A POLICY FRAMEWORK FOR HEALTH AND SERVICE NEEDS OF OLDER PERSONS IN AFRICA
PROF. NANA ARABA APT
HEAD, DEPARTMENT OF SOCIOLOGY &
DIRECTOR, CENTRE FOR SOCIAL POLICY STUDIES
UNIVERSITY OF GHANA, LEGON
2.0 AGEING IN THE AFRICA REGION
The proportion of Africa's elderly population 65 years and over on average stands at 3.0 per cent. Although sub-Saharan Africa's elderly population presently is not as large in size as in other regions of the world, it must still be considered as a potential cause for concern since the largest increase in the number of elderly people in the world between 1980 and 2000 will occur in Asia and Africa.
The most rapid growth in the elderly population is expected in Western and Northern Africa whose elderly population are projected to increase by a factor of nearly 5 between 1980 and 2025. Of relative importance to note is the fact that the number of the very old in Africa is also expected to grow at a very fast rate. Between 1980-2025 the 75 years and over age group will increase by 434 per cent in East Africa, 385 per cent in Middle Africa, 427 per cent in Northern Africa and 526 per cent in Western Africa. Nigeria in West Africa will be among the countries in Africa that will experience very large increases in this age group. Another unique feature of Africa's ageing situation is that by the year 2020, rural segregation of the old will be manifest and the elder segment of the African population will be concentrated primarily in rural areas.
While ageing has drawn considerable attention in developed societies for a very long time, it has barely been conceived yet in most of the African countries as a potential demographic change whose occurrence is only a matter of time. The reason for this lack of concern is understandable. It goes beyond the small proportion of the elderly populations at present projected in the population structure of African countries. Many countries in Sub-Saharan Africa, have other urgent and pressing demographic problems of rapid population growth, high infant and child mortality, excessive rural urban migration and most recently Hiv/AIDs pandemic. To these realities must be added cultural and particularly, economic factors whose impact on the elderly cannot be ignored.
In modern Africa, increasingly, the indicators are of a trend away from the traditional perceptions and practices of obligations towards respect for the elderly. When elderly Nigerians were asked "What sort of things give you status today (Ekpenong, Oyeneye, Peil, 1987:16-17), the general agreement was money, character, and education, in that order. Only a few people mentioned the traditionally accepted status norm, namely, children and family. The majority of Nigerian elders are said to be pessimistic about modern circumstances and about the present and future situation of the elderly. In the final analysis the conclusion of the authors was that even though elderly Nigerians continue their traditional roles, these roles are now less important to an increasingly materialistic society.
Elderly Temne of Sierra Leone, also in West Africa, assess themselves as a "short-changed generation". (Dorjahn, 199:272-2755). In this they meant that they had "paid their dues" when they were young but their turn for the pay-off was begrudged through social change. Of elderly Samians of Kenya in East Africa, Cattell (1989:233) observed that their influence has been "devalued, displaced, and replaced" and that a significant basis of their respect had been eroded. Many elderly Samians identified education as their crucial element in this change and emphasized that it has reduced respect for them, the support and care given them and the seeking of advice from them. Now they explained, one needs new knowledge which "old people, especially women lack" (ibid:236).
Perhaps modernization is an inevitable processes, but Africa should come to terms on this issue by recognizing that they have a past and their past is important for them as they and their children pursue their lives (Skinner,1996). The West evolved at a certain point in the evolution of the world and did what it had to do (Skinner, ibid). Africans have to realize that they must do what they have to do in their own terms, from their own experiences and within their own culture. They cannot replicate the history of the West to the disadvantage and loss of dignity and respect of the old. That is why Africa must not be forced or perhaps persuaded by world financial institutions like IMF and the World Bank to design their economic system in Western terms. The consequences will hurt the vulnerable poor of which the old constitute a fair portion in the region.
Health begins with well-being. Are older Africans satisfied with life? When this question was put to Ghanaian elders (Apt,1996),a significant association was found to exist between self assessed life satisfaction of elderly Ghanaians and the following variables: (1) type of accommodation (2)having children (3) living with family members and (4) involvement with community affairs. The analysis further showed a highly significant relationship between life satisfaction and living with family members. Very recent studies by HelpAge in Ghana (1999) has shown the tremendous social and economic contributions that older persons make to family and community as well as shown older people's need to be involved. From the Ghanaian field evidence we can conclude that given the right frame of financial and emotional support and ensuring confidence in older people's ability to be useful in the community, the social aspects of older people's health will be adequately met.
There is no doubt, a clear recognition for the need to preserve the traditional informal system of social welfare and support. However no deep knowledge of these systems has been acquired and little thought has been given to how traditional informal systems must be transformed to meet modern demographic requirements (Grieco and Apt, 1996). While these issues are critical to policy development for the protection of older persons, no program of detailed research has yet been developed to deal with them. Consequently, policy analysts are handicapped by insufficient knowledge of such cultural arrangements. They are also handicapped in identifying means for preventing the erosion of those arrangements. Currently, in the work of both the World Bank and many other donor agencies including the United Nations, there is a policy void: the identification of the workings of as well as the pressures upon traditional welfare systems and the design of policies that can support, incorporate and transform those same system into a viable modern form.
Well-being of old people is not synonymous with social security and health provision and yet much of the limited research and policy work on ageing has been concerned with welfare institutions rather than the social realities of the old. Even in economic terms in sub-Saharan Africa, economic activities do not stop at any given age. In many countries, between 74% and 91% of people over 65 years old continue to work. The World bank presents old age as an eventual crisis in economic terms (1994) but policy makers need to look critically at overall issues of dependency rather than assuming that the problem relates only to older people ((Aging and Development:1:4, 1998). This must begin with the preservation of older people's economic and social productivity, most especially of older women.
Poverty in old age usually reflects poor economic and education status earlier in life. Women in Africa are most affected. Social security systems generally base their support on continuous paid employment; this disadvantages women who face discrimination in the work force (Sadik,1196:42). In many African societies, women have unequal and inadequate access to basic services, food and nutrition. They have no rights to land ownership and widowed and divorced women suffer from degradation and extreme deprivation. All these factors have a disproportionate impact on the health of ageing women most of whom depend upon their families for economic support. Those without children and able relatives are most vulnerable.
Economic development in Africa is meaningless without social development. Within the context of social integration, and the rights of persons of age, Gerontology is concerned at least in part with the social status of the elderly in society. It excavates and illuminates the dearth of socio-cultural, political and legal conditions of a significant portion of the populace. Increasingly, to a large extent, this portion is experiencing lack of abilities and declining social power. To that extent, gerontology is concerned with the broader issue of social justice and fundamental human rights. The time is now for African societies to re-define family caring (Apt, 1995); the time is now for an inclusive and liberating gerontology in Africa that will re-define the African family in a progressive manner that recognizes the family as an integrated unit of parents, children and grand children (Attafuah, 1998).
Presently, both developed and developing countries suffer from the strains and stresses of development. We should however be clear in our minds that we cannot solve African problems by transferring, models, institutions and techniques from other societies. What this boils down to in terms of health of the aging is that policies and programs should be the products of our particular environment. That there must be a harmonious relationship between the educative experiences of African societies and the major beliefs, values, practices and needs, interests and problems.
Public assistance institutions were developed to provide the care-giving functions that the family was unable to. Their experience in the developed world, however, has proved less than satisfactory, and the upshot has been a global trend towards de-institutionalization (Chawla,1996). This has unfolded in a variety of ways, but its principal emphasis has been on strategies of community development and participation: to try to close the wide gap that exists between the deprived and the disadvantaged, on the one hand, and existing institutional structures on the other. The implementation of those strategies has often been problematic, particularly for the elderly, who are often in a double bind: being part of depressed communities of the urban or rural poor and also being regarded as passive recipients of care within those communities.
3.0 WHAT ARE THE ISSUES IN AFRICA?
Longevity:
Longevity is a cause of concern because of its consequence on the development of social security systems which is hardly developed in many African countries. Few countries in Africa have public pension schemes and where they do, these are typically restricted to a very small percentage of the older population; very often, those who have enjoyed formal sector employment and have been public officials. The reality of limited resources in the face of growing family disintegration, and the growing trend towards nucleated families become more and more apparent. On the other hand, there are no signs at the present moment of viable alternatives to provide care for older persons.
Developing an empowerment perspective, a movement away from the deterioration medical paradigm of the West, enables older persons to define an active part for themselves in social and economic life. Similarly, mutual support structure, well used in traditional African societies, provide older persons with more control over their own lives.
Low income:
Although there is a general consensus that the low income world that is normally representative in Africa does not have resources for catering for either the ageing of society or large increases in the numbers of older persons through the policy focus has largely been on the family as the key agency in meeting the ageing crisis (Phillips, 1992), this simple opposition between the public sector and informal sector provision conceals a wealth of policy options which must be explored to make old age planning relevant. The tendency to view the old simply as recipients of care and services is certainly no model for Africa and has served to conceal the prospects of and opportunities for mutual support.
The consequence of this current gaps in knowledge about indigenous structures and values on ageing in respect of Africa, leaves many key policy topics largely left undiscussed and therefore untaught. Ageing has not yet taken its necessary place on Africa's development policy radar. In discussions of older persons and development, older persons are regarded as constraints and not a resource and yet emerging information on this presents the contrary view.
Social Change:
In sub-Saharan Africa, older generations are living in a world which has undergone the fastest and greatest social and economic changes in history. Not only will there be increasingly larger numbers of older persons in our region but they have great educational needs which have to be studied and met if major human resources are not to be wasted. These educational needs range from literacy to technical training, through civic and political education to banking and enterprise skills.
Lack of education represents as large if not a larger problem that physiological constraints to the social and economic participation of older persons in Africa. An increase in the number of generations in a fast changing world necessarily accentuates the educational distance between the younger and older generations (Apt,1996) if education is viewed purely as the preserve of youth. A lifetime approach to education which equips older generations with new skills minimizes this distance.
Gender:
Gender has received very little attention in mainstream development operations, although, the signs are that after the Beijing meeting in 1995, change is now on the way. The issue of gender and ageing however has barely been addressed. Yet women progressively live longer than men in Africa and women more than men experience financial and cultural constraints which affect their quality of life as older persons. In Africa women are the principal care and health providers within the family and women have less resources available to them to take care of themselves when they are old, divorced or widowed. Longevity and health in Africa clearly has consequences for female workloads and work opportunities if care for the old is to take place within the family. It has consequences for the life opportunities of the care giver and stresses and strains are likely to take its toll on Africa's women care givers. The gender divisions in African societies which provide men with better access to employment market than women, mean that for women the loss of a partner often constitute a major change in their financial circumstances. Loss of husband is often the loss of a way of life. There is definitely a need for ageing policy in Africa to address the poverty problems of widowhood.
Consideration needs to be given to creating income opportunities for older women in order to tackle their poverty. The ageing of African societies necessitates a change in the traditional gender arrangements where women's financial position was mediated through their male partners. Developing programs and policies which endow women with social and economic resources at the point of widowhood, provides the opportunity for women to negotiate for better care and services within their own kinship structures. Thus the longevity of women as compared with men raises the issue of developing appropriate forms of education and training based on gender.
Gender and aging should immediately be activated as part of poverty alleviation strategies in Africa. The domestic character of women's life in Africa frequently leaves them unprepared for entering the public sphere on the death of a spouse. Thought must be given to enabling older women to take an active part in public life through appropriate training. Orientation and self esteem courses are necessary as routine features of women's education in their older years.
4.0 AGEING AND EMPOWERMENT
Empowerment of older people is not only about rights: it is also about obligations. The empowerment of older persons and their development of mutual support system is not a matter for older persons alone. There must be enabling conditions created in order for older persons to have the maximum autonomy and less pressure on scarce social resources. This area needs extensive study. Providing for example, leverage funding for mutual support schemes should be the more sustainable alternative to blanket social security provision. Tout (1989) discusses precisely these issues in his proposed new approach to the problems of older people in developing countries. Mutual support however should not be viewed simply as the cheaper option but should be viewed in terms of the active participation benefits it brings. Mutual support offers the opportunity for enhance sociability, greater bargaining power across the generations and greater security in the context of shrinking kinship structures.
Older persons with their greater endowments of available time can both make major contributions to education and training. The notion that education is for the young in Africa must be combatted. Assuming that classrooms are only for children closes the door of opportunity for older persons to gain literacy. Besides, older persons' generational skills such as traditional craft and cultural history can be brought to the classroom and enhance the educational process. Thus designing in appropriate roles for older people into the curricula of Africa's young generation is a policy step worth investigating.
5.0 CONCLUSION: BUILDING ON INFORMAL SOCIAL WELFARE SYSTEMS: A NEED FOR POLICY DEVELOPMENT:
In the main, social gerontology has something of a traditional focus: it focuses on the problems of the old rather than on the problems of the design of the society. Despite the limitations, it still has an important function to play in identifying the circumstances and social processes affecting older persons. Are we in Africa conversant with all the processes? We who are in the main dependent on kinship structures to cater for the new and increasing older generations have the least knowledge of the social processes involved. Which comes first? The cart before the horse or the horse before the cart? Do we search for meanings vis a vis the turnover of our cultural values and ethics, economics and politics and how these impact on aging before planning or do we just plan with any available information? The need for gerontology research in Africa has begun to receive some attention. Nevertheless, there is still a huge research gap to be filled. Not only is there need to collect better descriptive data on the social and economic support systems around ageing in Africa but there is also a need for a radical review of the policy options open to our governments, development agencies and communities in tackling the social and economic requirements of massive demographic change. Until such time that we can boast of having readily available information for policy makers and the public at large to be useful in shaping a new paradigm (our own paradigm) for an ageing world, let us not talk about ageing with health matters. Any strategy on health of older persons in Africa will only be meaningful if older persons are brought back into the mainstream and then rehabilitated.
Within Africa, both policy makers and ordinary people are clearly struggling to cope with the challenges of a modernizing and ageing world that places destructive pressures on indigenous social welfare arrangements. This nevertheless must be retained if a welfare crisis is to be averted. Within the struggle, new patterns of interaction are developing that retain linkages with customary arrangements but are adaptations to the increasingly monetized world. The search by older persons for a prolonged economic life in a monetizing society is one such adaption.
Social definitions of who should be economically active must change, but social and economic structures which support this change are also necessary. An effective life course perspective must be embedded in a cultural perspective. Patterns of daily living are learned in cultural settings that shape values and goals. Peer group pressure, together with traditions, religion and ethical values of society, habits of charity, duties of children and extended families are among the major influences shaping and maintaining ways of living. They are clearly defined for a large proportion of the world's elderly, and need to be considered when interventions aimed at improving well-being in older age are planned. Encouraging more positive attitudes towards the older person is the beginning of the health of older persons. As directed in the UN International Plan of Action on Ageing (1984):
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