Madrid international plan of action on ageing – some reflections

Introduction: The World Assembly on Ageing in 2002 came out with ‘The Madrid International Plan of Action on Ageing’ as guidance to member countries of the UN to plan their development policies by focusing on their respective population ageing pattern, current and projected. However, even after over twenty years since the document was signed by UN member countries to address multiple dimensions related to ageing issues, still certain challenges need attention, especially in countries where development resources are a constraint and populations ageing rapidly as seen for instance in South Asia as well as in Southern Africa and South America.

Methods: This article based on the available literature, reports, and author’s research reviews the progress of MIPAA globally, specifically in South Asia, and generally in regions of Southern Africa and South America given their certain special similar socioeconomic and demographic characteristics.

Result: The challenges faced globally and especially in these regions are analyzed through a review of the implementation of MIPAA. To what extent these specific regions given their circumstances have been able to adopt the long-term strategy of MIPAA and develop a perspective on building a society for all ages by forging partnerships between different stakeholders from a right-based approach is reflected in this discourse.

Conclusion: In the context of South Asia specifically and to some extent for other regions, certain suggestions are voiced out in removing respective shortfalls and taking forward the global guidance of MIPAA in the coming years.

Abbreviations

AU: African Union; MIPAA: Madrid International Plan of Action on Ageing; ESCAP: Economic and Social Commission for Asia and the Pacific; ILO: International Labour Organization; LASI: Longitudinal Ageing Study in India; SDGs: Sustainable Development Goals; UN: United Nations; UNDP: United Nations Population Division; UNFPA: United Nations Populations Fund; WHO: World Health Organization.

Introduction

Population ageing is a significant aspect of societies in the 21st century and the next 3 decades or so. The continuous increase in the number of older persons who as per projections would be 1.5 billion aged 65 years or over in 2050 in the world, almost double from 703 million in 2019 [1] calls for a serious review of the implementation of MIPAA which is a new bold agenda for addressing emerging ageing issues framed in 2002 by the UN Member countries by focusing on the 3 priority areas: older persons and development; advancing health and well-being into old age; and ensuring the existence of enabling and supportive environments. Population ageing is seen as an indicator of social and economic progress heralded by improved levels of health, with lowering of mortality and morbidities over the years due to the use of scientific knowledge and favorable development policies encourages us to think of population ageing as a cause of celebration [2]. But the achievement seen in increased longevity of populations also contributes towards rising challenges in maintaining health care systems and social institutions to cater to the growing needs of older people [3] as well as protect their rights [4] in all ageing societies but especially in nations which still have a substantial proportion of younger populations. The constraint of development resources and where rapid population ageing is happening, namely the low and middle-income regions and specifically South Asia, along with Southern Africa and South America in particular on which this article is based as covering all regions of the world was not workable given the limitations of a short reflection. In South Asia, a statistical review indicates that from the beginning of the 21st century, there has been a remarkable demographic transition with age structures changing rapidly and the proportion of older persons growing fast [5]. In Southern Africa, too data indicates that the proportion of older persons to the total population is increasing rapidly across the various decades in this century, for instance in 2020 statistics state that older persons were 8.9% and these are projected to rise to 17.9% in 2050 [6]. Similarly in South America, the proportion of older persons is expected to double between 2019 and 2050 [7].

MIPAA encourages countries to recognize that all citizens, young and old, have a role in building a future of security, opportunity, and dignity for people of all ages. There is a need for countries to promote solidarity between generations, have mechanisms in place to combat discrimination against older people, and put in place a comprehensive framework for the development of policies and programs concerning population ageing and older people [8]. To facilitate all this MIPAA presents 239 recommendations related to 35 objectives covering 18 issues consolidated under the 3 priority areas listed in the plan document, namely, 1) older persons and development, 2) advancing health and wellbeing into old age, and, 3) ensuring and supporting enabling environments which were endorsed by 159 UN Member States along with a Political Declaration [9] through the General Assembly resolution 57/167 and in its resolution 58/134 Member countries recognised the general guide for the implementation of the plan. This committed countries to a way of thinking about and acting upon the multiplicity of dimensions related to aging in the twenty-first century [10]. MIPAA thus stands out as a crucial comprehensive framework for adjusting to demographic transitions resulting in population ageing globally and as it gets implemented in different regions over the years it also works towards the aims of SDGs [11], which further anchors ageing on the global development agenda by stating “leaving no one behind”. In the 3 specific regions as part of the focus of this article, the common feature is that as demographic transitions are taking place, a significant window of opportunity is envisioned in the years ahead and it should be rapidly grasped.

Since 2002 when MIPAA was adopted by the Second World Assembly on Ageing, held in Madrid from 8 to 12 April a systematic review of its implementation initiated by UN organizations with the participation of governments and civil society agencies as well as older people has been happening at a 5-year interval to assess the Plan’s success in improving the quality of life of ageing populations. The United Nations Commission for Social Development in its resolutions 42/1, 44/1, and 45/1 decided that a review and evaluation of the implementation of MIPAA be carried out every five years with the help of the UN regional commissions within the framework of their mandates. These appraisals indicate that many initiatives engaging governments along with both civil society and older persons themselves have taken place the world over. They can be grouped as reflecting particular regions ageing situation by reviewing the respective nations’ demographic, social, economic, and political developments, and, in particular, the major challenges faced in relation to population ageing. These appraisals reflect the ‘bottom-up’ approach visible in the policies and programs implemented by the UN Member States at a regional and national level and suggest that action plans are adopted by the respective countries in developing socially responsible and future-oriented economic and financial strategies that can improve the image of older persons and acknowledge their contributions to society [12]. Yet when implemented some of the initiatives show limited successful outcomes due to various reasons, such as not appropriate use of available national resources to deal with the issues, or due to not adequate knowledge and experience in managing the needs of older persons, or because of not enough mechanisms in place to cater to varied ageing needs, etc. It is worthwhile reflecting on the challenges being faced by the global community and more specifically in the region of South Asia, and in comparison, to Southern Africa and South America, as all these represent special development and ageing characteristics. How are national plans since the adoption of MIPAA in these regions addressing the challenges of demographic transitions taking place, what kind of shortfalls are visible in meeting the needs of an increasing number of older persons showing diversity, heterogeneities based on age, gender, and socioeconomic features and what can be recommendations for future action?

Materials and methods

By drawing global information and also of specific regions, in particular of South Asia, and to some extent of Southern Africa and South America from a review of national ageing policies, specific programs, and initiatives as seen in the available literature, various UN reports including from WHO and the author’s own analytical analysis based on both primary and secondary research some of which is part of the author’s co-edited book on MIPAA [8] indicates a changing world over with different patterns in various societies since the adoption of the international ageing plan in 2002 by embracing positive view of human ageing. MIPAA pertinently led countries, especially the ones in South Asia, Southern Africa, and South America to think about the inclusion of ageing in their central and state policies and in addition to bringing in a development approach than a welfare orientation with regard to older persons in the national agendas. Thus, we can see a movement for mainstreaming ageing through various social and healthcare strategies, plans, and programs. The author’s attempt in this article is just to map the developments in these developing regions and more in detail for South Asia since MIPAA and not provide an analysis of the implementation or the impact of the ageing policies, which the author considers beyond the scope of this review.

At the global level, the traditional views of regarding older persons as dependents, linking old age only with frailty have changed towards working on policies in almost all regions of the world to make older persons independent, providing them with opportunities and using them as a resource in development planning for the country. However, the extent to which this has happened varies from region to region and from country to country. This change in overall perspective on ageing though with regional variations is also possible due to advances seen in the increasing number of older persons having ‘healthy’ life years. There is no doubt that while we generalize and put issues related to ageing under a global blanket, in terms of shared identity and destiny of comparable demography [13], however, an important caveat has to be kept in mind and it is that we cannot negate the huge diversity that exists across and within regions as each has their own socio-cultural, economic, geographic and political contexts. In many countries and especially in developing countries, for instance in South Asia [14], Southern Africa [15], and South America [16] on which the author focuses more as part of the author’s reflections, there have been attempts to improve public pensions, allowances, and benefits, in general, to provide better financial and income security and above all reduce the vulnerability of older people, towards risk of poverty. For instance, in Southern Africa, experts comment that greater attention has been paid to social policy that emphasizes cash transfers as a poverty alleviation mechanism for older people [17]. In South Asia, certain welfare measures have been taken for older persons but not so much for older women whose proportion in the population is steadily increasing, and those experiencing certain disabilities. It is interesting to note that in countries of South Asia, for instance, Afghanistan, India, Nepal, and Sri Lanka the percentage of older women is over half of the total population of sixty plus, 52.3%, 50.9%, 54.2% and 56.5% respectively [18]. MIPAA does emphasize specific and special planning for older women [19] yet in the case of South Asia it has been overlooked in most countries [20]. As regional reports indicate providing income and health security for older women in South Asia is an urgent need but so far has met with limited response while planning for policies and programs on ageing [21]. Interestingly, for the South American region, many initiatives have been taken to ensure ageing with dignity for both men and women. This region is known for establishing the Inter-American Convention on the Rights for Older Persons and Argentina has provided this convention constitutional status.

As part of implementing MIPAA different kinds of effective consultations and involvement of older persons have happened globally at different levels and are seen increasingly in designing proactive age-care policies. In South Asia India and Sri Lanka in particular, reports indicate that ageing concerns are becoming significant especially from 2005 onwards [22]. Various government initiatives can be observed for addressing issues of employment, better provisions for social security, pensions, and savings for the ageing population. Significantly, an outcome of implementing directions of MIPAA is seen in India through setting up a protocol for starting 2016 the first longitudinal study on ageing (LASI). This survey [23] uses world-standardized tools to capture pivotal aspects of the lives of older people such as their physical, health, and economic conditions along with various social security measures available for them. The study assesses their level of awareness of key indicators of the Active Ageing Index. In Southern Africa, too adoption of various accords is seen as part of following MIPAA Directions. Many countries have developed national policies on ageing [24] and based on WHO guidelines [25] different countries have adopted health systems that respond to the needs of older persons along with developing sustainable systems of quality long-term care provisions. It is remarkable that Argentina in South America over the last 20 years or so as stated by an expert [16] has included all its older adults in the pension system through which their basic needs are covered, though in recent times this has become unstable especially after the COVID-19 pandemic. It as a country is also an example for the region in offering care programs and services for older adults with an emphasis on gerontological education for care providers.

Globally volunteering of younger and older persons in mutually beneficial social and health care activities has been strengthened in many nations along with the development of age-friendly environments and housing. Many societies have progressed with the design of goods and services for older persons which are helping the ageing population in respective countries maintain improved levels of health and functional intergenerational relationships. However, despite age-friendly movement making inroads in many countries, in some more than in others, certain specific concerns of older persons are still unmet in countries of South Asia, Southern Africa, and South America in general. In particular, the limited response has developed over the years with regard to adequate and appropriate housing and transportation for ageing populations especially for those living in remote areas, slums, and marginalized communities. While steps have been taken to enhance the active social and civic participation of older persons, much more needs to be achieved for their adequate and appropriate inclusion in provisions for specific health and social care services and community support, in particular for end-of-life care. Many international development plans including MIPAA stress mainstreaming older people as an approach to meeting their needs. The author’s research shows that this intention was welcome in the South Asia region but practical application of it did not attract governments since they had difficulty in maintaining equity between generations and inclusiveness across development programs and plans [26]. Similarly, for the Southern Africa region available research shows that many gaps exist in provisions of health, long-term care, and social systems for older persons along the socio-economic and gender axes [6]. In addition, it is observed that older people remain behind the younger populations in accessing digital technology which can help in various ways to deal with managing day-to-day care [27]. As happened across the world, COVID-19 brought various hardships for older people along with other segments of the population, and the care crisis has been exacerbated [28]. Certain initiatives are being taken to include older people in using digital technology but preparing them for it requires many more efforts across the different groups of older people whose heterogeneity is becoming visible in almost all countries.

Most countries besides grappling with addressing existent and emerging unmet needs of ageing populations, are facing pivotal issues of combating ageism in many spheres that require urgent action. Elder abuse, which is on the rise in all societies is a serious menace for which solutions are not easy and requires consolidated public health, legal, and social perspectives to tackle it. This requires overcoming many challenges and, above all making older persons speak up against it. Increasing the visibility of elder mistreatment and violence as well as the growing physical, emotional, sexual, and financial abuse of older people is an urgent need in all societies in order to develop appropriate legislative mechanisms and community-based services to handle these cases from a human rights perspective [29].

Results

MIPAA has many recommendations to address various issues impacting ageing populations which are materializing in different forms as good practices under the 3 priority directions stated in the plan document. For the South Asia region, in the first decade after implementing MIPAA despite the resource crunch, progress was seen in accomplishing the 3 priority directions related to development issues, health concerns, and putting in place enabling environments. Bangladesh became a role model for initiating microfinance/credit schemes for older adults, Nepal for making provision for old age security for people over the age of 75 years, along with putting in place legal and institutional mechanisms towards fulfilling the rights of older adults, India for accomplishing providing adequate quality and quantity of health, economic and social care for its 60 plus population and Sri Lanka in making provisions for geriatric health services inclusive of mental health care along with domestic and nursing care within home environment [14]. Clearly, challenges remained as the growth in numbers of older persons with the majority living in poverty and rural areas exceeded the availability of provisions thus making critical measures for putting in place health, social care, and employment programs.

For the Southern Africa region various governments after MIPAA committed to establish or expand social protection measures. Different countries gave particular attention to cash transfers as a poverty alleviation mechanism. Some promising results are seen in countries such as Botswana, Lesotho, Namibia, and South Africa where the distribution of social pensions is seen to impact positively the living standards of older persons and their families [17]. It is also seen to increase intergenerational bonding as benefits are seen to percolate towards children too. In these developing regions of South Asia, Southern Africa, and South America remarkable steady progress is noticed with the health systems adapting to the needs of older persons especially in developing sustainable and equitable long-term care provisions with guidance provided by the WHO framework in recent years [30]. Directions from such frameworks facilitate the integration of long-term services within existing health and social care systems. Also, in tune with global initiatives, societies all over, even at different stages of population ageing are initiating practices to improve intergenerational relationships. In Asian societies, where living together of 2-3 or even 4 generations under the patriarch or the matriarch was the norm are being modified to a preference for intergenerational mutually beneficial practices that contribute towards the wellbeing of all generations. Clearly, what has been observed in the last twenty years or so at national levels is an emphasis on generational equity and inclusiveness by paying attention to the life-course approach in dealing with issues arising in later years. Most nations are incorporating a development approach towards population ageing and although a certain element of welfare predominates in setting policies and programs for older people pertinently there is also the practice of mainstreaming older persons and making them significant stakeholders in development plans.

Considerable steps have taken place at different paces in nations across regions to promote ‘society for all ages’ by emphasizing policies for better social and health security, eradication of poverty, and empowering older people, especially by supporting their associations that encourage self-development and wellbeing. In Southern Africa after MIPAA support for older adults’ participation in development processes has increased [15]. In the region of South America governments paid greater attention to transforming opportunities for older persons by bringing focus on the life cycle approach and laying the foundation for an inclusive society for all ages as well as putting recommendations in policies for recognizing older persons’ strengths, and contributions, [16]. Pivotally, we see evidence in the 4 countries of South Asia, namely, Bangladesh, India, Nepal, and Sri Lanka from the second decade of the implementation of MIPAA acceleration of plans in addressing ageing issues as documented in the second review of MIPAA [31] and it continued as stated in reports for the third review [32]. This indicates progress more from a development perspective [14] and it involves older people’s associations in the planning of policies. In Bangladesh, for formulating the National Policy on Older Persons 2013, various NGOs working on old age issues were consulted and recognition was given to the contribution of older people in building the nation [33]. Similarly, in Nepal and Sri Lanka government takes representation of older people in deciding on age-related policies [14]. In India, Meenai [34] and Shankardass [35] also note the involvement of older persons in discussions related to policy matters and their inclusion for assistance and relief in emergencies and natural disasters. In addition, attention is being paid in societies to understand gender differences and recognize the feminization of ageing occurring as a global and national phenomenon. This realization has led to a better understanding of gender inequalities and brought emphasis to policies on gender equality.

Another welcome outcome of MIPAA is the growth of the specialization of geriatrics and gerontology. Many countries are addressing concerns of ageing populations by building manpower of geriatric health and community care workers, providing training opportunities in geriatrics both for medical professionals and paramedical staff, and raising awareness on geriatric health and social care, though meeting such needs is progressing gradually as changing mindsets on ageing as a resource is seen to be a slow process. Both South Asia [14], India in particular, and South America [16] are indicating significant developments in this regard.

Discussion

Despite many noteworthy initiatives to accommodate and adjust to the demographic transitions resulting in populations ageing, many societies especially in the regions of South Asia, Southern Africa, and South America have yet to strengthen the necessary and robust responses which can improve the quality of life of older persons of not only the present cohorts but also in the future. It is seen that despite gender considerations being emphasized by MIPAA, these have not been given appropriate thought in planning programs and provisions for older women as noticed particularly in South Asia, where their involvement with the informal sector is high and these are deficient in providing social security [14]. Despite certain reforms in improving pension schemes in the region, a report by ILO [36] states that when the third review of the implementation of MIPAA was considered women still did not have enough old age protection. Provisions for health care insurance are limited as well as death and disability insurance are almost non-existent and further pension coverage availability varies from country to country. Bangladesh has better provisions for men compared to women, with India faring a bit more but less than Bhutan Nepal, and Sri Lanka out of all the countries in the region giving more consideration to these matters but being lower than many other Asian and Pacific countries [37]. In Southern Africa, too lack of access to requisite social and health security is noticeable [38]. In South America, while a bill of rights has been promoted in many of the countries in the region, as experts point out the implementation of concrete or effective measures is still very noticeably lacking [16].

Acceptance of provisions for long-term care especially from a holistic perspective, provisions for enabling and secure environments, for assisted care through digital and technological devices, end-of-life care facilities, etc. are still not part of common thinking in addressing ageing challenges of populations in many countries in the three regions under discussion. Significantly, while health care for older persons is gaining importance in countries accessibility to services is hindered by the cost of care, inadequate available infrastructure for its efficient utilization, and lack of knowledge among the general public about its benefits, especially as a preventive strategy. Unfortunately, much carelessness is attached by people in curing ailments of old age, and in certain parts of the world, there is a stigma of health issues that appear with age. As some experts point out [8] even after adopting the active ageing and progressive framework of MIPAA most countries have still not been able to address many concerns of older people and secure them in contemporary societies. Many lacking include a focus on the ‘fourth age’ in ageing policies for older persons who are either homebound or living in residential long-term care facilities, specifically people living with dementia. Preparedness for disasters as such is missing in most countries’ responses to crisis management but is particularly evasive for older persons. This was particularly visible during the COVID-19 pandemic when in many aspects older persons were marginalized from receiving appropriate care and attention to their various needs [28]. In almost all countries in the 3 regions under discussion, in different measures though, gaps are seen in the delivery of services, benefits, and allowances for the wellbeing of older persons. Much still needs to be done for their inclusion in adult and digital literacy programs, in developing age-friendly devices that equip them to handle day-to-day chores especially when challenged by certain disabilities or age-related ailments, in particular, while residing in areas that are out of bound for easily accessible care services and provisions. Besides, the vulnerabilities faced by older women, widows specifically in certain countries, and those belonging to low-income groups in most countries warrant more specific proactive policies for the well-being of ageing populations.

Research on ageing indicates that like people of younger ages whose mental health issues receive attention, older persons’ mental well-being, psychological ailments, and emotional security do not get appropriate recognition in the three mentioned regions. MIPAA provides direction towards taking note of these aspects but a review of what is being done for older persons in different countries suggests that the mental health of older people is not generally identified as a serious concern by health professionals, nor by governments and older people. Seeking recourse to deal with mental health issues by older people is generally not the practice and development of mental health services at the institution and the community levels including provision for counseling, helplines is scarce. Raising awareness on special later life concerns in relation to morbidities due to mental ill health because of different social factors such as losing a spouse or siblings/friends, decreasing source of income or increasing financial insecurities set in by retirement and lack of savings/investments needs as well as issues arising from not being able to cope with age-related ailments, disabilities, and frailty has not yet received the attention it deserves to improve the quality of life of older persons. Only a few countries have actually been able to put in place policies to support health from a life course perspective despite the intention and bring in emphasis on promoting preventive steps to lessen the burden of health and social care of the ageing population on society. For instance, in Southern Africa, such policy commitments are underpinned by the AU Protocol to the African Charter on Human and People’s Rights [39] but yet have not been ratified by all countries in the region. Clearly, the 3 regions under discussion indicate implementation challenges in making the directions of MIPAA a reality.

Conclusion

Pertinently, while MIPAA stresses understanding societal ageing from a holistic perspective, such deep and intense thoughts in national ageing policies are missing as each country in the regions being discussed here is still working on how to handle rapid demographic transitions being experienced since last few decades within its own issues of inherent inequities in using available resources and having development plans that can accommodate heterogeneous characteristics of its populations notwithstanding gender, socioeconomic, cultural, ethnic and spatial differences. No doubt MIPAA is a resource for policymakers and suggests ways for governments, non-governmental organizations as well as other stakeholder partners to reorient their approaches to ageing but since it does not provide mechanisms to generate funds for realizing ageing policies into action it to some extent lacks creditability as a directive. Further, MIPAA does not provide guidance in developing research tools or ways for collecting reliable data that can allow for measuring the success of ageing policies initiated since its adoption and reviewing the implementation of directions stated in the plan document. As a result, many countries in the regions of South Asia, Southern Africa, and South America have not done a critical analysis of what ageing policies are achieving and how they may need to be modified to absorb emerging concerns of their ageing population. In this respect, there is a drawback in the direction provided by MIPAA to adapt to changing situations. The recommendations of MIPAA are to some extent unidirectional and not sensitive to assess the pitfalls that emerge over a period of time in tackling ageing issues in respective countries. Population ageing then requires an approach that transcends from various directions put in by multiple agencies at different forums to address emerging concerns and find robust solutions together to the different challenges arising.

Referring to South Asia in particular, as the author comes toward the end of their deliberations, it would be worthwhile to comment that while assessing the implementation of MIPAA is necessary the region does not have essential robust data collection tools to capture the reality of ageing policies that are in place. Seldom are policies monitored and evaluated and thus progress in meeting the needs of older persons is hampered. Further, in the author’s opinion, the COVID-19 pandemic was a lesson for us to realize the vulnerabilities of older people in specific regions of the world and the author’s research work indicated that in India specifically but as much as for South Asia region as a whole, the disproportionately higher vulnerability of older persons in dealing with the pandemic [40] indicates our societal response to ageing issues is low and our normal response to crisis management gives limited priority to ageing concerns. Thus, we need to really reflect on what has MIPAA made us achieve when we are faced with demographic transitions resulting in the rapid growth of population ageing.

In concluding comments, however, the author would safely state that the value of MIPAA for the global community should not be underestimated. It did initiate thinking in responding to ageing issues for a better quality of life for older persons from a right-based approach. It also encouraged countries to learn from each other in developing policies, programs, and practices to improve the lives of older people and recognize different ways through which older people can be viewed as a resource and a development asset for countries. The recommendations of MIPAA are also indicative of how ageing issues can be comprehensively dealt with by taking various steps in different directions as listed as priorities in the plan document. However, it is important for countries to realize individually and collectively that the coming years bring greater focus on ageing issues and a global approach in addressing the concerns would be fruitful, thus the value of MIPAA as it stands today requires certain revisions which can overcome the present weak points should not be ignored. As mapping of ageing plans in South Asia indicates, the momentum to address ageing issues needs to be increased, the gaps between policies and practices reduced, and further learning is required about understanding the heterogenous factors among older persons so as to develop appropriate and adequate responses towards equity and inclusiveness. There is a need to use all opportunities to advance the directions of MIPAA.

This article is based on the author’s analysis based on years of involvement in the field of ageing as a researcher, academician, author, consultant, and activist. It also draws from the author’s recently edited volume titled ‘The United Nations Madrid International Plan of Action on Ageing: Global Perspectives’ co-authored with Marvin Formosa as listed in the references and various other published articles, a few mentioned in the reference section.

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