While the importance of healthy aging is increasingly recognized by governments, international institutions, and private-sector and civil society actors, barriers remain to the mainstreaming of healthy aging agendas and policies across society. Older adults are important stakeholders to include in the design and implementation of healthy aging policies, practices, and the development of technologies, with the aim of reducing these barriers and connecting individuals to opportunities for health in later life.
Accessibility of Care
Ensuring that all older persons—as well as the entire population—can access high-quality, affordable, and targeted care should be a core component of health care provision. However, older persons are often subconsciously divided, in the minds of many policymakers and broader society, into “unhealthy” and “healthy” groups. Although health disparities are particularly evident among older persons, those considered “healthy” and those considered “unhealthy” can both be ignored as rights-holders. “Healthy” older persons might be less likely to be considered or explicitly included in legislation or health care provision as they use fewer resources and spend fewer health-related funds, while those with health challenges, including disabilities in some cases, might have a much harder time accessing sufficient services due to the greater amount of care needed. As a result of these assumptions, older adults can struggle to access affordable, targeted, and equitable health care.
Affordable Health Care Remains out of Reach for Many
Expanding access to health care services is among the most important components of the healthy aging agenda. However, the cost of health care worldwide is rising—the WHO found that in 2018, global health care spending reached $8.3 trillion, equivalent to 10 percent of global GDP. Government responsibility for health care spending looks different across the globe. In many low- and lower-middle-income countries, around 40 percent of all health care spending by individuals was out-of-pocket, as governments in these regions have deprioritized funding for health costs. While much of the rest of the world relies on a combination of public- and private-sector health infrastructure, alongside a variety of state-funded and private insurance policies, 32 countries worldwide have implemented universal health care systems that are free at the point of access, including the UK, Japan, and South Korea. Private health insurance can be onerously expensive and often confusing to retain, deterring people with little education or low trust in public services from seeking acute and preventative care. The lack of such care can lead to complications and low quality of life in older age. As older people lose access to income streams in later life as a result of reduced employment, insurance premiums and out-of-pocket expenses can become untenable.
CASE STUDY
The Cost of Adequate Health Care
Comparing publicly and privately funded care systems can uncover disparities in the scope and quality of health care, as seen when contrasting the U.S. health care system with those of 10 OECD peer nations: Switzerland, Germany, France, Sweden, Canada, Norway, the Netherlands, the UK, Australia, and New Zealand. While in these peer nations publicly funded health services undertake much of the burden of payment, in the U.S., the provision of adequate care is hindered by a health care system that places the burden of payment on individuals and has relatively high health care prices. The average American spends $1,122 out-of-pocket on health care per year. Across peer nations, only the Swiss pay more per capita, while out-of-pocket expenses in New Zealand and France are less than half of those of Americans. High insurance premiums and out-of-pocket expenses can deter people from seeking care throughout their lives, contributing to double the obesity rate and a much higher prevalence of chronic diseases in the U.S. than the OECD averages. Overall, the U.S. spends nearly double what the OECD spends on average for care, as a share of the economy.
While few governments currently provide publicly funded health care for all, care providers at all levels can move toward greater affordability for health care, which in turn supports healthy aging agendas. This shift toward affordability would require sustainable funding streams, notably compulsory funding sources such as tax revenues, as well as investments in targeted care for older people and primary care systems that would support health at all ages and abilities. Political will is coalescing around expanding global access to affordable health care as well. The UN SDGs specifically identify increased government health care spending as key to the achievement of SDG 3: “Ensure healthy lives and promote well-being for all at all ages.” In 2019, 140 governments committed to the move toward universal health coverage—and affordable health care in general—during an Inter-Parliamentary Assembly held in Serbia, as well as through a “Political Declaration” signed at a United Nations General Assembly High Level Meeting the same year.
Preventative Care Promotes Healthy Aging Outcomes
As mentioned above, adequate and affordable preventative care is essential for ensuring a healthy population, especially for older persons. Preventative care, including annual physicals, routine cognitive and physical screenings, and vaccinations are critical to detecting or preventing serious diseases and medical problems. Promotion of healthy aging across the lifespan through preventative measures would reduce costs to health care institutions and reduce out-of-pocket costs for individuals. Preventative care might also include the promotion of behavioral and physical changes to support healthy aging through the lifespan, such as drug cessation, healthy nutrition, and exercise. For example, Cyprus and Israel host programs for physical activities for all citizens, including custom-designed initiatives to develop exercises specifically for the eldest of the cohort (ages 80 and above).
Targeted Care for Older People Can Maintain Individuals’ Dignity and Autonomy
In many countries, older people, particularly from marginalized groups, lack sufficient access to targeted care services, including geriatric, long-term, and palliative care services. In the U.S., approximately 30 percent of older adults will at some point need access to a geriatrician. Estimates indicate that by 2025, the U.S. will need around 33,200 geriatricians to keep pace with demand, but there are currently only 7,000 geriatricians, of whom only half keep full-time hours. This shortage causes many older adults who need targeted care to travel long distances to access these providers or to go without necessary care. Additionally, many health care professionals in developing countries must pursue specialized studies abroad, due to the lack of training opportunities for geriatricians globally. In the Eastern Mediterranean region, for example, there is just one dedicated educational institution—the Middle East Academy for Medicine of Ageing—serving the entire region, leading to a shortage of specialized care. Some of those who receive specialized training abroad may then choose not to return to practice in their home countries, as salaries for professional providers in developing countries tend to be much lower than in wealthier regions, contributing to “brain drain” migration toward the Global North.
Retraining health service providers to deliver targeted care and attracting new generations of geriatricians could both be paths toward overcoming this global gap in care for older adults. Familiarizing primary care professionals with the needs of older adults could be a rapid and relatively low-cost means of improving aging services in comparison to training new geriatricians, which has a timeline of many years and requires significant capacity, and thus may be most appropriate in developing economies where resources are scarce. For example, Abdulrazak Abyad, the Chairman of the Middle East Academy for Medicine of Ageing, was Lebanon’s first registered geriatrician when he registered in 1991, and he now trains non-geriatrician health care providers across the region, during short conferences, to be sensitized to older people’s needs. Governments, universities, and philanthropic organizations can encourage medical professionals to specialize in geriatrics by increasing funding for training. In testimony before the U.S. House of Representatives for the Fiscal Year 2022 Appropriations for the Department of Health and Human Services in the U.S., the American Geriatrics Society advocated for the U.S. government to commit at least $105.7 million to fund the Geriatrics Workforce Enhancement Program (GWEP) and the Geriatrics Academic Career Award (GACA) Program—more than double their budget in 2020. The GWEP program provides grants for 48 states and medical teaching facilities around the country to train health care workers on elder care and conduct innovative research into geriatrics, while the GACA funds individual junior geriatrics faculty and clinical geriatrics training. Similar programs, or other forms of expanded support and funding for geriatric students and geriatricians, could incentivize more doctors to specialize in this field.
Long-Term and Palliative Care Provide an Opportunity for Home-Based Services
Long-Term Care
Targeted care for older adults entails the provision of long-term and palliative care, which can be challenging to fund or access. As the share of older adults increases, so do needs for long-term care (LTC), yet only 5.6 percent of the world’s population lives in countries that mandate full, universal access to LTC through national legislation. Nevertheless, many countries—particularly those in the OECD—do have government-supported, public options for long-term care schemes. LTC is generally funded from one or more sources: 1) general taxation; 2) out-of-pocket contributions from individuals and families; and/or 3) social insurance, in which individuals are required to contribute to a fund, usually through payroll taxes, that is allocated specifically for LTC needs. Germany, Japan, and South Korea, for example, all have mandatory and universal public LTC insurance that provides services and support and is deducted from working citizens’ paychecks. In the U.S., by contrast, the vast majority of people have no protection against future catastrophic out-of-pocket costs for LTC and risk becoming impoverished. LTC is generally left up to the individual to self-finance and can be prohibitively expensive for most older persons, as it is only covered by Medicaid for the poorest individuals. In the U.S., by 2029, an estimated 54 percent of older persons will not have sufficient funds to afford the LTC that they need.
As the share of older adults increases, so do needs for long-term care (LTC), yet only 5.6 percent of the world’s population lives in countries that mandate full, universal access to LTC through national legislation.
While private long-term care facilities tend to be more comfortable and provide more amenities than public options, the private long-term care insurance industry (LTCI) is undergoing significant transformation. Few consumers have purchased long-term care insurance, primarily because of its high cost, in addition to the challenge of navigating complex insurance policies and concerns over rising premiums. This issue of affordability for private care is particularly impactful for middle-income older adults who may not be eligible for government-funded LTC assistance programs that target lower-income people or be able to afford the private care facilities that target high-income seniors. Community- and home-based services allow older people to age-in-place, which is predominantly preferred by older people across cultures and countries.
In developing economies, care responsibilities generally, and LTC specifically, have traditionally been undertaken by family members, usually women. As such, many countries, particularly in South America and Africa, lack a comprehensive plan for the delivery of high-quality LTC to older adults, whether through home- and community-based services or in institutional settings. Although ramping up the provision of formal LTC options presents a challenge for developing countries, experts noted during roundtables and interviews that developing countries are in a unique position to prioritize investment in community- and home-based care options, rather than institutionalized care, due to the pre-existing culture of aging-in-place and in the home, and a resultant lack of government- or private sector-run nursing homes. Despite this advantage, funding and ensuring quality of care will remain significant challenges for governments in these contexts.
It is also important to note that community-based LTC services are just one element of a comprehensive LTC system: community day care, respite care, transitional care services, and even institutionalized care will be necessary to ensure that all care needs are met. Many aging experts agree that choice across the continuum of care is vital to providing high-quality LTC to older and disabled adults, as everyone should have the opportunity to age with options. As Bethany Brown, human rights advisor at the International Disability Alliance, observed, receiving LTC at home is usually “less expensive than being institutionalized, and it also respects the inherent dignity and choice of individuals, but that choice can only happen where those home-based services and supports exist.” Individuals who wish to remain in their homes for as long as possible can be supported by family, government, and private and charitable services to do so.
Where long-term care is covered wholly or in part by government expenditure, there are some promising ideas for improvement, particularly greater facilitation of aging in place. One option is for governments to provide further support for home- or community-based services. In Canada, for example, a publication by the Canadian Medical Association advocates for the Canadian federal government, alongside the provinces, to fund home- and community-based LTC. Currently, Canadians spend roughly $9 billion Canadian dollars on care for older adults, which could increase to CA$23 billion by 2035 as the population ages. Better support for aging-in-place and reducing direct costs of care for older adults and family caregivers, through the creation of a “ Seniors Care Benefit” that may act like a direct payment to caregivers and older adults, could reduce pressure on health care providers and save about CA$794 million per year. Globally, extended support for aging-in-place could also target the middle-class seniors who tend to be “invisible” within care systems. LTC insurance could be another area for innovation, particularly in countries where there are large gaps in care between expensive private and means-tested public facilities. However, to-date, the industry has struggled to successfully cater to the needs of older and disabled adults, due in large part to fluctuation in the cost of premiums, and, in the U.S., the collapse of several large industry players.
Palliative Care
Like LTC, palliative care is a necessary component of person-centered health care, as it can increase the comfort and well-being of older adults at the end of life. However, only about 14 percent of people globally who need palliative care receive it— access to palliative care is more of an issue than its affordability, in contrast to LTC services. One major barrier to global palliative care access is understanding what it is and when it would be an appropriate intervention, as many health care professionals do not consider it a necessity. Where it is common palliative care is often provided by hospitals, despite the fact that much of it can be administered in the home or in hospice settings, straining health facilities and exacerbating the vulnerability of unwell and dying older adults. Much like LTC, high-quality palliative care prioritizes the wishes of the individuals receiving care, requiring a person-centered approach. The Let Me Decide program, piloted in both Canada and Ireland, provides an example that could be replicated by national health services or private palliative care providers.
CASE STUDY
Ireland’s Let Me Decide Campaign
Ireland’s Let Me Decide Advance Care Planning and Palliative Care Programme, originally developed in Canada and piloted in Ireland in 2014, aimed to provide expanded access to palliative care. The program allowed patients in six Irish LTC facilities (five nursing homes and one hospice) to establish end-of-life directives, including for palliative care, and 90 medical staff across the facilities were trained in palliative care techniques. During the three-year implementation period, there was a dramatic increase in palliative care services uptake among LTC residents—from 25 percent before the program to 76 percent during the program—which suggests that palliative care is attractive to older adults if it is offered as a viable option. There was also a precipitous drop in hospitalization rates, in-hospital time, and in-hospital deaths, compared to the baseline. The estimated cost savings from the reduction in hospital resources used, if the program were expanded throughout Ireland, could reach €17.7 to €42.4 million—equivalent to USD$20.6 to $49.3 million—nationally.
Educating insurance companies, governments, and health care professionals on the benefits of both LTC and palliative care may facilitate the wider adoption of subsidized, accessible care. One approach may be to communicate that both LTC and palliative care can save health care actors money, as well as improve well-being among older adults. A study by researchers at Stanford Medicine found that promotion of healthy aging, including better support for older adults to age in their communities and a clearer process for identifying and enacting end-of-life plans, would reduce costs to health care institutions and therefore reduce the cost burden for individuals. For example, a hospital that established an interdisciplinary palliative care program that has the capacity to see 500 patients per year could expect to save a net $1.3 million per year. For countries in which LTC and palliative care costs fall on individuals and families, with little-to-no government assistance, additional funding for necessary care could come from donations by civil society actors, a reduction in charges for care by health service providers, or the mainstreaming of long-term care insurance.
Disparities in Access for Marginalized Groups Persist
Finally, disparities in health among marginalized groups remain an overarching challenge when managing populations of older persons, as health disparities can contribute to more rapid and stressful aging. Before the COVID-19 pandemic, between 55 and 70 percent of elderly people across the world reported that they felt marginalized on the basis of ageism, sexism, or another form of discrimination. In addition to the impacts of ageism, older adults from marginalized groups may face additional issues when accessing or receiving care. In the U.S., for example residents of nursing homes with large racial and ethnic minority populations, as compared to the rest of the country, died of COVID-19 at a rate three times higher than nursing home residents living in mostly white communities. In addition to physical harm, marginalization can contribute to social isolation and loss of dignity and agency among older adults, which have implications for mental health and overall well-being.
CASE STUDY
Culturally Sensitive Service Delivery to New Zealand’s Maori Community
New Zealand provides an excellent case study in taking a holistic approach to healthy aging, particularly with regard to its historically marginalized Maori population. The Maori population typically experiences worse health outcomes throughout their lives than the country’s white population, due to poverty, racial discrimination, and lower access to proficient and culturally appropriate health services, all of which can cause higher incidences of chronic disease and disability.
Having identified this health disparity, New Zealand’s government has integrated new programs and service-delivery approaches tailored to the Maori’s needs and cultural practices into its “He Korowai Oranga: Māori Health Strategy” (2002) and “Whakamaua: Māori Health Action Plan 2020–2025” (2020). Maori communities face significant housing discrimination, and so the government has included affordable housing access into its approach to lifelong health care and has partnered with tribal and Maori-run service providers for service delivery. Such an approach could be replicated in other countries with a focus on relevant marginalized groups—including racial and ethnic minorities and the LGBTQ+ community—who experience health and housing discrimination and would benefit from culturally sensitive service provision.
Prioritized attention to the experiences and needs of older women, racial, ethnic, and religious minorities, displaced peoples, gender or identity minorities, persons with disabilities, and people in specific settings such as fragile states and poverty contexts would assist in having marginalized older adults access health care. For example, India has a social protection policy that recognizes the vulnerability of older women, including a pension fund for elderly women working in the informal economy and an initiative to enhance awareness of gender-specific diseases to which older women are susceptible.
COVID-19 Risk Reduction is an Ongoing Challenge in Care Settings
Countries with older populations have been particularly affected by the COVID-19 pandemic. Throughout 2020, older persons were more likely to be hospitalized with, or die from, COVID-19 infection, particularly those over 85 years old. While nursing homes and LTC facilities can be vital spaces of socialization and interaction for older people at risk of isolation, the COVID-19 pandemic has shown that they can also facilitate the spread of communicable diseases. By June 2021, nursing home residents and staff represented almost one-third of the U.S.’s total COVID-19 deaths, and in Canada, nursing home residents accounted for nearly 70 percent of all COVID-19-related deaths in the country in 2020. However, ageism and well-intentioned paternalism toward older persons was also particularly rampant during the COVID-19 pandemic. While the intent of strict travel and movement restrictions for older adults specifically was to protect them from spreading or catching the virus, these health measures have also reduced older persons’ rights to choose how to respond to the virus and to dignity in health care. This type of ageist health measure can portray all older adults as being uniquely and homogenously vulnerable to infection while downplaying the vulnerability of younger populations.
Key to protecting older adults while maintaining their rights and dignity during the crisis has been high-quality, accessible, and flexible health care provision, which prioritized action on safe housing, adequate resourcing, and cross-sectoral collaboration. The pandemic demonstrated the importance of strong health systems that can support vulnerable groups and be complemented by well-resourced and flexible capacities for health service provision and wider social support programs tailored to the crisis and scaled up to address any shocks. Though accessibility challenges remain, such as lack of access to technology, telehealth has the potential to significantly improve the flexibility of, and access to, care for older adults.
CASE STUDY
COVID-19 Response in Four Countries
According to the World Economic Forum and AARP research, South Korea, Hong Kong, Taiwan, and Singapore stood out in their ability to shield older persons from the pandemic. In all four cases, programming, resources, and capacity already existed, due to previous epidemics such as SARS and MERS, to support older persons across multiple areas of health. These capacities were drawn on to enable quick action when a crisis hit. All four jurisdictions engaged in pre-emptive epidemic planning, starting in February of 2020, and rapidly implemented aggressive and widespread testing, quarantining, and contract tracing across the country.
Many of these measures were then adopted and implemented by the rest of the world. The countries all had sufficient personal protective equipment to equip nursing homes and health care workers immediately, which reduced the spread of the virus, and nursing homes and long-term care facilities were included in the pandemic plans. By mid-2020, no deaths had been reported in nursing homes in Taiwan or Hong Kong, and fewer than 20 deaths had been reported each in South Korea and Singapore. The result of this advance preparation was significantly better outcomes than in many other countries and fewer deaths among older adults, despite some spikes in COVID-19 cases in South Korea and Singapore.
While COVID-19 increased health vulnerabilities among older adults, as well as social isolation, some older adults also demonstrated unexpected resilience. In a survey of older adults regarding their feelings and mental health, 63 percent of respondents reported at least one positive outcome from the pandemic, such as time and space to try new hobbies, the “freedom of simplicity,” and the establishment of closer community ties and solidarity. Respondents who reported positive feelings emerging from the pandemic were more likely to be in the workforce, as their routines and capacity for social interaction were relatively unchanged; in comparison, retirees, who were less able to conduct their social, family care, or volunteer routines, were more like to struggle with feelings of purposelessness. Those older adults who used technology throughout the pandemic, such as video calls, were less likely to report depression and more likely to express gratitude for those close to them. Increasing older adults’ personal resilience—including mental health resilience—fosters healthy aging and well-being and can help support older people in the event of a crisis. As this study demonstrates, mental health and resilience are closely tied to older adults’ ability to participate meaningfully in society, whether through employment, volunteering, or socializing with friends and family. As the pandemic continues, and beyond its conclusion, stakeholders in healthy aging can facilitate such meaningful connections to better support the well-being of older adults.
Mental health and resilience are closely tied to older adults’ ability to participate meaningfully in society, whether through employment, volunteering, or socializing with friends and family.
Importantly, this type of health support for both physical and mental health is also critical for younger populations. Reducing vulnerabilities and improving resilience through accessible health care and mental health support is important for populations of all ages as long as COVID-19 remains a global threat. Evidence suggests that older adults may be better able to cope with stress from the pandemic and other challenges than younger populations—older adults may therefore be able to help others struggling due to social isolation, perhaps through inter-generational volunteering programs. Such opportunities for older and younger people to interact and support each other through the difficulties of the pandemic may also serve to reduce ageism, particularly among those who see older adults as a “strain” on health resources. COVID-19 laid bare the importance of providing for human development and economic well-being across all demographic groups, and of creating opportunities to promote health and healthy aging across generations.
Finally, vaccinations represent the most important form of protection from COVID-19 for older adults. Vaccination has been shown to reduce spread of the virus and lessen the severity of illness. At least 6.06 billion COVID-19 doses have been administered worldwide. As of 2021, there has been no standardization of age groupings in reporting age-disaggregated data on COVID-19 vaccinations, with data from some countries often not disaggregated at all, making it difficult to track the number of vaccinated older adults. There is, however, a significant disparity between the vaccine supplies and vaccination rates of higher- and lower-income countries—this gap in vaccination levels is contributing to massive health and mortality disparities during the pandemic. Prioritizing vaccination of older adults in least-developed countries will be key to preserving lives and reducing the likelihood of the evolution of vaccine-resistant strains. Standardized age groupings, as recommended in both the SDGs and the UN Decade of Healthy Ageing, will enable easier tracking and comparison of progress toward complete vaccination of older adults.
Creation of Supportive Environments
Supportive environments—both physical and social—are a key factor in healthy aging, as the environments in, and conditions under, which an older person lives can influence their health outcomes. Creating age-friendly, supportive environments is one of the four UN Decade on Healthy Ageing action areas and is a key consideration for policymakers, communities, and actors that aim to promote healthy aging. As Meredith Wyse, a Senior Social Development Specialist at the Asian Development Bank, focusing on aging and care, explained in an interview, creating supportive environments requires “consider[ing] the circumstances that allow people to age healthily, whether that be housing, income, food security, meeting their basic needs…[and] getting the care and support to live as independently as possible in the way that people want.” Innovative policy approaches to building supportive environments center on ensuring the infrastructures needed for older people to exercise autonomy over their lives, including deciding where to live and how to spend their time. Fostering age-friendly environments might include ensuring that physical places like the home, workplace, and community are safe and accessible for older adults, as well as providing supportive policies. Supportive policies include ensuring that older adults are socially integrated into communities, have employment opportunities, have physical and mental health services at their disposal, and are not abused or neglected, as well as having their needs understood by governments and stakeholders through high-quality data collection and genuine input by older residents.
Innovative policy approaches to building supportive environments center on ensuring the infrastructures needed for older people to exercise autonomy over their lives, including deciding where to live and how to spend their time.
Aging-in-Place and Aging-in-Community Support Social Connectivity
The desire to exercise autonomy, especially regarding where one lives, cuts across cultures and contexts and has significant impacts on mental and physical health. Many individuals prefer to “age-in-place” and “age-in-community"—a 2018 survey of American adults over the age of 50 found that over three-quarters of respondents wish to remain in their current residence or in their current community for as long as possible—and governments are moving toward supporting these options for older adults. Aging-in-place generally means that an older adult continues living in their home as they age, usually by making modifications to support their mobility or health needs. Aging-in-place has the benefits of insulating older persons from certain health risks found in community environments and tending to be less expensive than living in long-term care facilities. Older adults who have the opportunity to age in the home, and who are supported by professional or unpaid care, have been found to live longer. This practice also protects individuals’ inherent dignity and respects older adults as human beings with rights.
Aging-in-community is a slightly broader concept than aging-in-place, in that older adults might have the option to remain in their homes, but if their homes are not safe or adequate for their needs, there are other options that are still connected to the community. As Robyn Stone, Senior Vice President of Research at LeadingAge and the Co-Director of LeadingAge LTSS Center @ UMass Boston, said in an interview, the “vision of aging-in-community means that you are living in the place that you call home wherever that is. And that could be, you remain in your own home with the best supports, and the environment allows you to have as much mobility and function as possible. You may have an option to move into some type of congregate residential setting, you may be living with family, you may end up living in a nursing home, which also is part of community.” Aging-in-place or in-community allows greater autonomy and tends to improve the overall quality of life for older persons by placing them in a comfortable environment surrounded by their support network, reducing the risk of social isolation and poor mental health. Aging-in-place also facilitates continued employment or volunteering obligations that individuals may need or want to maintain as part of a productive later life.
In many countries, the major challenge to healthy aging and aging-in-place is a lack of affordable housing that drives many older adults into homelessness. In the U.S., around half of all unhoused people are over the age of 50, and many of those people became homeless for the first time after turning 50, often as a direct result of losing work. Innovations that promote access to housing are key to supporting healthy aging policy. Despite having a low level of homelessness, as well as a relatively small population of older adults at only 2.5 percent over the age of 60, the Emirate of Sharjah in the United Arab Emirates implemented an innovative program in 2012 to ensure access to affordable, adequate housing for older persons. The program is arranged around three main services for older adults: 1) building a housing unit adjacent to an older person’s family; 2) building an entirely new house for an older adult and their extended family, tailored to the older adult’s needs; and 3) maintaining and modifying existing properties to support the needs of older persons, such as adding an elevator.
Some other promising practices identified by aging experts tend to focus on enabling older persons to exercise greater independence and autonomy, especially regarding the ability to age-in-place and in-community. In the Eastern Mediterranean region, for example, most older adults remain in their homes as they age, rather than relocating to nursing homes, and receive care either from family members or private providers—particularly migrant caregivers. In addition to family caregivers, volunteer or paid support might also be important to supporting aging-in-place. Taking a whole-of-society approach to elder care, the Care for the Aged Foundation in Ghana works with volunteers to undertake in-home care visits. In return for their work, volunteers receive free health care, creating a ripple effect in which healthy aging leads to improved health outcomes for the rest of the community. Where necessary, the practice of retrofitting and adapting older people’s homes to be suitable for their needs as they age should be an option to support aging-in-place, as is common in the Eastern Mediterranean and Israel.
While supporting older adults to age-in-place is important, this solution may not be appropriate in all situations or contexts, due to the particular needs or preferences of individuals, or a shortage in the supply of qualified caregivers working in home-based contexts. In cases where older adults want or need to transition from one setting to another care setting, they should be included to the greatest extent possible in deciding their care setting. NGOs, in particular, are working closely with governments and the private sector to implement in-home care infrastructures that prioritize the needs and health goals of individual older people. In South Africa, for example, the non-profit Rand Aid builds retirement villages that emphasize the autonomy and choice of older adults, who can adapt their homes or move into residential care facilities as their health needs evolve. Listening to older adults’ values and preferences in communities and care facilities is essential to avoiding the creation of ageist or patronizing policies that assume what older people need, and it can lead to more supportive age-friendly environments. Gretchen Alkema, the Vice President of Policy and Communications at the SCAN Foundation, also notes that barriers to aging-in-place are often non-medical—older adults may need assistance with household tasks or mobility. In an interview, she said that support for aging-in-place could therefore be as simple as connecting older adults with services or volunteers for “transportation or other things that people need, such as home-delivered meals, pest control, and shoveling the driveway.”
Ensuring that older adults can physically move through communities, as well as feel included and understood, is important to their inclusion in society. China’s Code for Design of Buildings for the Aged applies to roads, buildings, and other public places in China to ensure that they are accessible for older people, aiding the goal of aging-in-community. In Slovenia, dementia-friendly clinics and centers in the community provide information on dementia, including how to detect the first signs of dementia, how to communicate with a person with dementia, and where to find additional support and services. The service is targeted at persons with dementia, their caregivers, and stakeholders in the local community such as police; firefighters; retail workers; and employees of banks, post offices, community health centers, hospitals, and pharmacies.
Social Integration and Mental Health Care Reduce Social Isolation and its Risks
In addition to supporting access to safe and integrated physical environments, supporting psychosocial well-being and mental health is a core consideration for healthy aging agendas. In particular, the links between human connection and mental health are critical considerations for the development of effective healthy aging policies and initiatives. More than one-third of American adults aged 45 and older feel that they lack social companionship, and almost one-fourth of older adults are classified as socially isolated. Those living alone are generally considered to be more at risk for social isolation and loneliness than are those living with others. Independent living among older persons varies widely at a global level. For example, more than 75 percent of older persons ages 65 or above live alone in countries including Australia, Czechia, Germany, and Finland. In many developing contexts, fewer than 15 percent of older persons live independently, such as in Burkina Faso, Botswana, Honduras, India, Myanmar, Pakistan, Mali, Namibia, Sudan, Thailand, and Senegal. Older women are more than twice as likely to live alone than are older men, with about 24 percent of older women living alone globally, compared to 11 percent of older men.
CASE STUDY
Peer-to-Peer Support
To combat feelings of isolation, AgeWell, a peer-to-peer support program that was piloted among adults in vulnerable communities near Cape Town, South Africa, was shown to reduce loneliness, improve mood, and increase levels of physical activity among older adults. AgeWell participants are trained and paid to serve as companions to other older adults, many of whom are socially isolated. Participants are also trained to spot early signs of health issues, which can lead to overall cost savings and better health outcomes. One AgeWell pilot participant said, “I am 70 years of age. I didn’t know that I would be able to do something like this, go about and try to soothe people, comfort people, make friendship[s] and improve well-being and everything. It gave me a fresh life again.”
A related program that focused on connecting chronically ill and hospitalized older adults with healthy peers, called AgeWell Global, found that due to the social interaction with peers, the 30-day re-admission rate to the hospital among the ill participants was reduced by 25 percent. These programs are innovative because they target the needs of specific groups of older adults (e.g., those experiencing social isolation and chronically ill people), as well as provide social interaction and community integration for both the target and volunteer groups.
One in four older adults struggles with some aspect of their mental health, which might include anxiety, depression, or dementia. The right to adequate mental health care services has been addressed in numerous United Nations reports but is still far from normalized in many countries. Mental health challenges are often driven by isolation and loneliness. Isolation and loneliness are considered serious public health risks by the U.S. Centers for Disease Control and Prevention (CDC), which identifies those experiencing both states to be more at risk for dementia and other severe physical and mental health conditions. Depression, which is the most common mental health challenge among older adults, can be caused or exacerbated by loneliness and isolation. Mental health care for older persons entails more than simply treating an illness, and requires services and integration into communities in addition to health care. Canada’s Coalition for Seniors’ Mental Health, for example, is a non-profit that works to ensure that seniors have the right to services and care that promote their mental health and respond to their mental illness needs. It works to ensure that mental health is recognized as a key health and wellness issue through advocacy, coalition building, and information-sharing.
One in four older adults struggles with some aspect of their mental health, which might include anxiety, depression, or dementia.
To address social isolation, loneliness, and mental health challenges among older adults, a UN Decade of Healthy Ageing report suggests that policymakers and stakeholders working with older adults can promote face-to-face or digital communication, improve infrastructure, and enable age-friendly environments through laws and policies. Face-to-face or digital personal interaction—with therapists or care workers, family members, or friends or other members of care facilities—can assist seniors’ mental health and feelings of inclusion in a community. This type of personal social connection is particularly important for people who live alone or in care homes, and it can assist seniors in maintaining existing relationships and building new ones. Evidence also suggests that programs of this nature that promote social contact are particularly cost-effective. Improving community-level infrastructure, such as transportation links and internet access, can lead to better mental and physical health outcomes as older people are enabled to be active and independent. Also at the community level, promoting age-friendly communities and supporting volunteering around shared interests may reduce mental health and isolation challenges. Finally, policymakers should aim to address gaps in support or negative trends that impact older adults at the societal level, such as discrimination and marginalization, as well as abuse and neglect.
Protection from Abuse or Neglect Requires Urgent Global Attention
Also core to a supportive and enabling environment is the eradication of elder abuse, neglect, and violence, as well as support for mental health and social integration for older adults. The eradication of elder abuse requires urgent global attention that is mainstreamed across systems and sectors and addresses the mental health component of elder abuse. The WHO estimates that one in six people globally aged 60 and older has experienced some form of abuse, with particularly high rates in nursing homes and long-term care facilities. A survey carried out in Argentina, for example, found that almost 9 percent of people surveyed had experienced or knew of at least one elderly person who had been abused, beaten, or assaulted by members of their family, and women are considered particularly vulnerable. In response, Argentina set up a National Program on Prevention of Discrimination and Abuse toward Older Persons and provides a forum for older persons within the National Institute Against Discrimination, Xenophobia, and Racism. These estimates may understate global rates of elder abuse as there are noticeable gaps in data collection and research in this area, especially in developing countries. What is known, however, is that elder abuse has been particularly prevalent during the COVID-19 pandemic, with nearly 16 percent of older adults globally reporting that they experienced some form of abuse in 2020.
Elder abuse has been particularly prevalent during the COVID-19 pandemic, with nearly 16 percent of older adults globally reporting that they experienced some form of abuse in 2020.
Elder abuse is possible in all contexts, including with family caregivers and in care facilities. One important approach is to ensure that older adults are in regular contact with designated reporters who can spot signs of abuse or receive reports from older adults. This is particularly true for older adults who do not have many friends or relatives. For example, the Radars project in Igualada, Spain, specifically serves vulnerable older adults who may be at risk of social isolation, mental health challenges, or abuse by having volunteers call them and invite them to social activities. If a volunteer suspects any elder abuse or neglect, they can contact the City Council through an anonymous tip line, and the City Council will decide how to safely and discreetly intervene in the situation. Caregiver burnout can also, at times, lead to neglectful or abusive treatment of older adults. To avoid this, services that support caregivers as well as older adults can reduce the possibility for elder abuse. The Ehsan Club program in Doha, Qatar, which is operated by the Centre for Elderly Empowerment and Care, provides free community-based respite and day care for older persons who rely mostly on family-based care. Finally, supporting older adults and caregivers in recognizing neglect and abuse—particularly financial abuse, which accounts for 62 percent of cases in Canada, for example—can result in better assistance for those facing abuse.
Fostering Meaningful and Productive Economic Engagement of Older Adults
Many older adults remain in the labor force, whether by choice or due to the economic necessity of supporting themselves and their families. This can be a positive way for them to stay meaningfully engaged with the world around them, providing regular opportunities for social interaction and mental stimulation, both of which promote healthy aging outcomes and a higher quality of life. Equally, for countries with aged and aging populations—and in light of the global trend toward longer average lifespans and lower birth rates—encouraging the long-term health and productivity of older people will become increasingly central to these countries’ economic futures. However, ageism remains a major barrier to older adults’ meaningful and productive economic activity. Despite an uptick in the passage of anti-discrimination laws across the world, 41 percent of low-income, 46 percent of middle-income, and 31 percent of high-income countries lack explicit protection against age discrimination in the workplace. As such, ageism remains common, and many broad anti-discrimination laws fail to adequately protect the rights and dignity of older adults in employment. Australia, for example, passed the Age Discrimination Act in 2004, which seeks to protect older people’s rights to work and to receive service, but recent research has found that just 18 percent of age discrimination cases taken to the country’s courts between 2004 and 2017 were successful.
For countries with aged and aging populations encouraging the long-term health and productivity of older people will become increasingly central to these countries’ economic futures.
Facilitating meaningful and enjoyable employment for older adults will require governments to take a firm stance against age discrimination, and to actively enforce existing anti-ageism legislation. Mongolia, in its National Strategy for Population Ageing 2009–30, is one of the few countries that explicitly bans age discrimination in employment. The strategy plans for its population to substantially age and seeks to improve the livelihoods of older adults. It also encourages the implementation of “an elder-friendly environment by planning economic and social development in line with the changes in population age structure,” in preparation for the dramatic increase in older adults the country will see in the next several decades. Civil society organizations can also play a role in fighting ageism, both by acting as watchdogs to ensure that governments are enforcing anti-discrimination legislation in full, and by undertaking publicity campaigns that seek to shift societal attitudes toward aging and older adults. For example, the Age Diversity Forum holds an annual “Champion Age Diversity Day” intended to celebrate age diversity in the workplace and facilitate conversations about ageism. In addition to mitigating the negative impacts of ageism, stakeholders in healthy aging can foster productive economic engagement through skills-based training for older adults to re-train or remain concurrent with new processes, technologies, and techniques. The Philippines, for example, hosts a government-funded training program for older people, to support skills development and livelihoods, and it provides government subsidies for businesses that employ older people.
Closing the Digital Age Divide Is Key to Connecting Older Adults to Friends and Family
Expanding digital inclusion is another key challenge in the support of healthy aging agendas, not only to support older adults to continue working if they choose, but also because technology is being increasingly utilized to improve health outcomes and expand opportunities to age in place. Accelerated by the pandemic, telehealth and online booking systems are becoming increasingly common within the health service industry. However, for older adults, significant barriers in accessing technology exist, including lack of knowledge, cost, privacy concerns, and high-speed internet access. Experts interviewed for this report noted that digital inclusion is an area in which older adults’ rights and needs have been made invisible. Keren Etkin, founder of The Gerontechnologist, noted, “We’ve gone backwards on inclusion, and I really hope that we will move forward and that eventually, all of these public service providers that have gone forward with digital transformation without thinking of older adults and without thinking of anyone else who doesn’t have internet access or digital literacy” will do so in the future.
Digital exclusion of older adults is a worldwide trend but demonstrates significant regional disparities. In the U.S., for example, around three-quarters of older adults own and use smart phones, but just one-third of older adults in sub-Saharan Africa do so, and there continues to be a gender gap in both digital and general literacy in lower- and middle-income countries that affects women’s ability to access online health resources. Improving digital literacy around the world, but particularly in regions where older adults still lack access to smart phones and computers, will require investment in products, services, and training to connect older adults to the digital world and contribute to their dignity and autonomy in connecting to the world around them. This trend will also require the extension of broadband internet services around the world, which remain lacking in rural areas—only 22 percent of Africa has broadband connectivity currently, for example, compared to 78 percent of households in Europe.
In the U.S., around three-quarters of older adults own and use smart phones, but just one-third of older adults in sub-Saharan Africa do so, and there continues to be a gender gap in both digital and general literacy in lower- and middle-income countries that affects women’s ability to access online health resources.
Public-private partnerships may be one method of extending broadband coverage and also might be employed to improve the digital literacy of older adults. In 2015, for example, IBM and Google partnered with Japan Post, the country’s national postal service, to provide free iPads and tablets to older adults living at home. The tablets were loaded with easy-to-use software for booking medical appointments, hiring handymen, and video conferencing with friends and family, and postal workers were available during their daily routes to provide technical training and support to those in need. Similar schemes could be implemented around the world, while governments can also incentivize broadband providers to extend their coverage at low costs through tax incentives or partnerships with philanthropic foundations. In the U.S., Older Adults Technology Services (OATS), now an affiliate organization of AARP, began offering free technology courses to older adults in New York City in 2004 and now offers classes across the country. Between 2004 and 2019, the organization reportedly served over 29,600 older adults, across 165 program sites, with 76 percent of participants reporting feeling “more connected” as a result of attending the course. OATS also works with broadband and telecom providers to extend internet access to older adults around the country through its Aging Connected program.
Data Gaps Persist, Impeding Global Understanding of the Needs of Older Adults
Around 80 percent of the global population is thought to live in countries with low-quality or no data collection, and much of the data that is collected is not disaggregated by age, in part due to poor recordkeeping. This data gap obscures many of the challenges that older adults specifically face in their daily lives and contributes to the “invisibility” of older populations broadly, and marginalized or vulnerable sub-groups—such as women, racial and ethnic minorities, and LGBTQ+ people, about whom even less disaggregated data exists—specifically. While lack of data is a global phenomenon, regional disparities are clear, and much of the data that is collected tends to be biased toward wealthier regions and communities. Many sub-Saharan African countries, for example, suffer from a lack of data collection infrastructure that is only now being addressed by governments and international institutions such as the World Bank.
Data gaps around aging were highlighted during the COVID-19 pandemic, as many countries lacked basic data on the direct and indirect health impacts of COVID-19 on persons of every age. Without data, governments in developing countries are unaware of the challenges that older adults face in their daily lives or during crises. Understanding the size and needs of the region’s older population is hindered by multiple barriers, including a lack of consistent birth registration, particularly for past generations, meaning that many adults do not know their own age or birthdate. Gaps in data also range from the total absence of vital demographic data to the exclusion of older age groups from survey and data collection. Other countries have upper age cut-offs in data collection on issues relevant to older persons, such as gender-based violence. Experts noted that within high-income countries, privately collected data often derives from the use of costly interventions such as for-profit elder care delivery or wearable health devices, creating a dataset that is biased toward high-income individuals.
To prepare for future aging populations, governments in developed, and particularly developing, countries will need support to scale up data-collection infrastructure. Digitization of data and the adoption of technology to collect it will be critical to addressing gaps, as low- and middle-income countries tend to rely heavily on traditional face-to-face methods of data collection. However, researchers should note that electronic data-collection methods can exclude older people who have little experience with information technology. National statistical offices will need increased funding, capacity-building, and training as well as partnerships with other sectors for greater ease in monitoring and evaluating the well-being of older adults in their jurisdictions. International organizations can also help fill these gaps by creating resources and guidelines on survey design, data collection, and analysis.
Collecting high-quality, wide-coverage data will also require collaboration among governments, international institutions, the private sector, and civil society, all of which collect different kinds and levels of data separately and would benefit from the pooling of information and resources. Regional organizing bodies and national governments can act as leaders, coordinators, and guarantors of data privacy in the drive for new data, acting as trusted institutions and creating publicly accessible, anonymized data caches. For example, the UN’s Data2X initiative, while not focused on aging and older populations, acts as a repository for gender-disaggregated data sources from around the world and regularly calls on public- and private-sector institutions to improve their collection of gender-disaggregated data. Data collection on older adults and on relevant sub-populations could follow a similar framework on the global, national, or regional level.
Support for Caregivers and Health Care Professionals
As the share of older adults around the world rises, so too does demand for both paid and unpaid caregivers, positioning support for them and the development of the care economy as critical components of healthy aging policy. However, two key trends are simultaneously placing strain on the care economy, challenging existing sources of care for older adults: a shortage of professional caregivers, and a shift in labor and migration patterns disrupting traditional multi-generational households and care patterns. Strengthening the global care economy and easing the strain that aging services in many countries are facing will require addressing these two trends and their impacts.
There is currently a global shortage of health care workers, specifically long-term care (LTC) workers. The International Labour Organization (ILO) reports that there are currently only 234 million people working in health care worldwide—including those in support positions such as janitorial staff and administrators—compared to a global older population of over 700 million. Estimates also suggest that there is a global shortfall of 13.6 million skilled LTC workers specifically. The shortage of LTC workers is largely due to the de-prioritization of long-term care for older and disabled people, which leads to a lack of government funding and investment in LTC infrastructure, low pay, and poor working conditions for professional caregivers. This makes professional care work unattractive. The EU Green Paper on Ageing, published in 2021, notes that “recruiting and retaining qualified staff to work in long-term care is difficult given low pay and the demanding working conditions,” noting that shortages in professional care work staff place additional burdens on unpaid family caregivers, often women.
While this is a global challenge, some regions are facing more acute shortages: research by the EU has found that over the course of the coming decade, the region will require an additional 8 million workers in health and social care to fill gaps. At the same time, the number of people in the region is predicted to increase from 19.5 million in 2016 to 23.6 million by 2030. In richer, developed countries, the professional caregiving industry is characterized by a racialized and feminized care workforce. Women (particularly women of color) and immigrants represent the majority of family and professional caregivers in North America, for example, often working for low pay and living in low-income housing. As of 2020, an estimated 38 percent of the U.S. care workforce is made up of immigrants, many of whom are undocumented and thus work informally, unable to access labor protections and social services, which contributes to poor working conditions and risk of exploitation that deters people from entering the care economy.
In richer, developed countries, the professional caregiving industry is characterized by a racialized and feminized care workforce. Women (particularly women of color) and immigrants represent the majority of family and professional caregivers in North America often working for low pay and living in low-income housing.
While medical and LTC professionals provide vital services across the world, many older adults—particularly in developing economies—have traditionally lived in multi-generational households with children and grandchildren, relying on their offspring for any care needs and often providing child care in return. However, both internal and international migration patterns and an increase in women entering the workforce have begun to erode those traditional care arrangements, leaving older people without care, and creating a need for new publicly or privately provided care infrastructures, including home care services, community-based services, or nursing homes. In China, for example, internal migration from rural to urban areas is common among working-age people, with around one-third of the labor force considered to be migrant workers. At the same time, the high cost of living in cities is causing many older Chinese adults to migrate to the countryside. These contrasting trends mean that many older people in China live in single-generation households, without family caregivers.
International migration has caused concern among governments and care professionals regarding “brain drain,” particularly in countries like the Philippines, where well-trained caregivers and medical professionals can seek significantly higher pay and favorable visas by working abroad. While the resulting remittances are often relatively high—with some countries becoming so-called “remittance economies”—older adults are vulnerable to losing much-needed family care due to these arrangements. An influx of women entering the workplace, a notable trend in Latin America, is also affecting traditional patterns of unpaid care, leaving a gap in caregiving for both children and older people that was previously filled by non-working women and will now require an increase in paid care services and professional caregivers.
Despite these trends, unpaid caregiving by family or friends remains a key aspect of elder care, and informal caregivers are important actors in the care economy. In California, for example, almost five million people act as unpaid caregivers to their family members. Despite their importance, family caregivers are under-supported and under-resourced, receiving little support from state or national governments. As Heléna Herklots, the Older People’s Commissioner for Wales, said in an interview, “There’s quite a lot of research in the UK which suggests it can take a number of years between before you realize that [you are a caregiver], because to start with you’re just a daughter helping your mom or you’re a husband helping your wife... I think too often, caregivers are not visible enough. And sometimes, they’re quietly struggling, quietly caring for people, and sometimes not even on the radar of public services.” Lack of financial support can lead to burnout from caregivers who may be required to study or work to maintain their household alongside their caregiving duties. There is a dual need to support the rights and well-being of caregivers and their patients, as increased well-being among caregivers can mutually support an increase in well-being among patients. Leaving unpaid caregivers without training or guidance additionally runs the risk of endangering adults who need active medical care, if their caregivers are not trained to respond to their specific needs or to spot the warning signs of illness, necessitating acute medical care that costs both individuals and health care systems time and money.
“Too often, caregivers are not visible enough. And sometimes, they’re quietly struggling, quietly caring for people, and sometimes not even on the radar of public services.”
- Heléna Herklots, Older People's Commissioner for Wales
The growing shortage of both professional and unpaid caregivers has and will continue to negatively affect older adults in need of care, especially those who are poor or without families, including single women and members of the LGBTQ+ community—each of whom may experience intersecting and compounding vulnerabilities due to their gender or sexuality. The so-called “feminization of aging” phenomenon is being seen across the world: women, on average, live longer than men and are more likely to live in poverty, and in old age they are more likely to live alone. In the Western Pacific region, for example, women represent just over half of all people over age 60, and over 60 percent of people aged over age 80 and are often left to age alone after outliving their spouses, or if their children migrate for better work opportunities. Women also represent a significant share of the informal economy in developing countries, leading to higher rates of poverty and reducing the likelihood that they will have access to a pension or savings account once they are no longer able to earn a wage. Similarly, in Western Europe, women are more likely than men to live alone in old age. Strengthening and resourcing the care economy will therefore directly contribute to flattening gender-based disparities among older adults and contribute to the safety and well-being of older women.
Interventions to grow and professionalize the care workforce, and to provide greater support to unpaid caregivers, can take a multi-pronged approach to strengthen all aspects of the care economy:
- Subsidized training and education, increased pay, and improved working conditions, including through government-mandated and enforced labor protections, will encourage more people to enter and remain in the professional care workforce and to see it as a viable and attractive career. As Alexandre Kalache, President of the International Longevity Centre-Brazil, noted during an interview, “If you want an older person to be treated with dignity, treat the care providers with dignity.”
- Support a range of strategies to increase the pool of direct care workers. This can include, but is not limited to, immigration policy reform, which can sustain the health and economic security of older adults and play a role in addressing the need for caregivers and filling gaps.
- Government-led integration and coordination of paid and unpaid caregiving, particularly by offering services that provide respite and support for family caregivers. These may include adult day cares, respite care visits by professional caregivers, and access to medical care via telehealth appointments or mobile clinics, which can reduce the time and cost burden on family caregivers and contribute to their overall well-being. The government of New Zealand, for example, provides respite care for family caregivers for up to two weeks at a time.
- Greater financial support and training opportunities for informal caregivers can improve their ability to care for older family members and reduce the risk of accidents or illness. Financial support may come in the form of tax incentives, allowances, or stipends, while training is most accessible if it is free and offered remotely. The U.S. state of Oregon’s Multnomah County Health Department, for example, has piloted a program to offer its STAR-Caregiver training program entirely online for family caregivers of people with dementia, to reduce time pressures and encourage attendance.
Collaborative Policymaking
Policymaking is a continual process, requiring in-depth research, monitoring and evaluation of existing policies, and the balancing of the needs and interests of a variety of stakeholders and target audiences. The cross-cutting nature of support for healthy aging and older adults’ rights can make it challenging to design policies that address older populations’ needs in all areas of life and ensure their implementation by the wide range of relevant actors. While all countries have unique challenges and opportunities relating to aging, policymakers can benefit from cross-country learning in which they share expertise and experience in designing, implementing, and supporting the efficient allocation of resources for healthy aging. Countries with similar demographic, social, and economic characteristics can adapt successful policies to support the healthy aging of their own populations and learn from their failures. Such an approach can also facilitate greater innovation, as similar countries could opt to pool resources for policy development regarding shared challenges, facilitating experimentation and creativity.
Regional associations and governing bodies are a natural space in which to promote collaborative policy creation and knowledge-sharing, due to their establishment as institutions with shared values and interests. The European Union, for example, has positioned itself as a hub for the development of age-friendly policies and approaches that can be tested in the region and adapted to address other countries’ needs, through both the European Partnership in Active and Healthy Ageing and the EU4Health initiative. EU4Health creates a framework and forum for aging actors and governments to share expertise, recreate aging agendas and policies, and evaluate ongoing programs’ effectiveness. Despite the challenges that COVID-19 has presented to aging populations around the world, EU4Health was established as a result of the pandemic, demonstrating that the acute challenge of a health emergency can be a catalyst for creativity and innovation for the future. Current action areas for the European Union include strengthening national health systems and improving the quality of medicines and medical devices for consumers. The European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) specifically focuses on healthy aging promotion, creating a forum for aging actors to develop partnerships through events and requests for proposals.
Similarly, the Association of Southeast Asian Nations (ASEAN) has established a collaborative process in which governments and service providers from across the region can learn from each other’s recent policy successes and failures. Every five years, ASEAN members are encouraged to assess the impact of their existing frameworks for social welfare and health care—two areas that are highly relevant to aging services and the rights of older adults—and to update their policies in consultation and collaboration with other policymakers and practitioners from the region. This creates a regular process for official reflection, monitoring, and evaluation that encourages knowledge-sharing and the development and implementation of effective solutions to shared challenges.
Older adults can be “invisible” within policy frameworks, as they are often overlooked by policymakers who are focused on the needs of a whole population. When older persons are remembered, they can be infantilized—with policymakers assuming that they know best what older populations need—or seen as burdensome on society and its resources rather than as a population that both needs the protection of its government and contributes greatly to the economy and society more broadly. Claudia Mahler, the UN Independent Expert on the enjoyment of all human rights by older persons, noted that a large part of her role is “to further the human rights of older persons and to make them visible as rights holders because . . . very often, older persons are not seen as rights holders. They are seen as beneficiaries of social security, of health care, and not as persons with dignity and their specific human rights.” This kind of attitude can lead to the creation of ageist policies that ignore or discriminate against older adults. During the COVID-19 pandemic, for example, policies that have been intended to contain the virus have often had an outsized negative impact on older populations. In the UK, the government asked all adults over the age of 65 to “shield” by remaining in their homes for months at a time, in an effort to reduce the number of COVID-19 cases overwhelming hospitals, in what the chief executive of NHS England, Sir Simon Stevens, described as an “ age-based apartheid” that eroded the rights of older persons. Stevens noted that the policy made no distinction between older adults with health conditions that made them vulnerable to the virus and those who were simply above the age threshold, leading to the confinement of individuals for no reason other than their age.
“Very often, older persons are not seen as rights holders. They are seen as beneficiaries of social security, of health care, and not as persons with dignity and their specific human rights.”
- Claudia Mahler, UN Independent Expert on the enjoyment of all human rights of older persons
The creation of aging policies centered around the needs and priorities of older adults—and of non-discriminatory policies for the general public—can be facilitated by participatory processes in which older adults are consulted throughout the design process. Focus groups, consultations, and even observation of target users can ensure that their preferences and priorities are taken into consideration, an important step in reversing the “invisibility” of older adults and specific communities within that general population, such as older people of color. Participatory processes align with the stated values of the disability rights community—“ Nothing about us without us”—that the target users of policies, products, and services should be integral to their conception, design, and implementation. Co-design processes, including iterative co-creation that tests prototypes and ideas on a sample group of end users, are central to ensuring that policies, products, and services truly serve the needs of their targets. As Amal Abou Rafeh, the Chief of the UN Programme on Ageing, Division for Inclusive Social Development, noted, “we need to involve older people in these conversations. There’s so much that’s being done that assumes on their behalf what’s good for them. And their voices are there, but they’re just not integrated into these…conversations.”
While co-creation and participatory design practices are more commonly seen in product-development contexts, the principles of these processes are equally applicable to the development of new policies aimed at protecting and supporting the rights and needs of vulnerable populations. Such an approach is recommended for policymaking to address the needs and rights of older adults in the Madrid International Plan of Action on Ageing (MIPAA) and by the UN Decade of Healthy Aging. Several European countries have begun to integrate participatory and consultative processes into their aging policy design, primarily through the establishment of representative councils of older people. In Denmark and Germany, local municipalities are mandated by law to form Senior Citizens’ Councils (SCC) whose members are elected by residents over the age of 65 and 60, respectively, and are empowered to advise on policies directly affecting older adults, such as health and social care and local infrastructure. In Ireland, a similar approach has been taken, where so-called Older People Councils (OPC) are encouraged but not mandated. A review of these and similar participatory programs around Europe found that local policymakers largely agreed that consultation with older adults had increased the efficiency of resource allocation by identifying priorities, thus increasing the credibility of local politicians and policymakers in the eyes of their constituents and their peers across the country. Co-design processes for policymaking can therefore have a positive impact on the health and well-being of older adults and on the level of trust in the policymakers who take that approach.
Unique Considerations for Developing Economies
While specific regional demographics and characteristics may differ, developing economies share common challenges around supporting healthy aging that differ from the aging experiences of rich countries. The rates of aging in developing countries are expected to accelerate in the coming decades. By 2050, projections suggest that up to 80 percent of the world’s older adults will live in developing or less-developed countries. This section will aim to identify the common challenges and opportunities around healthy aging for low- and middle-income countries.
By 2050, projections suggest that up to 80 percent of the world’s older adults will live in developing or less-developed countries.
The Informal Economy Employs Many but Can Be Linked to Poverty Later in Life
One defining feature of many low- and middle-income economies is economic informality, which bears enormous challenges for healthy aging. Economic informality refers to activities with market value that are not formally registered, meaning that they are often untaxed, unregulated, and excluded from gross domestic product (GDP) estimations. The informal sector is estimated to account for more than 70 percent of total employment and nearly one-third of GDP in developing economies. High levels of informality have been associated with weaker development outcomes for countries, including higher levels of poverty and greater income inequality.
For older adults, a lifetime of work in the informal economy can prevent a financially secure retirement. Many pension systems in the world are pay-as-you-go schemes that are designed for workers participating in the formal economy and can severely limit pension coverage for older adults. For example, state pension plans in the Africa region only cover around 23 percent of the older population, due in large part to the prevalence of informal employment in the region—an estimated 85 percent of African adults worked in the informal sector in 2018 and were excluded from government-run pension or social service plans. Independently saving for retirement is also difficult for informal workers, whose wages tend to be lower than those of formal sector workers. Lacking the financial security necessary for retirement, many continue to work into old age in developing countries, where they will likely continue to work in the informal economy. The ILO estimates that 78 percent of global employment among older people is informal. Women and rural dwellers tend to be most affected, due to their greater likelihood of informal employment. Workers who have contributed to pay-as-you-go programs might ultimately not qualify for a pension. An analysis of Central and South American pension plans by the Inter-American Development Bank (IDB) found that the majority of programs in the region require the recipient to continuously maintain formal employment throughout their working life in order to receive benefits in their older age. As a result, many people who have paid into pensions are not eligible for the benefits, as nearly half of the economically active population of the region will work in the informal sector at some point during their careers, often shifting between formal and informal work based on need and availability.
State pension plans in the Africa region only cover around 23 percent of the older population, due in large part to the prevalence of informal employment in the region—an estimated 85 percent of African adults worked in the informal sector in 2018 and were excluded from government-run pension or social service plans.
One method of supporting older people who may lack access to a pension is through social pensions, which are non-contributory pensions paid entirely by the government. While these social pension payments are typically quite low, they have been shown to have large impacts on food security and poverty in low- and middle-income countries. Universal social pensions are also particularly important for gender equality, ensuring that inequalities, such as the pay gap, are not replicated in older age.
CASE STUDY
Universal Old Age Pension in Lesotho
In 2004, Lesotho introduced a non-contributory universal Old Age Pension to address intergenerational poverty and ensure that the country’s oldest people have access to income. The pension’s budget and monthly allowance have grown steadily since it was first introduced. Between 2015 and 2019, the allowance rose from 500 to 700 maloti and the share of the social budget allocated to the pension program also increased by 19 percent, indicating the government’s continued commitment to the oldest citizens of Lesotho. As of 2019, the pension distributed 700 maloti or about USD$47 per month to older persons aged 70 and above who were not receiving another pension.
Surveys have found that pensioners lead more financially secure, fulfilling lives. A 2015 survey of 215 pension recipients living in rural areas found that hunger and poverty were halved and that pensioners played increased roles in their communities and families, caring for dependent and orphaned children. Pensioners also contributed to household income, which allowed them to become active participants in household decision-making. However, recipients, particularly in urban areas, reported that the pension was insufficient to meet all of their basic needs. Despite these issues, the Old Age Pension provides proof that even countries with limited financial resources can implement non-contributory pension programs.
Developing Formal Long-Term Care Options Is a Challenge as Population Patterns Change
Providing decent, affordable long-term care (LTC) is a global challenge that will be particularly felt by developing countries, where population aging is outpacing the development of aged care services and policies. In the absence of formal LTC options, many developing countries rely on informal family systems to care for older persons, in some cases even legalizing the responsibility of families to care for older members. Legalization of filial responsibility for the aged is common throughout the developing world, with laws existing in every region of the world, including China, India, Bangladesh, Brazil, Mexico, Russia, Turkey, Algeria, Argentina, and Chile. Notably, filial support laws also exist in several developed jurisdictions, including Singapore, Israel, and 28 U.S. states. However, family care systems for older adults are weakening throughout the world as urbanization and rising population mobility encourage economic migration from rural to urban areas or even internationally. Countries that are dependent on families to provide elder care will need to adapt in order to fill an emerging gap between limited formal LTC options and a growing older population. Filling this gap will require governments in developing countries to develop appropriate policies and services that enable accessible, affordable LTC that meet older people’s needs.
CASE STUDY
Community-Based Long-Term Care (LTC) in Thailand
In 2016, Thailand began piloting a community-based LTC program, which aims to provide in-home care for homebound and bedridden older adults over 60 years of age. The initial pilot began with a budget of $19 million and a target of 100,000 beneficiaries in 1,000 subdistricts. Since its inception, it has been scaled up annually, providing services to almost 100,000 additional older adults by 2018. The LTC program, which is run by the National Health Security Office, utilizes local health and social services organizations to provide integrated services for its beneficiaries. Services provided include coordinated care and the provision of in-home visits by home caregivers for up to eight hours per week depending on need and availability. Care is provided by part-time volunteers and paid caregivers from the community, building on a decades-long history of community health volunteerism. Caregivers receive 70 hours of training covering first aid, the rights of older persons, drug administration, and care for critical and chronic conditions. While additional options for LTC will be necessary, this community-based LTC program will be vital to meeting the needs of Thailand’s growing older population, which is expected to double by 2050.
Humanitarian Crises Are a Threat to Healthy Aging
The number of older persons affected by humanitarian crises is on the rise, particularly in developing countries. HelpAge International estimates that “the proportion of the population aged 50 and over in fragile countries, where conflict and disasters are more likely to occur, is expected to rise from 12.3 percent (219.9 million) in 2020 to 19.2 percent (586.3 million) in 2050.” Older people are more at risk during health emergencies, conflicts, and extreme weather events than other populations.
Research from HelpAge International indicates that many older people’s basic needs, including access to shelter, water, and food, go unmet during crises. Accessing health care is also difficult in humanitarian crises. For example, the WHO estimates that over half of Syria’s hospitals have been severely damaged since the onset of the 2011 conflict, preventing all citizens but particularly older adults, from accessing much-needed care with ease and safety. In cases where older adults possess the mobility and resources necessary to migrate away from the site of a crisis, they will likely remain vulnerable, as their health can deteriorate rapidly. High-quality health care may not be available in transitional or resettlement locations, including in refugee and displaced persons camps, which tend to focus more on acute needs and disease prevention. For example, during the 2012 refugee crisis in Sudan, mortality rates among people aged 50 years or older were four times higher than for those aged five to 49 years in South Sudan.
Humanitarian policy and country-level disaster-risk-reduction strategies must account for the protection of older adults, particularly women and those with disabilities. Ensuring that older adults are adequately included in humanitarian response will require strengthening data collection during crises.
Humanitarian policy and country-level disaster-risk-reduction strategies must account for the protection of older adults, particularly women and those with disabilities. Ensuring that older adults are adequately included in humanitarian response will require strengthening data collection during crises. Without data, aid workers may rely on assumptions that do not adequately reflect the needs of older people. In response to the COVID-19 pandemic, the UN Secretary-General has issued a policy brief calling for older people to be integrated in humanitarian responses; technical guidance for humanitarian agencies has followed. Policymakers in vulnerable countries will also need to mitigate and address climate change, the effects of which will include increases in conflict, disease, and extreme weather events. Older persons are often disproportionately affected by climate-related harms such as the effects of temperature extremes, and they face higher mortality risks during extreme weather events. Although the effects of climate change will be felt by every country in the world, Pacific Island countries as well as countries in Central America and the Caribbean will be particularly exposed to extreme weather events, necessitating the rapid creation of frameworks to protect older adults in those regions.