Commentary: Defining a minimum income for healthy living (MIHL): older age, England—a comment on implications for application in the developing world
Director of Policy Development, HelpAge International. E-mail: mgorman{at}helpage.org
Accepted 6 August 2007
Professor Morris and his colleagues have introduced an important perspective on the relationship between income and health in older age in England. In doing so their article also raises questions for the situation of older people elsewhere. In the developing world for example, the inter-relationship of age, health and material security is a critical concern for older populations, many of whom are experiencing significant levels of poverty and ill-health as they age.
This should be a public policy concern for developing countries not least because the rapidly rising proportions of older people living in these countries mean that already nearly two-thirds of the global population of people over 60 live in the global South. This proportion is likely to exceed 70% well before mid-century. Asia, which is currently home to 10% of the world's older people, will have 23% by mid-century.1 For countries such as China and India, Nigeria and Brazil, population ageing is becoming a significant policy issue.
Despite these growing numbers, the health and material security status of older populations in the developing world are largely unknown. What is clear from the fragmentary evidence that exists is that older people are characteristically among the poorest in many countries.2 Poor people enter old age with chronic conditions inherited from a lifetime of physical labour, poor quality living conditions, and in the case of older women multiple pregnancies with inadequate perinatal care. In many cases older people experience chronic poverty, which deepens with advancing age and becomes increasingly difficult to alleviate, let alone escape. Household support is likely to be limited by the environment of poverty experienced by families and whole communities. The provision either of basic services which older people share with other community members, such as water and sanitation, or targeted provision such as pensions or specialized health care, is likely to be extremely limited or non-existent.
This situation notwithstanding, the principle of defining the requisites for healthy living as a basis for public policymaking is as important for older populations in the South as it is in the North. Good health for the older poor in the developing world has both an intrinsic and an instrumental value. The latter derives from the need for large numbers of older poor people to continue to work, often into very old age. The numbers of people aged 60 and over in poor countries who continue to work are not precisely known but are estimated to be 50% of older men and 19% of older women; in the least developed regions this rises to 71% of older men and 37% of older women.3 For these people a reasonable level of physical and mental health (or at least low levels of chronic ill-health) are essential attributes. Continuing physical activity is likely to be a feature of the lives of the older poor, though diet and nutrition are problematic; many older people survive on a minimal diet, where two meals a day and a sufficiency of fruit and vegetables are rarities.4
Adequate housing, sufficient to provide a ‘healthy home’ as defined by the authors is equally unlikely to be available to older poor people in the developing world. Sound, hazard-free structures, with adequate (or any) water supply and sanitation, and facilitating both privacy and the possibility of social exchange, are rarely available to older people.
Adequate health care is also rarely accessible for the older poor. Specialized services are almost non-existent, and most older people share with other age groups the possibility of access to inadequate and often remote general hospital facilities, where they take their chances in overburdened in- and out-patient facilities.5 It is routine for medical and nursing staff to discriminate against older patients, leading many to turn instead to pharmacies (for western medicines, nearly all of which can be bought over the counter without prescription) or traditional healers. Health spending remains consistently the second most significant expenditure item (after food) in the expenditure budgets of older people, using what tiny income may be available to them.6
In the absence of much of the basic ‘infrastructure’ of services and benefits which provide the foundation for material security and health in old age, it is extremely challenging to devise a meaningful index for basic income in old age in the developing world. Nevertheless, this is an important enterprise, especially in the context of the current debate in development circles on the role of social protection instruments (including ‘social transfers’ such as basic pensions) as development interventions. The ‘Decent Work Agenda’ of the International Labour Organisation includes a social protection pillar, and the recent G8 Summit in Germany concluded with a statement on the key role of social protection to underpin both social change and growth in developing countries [Federal Government of Germany G8 Summit 2007 summit document: ‘We believe that social security systems require further development and extension of coverage taking into account nations’ abilities to provide such coverage given their varying states of economic growth and recognizing the fact that there can be no one size fits all model of social protection. We agree to keep this issue on our development policy agenda, encouraging relevant international organizations to work in close cooperation on this issue’. www.g-8.de.] Thus it has arguably never been more important to identify ways which are accessible to policymakers of demonstrating the efficacy of basic income for marginalized groups such as the older poor in the developing world.
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1 United Nations. World population prospects: the 2006 revision. UN 2006.
2 Kakawani N, Subbarao K. Ageing and Poverty in Africa and the Role of Social Pensions, Working Paper, No. 8, August 2005: International Poverty Centre, UNDP. HelpAge International, Bolivia: Characteristicas socioeconomicos de lapoblacion Adulta Mayor, Encuesta de hogares MECOVI, 2001, HelpAge International and Bolivian Nacional Institute of Statistics, La Paz; 2002.
3 Population Ageing. (2006) Available at: http://www.un.org/esa/population/publications/ageing/ageing2006.htm.
4 Ministry of Community Development & Social Services. Poor households with limited self-help capacity in Zambia. MCDSS/GTZ Lusaka 2003.
5 Gorman M, ed. State of the world's older people. HelpAge International/Earthscan, 2002.
6 Lloyd-Sherlock P. Primary health care and older people in the south: A forgotten issue. Eur J Dev Res (2004) 16:283–300.[CrossRef]
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