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Aging in Sub-Saharan Africa: Recommendations for Furthering Research Part I Report
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research 1 Aging in Sub-Saharan Africa: Recommendations for Furthering Research Economic security, health and disability, and living conditions in old age are policy concerns throughout the world, but the nature of the problems differs considerably from continent to continent and between and within countries. In industrialized countries, old age support comes to a great extent from large public or private pension and health systems. These systems are becoming increasingly strained as population aging has increased the proportion of older people. At the same time, in much of the industrialized world (Russia being a major exception), the health of the older population is, at a minimum, remaining steady and, in many places, it is improving rapidly. By contrast, throughout most of the developing world, providing support for older people is still primarily a family responsibility. Traditionally in sub-Saharan Africa,1 the main source of support has been the household and family, supplemented in many cases by other informal mechanisms, such as kinship networks and mutual aid societies. With the notable exceptions of Botswana, Mauritius, Namibia, and South Africa, formal pensions (whether contributory or not) or other social welfare schemes are virtually nonexistent and, when they do exist, tend to pay minimal benefits and cover only a small fraction of the elderly population (Gillian, Turner, Bailey, and Latulippe, 2000). Population aging is only beginning and, because fertility is falling, it is occurring during a temporary phase of declining dependency 1 Unless otherwise specified, “Africa” refers to sub-Saharan Africa throughout this chapter.
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research burdens (see the paper by Velkoff and Kowal in this volume). Older people make up a relatively small fraction of the total population, which is expected to increase slowly, although their numbers are increasing rapidly. There are also major differences in the principal health challenges in sub-Saharan Africa compared with industrialized countries. In much of sub-Saharan Africa, gains in life expectancy that were achieved throughout the latter half of the 20th century have been eroded by the HIV/AIDS pandemic (see Chapter 2). Yet little is known about the health and disability of older people and patterns of change. In addition, traditional caring and social support mechanisms now appear to be under increasing strain (Apt, 1996; Dhemba, Gumbo, and Nyamusara, 2002; Kasente, Asingwire, Banugire, and Kyomuhenda, 2002; Mchomvu, Tungaraza, and Maghimbi, 2002; Mukuka, Kalikiti, and Musenge, 2002; Williams, 2003; Williams and Tumwekwase, 2001). Reasons for this strain include a series of profound economic and social changes associated with development and modernization. In sub-Saharan Africa, older people have traditionally been viewed in a positive light, as repositories of information and wisdom. To date, sub-Saharan African families have shown a great deal of resilience and are generally still intact. Changes associated with development and modernization can, however, combine to weaken traditional social values and networks that stress the important role of older people in society and that reinforce traditions of intergenerational exchange and reciprocity. These changes include increasing formal education and the migration of young people from rural to urban areas, leaving older family members behind. Far more is known about the impact of these changes in other regions of the world, particularly Asia (see Hermalin, 2002), compared with sub-Saharan Africa. Yet their effects pale, in parts of sub-Saharan Africa, in comparison to the effects of the HIV/AIDS pandemic. Sub-Saharan Africa has long carried a high burden of disease, including from malaria and tuberculosis; today it remains at the center of the HIV/AIDS pandemic. The Joint United Nations Programme on HIV/AIDS and the World Health Organization estimate that more than 60 percent of all people living with HIV are in sub-Saharan Africa—some 25.8 million in 2005 (Joint United Nations Programme on HIV/AIDS, 2006). The lives of older people may be affected by their own illness, but it is more likely, given the age structure of the pandemic, that they are affected by sickness and death of their adult children. Not only do these older people face the loss of a child or children who may well have been a vital source of support and caregiving, but many are also then faced with additional obligations and responsibilities for grandchildren and other members of their extended families.
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research Finally, AIDS and other social changes are occurring against a backdrop of persistent poverty and deprivation. Sub-Saharan Africa remains the least developed and least urbanized region in the world. Approximately two-thirds of the population of sub-Saharan Africa still live in rural areas and rely largely on near subsistence agriculture or traditional pastoralism for their livelihoods. In such settings, families have to be very self-reliant. Chronic poverty becomes a critical risk factor for the well-being of older people, and more than two of every five of the continent’s inhabitants remain trapped in debilitating poverty (United Nations, 2006). In addition, while the continent has witnessed a decline in the number of armed conflicts since the early 1990s, persistent violence and in some cases seemingly intractable conflicts compound the region’s problems and present critical obstacles to development in some countries (Marshall and Gurr, 2005; Porter, Robinson, Smyth, Schnabel, and Osaghae, 2005).2 Researchers in sub-Saharan Africa are only now beginning to ask how all of these factors—trends in socioeconomic conditions, changing cultural norms and values, changing levels of formal and informal social support, ongoing poor health conditions, and the AIDS crisis—are combining to affect the well-being of older people. African gerontology has expanded in recent years, much of the work based on anthropological approaches (see, for example, Makoni and Stroeken, 2002). Elsewhere—in Europe and Asia, for example—major research programs focused on older people are under way, and longitudinal studies now provide a great deal of information on economic well-being, health, and family processes (see, for example, Börsch-Supan et al., 2005; Hermalin, 2002). Comparable efforts are only beginning in sub-Saharan Africa; instead, much of what is known today comes either from censuses, which often are not particularly reliable or particularly detailed, or from small cross-sectional surveys, which often suffer from problems of nongeneralizability.3 2 According to the most recent Global Internally Displaced Persons Survey, there are currently more than 12 million such persons in Africa (Internal Displacement Monitoring Center, 2006). In addition, at least 3 million refugees have fled their own countries to seek refuge in neighboring countries (United Nations High Commission for Refugees, 2006). 3 The World Health Organization included 18 sub-Saharan African countries among the 72 in which World Health Surveys (WHS) were conducted in recent years (see Üstün et al., 2003). Data from these surveys are expected to be available shortly after the publication of this report. A further effort, the WHO Study on Global Aging (SAGE), is under way in six countries, two of which (Ghana and South Africa) are in sub-Saharan Africa. SAGE is planned to follow up respondents to the WHS over a 5-10 year period in order to, among other goals, study the determinants of health and health-related outcomes (see http://www.who.int/healthinfo/systems/sage/en/index3.html).
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research WORKSHOP ON AGING IN AFRICA It is against this backdrop that in 2004 the National Institute on Aging asked the National Academies’ Committee on Population to organize a workshop on advancing aging research in Africa. The workshop was to explore ways to promote U.S. research interests in aging in developing countries and to increase the capacity of sub-Saharan African governments and institutions to address the many challenges posed by the changing position of older persons in an era of AIDS. The workshop provided an opportunity for leading scientists from a variety of relevant disciplines to come together and review the evidence on economic security, health, and living conditions of older people and the ways in which critical changes are affecting their well-being. The Committee on Population appointed an eight-member panel comprised of U.S. and African researchers. The panel had two charges: to develop the two-day workshop and to identify, subsequently, a research agenda aimed at gathering new data that would enable policy makers to better anticipate existing and changing needs of older people and to better assess the viability and potential impact of various public policy options. In advance of the workshop, the panel commissioned 12 papers by prominent researchers to gather together recent research findings relevant to the goals of the workshop. These papers covered important domains of research on aging, including the changing demography of sub-Saharan Africa (Velkoff and Kowal), demographic impacts of the HIV epidemic on older people (Clark, Merli and Palloni, and Hosegood and Timaeus), formal and informal social security systems (Kaseke), health (Kahn et al., Kuhn et al., and Kuate-Defo), measurement (Kuhn et al.), the impact of social pensions (Lam et al. and Posel et al.), the situation of older people in urban areas (Ezeh et al.), living arrangements (Kuate-Defo and Ezeh et al.), and policy (Peachey and Nhongo). The primary focus of the workshop was to present and discuss recent studies using high-quality data from the region on the situation of older people. Selected papers from the workshop were revised and edited for inclusion in this volume. The workshop also included a focused discussion on data needs and future research directions. Thus, the principal inputs into this report are the panel’s interpretation of the literature consulted,4 the presentations of the commissioned papers, and the rich interactive discussion that occurred at the workshop. 4 This report is not intended to be an exhaustive literature review of the entire field of aging. Rather it draws on a selected subset of the literature that relates to the material covered by the workshop papers and additional literature known to the primary authors of the report.
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research KEY THEMES Five key themes emerged from the panel’s original planning meeting, the workshop papers, and the workshop discussion. The first is the lack of basic, agreed-upon definitions crucial to the study of aging in sub-Saharan African societies. Most fundamentally, who is elderly in sub-Saharan Africa? Do the definitions used in industrialized societies have the same meaning for sub-Saharan Africa? And, in the African context, with its complex and extended family structure, what constitutes a household, the usual unit in which older people are studied (van de Walle, 2006)? Research can adequately assess the situation of older people in sub-Saharan Africa only if it is conducted in a framework that can allow for a full range of actors and impacts on the well-being of older people. A second theme and persistent lament throughout the workshop is the lack of careful empirical research and the dearth of comprehensive data needed to rectify this situation. Third is the participants’ belief that the situation of older people in sub-Saharan Africa is changing fairly rapidly. Fourth is the need to recognize the considerable diversity across sub-Saharan Africa with respect to a wide range of indicators. The final central theme is the need to support the development of local research capacity and facilitate research. Each of these themes is amplified below. Definitions When asked who is old, participants in recent focus group interviews in Nairobi claimed that old people can be identified in a variety of ways: by their physical attributes or appearance (e.g., gray hair, wrinkles, obvious frailty), by their life experiences (e.g., their reproductive history), or by the roles that they sometimes play in their community (see the paper by Ezeh et al. in this volume). Consequently, chronological age—which in any event may not even be known in sub-Saharan Africa—may be a poorer indicator of being elderly than social standing. Chronological age may also differ markedly from functional age, which can be the most important dimension of aging in a rural subsistence agricultural context. In general, it is important to recognize that in some sub-Saharan African settings, people who are younger than 60 may be considered old because they exhibit morbidity profiles and take on status roles more usually associated with people over the age of 60 in other settings. Similar definitional problems surround the meaning of the term household (van de Walle, 2006). Due to the extended-family system, households are more likely to be larger, multigenerational, and less nuclear than in Western societies. For example, a recent study of household composition in Gabon found that about half of all households in Libreville and Port-Gentil
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research contained at least one guest who had some sort of kinship tie to the family but who did not belong to the nuclear family (Rapoport, 2004). A similar situation can be found in a large number of sub-Saharan African countries. Households can also be split across geographic locations, with families maintaining both a rural home and an urban home. This situation frequently occurs when households decide to allocate their labor resources between rural and urban areas in order to diversify risk, maximize incomes, or both (Agesa, 2004; Lucas and Stark, 1985; Stark, 1991, 1995). Sub-Saharan African family structures complicate the study of older people’s well-being, and basic definitional questions must be resolved before comparative analysis can take place easily. Lack of Data As stated above, research on aging in sub-Saharan Africa is still very much in its infancy. The current situation of older people in sub-Saharan Africa is, in fact, quite poorly known, and micro-level data are available only for a limited number of countries. The World Health Surveys and the follow-up Study on Global Aging (SAGE) will improve availability of data on health for some countries. Very little information is readily available for Francophone or Lusophone (Portuguese-speaking) Africa. In addition, the range of topics addressed at the workshop illustrates the need for multidisciplinary work that cuts across traditional research domains. In Asia, by contrast, a decade of in-depth and wide-ranging research on multiple aspects of peoples’ lives has generated considerable insight into the situation of older people in that region (see, for example, Hermalin, 2002), which may well be able to inform the design and implementation of similar research in sub-Saharan Africa (Knodel, 2005). The Changing Situation of Older People Despite the lack of longitudinal studies, many observers believe that older people are worse off than they were in the past. There are a number of reasons why this might be the case, although there is currently very little empirical research that documents whether older people are worse or better off on most measures of welfare. Three dimensions of change that have bearing on the well-being of older persons were repeatedly raised throughout the two days of the workshop: demographic change, modernization and development, and the impact of HIV/AIDS. Based on the demographic changes taking place, both the absolute size and the relative proportion of the population age 60 and over are projected over the next 25 years to grow faster than at all younger ages (Table 1-1,
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research TABLE 1-1 Demographic Indicators of Sub-Saharan Africa, Selected Years 1965-2030 1965 1985 2005 2030 Changea 1965-1985 1985-2005 2005-2030 Population (in thousands) 255,825 448,051 751,273 1,248,262 2.8 2.6 2.0 Under age 15 113,333 204,441 326,715 462,431 2.9 2.3 1.4 Age 60 and over 12,513 20,961 36,594 71,033 2.6 2.8 2.7 Age 80 and over 652 1,211 2,626 6,550 3.1 3.9 3.7 Percentage of the Population Under age 15 44.3 45.6 43.5 37.0 2.9 −4.6 −14.9 Age 60 and over 4.9 4.7 4.9 5.7 −4.1 4.3 16.3 Age 80 and over 0.3 0.3 0.3 0.5 0.0 0.0 66.7 Median Age 17.9 17.1 18 21.2 −4.5 5.3 17.8 Total Fertility Rateb 6.8 6.7 5.5 3.6 −1.9 −17.7 −34.0 Life Expectancy at Birthb 41.4 48.6 45.9 55.4 17.4 −5.6 20.7 Male 39.9 46.9 45.2 54.5 17.5 −3.6 20.6 Female 42.9 50.2 46.6 56.2 17.0 −7.2 20.6 Dependency Ratio 89.7 94.3 87.2 69.0 5.1 −7.5 −20.9 Child dependency 84.1 88.7 81.4 62.6 5.5 −8.2 −23.1 Old age dependency 5.7 5.6 5.8 6.4 −0.7 3.1 10.4 aChange figures represent the annualized growth rate per 100 people between population estimates and projections and the percent change among all other indicators. bEstimated for 5-year periods ending in the year indicated. SOURCE: United Nations (2005).
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research and see Chapter 2). The increase in the population age 75 and over will be particularly noticeable. Modernization and development have led to broad social and economic changes that put in doubt the continued viability of traditional arrangements for the care and support of older people. For example, formal education and modernization are generally associated with weakening traditional social ties and obligations and greater independence and autonomy, factors that tend to undermine traditional extended family systems. Similarly, economic development is associated with young people migrating from rural to urban areas, leaving older family members geographically isolated.5 Once established in urban areas, migrants tend to form new nuclear households. Although children may remit money and goods, such flows are typically irregular and may not be enough to provide much in the way of real economic security. These changes have combined to alter, probably permanently, the nature of the relationship between generations. The HIV/AIDS epidemic has severely affected many communities across sub-Saharan Africa, with multiple impacts on older people. The vast majority of the estimated 25.8 million people living with HIV are still in their prime wage-earning years—that is, at ages at which normally they would be expected to be not only wage earners but also the principal sources of financial and material support for older people and children in their families (Joint United Nations Programme on HIV/AIDS, 2006). There is a substantial amount of uncertainty about the future course of the pandemic. While some positive news about gradual, modest declines in HIV prevalence are emerging from East Africa and Zimbabwe, HIV prevalence has soared in Southern Africa in recent years (Asamoah-Odei, Garcia Calleia, and Boerma, 2004; Joint United Nations Programme on HIV/AIDS, 2006). In some antenatal clinics in urban areas of Southern Africa, HIV prevalence rates as high as 25 percent have been recorded, whereas they were only around 5 percent in 1990. Very high HIV prevalence—almost 40 percent of pregnant women found to be HIV positive—has been recorded recently in Botswana and Swaziland (Asamoah-Odei et al., 2004). Increasingly, because of the HIV/AIDS epidemic, older people are being asked to provide emotional and economic support both to their own children, the immediate victims of the HIV/AIDS epidemic, and to their grandchildren (Makiwane, Schneider, and Gopane, 2004; Nyambedha, Wandibba, and Aagaard-Hansen, 2003; Williams and Tumwekwase, 2001). While modernization theory has been the most prominent theoretical 5 For more information on cohort-specific rural-urban migration in Africa, see Becker and Grewe (1996).
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research framework used to explain the ongoing changes in family support to older people in Africa, some African gerontologists have criticized the theory, arguing that it is overly deterministic and simplistic (see, for example, Ferreira, 1999). Recently, contemporary African researchers have adopted alternative theoretical frameworks to better understand how ongoing economic and social changes are affecting older people. For example, some researchers have suggested an alternative explanation for a possible decline in material support for older persons: rising economic hardship (Aboderin, 2004; Nyambedha et al., 2003). Sub-Saharan Africa faces a greater set of development challenges than any other major region of the world, and, on average, income per capita is now lower than it was at the end of the 1960s (World Bank, 2006a, 2006b). Although the region’s per capita gross national income has grown at a rate of around 3 percent per year for the past two years, it still stands at only $600 per year. An estimated 516 million people in the region are forced to survive on less than $2 a day, and 303 million on less than $1 a day (World Bank, 2006a, 2006b). In contrast to such countries as China and India, where substantial progress has been made over the past 5 years in combating poverty, the number of extremely poor people in sub-Saharan Africa has almost doubled since 1981 (World Bank, 2005). Consequently, sub-Saharan Africa is home to a growing share of the world’s absolute poor (United Nations, 2006). Thus, rather than emphasizing weakening filial obligations, some researchers have argued that declines in support for older people may simply reflect a growing incapacity on the part of the younger generation (see, for example, Aboderin, 2004). Increasingly, it appears that sub-Saharan African societies are being asked to cope with population aging and a catastrophic health crisis with neither a comprehensive formal social security system nor a well-functioning traditional care system in place. Diversity Across the Region The second largest and the second most populous continent in the world, the diversity across sub-Saharan Africa is apparent in the region’s physical geography and climate, in its plurality of cultural heritages, official and native languages, traditions, beliefs, religions, and value systems, in its modes of production and levels of economic development, and in its diverse social and political structures. Differences across countries and cultures make generalization from small-scale studies quite problematic, and the current lack of long-term comparable data from multiple sites hinders the ability to make meaningful cross-country comparisons. This heterogeneity also implies that cross-country comparisons are never going to be possible without careful longitudinal and multidisciplinary research designs. At the same time, because many countries are now in the early stages of adapting
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research that a claim needs to go through before payment is dispersed, leads to long delays for legitimate recipients waiting to receive their benefits (Dhemba et al., 2002; Kasente et al., 2002). Rates of interest awarded annually to members of provident funds have invariably been negative in real terms, and the lump sums paid out generally represent no more than a few months’ earnings (Mchomvu et al., 2002). In addition to these problems, the devaluation of local currencies necessitated by structural adjustment programs has severely eroded the value of benefits in some countries (Kaseke, 2004). South African Pension Program No discussion of social protection of older people in sub-Saharan Africa would be complete without a description of the South African social pension program, which is quite unusual in sub-Saharan Africa with respect to its level of coverage and generosity of benefit (Case and Deaton, 1998). South African women age 60 or older and South African men age 65 and older may apply for a state pension irrespective of employment history. In 2006, the state pension was R820 per month (roughly US$115). The pension is means-tested, but the level is set at a point at which 80 percent of all age-eligible Africans may receive the pension (Lam et al., in this volume). Essentially a by-product of the dismantling of the apartheid system, the program, which was originally designed to provide protection for poor whites, is viewed in South Africa today as a way to achieve several broad development goals: providing assistance to households in rural areas, targeting women, and keeping significant numbers of households out of poverty (Ardington and Lund, 1995). It is the sole or major source of income for many poverty-stricken families (van Zyl, 2003). A considerable body of research has been conducted on the effects of such a large and generous transfer scheme on the welfare of older people and extended family members (Alderman, 1999; Ardington and Lund, 1995; Bertrand, Mullainathan, and Miller, 2003; Case, 2001; Case and Deaton, 1998; Duflo, 2003; Ferreira, 2003; Posel, Fairburn, and Lund, 2004; Lam et al., in this volume). Case and Deaton (1998) argue that the pension program is effective in reaching the poorest households and in fact is a useful tool for reaching the poor in general, not just older people. Because so many older people in South Africa’s African population live in multigeneration households, in part because young people tend to join households that receive a pension, the state pension program transfers money into households with children. Roughly one-third of all children age 4 and under live in households in which older people receive pensions, and the percentage of children living with pensioners is even higher among the poorest income quintiles (Alderman, 1999). Case (2001) also found that in the Western Cape, in households that pool income, the state pension ap-
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research pears to protect the health status of all adults and children in the household. Duflo (2003) found that the impact of the program depends on the gender of the recipient: pensions received by men have little effect on children’s health status, but pensions received by women have a large impact on the physical stature of girls. Impact on Older Persons An important policy question with respect to any social welfare program has to do with the extent to which the program creates dependency and has a negative effect on labor supply. Betrand et al. (2003) found that pensions can have a negative effect on the labor supply of working-age adults residing in pension-receiving households. However, Betrand et al. (2003) investigated only the labor supply of adults resident in the household. Posel et al. (2004) argued that the social pension also affects the propensity of household members to migrate to find work, which acts as a positive supply response to the receipt of a social pension. In their chapter in this volume, Lam et al. contribute to this debate by examining how the social pension affects the decision to withdraw from the labor force by older people. By analyzing census and survey data, the authors found that, although the pension is associated with high rates of withdrawal from the labor force, the rates are somewhat less sharp than those observed for similar programs in Europe. Another crucial policy question in the region is whether economic growth is needed in order to broaden the social safety net. Kakwani and Subbarao (2005) investigate the likely fiscal implications of providing some sort of social pension to older people in various sub-Saharan African countries and study the impacts on poverty rates. The authors have found that the fiscal cost of providing a universal noncontributory social pension to all of older people in sub-Saharan Africa would be quite high, around 2 to 3 percent of gross domestic product, a level comparable to—or even higher than—the current levels of public spending on health care in some sub-Saharan African nations. The authors argue that the case for universal social pensions also appears to be weak on welfare grounds, inasmuch as there are other groups competing for scarce safety net resources (such as families with many children) whose incidence and prevalence of poverty is much higher than that of older people. Given that a universal social pension program appears out of reach in most countries and is difficult to defend on purely social welfare grounds, the authors then explore various options for targeted social pensions using a fixed budget constraint of 0.5 percent of gross domestic product and a fixed benefit level of 70 percent or 35 percent of the poverty threshold for older people defined as age 60 or 65 and older. Two household types were
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research considered: households with older people living with children and households with older people only. The authors found that the introduction of social pensions targeted to these groups would yield considerable reductions in the prevalence of household-level poverty, both for the targeted groups and for the national average. Nevertheless, as the authors point out, the operational feasibility of such a program is very weak. The administrative burden of operating such a scheme is enormous and would be likely to lead to dissolution and reformation of certain types of households in order to make them eligible to claim a pension. Bearing this is mind, the authors also investigate the fiscal implications of providing a social pension to only poor older people, regardless of the type of household in which they reside. The authors conclude that the best option is to target the pension only to the poor, keep the benefit level low, and the age of eligibility at 65 and older (Kakwani and Subbarao, 2005). Informal Schemes Given the problems and formidable financial and administrative hurdles to expanding formal social security schemes in sub-Saharan Africa, policy makers also need to know whether there are ways to expand and support any of the various forms of informal social protection schemes that exist around the continent as a means to provide a vital safety net for certain vulnerable populations. A wide variety of informal community-based arrangements have been developed in rural areas aimed at spreading risk among friends and extended family members, with neighbors, or with other participants. These can often involve self-help or community based-initiatives that draw on sub-Saharan African traditions of shared support and kinship networks. In parts of Zimbabwe, for example, the government has successfully reintroduced the concept of the Zunde raMambo (literally “the Chief’s Granary”), which refers to the harvest from a common field that is stored in a common granary and used at the discretion of the chief in order to ensure that the community has sufficient food in the event of a drought or a poor harvest (Dhemba et al., 2002). There are many other examples of groups that have come together as spontaneous responses to poverty. Rotating savings and credit associations and mutual aid societies, for example, are commonly used throughout sub-Saharan Africa to compensate for failures in existing formal financial markets. In rotating credit and savings associations, participants periodically contribute fixed amounts of money and allocate the fund on a lottery or rotational basis to its members. The scheme encourages small-scale capital accumulation and savings and allows members to meet various welfare objectives, such as to pay school fees, meet medical expenses, or buy food. Funds can also be used to start or promote small businesses and acquire
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research assets, including livestock (Kimuyu, 1999). Burial societies are another form of rotating savings scheme. In burial societies, members pay periodically to the society, and, when the member dies, the family receives money to help offset the funeral expenses. These types of scheme are very popular in sub-Saharan Africa, particularly in urban areas. Much less is known about informal social security systems in sub-Saharan Africa than about formal social security systems, but it is generally believed that informal schemes also suffer from a number of chronic problems and in their current form fail to provide much in the way of long-term protection against various forms of risk (Mchomvu et al., 2002). Nevertheless, there is a need for more detailed country-specific analysis on the nature of both formal and informal schemes, the size and frequency of transfers, and the redistributive effects of those transfer payments on the health and well-being of older people and other household members. RECOMMENDATIONS Sub-Saharan African policy makers are increasingly aware of the challenges associated with population aging and with the changing needs and contributions of older people. While aging may not soon have highest priority, such actions as the development and adoption of the African Union Framework and Plan of Action on Ageing, the formulation of the African Common Position on Ageing, and the establishment, for the first time, of national policies on aging in a few sub-Saharan African countries are all indicators of a growing awareness of aging issues across the continent. Sound understanding of the links between key social and economic trends and the economic security, health and disability, and living conditions of older people in sub-Saharan African contexts is essential if appropriate new policies to enhance their lives are to be established. The recommendations below take into account the research essential to this new understanding, the need to overcome barriers to research, and translation of research findings into programs and policies. The substantive agenda for research was laid out in the previous section on key areas for future research. There are no easy solutions to the problems discussed in this report, but unquestionably understanding of some of the key issues and causal processes we have discussed would be greatly improved if the research community had the resources to use available information and undertake new data collection efforts, particularly those with a repeated sampling or longitudinal design. The consensus of the panel is that this type of longitudinal, multidisciplinary monitoring system would be most useful if implemented in several locations using comparable design. It would not only provide a reliable benchmark on the current socioeconomic situation of older people but would doubtlessly also contribute significantly to scientific knowledge.
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research In turn, it could inform those charged with the development of new programs and policies for older people. The returns on such an investment may be modest initially but will accumulate over time. The panel also wishes to emphasize the importance of facilitating research, building local research capacity, and supporting the development of a local research network in sub-Saharan Africa that can support essential studies on the nature and consequences of its population aging and the context in which it is occurring. Top priority for the immediate future should be given to building basic research infrastructure, improving access to data, removing burdensome administrative barriers to carrying out new research, and strengthening international collaboration.9 After consideration of the general state of knowledge about aging in sub-Saharan Africa, recent research developments and emerging opportunities, and the strength of local research capacity, the panel arrived at the following recommendations, grouped under research agenda and funding, enhancing research opportunity and implementation, and translation of research findings that they feel could help improve the future development of the field. Research Agenda Increase Research on Aging in Sub-Saharan Africa This report provides detail on the substantive agenda of needed research on aging in sub-Saharan Africa. There can be little doubt that, as a function of the emerging fertility transition in sub-Saharan Africa, the changing macroeconomic climate, and the impact of the devastating HIV/ AIDS epidemic, researchers are paying increasing attention to the social, economic, and demographic dimensions of aging in sub-Saharan Africa. This attention can be turned into action only with increased funding directed to this arena. Funders should consider mechanisms—existing or new—to enable the research agenda identified in this report to be carried out. These mechanisms should foster international collaborative research in ways that benefit researchers in both the developed and developing worlds. 9 Since the workshop took place, the Oxford Institute of Ageing has established a new network for researchers working on aging in Africa: the African Research on Ageing Network (AFRAN). The network is being coordinated jointly by the Oxford Institute of Ageing and the Council for the Development of Economic and Social Research in Africa (CODESRIA).
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research Explore Ways to Leverage Existing Data Collection Efforts to Learn More About Older People in Sub-Saharan Africa The ongoing economic and social changes taking place in sub-Saharan Africa as well as the projected changes in both the numbers and proportion of older people in sub-Saharan Africa pose a series of vital policy challenges: How are ongoing economic and demographic changes affecting the family structures, socioeconomic position, and health of older people? How is HIV/AIDS changing the roles and responsibilities of older people? Can some form of social protection scheme be designed and successfully implemented in this part of the world that will partially relieve some of the burden on sub-Saharan African families? With such vagaries and uncertainties there is a clear need to enhance understanding of the current situation of older people in sub-Saharan Af-rica as well as to improve understanding of some of the underlying causal processes that relate social and economic change to older people’s wellbeing in the sub-Saharan African context. Given that the proportion of the population that is older is still low, at least relative to other continents, sub-Saharan African policy makers have an important window of opportunity in which to act. Furthermore, as an earlier report of the National Research Council’s Committee on Population pointed out, each sub-Saharan African country’s response to the challenges of aging is liable to be slightly different. Consequently, a number of natural experiments are either already currently under way, or shortly will be that, provided they are well recorded and documented, could be used to enable countries to learn from each other’s experiences (National Research Council, 2001). In order for this to happen, national governments will need both to invest much more in basic research and to develop mechanisms to establish common definitions that will facilitate the harmonization of data collection across countries. Improving understanding of the situation of older people will also require a better picture of the simultaneous interplay among multiple factors, including health, economic, and social characteristics. Hence, the development and use of multidisciplinary research designs will be essential in the development and production of any new data on aging in sub-Saharan Af-rica. Furthermore, the very strong a priori assumptions that many researchers and social commentators hold concerning the deteriorating situation of older people over time imply the need for study designs that can trace the experiences of individuals over time. Experience from the United States, Europe, and Asia has shown that data collection efforts that use a multidisciplinary panel approach, involving researchers who are willing to work across traditional domains, can produce significant returns (Börsch-Supan et al., 2005; Hermalin, 2002; National Research Council, 2001). Ideally, data should be reliable, population and community based, and in-
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research clusive of all groups, should cover multiple domains of interest, and should be collected both prospectively and continuously. All of these challenges suggest the need for establishing a foundation of high-quality baseline data and tracking changes in many key variables over time. But collecting high-quality longitudinal data would undoubtedly be an extremely expensive and difficult undertaking. A more feasible first step may be to take advantage of already ongoing data collection efforts. The existing network of community-based population surveillance sites (INDEPTH) offers one likely vehicle for developing such a data collection effort, rather than investing in a completely new sampling framework. Although there are some inherent limitations of site-specific studies, greater investment in a growing number of (predominantly rural) INDEPTH sites around the continent is likely to substantially enrich knowledge of the living arrangements, economic activities, and health status of older people in sub-Saharan Africa if these data are made available and analyzed in a timely fashion. In general with ongoing data collection efforts, it is important to find a balance between protecting confidentiality and increasing access by qualified researchers to these valuable data. Sub-Saharan African researchers are likely to benefit most from greater access to African censuses, surveys, and demographic surveillance site data. Enhancing Research Opportunity and Implementation Improve Support for Library Infrastructure and Dissemination Tools to Create a More Integrated Body of Knowledge in Sub-Saharan Africa Researchers and policy makers in sub-Saharan Africa are often poorly informed about previous research that has taken place on their continent or elsewhere. The only sub-Saharan African journal dedicated to publishing the findings of research on various aspects of aging, the Southern African Journal of Gerontology, ceased publication in 2000 due to lack of financial support. Furthermore, even when studies are accepted and published in international journals, it is often quite difficult to obtain copies of papers locally. In fact, it is often far easier to obtain copies of research papers outside the country in which they were produced than inside it. In addition, researchers in sub-Saharan Africa are working in three main languages: English, French, and Portuguese, which slows down professional networking and the dissemination of findings. In most sub-Saharan African countries, there is no up-to-date bibliography of research or reports on aging to form a knowledge base, such as was compiled for aging research in Europe in the late 1990s (see Agree and Myers, 1998). Furthermore, there are few opportunities for national and international networking among scholars
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research interested in aging although the recent establishment of the African Research on Ageing Network (AFRAN) may lead to more opportunities in the future. Hence, there is a need for more support for library and information services as well as a need for greater information sharing and professional networking, perhaps through the sponsorship of more local or regional conferences. Given the rapid takeoff of electronic journal retrieval systems, such as JSTOR, increased investment in Internet access—both to high-speed Internet itself and to rights to use resources available on the Internet—may be one of the most effective means of closing the gap between continents in terms of access to existing research. Improve Archiving of Past Censuses and Surveys Generally speaking, African censuses and surveys have been greatly underutilized and much survey data collected over the past 30 years has deteriorated as a result of poor archiving. Yet even with the limited focus on aging issues in past social surveys, there may be significant potential for furthering knowledge of the social and economic conditions of older people from a more systematic analysis of previously collected data. But that cannot happen without improvements to the ways that data sets are archived and put into the public domain. Data handling and storage technology advance so rapidly that the burden of making data available in a useful format cannot rest with individual researchers. Hence there is a need for a more systematic archiving of sub-Saharan African microdata. The World Bank’s web-based African Household Survey database, the Minnesota Integrated Public Use Microdata Series (IPUMS-International), and the University of Pennsylvania’s African Census Project are good examples of initiatives designed to save previously collected data from destruction that have eased data constraints and produced new findings about older people (see, for example, Mba, 2002). Improve Access to Ongoing Data Collection Efforts If investments in new data are to be realized, better mechanisms will need to be put in place to improve storage, retrieval, and access to aging data. The experience of the Health and Retirement Survey and the Asset and Health Dynamics of the Oldest Old Study in the United States has shown that the return on research dollars is highest when the data collected are made available to the broad scientific community in a timely fashion (National Research Council, 2001; Willis, 1999). Yet in the sub-Saharan African context this may be far easier said than done. First, there are a number of ethical issues that need to be explicitly addressed when collecting any individual-level data (Cash and Rabin, 2002). But particularly in the
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research case of such sensitive topics as the HIV status of respondents or their other family members, it is quite easy to see how information collected by researchers could be damaging both to the individual and to others if it were disclosed to a third party. Different countries have different policies in place to protect the privacy and confidentiality of their informants. Issues of confidentiality may require developing complex informed consent procedures that may be difficult to devise and communicate when the concepts are new and foreign and the population being investigated is poorly educated. Furthermore, much of the best research undertaken to date has been made possible only by the establishment of international research partnerships between researchers in the developed and the developing world. These partnerships are quite complex to establish and maintain, since they involve negotiating such thorny issues as fair allocation of research roles, balance in infrastructure investments, and fairness in ascribing authorship and related credits (Tollman, 2004). At the same time, high functioning North-South institutional partnerships can accomplish a great deal with regard to research training as well as research and may well offer the best prospects for the foreseeable future. Thus, the challenge will be to strengthen these partnerships in ways that both support local institutions and increase timely access to data. Strengthen International Collaboration and Capacity-Building in the Short Term There is a critical and urgent need to strengthen research capacity in sub-Saharan Africa. More and better research on various dimensions of aging in sub-Saharan Africa cannot happen without an increase in the funding for research, more well-trained local researchers, and improvements in administrative procedures that currently hinder the execution of research projects. Many sub-Saharan African universities were badly neglected in the 1980s and 1990s. Funding for salaries, maintenance of facilities and equipment, library services, and sometimes even basic office supplies was often entirely inadequate, resulting in the demise of sub-Saharan African universities and the widespread flight of faculty into the private sector (National Research Council, 1996). At the same time, a lack of managerial and administrative capacity can often lead to inefficiencies in the way that available money is allocated. Although there are signs that African governments are beginning to value the role that science and technology can play in national development, it is unlikely that sub-Saharan African governments are going to increase their level of research funding substantially in the near future. In the short term, foreign financial and technical assistance will remain essential
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research to the development of local universities and the strengthening of local research capacity. Donors should explore funding mechanisms that increase incentives for work in this area, perhaps through the establishment of special funding mechanisms, particularly those that not only advance funding for research on aging in sub-Saharan Africa but also encourage cross-national collaboration and training. At the same time, African and other governments should do all in their power to facilitate linkages between sub-Saharan African institutions and international research centers in the United States and elsewhere by establishing agreements at the highest levels to expedite local review of projects as expeditiously as possible. Such linkages, especially if built on the basis of a strong mutual interest in collaborative research, can help local universities develop, can assist local researchers by providing funding and in-country technical assistance and training, and can help with the processing of data and the preparation of manuscripts for publication. Experience in a number of sub-Saharan African settings has demonstrated that such collaborations can lead to important scientific advances and be mutually beneficial to all institutions involved (Tollman, 2004). Remove Barriers to Implementation of Research Collaborative research with sub-Saharan African institutions requires approvals by all collaborating institutions, frequently involving more than one review board for the ethical conduct of research, as well as government offices and officials in the country in which the data collection takes place— whether representatives of the United States or the local government. The panel received informal reports of difficulties and delays in receiving the required approvals even for projects funded by the U.S. National Institutes of Health (NIH) after the usual exacting NIH reviews. One study was delayed for more than a year; another was delayed then finally dropped. If research on these important subjects is to be carried out in a timely fashion, it is essential that institutions, review boards, and government bodies at all relevant levels establish procedures and processes that make speedy review possible, without repetitive reviews of scientific merit. In the Long Term, Sub-Saharan African Governments Must Give Reasonable Priority to Aging Research and Strengthen Local Research Capacity In the long run, the importance of foreign-supported research in the region must be reduced. It will be up to sub-Saharan African national governments to prioritize aging as a focal area and to find the resources needed to be able to drive the region’s aging agenda. Numerous related processes
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Aging in Sub-Saharan Africa: Recommendations for Furthering Research are already under way in Africa aimed at strengthening research institutes and building research capacity, including programs at the Council for the Development of Social Science Research, headquartered in Senegal, and the African Centre for Research and Training in Social Development, headquartered in Ethiopia. Nevertheless, sub-Saharan African governments generally need to place a greater value on the role of higher education and find funding to rebuild and strengthen local universities. In many countries, pay scales will need to be adjusted in order to attract and retain the best researchers. Translation of Research Findings Improve Dialogue Between Local Researchers and Policy Makers There is an ongoing need for continued and expanded dialogue between the research and the policy communities. Researchers need to do a better job of drawing out the main policy and programmatic implications of their work, and policy makers need to better articulate what information they most need for more effective planning and program design. At the same time, there is also value in both sides engaging with older people themselves to ensure so that they are not excluded from a dialogue aimed ultimately at enhancing their future well-being. Otherwise, the danger is that local programs and policies will be only marginally based on a solid understanding of local needs and conditions, while research will continue to be undervalued by policy makers and therefore underfunded.
Representative terms from entire chapter: