As economies develop, they tend to go through three stages of medical development:
Stage 1: In the least developed economies, people die at home. Health services are typically limited and provided mainly through outpatient clinics.
Stage 2: As economies become increasingly successful and medical facilities are more widely available, people turn to healthcare services to address ageing issues. A larger proportion of the population is likely to die in a hospital than at home.
Stage 3: In the most prosperous economies, quality of life starts to play a more critical role in decision-making. Here, even in sickness, people would rather go home to die1.
South Africa is designated a lower-middle-income emerging economy by the United Nations. We are less developed but not least developed2.
In 2015, an index produced by Natixis ranked South Africa 130th out of 150 countries in retirement welfare, using four themes to cover key aspects of the retirement experience:
Figure 9: Natixis Global Retirement Index: retirement experience themes
Figure 11: Understanding South Africa’s rankings in the Natixis Global Retirement Index
The reason South Africa ranked so poorly was a function of combined extremes.
On the positive side, South Africa has a Declaration of Rights for Old People. We have relatively high pension coverage (92.6%) thanks to our non-contributory state pension, the Older Person’s Grant. That said, this pension is just R1 510 a month. But, importantly, we also have a high rating (relatively) on quality of life and one of the highest quality healthcare systems. If we consider only the private sector component of healthcare, this competes with world-class facilities elsewhere.
On the negative side, our image as a retirement destination is marred by perceptions of widespread poverty and an HIV/AIDS problem that has ‘hollowed out’ our caregiving resources. Our measure of material well-being (only 8%) was the lowest of all countries assessed. This measure assesses factors such as income per capita, unemployment levels and income equality. It’s the fact that we remain so much a ‘barbell economy’ that’s problematic. For higher income groups, retirement in South Africa can be highly desirable. For lower income groups, this is almost untenable without the support of family. The report points out that although older people are integrated into a development framework, there is no clear strategy for implementing this framework, or insight into who should be responsible for such a strategy.
If we scan the studies that assess the ageing experience in South Africa, the litany of issues is particularly concerning. These are highlighted as follows:
South Africa is not short of innovative ideas about how to deliver more effective, humanistic long-term care solutions.
What can we conclude then from this lengthy discussion of ageing in South Africa? The data is starting to tell an important story. While the attention of policymakers is focused on the issues of our youth and unemployment, demographic changes – specifically increasing longevity and urban migration – are placing an increasing strain on our assumptions that a culture of reciprocity will mean that families will take care of their elders. The title of one study on this phenomenon says it all: Who will take care of the caregivers? What will happen in the absence of a policy focus? The biggest issues lie not with ‘who’ and ‘how’ but rather with ‘what funding’ and ‘if funding exists, who ensures that it is properly administered?’
Potentially the answer may lie with the private sector, or with a hybrid for-profit/notfor- profit model. Probably one of the most successful models for funding long-term care solutions for both those who can pay and those who can’t is the Rand Aid Association, a non-profit organisation that addresses the needs of both older people who can pay for long-term care facilities and those who can’t. Two elements of the Rand Aid model make it stand out:
If we really want to start thinking creatively here, then perhaps it’s time that South Africans consider a model that has already been put to good use in both Japan and Germany. Both countries experience a double whammy when it comes to providing longterm care to their ageing population. Not only are medical care and caregiving expensive, but there is a serious shortage in locally sourced caregivers. The answer for many lies in a transnational care model. For the Japanese, the Philippines plays a key role. Any number of nursing homes have been set up by Japanese and Filipino businesses to take advantage of low medical care costs, the availability of English-speaking health professionals, and an attractive setting with a desirable climate. This is simply another variation of ‘medical tourism’, a phenomenon that has already proven to be an important foreign revenue generator for South Africa.
While this certainly challenges the notion that older people would prefer to stay near their loved ones, or are unwilling to make such drastic changes late in life, in European and North American contexts, finding lower-cost alternatives for retirement is making this a ‘must-consider’ option.
Consider what the implications could be for South Africa if such a model became more fully developed:
What makes this model particularly attractive is that it builds on aspects of strength for South Africa:
It could work!
The Eden Alternative is an international not-for-profit organisation dedicated to transforming care environments into habitats for human beings that promote quality of life for all involved. The brochure on The Eden Alternative uses the term ‘culture change’ to describe how the initiative is transforming our notions of long-term care globally.
Their care model advocates a shift from institutional models of care to person-directed values and practices that put the person first. This means it focuses on the unique needs, preferences and desires of each individual. Decisions and actions for care reflect the choices of the people receiving care, as opposed to standard routines designed to suit the care-giving institution. For The Eden Alternative, self-determination and purposeful living are at the heart of quality ageing. That means preserving choice, dignity and respect throughout an individual’s life is paramount. As a living environment, The Eden Alternative recognises how life-enhancing a steady flow of exposure to youth, animals, plants, the outdoors and a rich and diverse daily life can be for the elderly.
But where The Eden Alternative has had its greatest impact is in the training of the carer. The Eden Alternative model for caregiving training infuses a much-needed sense of purpose into the caregiver’s function. Here, caregivers are provided with the skills and tools to add real value to their patients’ lives. This training can be applied to caregivers servicing people in a retirement residence, the community or their homes. This makes it a model that is ideally suited to caregiver training in South Africa.
Perhaps the most chilling cautionary around the issue of ageing in a world that is making extraordinary medical studies is the one Gratton and Scott pose to governments, echoed in Yuval Noah Harari’s book, Homo Deus. All of these authors see health inequality as being the biggest challenge of longevity.
For Gratton and Scott, the problem is as follows:
“Life expectancy gains are not spread equally across the population and an ever-widening gap between rich and poor is developing within countries. It is also clear that many of the options we explore to make the most of a 100-year life are most easily available to those with professional or technical backgrounds with high income. A long life requires resources, skills, flexibility, self-knowledge, planning and respectful employers. The danger is that the gift of a long life will only be open to those with the income and education to construct the changes and transitions required14.”
For Harari, inequality of health could be an even greater disruptor to social order than financial equality. Here we return to our discussion of the Fourth Industrial Revolution and remember that, in addition to robotics and artificial intelligence, this revolution incorporates biotechnological advances. Harari paints a fairly realistic picture of a future where we have so mastered the art of body-part replacement and genetic re-engineering that amortality (not quite immortality) is within reach. He argues, though, that if only the wealthiest had access to these developments, we could well see the emergence of what he terms ‘biological castes’. There would be a segment of the population that could afford upgraded bodies and access to unprecedented creativity and skill enhancements and then there would be the rest of humanity. It’s a concept that might seem extreme to contemplate – but is it entirely outside the realm of possibility?
What it does suggest is that we start paying close attention to how health, ageing and caregiving play out in South Africa, lest this climate of inequality increase further.
1 Gawande (2015), p. 192.
2 Harper, S. 2016. How population change will transform our world. Oxford: Oxford University Press. p. 182.
3 Statistics South Africa. 2014. Census 2011: Profile of older persons in South Africa. Pretoria: Stats SA.
4 Kalula, S. 2016. Ageing and health in emerging economies: policies and programmes in South Africa. International Longevity Centre South Africa: University of Cape Town.
5 TAFTA website: www.tafta.org.za.
6 Samson Institute for Ageing Research (SIFAR). Assessing the needs, health and well-being of older adults in Cape Town, South Africa.
7 Statistics South Africa. 2014. Census 2011: Profile of Older persons in South Africa. Pretoria: Stats SA.
10 Department of Social Development. 2010. Final report: audit of residential facilities, April 2010.
11 Department of Social Development. 2010. Final report: audit of residential facilities, April 2010.
12 World Health Organization. 2015. World report on ageing and health. p. 16.
14 World Health Organization. 2015. World report on ageing and health. p.12.