OXFORD INSTITUTE OF AGEING Oxford Institute of Ageing Health Systems, HIV/AIDS and the Development Agenda in sub-Saharan Africa: Implications for Ageing

OXFORD INSTITUTE OF AGEING

Oxford Institute of AgeingOxford Institute of Ageing

Health Systems, HIV/AIDS and the Development Agenda in sub-Saharan

Africa: Implications for Ageing Populations

Dr Isabella Aboderin

Oxford Institute of Ageing

University Of Oxford



Outline of Presentation

• Background: HIV/AIDS and older persons in sub-Saharan Africa (SSA)

• Health systems: Central role in mediating or underpinning impacts of HIV/AIDS on older people

• Pathways • Recommendations



Background: HIV/AIDS and older people in SSA

• SSA is the epicenter of the worldwide HIV/AIDS crisis. Home to 63% of all adults and children with HIV globally. (24.7 million in 2006)

• AIDS disproportionately kills adults in the ‘prime’ of their lives.

Key Impacts:• Societal level: loss of human capital, labour productivity erodes

capacity for economic growth

• Family level: affects well-being and life chances of all generations



Background: HIV/AIDS and older people in SSA

• Rising international focus on impacts of HIV/AIDS on older persons (e.g. Valetta Declaration,Research Network on HIV/AIDS and the Elderly)

Focus on:• Older persons as carers of sick, orphaned or vulnerable kin (especially

children and grandchildren)• Loss of intergenerational support from younger generation kin• Older people themselves infected with HIV/suffering from AIDS



Health systems: central role

• These impacts hinge on (are underpinned or mediated by) the present functioning of health systems

• Also giving rise to additional indirect impacts of the HIV/AIDS epidemic on older persons

• Impacts linked to three key features of health systems: – Limited resource capacity – Core agendas and priorities for deploying health resources – Specific foci of HIV/AIDS related health programmes



Health systems: limited resource capacity

• Health care delivery dysfunctional in most SSA countries following years of debilitating under-investment (in large part due to World Bank/IMF structural adjustment programmes)

Expressed in dismal survival indicators: • Life expectancy at birth in 2005 was 46.7 years—lower than in 1975

• 1 in 10 babies die before the age of 1 year; almost 2 in 10 die before

the age of 5 years (UNDP, 2006; WHO, 2006)



Health systems: limited resource capacity

• Central problem: extreme lack of financial and human resources



Health systems: lacking financial resources • Per capita government expenditure on health ($) per year• At least $34 needed to achieve essential public heath interventions

Nigeria 6

Ghana 5

Kenya 8

Zimbabwe 14

Uganda 5

Belgium 1,880

UK 2,081

US 2,548Source: WHO, 2006


Oxford Institute of AgeingOxford Institute of Ageing Health systems: lacking human resources

• Human resource ‚crisis‘ – severe shortage of physicians and nurses (brain drain, rising demand)

Doctors (per 1,000) Nurses (per 1,000)

Nigeria 0.28 1.7

Ghana 0.15 0.9

Kenya 0.14 1.14

Uganda 0.08 0.61

Belgium 4.49 5.83

UK 2.30 12.12

US 2.56 9.37

Source: WHO 2006



Health systems: lacking financial and human resources

• In worst hit countries, resource constraints exacerbated by HIV/AIDS: numbers seeking HIV-related care adding pressure on services

• HIV/AIDS treatment more costly than treatment for other diseases

• AIDS illness and death among health workers (e.g. Botswana lost 17% of health staff to AIDS between 1999-2005)

• Stress and low morale migration of health workers to OECD, Middle East, other SSA countries with lower HIV/AIDS prevalence



Health systems: core agendas

• In recent years emergence of key international agendas to enhance

health and/or health systems in SSA: – UN Millennium Development Goals (2000) – Abuja Declaration of Leaders of African Countries (2001) – 2002 NEPAD Health Strategy (2002)– Commission for Africa Recommendations (2005)

Pledges for increased health spending: African countries 15% of annual countries; Donor nations 0.7% of GNP (largely not yet met)



Core priorities

• Crucially, agendas also set the priorities for deploying the resources that are available

• Highest Priority: Fight against HIV/AIDS, Tb and other infectious diseases (MDG 6)

• Economic Rationale: Tackling HIV/AIDS, Tb enhanced human capital, labour productivity, educational attainment to lead to economic growth (WHO, 2006, ILO, 2006)

• •



Specific foci of HIV/AIDS related health programmes

Set by: • UN Declaration of Commitment on HIV/AIDS & the MDGs (2001)

Top four programme priorities:1. Prevent HIV infection esp. among the young (15-24 yrs)

2. Stop mother to child transmission

3. Provide treatment to all those infected

4. Provide care to all whose lives are devastated by AIDS, esp. orphans



HIV/AIDS programmatic foci in practice

1. Expansion of Anti-Retroviral Treatment (ARV) (reduces complications, prolongs life, stops mother-child transmission)

2. Voluntary Counselling and Testing (VCT)

3. Support to families affected by AIDS, esp.orphans

(e.g. Child support grants, Community Home-Based Care initiatives)

• Explicit and implicit focus on children and reproductive ages (15-49 yrs)



Health systems impacts: pathways

• We can identify four key pathways through which these key features of health systems mediate or cause the impacts of HIV/AIDS on older people

• Impacts on present and future cohorts of older people



Impacts 1: Neglect of HIV/AIDS among current cohorts of older people

Limited finacial and human resource

capacity (exacerbated by HIV/AIDS)

Specific foci of HIV/AIDS

programmes (focus on the young)

Little provision for HIV/AIDS prevention/treatment among older age groups (50+ years) Yet, estimated 5%-7% are HIV+; observed mortality from AIDS among women 50-64 yrs, South Africa (Knodel et al. 2003; Kahn et al. 2006)

Health Systems: Impacts on current cohorts of older people:



Impacts 2. Creating extra care burdens for current cohorts of older people


capacity (exacerbated by HIV/AIDS

Specific foci of HIV/AIDS

programmes (i.e. ARV,

prevention etc. )

Little service provision for (terminal) care of AIDS sufferers: extra care burden on older

people, little support (e.g. information, material, practical)

physical and emotional strain (WHO, 2002; Ferreira, Keikelame & Mosaval, 2001; Knodel et al. 2003)



Oxford Institute of AgeingOxford Institute of AgeingImpacts 3. ‚Crowding out‘ service provision for age-related non-

communicable disease (NCD) among current cohorts of older people



Core Priority: fight against AIDS

(MDG 6)

Little, if any, service provision for: Management /prevention of the key conditions affecting older people: age- related NCDs (hypertension, stroke, diabetes, osteo-arthritis, visual impairments) and resulting impaired functional ability Yet: rising NCD prevalence and mortality among older age groups (WHO, 2006; Kahn et al.2006)



Oxford Institute of AgeingOxford Institute of AgeingImpacts 4: Crowding out service provision for prevention of NCDs among

future cohorts of older people



Core Priority: fight against AIDS

(MDG 6)

Little (no) service provision for: Prevention of NCD development among current cohorts of younger people Yet, such prevention is critical: risk of NCDs is influenced by factors over the whole life-course (Aboderin et al. 2001)

Health Systems: Impacts on future cohorts of older

people:



Age

Source:Aboderin, Kalache et al., 2002

PA: physical activity SEP: socio-economic position

Accumulated

Risk(Range) D

evelo

pm

en

t of

NC

D FetalLife

Adult Life Adolescence Infancy &Childhood

SEP,diet,obesity,lack of PA,diseases,growth rate

SEP,dietobesitylack of PAsmoking

SEP,established adult behavioural/biologicalrisk factorsSEP;

birth weight,maternal nutrition status

high

low

Life course and risk of CHD, stroke and diabetes



Recommendations

• Efforts to address the impacts of HIV/AIDS on present and future cohorts of older people must focus on enhancing health systems

• Efforts need to hinge on:

B



Recommendations

1. Expansion of current HIV/AIDS programmatic foci to include:• HIV/AIDS detection and treatment among age groups 50+• Adequate support (education, material, practical) to home-based care

for AIDS sufferers



Recommendations

2. Expansion of core priorities beyond MDG 6 (5,4) to include affordable measures to address NCDs :

• Primordial prevention: reduce exposure to risk-inducing environments

(e.g. control sale/marketing of tobacco, alcohol, unhealthy foods)

• Primary Prevention (among children, youth, adults) (health promotion to encourage healthy lifestyles, possibly integrated with HIV/AIDS programmes)

• Management/secondary prevention of NCDs among older adults

(Examples of successful low-cost programmes exist (WHO, 2006))



Thank you

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OXFORD INSTITUTE OF AGEING Oxford Institute of Ageing Health Systems, HIV/AIDS and the Development Agenda in sub-Saharan Africa: Implications for Ageing