Peter Lloyd-Sherlock

Hypertension among older adults in low- and middle-income countries: prevalence, awareness and control

Background This study uses data from the World Health Organization’s Study on Global Ageing and Adult Health (SAGE) to examine patterns of hypertension prevalence, awareness, treatment and control for people aged 50 years and over in China, Ghana, India, Mexico, the Russian Federation and South Africa. Methods The SAGE sample comprises of 35 125 people aged 50 years and older, selected randomly. Hypertension was defined as ≥140 mmHg (systolic blood pressure) or ≥90 mmHg (diastolic blood pressure) or by currently taking antihypertensives. Control of hypertension was defined as blood pressure below 140/90 mmHg on treatment. A person was defined as aware if he/she was hypertensive and self-reported the condition. Results Prevalence rates in all countries are broadly comparable to those of developed countries (52.9%; range 32.3% in India to 77.9% in South Africa). Hypertension was associated with overweight/obesity and was more common in women, those in the lowest wealth quintile and in heavy alcohol consumers. Awareness was found to be low for all countries, albeit with substantial national variations (48.3%; range 23.3% in Ghana to 72.1% in the Russian Federation). This was also the case for control (10.2%; range 4.1% in Ghana to 14.1% India) and treatment efficacy (26.3%; range 17.4% in the Russian Federation to 55.2% in India). Awareness was associated with increasing age, being female and being overweight or obese. Effective control of hypertension was more likely in older people, women and in the richest quintile. Obesity was associated with poorer control. Conclusions The high rates of hypertension in low- and middle-income countries are striking. Levels of treatment and control are inadequate despite half those sampled being aware of their condition. Since cardiovascular disease is by far the largest cause of years of life lost in these settings, these findings emphasize the need for new approaches towards control of this major risk factor.

Population ageing in developed and developing regions: implications for health policy

Population ageing is now recognised as a global issue of increasing importance, and has many implications for health care and other areas of social policy. However, these issues remain relatively under-researched, particularly in poorer countries, and there is a dearth of specific policy initiatives at the international level. For example, the 1994 International Conference on Population and Development agreed to 15 key principles for future policy, but none of these even make indirect mention of the aged (International Conference on Population and Development, 1995, Documents. Programme of action of the 1994 International Conference on Population and Development. Population and Development Review, 21(2), 437-461). This paper seeks to highlight some of the key issues arising from population ageing. It begins with a brief overview of international trends in demographic ageing, and considers the health needs of different groups of older people. It sketches out some implications for policy, paying particular attention to the financing and organisation of health services. The final part of the paper contains a discussion about how older people have been affected by, and have adapted to, processes of social, economic and political change. Given the wide scope of these concerns, it is not possible to discuss any issue in detail, and the paper does not claim to give the subject matter a comprehensive or global treatment. It must be stressed that patterns of ageing and their implications for policy are highly complex and variable, and, as such, great care should be taken in generalising between the experiences of different groups of older people, and between different settings.

The World report on ageing and health: a policy framework for healthy ageing

Although populations around the world are rapidly ageing, evidence that increasing longevity is being accompanied by an extended period of good health is scarce. A coherent and focused public health response that spans multiple sectors and stakeholders is urgently needed. To guide this global response, WHO has released the first World report on ageing and health, reviewing current knowledge and gaps and providing a public health framework for action. The report is built around a redefinition of healthy ageing that centres on the notion of functional ability: the combination of the intrinsic capacity of the individual, relevant environmental characteristics, and the interactions between the individual and these characteristics. This Health Policy highlights key findings and recommendations from the report.

Old Age and Poverty in Developing Countries: New Policy Challenges

Almost all developing countries are now experiencing demographic ageing. This paper examines the consequences of ageing for the poor. It assesses the extent to which the poor are participating in demographic ageing, or whether the process is largely restricted to relatively privileged groups. The paper observes that policy and research mainly focus on pensions programs, which have little relevance for most poor older people. It then describes livelihood patterns for poor elders, highlighting the importance of intergenerational exchange. Health policies are also found to largely ignore the needs of this group, and the expansion of private financing presents particular problems.

Population ageing and health

www.thelancet.com Vol 379 April 7, 2012 1295 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ agenda, there are worrying signs of discrimination against older people. Background documents from the UN High-Level Meeting in September, 2010, describe the deaths of people younger than 60 or 70 years as “premature mortality”, implying that deaths of people at older ages should receive a lower priority. If we do not challenge existing policy paradigms and the social attitudes that underpin them, population ageing might indeed lead to a crisis in the provision of health and welfare services. Instead, we should see it as a welcome opportunity to challenge outdated public perceptions, political priorities, and policy models. This challenge will include reorientating health and welfare models to deliver more effi cient, equitable, and sustainable interventions. It might also include the diversion of resources from consumer spending, which in many countries has risen spectacularly over the past 30 years, towards meeting the needs of vulnerable people, whatever their age. This is an overtly political challenge; responding positively to it will benefi t people of all ages in all societies.

Social policy and economic development in South America: an historical approach to social insurance

Abstract This article examines the structural and organizational problems facing social insurance systems in Brazil and the Argentine through the twentieth century. It provides insights which inform contemporary debates about pension reform in Latin America. This area of social policy intervention is central to ongoing analyses of state competence and state capacity that in turn inform efforts to theorize about the state. Much of the present discussion depicts social insurance ‘crisis’ as a modern phenomenon. Similarly, preoccupations with the macroeconomic objectives of reform, such as the promotion of profitable pension funds as an adjunct to capital market deepening, long-term sustainability, equity and coverage, are often assumed to be peculiar to the late twentieth century. By contrast, this article stresses the generational and cyclical nature of the crises that have plagued social insurance regimes in both countries. It notes that pension funds established for influential groups of workers in the early twentieth century quickly developed substantial deficits and that this was a key factor driving the extension of social insurance (and hence the pool of contributors). Financial instability was exacerbated by states frequently raiding pension funds in lieu of effective fiscal systems. As part of this, the article analyses historic shifts between different social insurance ‘models’ (individual, capitalized accounts versus pay-as-you-go schemes and monopolistic state systems versus competitive arrangements), evaluating their impact on coverage, equity, financial stability and administrative effectiveness. The article also identifies what may be learnt from differences, as well as similarities, between the two systems. Key points of divergence include the relatively large historic role of the private sector in Brazil and the earlier substantive provision for rural workers there. These differences call into question assertions about the common nature and origins of social insurance crises in Latin America, and in turn about the nature of the state itself. The article finds that, unlike models of Western European welfare capitalism with which they are sometimes compared, social insurance regimes in Brazil and the Argentine were precocious and institutionally fragile. They were also ad hoc and subject to repeated ‘reform’. For much of the second half of the twentieth century, the economic weight of the state in middle-income Latin American countries (particularly as regards economic outreach and social policy interventions) seemed to approach that of socialist countries in Eastern Europe. Yet the ‘ideology’ of growth often owed more to liberal capitalism, echoing East Asias emphasis on ‘state-supported late industrialization’. These contradictions are neatly captured in the historical trajectory of social insurance systems, which demonstrate that Latin American does not fit neatly with categorizations established in the varieties of capitalism discourse.

Is hypertension the new HIV epidemic

At first sight, this seems a ridiculous, crassly attention-grabbing assertion. HIV infection is a sexually transmitted infectious disease; hypertension is neither of these things. HIV is a major global health priority and is recognized as a serious threat to public health and development in many poorer countries. Hypertension is seen as a disease of the West, of prosperity and therefore of little relevance to poorer countries. Yet, these two conditions have a number of important things in common. Hypertension and HIV infection are both mostly asymptomatic, but can lead to fatal and disabling illness. It is estimated that in 2013 hypertension was responsible for at least 45% of deaths due to heart disease and 51% of deaths due to stroke.1 Between 2000 and 2013, the number of deaths attributable to hypertension rose from 7.6 to 9.4 million.2,3 Projections based on available data indicate that the number of deaths attributable to hypertension over the next 20 years may well exceed substantially the number resulting from HIV/AIDS. This is not just true on a global scale, but for most low- and middle-income countries. In Africa, the global burden of disease attributable to non-communicable disease is projected to increase by 27% over the next 10 years.4 Hypertension and HIV are both quite easily diagnosed through simple screening tests, particularly so with hypertension. Thanks to the roll-out of antiretroviral drugs, HIV is becoming a chronic health condition which can be managed through a combination of drug therapies and lifestyle change. This is also true for hypertension, and effective drugs are generally cheap and easily administered. From a health services perspective, chronic HIV infection and hypertension pose very similar challenges: they share the need for life-long treatment, regular monitoring and a reliable drug supply. As such, they require a major reorientation for health systems that are generally geared towards dealing with acute rather than chronic problems. For Africa as a whole, WHO estimates that antiretroviral therapies (ARTs) are now provided to over half the population who are eligible.5 By contrast, new WHO data for Ghana and South Africa show that less than 10% of people with hypertension had access to effective treatment.6 One reason for low treatment rates is that, as with HIV/AIDS, the asymptomatic nature of hypertension means most people living with the condition remain unaware of it until major pathological damage has happened. For example, a recent systematic review of hypertension studies for Africa found awareness ranged from 10% in Ghana to only 8% in Gabon.7 In the early stages of the pandemic, HIV was not a condition associated with poor countries, but that perception quickly changed. Similarly, the view persists that hypertension is mainly a disease of the West, despite the growing body of evidence that prevalences in poorer countries are quickly catching up. Indeed, in some cases they are already higher than in the West. As with HIV, South Africa has one of the highest rates of hypertension anywhere in the world.6 And as in the early stages of the HIV pandemic, the rapid spread of hypertension to rural areas in poor countries8 comes as a surprise. Risk factors associated with hypertension such as obesity, lack of physical exercise and unhealthy nutrition are believed to be urban problems in low-income countries. Yet, prevalences of hypertension in rural districts are already high9,10 and in some cases have fully caught up to urban levels.11 Whereas hypertension is not an infectious disease, the risky behaviours associated with it are spreading fast and seem to be as effectively transmitted as infectious agents. The classical divide between urban and rural areas is fast becoming blurred. HIV was faced with political denial and public misunderstanding in the early years of the pandemic, especially in some poorer countries. There is a similar pattern of denial with hypertension. Worryingly, this can also be seen at the international level: hypertension and associated cardiovascular conditions accounted for less than 3% of global health assistance between 2001 and 2008.12 This denial is based on the misguided view that hypertension does not affect poorer social groups. Yet there is substantial evidence that hypertension is highly prevalent among poorer groups and that they are less likely to have access to effective treatment.6 As with HIV, hypertension can be both a cause and a consequence of poverty. For example, a national survey in China found that 37% of patients and their families fell below a US

Population ageing and international development: from generalisation to evidence

1-a-day poverty line within 3 months of experiencing stroke.13 Rather than being understood as a condition of poverty, HIV remains a highly stigmatized condition and continues to be blamed on irresponsible personal behaviour. To some extent the same is true of hypertension, which is causally linked with behavioural factors such as obesity, high salt intake and alcohol consumption and tends to cluster with other risk factors—smoking, physical inactivity—for cardiovascular disease. In the West it is increasingly recognized that explaining these behaviours in terms of individuals’ moral shortcomings is unhelpful and misses the bigger picture of structural and environmental causes. There is less evidence of this enlightened approach among policy-makers in poorer countries or in international agencies, who struggle to persuade funders and taxpayers to help people who ‘eat and smoke too much’. The 2011 UN Assembly of Heads of States noted with concern that ‘the rapidly growing magnitude of non-communicable diseases (NCDs) affects people of all ages, gender, race and income levels, and … that poor populations and those living in vulnerable situations, in particular in developing countries bear a disproportionate burden’.14 Several developing countries have set up national NCD control programmes, but most of these remain a low priority and implementation creeps along with frustrating slowness: a situation very reminiscent of the slow build-up of AIDS control programmes in developing countries prior to 1990. Recent editions of IJE have featured a debate about the extent to which global health policy priorities should shift from infectious diseases such as HIV to non-communicable diseases such as hypertension.15–23 This debate has mainly pivoted on a social gradient ‘beauty contest’, disputing the pace at which conditions such as hypertension are spreading to relatively poorer groups. As argued by Remais et al. in IJE, rather than framing policy as a choice between competing priorities, the key challenge is to roll out services and interventions which address both.24 At the same time, it has been suggested that valuable lessons regarding hypertension could be taken from HIV/AIDS policies.25 Yet there is little indication that these lessons are being taken on board. Our response to the global epidemic of hypertension seems little better than our response to HIV/AIDS two decades ago: too little too late. Can we not wake up earlier this time, before millions have died?

Failing the needy: public social spending in Latin America

Introduction International development and demographic ageing Experiencing later life in a context of development Income security in later life: work, social protection and pensions Health trends and policy options Older people in society: families, social networks and the care economy Case study: South Africa Case study: Argentina Case study: India Conclusion.

Formal Social Protection for Older People in Developing Countries: Three Different Approaches

The paper accounts for the failure of public social spending in Latin American to reach poor and vulnerable groups of the population. It considers the level and allocation of expenditure; the distribution of entitlements across the population and the capacity of different groups to mobilize these entitlements. Whilst total spending levels compare favourably with other developing regions, only a small share is allocated to programmes with greatest potential for poverty reduction. Poor and vulnerable groups enjoy a much narrower range of entitlements than less needy sections and have greater difficulty in mobilizing these entitlements. Recent reform programmes have done little to reduce these inequitable effects. Copyright