successful ageing public health aspects of population ageing shah ebrahim london school of hygiene...
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Successful Ageing Public Health aspects of
Population Ageing
Shah Ebrahim
London School of Hygiene & Tropical Medicine
CADENZA Symposium 2008
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Population ageing – the challenges
• Size and rate of population ageing• Increased burdens of chronic disease• Appropriate and affordable health care
and social support• Inter-generational transfer of resources• Pensions and income security for older
people
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The global picture: 2000 and 2050
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Life expectancy, 2007Rank Country Males Females difference
1 Andorra 80.62 86.62 62 Macau, PRC 79.44 85.25 5.813 Japan 78.67 85.56 6.894 San Marino 78.33 85.57 7.244 Singapore 79.21 84.59 5.386 Hong Kong, PRC 78.99 84.6 5.617 Gibraltar 78.5 83.3 4.88 Sweden 78.39 83 4.619 Australia 77.8 83.59 5.79
10 Switzerland 77.75 83.63 5.8837 United Kingdom 76.23 81.3 5.0745 United States 75.15 80.97 5.82
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The demographic “time bomb”?
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An ageing population
Source: Buckingham Palace, Anniversaries Office
255 317 516 7961168
16242462
3083
45245218
4647
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1952 1956 1961 1966 1971 1976 1981 1986 1991 1996 2001
Num
ber
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The rise in numbers of older people is the major challenge
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Why has population ageing happened? The “rectangularisation”
of survival
0
10
20
30
40
50
60
70
80
90
100
Age
18501990
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China’s rapid demographic transition: a political cause
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The speed of population ageing in developing countries
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Population ageing is associated with increase in chronic diseases
• Transition to chronic degenerative diseases
• Continuing burdens of infectious diseases
• Greater impact of human immunodeficiency virus
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Omran, Milbank Mem. Quart 1971
Other
Violence
Stroke
Heart
Cancer
[Infancy]
Diarrhoea
Infections
TB
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Compression of morbidity and disability?
0102030405060708090
100
Mortality
Morbidity
Disability
A B
Years
Percent
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Percentage of life expectancy spent able to perform basic ADLs
40
50
60
70
80
90
100
Per
cent
age
75-79 85+ 75-79 85+
1976 1980 1985 1991
8.6 4.8 11.2 6.1
Source: Bone et al Health Expectancy, 1995
Men Women
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Percentage of life expectancy spent able to get outdoors
40
45
50
55
60
65
70
75
80
85
90
Per
cent
age
75-79 85+ 75-79 85+
1976 1980 1985 1991
8.6 4.8 11.2 6.1
Source: Bone et al Health Expectancy, 1995
Men Women
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The first big challenge for middle income countries
• Growing cost of health care– Population expectations for health care– Technological advances– Increased complexity of care delivery
• Who pays?
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Trends in different sectors of health care costs, USA 1960 -1997
1960 1965 1970 1975 1980 1985 1990 1997
Percent increase
Hospital Nursing home Physician services Other
100
1000
10,000
Source: National Center for Health Statistics, 1999
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Health policy
• Health promotion
• Free primary health care
• Geriatric/psychogeriatric services
• Community rehabilitation
• Respite care
• Nursing homes
• Training for family carers
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What might help meet the challenge?
• Focus on prevention
• Cost-effectiveness approach to prioritising health care
• Self and family care
• Development of primary care infrastructure
• Health care financing
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The second big challenge for middle income countries
• Will the family continue to support elderly people?
• Urbanisation– Young migrate leaving old behind
• Employment patterns– Working women
• Westernisation– Devaluing of older people
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0
10
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30
40
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60
70
80
90
100
0 10 20 30 40 50 60 70 80 90 100
Age
Survival %
The effect of social factors:wild versus protected
Protected
Wild
Survival
Age
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Jerry Morris (chair), Alan Dangour, Christopher Deeming, Astrid Fletcher, Paul Wilkinson , LSHTM, 2005
Single Couple
Estimated £123 £193
Actual Pension
£82 £131
Policy Unit Age Concern England
Minimum income for healthy living: older people
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Social policies
• Pensions
• Housing
• Caring/disability allowances
• Transport
• Organisations for elderly people
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The World Bank view
• The need for multi-pillar support systems– State pensions– Private sector pensions– Personal savings
BUT – what is the evidence (CHILE) and who benefits most?
Is the idiom of crisis appropriate?
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Income security
• Inter-generational transfer of resources– Young to old– Old to young
• Pensions and income security– confined to civil servants– affordability
• Loans and community income generation– old age should not be a barrier
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HelpAge International – role in promoting income security
e.g. universal pensions in Laos…
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Urbanisation and Modernisation
• Older people literally left behind in rural areas
• Under-valuation of verbal traditions, wisdom of old age
• Birthplaces and final resting places
• Housing in cities usually too small for extended families
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Old style work but new industries
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Employment prospects for older people?
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Economic productivity
% at each age classed as economically active
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Maintaining extended family lifestyles
• The “family will cope”
• Housing
• Transportation
• Reciprocal contributions to household
• Child care and rearing
• Tax incentives
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Malaysia: Mahathir’s 2020 vision
…the needs of elderly people will be met by "a social system in which the welfare of the people will revolve not around the state or the individual but around a strong and resilient family system"
Mohammad Mahathir. Vision 2020 In Malaysia: the way forward. Prime Minister Department of Malaysia, Kuala Lumpur 1991.
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How do we ensure inter-generational support?
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Housing fine for extended families is torn down to make way for housing suitable only
for nuclear families
Wu Ping and Yang Wu have been fighting off bulldozers in downtown Chongqing since 2004, when they were one of 280 households asked to make way for a redevelopment project in the booming southwestern city of nearly 28 million
CNN News, 2 April 2007
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The childless older people
• No family to cope
• 10-15% couples are infertile
• Adoptions may become more difficult
• Community support mechanisms required
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The public health problems
• Ageing is a major challenge to integrity of populations
• Rate of ageing is rapid, policy making is slow
• Development programmes and aid agencies are not considering impacts on older people
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How can we meet the social challenges?
• Ageing as central consideration in social policy (cf. gender, poverty, race)
• Incentives for families to care
• Move towards pensions for all
• Emphasise the economic productivity of older people
• Training and re-training for older people