REVIEW ARTICLE Older people’s exclusion from healthcare services in Nepal: An analysis of the political economy of development aid, domestic policy and research Lok P Sharma Bhattarai Faculty of Health and Social Sciences, Leeds Metropolitan University, Leeds, UK The objective of this review was to contribute to the discussion on older people’s access to healthcare in developing countries. Relevant research findings, survey reports, policy papers and planning documents were critically reviewed, placing a particular focus on their relevance in understanding issues of access, equity and justice. A number of factors are identified for their roles on the issue; that is, place of residence, economic factors/poverty, cultural stigma, situation and impact of research, and the prevalent policy framework in health and the approach of development assistance adopted by donor communities. In order to make healthcare facilities equitable for older people, the identified factors need to be addressed at different levels – at local policy work, in the allocation of funding for health service research and in designing overseas development work. Geriatr Gerontol Int 2012; ••: ••–••. Keywords: developing countries, health planning, health policy, health services accessibility, old age assistance. Introduction In the current times of uncertainty, politics of exclusion are more, rather than less, likely in different loci of social life. Similar to some other vulnerable groups, older people are considered to be one potential group that might become the victims of exclusion in different ends and means. Access to healthcare and medical facilities might potentially be an area where exclusion could have become rife. In the present review, the roles of different factors that potentially aggravate older people’s exclu- sion from their right to healthcare are discussed, with special reference to the context of Nepal. Although the discussion is based on experiences and evidence from Nepal, the discussion might be helpful in understand- ing the situation of many other developing countries in the world. At the present time, the debate on health inequalities in the literature seems to be unbalanced, where much attention is given to a person’s social situation with regard to health inequalities. In doing so, on the one side, self-rated health measures are widely used to measure one’s health status, and on the other side, various person-centered variables are considered for their role in rendering equalities or inequalities. 1–3 By arguing that an alternative approach can also be equally useful to examine the issue, this article, taking “a country” as a single case, shows how various policy or politico-economic factors can render health inequalities at a macro level. The article is based on an approach where the notion of health inequalities is not discussed at an individual/personal level, but it has presented an example of exploring macro level structural factors for their role in creating health inequalities against a par- ticular group. Demography, prevalence of illness, mortality and healthcare facilities available for older people The findings of the recent National Living Standard Survey III in Nepal 4,5 showed that in the past 15 years, the 60 years and older age group has increased from 7% to 9% of the total population. The report showed that a total of 19.9% of households were headed by a person aged >60 years in 2010/2011. In comparison with Western developed countries, the proportion of older people in the total population is still relatively low in Nepal. The reason for this is not that there is no sig- nificant number of older people in the total population; rather, it is instead related to the share of other age groups. Like other developing countries, Nepal has a bigger share of the <16 years age group in the total population, making an expansive population pyramid. If, however, the population of this age group was sepa- rated from the total population, then the percentage of Accepted for publication 5 August 2012. Correspondence: Mr Lok P Sharma Bhattarai MA, Faculty of Health and Social Sciences, Leeds Metropolitan University, Queen Square House, Civic Quarter, Leeds, LS1 3HE, UK. Email: lok.bhattarai@live.co.uk Geriatr Gerontol Int 2012 © 2012 Japan Geriatrics Society doi: 10.1111/j.1447-0594.2012.00947.x | 1