By Hilda Owii, Research Officer, APHRC
A growing number of Africans are experiencing an increase in life expectancy and survival to older ages. A longer old age, however, may involve not only an extension of good health but also periods of chronic illness and disability which require long term care- encompassing routine personal care for individuals with functional limitations. There are expectations that the demand for long term care will increase with the projected rapid increase in Africa’s older population.
Across the continent, the family plays a key role in the provision of care for elders. In the familial context, the organization of care is largely left in the hands of women in the family who face, inadequate recognition of their role and support for their contributions and pronounced risks of social exclusion and poverty. Further, economic and social changes in Africa such as, smaller family size, migration of adult children, increasing survival at older ages, and growing numbers of women joining the labor force, have lent to shifts in the organization of long term care by the family.
While social norms are prone to change, care for older people must be recognized as a priority human right. As such, society’s commitment to care work needs to be strengthened and positive attitudes towards care for older people upheld. The following popular myths and misconceptions about aging and long term care need to be taken seriously in order to develop appropriate approaches to long term care within contemporary African societies.
Misconception 1: families are able to provide adequate and sustained long term care without external support
The preference of aging in place has long been a feature of African societies. Long term care for older people has been bolstered by cultural values such as, filial piety which has placed normative obligations on family members to provide care towards ageing parents. Many governments in Africa have reinforced this care pattern through policies inscribing the family as the first line of support. However, little consideration has been given to ensuring appropriate and quality long term care for older family members, and, less to the barriers and the often adverse impacts that their caregivers face.
On the one hand, being with the family does not guarantee emotional or social wellbeing for care recipients- going by numerous reports of elderly abuse and exploitation. On the other, while caregiving can be beneficial for caregivers in terms of their self-esteem, it is often a full time engagement, which reduces its compatibility with full time employment. Caregiving may also cause burnout and stress, potentially leading to worsening physical and mental health for caregivers and eventual losses in human capital.
In assessing the future of family caregiving for dependent older persons in Africa, it is important to recognize that the context is changing. Policy decisions should therefore be shaped with the objective of alleviating the burden on family caregivers and reducing the economic and social costs associated with caring responsibilities. For instance, depending on the intensity of the care needs, families can get support from formal care professionals who perform certain care tasks in the home environment.
Overall, this calls on research to pinpoint the socio-economic consequences of changes within the continuum of care between informal and formal caregivers, and how these care arrangements affect families’ willingness to provide informal care.
Misconception 2: formal long term care services are inappropriate for Africa
While promoting options to provide support to family care is crucial, it is also important to rethink and reflect on the heterogeneity of family care arrangements and the need to complement and support these with flexible approaches. Although largely at very early stages of development, formal care resources (private homebased care provided exclusively in the home, and community based care models such as in day centers, or under arrangements made for respite care) are already finding an increasing market in parts of Africa. This implies that perceptions on formal care provision for older people may be shifting away from ‘taboo’ to a redefinition of filial piety where, if family members are unavailable or unable to provide direct care, they can substitute their filial duties by seeking appropriate formal care alternatives- even if as a last resort. If this trend continues, the position of formal long term care services is likely to hold greater significance in the foreseeable future.
Available evidence suggests that the use of trained, professional caregivers and advanced care facilities, that formal care services typically allow, can confer unique benefits by reducing unmet need and potentially improving the quality of care, deferring functional declines among care recipients and the expenditure on healthcare.
However, since evidence on the scope and operation of formal services is scanty, the extent to which formal care can substitute or supplement filial care in Africa, and to which an appropriate balance between the two can be achieved, remain open questions.
Misconception 3: long term care services equate to ‘institutional’ care
In Africa, formal long term care is widely perceived in relation to institutionalization and/or an abdication of family responsibility towards elders that is blamed for disruptions to kin relations and social networks. It may be that holding on to this pervasive misconception has to a large extent posed dire consequences for quality of life of functionally dependent older people, their families, and in particular for the health and lives of women who, as already pointed out, are the main family caregivers.
As earlier indicated, approaches are emerging in parts of the continent that combine assistance within the home environment and/or provide a supporting system of health care and social services within communities, without necessarily replacing the family care role.
Misconception 4: long term care has no economic implications
Key among the issues regarding long-term care for older people in Africa are: making visible the roles played by both informal and formal caregivers, their contributions to sustainable long term care arrangements, and the actual hidden costs of these contributions both for caregivers and for other sectors of the economy.
From an economic perspective, there are various primary benefits that may be derived from establishing comprehensive long term care approaches, include avoidance of complications for older people and wider benefits achieved through their participation in society, reduced health-care utilization and health-care costs, labour productivity gains where the working age population is concerned, reduced caregiver burden, and ripple effects to other economic sectors with corresponding long term care activities.
Importantly, policy priorities should aim to develop ways of linking the contributions made by long term care providers to the growing demands for care across Africa for a sustainable long-term care workforce for example, by developing and formalizing skills acquired by informal caregivers into employment-based competencies. Governments should also aim to expand and improve the attractiveness and accessibility of long term care services particularly, for women and youth among whom the unemployment gap is most severe, thus increasing human capital while providing access to urgently needed services.
The Common Africa Position on Long Term Care Systems in Africa
As populations in Africa grow older and the need for long term care expands, families, communities, private-sector actors, and governments will find themselves increasingly responsible for this care. To develop effective responses, the diversity and changing nature of care as well as the social forces affecting them, will need to be better understood and recognized. A roadmap expanding on the changes needed in society to dispel the foregoing self-perpetuating myths of ageing and long term care and enable Africa establish quality and appropriate long term care systems, would be valuable.
The African Union’s Executive Council Decision, to adopt the Common Africa Position (CAP) on Long Term Care Systems in Africa (July 2017) offers such an initial valuable resource. The CAP – designed as a generic model that countries across Africa can adapt to suit their local situations – offers recommendations for several target groups: the African Union, African Union Member States, and international development partners on a broad range of issues and actions, particularly in contexts where long term care agendas are now taking off.
Following adoption of the CAP, the African Union Commission recently released formal communication to create awareness among African governments. This presents a historic opportunity to develop a continent-wide framework for appropriate care systems that include oversight, regulation and other accountability mechanisms to ensure quality care.
Africa stands to benefit in the long run. Investing our resources in appropriate LTC services yields dividends down the road for our society as a whole, in the form of better opportunities for family caregivers and families, lower long term health costs, and improved dignity, respect and rights of our elders.