Successful Ageing Public Health aspects of

Population Ageing

Shah Ebrahim

London School of Hygiene & Tropical Medicine

CADENZA Symposium 2008

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

The global picture: 2000 and 2050

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

The demographic “time bomb”?

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

The rise in numbers of older people is the major challenge

Why has population ageing happened? The “rectangularisation”

of survival

0

10

20

30

40

50

60

70

80

90

100

Age

18501990

China’s rapid demographic transition: a political cause

The speed of population ageing in developing countries

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

Omran, Milbank Mem. Quart 1971

Other

Violence

Stroke

Heart

Cancer

[Infancy]

Diarrhoea

Infections

TB

Compression of morbidity and disability?

0102030405060708090

100

Mortality

Morbidity

Disability

A B

Years

Percent

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

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

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?

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

Health policy

• Health promotion

• Free primary health care

• Geriatric/psychogeriatric services

• Community rehabilitation

• Respite care

• Nursing homes

• Training for family carers

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

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

0

10

20

30

40

50

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

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

Social policies

• Pensions

• Housing

• Caring/disability allowances

• Transport

• Organisations for elderly people

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?

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

HelpAge International – role in promoting income security

e.g. universal pensions in Laos…

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

Old style work but new industries

Employment prospects for older people?

Economic productivity

% at each age classed as economically active

Maintaining extended family lifestyles

• The “family will cope”

• Housing

• Transportation

• Reciprocal contributions to household

• Child care and rearing

• Tax incentives

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.

How do we ensure inter-generational support?

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

The childless older people

• No family to cope

• 10-15% couples are infertile

• Adoptions may become more difficult

• Community support mechanisms required

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

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