Public and health policy for the aged in Africa to the South of Saara

Objective: to know the social and health responses for the elderly in sub-Saharan Africa. Methods : An integrative literature review. Results: There is a lack of specialized health care to meet the real needs of the elderly, and the shortage of health professionals does not contribute favorably to this situation. There is a small number of facilities for the elderly and most of them are inadequate. Although there are models of care as well as social and health support policies for the elderly, there are still inequities/inequalities in access to these policies, especially for the most disadvantaged populations. Conclusion: Social and health policies for the elderly in Sub-Saharan Africa are below standard and appropriate economic, political and social intervention is required.


INTRODUCTION
By 2050, the world's population aged 60 and older is expected to reach 2 billion, and there is also a tendency for the number of people over 80 to increase. This age group is expected to grow from the current 125 million to 434 million worldwide (1) . Such demographic changes imply the need to provide tailored responses.
In Sub-Saharan Africa, as we look at the population pyramid (Figure 1), we find that although the emphasis on the young population is noteworthy, there is a variation at the top of the pyramid, which indicates an increase in the elderly population and reflects the growth of this phenomenon.
Of the 42 main countries in sub-Saharan Africa, only 4 are highand middle-income economies and 6 are low-and middle-income countries. Regardless of economic status, the impact of the HIV / AIDS epidemic is still visible in the population pyramid of the region. Notwithstanding these aspects, many areas of Africa are growing steadily as life expectancy increases and fertility declines. It is estimated that by 2050, most African countries will double the aging population (2) .
In developing countries, the population is aging very rapidly, leaving government authorities little time to react to the aging phenomenon and to implement political social and economic strategies in this area. While high-income countries such as Japan and European countries, notably France, have had time to adjust to demographic change because it has been progressive, developing countries are not expected to do so, given the rapid pace of this transition. By the year 2050, it is estimated that around 80% of all older people will belong to low-and middle-income countries (2) .
In this sense, the future is somewhat predictable, and, unlike most changes societies will experience over the next 50 years, we know that the demographic transition to older populations will occur, and we can plan to make the most of this transition. Indeed, most people today can expect to live to be 60 or older. In low-and middle-income countries, this is mostly the result of great reductions in maternal and child mortality and the slowdown in infectious disease deaths. In contrast, in high-income countries, continuing increases in life expectancy were mainly due to the declining mortality among older people (2) .
Increasing average life expectancy means increasing opportunities for older people, families, and societies, but its effective development depends on one determining factor, which is health. In this regard, there seems to be little evidence that older people are currently living healthier than their ancestors because although rates of severe disability have been reduced, there have been no significant changes in mild and moderate disability. In this sense, the focus will be on promoting "healthy" life in this population and enabling them to live in a healthy environment that increases their ability to remain active (2) .
Several factors that influence aging from the beginning were identified, meaning there is influence from conception to death. These factors can be genetic, environmental (physical and social), and personal (gender, ethnicity, socioeconomic status) (1)(2) . Disability in this age group, in both high-income and middle-and low-income countries, often results in impaired mobility, visual and hearing impairment, and non-communicable diseases such as heart disease, chronic respiratory disease, cancer, and dementia (1)(2) . Note Maintaining healthy behaviors throughout life, such as eating properly, doing regular physical activity, and avoiding harmful substances, can contribute to the reduction of non-communicable diseases and the improvement of mental, cognitive, and physical abilities, which delay care dependence and minimize frailty (1)(2) .
Evidence shows the relevance of supportive settings for the elderly with some type of disability, as these settings empower them to perform fundamental activities. Therefore, it is recommended having safe public options, physical structures, transportation, as well as accessible structures, which means access without barriers to people with disabilities (2) .

OBJECTIVE
To research health and social policies for the aged in sub-Saharan Africa.

METHOD
The methodology used was an integrative literature review in scientific databases, namely CINAHL, Cochrane via EBSCO, and Medline via PubMed.

Research Protocol
The survey was conducted in August and September 2018 by combining Boolean operators with the terms MeSh: health services for the elderly OR social support AND aged AND Africa. Also by combining the keywords or natural keys: elderly people OR older people AND Africa.

Inclusion Criteria
Respond directly or indirectly to the study objective; have access to the full text; have been published in the last 5 years (from 2013 to 2018); include older people; have been written in English, French, Portuguese or Spanish. Articles were not excluded by the type of methodology used in the investigation.

Exclusion Criteria
The articles that do not involve the elderly population; do not refer to the population of sub-Saharan Africa; are related to specific pathologies such as HIV, asthma, tuberculosis, cancers; related to pharmacological interventions and therapeutic response to medications.
By searching with the terms MeSh, we obtained 47 articles, and with keywords or natural keys 137. A total of 184 articles were found. After excluding articles by title and for being repeated, 73 articles were selected. Then the abstracts were read and 23 articles were selected for a full reading. After that, one article was excluded, and 22 articles were selected for the analysis (Figure 2 The endemic context of HIV creates stressful situations (e.g., trying to survive, caring for sick adult children in a stigmatizing environment, raising grandchildren and losing those who should be their own caregivers in old age) that intervene in the health of individuals and their ability to participate in daily activities. Older women make links between compromised health and the (lack of) ability to perform the daily activities normally expected of them.  Household cross-sectional surveys conducted in Ghana and Senegal to study whether older people are aware of and enroll in existing insurance programs in these two countries (Senegal's Sesame Plan and Ghana's National Health Insurance -NHIS) and to explore if economic indicators and social exclusion determine the enrollment of the elderly in these programs.

Of
Older people, vulnerable to social exclusion, are less likely to enroll in the Sesame Plan, and politically vulnerable older people are less likely to enroll in NHIS. Additional efforts need to be made to specifically enroll older people in rural areas, ethnic minorities, women and isolated people due to lack of social support. The importance of modifying program resources, notably by eliminating the NHIS registration fee for seniors and setting up ID card administration offices in remote communities in Senegal. Focus group discussions and interviews with key informants with older people in the Kamwenge district of Uganda; and with people with disabilities from the Gulu region. The interviews were conducted in local language by trained interviewers.
Older people and those living with disabilities express feelings of marginalization, including political marginalization, discrimination and unequal access to health services, which are the factors responsible for their poor health. At the same time, existing clinical services appear to be of poor quality, with little or no access to facilities, trained professionals and medicines, and no rehabilitation and mental health services available. Interviews, clinical examination and medical record review for persons aged 60 and over in Bobo-Dioulasso in an urban area.
To be continued Individual and focus group interviews; visits and interviews with families living within 10 km of primary care facilities about their family, economic and health insurance-related conditions.
People over 60 are more likely to enroll in free health insurance than younger people. Non-registration is related to the lack of knowledge about insurance and its exemption. Social exclusion is a determining factor regarding the enrollment of the elderly in social programs. Exemption from the health insurance premium is a determining factor in health care. The low level of social support is associated with depression, especially social support from family and significant others. The severity of depression correlates negatively with the availability of social support. Perceived social support is assumed to be a significant determinant of depression in these older people. There is a need for intervention in the area of preventive mental health for depression. Data collection by applying a 40-item frailty index to 70-yearolds living in 6 villages in the rural district of Hai. Data on mortality and dependence were collected over three years.
The highest frailty index score was significantly correlated with the variables: older age, never having studied, falls, mortality and dependence on activities of daily living. Functional disability and cognitive function are shown to be significant independent predictors of the "mortality or dependence" outcome. Assessing fragility seems to be a useful way to identify those who need support the most. The instrument built for fragility assessment seems to have good construct validity.
To be continued There is a need for innovative policies and public services appropriate to the aging trend of this population. This innovation should include family involvement in caring (leveraging the workforce of African society), person-centered care, caregiver training, integration with health services, equity, favorable conditions for resource development and sustainability. Existing programs must be critically analyzed to be more appropriate, contextualized and thus more successful.
The themes that emerged from the articles included in this review were: Major health / social problems of older people in specific communities in sub-Saharan Africa, more specifically, chronic diseases (such as high blood pressure) and non-infectious diseases (such as depression), frailty, disability, isolation, exclusion, poor economic conditions; Elderly support structures, emphasis on family, formal limited and rudimentary support network and the existence of mostly free health insurance programs in countries such as Ghana and Senegal; and Recommendations for the possible resolution of identified problems, as well as for promoting healthier aging. The articles discuss the inefficiency of social policies to support the elderly and reflect particularities, namely the need to implement culturally sensitive care that prevents social marginalization and exclusion.
In general, the articles analyzed respond mainly indirectly to this research, in the sense that currently existing social support policies are scarce. Thus, it is subtly that they emerge.

DISCUSSION
Chronic diseases or conditions are common in the elderly, affecting their life. In a study conducted in Burkina Faso, to assess multimorbidity among the elderly, the most common chronic diseases identified were: hypertension (82%), malnutrition (39%), visual impairment (28%) and diabetes mellitus (27%). In some countries in sub-Saharan Africa, policymakers appear to does not meet the current health needs of the elderly (3)(4)(5) .
Besides chronic diseases, the studies also analyze the occurrence of depression in the elderly, which is associated with socioeconomic factors (interactions between their social network, poverty) and health factors that deserve attention, particularly in developing countries where socio-economic deprivation and poor health are common (6)(7) . It should be noted that in these countries there are unmet demands for depression diagnosis and treatment. That is, it is noticed that, either before or after diagnosis, often the elderly are not monitored by a health professional. In addition, in this context, health-seeking behavior can have an impact on treatment due to cultural factors (6)(7) .
In a community setting in West Africa (Nigeria), the severity of depression in the elderly correlated negatively with the availability of social and family support (including significant people), thus, there is a strong influence of these actors on elderly depression, so it is suggested to strengthen formal and informal social support for the elderly (6)(7) . The importance of the family's role in aged care, especially those who are dependent, is reinforced by the lack of long-term care in the community. However, it appears that not all families perform this role, contrary to the existing stereotype about the Africa population. This difficulty in ensuring care, by family members, is related to the necessity to combine this long-term care for the elderly with other activities, including work activities. In this sense, it is reinforced the idea of the need for the creation of paid care (guaranteed by government entities) as an alternative to family care (8) .
Age-related fragility and disability (functional and/or cognitive) are increasing concerns for the elderly population in low-and middle-income countries. Results in South Africa and Tanzania indicate that lower levels of frailty and disability can be achieved in older people, and studies highlight the need for preventive approaches and targeted support programs (9)(10)(11) .
According to a study in Uganda, disability is associated with aging, rural residence, isolated housing, divorced or widowed marital status, dependency on income, general illness, and selfreported non communicable diseases. In this regard, the authors state that socioeconomic limitations are associated with disability among the elderly (9) . In Tanzania, the study of this relationship highlights the need to properly diagnose people and intervene to prevent disability, optimizing social responses, as this type of population most often depends exclusively on family care and has not enough income to cover expenses (10) .
A study in Bobo-Dioulasso (Burkina Faso) shows that 68% of older people have good functional capacity or mild disability, and 32% have moderate to severe disability. Older people die before they recover (3%) or during recovery (14%) from moderate to severe deficits. This means that the quality of medical and social care does not maintain the functional autonomy of the elderly with disabilities of this nature. They also evidenced that those who contribute financially to the maintenance of functional autonomy are the elderly themselves and their families. Community structures (private or public) to keep the elderly in functional autonomy are nonexistent. Poor physical health results in functional limitations related to subjective well-being that restrain the daily activities of older people, particularly in rural areas (such as Malawi). This limits activities in key areas, such as survival, and leads to the recommendation of national and international policies for the rehabilitation of people with disabilities at this age group (12)(13) , as shown in previous studies.
The prevalence of self-reported quality of life (QOL) and difficulties in specific functions were estimated by age and gender Chart 1 (concluded) of Política pública e de saúde para o idoso na África ao Sul do Saara Assunção M, Pinto S, Jose H.
in Nairobi (particularly in the favela population), where women reported poorer QOL and greater functional difficulties than men in all groups domains except for self-care. Considering the eight functional domains that differently affect QOL, the researchers state that it is important to implement targeted interventions to improve affect, reduce physical pain, improve cognitive ability, and facilitate mobility. This implies assuming that investing in the health and quality of life of older people in sub-Saharan Africa is crucial to help the region achieve strategic development goals, improve health outcomes, and sustainable economic development (14) . Many older people, particularly in rural areas of sub-Saharan Africa, have activities that, generally, enable them to be self-reliant (e.g. cooking and cleaning), to care for their relatives (particularly those who are sick and infected with HIV), and to obtain some financial gains (e.g. by manually producing mats). These activities are influenced by a social environment in which well-being and health have been reported as inadequate or unsatisfactory by international authorities. There is a need to develop policies and programs aimed at improving the mental and physical health of older people to increase their well-being and their ability to contribute to their families' and communities' well-being (14) . The World Health Organization report also emphasizes the social contribution of the elderly in this context, especially the care of the young and sick relatives, as well as the development of agricultural activities (2) .
Looking at the review, Senegal and Ghana have emerged as countries that provide social protection for the elderly, particularly through free access to health care programs for the elderly, such as the National Health Insurance Scheme and the Sesame Plan. Nevertheless, studies have shown that the elderly, at risk of social exclusion, are currently at a disadvantage in enrolling in such programs and that none of the plans has yet reached the goal of equity in access for the elderly. Despite attempts to minimize financial barriers to enrollment, economically vulnerable people still suffer from inequity. According to the authors of this study, it is useful to implement measures to identify the poorest to ensure they know and enroll more in these programs. Besides, it is emphasized the importance of being able to reach in remote areas older populations who belong to ethnic minorities, women, and isolated people due to the lack of social support. Recognizing and implementing measures to address the factors that prevent the enrollment of older people at risk of social exclusion can improve the prospect of achieving equity and universal coverage in older populations (15)(16)(17) .
A study in Uganda shows that a sense of community marginalization is present in both the elderly and people with disabilities. These groups report the experience of political marginalization, discrimination, and unequal access to health services. These factors are identified as the main reason for their poor health. In this study, the authors found that there were poor quality clinical services, little or no access to the facilities, lack of trained personnel and medications, and no rehabilitation or mental health services available. On this basis, they recommend that measures must be taken to ensure healthcare equal rights for all citizens, by allocating resources to proactively support the most marginalized citizens (18) .
Older people's beliefs in South Africa regarding health and illness encompass the view that body and mind are inseparable, and spirituality and relationships are critical to improving and maintaining health. Older South Africans simultaneously believe in two healing systems (Western biomedicine and traditional African medicine), emphasizing the importance of contextualized care as well as the need to adapt to the ongoing transition, both in the personal and social spheres, giving careful attention to cultural generalizations. Failure to do so can lead to serious consequences, such as an apparent high risk of developing stereotypes, cultural misunderstandings, prejudice, and discrimination (19) .
Regarding the understanding of what is expected from caregivers of the elderly, particularly in old people's homes, in one of the studies found, the authors report that in-service training programs do not address cultural diversity, which means that this diversity is neither understood nor respected. Proper initial assessment and registration are suggested when older people are admitted, to learn about their physical, emotional, psychological, religious, cultural, and social habits and practices, personalizing care (20) .
A study based on a particular case in Uganda reinforces the importance of cultural care. Appropriate home care or institutionalization would have been helpful, especially because of the widespread care need and the multidimensional challenges faced. As a result of this study, recommendations emerge to create geriatric care programs focusing on culturally appropriate home care and training models for caregivers, in order to make the aging process healthier (21) . Given that often developing care models in developing countries follow those in developed countries, emphasizing the institutionalization of fragile older people in long-term care (such as retirement homes) may neglect the strength of the African social fabric (21) . We believe this situation could be surpassed when they implement the recommendations of the Executive Council of the African Union for long-term care (8) .
Evidence also points to the lack of qualified and specialized medical care for older people in sub-Saharan Africa, which is ascribed not only to the lack of doctors but also of other health professionals. There is a low offer of elderly facilities such as retirement homes, day centers, and rehabilitation centers, most of which are basic and use rudimentary equipment. There are, however, models of elderly care, notably in Ghana, Kenya, South Africa, Tanzania, Mauritius, Seychelles, and South Africa, where long-term care is available. The expenses of this type of care in the context under consideration are diverse, from free to very expensive, varying by country (22) .
This lack of health care may be justified by the large number of medical schools in sub-Saharan Africa that do not teach geriatrics. One study corroborates to this inadequacy of health services for this population, pointing to a gap in the teaching of this discipline, which is related to aspects such as the lack of specialized knowledge (72%), funding deficit (52%) and the absence of geriatrics studies in the national curricula(48%) (23) .
Perceptions about older people in Africa, contrary to common sense, can sometimes be associated with negative attitudes. Ageism is predominant, especially against elderly women. It is common to hold the elderly responsible for family misfortunes and may even label them as wizards. This attitude is reinforced by superstitions, religious, and cultural beliefs found in most African countries. Some believe that the elderly and those with mental disabilities are possessed by evil spirits and should be exorcised (22) . Ghana has identified and worked on 5 primary aging and health issues that gave rise to the Recommended Aging and Health Interventions in Ghana, which can be transposed to other sub-Saharan African realities (24) . These interventions focus on community awareness to address the needs of the elderly, integrating elderly healthcare in community programs, training health professionals, creating more aged-friendly services, increasing insurance coverage, provision of support resources, specifically for hearing and visual impairments, creation, and training of community support group (24) .

Contributions to the field
The publications systematization of studies on the elderly population in sub-Saharan Africa, specifically concerning social and health responses, allowed us to know this population's needs, existing social and health responses, main issues, and possible strategies to solve them, trying to enable older people of this geographical region to age healthier.

Study Limitations
There is a possibility that there are articles written in languages other than Portuguese (Spanish, French, and English) that were not accessed, which may have limited this study.

FINAL CONSIDERATIONS
The focus on population aging is mainly in developed countries. In comparison, there is less attention to the world's poorest region, sub-Saharan Africa, where children and adolescents still comprise a high proportion of the population. Despite this, nowadays, evidence suggests that aging is no longer an exception in Africa.
The 22 articles in this review include studies conducted in several sub-Saharan African countries, specifically South Africa, Uganda, Nigeria, Malawi, Ghana, Senegal, Kenya, Tanzania, and Burkina Faso. In this review, rather than clearly defining the existing social and health policies in sub-Saharan Africa, as there is still a void in this area, some of the needs of older people in such a context were highlighted, which allowed the authors, from different studies, making suggestions and recommendations. These should be the focus for policymakers to design policies that promote healthy aging based the community resources that meet their culture and empower them so that older people can enjoy the possible provided care.
In conclusion, aging is an increasing reality, and the number of aged people in the short term justifies policymakers to establish this theme as a priority in their agenda, ensuring adequate and fair economic, political, and social intervention. Policy measures aimed at equitable access and healthcare for the elderly (including free and adequate access to health) are desirable.