OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health Systems, HIV/AIDS and the Development Agenda in sub-Saharan
Africa: Implications for Ageing Populations
Dr Isabella Aboderin
Oxford Institute of Ageing
University Of Oxford
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Outline of Presentation
• Background: HIV/AIDS and older persons in sub-Saharan Africa (SSA)
• Health systems: Central role in mediating or underpinning impacts of HIV/AIDS on older people
• Pathways • Recommendations
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Background: HIV/AIDS and older people in SSA
• SSA is the epicenter of the worldwide HIV/AIDS crisis. Home to 63% of all adults and children with HIV globally. (24.7 million in 2006)
• AIDS disproportionately kills adults in the ‘prime’ of their lives.
Key Impacts:• Societal level: loss of human capital, labour productivity erodes
capacity for economic growth
• Family level: affects well-being and life chances of all generations
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Background: HIV/AIDS and older people in SSA
• Rising international focus on impacts of HIV/AIDS on older persons (e.g. Valetta Declaration,Research Network on HIV/AIDS and the Elderly)
Focus on:• Older persons as carers of sick, orphaned or vulnerable kin (especially
children and grandchildren)• Loss of intergenerational support from younger generation kin• Older people themselves infected with HIV/suffering from AIDS
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health systems: central role
• These impacts hinge on (are underpinned or mediated by) the present functioning of health systems
• Also giving rise to additional indirect impacts of the HIV/AIDS epidemic on older persons
• Impacts linked to three key features of health systems: – Limited resource capacity – Core agendas and priorities for deploying health resources – Specific foci of HIV/AIDS related health programmes
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health systems: limited resource capacity
• Health care delivery dysfunctional in most SSA countries following years of debilitating under-investment (in large part due to World Bank/IMF structural adjustment programmes)
Expressed in dismal survival indicators: • Life expectancy at birth in 2005 was 46.7 years—lower than in 1975
• 1 in 10 babies die before the age of 1 year; almost 2 in 10 die before
the age of 5 years (UNDP, 2006; WHO, 2006)
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health systems: limited resource capacity
• Central problem: extreme lack of financial and human resources
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health systems: lacking financial resources • Per capita government expenditure on health ($) per year• At least $34 needed to achieve essential public heath interventions
Nigeria 6
Ghana 5
Kenya 8
Zimbabwe 14
Uganda 5
Belgium 1,880
UK 2,081
US 2,548Source: WHO, 2006
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing Health systems: lacking human resources
• Human resource ‚crisis‘ – severe shortage of physicians and nurses (brain drain, rising demand)
Doctors (per 1,000) Nurses (per 1,000)
Nigeria 0.28 1.7
Ghana 0.15 0.9
Kenya 0.14 1.14
Uganda 0.08 0.61
Belgium 4.49 5.83
UK 2.30 12.12
US 2.56 9.37
Source: WHO 2006
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health systems: lacking financial and human resources
• In worst hit countries, resource constraints exacerbated by HIV/AIDS: numbers seeking HIV-related care adding pressure on services
• HIV/AIDS treatment more costly than treatment for other diseases
• AIDS illness and death among health workers (e.g. Botswana lost 17% of health staff to AIDS between 1999-2005)
• Stress and low morale migration of health workers to OECD, Middle East, other SSA countries with lower HIV/AIDS prevalence
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health systems: core agendas
• In recent years emergence of key international agendas to enhance
health and/or health systems in SSA: – UN Millennium Development Goals (2000) – Abuja Declaration of Leaders of African Countries (2001) – 2002 NEPAD Health Strategy (2002)– Commission for Africa Recommendations (2005)
Pledges for increased health spending: African countries 15% of annual countries; Donor nations 0.7% of GNP (largely not yet met)
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Core priorities
• Crucially, agendas also set the priorities for deploying the resources that are available
• Highest Priority: Fight against HIV/AIDS, Tb and other infectious diseases (MDG 6)
• Economic Rationale: Tackling HIV/AIDS, Tb enhanced human capital, labour productivity, educational attainment to lead to economic growth (WHO, 2006, ILO, 2006)
• •
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Specific foci of HIV/AIDS related health programmes
Set by: • UN Declaration of Commitment on HIV/AIDS & the MDGs (2001)
Top four programme priorities:1. Prevent HIV infection esp. among the young (15-24 yrs)
2. Stop mother to child transmission
3. Provide treatment to all those infected
4. Provide care to all whose lives are devastated by AIDS, esp. orphans
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
HIV/AIDS programmatic foci in practice
1. Expansion of Anti-Retroviral Treatment (ARV) (reduces complications, prolongs life, stops mother-child transmission)
2. Voluntary Counselling and Testing (VCT)
3. Support to families affected by AIDS, esp.orphans
(e.g. Child support grants, Community Home-Based Care initiatives)
• Explicit and implicit focus on children and reproductive ages (15-49 yrs)
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Health systems impacts: pathways
• We can identify four key pathways through which these key features of health systems mediate or cause the impacts of HIV/AIDS on older people
• Impacts on present and future cohorts of older people
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Impacts 1: Neglect of HIV/AIDS among current cohorts of older people
Limited finacial and human resource
capacity (exacerbated by HIV/AIDS)
Specific foci of HIV/AIDS
programmes (focus on the young)
Little provision for HIV/AIDS prevention/treatment among older age groups (50+ years) Yet, estimated 5%-7% are HIV+; observed mortality from AIDS among women 50-64 yrs, South Africa (Knodel et al. 2003; Kahn et al. 2006)
Health Systems: Impacts on current cohorts of older people:
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Impacts 2. Creating extra care burdens for current cohorts of older people
Limited finacial and human resource
capacity (exacerbated by HIV/AIDS
Specific foci of HIV/AIDS
programmes (i.e. ARV,
prevention etc. )
Little service provision for (terminal) care of AIDS sufferers: extra care burden on older
people, little support (e.g. information, material, practical)
physical and emotional strain (WHO, 2002; Ferreira, Keikelame & Mosaval, 2001; Knodel et al. 2003)
Health Systems: Impacts on current cohorts of older people:
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of AgeingImpacts 3. ‚Crowding out‘ service provision for age-related non-
communicable disease (NCD) among current cohorts of older people
Limited finacial and human resource
capacity (exacerbated by HIV/AIDS)
Core Priority: fight against AIDS
(MDG 6)
Little, if any, service provision for: Management /prevention of the key conditions affecting older people: age- related NCDs (hypertension, stroke, diabetes, osteo-arthritis, visual impairments) and resulting impaired functional ability Yet: rising NCD prevalence and mortality among older age groups (WHO, 2006; Kahn et al.2006)
Health Systems: Impacts on current cohorts of older people:
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of AgeingImpacts 4: Crowding out service provision for prevention of NCDs among
future cohorts of older people
Limited finacial and human resource
capacity (exacerbated by HIV/AIDS)
Core Priority: fight against AIDS
(MDG 6)
Little (no) service provision for: Prevention of NCD development among current cohorts of younger people Yet, such prevention is critical: risk of NCDs is influenced by factors over the whole life-course (Aboderin et al. 2001)
Health Systems: Impacts on future cohorts of older
people:
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Age
Source:Aboderin, Kalache et al., 2002
PA: physical activity SEP: socio-economic position
Accumulated
Risk(Range) D
evelo
pm
en
t of
NC
D FetalLife
Adult Life Adolescence Infancy &Childhood
SEP,diet,obesity,lack of PA,diseases,growth rate
SEP,dietobesitylack of PAsmoking
SEP,established adult behavioural/biologicalrisk factorsSEP;
birth weight,maternal nutrition status
high
low
Life course and risk of CHD, stroke and diabetes
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Recommendations
• Efforts to address the impacts of HIV/AIDS on present and future cohorts of older people must focus on enhancing health systems
• Efforts need to hinge on:
B
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Recommendations
1. Expansion of current HIV/AIDS programmatic foci to include:• HIV/AIDS detection and treatment among age groups 50+• Adequate support (education, material, practical) to home-based care
for AIDS sufferers
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Recommendations
2. Expansion of core priorities beyond MDG 6 (5,4) to include affordable measures to address NCDs :
• Primordial prevention: reduce exposure to risk-inducing environments
(e.g. control sale/marketing of tobacco, alcohol, unhealthy foods)
• Primary Prevention (among children, youth, adults) (health promotion to encourage healthy lifestyles, possibly integrated with HIV/AIDS programmes)
• Management/secondary prevention of NCDs among older adults
(Examples of successful low-cost programmes exist (WHO, 2006))
OXFORD INSTITUTE OF AGEING
Oxford Institute of AgeingOxford Institute of Ageing
Thank you