Population Ageing - Egypt Report

December 2016 , Volume 13 - Issue 2

Population Ageing - Egypt Report

Author: Hala S Sweed

Correspondence: Prof Hala S Sweed Founder of the Egyptian Society of Geriatrics and Gerontology Head of the Geriatrics and Gerontology Department Faculty of Medicine - Ain Shams University Egypt Email: halasweed@yahoo.co.uk

Introduction

Egypt is the most populous country in the Middle East and the second most populous on the African continent (after Nigeria). The population of Egypt represents 1.20 percent of the world´s total population which arguably means that one person in every 84 people on the planet is a resident of Egypt. One of the main features of the Egyptian population over the last few decades is the gradual increase in the absolute and relative numbers of older people. This trend is expected to continue over the next decades. Egypt is expected to maintain the highest rank in absolute numbers in both old and oldest populations in the region, in 2050 Egypt is expected to have the largest number of old (23.7 million) and oldest old (3.1 million) populations in the region.

The Egyptian census is carried out every 10 years; the last one was in 2006. The percent of older people "defined as 60 years of age and more" was 4.4% in 1976, 5.75% in 1996, rising to 6.27% in 2006. The percentage is projected to be 6.9% in 2015, 9.2% in 2021, and it is expected to reach 20.8% in 2050. This means that, around 20 million Egyptians will be categorized as elderly by that time; this is a big number that resembles a full nation in some parts of the world.

Figure 1: Population Estimates & Projections of Egypt (1950-2050) (Source: world population prospects. Revised 2012)

Population ageing is widespread across the world. It arises from two demographic effects: increasing longevity and declining fertility. An increase in longevity raises the average age of the population by increasing the numbers of surviving older people. A decline in fertility reduces the number of babies, and as the effect continues, the numbers of younger people in general also reduce. 

The decline in fertility in Egypt is actually planned too. Since mid of the 20th century, Egypt has been suffering from the problem of rapid population increase, a phenomenon faced by most developing countries as a result of programs of environmental improvement, preventive care, as well as medical progress in better diagnosis and treatment of diseases causing a dramatic decline in number of deaths. That decline was not accompanied with a similar decrease in number of births which resulted in a major population increase associated with a growing pressure on the scarce economic resources.

As a result, since 1973, Egypt has been adopting a set of population policies and strategies aiming for family planning. As a result, the average number of children per family declined from about five children during the eighties to about three in 2005. And still the National Population Strategy (2002-2017) is targeting to bring down the average number of children to two per family by 2017.

Life expectancy in Egypt at birth is 72.9 years for females and 70.1 for males (CAPMAS, 2016). In 2014, it was 71.8 years, 74 years for females, and 69.5 years for males. The life expectancy for males at birth was 60.5 years in 1986 while for older people was 14.3 years. In 2026 the expected life expectancy for males at birth will be 74.7 years and for older people will be 19.3 years. So the percent of increase in life expectancy for males at birth from 1986 to 2026 is 23.5% and for older people is 35%. Similarly, for females at birth the percent increase is 25 % and for older females 44%.

The rate of population aging may also be modulated by migration. Immigration usually slows down population aging, because immigrants tend to be younger and have more children. On the other hand, emigration of working-age adults accelerates population aging. 

Although the effects of migration on population aging are usually stronger in smaller populations, because of higher relative weight (proportion) of migrants in such populations, still, the Egyptian aged population can be affected by migration. According to the International Organization for Migration, an estimated 2.7 million Egyptians live abroad and contribute actively to development of their country through remittances, circulation of human and social capital, as well as investment. Approximately 70% of Egyptian migrants live in Arab countries (923,600 in Saudi Arabia, 332,600 in Libya, 226,850 in Jordan, 190,550 in Kuwait with the rest elsewhere in the region) and the remaining 30 % are living mostly in North America (318,000 in the United States, 110,000 in Canada) and Europe (90,000 in Italy). Still, this number may be much less than the actual number, if there is a defect in reporting to the embassy on arrival to a new country.

In addition, there is the migration within the country from rural to urban areas, leaving the elderly behind. This causes variation in the distribution of the aged population within the Egyptian governorates. According to the last Egyptian census, the absolute total number of the elderly is greater in rural areas than urban ones, in spite of the fact that their percentage is more in urban (7.18%) than rural (5.6%).

A distinctive feature of the elderly population throughout the world is the preponderance of women over men "feminization" of population aging (because of longer life expectancy among women). The greater improvement in female life expectancy than that for males will not only result in lower sex ratios for the elderly population as a whole, hence a predominance of females, but for the individual elderly females, greater longevity will very often result in loss of support from spouse, and greater economic deprivations. Current sex ratio in Egypt is 83 men for 100 women.

Click here for Figure 2: Population Pyramid of Egypt

Population ageing is a medal with two sides. Currently the public focus is primarily on negative aspects related to the socio-demographic development, such as increasing spending for pensions, as well as problems in the field of social and health care. Yet population ageing also offers opportunities, for example, in the voluntary work on behalf of retirees.

Positive aspects of aging

Although elder people are often considered as a homogeneous social group which is 'passive', 'unproductive' and dependent, yet, ageing is an individual process and elder people are anything but a homogeneous group. 

Not all seniors will become terminally ill the day after they turn 60. Many old people are not in need of the care of others, and, on the contrary, may be caregivers themselves. In fact, they could live up to 30 or more additional years and, without major disabilities. 

Older people can live vigorous and active lives until a much later age than in the past and if they're encouraged to be productive, they can be economic contributors as well. 

They can be creative, have a network of friends and family, exercise, be reasonably healthy and they continue to grow, learn, help and teach others, using their cultural background, knowledge, expertise and experience.

For instance, they are able to guide the young people through various ways. Elderly Egyptians are the resource for providing training, advice and skills in many fields. In the Egyptian Universities for instance, retired Professors after 60 years of age, continue giving lectures, training courses, and supervising theses and research. 

Not only that, the elderly people can also assist in taking care of their grandchildren. Thus, this will allow their children to work thus increasing economic productivity.

As long as the elderly female is in good health, she is carrying out her household work, helping in bringing up her grandchildren, whereas the older man carries out the outdoor activities, like taking grandchildren out or driving them to school, especially within families with young men travelling abroad, working in the gulf area for example, and leaving the wife and children behind with the grandparents.

Egyptians have a strong family web, supporting each other. Some elderly even provide financial support to their sons, daughters and grandchildren. 

Implications of population ageing and Policy response

While population aging represents, in one sense, a success story for mankind (massive survival to old ages has become possible), it also poses profound challenges to public institutions that must adapt to a changing age structure. The rapid ageing of the population can be considered a great threat to the preservation of society welfare.

Population aging has many important socio-economic and health consequences, including the increase in the old-age dependency ratio (the number of individuals of retirement ages compared to the number of those of working ages). It presents challenges for public health as well as for economic development. 

Detailed and accurate data on elderly population size and characteristics is the essential first step to describe the real situation, to conduct effective development planning and help project future needs of elderly in context with other sectors of population and to determine gaps that need to be closed and achievements that need to be sustained.

Table 1: Egyptian Elderly population and services

The policy making bodies in Egypt, mainly the Ministry of Health and Population, Ministry of Social Solidarity, the universities and the academic institutions have been long acting to cope with population ageing.

Social highlights

The family has been and still is the main social institution, which offers support and services to the aged. However, social changes e.g. rural-urban migration with older people left behind, Egyptian women increasingly being employed outside homes, changing in housing stock (nuclear instead of extended family) and decreasing family size with fewer people in the 'young generation' available to take care of larger numbers of people in the 'old generation', have created some demands for extra-familial services.

According to the Egyptian constitution, the government is obliged to provide services of medical and social security for aged. Legislation, laws, resolutions and programs on the protection and promotion of seniors' human rights were laid down for the social and medical security systems aiming to give the elderly the maximum support they need. 

There are some privileges offered to older people by the government including; 25% discount for local transportation (50% for railways), 50% discount in the price of entry tickets for theaters, cinemas, clubs, and fairs, 10% discount in the price of air tickets for local/national flights and 5 % for international flights, and 20% for internal tourism (trips).

Social insurance law: The law adjudicates disbursing security pensions - through the Social Insurance Fund for the governmental sector and the Insurance and Pensions Fund for the public and private sectors in the following cases: (aging, disability and death- work injuries- illness- unemployment- social welfare for pension beneficiaries), on top of this pension beneficiaries' list come elderly.

The ministry of Social Solidarity also has laid down a number of laws and regulations over the past years supporting the elderly. In 1990 the Ministry laid down the internal regulations of the geriatric clubs, in 1992 set a committee for celebrating with the day of the elderly, and in 1997 established the higher committee for the geriatric care. Law 84/2002 on regulating the work of NGOs and private foundations, allowed elderly to participate in the management of some NGOs, run projects and utilizing their capabilities; it is worth noting here that most NGO's boards in Egypt consist of seniors.

Health care services

Population aging is a great challenge for the health care systems. Although the health status of older people is improving over time now and the life expectancy is increasing, still, with aging, the prevalence of disability, frailty, cancer, and chronic diseases (Alzheimer's disease, cardiovascular and cerebrovascular diseases, etc.) is expected to increase, especially with the large growth in the oldest old group (+70yrs old) that constitutes 31.73% of the Egyptian elderly and 2.5% of the Egyptian population. The older the person is, the more likely they are to face a compounding of multiple health, psychological and social problems that make accurate medical diagnosis and proper medical management difficult.

Elderly people have high risk for functional impairments with inability to perform ordinary activities of daily living (ADL) and activities related to household management termed instrumental activities of daily living (IADL). 

Therefore, a country in which there are increases in the older population has to be prepared for the epidemiologic transition from infectious diseases of the young population to the chronic diseases of the old population. In such conditions health services and resources have to be directed to medical care as well as home and institutional care.

Various services for elderly are provided through governmental, private, and non- governmental sectors. The government also provides some medical services through the medical insurance scheme. It has been estimated that 6% of the total population have been covered by the Health Insurance Organization (HIO).

The Egyptian national medical security covers all pensioners with subscription of 1% from monthly pension salary (2% for widows). The medical services are distributed all over the governorates.

In addition to the general health services, whether governmental or private, available for the use by the elderly, there are other special services for the older people that have developed in Egypt.
Since 2007, 11 geriatric healthcare centers (offering health care services to elderly people through specialists from different branches) have been set up by the Ministry of Health distributed all over the governorates. 

Ministry of Health has also established Clinical Diagnostic Service to the dementia patients (Memory clinic in hospitals) since January 2000. The service included assessment service, counseling and family support.

Outside the ministry of health, academic units provide a very satisfactory unique model of care including; 

• Geriatrics and Gerontology Department - Ain Shams University

The Geriatrics and Gerontology Department at Faculty of Medicine- Ain Shams University started in 1982, as a day care unit providing services to the elderly patients of the medical and psychiatry department, then development and growth went on where an outpatient clinic was established and the department was developed in 1994, and over time more services were developed in the department including geriatric intensive care unit in 2000, and an osteoporosis unit in 2002.

The department involved 23 inpatient, plus 9 ICU beds, an osteoporosis Unit which offers diagnostic and therapeutic services, and daily outpatient clinic. Comprehensive geriatric assessment is being carried out through a multidisciplinary team including geriatricians, nurses, social workers, physiotherapists, psychologists, dieticians, and speech therapists. In addition to the care offered to the patient, family and caregiver education and psychological support is offered by the team. 

Currently the department is being renovated; the 3 floor building was put down and in its place a 7 floor building is being established with a capacity of 109 beds including 36 ICU beds. The new hospital will be offering several levels of care including acute and subacute care, long term care and day care services.

• Center of elderly care, Helwan University (CEC)

The center of elderly care - Helwan University was established in 1996, as a self-financed unit under the umbrella of the center for community development in Helwan University. Services offered include; 10 inpatient beds, day care services and out-patients clinic. 

A Long term unit is also available in the CEC mainly for frail older people who are functionally dependent on others for their ADLs and IADLs. 

Examples of other unique centers include; center of geriatric service, Nasr city, and geriatric department in Palestine Hospital.

Military hospitals also provide elderly care services, and NGOs and the private sector also play a role. 

In addition, population aging implied new services that meet the specific needs of the elderly including homes for the aged and geriatric clubs. 

As for the Egyptians themselves, the family has been and still is the main social institution, which offers support and services to the aged. According to a report from Cairo Demographic Center most elderly people (66.8%) live with sons and daughters and (13%) live with spouse. A small percentage (9.1%) of elderly people live with relatives other than mentioned above and the same percentage live alone due to different reasons.

However, social changes e.g. rural-urban migration with older people left behind, Egyptian women increasingly being employed outside homes, changing in housing stock (nuclear instead of extended family) and decreasing family size with fewer people in the 'young generation' available to take care of larger numbers of people in the 'old generation', have created some demands for extra-familial services.

All these factors caused changes in living arrangements resulting in an increasing number of older people living alone especially females, raising the need for institutions for the aged. 
The beginning of the twentieth century witnessed a great concern of the Egyptians about institutions. The establishment of the first ministry of social affairs in 1939 represented a milestone in social work. Since then, official policy has encouraged and supported social work through numerous associations. One of these is the General Association for the Care of the Aged established in 1981 to offer social, cultural, and religious services to the aged with branches in different governorates. The association has given the priority to two services: setting up homes and clubs for the aged and training staff for this purpose. By the financial support of the Ministry of Social Affairs, several associations have set up homes in different parts of the country.

The participation of NGOs in care of elderly started before 1939. Many houses for the elderly had been established by local and foreign social organizations before that date; many of these houses are still operating in the present and such services were sometimes offered on a religious basis. 

The first home for aged in Egypt was established in 1900. In 1980, the total number of geriatric homes in Egypt was 63, increasing to 94 in 1990, 103 in 2000, 161 in 2011and currently reaching to 170 in 2015 with a capacity of more than 4,800 elderly. All of the registered geriatric homes are supervised by the ministry of social affairs.

These homes provide medical, social and recreational services and allow the elderly to live with dignity.

Several elderly clubs have been established all over the country with different activities practiced under the supervision of the organizing committees and the ministry of social affairs. The number of these clubs was 50 clubs in 1990, and increased to be 110 in 1999 with a ratio of increase 120%. The numbers of elderly who benefited from this service were 8,538 in 1990 which increased in 1996 to be 23,970 with an increase of 181%. In 2011, there was 193 clubs with 40,171 elderly benefiting from them. Currently, the number of these clubs reached 196 all over Egypt.

The day services are offered in the elderly clubs through which medical, social and recreational services are introduced.

Since 2011, 52 physiotherapy units attached to the geriatric homes and clubs are offering rehabilitation for 50,000 elderly.

In 2009, the Ministry of Social Affairs developed offices (most of them were attached to elderly clubs) that provide home care services (as basic activities of daily living) for the elderly especially those living alone. These offices were 30 distributed all over the Egyptian governorates serving 40,000 elderly but unfortunately this service stopped in 2011.

There are 857 NGOS concerned with geriatric care and their branches are distributed all over the Egyptian governorates. In spite of being a large number, this represents only 1.55% of the whole Egyptian NGOS. NGOs play a key role in the field of social work in support of governmental plans. They carry out their plans within the framework of stable regulatory and structural mechanisms, namely the General Union of NGOs, regional unions and specific unions.

Some of them are offering social and medical services e.g. the Egyptian society of geriatric care. Others are scientific e.g. Egyptian Society of Gerontology, Egyptian Alzheimer's Society, and Egyptian Society of Psycho-geriatrics. Some of these NGOS do provide some integrated services in the form of homes for the aged along with hospital and religious services.

Still, there is minimal role of NGOS in policy planning of care of elderly, in research work, and in media to increase the awareness of population by the problem of aging. Every individual organization works separately, with minimal communication between each other.

Alzheimer Egypt society was started in 1999. It aims at raising awareness among the health and social care providers to persons with dementia and their caregivers. It has many activities such as monthly "Alzheimer café" a meeting to support persons with dementia and their carers; annual celebration of the "Alzheimer day"; non-regular Alzheimer bulletin; and a health education book for caring after persons with dementia at home.

The Egyptian Society of Geriatrics and Gerontology, an NGO, was founded late in the year 2014. Being founded by geriatric specialists, The Geriatric and Gerontology Department, Ain Shams Faculty of Medicine, it adopted a more specific way to decide on its goals that are to be based more on the needs of the seniors in the Egyptian community goals than most others. In order to attend to actual needs of the senior Egyptian citizens on multiple levels (e.g. medical, social, financial and any other societal services) rather than the expected, the Society started a project of building a database on the needs of the Egyptian seniors. 

Wikiageing, a knowledge management tool, was established in 2014 by academics from Ain Shams Geriatrics and Gerontology Department. Its mission is to promote and improve the elderly care in MENA. The tool operates by the Wiki technology based on a dynamic website (http://wikiageing.org/). It is a collaborative, voluntary, open access knowledge project aiming at improving the elderly care in the Arab speaking region. Wikiageing as an open access knowledge tool provides a means to pool knowledge, categorizes knowledge, networking, and general knowledge management. 

Several conferences, symposiums, and workshops concerned with ageing have been held in Egypt over the past years. These were sponsored by either the Ministry of Health, Ministry of social affairs, Universities, and non-governmental organizations. They were aiming to orient the health-professionals and also the general people with aging and the elderly needs.

Media also made modifications to cope with the graying of the population. The Radio developed a channel specific for old people, and the television developed a program since 1994 called
'Age Spring'  The national newspaper 'Al-Ahram' developed a page since 2001 named
'Age Flower'  concerned with older people. There is also a special Radio channel for elderly named 
"Elderly specialized Radio " broadcasted all through the day.

Large amounts of research in the field of aging was done and still ongoing to develop a data base of the elderly population and their needs.

Bulletins are published regularly by non-governmental organizations e.g. 'towards healthy aging', 'sound of time'  "the Butterfly  ", and 'for better mental health for the elderly'.

Social training programs are presented by the Ministry of Insurance and Social Welfare including a program for older people to prepare the population for the changes that occur after retirement.
The whole health system in Egypt became oriented to the phenomenon of aging. For several years now, the Ministry of Health started to have residents for geriatric medicine with training courses and residency programs offered to them in collaboration with the academic departments. As mentioned above several services were established to cope with the elderly needs and others will be. A large number of Egyptian geriatric specialists and consultants are available nowadays across the country. Health professionals were trained and are being trained for geriatric care.

Training programs for health professionals

With the graying of the population, geriatric medicine specialty was developed and well established in Egypt with continuous education and training programs for the health professionals dealing with elderly patients.

Geriatric medicine education programs

• The Geriatrics and Gerontology Department at Faculty of Medicine, Ain Shams University

The Geriatrics and Gerontology Department at Ain Shams University is the only academic department in Egypt that offers Diploma, Master Degree and Doctoral Degree in geriatric medicine connected to a specialized residency program and clinical training courses.

The Ain Shams geriatrics and gerontology department is a center of excellence specialized in elderly care in Egypt and the MENA region. The scope of the department involves three main domains; education, research and medical services. 

By now there are more than 80 trained physicians working in the department with positions and titles of professors, associate professors, consultants, lecturers, and residents fulfilling the residency program. In addition the department has trained and graduated many physicians to work in the Ministry of Health in Egypt and in some Arab countries. Establishing a stable system and advocating the specialty led to training of new generations of geriatricians and spreading the department mission locally and regionally.

The department is also involved in the teaching process of the undergraduates and introduced the first undergraduate curriculum in geriatrics in Egypt to promote skills of handling elderly patients, and to spread knowledge about geriatric medicine and gerontology. Also courses are designed for physicians of the Ministry of Health, nurses and caregivers. The department is helping build capacities and training doctors for other equivalent departments in Egyptian universities (Mansoura, Suez Canal and Helwan) and the Ministry of Health (11 departments). 

A large amount of research was carried out by the department covering varying fields of geriatric medicine and gerontology and has been published in varying national, regional and international journals and still ongoing research is being carried out to study the old aged population and their needs.

0n 2014, the department developed the Egyptian Journal of Geriatrics and Gerontology, a peer-reviewed journal aiming to address the most significant aging issues affecting health status and quality of life of older individuals. The journal addresses research on biological, clinical, epidemiological, and psychosocial aspects of later life. 

Geriatric Physical therapy education programs

Geriatric physical therapy education is available in three Physical therapy colleges. The study of geriatrics is introduced at the third year undergraduate for two terms. Postgraduate studies are available to attain higher diploma, Master and Ph.D. degrees.

Geriatric Nursing education programs

At the colleges of nursing (Alexandria, Tanta, Mansura, Cairo universities, etc) there is a module in geriatrics nursing both at the undergraduate level as well as postgraduate level at the diploma level, M.Sc., and Ph.D. in geriatric nursing.

• The Higher Institute for Public Health, Alexandria university

This is a postgraduate institute for public health. There are 9 academic departments of which one is the Department of Health at old age. This department offers postgraduate training in geriatric health at the diploma level, Master degree level and Ph.D. degree level in Geriatric public health.

• Colleges of Social Services:

In Helwan, and Assiut Universities, provide Diploma, Master degree and Ph.D. in geriatric care. Also in the other Universities, geriatric care is included in the undergraduate curriculum with training courses and field training.

The Ministry of Health and Population started from 2001 to develop health programs targeting older people within its structure. These include;

• Short term training program for family physicians held with the collaboration of experts from Ain Shams University. These programs are held twice a year and aim to train such physicians to acquire skills in geriatric practice. • Short term training program for community nurses held with the collaboration of experts from Ain Shams University. These programs aim to train such nurses in geriatric nursing skills.

Training courses for professional caregivers

Different governmental and non-governmental organizations are involved in training of professional caregivers. These programs are very variable in terms of method of training, length of training, and course objectives. Some of these programs would link such training with mechanisms to employ the trainee either in long term units or home care programs, but others would just offer the training. Organizations offering these courses include; Geriatrics and Gerontology Department at Ain Shams University, College of Nursing at Cairo University, CEC, and the Red Crescent.

Recommendations

• According to the principles and recommendations for action of the International Plan of Action on Ageing, endorsed by the United Nations General Assembly in 1982, and the United Nations Principles for Older Persons, adopted by the General Assembly in 1991, which provided guidance in areas of independence, participation, care, self fulfillment and dignity, Aging is a mass phenomenon, and international and regional cooperation is needed for creating a supportive community for the aged worldwide. National, regional and inter-country dialogues need to be established to lay down a joint strategy and plan of action.
• Ageing must be incorporated within social and economic strategies, policies and action. The national security system umbrella must be enlarged to cover a wider range of older population.
• Good linkage between all the governmental and non-governmental organizations is needed for more success in the aging story.
• Empowering NGOs is needed to achieve their objectives and functions through supporting them technically and financially. In addition, the role of the private sector must be activated.
• Elderly must be encouraged to participate actively in the economic, political, social and cultural life of their societies enabling the society to rely increasingly on the skills, experience and wisdom of older persons. The potential of older persons is a powerful basis for future development.
• In spite of all the efforts carried out in the field of elderly care and support, these efforts are still segregated. Properly managed integrated systems for health and welfare services would result in more effective and efficient coordination of the care needed by older persons.
• The significant increase in life expectancy implies not only heightened demand for the existing services but also for new services and alternative approaches to meet the varied and specific needs of the older persons. A good health status of elder people can have a positive influence on public budgets in this context; hence, an increase of preventative measures may pay off in the long-run.
• Existing services need also to be expanded to cover the increasing number of the elderly all over the Egyptian governorates.
• Educational and training programs must be extended to include physicians and health professionals all over the governorates.
• Programs to educate the people on how older people can contribute, and how their life experiences can be a tremendous asset to the community and not a threat to the younger generations must be established aiming to change society's perception of older persons and establish age-friendly community.
• Also programs for the older people must be carried out for orienting them to retirement coping and establishing the attitude of positive aging.
• Research on ageing and age related issues must be encouraged as an important instrument for the formulation of policies on ageing. The results of this research should be taken into consideration in planning the strategy and policy of health care for ageing

Acknowledgment:

I would like to appreciate the effort of Dr Ahmed Shawki Mohamedeen, Lecturer of Geriatrics and Gerontology- Faculty of Medicine- Ain Shams University, in enriching the report with updated data.

Main References

• Central Agency for Public Mobilization and Statistics (2016): Egypt by figures, Cairo http://www.capmas.gov.eg/Pages/StaticPages.aspx?page_id=5035
• Central Agency for Public Mobilization and Statistics (2006):Census book 2006, Cairo
• www.un.org/ageing/documents/workshops/Vienna/egypt.pdf
• http://www.worldbank.org/.
• Refaay M A et al (2007): Role of Non-governmental Organizations in the Care of Egyptian Elderly. Msc Thesis. Geriatrics and Gerontology Department Library. Ain Shams University.

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