experiences
PAGE 40
ACTIVE AGEING:A POLICY FRAMEWORK
are worsened through further exclusion from
in socioeconomic status. Recent World Bank
health services, credit schemes, income-gener
data reveal that in many developing countries
ating activities and decision-making. Inequities
well over half of the population lives 'on less
in care occur when small and comparatively
than two purchasing power parity (PPP) dol
well off portions of the ageing population,
lars per day (see Table 4).
particularly those in developing countries,
consume a disproportionately high amount of
It is well known that socioeconomic status
and health are intimately related. With each
public resources for their care.
step up the socioeconomic ladder, people live
In many cases, the means for older people to
longer, healthier lives (Wilkinson, 1996). In re
achieve dignity and independence, receive
cent years, the gap between rich and poor and
care and participate in civic affairs are very
subsequent inequalities in health status has
limited. These conditions are often worse for
been increasing in countries in all parts of the
older people living in rural areas, in countries
world (Lynch et al. 2000). Failure to address
in transition and in situations of conflict or
this problem will have serious consequences
humanitarian disasters.
for the global economy and social order, as
well as for individual societies and people of
In all regions of the world, relative wealth and
all ages.
poverty, gender, ownership of assets, access to
work and control of resources are key factors
Table 4. Percentage of the population below international poverty tines in countries
with a population approaching or above 100 million in the year 2000
Countries
Population
(millions)#
Percentage with
<1dollar/day*
Percentage with
<2dollar/day*
China
1.275
18.5
53.7
India
1.008
44.2
86.2
Indonesia
212
7.7
55.3
Brazil
170
9.0
25.4
Russian Federation
145
7.1
25.1
Pakistan
141
31.0
84.7
Bangladesh
137
29.1
77.8
Nigeria
113
70.2
90.8
Mexico
98
12.2
34.8
’adjusted for purchasing power
Source:World Bank, 2001, S Source: UN, 2001
PAGE -11
Challenge 6: The Economics of an
Ageing Population
Perhaps more than anything else, policy mak
ers fear that rapid population ageing will lead
to an unmanageable explosion in health care
and social security costs. While there is no
doubt that ageing populations will increase
demands in these areas, there is also evidence
that innovation, cooperation from all sectors,
planning ahead and making evidence-based.
culturally-appropriate policy choices will
enable countries to successfully manage the
economics of an ageing population.
Second, the costs of long-term care can be
managed if policies and programmes address
prevention and the role of informal care. Poli
cies and health promotion programmes that
prevent chronic diseases and lessen the degree
of disability among older citizens enable
them to live independently longer. Another
major factor is the capacity and willingness
of families to provide care and support for
older family members. This will depend to a
large extent on the rates of female participa
tion in the labour force and on workplace and
public policies that recognize and support the
caregiving role
Research in countries with aged populations
has shown that ageing per se is not likely to
lead to ‘'health care costs that are spiraling out
of control”, for two reasons.
In many countries, the bulk of spending is on
curative medicine. Care for chronic conditions
leads to an improved quality of life: however,
it is always preferable if those conditions could
First, according to OECD data, the major
be prevented or delayed until very' late in life.
causes of escalating health care costs are
Decision makers need to evaluate whether such
related to circumstances that are unrelated to
outcomes can be achieved titrough policies that
the demographic ageing of a given population.
address the broad determinants of active age
Inefficiencies in care delivery, building loo
ing. such as interventions to prevent injuries,
many hospitals, payment systems that encour
improve diets and physical activity, increase
age long hospital stays, excessive numbers
literacy or increase employment.
of medical interventions and the inappropri
ate use of high cost technologies are the key
factors in escalations in health care costs. For
example, in the United States and other OECD
countries, new technologies were sometimes
rapidly introduced and used where alternative
and less expensive procedures already existed.
and for which the marginal effectiveness was
relatively low (Jacobzone and Oxley, 2002).
There appears to be considerable scope for
policy makers to address these issues and
improve the effectiveness of health care.
PAGE 42
Ultimately, the level of funding allocated to
the health system is a social and political
choice with no universally applicable answer.
However, the WHO suggests that it is better
to make pre-payments on health care as much
as possible, whether in the form of insurance,
taxes or social security. The principle of “fair
financing" ensures equity of access regardless
of age. sex or ethnicity and that the financial
burden is shared in a fair way (WHO, 2000a).
ACTIVE AGEING: A POLICY FRAMEWORK
A second major concern to policy-makers is
the demand that an ageing population may
put on social security systems. Alarmists point
to the growing proportion of the “dependent"
population that has retired from the formal la
bour force. The idea that everyone over age 60
is dependent is, however, a false assumption.
Many people continue to work in the formal
labour market in later life or would choose to
do so if the opportunity existed. Many oth
ers continue to contribute to the economy
through informal work and voluntary activities,
as well as intergenerational exchanges of cash
and family support. For example, older people
who look after grandchildren allow younger
adults to participate in the labour market.
Challenge 7: Forging a New Paradigm
Traditionally, old age has been associated with
retirement, illness and dependency. Policies
and programmes that are stuck in this out
dated paradigm do not reflect reality. Indeed,
most people remain independent into very old
age. Especially in developing countries, many
people over age 60 continue to participate
in the labour force. Older people are active
in the informal work sector (e.g., domestic
work and small scale, self-employed activi
ties) although this is often not recognized in
labour market statistics. Older people’s unpaid
contributions in the home (such as looking
after children and people who are ill) allow
younger family members to engage in paid
An ageing population provides other advan
labour. In all countries, the voluntary activities
tages to the overall economy. Nations with
of older people provide an important econom
declining working-age populations will be
ic and social contribution to society.
able to draw on older experienced workers
and industries will be able to grow as they
serve the needs of older consumers.
Global ageing does require governments and
the private sector to address the challenges to
It is lime for a new paradigm, one
that views older people as active
participants in an age-integrated
society and as active contributors as
well as beneficiaries of development.
social security and pension systems. A bal
anced approach to the provision of social
protection and economic goals suggests that
societies who are willing to plan can afford to
grow old. Labour market policies (for exam
This includes recognition of the contributions
of older people who are ill, frail and Milner-
able and championing their rights to care and
security.
ple, incentives for early retirement and manda
tory retirement practices) have a more dramat
This paradigm takes an intergenerational
ic impact on a nation’s ability to provide social
approach that recognizes the importance of
protection in old age than demographic ageing
relationships and support among and between
per se. The goal must be to ensure adequate
family members and generations. It reinforces
living standards for people as they grow older,
"a society for all ages’’ - the central focus of
while recognizing and harnessing their skills
the 1999 United Nations International Year of
and experience and encouraging harmonious
Older Persons.
intergenerational transfers.
PAGE 43
The new paradigm also challenges the tra
Older people themselves and the media must
ditional view that learning is the business of
take the lead in forging a new, more positive
children and youth, work is the business of
image of ageing. Political and social recogni
midlife and retirement is the business of old
tion of the contributions that older people
age. The new paradigm calls for programmes
make and the inclusion of older men and
that support learning at all ages and allow
women in leadership roles will support this
people to enter or leave the labour market in
new image and help de-bunk negative stereo
order to assume caregiving roles at different
types. Educating young people about ageing
times over the life course. This approach sup
and paying careful attention to upholding the
ports intergenerational solidarity and provides
rights of older people will help to reduce and
increased security for children, parents and
eliminate discrimination and abuse.
people in their old age.
PAGE 44
ACTIVE AGEING:A POLICY FRAMEWORK
5. The Policy Response
The ageing of the population is a global phe
The policy framework for active ageing shown
nomenon that demands international, national,
below is guided by the United Nations Prin
regional and local action. In an increasingly
ciples for Older People (the outer circle). These
inter-connected world, failure to deal with the
are independence, participation, care, self-ful
demographic imperative and rapid changes in
fillment and dignity. Decisions are based on
disease patterns in a rational way in any part
an understanding of how the determinants of
of the world will have socioeconomic and
active ageing influence the way that individu
political consequences everywhere.
als and populations age.
Ultimately, a collective approach to
ageing and older people will deter
mine how we, our children and our
grandchildren will experience life in
later years.
The policy framework requires action on three
basic pillars:
Health. When the risk factors (both environ
mental and behavioural) for chronic diseases
and functional decline are kept low while the
protective factors are kept high, people will
enjoy both a longer quantity and quality’ of
PAGE 45
life: they will remain healthy and able to man
responsibility for policies in all of these other
age their own lives as they grow older; fewer
sectors, they belong in the broadest sense
older adults will need costly medical treatment
within the scope of public health because they
and care services.
support the goals of improved health through
intersectoral action. This kind of an approach
For those who do need care, they should have
access to the entire range of health and social
services that address the needs and rights of
women and men as they age.
Participation. When labour market, employ
ment, education, health and social policies and
programmes support their full participation in
socioeconomic, cultural and spiritual activi
ties. according to their basic human rights,
capacities, needs and preferences, people will
continue to make a productive contribution to
society in both paid and unpaid activities as
stresses the importance of the numerous dif
ferent public health partners and reinforces the
role of the health sector as a catalyst for action
(Yach, 1996).
Furthermore, all policies need to support intergenerational solidarity and include specific
targets to reduce inequities between women
and men and among different subgroups
within the older population. Particular atten
tion needs to be paid to older people who are
poor and marginalized, and who live in rural
areas.
they age.
An active ageing approach seeks to eliminate
Security. When policies and programmes ad
dress the social, financial and physical security
needs and rights of people as they age, older
people are ensured of protection, dignity and
care in the event that they are no longer able
to support and protect themselves. Families
and communities are supported in efforts to
of older populations. Older people and their
caregivers need to be actively involved in the
planning, implementation and evaluation of
policies, programmes and knowledge develop
ment activities related to active ageing.
care for their older members.
Key Policy Proposals
Intersectoral Action
The following policy' proposals are designed
Attaining the goal of active ageing will require
action in a variety of sectors in addition to
health and social services, including educa
tion, employment and labour, finance, social*
security, housing, transportation, justice and
rural and urban development. While it is clear
that the health sector does not have direct
PAGE 46
age discrimination and recognize the diversity
to address the three pillars of active age
ing: health, participation and security. Some
are broad and encompass all age groups
while others are targeted specifically to those
approaching old age and/or older people
themselves.
ACTIVE AGEINC : A POLICY FRAMEWORK
1. Health
Prevent and reduce the burden of
excess disabilities, chronic disease and
premature mortality.
1.1
• Goals and targets. Set gender-specific,
measurable targets for improvements in
health status among older people and in
the reduction of chronic diseases, disabili
ties and premature mortality as people age.
• Economic influences on health. Enact
standards that protect older workers from
injury. Modify formal and informal work
environments so that people can continue
to work productively and safely as they
age.
• Hearing and vision. Reduce avoidable
hearing impairment through appropriate
prevention measures and support access
to hearing aids for older people who have
hearing loss. Aim to reduce and eliminate
avoidable blindness by 2020 (WHO, 1997).
policies and programmes that address the
Provide appropriate eye care services for
economic factors that contribute to the
people with age-related visual disabilities.
onset of disease and disabilities in later life
Reduce inequities in access to corrective
(i.e., poverty, income inequities and social
glasses for ageing women and men.
exclusion, low literacy levels, lack of educa
tion). Give priority to improving the health
status of poor and marginalized population
groups.
• Prevention and effective treatments.
Make screening services that are proven
to be effective, available and affordable to
women and men as they age. Make effec
tive, cost-efficient treatments that reduce
disabilities (such as cataract removal and
hip replacements) more accessible to older
people with low incomes.
• Age friendly, safe environments. Cre
• Barrierfree living. Develop barrier-free
housing options for ageing people with
disabilities. Work to make public buildings
and transportation accessible for all people
with disabilities. Provide accessible toilets
in public places and workplaces.
• Quality of life. Enact policies and pro
grammes that improve the quality of life
of people with disabilities and chronic
illnesses. Support their continuing indepen
dence and interdependence by assisting
with changes in the environment, providing
rehabilitation services and community sup
ate age-friendly health care centres and
port for families, and increasing affordable
standards that help prevent the onset or
access to effective assistive devices (e.g.,
worsening of disabilities. Prevent injuries
corrective eyeglasses, walkers).
by protecting older pedestrians in traffic,
making walking safe, implementing fall pre
vention programmes, eliminating hazards
in the home and providing safety advice.
Stringently enforce occupational safety
PAGE 47
• Social support. Reduce risks for loneli
• Physical activity. Develop culturally
ness and social isolation by supporting
appropriate, population-based informa
community groups run by older people,
tion and guidelines on physical activity for
traditional societies, self-help and mutual
older men and women. Provide accessible,
aid groups, peer and professional outreach
pleasant and affordable opportunities to be
programmes, neighbourhood visiting,
active (e.g.. safe walking areas and parks).
telephone support programmes, and family
Support peer leaders and groups that
caregivers. Support intergenerational con
promote regular, moderate physical activity
tact and provide housing in communities
for people as they age. Inform and educate
that encourage daily social interaction and
people and professionals about the impor
interdependence among young and old.
tance of staying active as one grows older.
• HIV and AIDS. Remove the age limitation
on data collection related to HIV/AIDS.
• Nutrition. Ensure adequate nutrition
throughout the life course, particularly in
Assess and address the impact of HIV/AIDS
childhood and among women in the repro
on older people, including those who
ductive years. Ensure that national nutrition
are infected and those who are caring for
policies and action plans recognize older
others who are infected and/or for AIDS
persons as a potentially vulnerable group.
orphans.
• Mental health. Promote positive mental
Include special measures to prevent malnu
trition and ensure food security and safety
as people age.
health throughout the life course by provid
ing information and challenging stereotypi
propriate, population-based guidelines for
and mental illness.
healthy eating for men and women as they
• Clean environments. Put policies and
programmes in place that ensure equal
access for all to clean water, safe food and
clean air. Minimize exposure to pollution
throughout the life course, particularly in
childhood and old age.
1.2 Reduce risk factors associated with
major diseases and increase factors
that protect health throughout the life
course.
age. Support improved diets and healthy
weights in older age through the provision
of information (including information spe
cific to the nutrition needs of older people),
education about nutrition at all ages, and
food policies that enable women, men and
families to make healthy food choices.
• Oral health. Promote oral health among
older people and encourage women and
men to retain their natural teeth for as long
as possible. Set culturally appropriate policy
• Tobacco. Take comprehensive action at
goals for oral health and provide appropri
local, national and international levels to
ate oral health promotion programmes and
control the marketing and use of tobacco
treatment sendees during the life course.
products. Provide older people with help to
quit smoking.
PAGE 48
• Healthy eating. Develop culturally ap
cal beliefs about mental health problems
ACTIVE AGEING:A POLICY FRAMEWORK
• Psychologicalfactors. Encourage and
grow older. Re-orient current systems that
enable people to build self-efficacy, cogni
are organized around acute care to provide
tive skills such as problem-solving, pro
a seamless continuum of care that includes
social behaviour and effective coping skills
health promotion, disease prevention, the
throughout the life course. Recognize and
appropriate treatment of chronic diseases,
capitalize on the experience and strengths
the equitable provision of community sup
of older people while helping them im
port and dignified long-term and palliative
prove their psychological well being.
care through all the stages of life.
• Alcohol and drugs. Determine the extent
• Affordable, equitable access. Ensure
of the use of alcohol and drugs by people
affordable equitable access to quality
as they age and put practices and policies
primary health care (both acute and
in place to reduce misuse and abuse.
chronic), as well as long-term care services
• Medications. Increase affordable access
to essential safe medications among older
for all.
• Informal caregivers. Recognize and
people who need them but cannot afford
address gender differences in the burden
them. Put practices and policies in place to
of caregiving and make a special effort to
reduce inappropriate prescribing by health
support caregivers, most of whom are older
professionals and other health advisors.
women who care for partners, children,
Inform and educate people about the wise
grandchildren and others who are sick
use of medications.
or disabled. Support informal caregivers
• Adherence. Undertake comprehensive
measures to better understand and correct
poor adherence to therapies, which severely
compromise treatment effectiveness, particu
larly in relation to long-term therapies.
1.3. Develop a continuum of affordable,
accessible, high quality and age
friendly health and social services that
address the needs and rights of women
and men as they age.
• A continuum of care throughout the
life course. Taking into consideration their
through initiatives such as respite care,
pension credits, financial subsidies, training
and home care nursing services. Recognize
that older caregivers may become socially
isolated, financially disadvantaged and sick
themselves, and attend to their needs.
• Formal caregivers. Provide paid caregiv
ers with adequate working conditions and
remuneration, with special attention to
those who are unskilled and have low so
cial and professional status (most of whom
are women).
opinions and preferences, provide a con
tinuum of care for women and men as they
PAGE 49
• Mental health services. Provide compre
hensive mental health services for men and
women as they age, ranging from mental
health promotion to treatment services for
mental illness, rehabilitation and re-integra
tion into the community as required. Pay
special attention to increased depression
and suicidal tendencies due to loss and so
cial isolation. Provide quality care for older
people with dementia and other neurologi
cal and cognitive problems in their homes
and in residential facilities when appropri
ate. Pay special attention to ageing people
with long-term intellectual disabilities.
• Coordinated ethical systems of care.
Eliminate age discrimination in health
and social service systems. Improve the
coordination of health and social services
ing support when it is required.
• Partnerships and quality care. Provide
a comprehensive approach to long-term
care (by informal and formal caregivers)
that stimulates collaboration between the
public and private sectors and involves all
levels of government, civil society and the
not-for-profit sector. Ensure high quality
standards and stimulating environments
in residential care facilities for men and
women who require this care, as they grow
older.
1.4 Provide training and education to
caregivers.
• Informal caregivers. Provide fam
ily members, peer counsellors and other
and integrate these systems when feasible.
informal caregivers with information and
Set and maintain appropriate standards of
training on how to care for people as they
care for ageing persons through regulatory
grow older. Support older healers who
mechanisms, guidelines, education, consul
are knowledgeable about traditional and
tation and collaboration.
complementary medicines while also as
• Iatrogenesis. Prevent iatrogenesis (disease
and disability that is induced by the process
sessing their training needs.
• Formal caregivers. Educate health and
of diagnosis or treatment). Establish ad
social service workers in enabling models
equate systems for preventing adverse drug
of primary health care and long-term care
reactions with a special focus on old age.
that recognize the strengths and contribu
Raise awareness of the relative risks and
tions of older people. Incorporate modules
benefits of modern therapies among health
on active ageing in medical and health
professionals and the public at large.
curricula at all levels. Provide specialist
• Ageing at home and in the community.
Provide policies, programmes and sendees
that enable people to remain in their homes
education in gerontology and geriatrics for
medical, health and social service profes
sionals.
as they grow older, with or without other
Inform all health and social service profes
family members according to their circum
sionals about the process of ageing and
stances and preferences. Support families
that include older people who need care in
their households. Provide help with meals
PAGE 50 :
and home maintenance, and at-home nurs
ACTIVE AGEING: A POLICY FRAMEWORK
ways to optimize active ageing among
individuals, communities and population
groups. Provide incentives and training
for health and social service professionals
to support self-care and counsel healthy
lifestyle practices among men and women
as they age. Increase the awareness and
sensitivity of all health professionals and
community workers of the importance of
2.2 Recognize and enable the active par
ticipation ofpeople in economic devel
opment activities, formal and informal
work and voluntary activities as they
age, according to their individual
needs, preferences and capacities.
• Poverty reduction and income genera
tion. Include older people in the planning,
implementation and evaluation of social de
social networks for well being in old age.
velopment initiatives and efforts to reduce
Train health promotion workers to identify
poverty'. Ensure that older people have
older people who are at risk for loneliness
the same access to development grants.
and social isolation.
income-generation projects and credit as
younger people do.
2. Participation
2.1 Provide education and learning op
portunities throughout the life course.
• Formal work. Enact labour market and
employment policies and programmes that
enable the participation of people in mean
• Basic education and health literacy.
ingful work as they grow older, according
Make basic education available to all across
to their individual needs, preferences and
the life course. Aim to achieve literacy for
capacities (e.g., the elimination of age
all. Promote health literacy by providing
discrimination in the hiring and retention
health education throughout the life course.
of older workers). Support pension reforms
Teach people how to care for themselves
that encourage productivity, a diverse sys
and each other as they get older. Educate
tem of pension schemes and more flexible
and empower older people on how to ef
retirement options (e.g., gradual or partial
fectively select and use health and commu
retirement).
nity services.
• Lifelong learning. Enable the full par
• Informal work. Enact policies and pro
grammes that recognize and support the
ticipation of older people by providing
contribution that older women and men
policies and programmes in education and
make in unpaid work in the infonnal sector
training that support lifelong learning for
and in caregiving in the home.
women and men as they age. Provide older
people with opportunities to develop new
• Voluntary activities. Recognize the value
skills, particularly in areas such as infor
of volunteering and expand opportuni
mation technologies and new agricultural
ties to participate in meaningful volunteer
techniques.
activities as people age, especially those
who want to volunteer but cannot because
of health, income, or transportation restric-
6 jC /07287
2.3 Encourage people to participate fully
in family community life, as they grow
older.
• Transportation. Provide accessible, af
fordable public transportation services in
rural and urban areas so that older people
(especially those with compromised mobil
ity) can participate fully in family and com
munity life.
• Leadership. Involve older people in
political processes that affect their rights.
Include older women and men in the
planning, implementation and evaluation
of locally based health and social sendee
and recreation programmes. Include older
people in prevention and education efforts
• A positive image of ageing. Work with
groups representing older people and the
media to provide realistic and positive im
ages of active ageing, as well as educational
information on active ageing. Confront
negative stereotypes and ageism.
• Reduce inequities in participation
by women. Recognize and support the
important contribution that older women
make to families and communities through
caregiving and participation in the informal
economy. Enable the full participation of
women in political life and decision-mak
ing positions as they age. Provide educa
tion and lifelong learning opportunities to
women as they age, in the same way that
they are provided to men.
to reduce the spread of HIV/AIDS. Involve
older people in efforts to develop research
agendas on active ageing, both as advisors
and as investigators.
• A society for all ages. Provide greater
flexibility in periods devoted to educa
tion, work and caregiving responsibilities
• Support organizations representing
older people. Provide in-kind and financial
support and training for members of these
organizations so that they can advocate,
promote and enhance the health, security
and full participation of older women and
men in all aspects of community life.
throughout the life course. Develop a range
of housing options for older people that
eliminate barriers to independence and
interdependence with family members, and
encourage full participation in community
and family life. Provide intergenerational
activities in schools and communities.
Encourage older people to become role
3. Security
3-1 Ensure the protection, safety and dig
nity of older people by addressing the
social, financial and physical security
rights and needs ofpeople as they age.
• Social security. Support the provision of
models for active ageing and to mentor
a social safety net for older people who are
young people. Recognize and support
poor and alone, as well as social security
the important role and responsibilities of
initiatives that provide a steady and ad
grandparents. Foster collaboration among
equate stream of income during old age.
nongovernmental organizations that work
Encourage young adults to prepare for
with children, youth and older people.
old age in their health, social and financial
practices.
PAGE 52
ACTIVE AGEINGtA POLICY FRAMEWORK
• HIV/AIDS. Support the social, economic
tion that older people can make to recover)'
and psychological well being of older
efforts in the aftermath of an emergency'
people who care for people with HIV/AIDS
and .include them in recovery initiatives.
and take on surrogate parenting roles for
orphans of AIDS. Provide in-kind sup
port, affordable health care and loans to
older people to help them meet the needs
of children and grandchildren affected by
HIV/AIDS.
• Elder abuse. Recognize elder abuse (phys
ical, sexual, psychological, financial and
neglect) and encourage the prosecution of
offenders. Train law enforcement officers,
health and social service providers, spiritual
leaders, advocacy organizations and groups
• Consumer protection. Protect consumers
of older people to recognize and deal
from unsafe medications and treatments,
with elder abuse. Increase awareness of
and unscrupulous marketing practices,
the injustice of elder abuse through public
particularly in older age.
• Social justice. Ensure that decisions be
information and awareness campaigns. In
volve the media and young people, as well
as older people in these efforts.
ing made concerning care in older age
are based on the rights of older people
and guided by the UN Principles for Older
3.2 Reduce inequities in the security
rights and needs of older women.
Persons. Uphold older persons’ rights to
maintain independence and autonomy for
the longest period of time possible.
• Enact legislation and enforce laws that
protect widows from the theft of property’
and possessions and from harmful practices
• Shelter. Explicitly recognize older people's
right to and need for secure, appropriate
such as health-threatening burial rituals and
charges of witchcraft.
shelter, especially in times of conflict and
crisis. Provide housing assistance for older
people and their families when required
(paying special attention to the circum
stances of those who live alone) through
• Enact legislation and enforce law's that pro
tect w'omen from domestic and other forms
of violence as they age.
• Provide social security (income support)
rent subsidies, cooperative housing initia
for older women w'ho have no pensions or
tives, support for housing renovations, etc.
meager retirement incomes because they
• Crises. Uphold the rights of older people
during conflict. Specifically recognize and
have worked all or most of their lives in the
home or informal sector.
act on the need to protect older people in
emergency situations (e.g., by providing
transportation to relief centres to those who
cannot walk there). Recognize the contribu
PAGE 53
WHO and Ageing
In 1995 when WHO renamed its "Health of the Elderly Programme" to "Ageing and
Health" it signaled an important change in orientation. Rather than compartmentalizing
older people, the new name embraced a life course perspective: we are all ageing and
the best way to ensure good health for future cohorts of older people is by preventing
diseases and promoting health throughout the life course.Conversely, the health of
those now in older age can only be fully understood if the life events they have gone
through are taken into consideration.
The aim of the Ageing and Health Programme has been to develop policies that ensure
"the attainment of the best possible quality of life for as long as possible, for the largest
possible number of people." For this to be achieved, WHO is required to advance the
knowledge base of gerontology and geriatric medicine through research and training
efforts. Emphasis is needed on fostering interdisciplinary and intersectoral initiatives,
particularly those directed at developing countries faced with unprecedented rapid
rates of population ageing within a context of prevailing poverty and unsolved infra
structure problems. In addition the Programme highlighted the importance of:
• adopting community-based approaches by emphasizing the community as a key
setting for interventions
• respecting cultural contexts and influences
• recognizing the importance of gender differences
• strengthening intergenerational links
• respecting and understanding ethical issues related to health and well being in old
age.
The International Year of Older Persons (1999) was a landmark in the evolution of
the WHO's work on ageing and health.That year, the World Health Day theme was
"active ageing makes the difference"and the"Global Movement for Active Ageing" was
launched by the WHO Director-General, Dr Gro Harlem Brundtland. At this occasion,
Dr Brundtland stated: Maintaining health and quality of life across the lifespan will do
much towards building fulfilled lives, a harmonious intergenerational community and a
dynamic economy. WHO is committed to promoting Active Ageing as an indispensable
component of all development programmes.
In 2000, the name of the WHO programme was changed again to "Ageing and Life
Course" to reflect the importance of the life-course perspective.The multi-focus of the
previous programme and the emphasis on developing activities with multiple partners
from all sectors and several disciplines have been maintained. A further refinement of
the' active ageing'concept has been added and translated into all the programme ac
tivities, including research and training, information dissemination, advocacy and policy
development.
In addition to the Ageing and Life Course Programme at WHO Headquarters, each of
the six WHO Regional Offices have their own Adviser on Ageing in order to address
specific issues from a regional perspective.
PAGE 54
ACTIVE AGEINGtA POLICY FRAMEWORK
International Collaboration
With the launch of the International Plan of
Action on Ageing, the 2002 World Assembly
International agencies, countries and regions
will need to work collaboratively to develop a
relevant research agenda for active ageing
on Ageing marks a turning point in addressing
the challenges and celebrating the triumphs
of an ageing world. As we embark on the
implementation phase, cross-national, regional
and global sharing of research and policy
options will be critical. Increasingly, mem
ber states, nongovernmental organizations,
academic institutions and die private sector
will be called upon to develop age-sensitive
solutions to the challenges of an ageing world.
They will need to take into consideration the
WHO is committed to work in col
laboration with other intergovern
mental organizations, NGOs and the
academic sectorfor the development
of a globalframework for research
on ageing. Such a framework should
reflect the priorities expressed in
the International Plan of Action on
Ageing 2002 and those in this docu
ment.
consequences of the epidemiological transi
tion, rapid changes in the health sector, global
ization, urbanization, changing family patterns
Conclusion
and environmental degradation, as well as
In this document, WHO offers a framework
persistent inequalities and poverty, particularly
for action for policymakers. Together with the
in developing countries where the majority of
newly-adopted UN Plan of Action on Age
older persons are already living.
ing, this framework provides a roadmap for
designing multisectoral active ageing policies
To advance the movement for active age
which will enhance health and participation
ing, all stakeholders will need to clarify and
among ageing populations while ensuring that
popularize the term “active ageing" through
older people have adequate security, protec
dialogue, discussion and debate in the political
tion and care when they require assistance.
arena, the education sector, public fora and
media such as radio and television program
WHO recognizes that public health involves
ming.
a wide range of actions to improve the health
of the population and that health goes be
Action on ail three pillars of active ageing
needs to be supported by knowledge develop
ment activities including evaluation, research
and surveillance and the dissemination of
research findings. The results of research need
to be shared in clear language and accessible
and practical formats with policy makers,
yond the provision of basic health sen ices.
Therefore, it is committed to work in coopera
tion with other international agencies and the
United Nations itself to encourage the imple
mentation of active ageing policies at global.
regional and national levels. Due to the spe
cialist nature of its work. WHO will provide
nongovernmental organizations representing
older people, the private sector and the public
at large.
PAGE 55
technical advice and play a catalytic role for
The active ageing approach provides a frame
health development. However, this can only
work for the development of global, national
be done as a joint effort. Together, we must
and local strategies on population ageing. By
provide the evidence and demonstrate the
pulling together the three pillars for action of
effectiveness of the various proposed courses
health, participation and security, it offers a
of action. Ultimately, however, it will be up
platform for consensus building that addresses
to nations and local communities to develop
the concerns of multiple sectors and all re
culturally sensitive, gender-specific, realistic
gions. Policy’ proposals and recommendations
goals and targets, and implement policies and
are of little use unless follow-up actions are
programmes tailored to their unique circum
put in place. The time to act is now.
stances.
PAGE 56
ACTIVE AGEING: A POLICY FRAMEWORK
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ACTIVE AGEING: A POLICY FRAMEWORK
We gratefully acknowledge the support provided by Health Canada. UNFPA contributed to the printing of
the brochure through the Geneva International Network on Ageing (GINA).
Graphic Design: Marilyn Langfeld
© Copyright World Health Organization, 2002
This document is not a formal publication of the World Health Organization (WHO), anil all rights are
reserved by the Organization. The paper may, however, be freely reviewed, abstracted, reproduced and
translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes.
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