Introduction

The number of older people in many developing countries is growing more rapidly than those in industrialized nations. However, population ageing also reveals social inequality. In South Africa it is interesting to note that only 7% of the blacks, people of colour and Indians (who constitute 89% of the total population) are old people, whereas 14.2% of the minority white population are 60 years and over.1 Other determinants rather than the Gross National Product (GNP) have a strong influence on life expectancy. Cuba, Costa Rica, Barbados and Sri Lanka are low-income countries with life expectancy similar to North America and many industrial countries of Europe.

The usual view of the developing world held by people living in the West, namely that of families with many children and high infant mortality rates, nowadays applies only to the least developed countries, mainly in Africa. Major fertility reductions in the developing world took place over the last three decades of the twentieth century. From 1950–1955 to 2005–2010, the total fertility rate in the developing world dropped by almost 60%, from 6.2 to 2.7 children per woman.2 In 2009 the fertility rate in Brazil was similar to the rate in France (1.9 children per woman). Children begging in the streets of some Latin America countries for instance, reveal a lack of adequate social policies despite the reduction in fertility.

There are several possible explanations for the recent demographic scene in the developing world; these include urbanization, improvement in basic sanitary conditions and education, better health assistance and economic growth. Dissemination of information and access to the health system, including distribution of oral contraceptive pills, have strongly contributed to the decline in family size. Greater female participation in the labour market has also played a key role. The size of families parents wish to have has declined, as the cost of raising a child has risen and child survival has increased.3 In China, government intervention consisted of the coercive and unpopular one-child policy.

Demographic development poses widespread social and economic challenges for societies. The total dependency ratio is a measure of potential social support needs. It represents the ratio of children (persons under age 15) and older persons aged 65 and over to the number of potential working people aged 15 to 64, expressed per 100 population. In developing countries there will be a fast shift from young to old age dependency, since the number of children is declining and the proportion of older persons is increasing rapidly. In African countries with a high prevalence of HIV/AIDS the supposed support given by potential working adult people does not always apply. Many older Africans find themselves in a double-bind. They constitute the majority of the community in the rural areas, responsible for the care of their ill and dying relatives. After sick relatives pass way, older people are often left with grandchildren to support with no middle-age generation present. In Africa alone, 12 million orphaned children grow up without their parents and very often live with their grandparents.1

One of the key challenges confronting developing countries with an increasingly ageing population is to guarantee to the whole elderly population an adequate level of income, without placing excessive demands on younger generations and national economies. This dilemma has direct implications for social security systems. Many countries do not have a full pension scheme covering all the working population, mainly those in informal activities or living in rural areas. The increasing life expectancy has not been fully considered by social security schemes in many countries, and a move from early retirement would require a major change in sociocultural model attitudes. In developed and developing countries, early withdrawal from the labour market is currently seen as both desirable and acceptable, even for people in full possession of their faculties and in sound health.4 At the same time in nations with low and middle economies, elderly people who did not make any contribution to social security are left without any income. However, it is estimated that at least 50 developing countries provide social pensions for their elderly citizens, defined as non-contributory cash income.

Social security systems will also be stretched in response to the new demands made by the health needs of older persons.

Ageing and Health

The epidemiological transition is the correlate of demographic transition in health. Deaths due to communicable disease are declining and there is a worldwide increase in deaths due to chronic disease, mainly cardiovascular disorders, cancer and diabetes. Despite this trend, it is appropriate to consider that developing countries are facing an epidemiological polarization. Communicable disease remains an important cause of morbidity and mortality, notwithstanding the predominance of deaths due to chronic disorders. Increased vulnerability, a hallmark of the poor and the elderly, and inequity make the risk of infectious disease unfairly high, depriving this section of the population of benefits of human progress achieved as long as a century ago.

In 2002, chronic diseases were responsible for 46% of all deaths in developing countries, a figure that is projected to grow to 59% by 2030.5 However, the increased risk of chronic diseases is not simply a result of a reduction in infectious disease mortality, nor due to an ageing population alone. Life-course epidemiology reminds us of a new approach to chronic disease. Subnutrition and an unhealthy environment in early life may increase the incidence of chronic disease in later life. So, today’s epidemiological scene in developing countries may also reflect past conditions of people who survived despite sub- or malnutrition and poor health conditions in early life.6 There is a significant association between economic status and good, basic and advanced functional ability. Geriatric functional ability is closely associated with income not only in developing countries, but also in developed countries.7

Behavioural risks are estimated to account for 30–60% of chronic disease. In developing countries experiencing economical growth without a corresponding increase in the education level, new behaviours can be imposed by poorly controlled publicity inducing the consumption of tobacco, alcoholic beverages and junk foods.

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