Regional Dimensions of the Ageing Situation

Regional Dimensions of the Ageing Situation

Department of Economic and Social Affairs

United Nations New York, 2008

ST/ESA/318

ISBN 978-92-1-130263-9

• http://www.globalaging.org/agingwatch/desa/aging/mipaa/regionaldimensions.pdf

Ageing in Western Asia

Madiha El Safty

Madiha El Safty is Affiliate Professor of Sociology at the American University in Cairo.

This chapter addresses the situation of older persons in the 13 countries of the United Nations Economic and Social Commissionfor Western Asia (ESCWA) from the perspective of the age group of 60 years and above, considering that 60 years marks the legal age of retirement in most countries of Western Asia. In certain instances, reference may be made to the Arab States, since the situation of older persons does not exhibit significant variations in the whole Arab region, and hence available data in many cases lump the countries together under an Arab umbrella.

The report starts with an overview of the demographic indicators in the ESCWA countries, highlighting changes as they reflect the situation of older persons, especially future projections. Variables relevant to the issues of ageing in the region are reviewed: poverty and employment, health, gender issues and services for older persons. Selection of particular variables has been based on their relevance to the situation in the region and their impact on ageing issues. Primarily, poverty constitutes a serious problem in most ESCWA countries. Secondly, the culture reveal s persistent gender inequalities, to the disadvantage of women. Scarcity of resources is yet another significant factor, reflected in the lack of availability of quality health and social services. This chapter also looks critically at the Madrid International Plan of Action on Ageing, examining how its different components rela te to action plans and strategies in the ESCWA region. The conclusion spotlights those ar eas of priority that merit action if the issues of ageing are to be met as older pe ople in Western Asia and their Governments would want them to be.

A. Introduction and overview

Countries of the ESCWA region have witnessed increases in their older population, despite the youthfulness of the population pyramid in most of those societies. The young segment of the population remains fast growing because of the high birth rates in the region. Youth aged 19 and under represent approximately one quarter to one half of the population in each country, with Iraq, the O ccupied Palestinian Territory and Yemen having the highest proportion of young people. By contrast, the share of the population aged 60 years and above stands at about 5 per cent in the region, ranging from a low of 1.8 per cent in the United Arab Emirates to a high of 10.2 per cent in Lebanon (United Nations, 2007a).

While the growth of the older population is a global phenomenon, it is not monolithic and disparities cut across regions and individual countries, not only with respect to growth rates but also in the structure of the older population. The situation of older persons in any society is made up of a multitude of conditions. The cultural specificities in each society leave their impact on the whole ageing “problematique”. Attitudes are shaped

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according to norms and values of their respective cultural settings; the hardware, the availability of physical facilities provided in response to ageing issues, is likewise conditioned by the cultural base. A major determinant in each country is the economic resources that necessarily condition the scope and extent of different measures and policies targeting the older population.

A starting point in gaining an understanding of the situation of older persons is the mix of demographic changes taking place in the region. The growing proportion of older persons is a result of the improved public health situation: the expansion in health facilities and eventual rise in life expectancy, coupled with a decrease in infant and child mortality. The improvement in health conditions can be seen especially in the case of women’s health, with the positive outcomes of reduced fertility and maternal mortality rates. In that context, technology transfer has played a significant role in the upgrading of health services and facilities.

A low level of policy concern. The demographic transition to an ageing society does not receive sufficient attention in most ESCWA countries. Policies and strategies concentrate on other priorities, probably underestimating the future impact of the changing situation in the population structure. With increasing social, economic and political problems on the horizons of policymakers, the ageing situation unfortunately does not occupy a prominent position on the lists of national priorities.

The increase in the older population is paralleled with other changes in their situation. In a tradition-dominated culture, ageing has been a guarantee of a privileged status, especially within the family structure. The extended family has allowed for the provision of care for older persons, not only as a service, but as an obligation. Religious values in the region, both Islamic and Christian, hi ghly emphasize the caregiving role of the family. That may partially explain the relatively low concern of policymakers with ageing issues. The older segment of the population has traditionally been considered outside the Government domain, lying within family boundaries. Changing conditions in society have, however, led to shrinking family functions, including those related to care of older persons. Urbanization, labour migration and the changing role of women are major influences as well.

Urban and rural influences. Societal shifts towards urbanization have contributed to changes in the situation of older persons, often for the worse. The rural population retains its traditional value system, whereby care of older persons remains a family function. An older person in the rural family, according to cultural beliefs, is considered a source of blessing and wisdom. The demographic structure in the villages is likely to exhibit variations when compared with that of the city because of the tendency to have higher birth and death rates. Likewise, there may be differences between the two subcultures with respect to life expectancy. Yet, whereas the rural family position in caring for older persons remains unchanged, the urban milieu feels pressures that lead toward changes in those values and practices.

Although the rural family remains responsible for caring for older pe rsons, their changing socio-economic situation still needs to be addressed by policymakers. The highest

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150 proportion of older persons is in the rural areas of the region. Even if the culture provides for the care of elders within the family st ructure, their needs ma y not necessarily be properly covered. Health care is usually inade quate in rural areas. In addition, attitudes toward ageing may not be conducive for the provis ion of health care, since, in most cases, older people’s health problems are attributed to their age. Furthe rmore, poverty is more prevalent in villages than in cities. Labour and gender influences. Economic, social and pol itical conditions have stimulated movement of labour between c ountries. Such labour-exporting countries as Egypt, Lebanon, the Occupied Palestinian Te rritory and the Syrian Arab Republic experience migration outflows, normally to the Gulf States, where better economic opportunities prevail. The youth mi grate in search of jobs wh ile the older members of the family remain in the mother count ry, frequently in need of care. Another variable is the changing role of women, who are now permitted educational and employment opportunities. Traditionally, wo men have been mainly responsible for looking after the older persons in a family. Female employment outside the home has, however, made it difficult for women to cope with their many family obligations, care of older persons being among them. That responsibility might come last on the list of a woman’s domestic chores, hence the rising concern for the situation of the older population in families where women are working outside the home. Changes in society. As a result of these societal conditions, families are finding it difficult to retain their caregiving role, partic ularly as the patterns of extended family life have given way to the lifestyle of the nuclear family. Family values have been changing in line with changing social and economic conditions. The re sult is a culture that has shifted the position of the older family memb ers from one on top of the family hierarchy to a lower one, in tandem with a change in attitude toward them, especially with respect to their care. Gradually society in the region is coming to recognize the need to a ddress the issues of ageing, at both community and national levels. Yet in the area of social security, for example, the needs of older persons are treate d as part of a package for several target beneficiaries, including the poor, persons with disabilities and other marginalized groups. In the case of such a vulnerable segment as older persons, the bureaucratic and practical constraints interfere with their utilization of social security be nefits and they find themselves thus in an increas ingly disadvantaged situation. Demographics of the aged. Reference to the older popula tion must distinguish between the variations that cut across the ESCWA re gion. Older persons cannot be treated as a homogeneous group, but as a collection of diffe rent categories of people that must be taken into account when designing policies, programmes or any other form of action. First, there are differences based on age, between the “oldest old” aged 80 years and above and the “young old” aged 60 to 79 years. Second, there are variations in physical ability, as older persons may develop func tional limitations, including physical, mental, intellectual and sensory limitations, resulting fr om disabilities acquired later in life which

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B. Demographic changes

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C. Ageing, poverty and employment

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D. Ageing and health

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The ageing of the population has given rise to new needs in health care. Countries are expanding their health services, especially in primary health care. National health programmes for immunization, infectious diseases, reproductive health, children’s diseases and especially oral rehydration therapy have been launched in Egypt, Jordan and Yemen, for example. Expansion of services in reproductive health in particular is a priority in the region. State-provided services, for the most part, cover primary health care and are offered free or at nominal cost . Funds for primary health care may include varying proportions from foreign sources in the low-income countries, which have budgetary deficiencies in the health sector, as is evident in Egypt, Iraq, Jordan, Lebanon, the Occupied Palestinian Territory and Yemen. The health needs of older persons receive no special emphasis in the provision of primary health care services, however.

The Gulf States rank highest in availability and quality of health services. Kuwait and the United Arab Emirates are highest-ranked. Jordan provides another example of good health services. Yemen is one country in the region where efforts are being made to expand and upgrade available health services because of the currently low level of health indicators. In Egypt, religious institutions are additional providers of health-care services, as mosques and churches frequently include clinics where services are offered free or at very low cost.

Older persons have nonetheless benefited from the situation, although geriatric medicine is not commonly practiced; geriatrics is selected neither as a specialization by physicians nor as a service by target patients. Introducing geriatrics to address the health situation of older persons as a specialized branch of medicine is a positive step that has been taken in several countries. Egypt, Jordan and Lebanon have established geriatric departments in some faculties of medicine, leading to a relative increase in that specialization by physicians, followed by a relative increase in its practice.

The importance of geriatric medicine can be appreciated in relation to the general health condition of older persons. Ailments associated with ageing receive no special medical attention because of the widespread belief that they happen to be “normal” at that age. Hypertension, diabetes and cardiovascular, kidney and chronic renal diseases, Parkinson’s disease, and even poor memory can go untreated, as a result. Also, older persons commonly suffer from multiple chronic diseases, in many cases resulting from lack of health care at younger ages. An older woman suffering from health problems usually blames the situation on her age, although the reason may lie in neglect of her health earlier in her life.

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160 Specifically, there is growing concern about Alzheimer’s disease. In Egypt the Alzheimer Society has initiated efforts to raise awareness about the disease, handling of patients and appropriate advice to give family members about dealing with the situation. The Middle East Association on Alzheimer’s (MEAA), which is headquartered in Tripoli, Lebanon, has as its objective to expand education, stimulate research as well as its application, and train personnel, in the treatment of Alzheimer’s disease.

The major dilemma in the health situation of older persons is not the unavailability of health care — although specialization may be lacking — but rather its inaccessibility. The State system, which is available either free of charge or at low cost, does not necessarily guarantee access to proper care, especially where resources are short, both human and financial. The rural sector, in particular, is highly disadvantaged. Moreover, the common prevailing attitude is that free services are of poor quality. On the other hand, the parallel private system is, for the most part, beyond the reach of the majority of older persons, considering their limited financial means. Providers in the private system include clinics and hospitals that charge different fees, some exorbitant. The health status of older persons is highly correlated with their economic condition. The two variables constitute a vicious circle that is closely linked.

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E. Older women: their marginalization in an ageing society

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F. Services for older persons

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G.The Madrid Plan and ESCWA countries: the relevance of international priority directions

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H. Priorities for future action

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1.Database on ageing by country

Better data on older persons in the ESCWA region are needed, encompassing a full range of age groups, socio-economic levels, rural–urban distribution and disaggregation by sex. The collection of reliable data could ensure that policies and measures are appropriately directed toward the target beneficiaries. The various countries in the region have agencies responsible for statistical surveys that can undertake this data collection. These efforts can be supported at the regional level by such organizations as ESCWA, the Arab Gulf Programme for United Nations Development Organizations (AGFUND) and various Arab League committees.

2.Coordination among agencies

Currently, there is a lack of coordination between agencies concerned with ageing, both formal and informal, creating unnecessary duplication of effort. Better coordination could be achieved through networking among all concerned parties, including Government, civil society and the private sector. However, greater effort is needed by the private sector to provide services for older age groups, especially in countries where the private sector has become an active partner in building the economy. A coordinated approach would also ensure that ageing issues are addressed from a broadened perspective – one that includes the protection of rights of older persons, their active participation and contribution to society, intergenerational issues and research on factors affecting their situation. Ageing issues should also be incorporated into a wide range of sectors and programmes, including, for example, those dealing with poverty, health and women’s issues.

3.Empowerment of older persons

The Commission for Social Development has emphasized the empowerment of older persons through a bottom-up participatory approach. Thus the first five-year review and appraisal of the Madrid Plan that started in 2007 is to be based on the opinions of older persons. “The immediate purpose...is to ensure that older persons have an opportunity to express their views on the impact of national policy actions affecting their lives. However, the overall goal is to ensure that older persons are involved in all phases of policy actions on ageing, including policy design, implementation, monitoring and evaluation” (United Nations, 2006c, para. 50).

4.Providing an enabling and supportive environment

ESCWA countries need more nursing homes for older persons, especially considering the changing social and economic conditions in the region that will leave increasing numbers of older persons with no other care available. Efforts are needed to upgrade conditions in such institutions, although in most cases, Governments have not allocated sufficient funds to achieve this objective. The private sector could also play a role, especially for vulnerable low-income groups.

To counter the persistent social stigma associated with nursing homes, Governments should begin to provide home-based support to families with older persons to help them

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fulfil their caregiving responsibilities. Such support could take the form of subsidies, tax exemptions and social security. The benefits could help families provide care for older persons in their own homes, thus avoiding negative psychological repercussions of neglect, exclusion and marginalization. At the same time, older family members would remain in the company of their loved ones in the warmth of a family atmosphere, further enhancing their psychological well-being. Family support benefits would also serve to protect families from the social stigma associated with placing older family members in institutions.

The League of Arab States adopted a charter in 1970, which was amended in 2001, affirming “the need for older persons to be cared for in their natural environment, namely, the family, and for needy families to be provided with the assistance necessary for them to continue to provide such care” (United Nations, ESCWA, 2002, p.8). Similarly, the Strategy for Social Work in the Arab Countries, which was adopted in 1979 and amended in 2001, confirmed the goals of the Charter of the League of Arab States. The charter advocates the role of Governments in establishing nursing homes for those older persons whose situation requires that they be housed in such institutions.

Further efforts have been made by the Council of Arab Ministers of Social Affairs. The Council, which was established in 1980, has held conferences, seminars and workshops in order to broaden the scope of ageing issues for those working in that field. One major component of those efforts has been NGO support to caregivers of older persons at day-care centres and nursing homes, as well as the provision of home support for families with older persons.

5.Health and well-being for older persons

Although the health status of older persons has improved generally in the region, older persons still lack adequate health-care services in general and primary health care in particular, especially in rural areas. If older persons are to enjoy active ageing, they will need appropriate health care, even if their health had been neglected earlier in life.

The health status of older persons is the cumulative result of health care received throughout their lifetime. Health-care facilities should thus be available for the population at large, enhanced by centres of geriatric medicine for older persons. Moreover, older persons with disabilities need special care. Extensive awareness campaigns are also necessary to clarify cultural misconceptions about the health conditions of older persons. In general, the proper provision of care for older persons must integrate “preventive, curative and rehabilitative measures within a continuum of care, including palliative care, and enhancing support for caregivers”(United Nations, 2006c, para. 26).

6.Building national capacity

National capacity to implement the Madrid Plan is lacking in the ESCWA region, as the institutional and legal infrastructure is inadequate to the task. Where Government agencies dealing with issues of older persons exist, for example in Egypt and the Syrian Arab Republic, they are departments within the ministries of social affairs and tend to

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have a relatively low profile. They need to be upgraded and expanded, with the objective of mainstreaming ageing issues into national policies and programmes, as specified in both the Madrid and Arab plans. In a ddition to securing be tter coordination among agencies, advisory bodies on ageing should be established at different levels of the Government. More ambitiously, special bodies on ageing issues coul d be designated to act as focal points for all relevant policymaking units.

Appropriate human resources ar e also needed to deal with ageing issues, and personnel should be trained in designing and managi ng social security programmes, budgetary plans, health-care and social services. Ex isting systems in the region mostly depend on NGOs with little, if any, training. Currently, health-care personnel, social workers and policymakers are not specialized in deali ng with ageing issues. Training for social workers in the needs of older persons or their caregivers is “rare, or even nonexistent” in the ESCWA region (United Nations, 2006c, pa ra. 34). Field training for health-care professionals is lacking and therefore highly recommended.

Training support from international agencies can help in devel oping national capacity on ageing issues. The Arab Plan highlights the importance of regional and international cooperation; although technical s upport for capacity-bu ilding in the region tends to focus on issues other than ageing that assume great er priority for the countries concerned.

A shortage of financial resources also c onstrains policies and programmes on ageing. If older persons are to be target ed in poverty reduction strategi es, social security and other policy areas, additional financial resources ar e needed. Given the projected demographic transition, Governments should allocate an in creased share of State budgets to meeting the needs of the growing number s of older persons – particular ly in the areas of health care and social security. Inte rnational assistance can also help in providing funds for capacity-building in cases wher e national budgets fall short.

Progress in building national capacity can be boosted with greater research on ageing issues, since very little research is availabl e outside of academic circles. Steps to expand research and enlarge the available pool of data and information c ould doubtless point to effective modes of action. One relevant exam ple is the in-depth study conducted in 2003 by the WHO Regional Committee for the Eastern Mediterranean, focused on the current state of community-based care for older pe rsons in Bahrain, Egypt and Lebanon. Such a study could serve as a good basi s for devising appropriate polic ies for the integrated care of older persons.

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