 |
|
|
July 1997 |
A Profile of the Health Conditions of Older Persons of Latin America and the Caribbean
Background and Rationale
The formal dynamics of fertility, mortality, and age structure implies that the trajectory of vital rates of countries in Latin America over the past forty years will systematically and inexorably lead towards the aging of the population in the continent. This heritage from past trends cannot be tinkered with, halted, or modified in any way, except through unlikely sudden events or bizarre population policies. The die has been already cast.
By the end of 1995, in only five countries: Argentina, Barbados, Cuba, Martinique and Uruguay, the proportion of the population older than 65 approximated or exceeded 10 percent, a level slightly below those attained in Canada and the United States (about 12 percent). However, the bulk of other countries in South and Central America and the Caribbean will attain or exceed such levels very soon, almost surely within the next ten or twenty years. Current projections indicate that for the year 2025, more than half of the countries in the continent will be on their way toward substantial aging of their age structure. Of course, the path toward aging will appear more accelerated if we define more inclusively the older population as the subset aged 60 and above.
The aging of countries in the continent will not follow a unique, homogeneous course. Indeed, there will be substantial intercountry heterogeneity in the timing, levels, and other characteristics of the aging process. The timing and speed of past fertility declines will largely determine the timing and speed with which the aging of the age structure is occurring or will occur. Thus, for example, Brazil and Mexico will age later but in a more compressed period of time than Chile and Costa Rica or Uruguay and Argentina. An essentially equivalent, but less dominant, role will be played by the widespread survival improvements in infancy and early childhood that took place during the post-World War II period. Finally, prospective changes in adult and old age mortality will shape the age distribution of the older population, particularly the relative sizes of the youngest old (aged between 65 and 84) and the oldest-old (aged 85+), and thus determine a most central characteristics of the aging process.
The aging process has a sizable and formidable impact on a number of dimensions that affect the normal functioning of societies and the relative well-being not just of elders but also of the younger generations. The most important among these dimensions are pension and retirement systems, composition of the labor force, family and household arrangements, intergenerational intra-family transfers, and health status and health conditions of elders. The relative importance of each one of these aspects is of course variable and dependent on peculiarities of the demographic regimes and the institutional idiosyncrasy of countries. But, as the experience in Europe and North America plainly demonstrates, none of them is likely to be as paramount and influential as the health status and health conditions of older persons.
The gradual impairment of physical and mental health conditions that accompany the individual aging process the resulting reduction in the expected years of active and healthy life expectancy, the reduction or complete cessation of participation in the labor), and the increased dependency on income transfers from various public and private sources, all dictate that the growth of the older population should lead to mounting demand for health care and health services. Since the most relevant health conditions of older persons are chronic rather than acute and progressive rather than regressive), this demand could also entail steep escalation of health care costs. As the case of the United States, England and most Western European countries attest, these costs can attain formidable magnitudes. And as the sad experience of Eastern European countries also shows, inability to confront these problems leads to rapid deterioration of the health status of elders and to the shocking loss of years of life expectancy.
The health problem associated with the growth of the older population also involves important equity issues. First of all, there will be class differentials since members of different social classes will experience sharply different health profiles. Similarly, the ability to access and use comprehensive and high quality health care will differ substantially across social strata. Unless properly addressed, the aging process in these societies will result in sharp increases in inequality in the quality of life and well being of members of different social classes.
Second, there will be gender differentials to contend with since male and females experience very different mortality regimes and are affected by significantly different health problems. Moreover, since women have had a history of lower levels of labor force participation, their access to health care and services when they age will differ substantially from that of men. This is likely to generate important deterioration of women's well being at very old ages, where the majority of them are widowed.
Finally, the growth of the older population will be accompanied by important intercohort differentials. This will occur for two reasons. First, members of different cohorts were exposed to very different regimes of disease, behaviors, and health care during their youth. This is because, as is well known, past exposure to diseases, behavioral practices and health care all affect subsequent health of the individuals. Second, to the extent that the nature of the labor force participation and education of members of a cohort affect their ability to demand and receive resources, younger and older cohorts will experience important differentials in their access to resources in general and to medical and health care in particular.
To understand the nature and magnitude of the health problem and the equity-relevant issues associated with it, to identify the social institutions that will bear the costs, and to ensure that policies implemented in the future translate into acceptable standard of well-being among older persons without unduly eroding equity concerns, it is necessary to evaluate the health status of those who are elders now and, equally importantly, of those who will become elders in the near future.
In a recent review of the health status of elders in Latin America, the authors note with some frustration that "...the difficulties outlined in this paper associated with the aging of the population in the region are compounded by the lack of adequate information systems which could inform decision-makers on the best course of action for specific problems.
This lack of ‘quality data’ also prevents the long-term evaluation of interventions: in the absence of baseline data measuring their impact, such interventions become fruitless exercises...".
It is worrisome and paradoxical that whereas in the United States, Canada, Europe and even Asia, aging was anticipated and accompanied by a surge of research into the nature and consequences of the problems associated with it, particularly on the health dimension, nothing of the sort is occurring in Latin America. A recent publication of the United States National Academy of Sciences identifies about 25 surveys, completed or in course, designed to study various aspects of aging, and about half of them are dedicated to health. Similarly, Canada and most countries in Western Europe have fielded or are in the process of fielding numerous surveys which directly or indirectly retrieve information on health status of older persons and other related aspects.
This lack of information in Latin America is worrisome not just because Latin American countries will face problems associated with aging in the very short run but because the combination of demographic regimes and institutional contexts are likely to increase the magnitude of the problems and to force their occurrence in a much more compressed period of time than ever before. This lack of information is also paradoxical for while funding for family planning continues unabated as levels of Total Fertility Rates rapidly dip below 3, only scarce resources are flowing to investigate the aging consequences of the unprecedented sudden and rapid fertility decline for which family planning programs are partly responsible.
Comparative studies on the health conditions of elders in Latin America simply do not exist. The only pertinent and most comprehensive data base ever assembled was produced through an intercountry study sponsored by PAHO. However, the results of these studies are based on protocols that are not consistent across countries and that retrieve information on only the most elementary aspects of health status of elders, necessary but insufficient to characterize thoroughly the health profile of elders. These studies cannot be used to study the prevalence of important illnesses that are typical among older persons or to compare prevalence across countries, nor can they be utilized to support an understanding of the type of medical and health care that older persons require, demand, and effectively receive. Similarly, these data are of limited value to draw inferences about relations between behavioral aspects of risk profiles and health conditions nor to carry out a study in a comparative perspective to explain how country-specific factors affect the prevalence of physical or mental disability and disease or the extent to which the associated needs of elders are satisfied.
The information on the health status of older persons or, for that matter, any other dimension of the aging process in Latin America, consists of studies of local, most of which are highly selected and thoroughly unsuitable to draw inferences about current and future health status profiles.
In the absence of information of any sort, collection of single country data sets is useful whether or not the data sets resist tests of rigorous comparability. However, for scientific and policy purposes, it is more efficient to invest resources in comparable data sets. As stated before, past demographic trends dictate that the experience of population aging in countries of Latin America will occur at sharply different speeds and so will the societal and economic stressors generated by it. Similarly, each country offers unique social, political, and cultural conditions conforming an institutional context where aging occurs and offering the resources to deal with the problems posed by it.
The nature and magnitude of the aging problem and of all its dimensions is determined by the interaction of these two factors, the demographic regime itself and the socio-political-cultural institutional context. If so, a comparative perspective for the study of any dimension of aging is not only useful but necessary. The study of a single case is not without value--particularly for understanding the case itself--but it is hopelessly limited as a basis for making broad inferences or for drawing sweeping policy implications. Comparative studies have important return to scales and unique benefits relative to a set of unconnected single country studies.
A comparative data collection project about health status and conditions of older persons is invaluable for scientific and policy purposes. Basic research into the aspects that determine health status and conditions among elders requires at the very minimum an assessment of the status and condition among current elderly cohorts. Ideally, the project should be longitudinal and apply protocols already validated elsewhere thus enhancing comparability with the experience of other countries.
Similarly, the foundation of any health policy formulation cannot be erected without an evaluation of current health status and health conditions and an assessment of the relation between current status and conditions, on the one hand, and behavioral and social and economic determinants on the other. The latter is a crucial input for reliable and robust forecasts and projection of the short and medium run of the magnitude and nature of the health demands of older persons.
The Pan American Healh Organization has proposed a study will be carried out in the following seven urban areas: Bridgetown (Barbados); Santiago (Chile); San Jose (Costa Rica); Mexico City (Mexico); Havana( Cuba); San Paulo (Brazil); Montevideo (Uruguay). These are all large urban centers in countries representing a broad spectrum of demographic regimes and institutional contexts. Barbados, Uruguay and Cuba are countries experiencing gradual and ‘early’ aging in the Latin American context whereas Chile and Costa Rica will do so slightly later, and Brazil and Mexico represent examples of demographic regimes with more sudden but ‘late’ aging. Similarly, these countries represent a fairly broad population of ‘institutional contexts’, from one totally relying on the role played by central governments to those where support for the elderly is virtually all in the hands of families and private enterprise. This proposal was prepared by Alberto Palloni, Center for Demography and Ecology, University of Wisconsin-Madison and Martha Peláez, Regional Advisor, Aging and Health. With contributions by Eduardo Arriaga and Kevin Kinsella, of the U.S.Census Bureau.
Source: Division of Health and Human Development, Research Coordination program, HDP/HDD, PAHO.
Return to issue index
Index of Online Bulletins
