Challenges Faced by Older Persons in Eastern and Southern Africa and Implications for Social Work Practice

Jotham Dhemba, University of Eswatini

Abstract: This article explores the challenges faced by older persons in Eastern and Southern Africa and their implications for social work practice. The phenomenal increase in the number of older persons in Eastern and Southern Africa, like elsewhere regionally and internationally, is occurring in a context where this demographic shift is yet to be matched with the resources, skills and government commitment to respond to their needs. As a result, older persons in Eastern and Southern Africa face a myriad of challenges including poverty, food insecurity, poor health and lack of or limited access to social services, abandonment and neglect, and abuse. Their plight is exacerbated by diminishing inter-generational support, due to the pervasiveness of poverty in these countries, and sociocultural processes such as modernisation, globalisation, migration and urbanisation. Nonetheless, although ageing cannot be prevented, some of its consequences can be mitigated or delayed to enable older persons to age successfully and with dignity. As such, vulnerability in old age requires new frameworks of support to ensure their well-being. In this regard, the Global Agenda for Social Work and Social Development 2012 commits social workers to promote social and economic justice and the dignity and sanctity of human life, older persons included.

Keywords: Older persons; old age pension/grant; poverty; social work; vulnerability

Introduction

Demographic trends internationally, show that the proportion of older persons is not only increasing, but rapidly ageing as well (Wamara & Carvalho, 2022). The United Nations Department of Economic Affairs (2019) asserts that there were 703 million older persons aged 65 or over globally in 2019. The same source projects this figure to rise by more than double, to reach 1.5 billion by 2050. It is also projected that the fastest increase will occur in the least developed countries, where it is likely to rise from 37 million in 2019, to 120 million older persons in 2050 (United Nations Department of Economic and Social Affairs, 2019). Of grave concern though, in the case of countries in Eastern and Southern Africa is that ageing is occurring in the absence of systematic and effective arrangements to ensure the well-being of older persons, thereby exposing them to many vulnerabilities. It should be pointed out that the definition of older persons, also referred to as the elderly is contested terrain, due to the fact that in some contexts, particularly in Africa, it is culturally determined and also because biologically, people age at different rates. Nonetheless, although most developed countries use the chronological age of 65 years or more to define an older person (Kowal & Dowd, 2001; WHO, 2010), this paper adopts the age of 60 years and above, which was agreed upon at the United Nations General Assembly at Vienna, Spain in 1982, and is deemed to be more appropriate for African countries (Kowal & Dowd, 2001).

As elsewhere in other parts of the world, Eastern and Southern Africa are in the midst of a longevity revolution which represents a major demographic shift. The East African Community (EAC) comprises of Burundi, Democratic Republic of Congo (DRC), Kenya, Rwanda, Uganda, and Tanzania. Southern Africa on the other hand consists of Angola, Botswana, Eswatini, Lesotho, Malawi, Mozambique, Namibia, South Africa, Zambia and Zimbabwe.

According to Spitzer and Mabeyo (2017) the total population of the EAC in 2015, excluding the DRC, was 161.3 million and this is expected to rise to 384.4 million by 2050. They also point out that the proportion of those aged 60 years and above averaged 4.4% in 2015 and this is projected to rise to 8.3% by 2050. The growth rate for the population aged 60 years and above in Southern Africa was projected to increase from 7% in 2009 to 14% in 2050 (Pillay & Maharaj, 2013). On the same note, life expectancy, which was at about 60 years in 2015 in both regions, is expected to be about 70 years in 2050, courtesy of advances in medicine and improved health and nutrition in the 21st century. It is also important to note that that the majority of older persons in the EAC (Society for International Development, 2013) as is the case in most African countries, live in rural areas, surviving mainly on subsistence farming and in slums around towns and cities.

Nonetheless, although longevity should be celebrated as one of humanity’s achievements, it is paradoxical that older age is a major risk factor as older persons in many African countries, those in the EAC and Southern Africa included, experience poverty, ill-health, neglect, abuse, ageism and social exclusion in general. Furthermore, notwithstanding that population ageing is a global phenomenon, its consequences are more devastating in poor countries, those in the EAC and Southern Africa included.

In line with the International Federation of Social Workers (IFSW) Policy on Ageing and Older Adults (IFSW , 2015) social workers should play a lead role in responding to the needs of the poor and vulnerable, older persons included. Moreover, the purpose of social work is to transform the social environment to make it more just, inclusive and receptive (Gonzalez & Puelles, 2019). Hence, social workers should play a lead role in assisting older persons to leverage greater influence in policies and programmes that respond to their human rights and needs.

Statement of the problem

The exponential growth in the number of people 60 years of age and over in Eastern and Southern Africa, as elsewhere in many developing countries poses serious challenges to their well-being. Herein lies the conundrum, while longevity is one of the achievements of the 21st century, the ageing process has created a population cohort that is at-risk of physiological, functional and cognitive challenges, thereby heightening their risk to poverty, ill-health, loneliness, abuse and neglect among others. East and Southern African countries, like many other African countries are confronted with the clinical, social and fiscal challenges of meeting the needs and demands of an ageing population. This is primarily because this demographic shift is yet to be matched with the resources, skills and government commitment to respond to the needs of the growing number of older persons (Adamek, Kotecho, Chane & Gebeyaw, 2021). These demographic changes also tend to increase the demand for health care, social security, affordable housing, personal care needs and other basic social welfare services for older persons (MoSD & Help Age, 2014).

Furthermore, although historically the extended family’s multi-generational household has been an important source of care for older persons in African settings, it has been rendered ineffective by factors such as poverty, modernisation, urbanisation and globalisation. Life in old age, especially in the  poor countries in the Global South is at the crossroads, given the weakening of the extended family support system and the lack of or inadequate social protection measures for older persons.

As ageing in many African countries is occurring in a context of increasing poverty, political unrest, changing family structures, and weakening infrastructures, this heightens the vulnerability of older persons. Covid-19 has also exposed the absence of adequate social protection measures for the majority of the people, older persons included, thereby exposing them to various forms of vulnerabilities. In addition, the COVID-19 clinical presentation showed that it has a disproportionate impact on older persons (Landry, Van den Burgh, Hjelle, Jalovcic & Tuntland, 2020). Consequently, with the increasing numbers of older persons, more and more of them are likely to need external assistance to meet their needs.

Moreover, older men and women throughout Africa make vital contributions to their families, communities and society in general. Their contribution ranges from caring for orphaned grandchildren as a result of HIV and AIDS, to providing much needed household income. For example, in countries such as Eswatini (Schubert, 2020), Lesotho (MoSD, 2014), South Africa (Bulose, 2020) and Uganda (Uganda Social Protection Platform (USPP) 2017), where older persons receive old age pension/grant, it is the only source of income for many households with an older person, because of the high levels of unemployment. In addition,  most of them continue to perform their domestic and subsistence farming roles. In fact, millions of families across the continent would not survive without the contribution of older people. They are also the vanguards of morality in many African countries, hence they should be revered and protected to avoid the scourge of moral decadence within the society (Kang’ethe & Khayundi, 2014).

As such, population ageing in the EAC and Southern Africa, like elsewhere in many African countries, exposes older persons to vulnerability to poverty, abuse and violation of their human rights.        Hence, considering that older persons also have rights to survival, income and health among others, and that they “should not be left behind” in terms of the 2030 Agenda for Sustainable Development, there is need to explore the challenges they face, with a view to coming up with measures to ensure their health and welfare.

Methodology

This is a qualitative narrative study, based on a rigorous scoping of relevant literature as its primary methodology. It comprised mainly of secondary sources of data including research reports, and publications by HelpAge International, Unicef, UN and WHO, and eminent scholars in the field of gerontology and social work. In addition, government policy documents and international (UN) and regional (AU) human rights instruments were used as sources of information for this article. Two, web-based data bases, namely Ageline and Google Scholar were searched to identify peer-reviewed journal articles focusing on population ageing and challenges faced by older persons aged 60 years and above in East and Southern Africa. The search terms used to obtain data from online sources were, ageing in EAC and Southern Africa, care of older persons, challenges faced by older persons and social work with older persons. In addition, the reference list of all the papers identified was searched for additional information on the aforementioned issues. The data collected were analysed using the content analysis approach.

Challenges faced by older persons

Population ageing has profound implications for many facets of human life, as it involves changes in life. Some of the challenges faced by older persons in East and Southern Africa are poverty, hunger and food insecurity, poor health and difficulties accessing health care services, negative attitudes of health personnel, limited or lack of access to social services, poor housing, neglect and abandonment and witchcraft accusations. These are presented in more detail below starting with poverty.

Poverty and food insecurity

Poverty in the African context constitutes a complexity of multiple and vexing realities. It is described as an interlocking and multidimensional phenomenon caused by a lack of resources such as employment, food, assets like housing and land, basic infrastructure, and health care (Patel, 2015). Poverty, food insecurity and nutritional vulnerability are serious problems that impair the quality of life of older persons.

According to Spitzer and Mabeyo (2011) the majority of the older people in the EAC live in poverty due to lack of income and food security. This is partly because social security pensions in the East Africa region cover only a small percentage of the workforce, mainly those in government employment. Burundi, Rwanda, Tanzania, Uganda cover less than 10% of their population, while Kenya covers 15% (Turner, 2014). As such, older persons in retirement in these countries are unlikely to be receiving pension due to lack of coverage and high levels of unemployment.

On the same note, a study on the quality of life of grandparent caregivers in Zimbabwe (Southern Africa) showed that poverty is a major problem in raising grandchildren (Mhaka-Mutepfa, 2018). This is corroborated by Chingono (2021) asserting that 80% of older persons in Zimbabwe live in abject poverty. The ILO (2016) lends further credence to this state of affairs, contending that older persons in Lesotho experience higher food shortage at 39.3%, compared to 34.2% for the general population. The old age pension amount in Lesotho is only US$48 (Government of Lesotho (GoL), 2023), which is not enough to take recipients out of poverty. The same situation obtains in Malawi where the availability of food is erratic and as a result, older persons are food insecure (Republic of Malawi, 2016). A study by Dhemba (2022) in Lesotho also showed that most older persons occupied sub-standard housing as they could  not afford the costs for their repair and maintenance.

Poor health and lack of or limited access to healthcare and other services

Given that people are now living longer than before, medical conditions are inevitably part of older life.  In fact, research internationally shows that old age is generally spent in ill-health (Hussein & Ismail, 2017). It should therefore not be surprising that the overall health status of older persons in East and Southern Africa is generally poor, with a high prevalence of chronic comorbidities, including hypertension, diabetes and arthritis. This was confirmed in a study in South Africa, by Chazan (2003) cited by Dolbin-MacNub and Yangura (2018), which showed that older persons experience a variety of health problems, including hypertension, diabetes, and arthritis. A study by the MoHCC, WHO and Age  International (2017) also showed that 20% of all people with disabilities in Zimbabwe comprise of older persons. Nonetheless, although hypertension and diabetes are prevalent among older persons, cancers of the prostate and cervix are the most common in the case of Zimbabwe (MoHCC, WHO & Age  International, 2017).

As such, given that health is of major concern in old age, issues of access to health care services for older persons are some of the major health-related problems for older persons in Southern Africa (Chipfupa, 2016).  The shortage of doctors and medicines, long waiting queues at clinics and hospitals, and prohibitive transport costs to health centers and negative attitudes of health personnel are the major obstacles to accessing health care.

Another example is provided by the study by Makoa, Mpemi, Tsekoa, Tlali, Ralejoane, Biesma, Brugha & Odonkor (2009) which revealed an acute shortage of doctors and drugs at health centers in Lesotho. On the same note, a study of Lesotho’s health care system showed that the ratio of health caregivers to patients is very poor (Matlanyane, Makatjane & Lebuso, 2013). Similarly, a study of older persons from Langa and Khayelitsha, on the outskirts of Cape Town, South Africa, revealed that older persons struggled to get to the nearest clinic, because of the long distances and travel costs involved (Knight, Schatz & Mukumbang, 2018).

In addition, older persons in in East and Southern Africa face the challenge of overcrowding and long waiting times at health facilities. A case in point is that of  Namibia where older persons are subjected to long waiting periods before receiving medical help (Ananias, 2014). This is also the case in Tanzania where a research study by HelpAge showed that over one-third of older patients waited at the hospital for four to six hours before being attended to by a doctor (Stanley, 2008). Thus, overcrowding and long waiting times at health facilities are major obstacles to accessing health care for older persons. As a result some of them either do not bother to seek medical attention or give up and go back to their homes without receiving care.

Lack of national identity documents

The possession of a national identity document is usually a requirement for one to register for most services including cash transfer benefits in many countries in East and Southern Africa. This is usually required for purposes of verifying the applicant’s age to determine eligibility for services. Similarly, access to other services such as public assistance and opening of bank accounts require proof in the form of national identity documents.

Findings of studies carried out in several African countries, including Lesotho (Dhemba, 2022) Kenya, Mozambique, Uganda and Zanzibar show the lack of identity documents as the most common problem experienced by older persons in accessing cash transfer schemes (CTS) and other social security benefits (Livingstone, 2018). In the case of Mozambique, it was found that this problem is a result of the long, complex and costly process that one has to go through to secure identity documents.

Neglect and abandonment

While neglect and abandonment can be viewed as having the same meaning, neglect is the refusal or failure to provide the necessities of life to an older person. Abandonment on the other hand refers to their desertion by people with the responsibility for their care. A study by Dhemba (2022) in Lesotho found that older persons in that country were experiencing both neglect and abandonment. This was attributed largely to poverty and the migration of adult children to urban areas and the diaspora in search of employment opportunities. The SAOPF (2012) is also of the view that older persons in South Africa are experiencing neglect, a situation that is typical of both East and Southern African countries.

Witchcraft accusations

According to Machangu (2015), the belief in witchcraft and its impacts is a widespread phenomenon on the African continent. Witchcraft refers to the use of magical powers to inflict harm to another person’s mind, body or even possessions.

The Ministry of Health and Child Care (MoHCC), WHO and Age International (2017) posits that old age in Zimbabwe is associated with witchcraft. On the same note HelpAge International (HAI) (2010) asserts that more than 2,585 older women in Tanzania were reportedly killed between 2004 and 2009 following accusations of witchcraft. The belief in witchcraft is also still strong in South Africa, especially in the rural areas (SAOPF, 2012). In this regard, SAOPF contends that those alleged to be witches can be subjected to “jungle justice” by way of extrajudicial killings, burning, beatings or forced disappearance.

Similarly, in Gusiiland in Kenya, about six older persons face accusations of witchcraft every month (HelpAge 2021). In Uganda, older persons have also been shown to experience accusations of preventing rain in times of poor harvests, or causing the death of children in their communities (Namuddu, Barrett, Wandera, Okillan & Kasaija, 2014 cited by Wamara & Carvalho, 2022).

Discussion

Although customarily, filial piety was the bedrock of care and support for older persons in the African context, this age-old kinship system has been destablised by the forces of modernisation, urbanisation and globalisation thereby exposing them to vulnerability. Their plight is exacerbated by the lack of, or fragmented and rudimentary nature of social protection measures for this population group. As a result, older persons in East and Southern Africa, as elsewhere in many countries in the Global South are experiencing a myriad of challenges, chief among them being poverty.

Although it is laudable that most of the countries in East and Southern Africa have introduced social pension/grants to address the syndrome of poverty in old age, this remains a major challenge facing older persons in these regions. This is primarily because the social pension/grant is often very little and inadequate and cannot be expected to take recipients out of poverty, let alone meet their needs for food, housing, clothing and healthcare.

Moreover, old age pension and other cash transfer schemes that exist only target household poverty and are not designed to empower older persons for independent living. Their focus is to maintain the minimum living standards and to satisfy the immediate needs of vulnerable people. Yet, independent living is one of the fundamental human rights of older persons in terms of the United Nations Principles for Older Persons (UN,1991), African Union (AU) Policy Framework and Plan of Action on Ageing (African Union & HelpAge International, 2002), among others.

Furthermore, although social pension schemes for older persons exist in most EAC countries and  in Southern Africa, these are inadequate in addressing the underlying structural causes of poverty and the social challenges they face. Thus, whilst the social work profession still carries features of a residual nature, there is a general consensus among practitioners, educators, clients and policy makers that a developmental social work approach, also referred to as the developmental approach or social development, is the most appropriate to tackle issues of poverty and underdevelopment (Lombard, 2014). Moreover, the developmental approach is about empowering participants (older persons) to become self-reliant and not depend on state assistance.

Hence, social workers need to adopt a developmental approach in the provision of services to older persons to address the problem of poverty. Implementation of the developmental approach involves projects, programmes, building assets for the poor, community development, promoting productive employment and the development of policies as catalysts for progressive change (Midgley, 2014). Poverty eradication, which is Sustainable Development Goal (SDG 1), is central to the achievement of the UN 2030 Agenda for Sustainable Development. The achievement of SDG 1 is critical in the development process in that it intersects with other SDGs such as achieving zero hunger (SDG 2), good health and well-being (SDG 3) and inequality (SDG 10), all of which are challenges confronting older persons in the EAC and Southern Africa.

The lack of identity documents for proof of age and citizenship required to access cash transfers also excludes some older persons in East and Southern Africa from benefiting under these schemes. Ironically, cash transfer schemes are the only potential sources of income for the poor in many developing countries. Given that in terms of the Universal Declaration of Human Rights of 1948, a national identity document is a basic human right for all the citizens in any given country, this accentuates the need for social workers to carry out advocacy to ensure the issuance of national identity documents by the relevant government departments. Hence, social workers should collaborate with the government Ministries/Departments responsible for national registration to ensure that older persons get identity documents to enable them to access the services they require. This, to some extent would contribute towards alleviating poverty among older persons.

The right to health, social protection, and well-being throughout the life cycle are some of the inalienable human rights of older persons enshrined in the Madrid International Plan of Action on Ageing (MIPAA) 2002. Considering that the health status of older persons is generally poor, they require advocacy for the provision of age-friendly health systems as well as efficient geriatric healthcare services. This is particularly important given that many people are now living longer into old age, which inevitably increases demand for health care services. As such, it is important to promote healthy ageing.

Moreover, diseases afflicting older persons affect their functional capacity, thereby exposing them to vulnerability and dependency on other people for their survival. On the same note, it should be understood that the onset of some of the ailments can be delayed or even prevented, with timely intervention. Hence, intervention to enhance and maintain the functional capacity of older persons is a crucial component in promoting healthy and successful ageing.

Also requiring attention is the problem of subjecting older persons to waiting for a long time in queues to access health services, which is an affront to their dignity and well-being. The right of older persons to healthcare is stipulated in MIPAA 2002, and the United Nations Principles for Older Persons Resolution 42/91, which most if not all of the EAC and Southern Africa countries have ratified. As such, social workers should advocate for a “no queuing” policy or separate queues for older persons at hospitals and other service points to ensure that they access the services they require.

Concerning elder abuse, manifested through accusations of witchcraft, which is common in both the EAC and Southern Africa, social workers have an ethical obligation to safeguard and and protect older persons against this form of abuse. Considering that the consequences of witchcraft accusations are demeaning and can lead to loss of life, social workers should engage in advocacy and awareness raising on the rights of older persons to protection and dignity, among others. This is important as older persons are likely to live in constant fear of being accused as witches. Moreover, these potential risks heighten their vulnerability to abuse, neglect and abandonment, thereby necessitating proactive intervention to avert such forms of abuse.

Thus, on the basis of the foregoing and also from a human rights perspective, older persons require protection from all forms of abuse. This is in line with the United Nations Principles for Older Persons 46/91 and the MIPAA 2002, which emphasise the protection of older persons from abuse, to promote their well-being. Even more important is that social workers have an ethical responsibility to provide services to older persons who are a marginalised population group. It is therefore ironic that older people represent the most neglected target group in the EAC, with only 1% of social work interventions explicitly targeting this age group (Twikirize, Spitzer, Wairire, Mabeyo & Rutikanga, 2014).

It is also important to note that some of the challenges faced by older persons in the EAC and Southern Africa are not as a result of the absence of policies and legislation but the failure to implement existing ones effectively. As an example, although the EAC countries, namely Kenya, Uganda and Tanzania, have adopted national policies on ageing (Spitzer & Mabeyo, 2017), they are not backed by effective implementation plans. The aforementioned authors cite the example of the Tanzanian National Ageing Policy of 2003, which provides for the promotion of healthcare, rights to participation and income security for older persons, which has not been fully implemented. Similarly, Lesotho has a relatively comprehensive policy for older persons namely, the Lesotho Policy for Older Persons of 2014, whose provisions are not being fully implemented. In this regard, it is incumbent upon social workers to lobby parliamentarians and to advocate for the full implementation of policies for older persons.

Conclusions

Like elsewhere globally, the population of older persons in East and Southern Africa is increasing. However, this is happening against a backdrop of diminishing inter-generational solidarity and a  demographic shift that is yet to be matched with the resources, skills and government commitment to respond to the needs of the growing number of older persons. As a result older persons in East and Southern Africa face numerous challenges, chief among them being poverty. Furthermore, although most of the countries in the EAC and Southern Africa have cash transfer and social pension schemes, their focus is still to maintain the minimum living standards and to satisfy the immediate needs of vulnerable people, older persons included. What is critical though, are interventions that not only satisfy the immediate needs of older persons, but also create opportunities for their long-term social security. Furthermore, although there are policies providing for the needs of older persons in these countries, they are not being fully implemented owing to the lack of resources and political will. Hence the challenges of poverty, food insecurity, elder abuse, ageism and social exclusion, among others, that older persons in East and Southern Africa are facing.

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Author´s Address:
Jotham Dhemba
Department of Social Work and Sociology, University of Eswatini, Eswatini
G8C4+9P8, Kwaluseni, Eswatini
jdhemba@uniswa.sz