HelpAge International, PO Box 32832, London, N1 9ZN, UK. E-mail: mgorman{at}helpage.org
In an increasingly globalized world, many issues once seen as exclusive either to developed or developing countries are becoming the shared experience of both. One such issue is that of the demographic transition of the late 20th century, the major feature of which has been accelerating population ageing in all countries, rich and poor. Awareness of this transition is growing, albeit at varying rates. In countries whose populations already include significant numbers of older people, questions affecting old age are already high on policy agendas. In countries yet to experience the full force of demographic changes these questions still have a lower priority. However, some common themes between North and South are already beginning to emerge strongly. These concerns include the potentially rising costs of social welfare that are seen to be associated with older populations. The capacity of public pro-vision to support such costs is being questioned. Consequently there is increasing emphasis on identifying what are seen as cost-effective measures, such as enhancing the caring capacity of families and communities, asserting the responsibility of individuals to make provision for their own old age, and drawing on collective support for older people from civil society institutions, including non-governmental organizations (NGO).
In such a context this article examines the roles of NGO particularly in the newly-ageing countries of the South. It seeks to illustrate some of the ways in which NGO are responding to the demographic transition and to policy change relating to ageing societies, by moving beyond narrowly defined service delivery roles, to become advocates for policy change.
Demographic transition, implications and responses
The 20th century witnessed a historic demographic transition. Societies have been experiencing rapid declines in both fertility and mortality, and the pace of these changes has been gathering over the past 100 years. In France for example, it took just over a century for the percentage of the population over 65 to double (from 7 to 14%). In Japan the same growth has taken just 25 years.1 Older populations are expanding at a rate unprecedented in human history, and at the beginning of the 21st century there is a reasonable expectation that most newly-born children in most countries will live into old age. Not only have there been gains in life expectancy at birth, but at all ages thereafter, including old age itself. The global net balance of older people is increasing by about one million people a month, of whom two-thirds are living in the developing world.2
The first half of this century will see an acceleration of the growth of older populations, so that (according to the United Nations median variant projections) 19% of the worlds people will be aged 65 or more by 2050. While Africa, Asia and Latin America will still be the youngest continents; they will have substantial older populations. Latin America and Asia will have higher proportions of over-65s than Europe and North America have today. Even Africa, the youngest region of all, will have reached the same level of older people as Europe had in the mid-20th century.3
A number of features of the ageing transition are relevant to this discussion. Older people are as diverse socially, culturally and economically as other age groups, but with notable distinguishing features. One distinctive feature is the greater longevity of older women in nearly all countries. Since women tend to live longer than men, and to marry younger, the prospect of widowhood in old age is increasingly strong. However, this advantage is offset by the greater risk for women that they will suffer from chronic disease. Lifetimes of under-nutrition, starting from childhood, multiple pregnancies and hard physical labour combine to ensure that many women in the worlds poorest countries enter old age with multiple chronic ailments. The rate of growth of the oldest-old, over 80 years of age, is increasing fastest of all, in all parts of the world.
There is great diversity not only at individual but also at population level. In the countries of the developed world greater longevity is by and large the result of improved living standards resulting from (for example) rising income, better housing and better nutrition. In much of the developing world, by contrast, the years that have been added to life have largely been the outcome of advances in medical technology, in the absence of social and economic development.4
Meanwhile, particularly in many resourcepoor countries, there is a fierce debate over the capacity of communities, families and individuals to provide care for themselves and their older members. Arguments over family breakdown have continued for over three decades, and whatever the merits of the case it is clear that family and community support is under severe stress, particularly in poor countries. Public policy responses have also been piecemeal and unstrategic, attempting to answer immediate problems rather than looking at the longer term. Policy thinking is still largely predicated on assumptions of very different age structures, emphasizing early years education, adult employment and assuming retirement phases which (if they exist at all) are relatively brief. In all countries, but particularly the poorest, resource allocation is the subject of fierce competition. At the same time the ideological challenges from international institutions to public welfare expenditure have been sustained during the last decade.5
Policy debate has therefore increasingly begun to include consideration of the roles in old-age support of formal collective provision beyond the state. Civil society including NGO as well as other collective institutions such as community groups, faith organizations and the private sector, have been increasingly invoked as providers of late-life support.6
The non-governmental organization role
While there is a large NGO sector active in the field of ageing in countries where demographic transition is already advanced, in the developing world the number of organizations is much smaller. Non-governmental organizations working with older people have tended to focus quite narrowly on a welfare role, deriving from the origins of many of the older organizations in charitable institutions, including religious orders. Those founded in recent years have continued to see themselves primarily or solely as service providers to older people in need. In many cases these NGO share a view of ageing as problematic, a time of increasing difficulty compounded by social and cultural change, particularly the set of phenomena collectively referred to as modernization. These include perceptions of family change (notably the decline of the extended family) as well as of changing cultural values, which are seen as leading to the social and economic marginalization of older people. Responses to these problems have therefore emphasized approaches which meet the perceived needs of individuals or small groups of elders at a local level. In developing countries this has often taken the form of work which substitutes for inadequate or non-existent public services, most characteristically residential, domiciliary or day care for frail older people. Other services include basic health provision, and development of income-generating or credit schemes for older people and their families. These activities tend to be relatively small-scale, urban-based projects, operating on short-term and/or precarious funding.
Modernization theory as it relates to old age has been subjected to serious critical scrutiny in recent years. This has challenged its universal typology of social change, in positing a pre-modern before and correlating the status of older people with industrialization.7 It has been argued, for example, that any loss of status on the part of older people is more likely to have been linked to ingrained structural inequalities experienced by most people in most developing countries in earlier life. Impoverishment in old age may be a common cross-cultural experience of the ageing process, rather than simply resulting from modernization.8 However, such challenges have been slow to permeate the thinking of NGO in the developing world.
Nevertheless, since the early 1990s a body of work has developed which implicitly draws on the critique of modernization theory in seeing older people not merely as passive recipients of services, but as actual or potential actors in the process of their own development. This implies an understanding that deprivation in old age is not a product of cultural or moral change, but of structures and rules by which societies govern the position of older people, in particular creating barriers to the participation of those who are poor and disadvantaged by specific status, notably widowhood. Such understanding is reflected in, for example, the growing body of experience in context-bound participatory research linked to policy development. Participatory approaches are aimed at eliciting the perspectives of poor people in order to deepen the understanding of poverty, and are increasingly included in research aimed at influencing policy and policy delivery frameworks.9
In relation to ageing a body of expertise has grown up, starting with the work of HelpAge Kenya and HelpAge International in the early 1990s, which has now begun to influence a small but increasing number of governments to employ such approaches to compliment more quantitative research in the formulation of policy on ageing. (HelpAge International has supported participatory-based research studies in, inter alia, Cambodia [1997], Tanzania [1998], Ghana and South Africa [1999], Mozambique [2000], and Vietnam [2001].) Participatory approaches enable older people to express their concerns and participate in activities to address them (not only at community level but also in engagement with policy makers). These processes have the capacity to raise awareness within communities regarding rights and issues of social exclusion and can be an empowering experience for older people, leading to meaningful change.10
Such involvement of older people in problem-solving research and development activities implies the encouragement of partnerships with organizations to further the involvement of older people in community-level action. Again however, NGO working in ageing have been relatively inactive in this area. This may be seen in part as a function of their own relatively disadvantaged position, viewed by other organizations as having a welfare rather than a development approach. Out of the mainstream of development thinking and activity, NGO working with older people are isolated from the contacts that would nurture learning and exchange.
Yet there is important learning to be gained by such contact. For example, there are instructive experiences from NGO working with people with HIV and AIDS in fighting discriminatory practise, such as isolation and stigmatization of sufferers. In the early 1990s these NGO successfully developed and promoted at international forums a concept of the right of people with AIDS to community support. This principle is being upheld by innovative community-level education programmes, including HIV/AIDS awareness training for older midwives in East Africa. Likewise, the rights of older people to community support need to be promoted with other issue-based organizations and across sectors. There is a strong case for reversing the often held view that older people, particularly those who are poor and frail, are a burden to their communities. As a starting point, discriminatory practices by some of these same organizations have been challenged, for example the consistent refusal of local-level officials in micro-credit organizations to make loans available to older people. (At such points direct advocacy can achieve a positive response. Recent HelpAge International lobbying of BRAC, a Bangladeshi NGO specializing in micro-credit, has led to a change in their age-restriction policy.)
For rights-based approaches at community level to take hold and have significant impact they need (as shown by the examples of NGO working in fields such as HIV/AIDS and disability) to be increasingly supported by NGO at all levels. Again progress has so far been slow. However, there are some examples of effective NGO activity. In 1996 NGO working in Bolivia for example, helped to achieve the passage of a law recognizing the rights of older people and launched a national programme for their legal protection and support, including the payment of a non-contributory annual lump sum pension. Whilst such national law can uphold rights and promote good practice, resources will continue to be contested at various levels. Thus NGO increasingly need to monitor policy implementation. National policies already exist in some countries for example, such as free medical care for older people, that fail to take effect because of poor communication, implementation and enforcement structures.11 A developmental approach, based in a human rights perspective, will need to go beyond welfarist orientations in promoting awareness and protecting legislation. Enabling older people to participate fully in this process is thus a priority.10
Non-governmental organization response to policy change should also take account of the international policy agenda. The international debate involving ageing more or less directly has taken place in three separate, hardly overlapping arenas, in the past 20 years.
Firstly there has been the discourse framed by the United Nations 1982 World Assembly on Ageing. This extension of the archetypal gerontological conference named old age as a problem ... inculcating the need for a uniform response among the ignorant.7 Its outcome was an International Plan of Action on Ageing (the Vienna Plan), framed as a set of universal recommendations for government action, which have proved far beyond the means of most countries in the developing world to fulfil. Non-governmental organizations were accorded little or no role in the implementation of the Vienna Plan. A Second World Assembly is planned for 2002. Significant developments have taken place in the structure of the UN in the intervening 20 years, and the Group of 77 developing countries will not permit the kind of universal approach which emerged from Vienna. However, it remains to be seen whether the next plan (or Strategy, as it will be called) will do more than subdivide ageing problems into those affecting the developed, developing and transitional countries, respectively. Non-governmental organizations have belatedly begun to recognize the opportunities for involvement in the debates leading to the Assembly and the event itself. Action to try to influence government delegations is however limited by NGOs lack of familiarity with national level decision-making and the UNs own processes.
A second arena for policy development in the last decade has involved NGO even less. This has revolved around the wide-ranging debate over social security reform with which nearly all developing countries have been engaged. For older populations, the key focus has been the debate over pension reform that the World Bank has largely monopolized since the publication of its study Averting the Old Age Crisis. The study names income security in old age [as] a worldwide problem and states that the challenge is to move forward systems of income maintenance without accelerating the decline in informal systems and without shifting more responsibility to government than it can handle.12 The World Banks diagnosis and its prescription for pension reform have not gone unchallenged,13 and there is vigorous debate as to the appropriate roles of public and private provision of old-age social protection. The point to make here is that the NGO sector has up to now played little or no role in this dialogue.
The third policy arena in which ageing has begun to play a role is that occupied by the wider development debates, those concentrating on the core development issues, on issues such as poverty, health, gender, the environment and the like. Here the NGO lobby on ageing, so conspicuous in other development debates, has been notably absent. The International Development Targets, benchmark indicators set for development progress by the Copenhagen Social Development Summit of 1995 and modified by the General Assembly at the Millennium Summit, make no mention of ageing as an issue, and there has so far been little discussion or inclusion of ageing as more than a peripheral issue on the margins of the main debates.
The disconnections between these three arenas for policy discourse are not of course simply the result of a collective failure of the NGO working on ageing issues. Relatively little progress has been made in linking the various elements of the growing global debate on ageing by dialogue between international organizations such as the United Nations and the International financial institutions, notably the World Bank. Academic gerontology and academic development studies have been, to a large degree, mutually exclusive disciplines. National level policy making rarely achieves the degree of integration called for by the encompassing experience of ageing.
In this context it is not feasible to expect a small and under-resourced NGO sector to make the necessary connections between all these policy arenas. The challenge for NGO in ageing is to build on the experience they have derived from their substantial body of knowledge and experience in direct work with older people. They need to go beyond the immediacy of service delivery to make the necessary causal links between the reality of their experience of older peoples poverty at community level and the wider policy agendas of which old-age poverty is one outcome. They need to learn the vocabulary of policy making, to understand the ways that ageing, which has been described as one of the great architectural issues of this century14 can be inserted into the policy agendas of governments and international organizations. Non-governmental organizations need to forge better links not only among themselves, but also with organizations working in related fields, many of whom have relevant experience to offer. They also need to make connections with the growing number of academics working on gerontological issues in the developing world, and to raise the awareness of those in development studies who as yet have had little exposure to ageing issues. This is a substantial and ambitious programme.
References
1 World Health Organization. Population Ageing: A Public Health Challenge. Geneva: WHO, 1998. http://www.who.int/inf-fs/en/fact135.html
2 International Programs Centre. An Aging World II. Washington DC: US Bureau of the Census, 1993.
3 United Nations Population Division. World Population Prospects: The 2000 Revision. New York: UN, 2000. http://www.un.org/esa/population/publications/wpp2000/wpp2000h.pdf
4 Sen K. Ageing. Debates on Demographic Transition and Social Policy. London: Zed Books, 1994.
5 Wilson G. Globalisation and support in old age. Educ Ageing 2001; 16:12134.
6 United Nations Commission for Social Development. International Strategy for Action on Ageing. New York: UN, E/CN.5/2001/PC/L, 9 August 2001. http://www.un.org/esa/socdev/ageing/waa/isaa1e.htm
7 Cohen L. No Aging in IndiaAlzheimers, the Bad Family, and Other Modern Things. Berkeley, CA: University of California, 1998.
8 Sen K. Ageing, Health, Social Change and Policy in Developing Countries. London: London School of Hygiene and Tropical Medicine, 1993.
9 Holland J, Blackburn J. Whose Voice? Participatory Research and Policy Change. London: Intermediate Technology Development Group (ITDG), 1998.
10 Heslop A. Ageing and DevelopmentWorking Paper 3. London: Department for International Development, Social Development Department, 1999.
11 Gorman M. The Ageing and Development Report: Development and the Rights of Older People. London: Earthscan Publications Ltd, 1999.
12 World Bank. Averting the Old Age Crisis. New York: Oxford University Press, 1994, pp. 45.
13 Charlton R, McKinnon R. Pensions in Development. Aldershot: Ashgate, 2001.
14 United Nations. Way Must be Found to Utilize Vast Contributions of Older Persons Preparatory Committee Told. New York: UN Press Release, February 2001. http://www.un.org/News/Press/docs/2001/soc4570.doc.htm