Ageism in healthcare: UN seeks to guarantee equal access for senior citizens

healthcare, senior citizen
Several challenges remain in ensuring equitable access to healthcare for senior citizens, including a shortage of geriatric specialists.

Healthcare for senior citizens: The World Health Organisation (WHO) defines healthy ageing as “the process of developing and maintaining the functional ability that enables wellbeing in older age. Functional ability is about having the capabilities that enable all people to be and do what they have reason to value.” This concept of functional ability, which encompasses physical, mental, and social aspects of health, is central to the idea of healthy ageing. It emphasises the importance of not just living longer but also living a meaningful and fulfilling life, which is a key aspect of the right to health and access to health services for older persons.

At the global level, several initiatives are being undertaken to explore the concept of healthy ageing. One such initiative is the Open-ended Working Group on Ageing, established by the United Nations (UN) General Assembly through resolution 65/182. This group plays a crucial role in advocating for the rights of older persons, including the right to health and access to health services. It is preparing for its fourteenth session at the United Nations Headquarters from May 20 to 22 and 24, 2024, where it will discuss and potentially adopt international standards and policies on these issues.

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Under item 6 of the provisional agenda, the Working Group will examine normative inputs following up on the thirteenth session’s focus areas: the right to health, access to health services, and social inclusion. This session is a pivotal moment in our ongoing efforts to strengthen the protection of the human rights of older persons. Your involvement and insights are invaluable in this process.

In this context, the Chair of the Open-ended Working Group has specifically invited key stakeholders to share their input on ‘Social Inclusion’ and ‘Right to Health and Access to Health Services.’ Your inputs, along with others, have formed the basis for the document prepared by the Office of the High Commissioner for Human Rights, which aims to develop a possible international standard on the focus areas of “right to health and access to health services” and “social inclusion.” Your contribution is instrumental in shaping this international standard.

The Open-ended Working Group on Ageing has included these topics as Item 6 of the provisional agenda. This commitment aligns with the follow-up to UNGA resolution 78/177, which focuses on measures to promote and protect older persons’ human rights and dignity. The group aims to identify best practices, lessons learned, possible content for a multilateral legal instrument, and areas and issues where further protection and action are needed.

The background document, prepared by the Office of the High Commissioner for Human Rights, summarises the contributions received. It also draws from the working papers submitted to the thirteenth session, summarising the substantive inputs on the focus areas mentioned.

Healthcare for Older Persons 

The right to health and access to health services covers issues such as international frameworks and legal obligations, normative standards and national application, special considerations, and implementation. Implementation poses several challenges, including inadequate healthcare infrastructure, lack of trained healthcare professionals, and age-related barriers to healthcare access. However, there are also promising practices, such as community-based healthcare models and age-friendly healthcare services, that can help overcome these challenges.

“The right to the enjoyment of the highest attainable standard of physical and mental health is a fundamental human right, central to the enjoyment of all other human rights.” This is not just a legal concept but a fundamental aspect of leading a dignified life. Violating it would be violating someone’s right to life. As stakeholders committed to the protection of human rights, we must ensure that this right is upheld for all, especially older persons. Several regional and global international documents, such as the International Covenant on Economic, Social, and Cultural Rights and the Global Declaration of Human Rights, support it.

Articles 12 of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and 11 of the Convention on the Elimination of All Forms of Racial Discrimination (CERD) are two other human rights treaties containing provisions about the right to health, along with Article 25 of the Convention on the Rights of Persons with Disabilities (CRPD).

Older people have the same rights as everyone else to enjoy the best possible standard of health. Under the heading “care,” the United Nations Principles on Older Persons (A/RES/46/91) state that older people should have access to healthcare to preserve or regain the highest possible degree of physical, mental, and emotional well-being and to postpone or avoid the development of sickness.

The right to health in old age is mentioned in further detail in two recent regional treaties on the rights of older people. (See in particular articles 11, 12, 19, and 25 of the Inter-American Convention on Protecting the Human Rights of Older Persons; articles 11 and 15 of the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Older Persons in Africa.)

Moreover, states must enact policies that guarantee access to residential long-term care and palliative care, assist families in providing care for older people, and ensure the availability of long-term care and support in the community. Article 23 of the Revised European Social Charter for Older Persons addresses the right of elderly people to social protection. There must be policies and programs for healthcare specifically aimed at older people, as well as primary healthcare services, including ambulatory nursing and healthcare services.

Ample palliative care treatments and mental health programs should also be available for elderly people with mental health issues. The Inter-American Convention on the Protection of Older People’s Human Rights includes more detailed provisions on informed consent, long-term care, health, and a healthy environment.

Respondents assert that states must provide healthcare to senior citizens regardless of race. Ageism, a form of discrimination based on age, must be outlawed in terms of law, policy, and practice. It must also be illegal to discriminate in any way, including on several grounds, when it comes to medical research and trials, healthcare delivery, service access, treatment decisions (including triage), life and health insurance, access to the underlying factors of health promotion programs, and other areas related to the right to health.

Ageism not only undermines the dignity and rights of older persons but also hampers their access to healthcare and health services, making it a critical issue to address in the context of the right to health and access to health services.

A few submissions emphasised the need to forbid age restrictions or age-based rationing when distributing services and benefits (such as access to rehabilitation, disability allowance, cancer prevention, or surgical treatment). Age-based rationing, for instance, could mean that older persons are given lower priority for certain treatments or services, based solely on their age. This practice not only violates the right to health and access to health services but also perpetuates age-based discrimination in healthcare. States need to ensure that health initiatives do not discriminate against older people.

Contributions emphasised the connection between ageism and older people’s earlier mortality and worse physical and mental health. This is why, when developing normative content on the right to health of older people, the effects of ageism and steps taken to address and combat age discrimination must be considered. Several contributions also mentioned the necessity of a significant overhaul of the care model, emphasising the importance of older people’s autonomy and engagement. This person-centeredapproach to care cannot only enhance the quality of care but also empower older persons and promote their health and well-being.

States have the responsibility to provide equitable access to healthcare and other health-related services offered by third parties. This involves ensuring that healthcare services are geographically accessible, providing financial support for healthcare, and promoting health literacy among older persons. States should also prohibit discrimination in the provision of health services and enact laws or take other appropriate actions to eliminate current disparities. This involves ensuring that services are inclusive of people with disabilities and people of all genders, as well as protecting and assisting marginalised elderly populations and those without adequate access to resources.

Contributions indicated that the right to health’s definition, extent, and use must be included in legally enforceable frameworks. To guarantee adherence to the requirements of the right to health and access to healthcare, states must periodically evaluate all national laws and policies, both drafted and existing. A few submissions also recommended that states prioritise the needs of the elderly in their national health policies and action plans.

Ageing Policies: Moving from a Needs-Based to a Rights-Based Perspective 

Historically, ageing has been viewed as a biomedical issue linked to cognitive and physical deterioration. However, older people are a very diverse population with a wide range of needs and abilities. When ageism and gender preconceptions are coupled, it can be more challenging, particularly for women, to exercise their entitlement to the best possible equitable quality of health. Thus, the implementation of the right to health must promote older people’s full and active involvement in society rather than stigmatising them as ill, weak, or dependent. This calls for a fundamental shift in how society views ageing and the elderly, moving from a needs-based to a rights-based perspective.

To satisfy suitable standards of education, skills, and ethical norms of conduct, submissions emphasised the State’s need to build geriatric care facilities and incorporate geriatric training into the education of medical practitioners, other health professionals, and informal carers. The necessity of including a gerontological/geriatric perspective, raising awareness of ageism and its effects on personal health and medical practice, and offering training on older people’s rights were all highlighted in the inputs. Additionally, states need to strengthen patient rights information, raise awareness of palliative care, and teach carers and medical personnel how to interact with patients respectfully and effectively. The submissions also underscored the necessity of enhancing the integration of specialised and general healthcare services.

States must also address the underlying social determinants of health, such as harmful effects on health resulting from environmental changes, air pollution, water pollution, and sanitation hazards, to prevent the onset of diseases and health-related dangers. More focused actions might be necessary if elderly people are especially vulnerable to emerging environmental crises.

According to the United Nations Economic and Social Commission for Asia and the Pacific (ESCAP), older people’s right to health encompasses more than just having access to medical care; it also includes social protection, housing, access to adequate water and sanitation, and health education. According to Colombia, the country’s national strategy takes a social determinants approach to eradicate economic reliance, promote inclusion, prevent violence, encourage healthy ageing, and offer training, education, and research.

Malta included programs for health education, institutional housing choices for elderly people in need of care, and simple access to water and sanitation. The Mexican Constitution guarantees the following rights: a respectable and dignified home, a sufficient and nourishing diet, and the freedom to live in an environment appropriate for personal growth and welfare.

Equality and Non-Discrimination 

Most inputs attest that non-discrimination is a fundamental human right and a prerequisite for the right to health. Everyone, including older people, should have equal access to healthcare and the underlying determinants of health without discrimination based on any grounds, including race, colour, sex, language, religion, political opinion, national, social, or economic status, physical or mental disability, health status, sexual orientation, and civil and political status, among others.

“The right to enjoy the highest attainable standard of physical and mental health on an equal basis with others and without discrimination based on age or any other status” is how the World Health Organisation defines health. Equality is a crucial component of the human rights-based approach to health, which offers a set of precise guidelines for establishing and assessing health policy and the provision of services, focusing on the discriminatory behaviours and unfair power dynamics that are the root cause of unequal health outcomes.

Overall, the inputs illustrated that existing frameworks lack consistency and comprehensiveness in adequately addressing the different facets of the right to health of older persons. National governments must ensure that the approach towards older people is aligned with international standards on the right to health. Health facilities, goods, and services should be made available, accessible, affordable, acceptable, and of good quality for older persons. Provisions should address particular health needs, such as the concurrent presence of many diseases (multimorbidity) and the need to access various medications (polypharmacy); the State should guarantee the comprehensive assessment of senior citizens and the delivery of integrated healthcare.

Conclusions 

Numerous international conventions provide normative support for the right to health and access to healthcare, and political support for achieving this goal is broad. However, the definition of old age and the unique circumstances of the elderly have not been adequately defined. Despite mentioning a wide range of national policies and initiatives, the inputs do not provide proof of coherent and all-encompassing domestic frameworks that adequately protect the rights of older people to the best possible quality of life and access to healthcare.

While socially embedded ageism in law, policy, and practice still obstructs the equal realisation of the right to health, anti-ageism awareness is widely acknowledged as a way to address structural inequalities and promote health. There are emerging examples of progress made in domestic provisions. Several health promotion initiatives have shifted away from the dependency, needs, and welfare paradigm that has historically defined ageing policies and towards an awareness of the necessity of implementing rights-based, integrated, and all-encompassing approaches to health.

The significance of geriatric specialisation, which addresses the needs and comorbidities of older adults, is becoming more widely recognised. Nonetheless, there are still significant gaps in geriatric professional availability, training, and integration with the rest of the healthcare system. Many older people still have difficulty accessing healthcare services. This problem is especially acute in rural and remote areas with a shortage of healthcare professionals and insufficient healthcare infrastructure.

Social and economic variables that increase health disparities, such as poverty and the cost of paying for healthcare out of pocket, make it more difficult for older people to access care. The practice of ageism and prejudice in healthcare leads to elderly patients receiving substandard care or being denied access to necessary medical interventions, facilities, goods, and services, undermining their right to health.

Contributions identified the intersectionality of socioeconomic disadvantages and other discriminations not sufficiently recognised or addressed in public policy. The structures that are now in place do not always include measures to alleviate gender inequality. The informed consent model used by domestic health regulations appears at least partially at odds with the right to assisted decision-making outlined in the Convention on the Rights of Persons with Disabilities. There is no proof that many of the current redress mechanisms are successful.

There are significant shortcomings and conceptual limitations related to state obligations regarding the right to health and access to health services. The findings of the Office of the High Commissioner for Human Rights report only partially, narrowly, inconsistently, and insufficiently address the broad scope of this right and its interdependence with other human rights. One significant barrier to the realisation of the right to health in old age is the lack of explicit frameworks requiring states to take decisive action to eradicate ageism. The responses acknowledged the need for more robust legislative frameworks about health and healthcare access rights based on equality, autonomy, and older people’s involvement.

In its fourteenth session at the United Nations Headquarters, the Open-ended Working Group on Ageing may contribute to greater clarity and possible international standards on the focus areas of “right to health and access to health services” and social inclusion.

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Dr Joe Thomas is Professor of Public Health, Institute of Health and Management, Victoria, Australia. Opinions expressed in this article are personal.