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Albert Einstein famously said that, “I have reached an age when, if someone tells me to wear socks, I don’t have to”. Einstein’s observation conjures up images of older age as a time of serenity and fulfilment where social contract obligations have been met through pensions and high quality health care provision. It is a wonderfully aspirational state – but one which also reminds us that there are huge challenges for older people, not only in the UK, but, perhaps more urgently, for those living in so-called low- and middle- income countries

Recent research is disturbing. A number of papers have provided much needed insights into issues related to ageing populations in sub Saharan Africa and have underlined the need for action if an old age ‘time bomb’ is to be prevented from exploding. For once, the emotional language and calls for global attention might actually be underestimating the case for action. 

The world’s population is ageing rapidly, even in low- and middle-income countries where the overwhelming focus of ‘development’ has been on young people of mainly reproductive age. This has tended to defocus attention away from dependent older people (aged 60 and over), which is troubling when one considers the fact that the number of older people is predicted to rise in sub-Saharan Africa, from 46 million in 2015 to 157 million by 2050.

Also currently, if a woman reaches the age of 60, she can expect to live 16 more years (14 for a man), which suggests that, for those who have reached 60, old age is indeed already a reality. 

In focusing much of ‘development’ on the needs of the relatively young, attention has been diverted away from recognising the role older people play in helping the young to achieve their potential. Research has shown the important role which older people play as carers and guardians of the young, as well as how they shape access to health, education, and livelihoods. Caregiver roles performed by older people are even more important within the context of illnesses such as HIV-AIDS, TB, and malaria. Beyond the family, older people play a vital role in the economy of all countries across sub-Saharan Africa, largely in the context of remaining in the labour force as smallholder farmers, without which it is difficult to see how ‘food security’ can be secured throughout the region. 

Whether in the family or the wider economy, older people can only execute these “essential functions” if they have the physical and mental capacities to do so. However, a vicious cycle can often be created within families if these functions fail and other family members (often women) have to dedicate time and other scarce resources to care for them. This is a real issue for carers whose older relatives and friends face challenges such as cardiovascular and circulatory disease, nutritional deficiencies, cirrhosis of the liver, and diabetes, as well as hypertension, musculoskeletal disease, visual impairment, functional limitations, depression, and dementia (all of which create complex needs over time). 

A key challenge lies in the age-based inequality related to health care across sub-Saharan Africa, as older people tend not to access it as often as younger people do. Many reasons have been put forward for this, with the most common suggesting the absence of an escort to travel with, the relatively high cost of transport, and the fees charged for treatment and medication – even when health care is supposed to be free at the point of delivery. Pivotally, older people are also often aware that many health facilities are tailored towards the needs of the young. 

Given the social and economic role which older people play throughout sub-Saharan Africa, there is a clear need for enhanced recognition of their physical and mental health needs. Greater attention needs to be given to policy frameworks which balance the prevention of early mortality with the provision of chronic care for key non-fatal conditions which impact on older people. Pensions and health insurance schemes are also important in this regard. This reflects the fact that families (seen as the central pillar of care and support to the old) might be increasingly less able to cope with the challenges associated with ageing as ‘modernity’ takes hold. Governments (through policy frameworks and funding channels) must, therefore, be able to keep up with sociodemographic and social change. This has not, however, always been the case, and remains deeply problematic across the region. 

These insights have come with calls for more research into the better definition of health needs for older people, and care gaps, as well as the identification of practical ways in which to adapt and bolster sub-Saharan health systems through the development of ‘priority interventions’, such as the Integrated Care for Older people framework pioneered by WHO. 

Unusually, but positively, the ICOPE guidelines do not target a single disease, which tends to be the modus operandi of many development initiatives. Instead, ICOPE has developed a set of guidelines for dealing with the many complex problems associated with older age and has been designed for use by non-specialist health professionals in primary health care settings – something akin to the mental health guidelines currently being used in low- and middle-income countries. As many of the challenges facing those in old age are cognitive in nature, it will be interesting to see where the connection points are between these two important initiatives. A pilot programme in India has shown the efficacy of ICOPE and it is to be hoped it will be adapted and rolled out across sub Saharan Africa over time. 

Given the fact that many sub Saharan Ministries of Health aim for people to live ‘longer and better’, the challenges of ageing populations are not going to go away. If RSA Fellows are interested in raising awareness of the key challenges as well as exploring how 21st century enlightenment can help to address them, please contact me at


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