Healthcare for older people in Central and South America.

Latin American countries (LAC), with their culturally and ethnically diverse populations, form a region that is difficult to define and to understand. The region's health systems are deeply fragmented, which poses great challenges to overall equity levels in health. This is also one of the fastest ageing regions in the world, with increasing demands as well for acute and long-term care (LTC). Demographic and epidemiological transitions across the region are heterogeneous. In this context, health systems are in general, largely unprepared to face the challenge of promoting healthy ageing. This unpreparedness has been magnified by the Coronavirus disease-2019 pandemic. Here, we analyse the burden of disease in the older population and identify priorities to improve the care and quality of life for people living in LAC. Besides an adequately prepared workforce, we must remediate disparities and inequities; develop and implement integrated care; achieve patient-centred care and further develop palliative and end-of-life care; simultaneously, we must develop the structure and financing of LTC services and strengthen the role of public health making healthy ageing an essential component.

By 2030 there will be more people in Latin America older than 60 years than there are people younger than 5 years.

The region’s health systems are deeply fragmented, which poses great challenges related to the provision of quality care.

COVID-19 has provided an intensive stress test, exposing pervasive ageism in society and health care systems.

Increased life expectancy but with a lesser health span under the pressure of stark age-related inequities.

Introduction

Latin American countries (LAC), with their culturally and ethnically diverse populations, burgeoning economies, high levels of violence, growing political instability and striking levels of inequality, form a region that is difficult to define and to understand. The region’s health systems are deeply fragmented and segmented, which poses great challenges related to the provision of quality care and overall equity levels in health. Besides, this is one of the fastest ageing regions in the world, with increasing demands as well for acute and long-term care [1]. Demographic and epidemiological transitions across the region highlight the different levels of unpreparedness to address the needs of an ageing society, such as efforts to maintain older people’s functional ability, and to manage chronic conditions and infectious diseases outbreaks, like the Coronavirus disease-2019 (COVID-19) pandemic [2].

Population ageing in this difficult context is a challenge to social and health care systems (HCS) across the region. Here we provide an overview of the regional health system’s responsiveness to the needs of older adults. We will glance at geriatric training, clinical practice and institutional support in 15 countries, bearing in mind great variations in the organisation of their health systems, training, roles and functions of geriatricians and other geriatric health professions.

Superimposed on the rapid ageing of our populations, COVID-19 has provided an intensive stress test, exposing pervasive ageism in society and HCS. Stark age-related inequities in healthcare delivery and outcomes have come to the forefront [3]. Despite this attention, the issues ‘uncovered’ by COVID-19 have been long-standing, deeply entrenched and steadily increasing over time [4]. This is the case for ageism, which has adversely impacted our HCS, leading to poorer clinical outcomes. Well documented in several studies [5], ageism leads to barriers in access or denial of healthcare services and treatments, with age being the primary factor determining who receives certain procedures and treatments. Ageism is also common in both traditional and social media, and this has increased due to COVID-19, impacting the public’s perception of social and economic policies associated with ageing [6].

Increased life expectancy but with a lesser healthspan

Life expectancy at age 65 increased from 17.1 years in 1990 to 19.2 in 2019 whereas healthy life expectancy only increased from 12.2 to 13 years. The leading cause of mortality and morbidity among older adults in LAC is cardiovascular disease (including cardiac ischemia and stroke), representing 25% of the total disease burden among those aged 60 and over, followed by diabetes which has been on the rise in recent decades, to the point some studies speak of a ‘diabetes epidemic’, occurring in 7% of people older than 60, and being particularly burdensome in Mexico and Caribbean countries [7]. During the last 30 years, all-cause Disability Adjusted Life-Year (DALY) rates have decreased in each older persons’ age group; however, absolute proportional DALYs increased from 22% to 32%. Ischemic heart disease, stroke and chronic obstructive pulmonary disease were the leading causes of premature mortality. Diabetes mellitus, age-related and other hearing loss, and lower back pain were responsible for most disability [8]. Evidence indicates that most of the causes of mortality that are decreasing life expectancy in LAC are potentially avoidable [9].

Profound health inequality contributing to a complex epidemiological picture

Latin America has some of the most profound health inequalities in the world, and a wide range of life expectancies at birth [10], due to health disparities but also affected by the surrounding social dynamics. Large spatial differences in average life expectancy at birth in our cities exist that illustrate these gaps [11].

Disability and care dependence are raising

More than eight million people aged 60 and over are dependent, representing more than 1% of the region’s total population, and 12% of individuals in that age group. These figures are significant and account for the magnitude of the regional care problem. They also coincide with data from the Organization for Economic Co-operation and Development, where around 15% of older adults require care services, received most often at home [12].

Training and certification of geriatrics specialists

Despite accelerated ageing, geriatrics remains a small field in the region, and training and certification, as well as competencies, vary among countries: some, with early emerging roles for geriatrics specialists, largely ‘import’ nationals who have been trained from other countries. Some address formal individual certified training programs to physicians, offering either 1–2 years of advanced training after residency in Internal Medicine or Family Medicine or combined Internal Medicine and Geriatrics training lasting 4–5 years after medical school. Most offer a national certification examination and require recertification. In some countries, formal training and certification is offered for health professionals other than physicians, like nurses, physical and occupational therapists, and social workers (Table 1) [13]. There are clear signs that some nations are working to increase training and availability of geriatricians and geriatrics services. Most clearly, there exists a regional community of dedicated academic geriatricians working since 2002 to improve care for older people in their countries throughout a network developed in liaison with the Pan American Health Organisation, The Latin American Academy for the Medicine of Older Adults (ALMA) [14].

Table 1

Geriatric medicine training and geriatricians practicing in Latin American countries

Country	Type of training	Number of training programs	Other disciplines with certification	Number of geriatricians trained per year	Number of geriatricians per 100,000 age 65+
Argentina	2 or 3 years after IM or FM	10	Nursing, PT, OT, SW	80	>100
Chile		5	Nursing, PT	70 total all years	<1
Costa Rica		1	Gerontology masters available	10	33
El Salvador		1	Gerontology certificate	2	1.8
Panama		2	Nursing	24	7
Paraguay		2	None	4	8.5
Brazil	2 years after IM or FM OR direct entry combined IM/Geriatrics	50	Gerontology training in many other disciplines	100	<1
Colombia		4	None	60	2
Cuba	Direct entry combined IM/geriatrics	1 program multiple sites	Nursing, PT, OT, SW	>270	24
Mexico		33	Nursing	130	12
Peru		5	Nursing, OT	20–30	8.1
Uruguay		1	None	18	16
Venezuela		1	Nursing	3	1
Guatemala	2 years after IM or FM OR combined IM/Geriatrics	0 (accept training in other countries)	PT	N/A	<1
Nicaragua			0	2	3

Note: We are grateful for the information provided by national ALMA leaders through an online survey that will also be published in the new 8th edition of the Hazzard’s Geriatric Medicine and Gerontology, chapter: ‘Geriatrics around the world’ authored by: Arai H, Close J, Martin F, Gutiérrez Robledo LM and Studenski M. IM, internal medicine; FM, family medicine; PT, physical therapy; OT, occupational therapy; SW, social work.

Health systems preparedness

Any system reform, aiming to get better health of older people, should be focused in improving its performance, which entails an assessment in terms of efficiency, access and quality. In the context of an ageing population, several forces are at work. Providing health is becoming increasingly expensive, largely because of more technology. A comprehensive framework is needed to assess how and to what extent health systems are responding to the needs of older people. We think that such an evaluation is feasible in the Americas, even if countries have different levels of data availability. Developing consensus on key tracer indicators is ongoing to better target the needs of older populations in accordance with local realities of each health system. The results of integrative responsiveness assessments will be helpful to increase health systems’ efficiency and inform public policy to better suit an ageing world [15].

Long-term care

The region may be able to withstand increased care dependence in the short term, but in the long term, the demographic capacities related to traditional informal care are expected to decline, adding pressure and burden both to families and health systems. Regional demographic and epidemiological shifts pose many challenges that demand long-term solutions [16]. Brazil, for example, between 2000 and 2010, illustrates what has typically happened across the region: increase in disabilities from 49.6% to 63.4% and 32% of users of the public health system having some functional limitation, putting an estimated cost of minimum 123 million USD per year on prolonged hospitalizations, including those unrelated to a medical cause [17]. Another long-standing concern is the preparedness of the health workforce. There is an overall lack of trained LTC workers, and health professionals are often unequipped to handle the unique health needs of older people due to training deficiencies and health systems that are disease-specific rather than focused on capacities and prevention. Additionally, LTC has relied mostly on family care, and due to changes in society and family structure, family capacity will be very limited in the coming decades, with issues like being unpaid (Mexico, 95% of informal caregivers), lack of financial support (Mexico 24% of caregivers), the need of giving up jobs, and lack of specific training (less than 7% of caregivers in Brazil). Research in the region shows that percentages of people over 65 needing help to carry out activities of daily living (ADLs) are higher than in high-income countries in Europe or Asia. The reported estimates, in addition to shedding light on the social, economic and political challenges associated with ageing, reveal the regional demand for help and indicate the magnitude of the challenge [18].

Opportunities and challenges

The Decade of Healthy Ageing from 2021 to 2030 opens a space for opportunities on four action areas: (i) create and strengthen age-friendly environments. (ii) Cvombat ageism. (iii) Provide integrated care and (iv) support LTC. In the first two areas, the Inter-American convention on protecting the human rights of older persons [19] creates a framework for specific actions. In the third and fourth, PAHO, together with ALMA are leading the dissemination of the ICOPE initiative, besides other evidence-based interventions aiming to preserve intrinsic capacity [20] and collaborating towards the development of LTC systems [21].

Conclusions

By 2030 more people in Latin America will be older than age 60 than younger than age 5. Our HCS are unprepared for the complexity of caring for a large and heterogenous population of older adults, a problem that has been magnified by the COVID-19 pandemic. Here, as part of the Age & Ageing anniversary series, we identify several priorities to improve the care and quality of life for people living in LAC. First, we need an adequately prepared workforce; next, we must remediate disparities and inequities; develop, evaluate and implement new approaches to integrated care delivery; strive to achieve patient-centred care and develop palliative and end-of-life care; develop the structure and financing of LTC services and strengthen the role of public health making healthy ageing an essential component.