Guiding Questions for the focus areas of the IX Session of the Open‐endedWorking Group on Ageing:  Autonomy and independence;

1) In your country/region, how is the right to autonomy and independence of olderpersons defined in legal and policy frameworks?
In medical practice autonomy is usually expressed as the right of competent adults to make informed decisions about their own medical care. The principle underlies the requirement to seek the consent or informed agreement of the patient before any investigation or treatment takes place.
Personal autonomy is widely valued. Recognition of its vulnerability in health care contexts led to the inclusion of respect for autonomy as a key concern in biomedical ethics. The principle of respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. In this paper, we suggest that a strong focus on decision situations is problematic, especially when combined with a tendency to stress the importance of patients’ independence in choosing. It distracts attention from other important aspects of and challenges to autonomy in health care. Relational understandings of autonomy attempt to explain both the positive and negative implications of social relationships for individuals’ autonomy. They suggest that many health care practices can affect autonomy by virtue of their effects not only on patients’ treatment preferences and choices, but also on their self-identities, self-evaluations and capabilities for autonomy. Relational understandings de-emphasise independence and facilitate well-nuanced distinctions between forms of clinical communication that support and that undermine patients’ autonomy.
2) What other rights are essential for the enjoyment of the right to autonomy and independence by older persons, or affected by the non‐enjoyment of this right?
Officials in healthcare sectors in Islamabad and Sindh said that Pakistan — among the 15 countries with more than 10 million people — had already close to 18 million people aged 60 and above, which would rise to 45 million or more after 10 years.
The Sindh Senior Citizens Welfare Bill, 2014, is awaiting approval for a year but a similar bill has been languishing in the rulers’ corridors of Islamabad since 2007.
But until the law is finally passed and promulgated, serious social, economic and health problems are on the rise in Sindh and elsewhere in the country,Medical care is cheaper in government hospitals; however patients prefer private hospitals because of quality of service. The pattern (loneliness) in the country’s biggest metropolis is attributed to children moving out of joint family system or migrating to other countries for better employment opportunities.
The 1998 census cites a disability rate of people aged 60 and older. Disability was defined as deafness (including mutism), crippled status, blindness and mental retardationAnother study on Pakistan reports that incidence of chronic illnesses rises with age requiring medical care. Fatigue, mobility impairment, dyspnoea (difficult or laboured breathing), urinary incontinence and visual impairment had the worst impact on the life of the aging individual and diabetes mellitus , hypertension , and arthritis  were the most frequently reported chronic ailments.
Rights of senior citizens are flouted with rampant abandon in the country with around 20 per cent of aged people struggling with their everyday basic needs such as food and shelter, a national level research study said.
It further discovered that older women were at a greater disadvantage to men.
The first ever national-level research on the rights of older people ‘Moving from the Margins: Promoting and Protecting the Rights of Older Persons in Pakistan’, has been conducted by the HelpAge with the collaboration of British Council. A concise version was shared on the eve of International Day of Older People (falling on October 1) with the full report expected to be launched later this year.
Pakistan urgently needs to develop clear and comprehensive institutional arrangements for the protection of human rights of older people, including guaranteed minimum pensions for everyone and specialised and affordable geriatric health care provisions.
 The country has the unwanted record of having one of the lowest pension income coverages in the world. It ranks particularly low with respect to the health of older people, with a relatively low life expectancy and even lower healthy life expectancy.
Pakistan also ranks low with respect to satisfaction of older people and social connectedness, civic freedom and public transport.
3)  What are the key issues and challenges facing older persons in your country/regionregarding autonomy and independence?  What studies and data are available?
According to World Bank statistics, the world’s population of the elderly has been steadily increasing since 1948 due to declining fertility and increasing life expectancy. The world’s elderly population (60 years and older) reached 251 million in 1950 and 488 million in 1990. It will reach 1,250 million in 2025 — an increase of 146 per cent. Most of the current and future increase will take place in the developing world, in Asia and South Asia in particular. South Asia will experience a dramatic increase in its elderly population by nearly nine times between 2010 and 2025 when life expectancy will increase to 75 years for men and 82 years for women.
In Pakistan, the elderly population is estimated to be 7.2 million and is steadily increasing to about 10 per cent of the population. By the next decade it is expected to rise to about 15 per cent of the population. This means a heavier burden on the younger generation who are duty-bound to care for them. It also means an additional burden on the exchequer. More nurses and medical personnel will be required to care for the elderly.
In a recent study conducted by the Senior Citizens Welfare Trust, it was revealed that 98 per cent of the elderly population prefer to stay with their families rather than be admitted to homes. The emotional and social satisfaction of being with their children and grandchildren cannot be replaced by the barren atmosphere of homes managed by strangers.
However much we may discourage building homes for seniors, the need for a few still remains unfulfilled. These are the elderly whose children leave them in Pakistan while they go abroad for a better future. There is enough evidence to prove that the children send money to take care of their needs. Yet they need suitable accommodation with assisted living. For them, a condominium-style of building complex is the answer.
No doubt the government cannot do everything and civil society must share some of the responsibilities of caring for senior citizens. Yet some of the services fall within the exclusive purview of the government. Healthcare is one of them.

4) What steps have been taken to ensure older persons’ enjoyment of their right to autonomy and independence?
We're delighted to announce that legislation has been introduced in Pakistan for the protection of older people's rights.
Khyber Paktunkhwa (KP) assembly has passed “Senior Citizen Bill” on 19 November 2014 in Peshawar. The bill was presented to the assembly on 23 October and it has now been passed.
This is great news not only for older men and women in KP but for every one in Pakistan, as before this there was no legislation to protect older people rights.
This is the first ever law which will now protect rights of older people.
We have been advocating for this for the last three years and the draft of the bill was developed in consultation with the government and older people themselves.
We congratulate everyone from HelpAge in Pakistan, London and South Asia. A special thanks goes to Mr Shakir Hussain, the District President of older people's associations in Nowshera, who has been actively involved in advocating for this law.
In Pakistan, celebrations for HelpAge and older people's associations started on 30 September. A policy advocacy seminar was organised with the Government of Punjab in Lahore, urging them to approve the Senior Citizen Bill.

Unfortunately, there is no law for the protection of older people's rights in Pakistan and provinces have the power to make their own policies in their respective parliaments. Therefore HelpAge in Pakistan along with older people's associations have been advocating with federal and provincial governments for legislation to protect older people's rights.
The parliamentarians at the seminar gave their full support and stated that the bill will be presented shortly to the provincial assembly for approval.
Success in Nowshera
On 1 October, a great event was organised in Nowshera, in Khyber Pakhtunkhwa (KP) province by older people's associations. Older people in Nowshera celebrated 1 October through walks, rallies, seminars and meetings.
Calling for age-friendly services in Sindh
Older men and women in Sindh province also celebrated 1 October by organising an awareness raising walk to highlight the issues they face.

Delegations of older people also met with key government officials, including the district health officer, the deputy high commissioner and district support manager.

Older people called on these decision-makers for age-friendly public transport and health services.

They urged the officials to take concrete actions in order to protect their rights and make services age-friendly.

Older people and emergency responses
In Pakistan, HelpAge is actively engaged in responding to emergencies and disaster risk reduction work. We advocate for inclusive emergency responses and DRR programmes, policies and strategies.

To achieve this, we work closely with government departments at the national and provincial level. We were thrilled when the National Disaster Management Authority (NDMA) approached us to mark this year's International Day of Disaster Reduction.

We were also delighted when Prime Minister, Nawaz Sharif sent out a statement emphasising the importance of including older people in disaster risk reduction polices, programmes and strategies. The Prime Minister also highlighted the need to recognise older people's potential in preparing and responding to emergencies.
The Chairman of the NDMA also spoke about demographic transition and the need to include older people in preparedness plans and programme.
The Ageing & Disability Task Force (ADTF) Pakistan also sent a call for inclusive emergency responses to over 5,000 humanitarians actors including UN agencies.
Find out more about our work on disaster risk reduction.
5) What mechanisms are necessary, or already in place, for older persons to seek redressfor the denial of autonomy and independence?  
The increasing number of ageing population is a signpost for re-directing the resources to ensure quality of life for elderly thus promoting active ageing. However, the challenges to achieve the goal outweigh the opportunities due to scarcity of resources.
Several factors including, brain drain, poverty, lack of knowledge of elderly to protect their rights in association with poor state laws determines the poor quality of life for elderly in Pakistan. Although, the apparent scenario is quite unpleasant yet there are several opportunities such as improved crude birth and death rates, increased awareness about gerontology as a specialty care area and constitutions of Pakistan can be significant to ensure the well being of elderly and overcome the challenges to achieve active ageing in Pakistan.
It is important to make best use of opportunities at hand by redirecting the resources to improve the quality of life to promote active ageing in Pakistan,
6) What are the responsibilities of other, non‐State, actors in respecting and protecting theright to autonomy and independence of older persons?
The human rights of older persons in Pakistan remain neglected. Initial findings of a national study show 20% of older persons in Pakistan struggle with their everyday basic needs of food and shelter. A greater disadvantage is observed for older women as 24% of them struggle in accessing the basic needs of food and shelter.
To better understand the challenges facing older people in Pakistan, a first-ever national level research study has been conducted by HelpAge International with the support of British Council. Titled ‘Moving from the Margins: Promoting and Protecting the Rights of Older People in Pakistan,’ the study was led by Dr Asghar Zaidi, Professor in International Social Policy at University of Southampton. Qualitative and quantitative data collection was collected from all four provinces of the country. The complete report will be launched later in this year.
According to the report, a higher proportion, about 25%, struggle with everyday basic needs for healthcare and medicine. Women do worse than men in this respect. Close to one-half believe that younger members of the family have a greater ability to pay for the costs of their health care.
One out of ten older persons believe that they have been looked down upon or treated in humiliating, shameful or degrading way because of their age. A similarly large proportion of Pakistani older persons believe that their family members make important decisions without their permission or consent.
Commenting ahead of the release of the report, Professor Zaidi said: “Pakistan urgently needs to develop clear and comprehensive institutional arrangements for the protection of human rights of older persons, including guaranteed minimum pensions for everyone and specialised and affordable geriatric health care provisions.”
As of today, only a limited number of policy instruments have been developed to address issues associated with the wellbeing of older persons. The government of Pakistan has also initiated the legislation process, and the Senior Citizens Act has been approved in the province of Sindh, KP and Balochistan. However, implementation of these acts is still a question mark.
The government of Punjab has also initiated the legislation process and a Senior Citizens Bill has been finalized by the government but it’s been pending for the approval for last two years. Unfortunately, no policy or law has been enacted at the federal level.
Ageing is under strong focus of international development now. It is clearly recognized in the Sustainable Development Goals (SDGs). These call for leaving no one behind and ensuring that development goals met for segments of society.