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Poverty, Independence &
the World’s Older People
HelpAge
INTERNATIONAL
Leading Global Action on Ageing
HelpAge International is a
global network of not for profit
organisations with a mission to
work with and for disadvantaged
older people worldwide to
achieve a lasting improvement
in the quality of their lives.
1
What is The Ageing &
Development Report?
Community Health Cell
Library and Documentation Unit
367, "Srinivasa Nilaya"
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Phone : 5531518
The Ageing & Development Report
What is The Ageing & Development Report?
The Ageing & Development Report is the first extensive survey of the roles and
needs of older people in developing countries. The report examines the major social
and economic implications of the rapid growth in numbers of older people in Africa,
Asia, the Americas and Russia, Eastern and Central Europe. It covers the impact on
economies, health systems, housing, working patterns and family relationships.
The report draws on HelpAgc International’s 20 years experience in over 60
countries, with contributions from world experts in the field. Key themes, such as
community involvement, family life, health and wellbeing, poverty and exclusion,
gender, migration and economic security are addressed.
One goal of the report is to fill the current gap in the information available on
older people. Case studies, summaries of national policies on ageing and statistics
provide a comprehensive review of the condition of older people in over 45 of
the world’s poorest countries.
The report argues for a fundamental shift in policy and opinion on ageing to reflect
the real economic and social contributions of older people and enable them to retain
their independence. It is essential reading for development policy makers, practitioners
in government and non-governmental agencies, demographers and gerontologists.
The report contains:
Part I: An introduction to ageing and development
Development and the rights of older people
Poverty and livelihoods in an ageing world
Gender and ageing
Reinforcing capability: Informal community-based support services
for older people in the developing world
Ageing and health
Older people’s strategies in times of social and economic transformation
Economic security in old age: A family-government partnership
Change, family life, coping strategies and seniors
Conflict, humanitarian assistance and older people
Part II: The state of the world’s older people
The situation of older people in Latin America and the Caribbean
The situation of older people in rural and urban India
The situation of older people in Cambodia
The situation of older people in Tanzania
The situation of older people in Zimbabwe
The situation of older people in the transitional economies
of central and eastern Europe
Part III: Ageing and development data
Part IV: Reference section
For availability sec back cover.
The Ageing & Development Report:
Ageing societies:
The global challenge for the new millennium
The rapid growth in the numbers of older people worldwide is creating an
unprecedented global demographic revolution. During this century, improvements in
hygiene and water supply and control of infectious diseases have greatly reduced the
risk of premature death. As a consequence, the proportion of the world’s population
over 60 years is increasing more rapidly than in any previous era. In 1950 there were
about 200 million people over 60 throughout the world. By the year 2000, there will be
about 550 million, and by 2025, the number of over-60s is expected to reach 1.2 billion.
You are never too old to learn
The increase in the numbers and proportion of older people is predictable. For the
first time in history, the majority of those who have survived childhood in all countries
can expect to live past 50 years of age.
The share of older people in the population of developing countries
Most older people live in the South
The myth that older populations do not exist in the developing world because life
expectancy is low is contradicted by the statistics. Even in the world’s poorest countries,
those who survive the diseases of infancy and childhood have a very good chance of
living to be grandparents. This means that the number of older people in developing
countries will more than double over the next quarter century, reaching 850 million by
2025 - 12 per cent of their total population. By 2050 the proportion will be 20 per cent.
For example, in Latin America and the Caribbean, reduced fertility rates have been
matched by lower mortality. As a result, by 2025, the proportion of people aged over 60
will exceed 10 per cent of the population in all Latin American and Caribbean countries.
By 2020, Cuba, Argentina, Thailand and Sri Lanka will have a higher proportion of
over-65s than the United States.
Ageing in poverty
The growth in life expectancy offers new opportunities but it also creates challenges for
the future. In the developing world populations are now ageing at unprecedented speed
while most of their people still live in poverty. The development of medical technology
that allows people to live longer has overtaken the achievement of economic prosperity.
The Ageing & Development Report:
It is appropriate that the United Nations has chosen the closing year of the century
as the International Year of Older Persons, to celebrate their contribution to social
wellbeing. But eight years after the adoption of the United Nations Principles for
Older Persons, too many people still spend their later years in poverty, living on the
margins of their society.
The growing majority of the world’s older people living in
developing countries
Source: UN Population Dut-on. 1996
Numbers of older people (millions)
600
An invisible population
The existence of large populations of older people is undoubtedly becoming a major
issue for governments, international organisations, non-governmental organisations
(NGOs) and communities. But at present, older people still remain a neglected
group, largely invisible to those who promote economic development, health care
and education. Although the high birth rates previously experienced in many countries
are now falling, young people remain the focus of planners’ attention.
For the past fifty years, economic growth and increased productivity have been the
goal of development policy. Older people, on the other hand, arc usually thought of
as economically dependent and passive. As a result, they have been treated at best as
irrelevant to development, and at worst, as hampering the prospects for prosperity.
lopmont Report: a summary
Key action points from
the report
The United Nations Principles for
Older Persons should be given
much greater global prominence.
Key action point: adopt the
UN Principles for Older Persons
as a legally binding charter of
rights, to which all governments
are accountable.
National and international action
to address the situation of older
people needs to be based on an
integrated approach within the
context of broader social policy.
Key action point: develop
integrated strategies to enable
older people’s basic needs to be
met in the areas of income, health,
housing, and community support,
as well as social attitudes,
addressing isolation, fear.
discrimination, disability and abuse.
The profile of ageing and the
policy issues it raises in the
South need priority attention.
Key action point: increase
research, data collection and
analysis relating to the special
needs and capacities of older
people.
Policy makers need to
acknowledge, measure and
support the contributions of older
people to their societies.
Key action point: set and
measure development targets together with appropriate indicators
- which relate to older people,
particularly in areas such as health
status, income and poverty.
Policy making for older citizens
should actively involve them in
identifying key problems and their
solutions. The experience of
older people needs to be
recognised as a major resource
in the development process.
Key action point: ensure that
policy research, planning exercises,
programme design and monitoring
directly involve older people,
especially the most disadvantaged,
in the consultation process.
Ageing should be a positive experience
Being able-bodied has come to be equated with normality, and since older people
cannot always conform to this ideal, they are viewed in negative terms. But if ageing is
to be a positive experience there must be improvements in the quality of life for older
people. To ignore their needs is both to deny their rights and to waste the fund of skills
and experience that they represent.
At present, older people receive a fraction of the resources they need, while their
continuing contribution to society is unrecognised. Discrimination, exclusion and
even persecution or violence cast a shadow over the later years of many older people.
Reducing vulnerability and promoting inclusion is not so much about creating special
services for older people but rather ensuring that they have equal access to mainstream
services along with other vulnerable groups.
National development policies to support older people
The far-reaching economic and social implications of global ageing during the next
century arc finally receiving recognition in countries throughout the South and the
North. Much of the focus, however, is on the ‘crisis’ represented by the growing
number of older people, rather than the challenge of ageing itself.
The growth of older populations does not need to be a crisis for governments; it can
be planned for. Work is in progress in a number of countries to develop new policies
that address the changing demographic balance, but ageing is still a low priority on
most governments’ agendas. At the moment, most older people cannot rely on any
form of state support. Only 30 per cent of the world’s older people arc currently
covered by pension schemes, and in most societies, health, employment and transport
services are not easily available or accessible.
Progress towards effective implementation is slow in most cases. Both resources and
legislation arc required. National laws can only be effective if adequate resources are
available to implement them. In some countries, national policies already exist - for
example, to provide free health care for older people - but they fail because of poor
structures for communication, implementation and enforcement.
Key policy issues
National policies need to incorporate the issue of ageing and appropriate support
mechanisms for older people into the mainstream of their social and economic
planning. Policies for employment, health, transport and social care should take
account of the needs of older people. These sectoral targets should also be integrated
into broader social strategies.
National governments should seek the active involvement of older people themselves
and of their families, communities and non-governmental organisations in research,
planning and policy implementation on issues that are of concern to them.
Bilateral and multilateral donors must also take account of the contributions and needs
of older people living in developing countries as a critical element in poverty reduction.
Invisible figures:
Why is so little known about older people?
Ageing is a biological process with its own dynamic. But each society has its own
sense of old age. In industrialised countries, the beginning of ‘old age’ is usually equated
with ‘retirement’, at the age of 60 or 65. In many developing countries, chronological
time has little or no importance in defining old age. Old age is defined as a state of
dependence and incapacity thought to begin at the point when the person can no
longer work.
The Ageing & Development Report: >
The challenge for policy makers is to
make the extra years worth living
Insofar as older people appear on the development agenda, they are usually viewed as
a distinct but homogenous group. In fact, the experience of ageing is different for men
and women, and varies between cultures. Differing standards of living also influence
conditions for older people.
For example, at all stages of life, men and women experience social and economic
structures differently. Although more boys than girls arc born each year throughout
the world, in almost all countries women live longer than men. But the gender gap
is much smaller in developing countries where women live around three years longer
than men, compared with seven years in more developed countries. This is largely
due to much higher rates of maternal mortality. A few countries - for example, India,
Bangladesh and Egypt — report more men than women in most older groups. Other
exceptions arc countries such as Uganda, suffering the impact of the HIV/AIDS
epidemic, where life expectancy for women has only increased by two years since 1950.
The impact of these differences can only be understood by conducting in-depth
research within communities. Health issues arc of particular concern - for example,
the prevalence of malnutrition among older people and the problems of dementia have
been little studied. There is also evidence of increasing violence against older people,
but in most countries, the extent of the problem is unknown.
The lack of research data on issues relating to ageing and the absence of funds to
support further research severely hampers policy-making. The promotion of such
research should be a priority on any future policy agenda. Adequate support is needed
for research which enables older people themselves to raise the issues which they sec
as important and to participate in planning and implementing projects to address their
needs. The knowledge and expertise accumulated by people over their lifetimes are the
primary resources on which they rely in old age. They are also assets of great value
in planning and delivering services involving older people.
‘We are the
reflection of
your future’
Older people's campaign
slogan in Bolivia
Tho Ageing A Development Report:
Ageing in a changing world
The demographic shift towards older populations has to be seen in the context of rapid
economic change, shifting attitudes towards social welfare and large-scale population
movements. International migration and the movement of people of working age from
rural to urban areas have led to major changes in family structures, and in the roles
available to older people in their own communities. Similarly, the increasing number
of younger women joining formal employment has altered family life.
Because older people have not always been visible actors in the ‘modernisation’ process,
they have come to be associated with traditional ways. But urbanisation, increased
social and geographical mobility, changes in family structures and social values are said
to have undermined the ‘traditional extended family’.
Older people's rights need to be
supported
This concept of modernisation does allow us to see how older people can be
vulnerable to social and economic change, but it overlooks the part played by structural
inequalities in the exclusion and impoverishment of older people. Lifelong poverty caused by low wages and high unemployment, poor health services, gender
discrimination and lack of access to education - leaves successive generations less able
to help each other. ‘Poor from the parents down to the grandchildren’, as one older
Cambodian woman put it.
Since the 1980s, the policy focus on efficiency and cost-saving advocated by donor
agencies such as the World Bank in many developing countries has drastically reduced
investment in public health and welfare provision. The reduction of social spending
under structural adjustment programmes has shifted the burden of care back onto
the family, and particularly onto older women.
In Eastern Europe and the states of the former Soviet Union, the development of
market forces has undermined the previous system of state pensions, health and welfare
services without providing other means of survival. For the poor in these societies,
including many older people, these economic changes have brought neither prosperity
nor financial security.
Migration and family life
The 20th century has seen greater mass movements of people, whether as individuals
or whole populations, than any other era in history. People have migrated not only
across frontiers but from rural areas to cities, and between regions in the same country.
Many features of these migrations have had an impact on the lives of older people,
whether they have become migrants themselves, or have remained in their original
homes. Urban migration in developing countries has often been a circular process,
with migrants investing in their home community and seeking to return to that home
in old age.
At present, a little over one-third of older people live in urban areas, but this is
expected to rise to more than one-half by 2015. In Latin America and the Caribbean,
urban migrants tend to remain in the cities in old age, hence these older populations
are already substantially urbanised. Even in the harsh conditions of city slum life, the
majority of older people continue to support themselves, although the possibilities
of paid labour decline with advancing age.
Older people who remain in rural areas may receive remittances from migrant relatives,
but these are not necessarily adequate to cover their needs. In India, three-quarters of
older people still live in rural areas, largely as landless labourers, surviving on day-to-day
earnings, without any long-term savings. They are severely disadvantaged by economic
hardships, unresolved chronic health problems, functional impairment and illiteracy.
Many older people living alone in rural areas find it impossible to cope and move into
the town to be near family members. Research suggests that those who move late in life
find it very difficult to adapt to urban life. A report on slums surrounding New Delhi
The Ageing & Development Report:
describes the living conditions of older residents. Many dwellings consist of only one
room, in which families of 4-6 people are living. The lack of space causes some older
family members to sleep outside. Many older people cannot afford to use public toilets
- the only ones available - because charges are made. Severe environmental pollution
is particularly hazardous for older people.
Surviving disaster: Older people in humanitarian crises
War, civil conflict or natural disaster may turn the chronic daily problems faced by
older people in the developing world into acute emergencies. Alongside economic
migration, the century has seen the forced movement of refugees and displaced people,
the survivors of natural and human disasters, sometimes on a massive scale. While
such crises affect all sections of the population, older people arc among those whose
capacity to respond is most seriously compromised. They are often discriminated
against and regarded as less worthy of help than the young.
In the early stages of an emergency, older people are physically less able than most
adults to struggle for food and other resources, to travel long distances and to live
without shelter. Emergency medical care tends to require refugees to visit medical
centres, which arc focused on acute rather than chronic illnesses. Both these factors
put older people at a disadvantage.
Albanian refugees hide from Serb
shelling: older refugees are especially
vulnerable
Other community members are less able to care for vulnerable older people in the
absence of sufficient food, medical care or shelter. Many older people care for young
dependants whose parents are missing or support other members of their families.
In this respect, they contribute as much assistance as they receive.
Many older people never become refugees but remain in their homes when the
younger people flee. This may be because they arc unable or unwilling to leave. As a
consequence, they are left isolated, often in damaged homes and without basic services.
In Eastern Slavonia, an area handed to Croatia after the Dayton Peace Accords, Serb
families left for the Federal Republic, in some cases leaving their elders behind to care
for their property. Many of these elders remaining in their homes had health needs,
which were not met due to their own isolation and fear, and because of discrimination
by service providers.
At the rehabilitation stage, those older people who were working before the crisis
are still perceived as aid-dependent victims, rather than part of more durable solutions
to the common problems of refugee environments. They are seldom offered credit or
training to re-establish a livelihood.
A further consequence is the loss of children as a result of war and conflict.
In Cambodia, for example, large numbers of older people lost their children during the
1970s and 1980s and therefore have no one to support them as they become older.
Poverty: The enemy of older people’s independence
Older people arc consistently among the poorest in all societies, and material security
is therefore one of the greatest preoccupations of old age. Many experience the same
lack of physical necessities, assets and income felt by other poor people, but without
the resources which younger, fitter and more active adults can use to compensate.
The prevalence of poverty among older people is also linked to educational levels,
including differing levels of literacy. In Latin America, for example, the percentage
of literate men over 60 varies from 93 per cent in Argentina to only 39 per cent in
Honduras. For women, the figures for these countries arc respectively 91 per cent
and 33 per cent.
‘They only tell
the young
people about
[development]
projects, not
the old people’
Older man, Cambodia
Tho Agoing & Development Report:
‘Before I was
like a thrown
away item.
Now after sitting
for two weeks
in this workshop
alongside
government
officers and
respected
people, I am
rising up’
Older woman, Ethiopia
Lack of material means is not the only problem of poverty. Another consequence is
the inability to participate effectively in economic, social and political life. Older people
living in poverty find themselves socially excluded and isolated from decision-making
processes. This affects not only their income and wealth but also contributes to poor
housing, ill health and personal insecurity.
It is often argued that the informal networks of family and community in many
developing countries reduce the social exclusion of older people. But this has always
been contingent on factors such as the individual’s gender and material means, rather
than their age. Furthermore, rapid social and economic change has often undermined
the capacity of these informal networks to provide support.
In many societies older people had leadership roles such as conflict resolution and
cultural, religious and health education. While these roles still exist, they have been
eroded by the changing structure of the family, migration and the emergence of a
dominant culture which gives higher status to literacy and formal education and has
moved away from communalist forms of governance.
Efforts to understand poverty have dominated much of the debate on development
over recent years, but the poverty experienced by the majority of older people in
developing countries has been largely ignored. In many development initiatives, such
as literacy programmes or credit schemes, programme managers appear to believe that
older people are unable to participate and have no productive role, or are merely
passive recipients of support.
Tackling poverty among older people
■ Any credible anti-poverty strategy must seek ways to allow older people to live
independently and contribute to their families and communities, and to support frail
older people living in poverty.
■ Anti-poverty strategies will have more chance of success if older people play a major
part in identifying the problems as well as the solutions.
Percentage of older population
AH
. Women
The Ageing & Development Report: > . .-rmjr,
The economic contribution of older people
Older people are not passive and they continue to contribute to their families and
communities, but their capacity for productivity is also overlooked. The work
contributed by older people is severely undervalued, even by older people themselves.
Frequently an elderly woman, when asked if she ‘works’ will reply ‘no’ even though
she spends most of her day selling vegetables or fruit in the market, or selling home
prepared food in the street... this kind of informal work is not given the value it
deserves and is not seen as ‘work’.
International Labour Organization studies of labour force participation by older
people show that, in 1993, in at least 20 African countries, between 74 per cent and
91 per cent of people over 65 continued to work. As a writer on older women in
India notes: ‘In fact, there is no retirement for an elderly woman until either death,
dementia or disability claims her.’
Older people engage in a variety of occupations, including farming, trading and
small-scale enterprise. They may use special skills as health care providers, herbalists
and traditional birth attendants. Older family members are also active, though often
unacknowledged, participants in the household economy. They look after children,
do domestic work and make cash or in-kind contributions. In Russia and Romania,
surveys in the early 1990s found that people over 60 spent 20 hours a week queuing
in shops, freeing other family members to do paid work.
By maintaining their own livelihoods where possible, older people contribute to
the wellbeing of the household and family. Factors that reduce these assets and limit
the capacity of older people to provide for themselves include diminished physical
strength, poor health, low status, landlessness, absence of or limited family or
community support, lack of capital, lack of education or training opportunities.
Barriers to work
In many developing countries increasing export dependency, international
indebtedness and industrialisation have drawn resources away from regions and sectors
such as agricultural production and informal trade, where older people, especially
women, are most active. In many of the transitional economies of Eastern Europe and
the former Soviet Union, high unemployment has intensified competition for jobs of
all kinds, with older people increasingly marginalised from all job opportunities.
Older people involved in small businesses in Tanzania emphasise that activities such
as selling coconut husks, fish and tomatoes, and running their own tailoring shops
generate very little income for the amount of effort invested. Marketing their produce
is also difficult for older people who are not very mobile.
Older people living in rural areas who still depend on farming for a living find that
their capacity to farm the land is restricted. Their lack of capital means they cannot
maintain their land or pay others to do it for them. They are unable to raise credit
due to their low incomes, lack of savings and collateral. Most credit and loan schemes
discriminate against older people. Women are further disadvantaged by the fact that
they often have no independent income, no control over fixed assets such as land, and
very limited exposure to business or the formal sector. Many development programmes
do not consider these needs: for example, the rules of most credit schemes still make
it impossible for older people to join.
A credit to perseverance
In Lima, a local NGO, Pro Vida
Peril, has established a revolving
credit scheme, with backing from
CARE Peril, to give older people
loans to start up small businesses,
such as making clothes and tools.
running market stalls and shops.
and providing services such as
hairdressing.
The scheme was piloted with
women members of a Third Age
Club who chose three of their
members to serve as a credit
committee, to approve loans,
manage the accounts and report to
members. The borrower must agree
to repay the loan punctually, and to
use it for production, commercial
activities or service provision.
Despite some initial difficulties when
women used loans to pay family
expenses rather than investing in
income-earning activities, many of
the women have now established
viable businesses. The credit
scheme has also improved women's
confidence, and their sense of
security and responsibility,
overcoming barriers created
by poor education, economic
dependency and ill-health.
Th© Ageing & Development Report: <i
Witchcraft and older
women
In Tanzania, an estimated 500
women are murdered every year
after being accused of witchcraft.
Many more are driven from their
homes and communities.
becoming destitute as a result.
A recent study in Tanzania by
HelpAge International found that
widowhood exposed many older
women to the charge of witchcraft.
This was typically related to their
solitude: 'If she is not seen much
around the village, an air of
mystery may grow up around
her. which contributes strongly
to accusations of being a witch.’
Family and in-laws sometimes
use such accusations to prevent
a widowed woman from inheriting
property and possessions.
Defenceless older women have
been hacked to death under
the guise of ridding the village of
a witch.
Women are much more likely to
be targeted than men as they often
do not have a family or community
network to defend them.
The Tanzania study found that
women were often seen as being
'cleverer' than men and therefore
more capable of witchcraft.
Sustaining older people in work
■ The capacity of older people to work, often in spite of physical frailty, needs to
be recognised and supported.
■ Since most older people in developing countries live in rural areas, policies
favouring agriculture and rural development could assist them.
■ On an individual level, training opportunities and the opening up of credit
programmes to older people would significantly improve their chances of being
self-supporting. HelpAge International’s experience with credit schemes suggests that
the hurdle ofproviding collateral for loans can be overcome. This can be done by
establishing the collective responsibility of all savings and credit group members for
meeting loan repayments if an individual defaults.
Different needs, different expectations:
Gender roles in older age
Gender continues to influence older people’s participation in social and economic life,
according to a study of livelihood security in Ghana, conducted by HelpAge Ghana
and HelpAge International. The survey, part of a six-country study on the contribution
of older people to family and community life, aimed to make policies and services more
responsive to the needs and capabilities of poor and disadvantaged older people.
Older women, according to the study, are the bedrock of support for the family.
In addition to providing childcare for the family, they also offer physical care and
financial assistance to older men. Although older men appear to place a high value on
this support, the contribution of older women is less likely to be officially recognised.
It is regarded as ‘domestic’ and therefore an extension of their normal responsibilities.
The shift from dependence on economic sources of support (such as trading or
wages) to dependence on social sources (such as provision by relatives) tends to be
swifter for older men than older women. Women are better able to diversify their
activities at times of need: for example, if older people become homebound, the men
are unlikely to remain economically active, whereas the women may still undertake
petty trading activities.
Differing economic roles also give women more flexibility. Older men have
the responsibility for providing for the household and the purchase of major assets
such as land and livestock, but older women manage household income and daily
expenditure. As a result women are more often able to economise in times of stress
or to invest when they have small savings.
Vulnerable widows
In general, women’s greater longevity and earlier age at marriage mean that widowhood
is a common experience of their older age. The rise in divorce rates in many societies
also tends to leave women in a more precarious economic situation than men as they
grow older. Lack of access to education reduces their ability throughout their lives to
enter the formal labour market and limits their earning power.
In societies where older people have to rely on their own resources, without the support
of state benefits, older women are also less likely to own or have control over property
or assets. The pattern of women’s dependency is a function of role changes due not to
age but to family events, such as the death or remarriage of the household head. Women
often lose land and property on being widowed. The death of a husband may therefore
result in severe poverty for the widow. In a survey of older people in Zimbabwe, rural
elderly widowed women were clearly identified as the most vulnerable group.
The Ageing & Development Report:
Older women are one of the poorest population groups yet they arc often the primary
carers for the other poorest group - children. In several African countries, rural
grandmothers have taken on the responsibility of caring for children and grandchildren
with HIV/AIDS and for bringing up children orphaned by the death of their parents
from AIDS.
The unpaid work done by older women in support of household economies, such
as caring for older or younger dependants, provides no guarantee of future material
security. In Tanzania, a woman of 80 who had been left with four orphans after the
death of her daughter, said: ‘I know I am too old to depend upon, but what can I do
except try to support them?’
Gender-sensitive policies for older people
Policies need to address the particular •vulnerabilities to long-term poverty in old age
that result from women’s life-long disadvantages in health and nutrition, limited labour
force participation and discrimination in property and inheritance.
Policy makers also need to recognise the disadvantages which older men experience
through the loss of their established adult roles at retirement and the relatively greater
problems experienced by men in maintaining social support networks outside their
families in old age.
The gender gap between older men and women
The number of older men for every 1000 older women
1995
2020
In all parts of the world women have a higher life expectancy than men, and men and
women have different experiences and expectations of old age.
06841
Tho Ageing & Development Report: a summary
Community age care
Life-long deprivation and older people’s health needs
A programme launched in 1996
by the NGO Coalition of Services
of the Elderly (COSE) in 21
communities of Metro Manila.
Philippines, provides an alternative
for older people unable to afford
access to health facilities. COSE
has set up outpatient and mobile
clinics, trains older people as
‘community gerontologists' and has
a health promotion programme.
A second major concern for older people is their personal health, which affects their
ability to work and to play an active role in their communities.
Many people in developing countries have a lifetime’s exposure to health problems,
suffering chronic illness and disability, without access to adequate health care facilities.
They are therefore functionally ‘old’ by the time they are in their forties or fifties.
This is particularly true for women, who, after years of hard physical labour, poor
nutrition and multiple pregnancies, are on the threshold of old age by the end of
their reproductive years.
The initiative came from older
people themselves, through the
consultation meetings that are
a feature of COSE’s process.
The programme is thus highly
responsive to community need.
and this is reinforced by the use
of older people as primary health
care workers at community level.
Chronic illness is therefore a serious problem. In a major survey on health profiles of
older people in India, covering 5,000 households in urban and rural areas, 45 per cent
of both men and women in the sample reported chronic illnesses. Smaller studies in
India have also indicated that in addition to coronary, muscular and respiratory
problems, close to 90 per cent of older people surveyed had visual impairment and
more than 40 per cent suffered from some form of depressive illness.
Community-based primary health
providers complement a core
team (a doctor, dentist and nurse).
In the first two years some 30
community gerontologists received
initial training which equips them
to do basic medical checks, keep
records and refer more complex
cases on to the health
professionals. They are unpaid.
although they receive an allowance
when assisting at the clinic.
and are entitled to free medicines
under the programme.
For older people, there are numerous barriers to effective health care. Most health
care facilities are concentrated in urban areas, while the majority of older people in
many developing countries are concentrated in rural areas. Transport and treatment
costs - drugs invariably have to be purchased — are a further barrier. Finally, older
people encounter negative attitudes from medical personnel who give them low
priority for treatment, while at national level, health care planners also neglect the
problems of old age.
Inaccessible health care
As a consequence, many resort to self-treatment, such as buying drugs without
prescription, and consulting traditional healers. Otherwise, they have to weigh the
seriousness of the illness, and the cost of treatment, against the effects for themselves
and their families of selling assets or getting into debt.
In Cambodia, the majority of older people in rural areas have to go without the basic
aids for sight and eating which would greatly improve their quality of life, because they
are too poor and eyeglasses and dentures arc not easily available.
In a survey conducted in Mumbai, India, older people identified financial stress,
community discrimination, lack of information and support from health services,
as well as their own illness and frailty, as their main problems.
In the transitional economies, the declining economic situation of older people, and
the collapse or shrinkage of health care and welfare systems has rapidly been reflected
in rising mortality rates, especially among men. In contrast to most other countries,
male life expectancy in the Russian Federation fell from 65 to 58 years between 1987
and 1994. In Estonia, life expectancy for men in 1993 was 62.6 years compared with
74 for women.
The Ageing & Development Report: ■
Promoting older people-friendly health care
■ Raising the quality and coverage of basic health care for all age groups will minimise
the impact of lifelong illness and disability for older people.
■ A much greater effort is required to target the needs of the many people who reach
old age in chronic ill health. Primary health care and outreach services need to be
accessible and affordable for older people. Exemptions from health care fees can only
work if the cost of implementation is adequately subsidised and information campaigns
raise awareness both among potential users and health care staff.
■ Training health staff offers substantial scope to improve the quality of health care for
older people. The importance of understanding the specific health needs of older people
is beginning to be reflected in the inclusion of basic ‘age care’m training curricula for
health care staff.
‘With modern
medicine, many
older people are
living too long;
longer than they
are prepared for’
Zadek Plaches, Zivot 90,
Czech Republic
■ There is much unrealised potential for links between formal public health systems and
non-governmental and community-based health care programmes. For example,
home visiting schemes and training for family carers preserve the role of older people
as health providers.
Supporting capability:
Building state, family and community partnerships
Although most countries have some form of social security or insurance cover for older
people, in practice these benefits are often limited to a small group of professionals and
civil servants. According to World Bank figures, in OECD countries 84 per cent of
people over 60 years old had pensions, but in Cote d’Ivoire the figure was only 5.7 per
cent, 7 per cent in the Philippines, 9.8 per cent in Indonesia, and 17.8 per cent in Bolivia.
In India, although the government recognises old age poverty, the pension scheme for
destitute elderly people reaches only 2.76 million out of an estimated 28 million older
people below the poverty line. Even in countries such as China which have greater state
social welfare provision, only 22.5 per cent of older people are reported to have pensions.
Even where pensions arc provided, they arc frequently inadequate to meet the
pensioner’s needs, and are eroded by inflation. In Russia, not only has inflation
undermined the value of the state pension but the collapse of the rouble in 1998 has left
pensions unpaid since that time. The opportunities for poorer informal sector workers
to save or sustain pension contributions to private schemes arc very limited.
Retirement is not an option for most
older people
The Ageing & Development Report: > 'w>nwy
‘Worry, I think a
lot because I
have no money
and am often
sick. I have no
children except
an adopted
grandchild, but
the grandchild is
also poor. I don’t
know what to
think every day I think this way,
think that way,
like a cat with its
head caught in
a coconut shell’
Older woman, Cambodia
South Africa is one of the few countries of the South which has universal state pensions.
However, it has been found that where poor rural women are receiving pensions, they
commonly use them not to provide for their own needs, but to pay school fees for their
grandchildren or give loans to other family members.
The vast majority of workers in developing countries are excluded from any form of
state provision. Since the 1940s, the International Labour Organization has advocated
a universal, state-provided social security system. In contrast, the World Bank has
argued that most people could save for their old age. Although it supports limited
safety nets for the poorest, it is opposed to the idea that social welfare is required to
assist older people whose families are less able to support them.
However, neither market forces nor state pensions have come to the aid of the rural
poor. For example, most countries of Latin America and the Caribbean are projected
to have between 15 and 40 per cent of their total older population in rural areas in the
early 21st century. These rural populations form part of fragile labour markets.
They only receive marginal income support from public programmes and do not
participate at all in existing private schemes.
Family support
In practice, family care remains the most widely used survival strategy for the majority
of the world’s older people, whether in the context of extended families or co-rcsidence
of parents with adult children.
In Zimbabwe, research suggests that the family is still a major support mechanism,
with 45 per cent of older people in the sample receiving cash transfers, albeit for small
amounts, and 61 per cent receiving transfers in kind. On the other hand, 23 per cent of
older people provided financial support to children, nieces, nephews and grandchildren,
mainly in the form of school fees, food or cash payments.
But economic and demographic change has had a profound effect on family structures.
Social processes and institutional arrangements often result in social isolation, the
effective distancing of older people from the mainstream of their communities. In many
countries of Latin America and the Caribbean, the current trend towards more older
people living alone may have negative consequences, made worse by inadequate pension
systems. On the other hand, co-rcsidence, which is still common, is part of an exchange
that provides material goods (cost of housing, sharing of food) and emotional and
psychological support for older people.
Moreover, when families are scattered by migration or forced movement, their support
cannot always be relied upon. For families trapped in endemic poverty, the capacity of
younger generations to help older relatives is severely limited. The trend towards
smaller families means that the proportion of older family members is increasing.
With the decline in extended family networks, there are fewer relatives available to help
older members who are in need. Poverty and isolation face those who have no children,
and those whose children have died (in particular of AIDS which claims the lives of
many young adults) or are absent and unable to help their parents.
In some countries, there have recently’ been examples of effective self-organisation by
groups of older people who do not have sufficient family support. Older people are
involved in a wide range of collective activities, including community groups, centres
and clubs, religious societies and the like.
The support offered by NGOs, communities and families needs to reflect the great
diversity of national contexts. In Singapore, for example, there arc well-developed
public services, so that NGOs can focus on covering gaps in provision. In contrast,
Bangladesh has neither comprehensive public service provision, nor substantial NGO
support to older people.
The Ageing & Development Report: > 5<rr.<Twz
The care giving roles of older people
need wider recognition
Social service for
familyless elderly people
in Korea
With Korea’s average lifespan
expected to rise to 74 early in the
next century, nuclear families make
up two-thirds the total, and nearly
a quarter of over-65s are living
alone. Support systems within the
community are mainly on a one-off
basis and not a foundation for
continuous long-term care.
Family care to older members has
decreased in recent years.
Strengthening capacities
In the absence of any prospect that comprehensive state support for older people
will be available in the near future, other strategies have to be considered:
■ The key aim is to enable older people to support themselves and remain independent
for as long as possible.
■ A priority is to increase the family's ability to support those members who cannot
provide for themselves. Public services should aim to complement, not replace, these
informal systems. Family support should not be used as a justification for reducing public
services.
■ For those with access to insurance programmes, whether privately or publicly provided,
their savings should be adequately protected.
■ Efforts need to be made to design financial services to support sustainable incomes
for the poorest in old age.
■ Special attention is required to meet the needs of the most vulnerable older people
who have no means of support, and to encourage self-help groups. Many of these groups
provide important material and psychological support for their members, but remain
fragile because of the lack of continuity which external subsidy could provide.
In response, HelpAge Korea has
established a wide network of
volunteer home helpers, recruited
through the media. These helpers
are assigned to familyless elderly
people on a one-to-one basis.
There are now 800 paid helpers
and 4,000 volunteers.
Government policy is ‘family
protection first, social protection
second’, which assumes that
traditional forms of family care for
older people will be maintained.
But HelpAge International’s work
convinced the Ministry of Health
and Social Affairs that the home
help programme should be
incorporated into the Act for the
Elderly in December 1989.
In 1993, the government amended
its national policy on supporting
older people to put more emphasis
on community-based service.
The target is to extend
government-funded community
care so that there are 520 teams of
home carers across the country.
The Ageing & Development Report: a summary
Promoting the United Nations Principles
for Older Persons
Ageing brings an inevitable decline in capacity and greater vulnerability to sudden
change. But older people have greatly varying capacities, and a variety of ways in which
they can continue to contribute to their families and communities. A balance has to be
found between acknowledging active older people and supporting those who arc unable
to work.
Older people's coping strategies need
to be supported and replicated
A crucial overall goal of policy development must be to challenge and overcome the
invisible barriers of age prejudice that prevent older people playing a full and valued
part in the development of their societies. There are a growing number of examples at
community and national levels that demonstrate the value of a rights-based approach
in relation to older people.
Involving older people in the design and implementation of projects enables them to
express their concerns and participate in activities to address them. These methods
of working can raise awareness within communities of the rights of older people and
the problems of social exclusion and provide an empowering experience for older
people themselves.
It makes economic sense to recognise and respond to the rights of older people.
For example, supporting their right to health enables them to work, maintain an
adequate standard of living and contribute to their families. As a result their household,
family and community' members gain both economically and socially.
For rights-based approaches at community level to have a significant impact, they must
be supported at all levels. The United Nations Principles for Older Persons, agreed in
December 1991, outlined fundamental aspects of social, political, cultural and economic
rights of older people. This document has been used in advocacy work worldwide to
promote awareness of the needs of older people.
Promoting rights
■ A human rights approach implies responsibility on the part of groups at all levels local, national and international - and across sectors to promote these rights and to
develop effective legislation to protect them.
■ A priority is to enable older people to participate fully in this process through training
and awareness-raising programmes.
■ Further work is required to develop participatory approaches, establish good practice
and develop advocacy work based upon them.
■ The United Nations Principles for Older Persons need to be established as a
convention or charter that is legally binding on all governments.
United Nations Principles
for Older Persons
Independence
Participation
Care
Self-fulfilment
Dignity
HelpAge
INTERNATIONAL
Leading Global Action on Ageing
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