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Long Term Care Systems for Older Adults in sub-Saharan Africa: Are new approaches needed?

By Agnes Nanyonjo
on December 16, 2016

The population of sub-Saharan Africa (SSA) is ageing rapidly due to improved childhood survival and declining overall fertility. True, the total population share of older adults ( 60 years or more) will remain lower in the SSA region than in other parts of the globe, it is projected – rising from 5% to just under 8% by 2050.  However, the absolute size of SSA’s older population is already considerably large at 47 million, and is expected to reach 161 million by mid-century. A couple of global stats perhaps to put this SSA picture into perspective: in 2015, there were 901 million people aged 60 or over (i.e. 12 % of the global population). The population aged 60 or above is growing at a rate of 3.26 % per year  – it is the fastest growing population segment globally – and the number of older persons in the world is projected to be 1.4 billion by 2030 and 2.1 billion by 2050.

There is growing research evidence pointing to substantial levels of functional impairment among older adults in the SSA, partly attributable to the chronic disease burden. Older adults with functional disabilities have limited ability to carry out essential tasks of daily living independently. There is  thus a huge need  for long-term care (LTC) for older adults in SSA and this need can only be expected to rise further as the region’s chronic disease burden increases. LTC has been defined by the WHO as ‘activities undertaken by others to ensure that older adults with a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity.’  As such the premises upon which LTC for older adults should be provided include fairness to those who require care and those who provide it; enabling dependent older people to continue doing what they value while living their lives in dignity; being viable and sustainable in the long run and finally, a firm sub-Saharan grounding in broader development and human rights agendas.

Against this backdrop, the African Population and Health Research Center (APHRC) hosted  the   2nd Africa Region International Association of Gerontology and Geriatrics (IAGG) conference in Nairobi, Kenya, from 6-8 December.   The conference focused on setting the agenda for LTC systems in Africa. The conference, a structured policy-research-practice dialogue, attracted researchers and experts on ageing from all over the world, be it government representatives, staff from international organisations, non-governmental organisations, academia or civil society.

The field of research on ageing issues in Africa is still very young – by way of example, the youngest generation of researchers is only the third. Conference discussions and presentations  can be accessed on the IAGG website, in the rest of this article I will present my personal reflections and lessons learnt while interacting with a vast body of “ageing experts” (pun intended).


On ageism

The term “elderly” itself is ageist. It is more dignified to refer to people who are advanced in age as ‘older adults’.  Hidden in ageist terminology like ‘elderly’ are discriminatory prejudicial attitudes that portray older adults as frail, leading to a lack of respect for their autonomy and dignity. Even global health policy isn’t immune for institutional ageism.

Although ageism is pervasive in society, today’s older adults play a significant role in SSA settings. Roles include taking care of children orphaned by AIDS, being agriculturalists, mentoring younger generations in agriculture or actively participating in politics with one standing example of Nelson Mandela who began his political career at the cool age of 75 years (at least at the highest level). True, older statesmen aren’t always as exemplary as Mandela, but let’s not go into that.


Will families continue to care for older adults?

Traditionally, families gladly took care of frail older adults as a reciprocal act of human kindness (Ubuntu). However, families become overburdened, financially and physically, by the pressure of caregiving, especially if the care is to be provided over long periods of time single handedly. Many scholars now argue that the family structure has changed due to rural-urban migration, emigration,  missing generations in families (due to the HIV/AIDS scourge) and urbanization and modernization trends. Care giving roles are thus more likely to disproportionately fall on young females whose education and employment prospects are, as a consequence, often negatively affected. Therefore there is a need for formal LTC systems to alleviate some of the burden and pressures of caregiving from the families. However, in several African settings, “formal long-term care systems” are unfairly equated to residential homes for older adults without any further in-depth analysis of the premises for the need of these. For example, South Africa’s President Zuma worried about the institutionalization of care outside the home, “As Africans, long before the arrival of religion and [the] gospel, we had our own ways of doing things. Those were times that the religious people refer to as dark days but we know that, during those times, there were no orphans or old-age homes. Christianity has brought along these things.”

As much as Zuma’s cry resonates with many Africans, which busy employed person would not be happy to know that the care “their” older adult is receiving is of the best possible standards? That while they are away, it is possible for their older adults to receive quality care from a day center? Wouldn’t it be great to occasionally relieve a busy or tired family member from a caregiving responsibility? And who wouldn’t be at ease knowing that health institutions in Africa are well equipped to handle chronic diseases attributable to older age?

Most African countries do not have policies on ageing, and those that do have no clear-cut policy on long term care for older adults with functional disabilities. Different issues of ageing for older adults such as the need for financial support and health care are often handled separately in a rather uncoordinated way. It is therefore imperative for family care to be seen as part of a broader care system that spans both informal and formal spectrums with the needs of older adults at the center of the care, and with overall stewardship being provided by individual governments.


Last but not least: on the emigration of Africans, and the interface between LTC and broader development agendas

Curiously, Africans leave Africa and many (health staff) end up in the Western world’s care sector, but most return to Africa when they themselves are old and frail, and with little care options. There needs to be a way, somehow, to pass on these newly acquired caregiving skills to benefit them and future generations.

Within broader development agendas, human rights frameworks as enshrined in the Sustainable Development Goals (SDGs) for example dictate that older adults are entitled to the right to health and the right to age in a friendly environment – rights not based on an individual’s ability to contribute to the economy. Having said that, even in the (generally lofty) SDG agenda, older adults still fall prey to ageist approaches, see for example the concept of premature mortality, an approach that is clearly discriminatory against older adults, as has been pointed by scholars. Also, it’s good to keep in mind a holistic lens: everything is connected with everything in the SDG agenda. In SSA, younger women responsible for caregiving suffer increasing gender inequalities in terms of education and employment; and yet, a woman’s education status is known to be a key predictor for the health of her children. In addition, given the fact that there is a high burden of youth unemployment all over the SSA region, does LTC for older adults provide an employment opportunity into which the younger generations can venture?

In conclusion, LTC provision like other forms of care is a risk but how much of that risk should go to the government? How much should go to the societies and what will be the effects of failure to enshrine ageing and LTC agendas into the development prospects of young economies in Africa?  All remain unanswered questions, for the moment.  Let’s hope this week’s High-Level Ministerial Meeting on Health Employment and Economic Growth in Geneva provided some answers, as time is running out.

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