How to address UHC's age limit

BARCELONA — “You’re not sick, you’re just old.” This is something Margaret Kabango, a 76-year-old activist for older women’s rights, and board member for Uganda Reach the Aged Association, hears all too often when she, or others her age, visit a doctor.

“I went to the hospital recently with a backache. The first thing the doctor told me was that it was due to old age,” Kabango said, adding that regardless of age, anyone can get sick and should have access to adequate care. After all, universal health coverage means that “all people” should receive the health services they need without suffering financial hardship.

Unfortunately, that is often not the case. According to “Global AgeWatch Insights 2018,” a lack of data on older people — 60 years and above according to the United Nations — means the older generation is at risk of having their health needs ignored, despite younger generations experiencing improved health care as the world pushes to achieve UHC by 2030. This can be especially felt in low- and middle-income countries.

But older people make up a significant portion of the global population and ignoring this population jeopardizes truly achieving UHC. In 2017, there were 962 million people aged 60 or over worldwide — 62% of whom live in LMICs; by 2050 that is estimated to rise to 2 billion, 80% of whom will be living in such regions.

There’s the old adage that you treasure what you measure, said Kate Bunting, CEO at HelpAge USA, which helps older people claim their rights, challenge discrimination, and overcome poverty. “When we’re not measuring or keeping track of people who are living well beyond 49, we really don’t know how to meet their health needs,” she said.

It is hard to get the development sector to understand, Bunting said, explaining that aging as a field is relatively new given that people did not previously live as long. In 2016, the average life expectancy globally was 72, compared to 52 in 1960.

Discrimination against older people

Within the older population, Kabango said there is then further disproportionality. For example, while sexual and reproductive health and rights are widely discussed on the development conference circuit, she said the sexual and reproductive health needs of older women are rarely covered — particularly topics such as menopause and sexual violence.

“It is time to start talking about some of the needs that older women have and it shouldn’t stop when you stop reproducing,” Bunting agreed. “That’s definitely a piece that’s missing in this whole conversation.”

Not only are older people not being counted when it comes to health care data, but they’re often not targeted when programs are implemented and the training of geriatricians is deprioritized, Kabango said.

“We continue to go to the physicians, but that touch of how to handle an older person is missing. When we grow older, our systems change and when you do geriatrics [specialism] you learn how to handle them, learn the dosage of drugs they should get, and the type they should be given.”

The skill set necessary to assess and care for an 80-year-old person with dementia, for example, is not universally provided in undergraduate or postgraduate training, agreed Finbarr Martin, president of the European Geriatric Medicine Society.

“[Older people] may, at a formal level, have access to health care, but the health care they receive is not suitable for them,” he said. “That’s a big problem internationally, including in areas that are reasonably well-developed.”

When it comes to making sure that a solution is context-appropriate, Michael Shafer, founder and director of Warm Heart — a Thailand-based organization that helps isolated villages become more socially and economically sustainable communities — said there is also a huge difference between “urban aspirations and rural realities.” Older people living in a rural area are often unreached by health initiatives that work well in the cities, for example, a city-wide wheelchair distribution initiative may not make sense in a rural area with no smooth curbs.

Steps to address poor quality of care

Aside from training health care workers in geriatric care, gathering more data on persons above a certain age, and ensuring the inclusion of all age groups in health programming, there are other actions that can be taken to ensure older people are not left behind in the bid for UHC.

The World Health Organization’s “Global strategy and action plan on ageing and health” suggests developing commitments on healthy aging in every country, age-aligning health care systems, and developing sustainable and equitable systems for providing long-term care. “Global AgeWatch Insights 2018” also highlights the need to recognize mental and cognitive conditions such as dementia in older age, acknowledge the violence, abuse, and neglect that can sometimes be experienced by older people, and develop models of UHC that are holistic, person-centered, and integrated across health care systems.

Bunting said ageism and discrimination within a health workforce also needs to be addressed. She called for national declarations on aging — much like those that prevent discrimination of people with a disability — that could then form the basis of a legal framework for a person’s rights as they age.

While HelpAge works with governments around the world to build up health systems to adequately account for people of all ages, it has to start with the international institutions, Bunting said. The recent release of the zero draft of a political declaration on UHC — currently under consideration by U.N. member states — included some language on older people, but it is not enough, she added.

Including older people as partners, not just as a token representation, in such conversations could help fix that, she said. “We spend a lot of time in the field talking to older persons, ensuring they are the ones going to testify. We’re the connective tissue between all of our network members and help bring their voices to the table.”

In Uganda, for example, Kabango and other people of a similar age are collecting data on how older people perceive their own health and feeding that back into the national health system via Uganda Reach the Aged, a government-sanctioned structure and HelpAge network member.

However, Shafer warned that as much as it is important to listen to what older people believe they need, they, like all people, could be influenced by what other projects are doing, potentially overshadowing what is most suitable for their community.

He described being told by people living north of Phrao in Thailand’s Chiang Mai province that building a senior center would best serve their needs. Once the center was established, the organization quickly discovered that many people didn’t actually want to leave their neighborhoods and go to the center. It was only when the organization’s staff went house to house and saw the lack of support the older people had that they were able to identify what would be most impactful — such as ramps and renovations to make homes more accessible, and availability of car rides to hospitals.

Without attitude and cultural changes, no real advances in how Thailand’s health care system sees older people will happen, he said. He urged international bodies such as the U.N. Development Programme, Food and Agricultural Organisation, and WHO to push governments to do what they have committed to with the UHC agenda and not leave anybody behind.

“I think the problem here is that you get organizations like the U.N. and WHO talking to countries about UHC and the governments say ‘yeah, yeah, yeah, go, go, go’ but they don’t actually invest in it,” he said. He stressed that it is up to international bodies to hold them accountable.

While working to ensure older people are included in health care plans at the international and national level, initiatives at the grassroots level can also make a huge difference to a person’s health, Bunting said. HelpAge runs intergenerational self-help clubs that provide companionship and information on common geriatric health challenges with the aim of helping people feel included.

“By having access to a group, we can ensure they get a general awareness about some of the basic diseases they might face, she said. “They get opportunities to have health checks that they may not get otherwise, there’s exercise and classes in healthy eating, so it’s really a range of things that we’re able to do at the grassroots level.”

Motivation to put such programs in place should derive from the fact that the work done today in fighting for the rights of older people, will make a difference for people who are now 25, said Bunting. “By 2050, they’re going to be older people, according to today’s definition, so it’s a really important connection and we shouldn’t forget it.”

For a closer look at the innovative solutions designed to push for progress on universal health coverage around the globe, visit the Healthy Access series.