PRB

(April 2006) Populations in developing countries will be aging rapidly in the coming decades: The number of older persons (those age 65 or older) in less developed countries is expected to increase from 249 million to 690 million between 2000 and 2030.¹ And because the elderly are at high risk for disease and disability, this population aging will place urgent demands on developing-country health care systems, most of which are ill-prepared for such demands.

Chronic disease now makes up almost one-half of the world’s burden of disease, creating a double burden of disease when coupled with those infectious diseases that are still the major cause of ill health in developing countries.² The challenge for developing countries is to reorient health sectors toward managing chronic diseases and the special needs of the elderly. Policymakers must take two steps: Shift health-sector priorities to include a chronic-disease prevention approach; and invest in formal systems of old-age support (see A Critical Window for Policymaking on Population Aging in Developing Countries for more discussion on population aging and the options for old-age support).

More specifically, these countries should institute prevention planning and programming to delay the onset of chronic diseases, enhance care for the chronic diseases that plague elderly populations, and improve the functioning and daily life for the expanding elderly population.

The Shift to Prevention

Population aging has been accompanied by an epidemiological shift in the leading causes of death from infectious and acute conditions associated with childhood to chronic conditions. A confluence of factors has spawned this epidemiological transition: modernization and urbanization (especially improvements in standards of living and education); and better nutrition, sanitation, health practices, and medical care.

Projections made by the World Health Organization (WHO) suggest that, by 2015, deaths from chronic diseases—such as cancer, hypertension, cardiovascular diseases, and diabetes—will increase by 17 percent, from 35 million to 41 million.³ But few developing countries have implemented primary prevention programs to encourage those healthy lifestyle choices that would mitigate chronic diseases or delay their onset. Rarely do developing countries have the appropriate medicines or adequate clinical care necessary to treat these diseases.

To encourage a prevention approach, WHO launched in 2002 its Innovative Care for Chronic Conditions Framework (ICCC), aimed at policymakers in the health sector. This framework takes the approach that nonadherence to long-term treatment regimens is fundamentally the failure of health systems to provide appropriate information, support, and ongoing surveillance to reduce the burden of chronic disease. The framework also advises that a prevention approach can mitigate these problems and contribute to healthier lifestyles.⁴

Delaying the onset of disability through prevention approaches can both alleviate the growing demand for health care and, more important, improve the quality of life for the elderly.

Primary Prevention. A prevention approach can be undertaken even where there are resource constraints and age discrimination. Unfortunately, a “negative aging paradigm” found in both developed and developing countries assumes that older people’s health needs require high-cost, long-term treatments.⁵

Critics of this paradigm point out that, while the elderly are indeed more likely than younger groups to suffer from chronic diseases, there is still considerable scope to improve their health and quality of life through relatively low-cost interventions. Some chronic conditions—such as heart disease, diabetes, and many cancers—have well-known risk factors that can be affected by lifestyle and behavioral changes that include quitting smoking, improving diet, and increasing physical activity.⁶

Primary prevention programs such as tobacco education and control are one example of these low-cost interventions. In India, the world’s second-largest producer and consumer of tobacco, cardiovascular disease mortality is projected to account for one-third of all deaths by 2015.⁷ In response, the Indian government enacted in 2003 a comprehensive national law for tobacco control; it also established a National Tobacco Control Cell within the Health Ministry that encourages state governments to develop tobacco cessation programs in selected health-care facilities.⁸

These measures resulted in the establishment of 13 smoking cessation centers in settings as diverse as cancer treatment centers, psychiatric units, medical colleges, and nongovernmental organizations. In 2005, the programs expanded to include five new Indian states.⁹

Secondary Prevention. Whereas primary prevention programs target populations before a disease develops, secondary prevention involves identifying (through screening) and treating those who are at high risk or already have a disease.

Secondary prevention is also necessary to prevent recurrence of the disease. For example, all developing-country health sectors should use aspirin, beta blockers, and statins as mechanisms for secondary prevention of chronic diseases. Incorporating such secondary prevention measures also means providing the technical skills to diagnose and care for patients as well as providing the appropriate medication.

Many countries may not be able to afford these drugs alone, but through the WHO Essential Medicines program, countries can receive guidance on the formularies that meet the standards for a particular drug.¹⁰ In China, blood pressure has been shown to decline in individuals involved with community-based hypertension control programs, where activities include weight control, modification of dietary salt and alcohol intake, and increased physical activity.¹¹

Tertiary Care. Once a chronic disease has been diagnosed, tertiary care involves treatment of the disease and attempts to restore the individual to her or his highest functioning. However, WHO reports that adherence to long-term therapy for chronic illnesses is only 50 percent in developed countries, and is likely even lower in developing countries.¹² Such poor treatment compliance could be bolstered by cultivating better health awareness through education and outreach programs.

Disability and Quality Caregiving

Disability significantly affects quality of life in old age. Types of disability frequently considered among the elderly include limitations in general functioning (such as walking or climbing stairs); managing a home; and personal care. In addition to being consequences of the normal aging process, disabilities are also often caused by chronic diseases. And population aging also increases the prevalence of mental health problems—especially dementia, which results in disability by limiting the ability to live independently. WHO projects that Africa, Asia, and Latin America will have more than 55 million people with senile dementia in 2020.¹³

Caring for the elderly in a way that addresses disability and maintains good quality of life has become a global challenge. Informal care—often provided by spouses, adult children, and other family members—accounts for most of the care the elderly currently receive in developing countries. Care provided at home is often considered the preference of the elderly and, from a policy standpoint, is essential for managing the cost of long-term care. However, despite the increasing demand for home-based care due to population aging, decreasing fertility rates means that future cohorts of elderly will have smaller networks of potential family caregivers.

The need for public policies to address the demand for caregivers is one of the priority issues for long-term care and a guiding principle for WHO’s 2000 publication Towards and International Consensus on Policy for Long-Term Care of the Ageing.¹⁴ In it, WHO urges developing countries to urgently train more professional caregivers to focus on elder care in order to meet current and future demand.

According to WHO, future caregiving for the elderly will also require models of both formal and informal care and systems for supporting caregivers.¹⁵ Although formal long-term care programs are vastly underdeveloped in poor countries, they will be essential for complementing the informal support system and sustaining the major role that family caregivers currently play.

Examples of formal long-term care programs that assist informal caregivers include training, respite care, visiting nurse services, and financial assistance to cover care-related expenses. For instance, many East Asian and Southeast Asian countries are providing adult day care and counseling services to help family caregivers.¹⁶ Singapore is providing home help, nursing care at home, and priority in housing assignments to family members who were willing to live next door to their older relatives, and Malaysia is offering tax benefits to adult children who live with their parents.

Potential to Reduce the Impact of Aging Exists

Policies and health promotion programs that prevent chronic diseases and lessen the degree of disability among the elderly have the potential to reduce the impact of population aging on health care costs. Research shows increasing health care costs are attributable not just to population aging but also to inefficiencies in health care systems such as excessively long hospital stays, the number of medical interventions, and the use of high cost technologies.¹⁷ Appropriate policies to address health care challenges for aging populations are crucial for developing countries if they are to simultaneously meet the health care needs of their elderly populations and continue their economic development.

For instance, how is a country such as China, the world’s most populous country with one of the fastest aging populations, coping with these issues? What is China doing to address the emergence of chronic disease and population aging? These questions will be explored in-depth in a future article on aging in China.

Toshiko Kaneda is a policy analyst at the Population Reference Bureau.