The global population is ageing rapidly, with the number of those aged 60 years or over predicted to rise from 962 million in 2017 to 2.1 billion in 2050 and to 3.1 billion in 2100 (1). Worldwide, most older people live in low- and middle-income countries (LMICs), with the greatest number in Asia. This older population is growing fast due to the continuing demographic transition (2). At the same time, these older populations have experienced a massive increase in the prevalence of non-communicable diseases (NCDs) (3), and the syndrome of frailty has been increasingly recognised (4). Currently, services are not well adapted for the provision of care for older people with long term conditions, in whom there is significant comorbidity (5).
Multimorbidity increases significantly with age and is common in LMICs (mean standard prevalence of 7.8%) (6). A population-based cross-sectional survey of LMICs highlighted that multimorbidity is strongly associated with negative effects on older adult quality of life, physical functioning, and mental health (7). Similarly, a large population-based cohort study of frailty indicators in LMICs identified an association between frailty (including cognitive impairment) and dependence and mortality in older people (8). Hence, it is necessary to provide services to address the interdependent physical and mental health needs of chronically multimorbid and frail older people in LMICs. Approaches focused on a single disease process or psychiatric disorder, to the exclusion of socioeconomic factors, comorbidities and disabilities in older people, are unlikely to be successful or sustainable.
With the United Nations Sustainable Development Goal (SDG) 3, there is a growing trend for the provision of universal healthcare coverage (UHC) within LMICs, in particular, care for vulnerable groups such as the elderly. Moreover, the World Health Organisation (WHO) has recognised that “without considering the health and social care needs of the ever-increasing numbers of older people, SDG 3 will be impossible to achieve” (9). The associated healthcare costs may be covered by insurance schemes or from taxation, out-of-pocket payments, or a combination of two or more of these. Countries have decided to tackle these issues in different ways, both in terms of recommendations and legislation. Lessons can be learnt from understanding the systems in different countries, and how well different ideas work in practice.
Mental and substance use disorders account for 7.4% of disease burden worldwide and their contribution to the global burden of disease is rising (10). Stressors such as bereavement, inadequate social support and isolation are prevalent in the elderly and contribute to worsening mental health. A systematic review of the prevalence of common mental disorders found 29% of adults experience mental and substance use disorders in their lifetime, with a disproportionate number in LMIC settings (11). Worldwide, an estimated 322 million people (of all age groups) are living with depression and 264 million with anxiety (12). Specific prevalence figures for older adults are not available, reflecting the suboptimal screening and identification of these disorders in the elderly.
Despite the substantial burden of mental health disorders worldwide, the gap between mental health service need and provision in LMICs persists (13–15). The WHO states resources available are “insufficient, inequitably distributed, and inefficiently used, which leads to a treatment gap of more than 75% in many countries with low and middle incomes” (9). The WHO increasingly recommends the scaling up of mental health care, through integration into primary health care and general medical services (9). Specifically, this could be achieved by training non-specialist primary care workers in diagnosing and treating mental disorders (13, 16, 17). Similarly, there is a need for an accessible primary health service, adapted with trained workers equipped to diagnose and treat the needs of older people, likely to have multiple comorbidities (18, 19), but the gap in provision for older people is not so well characterised.
There is an increasing awareness of the contribution of poverty, and social and environmental factors to mental disorders and disability in older people worldwide, but particularly in LMICs (20). Inequities in healthcare access for older people are well recognised in LMICs: a recent population-based cross-sectional survey of 17,994 individuals aged 65 years and over noted a positive correlation between higher education, more household assets, receiving a pension, health insurance and the proportion using healthcare services (21).
The North East England South Asia Mental Health Alliance (NEESAMA) inaugural meeting took place on the third and fourth of November 2018 in Kathmandu, Nepal. Clinician representatives from each country (psychiatrists, psychologists and other health professionals), were identified to establish a clinical academic network focussing on the mental health of older people. It was agreed amongst delegates that the biggest concern, regarding the care of the elderly, related to the provision and cost of medical and social care for older people. Thus, the need for data from South Asian countries, Bangladesh, India, Nepal, Pakistan and Sri Lanka, concerning socioeconomic resource provision for older people, was established, and a plan of action formalised.
The authors seek to gather and review data from Bangladesh, India, Nepal, Pakistan and Sri Lanka, about provision for older people, to identify gaps in health and socioeconomic provision, as well as examples of good practice, that may impact on the physical, mental and social wellbeing of older people in South Asia.