INTRODUCTION

A Global Demographic Transition

Aging populations represent one of the greatest achievements of medical science in the last century, as every global region has experienced considerable increases in life expectancy since 1950. According to the United Nations (UN), “Population ageing is poised to become one of the most significant social transformations of the twenty-first century, with implications for nearly all sectors of society as well as family structures and intergenerational ties.” Along with rising life expectancy, declining fertility levels have skewed the global population older and dramatically changed the age structures of the world’s populations. Older people are now a significant and growing share of the global population. People aged 60 and over already account for more than one billion of the world’s population; this age group is expected to double—to over two billion—by 2050. This demographic trend will have major implications for women in particular, who represent the majority of older persons and also make up about 66 percent of family and professional care workers. Currently, approximately 70 percent of the world’s older people live in low- and middle-income countries where programs to foster the well-being of older adults are relatively under-developed and under-resourced.

Globally, efforts to facilitate older people’s continued social and economic engagement, as well as ensure their health and well-being remain under-developed, as evidenced by the COVID-19 pandemic, which disproportionately impacted older adults. Around 95 percent of deaths between March and October 2020 from the pandemic in the United States were concentrated among those aged 50 and older, and about 80 percent of deaths were of people age 65 or older. The pandemic has exposed the vulnerabilities, needs, and rights of older people as well as the national governments and global health systems to sufficiently protect them—highlighting a range of complex challenges that must be addressed. The newfound global attention on the health and well-being of older adults sparked by the pandemic presents an opportunity for innovation and policy action.

While these issues are not new, the COVID-19 crisis has raised awareness of healthy aging as a fundamental building block of societal security, and as a core and often under-recognized issue in national policy frameworks. Rapidly aging populations will prompt governments around the world to re-design health systems and implement policies targeted toward supporting older people and healthy aging more holistically. To foster healthy aging and reap the benefits it entails, governments will need to invest in developing high-quality, affordable, and equitable health systems, and engage other stakeholders into strategy development and program implementation. The policy focus and associated investments could yield a demographic dividend characterized by older persons more actively and meaningfully engaged in the workforce and economy, reduced health care costs, and improved family and community well-being.

The following report and accompanying online toolkit provide analysis, case studies, and recommendations derived from leading research, expert roundtables, surveys, and one-on-one interviews that collectively reached over 70 healthy aging experts around the world.

In recognition of the challenges and opportunities associated with this demographic transition, AARP partnered with FP Analytics to identify innovative policies and practices that address existing gaps and foster health and well-being among older adults. This initiative coincides with the beginning of the United Nations Decade of Healthy Ageing (2021–2030), which aims to improve the lives of older people—as well as their families and communities—through a global multi-sectoral, multi-stakeholder approach. The following report and accompanying online toolkit provide analysis, case studies, and recommendations derived from leading research, expert roundtables, surveys, and one-on-one interviews that collectively reached over 70 healthy aging experts around the world. It is intended to be a resource for policymaking and investment decisions by leaders across all sectors. Both the report and toolkit are aligned with the Decade’s call for a whole-of-government and whole-of-society approach to healthy aging, which will require stakeholders to fundamentally rethink the roles older adults can and should play in communities and economies. Key to this report and the online toolkit is the importance of innovation in healthy aging—in policies, approaches, and technologies—and the need to center action on supporting the needs, goals, and wants of older people and making them more “visible” in society.

Older adults represent a significant and growing share of the global population. People aged 60 and over already account for more than one billion of the world’s population; this age group is expected to double—to over two billion—by 2050. Amid these major global trends, the United Nations Decade of Healthy Ageing (2021–2030) aims to improve the lives of older people—as well as their families and communities—through a global multi-sectoral, multi-stakeholder approach. Fostering a more holistic approach to healthy aging throughout life is vital for the well-being and strength of individuals, societies, and economies around the world.

In alignment with the U.N. Decade of Healthy Ageing, FP Analytics has partnered with AARP to identify groundbreaking and integrated approaches to healthy aging to help inform policymaking, catalyze program implementation, and stimulate innovations in the marketplace. Through a meta-analysis of leading research, a series of closed-door roundtables, expert surveys, and one-on-one interviews, FP Analytics has produced an in-depth analysis and an online toolkit highlighting innovative policies and human-centered practices from around the world. These resources are intended to support policymakers, practitioners, and leaders in private industry working in this space. Throughout the course of the research, several key insights and areas for action emerged:

A more integrated and holistic approach to healthy aging is needed to close service delivery gaps: The COVID-19 pandemic has focused global attention on the health and well-being of older adults, presenting an opportunity for innovation and policy action to address chronic gaps in health care access and service delivery and more effectively support older adults to maximize their potential in society. Critical barriers to healthy aging persist, particularly in relation to the affordability, availability, accessibility, suitability, and quality of support for older persons.

Cross-country learning can help inform and catalyze national action plans. As governments increasingly link healthy aging to a range of security, economic development, and environmental agendas, there is a growing interest in exploring intersectional and collaborative approaches to proactively support healthy aging and protect the human rights of older adults. National plans, strategies, and policies around healthy aging play pivotal roles in defining a country’s priorities for maintaining and improving the well-being of older adults, with innovative programs having the potential to inform national strategies currently under development. Important components of more holistic policymaking include taking a life-course and rights-based approach to aging, monitoring and evaluation guidelines, appointing department and agency leads to address aging, establishing implementation timelines, allocating budgets, and targeting financial and non-financial resources to help ensure program viability and sustainability. Mainstreaming aging issues across government departments, implementation agencies, and private industry will help ensure that intersectional needs of older adults (such as transportation and housing) are addressed and budgeted.

Implementing multi-sectoral approaches to healthy aging that engage relevant stakeholders and are informed by older adults is vital: Governments, civil society actors, the private sector, and health service providers are particularly key to the promotion of healthy aging, demonstrating the need for a collaborative, multi-sectoral approach. These four contingents play critical roles in providing leadership and setting norms, incorporating and amplifying the voices and demands of older adults, driving innovation through funding and experimental approaches, and ensuring high-quality service delivery.

Cross-cutting principles and recommendations to support healthy aging

The analysis illuminates seven attributes of innovative and holistic approaches to healthy aging that actors across stakeholder groups can apply to the development and strengthening of healthy aging policies and initiatives.

Principles for Innovations in Healthy Aging:

  1. Participatory Processes and Co-design: Taking inspiration from the disability rights slogan “Nothing about us without us,” public- and private-sector actors can ensure that new programs and products reflect the needs and priorities of older adults through an iterative co-design process.
  2. Equity and Inclusion: Systemic and individual interventions to support healthy aging benefit from a culturally sensitive and adaptive approach that can evolve as the population’s needs do and acknowledges the diversity of the older population.
  3. Focus on Dignity: Pervasive ageism still exists across the world, eroding the rights, quality of life, and quality of care of older adults. Protecting the inherent dignity and rights of all people—including older people—is essential to the promotion of healthy aging and health at all ages.
  4. Life-Course Approach: Aging begins at birth. Interventions to support healthy aging should therefore begin early in one’s lifetime, through a life-course approach that promotes mental and physical health at every age.
  5. Whole-of-Society Approach: A whole-of-society approach acknowledges that healthy aging is influenced by a range of factors within our societies and economic structures and seeks to develop integrated strategies to support older adults through collaboration with public, private, non-profit, and civil society groups.
  6. Commitment to Monitoring and Evaluation: Careful monitoring, data collection, and evaluation practices will benefit existing and developing healthy aging interventions. Systematically collected information and transparent reporting are critical to refining existing programs and to helping to inform the expansion, replication, and adaptation of the initiatives in other contexts.  
  7. Support for Caregivers: Supporting and growing the care economy, with specific attention to the needs of paid direct care workers as well as unpaid family caregivers, is vital to the success of healthy aging work, as caregivers are responsible for monitoring and maintaining physical and mental health—and are often older adults themselves.

Recommendations:
The promotion of healthy aging across society will necessitate actions by national and local governments, civil society organizations, the private sector, and health care service providers—with ongoing input from older adults in order to attain healthy aging goals and meet the needs of this growing cohort. With the seven principles for innovation in mind, the following actions explored in the report could be taken to accelerate progress.

National Governments:
Governments are central to the implementation and promotion of healthy aging agendas, and to providing the services and resources to support them, including by allocating funding. Recommendations for governments include:

  • Invest in the care economy to encourage more people to enter the care workforce;
  • Support unpaid family caregivers to provide safe, high-quality care through publicly-funded programs and incentives; and
  • Adopt a rights-based approach to confront ageism and encourage older adults’ active participation in daily life.

Civil Society Organizations:
Civil society organizations play a major role in advocating for and on behalf of older adults, facilitating healthy aging agendas, and convincing policymakers to commit resources to healthy aging agendas and older persons’ needs. Recommendations for civil society organizations include:

  • Engaging directly with older adults and empowering them to tell their own stories and inform policymaking and program development;
  • Amplify the voices of older people on the national and global stages;
  • Tackle ageism by encouraging meaningful engagement between older persons and their communities; and
  • Act as a watchdog for government policies on healthy aging.

The Private Sector:
Private sector firms of various sizes and scales are often integral to the promotion of healthy aging around the world, including through delivery of care, and can support and expand the work of other major actors. Recommendations for the private sector include:

  • Invest in and/or co-fund innovative research into healthy aging products and services, including through public-private partnerships;
  • Support older adults seeking to remain in the labor force; and
  • Share anonymized data collected via service delivery and product use.

Health and Social Service Providers: 
Health and social service providers are key to the implementation and enforcement of healthy aging agendas at the national and international levels and can be on the cutting edge of health and healthy aging innovation. Recommendations for private and nonprofit health service providers include:

  • Professionalize the care workforce through investment in human capital, and support unpaid family caregivers with formal respite service provision;
  • Address health disparities exacerbated by race, ethnicity, gender, and sexuality; and
  • Shift to an integrated care approach that treats all aspects of health in harmony.

Older adults, both now and in the future, have a right to high-quality, integrated care that allows them to maintain their dignity and autonomy, and supports meaningful connections to their communities. As Paul Irving, chairman of the Milken Institute Center for the Future of Aging, noted optimistically during an interview, “If societies can keep their aging populations healthy and engaged, think of how exciting those future years might be.” This report and the corresponding toolkit seek to contribute to this effort and provide a resource for policymakers and practitioners as we collectively work toward these common goals.

Innovation in Healthy Aging

In the context of this report, innovation refers to cutting-edge policies, approaches, or technologies to support and protect older adults. This approach to aging-related innovation acknowledges that the policies and practices aimed at supporting healthy aging around the world do not at present sufficiently meet older persons’ needs. The identification of promising practices in aging policy innovation is framed within the AARP and FP Analytics’ 2017 and 2018 Aging Readiness & Competitiveness (ARC) reports’ core principles for innovation, which define innovative efforts as those that are:

  • People-oriented,
  • Bottom-up,
  • Holistic,
  • Interdisciplinary, and
  • Evidence-based.

The 2021 edition of the ARC builds on these foundational principles. Central to aging-related innovation is the recognition that populations, cultures, and economies differ, requiring context-specific policies and programs. Although there is no one-size-fits-all solution to healthy aging, innovative solutions can be informed by promising practices being developed and implemented elsewhere in the world. Approaches that effectively address healthy aging will be cross-sectoral and co-created with the input of affected populations. It is also necessary that these approaches are dynamic, actively integrating new ideas and learning as local demographics, technology, and environments evolve. 

Who Is Considered An Older Person?

While an older person is defined by select UN entities as someone who is chronologically aged over 60, there is no internationally agreed upon definition of older person. Discussions regarding an official definition of an older person are being held at the Titchfield Group on Ageing-related Statistics and Age-disaggregated Data as part of their efforts to develop standardized research tools and methods, but the challenge in defining an older person is in part due to the use of socio-cultural indicators such as family status, age-related conditions, or physical appearance by individuals and communities to identify older persons. These indicators vary widely across different populations, cultures, and nations. In particular, vulnerable populations, including those experiencing poverty, discrimination, or displacement, may “age faster,” appearing older or developing age-related conditions at a younger age, due to the physiological or psychological effects of trauma, poor nutrition, or exposure to disease. Life expectancy also varies widely across countries, ranging from a low of 50.75 in Lesotho to a high of 84.26 in Japan. As a result, age-related policies may apply to older adults above or below the age of 60, depending on the national context. This analysis, therefore, does not denote a specific age range that defines who is an older person, but it does assume that the policies, research, and case studies mentioned target those in the second half of their lives. Beyond the individual, a population is defined by the UN and the World Health Organization (WHO) as “aging” when 7 percent of the population is older than 65. It is defined as “aged” when the share is greater than 14 percent, and “super-aged” when the share is over 20 percent.

A population is defined by the UN and the World Health Organization (WHO) as “aging” when 7 percent of the population is older than 65. It is defined as “aged” when the share is greater than 14 percent, and “super-aged” when the share is over 20 percent.

Conceptions of Healthy Aging

As attention to aging increases around the world, there is a growing convergence around the concept of “healthy aging” among scientists, policymakers, and practitioners. Functional ability for older people includes not only the ability to meet basic needs and be mobile, but also the ability to build and maintain relationships, make decisions, learn, and contribute to society. According to many of the experts interviewed for this report, supporting healthy aging requires not simply managing health conditions, but also helping older adults—and all people across all populations—to maximize their potential in society. Taking a “life-course approach” to healthy aging, which entails facilitating health and well-being from an individual’s youth, with the knowledge that aging begins at birth and that functional ability can be preserved over time, was a commonly cited strategy for fostering healthy aging more holistically.

Figure 1

Life Expectancy Compared to Healthy Life Expectancy by Region

Distinct from life expectancy, healthy life expectancy refers to the number of years an individual will maintain good health and functional ability

Source: The World Health Organization, 2020


Healthy aging is supported by choices made at the individual level and policies and systems implemented at the societal level. At the individual level, part of healthy aging is supporting health and mitigating harmful impacts caused by lifestyle or material circumstances. Among individual choices that support health are having an active lifestyle, eating a healthy and high-quality diet, avoiding smoking or excessive alcohol intake, maintaining existing cognitive function, and cultivating new emotional and social connections. These types of individual choices should be promoted from youth.

Health throughout the lifespan is closely tied to socioeconomic and environmental circumstances. According to the WHO, the vast diversity seen in older persons’ health security and functional capacity “is the result of the cumulative impact of advantage and disadvantage across people’s lives. Importantly, the relationships we have with our environments are shaped by factors such as the family we were born into, our sex, ethnicity, level of education and financial resources.” Social determinants of health include, but are not limited to, access to quality health care, affordable and appropriate housing, nutritional food, safe social and community infrastructure—including public spaces and other aspects of the built environment—and opportunities for education and continued learning. For this reason, several interviewees highlighted that equity in opportunity to overcome negative social determinants of health is critical to healthy aging agendas, as healthy aging should be viable for every individual. Social determinants of health bridge the individual and societal levels of health, as individuals do not have full control over their circumstances and governments can play a role in improving or otherwise influencing the determinants through policy and regulation.

Social determinants of health include, but are not limited to, access to quality health care, affordable and appropriate housing, nutritional food, safe social and community infrastructure—including public spaces and other aspects of the built environment—and opportunities for education and continued learning.

At the societal level, governments, and other advocates for older adults can support individuals as they age by implementing supportive policies and systems. Equitable, accessible, and affordable public health systems are critical to enabling healthy aging across populations. By focusing on healthy aging throughout the lifespan, government policies around public health and long-term care institutions can positively impact the whole of society as everyone would be able to access support and programs throughout their lives. Other types of supportive environments include the absence of ageism, the ability to work or volunteer if necessary or desired, and access to affordable, safe, diverse, desirable, and accessible housing options.

Societal promotion of healthy aging will require some level of institutional redesign. Many of the institutions that support older populations were developed when life expectancies were much shorter, and youth populations larger, with many ill-equipped to deliver services to aging populations. However, persuading policymakers and the general public to devote resources to healthy aging agendas is a challenge in many societies. Robyn Stone, the Senior Vice President of Research at LeadingAge and the Co-Director of LeadingAge LTSS Center @ UMass Boston, said that “one of the challenges is to get everybody on the same page—we’re not talking about just today’s generation, but we’re talking about everybody’s generation. It’s analogous to climate change.”

Ultimately, healthy aging requires creating the conditions for health, livelihood, wellness, and fulfillment at all ages—and accepting that health varies among individuals, and throughout individuals’ lifetimes. S. Jay Olshansky, Professor in the School of Public Health at the University of Illinois at Chicago, said that his “concept of healthy aging is not becoming a younger version of yourself—it’s not becoming the 20-year-old version of yourself, but it’s experiencing life in a healthy way in all of these phases of life whether you’re a teenager, a 20-year-old, 30-year-old, or 60+ -year-old.” One broader way to conceptualize healthy aging is to attempt to promote and sustain optimal aging for every individual—with any type of health challenge, at any age, and in any society or socioeconomic circumstance.

Part 1

Global Frameworks on Healthy Aging

Healthy aging is a leading policy priority for the UN and its Member States. A 2019–2020 UN Department of Economic and Social Affairs (UNDESA) survey found that one-third of governments surveyed identified population aging as a trend of “major policy concern at the present time,” while two-thirds named it as a key concern for the coming decades. As governments increasingly link healthy aging to a range of security, development, health, and environmental agendas, there is a growing interest in exploring intersectional and collaborative approaches to proactively support healthy aging, as evidenced by a growing number of global, regional, and national frameworks with that overarching goal in mind. 

An important, recent example of this trend is the UN Decade of Healthy Ageing (2021–2030). Established by the WHO’s Global strategy and action plan on ageing and health 20162030, the Decade of Healthy Ageing’s plan promotes four key action areas: providing age-friendly environments, combating ageism, expanding access to long-term care, and increasing integrated care options for older persons. The ultimate goal for the decade is to encourage the creation of age-friendly environments and the delivery of person-centered, holistic, and compassionate care to older persons around the world. This Decade aligns with several of the UN Sustainable Development Goals (SDGs)—specifically SDGs 1 through 5, 8 through 11, 16, and 17—and also builds upon the Madrid International Plan of Action on Ageing (MIPAA).

Figure 2

Achieving the Sustainable Development Goals Through the UN Decade of Healthy Ageing


International Frameworks Provide Vital Recognition but Fall Short on Implementation

Adopted in 2002, the Madrid International Plan of Action on Ageing (MIPAA) is a key non-binding global agreement that provides a plan of action for governments and civil society to build an age-friendly world. The Madrid Plan is complemented by regional implementation strategies that cover much of the world, and it succeeds the Vienna International Plan of Action on Ageing (1982), the world’s first international policy framework on aging. Building on the commitments of the Vienna Plan, MIPAA focuses on three priority areas: (1) older persons and development, (2) advancing health and well-being into old age, and (3) supportive environments. But unlike its predecessor, MIPAA was designed to be more relevant for developing countries, where little progress had been made in implementing the recommendations set out in the Vienna Plan. 

Despite MIPAA’s enhanced attention to aging in developing countries, roundtable participants noted that implementation has been incomplete—particularly in developing contexts—and that more needs to be done. The challenges in implementing MIPAA were attributed to a lack of disaggregated data, insufficient guidance on multi-sectoral collaboration, and the absence of clear monitoring and implementation guidelines in MIPAA itself. National governments are also not fully committed to implementing the framework; while 84 percent of Member States are participating in the Third MIPAA review, this does not guarantee implementation of its outcomes. At least two of these gaps have been filled by more recent international and regional frameworks. For example, the WHO’s Global strategy and action plan on ageing and health 2016–2030 provides clarity on measurement and monitoring in addition to multi-sectoral action. It will remain unclear whether these gaps have been adequately filled by more recent frameworks, however, until MIPAA’s next periodic review is completed by the Regional Economic Commissions of the UN in 2023. These shortcomings are clarion calls to governments and other stakeholders to take concrete actions and accelerate program implementation.

Need for Rights-Based Approaches to Aging

Unlike other recognized vulnerable groups, including women, children, or persons with disabilities, there is no United Nations treaty that explicitly addresses the rights of older persons and defines how universal human rights should be interpreted for this age group. While older persons’ rights are technically protected under existing international human rights laws, significant gaps exist. Claudia Mahler, the UN Independent Expert on the enjoyment of all human rights by older persons, noted in an interview, “What we’ve seen now for more than 10 years, more than a decade, is that older persons are still invisible in the human rights framework.” With the exception of the Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, international human rights conventions do not explicitly recognize age discrimination as a rights violation. Additionally, there are currently no international standards establishing the rights of older adults or their caregivers within long-term care or community-based care settings. Without these explicit protections, countries are unable to determine the policies and actions necessary to protect and promote the rights of older adults, which can result in those rights being ignored or overlooked in policymaking, leading to poor health and well-being outcomes.

To ensure that older people can fully enjoy their human rights, the UN General Assembly established the UN Open-Ended Working Group on Ageing (OEWGA) in 2010 and appointed a UN Independent Expert on the enjoyment of all human rights by older persons in 2014. The OWEGA was charged with identifying and filling legal and policy gaps in the protection of older people, especially with regard to discrimination, poverty, violence, and abuse. The group is also exploring the viability of an international legal instrument to protect the rights and dignity of older persons, but a UN Convention on the Rights of Older Persons is yet to be established.

AGEISM

A Human Rights Concern

Ageism is a major human rights concern that hinders the full enjoyment of human rights by older persons. During an interview, Claudia Mahler, the UN Independent Expert on the enjoyment of all human rights by older persons, recognized that “combatting ageism in ourselves, in our ideas, in our behavior, in our policy, and in our law” is “a major goal” of the Independent Expert and the Decade of Healthy Ageing. Ageism is defined by the WHO as the “stereotypes, prejudice, and discrimination directed toward others or oneself based on age.” It is a pervasive, systemic issue that can manifest overtly or indirectly at the institutional or interpersonal level. Ageism can also be self-directed, as a result of internalized ageism. The Global Report on Ageism (2021) finds that one in two people globally harbors ageist attitudes toward older adults.

While ageism can affect people of all ages, it has serious consequences for older people’s health, well-being, and economic security. For older adults, ageism is associated with poorer physical and mental health, which results in a shorter lifespan. Ageism has also been shown to increase the risk of violence against older adults as well as increase social isolation and loneliness, which can lead to mental disorders and deteriorating cognitive health. It can impact financial security among older individuals and has major economic costs for society as a whole, as it can prevent older adults from achieving their potential in the workplace. For example, an AARP report found that age discrimination against workers aged 50 and older cost the U.S. economy $850 billion in 2018. This social phenomenon often intersects with other forms of negative stereotypes and prejudice, such as racism, sexism, and ableism. Compounding biases, such as racism and sexism, can cause even worse health and well-being outcomes for those affected.

As a result, addressing the root causes of ageism are critical to ensuring that the rights of older adults are protected and respected. The UN Decade of Healthy Aging has named ageism as one of its four key action areas. Governments, civil society, and the private sector are responsible for enacting laws, policies, or frameworks to address age-related discrimination, change attitudes and perceptions of older adults, and improve research and data collection around ageism. 

In the absence of an international convention, the Organization of American States (OAS) and the African Union (AU) have both developed independent regional treaties for the protection of the rights of older persons. The Inter-American Convention on the Protection of the Human Rights of Older Persons (2015) is the first binding convention on the rights of older persons. This regional convention establishes 26 protected rights of older persons, including the rights to non-discrimination and long-term care. The convention has been ratified by only nine Member States out of 35 so far. In 2016, the AU’s Protocol to the African Charter on Human and People’s Rights on the Rights of Older Persons in Africa became the second international treaty related to the rights of older persons. The Protocol establishes the right to health care and income for older persons in addition to protecting them from discrimination and violence. However, only three of 55 AU Members have ratified the Protocol to date. While these regional treaties have made major strides in the promotion and protection of the rights of older persons, the Protocol and Inter-American Convention are limited in power and reach, applying only to countries that have ratified the treaties within their respective regional memberships.

Experts interviewed for this report agreed about the growing need for the definition, promotion, and protection of the rights of older persons. Among these experts, several argued that an international convention on the rights of older persons is necessary to combat ageism, standardize international norms around older persons, and achieve the recommendations set out in MIPAA, particularly in developing countries. “When the Convention on the Rights of People Living with Disabilities was enacted, it was immediately translated into laws and practices to protect those with disabilities throughout the world, particularly in developing countries like Brazil,” explained Alexandre Kalache, President of the International Longevity Centre–Brazil, in an interview. Still, during the roundtables and interviews conducted for this report, some experts expressed serious doubts as to whether a convention was possible due to political resistance, mostly from developed countries. Many states that are not yet committed to a new convention are instead calling for the improved implementation of current human rights laws to protect older persons. This call reflects the fact that ratification of a convention or treaty does not guarantee implementation of its recommendations or laws—protecting the rights and health of older adults is dependent on national governments integrating these commitments into their national policymaking and service delivery.

Part 2

National Strategies, Plans, and Policies for Healthy Aging

National plans, strategies, and policies around healthy aging play pivotal roles in defining a country’s priorities for maintaining and improving the well-being of older adults. First recommended in 2002 by the MIPAA, these national-level frameworks are vital for guiding budgetary decisions and fostering collaboration among public, private, and non-governmental stakeholders. All 194 WHO Member States have since committed to developing a national plan, policy, or strategy relating to healthy aging with the adoption of the WHO Global strategy and action plan on ageing and health in 2016. By 2020, at least 105 countries had developed such a framework, up from 88 in 2018. However, only 54 percent of all WHO Member States reported a country-level policy or plan that is aligned with the latest WHO framework on aging.

Figure 3

Number of Countries with a National Policy, Plan, or Strategy Around Healthy Aging, by Region

Data note: Countries without data did not disclose whether a national plan, policy, or strategy existed to support healthy aging. While many countries have subnational plans to support healthy aging, such plans are not included in this analysis.


National agendas do not appear to be evenly distributed across the six WHO regions, as depicted in the chart above. The WHO’s Europe region, which consists of 53 countries in Europe and the Western Pacific, has the highest number of plans at 37. However, proportionally, the Southeast Asia region ranks above all other regions at 91 percent, with 10 of 11 countries possessing a national policy or strategy around healthy aging. As of 2020, the Eastern Mediterranean and Western Pacific regions remained behind other regions in terms of total plans and percentage of countries with plans. Neither region made any additional gains in reported national frameworks between 2018 and 2020, prompting concern that some countries in these regions may not meet their commitments around healthy aging by 2030.

One key component of national plans is accounting for country-level challenges in addition to aligning with international conventions and frameworks on healthy aging. Progressive plans tend to include a life-course and rights-based approach to aging—which promote autonomy and dignity—monitoring and evaluation guidelines, appointing department and agency leads to address aging, establishing implementation timelines, allocating budgets, and targeting financial and non-financial resources to help ensure program viability and sustainability. These components transcend country-level differences, providing a basis for global cross-country engagement around national plans. 

National plans will naturally differ across countries within a region, depending on culture, demographics, and level of economic development. However, countries are likely to share opportunities and challenges around addressing healthy aging within their respective region, which is evidenced, in part, by the regional implementation strategies developed for MIPAA. Identifying such shared regional challenges can facilitate cross-country engagement and learning around national plans within regions. In addition, international frameworks around healthy aging offer insight into the components that help make plans on healthy aging a reality. Given these similarities across regions, the map below offers a look at demography and challenges in supporting older adults within each WHO region.

FIGURE 4

Demographic Trends and Challenges by WHO Region

The Americas

The Pan-American Health Organization (PAHO) projects that by 2030, one in six people in the Americas will be aged 60 or older. However, there is wide variation in the rate of aging across this broad region, which can generally be divided into two subregions: the U.S. and Canada, and Latin America, which encompasses the Caribbean, South America, and Central America. While Canada and the U.S. are rapidly becoming “super-aged” societies, Latin America and the Caribbean are aging at a slower pace, with only 13 percent of Latin America’s population aged 60 years or older. Brazil—with over 200 million people—is a standout in Latin American and the Caribbean, as the population of people over age 60 doubled within 20 years, to 20 percent.


Regional Challenges:

  • AFFORDABLE CARE: The cost of health care is a major concern throughout the region—including in the U.S., where health coverage is not universal, and premiums are high. Over the next 80 years, the IMF projects that Latin American countries will need to increase health care spending from an average of 4 percent of GDP to over 14 percent. 
  • LONG-TERM CARE: Long-term care presents another major challenge for the region, due to insufficient services and staff to meet current and future needs. The number of older people in need of long-term care in Latin America could grow from 12 million in 2021 to 55 million by 2050. In, Canada and the U.S., long-term care facilities were shown to be places of acute vulnerability during the COVID-19 pandemic.

Europe

The WHO European region has the oldest regional population in the world and will continue grow older. The region, however, is not aging equally and can be divided into two sub-regions—European Union (EU) countries, which tend to be wealthier and longer-lived, and the countries that are outside the EU. In 2020, more than 20 percent of the EU’s total population was older than 65 years of age, and by 2100, the population of people over age 80 in the EU is predicted to more than double, from 5.9 percent to 14.6 percent. For the countries outside of the EU, the working-age population dropped by 7 percent between 1995 and 2017 and is projected to decline by another 25 percent by 2050, due to migration, while the proportion of adults over age 65 is expected to almost double by 2050 across the whole European region, from 14 percent to 25 percent of the population, affecting the age-dependency ratio


Regional Challenges:

  • PENSION SYTEMS: The number of employed people relative to the number of retirees is expected to fall in Europe, as older people retire without working-age adults to replace them. This creates a financial imbalance, as pension spending is higher than contribution rates, prompting countries to consider increasing formal migration or adjusting pension systems.
  • CARE WORKFORCE: The decline of intergenerational living, accompanied by an aging population, will place increasing stress on Europe’s care workforce. 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.

Africa

Across the 47 countries included in the Africa region, people are living longer, healthier lives than in any previous generation. As of 2020, an estimated 74.4 million Africans were aged 60 years or older, and this number is projected to triple to 235.1 million by 2050, which would outpace the growth of all other regions.


Regional Challenges:

  • ACCESSIBLE CARE: Older adults are more likely to reside in rural areas, where they may suffer from understaffing of health workers, high out-of-pocket payments, insufficient financial resources, and inadequate health coverage.
  • LONG-TERM CARE: The provision of long-term is placed on families, due to customary norms and largely underdeveloped systems of long-term care. 
  • FINANCIAL SECURITY: Fewer than one-fourth of older persons in Sub-Saharan Africa have a pension due to largely informal economies and a lack of social pensions.
  • DATA COLLECTION: As a result of many countries’ insufficient capacity to collect data, there are fundamental data gaps, particularly around birth and death as well as health and social outcomes.

Eastern Mediterranean

The Eastern Mediterranean is currently experiencing a youth bulge—the World Bank estimates that two-thirds of the region’s population was under the age of 30 in 2020, while its population over 65 years old stood at just 7 percent. However, this demographic trend will reverse as fertility rates decrease over time; by 2050, a projected 18 percent of the region’s population will be over age 65.


Regional Challenges:

Western Pacific

Aging is taking place at a varied pace across the Western Pacific region. Of the 700 million people aged over 65 worldwide, 240 million live in the Western Pacific—most notably in Australia, New Zealand, and Japan. Aging populations are a priority for many Asian governments, as the number of people over age 60 in the region is projected to triple by 2050, to over 1.3 billion. Despite its high concentration of older adults, the Western Pacific region is also home to almost 60 percent of the global youth population when combined with Southeast Asia, with around 700 million individuals aged between 15 and 24 years.


Regional Challenges:

Southeast Asia

The population of Southeast Asia is aging at a rapid pace, with the proportion of the population that is aged over 60 projected to more than double by 2050 to 20.3 percent, from 9.8 percent in 2017. In the Southeast Asia region, women represent just over half of all people over 60 and over 60 percent of people aged over 80. By 2100, the population under 24 years of age could equal the number of older persons, which would have significant implications for regional workforces, intergenerational care structures, and care economies.


Regional Challenges:

  • RURAL-URBAN MIGRATION: As Southeast Asia experiences rapid urbanization, younger people are leaving rural areas to search for economic opportunities in cities. This trend, while not unique to the region, is changing family dynamics as older people are increasingly left behind in rural areas with limited options for care and support.
  • GENDER GAPS: The region’s changing family dynamics particularly impact older women, who are more likely than men to live alone. Older women, particularly those who are unmarried, also face barriers to accessing government services and are more likely to lack a source of financial support (e.g., income, assets, or pension). They are therefore likely to live in poverty, which can negatively affect health outcomes. While older women are acutely vulnerable in every region of the world, this trend is particularly pronounced in Southeast Asia.

Part 3

A Multi-Sectoral Approach for Healthy Aging

Experts consulted for this report agreed that enabling and supporting healthy aging requires a whole-of-society approach in order to achieve long-lasting impact. A multi-sectoral, whole-of-society approach that integrates governments with other stakeholders—and notably older adults—could support the implementation of more effective interventions for healthy aging across society. A collaborative, multi-sectoral approach could also help avoid mission creep and minimize the inefficient use of funds and other resources. Each stakeholder group could serve as critical knowledge brokers, agenda setters, and advocates for supporting health and the rights of older persons around the world. Each of these stakeholders should be guided and directed by the needs and wishes of older adults, as the “end users” of the system that these actors are seeking to establish and implement. The primary actors enabling healthy aging on the national level include governments; civil society and advocacy organizations; private-sector enterprises; and health service providers.

Figure 5

Healthy Aging Stakeholders Perform Intersecting and Complementary Roles


Government: Leadership for Healthy Aging

Among these stakeholders, national and subnational governments are central to the implementation and promotion of healthy aging agendas, and to providing the services and resources to support them, including by allocating funding. In relation to healthy aging, governments play five relevant roles:

  1. System Development
  2. Leadership and Funding
  3. Regulation, Data Collection, and Research
  4. Protection of Human Rights
  5. International Collaboration and Establishment of Norms

1. System Development

Governments at all levels are responsible for providing public services across many sectors and ensuring sufficient access, quality, and equity to those services. Social pension systems, housing services, and public health systems are all components of a coordinated government system to support healthy aging. This type of publicly provided service is critical for older adults who may have exhausted paid care options or who have no access to family or community support. While some of these systems and services are provided at the national level, some are devolved to subnational government or coordinated across multiple levels. For example, every state in the U.S. is required to submit a State Aging Plan for Older People, a coordinated plan for the implementation of services and programs for older adults, to the U.S. Administration of Community Living every three years. Submitting a coordinated plan is a condition of receiving federal funds earmarked for elder care through the Older Americans Act. 

Governments also often formally coordinate or delegate some responsibilities of care; for example, by working with private sector-run nursing homes. Systems of care tend to develop over decades, and, “What we see happening in Asia and Pacific is emerging examples of developing on existing systems and programs in health and social protection, piloting, testing, building consensus and then agreement on scaling up and national rollout,” according to Chief of the Social Development Thematic Group at the Asian Development Bank, Wendy Walker. This collaborative process of testing and refining systems design can be a means to more effectively target service delivery to the needs of older adults.

2. Leadership and Funding

Governments are principally responsible for setting agendas and guiding action around healthy aging. Experts and practitioners interviewed and surveyed for this report recommended that governments implement whole-of-government and whole-of-society approaches that apply an “aging lens” to all existing and proposed policies to mainstream healthy aging within policy formation. A whole-of-government approach assumes a series of multi-scale interventions that engage diverse government actors and agencies, with norms and resources for aging to be mainstreamed across all levels. This can work to reduce zero-sum thinking in budget allocation, which can marginalize and lead to the under-funding of aging services, by emphasizing the overlap between aging and other sectors and services in need of funding. A whole-of-society approach goes one step further and promotes close collaboration among governments and other stakeholders, including the private sector, to avoid the fragmentation of resources and services, enhance communication and integrated decision-making, and improve service delivery. Experts noted that non-governmental actors often wait to act to address existing gaps and challenges facing older adults until governments have led by example, which can cause stagnation and disincentivize private-sector innovation. A whole-of-society approach allows governments to lead in setting norms and agendas for healthy aging while encouraging other stakeholders to be part of the process and take action quickly. 

A whole-of-government approach assumes a series of multi-scale interventions that engage diverse government actors and agencies, with norms and resources for aging to be mainstreamed across all levels.

Government leadership also entails establishing an overarching framework that includes crafting and enforcing laws to protect the rights of individuals and groups, helping to ensure the equitable allocation of resources at the national and subnational levels. The passage and enforcement of anti-age-discrimination legislation, for example, can not only protect the rights of older adults in the workplace and in service delivery through regulations, but also combat widespread ageism that is pervasive across governments and sectors by sending a message to the wider society that older people are valued members of our communities.

CASE STUDY

California Master Plan for Aging

One example of a government-led, multi-stakeholder approach is the California Master Plan for Aging. The Master Plan includes goals for public- and private-sector health institutions to attain through program implementation, such as improving the standard of care for older adults, training new elder care workers, and providing affordable housing. The Master Plan was designed following extensive civil society engagement with older adults: The SCAN Foundation, along with other foundations and partners, conducted polling work among older adults in California that found that, regardless of party affiliation, voters wanted the state government to design a plan to address population aging, leading to its creation and implementation in 2019 by the incoming state governor. 

3. Regulation, Data Collection, and Research

Government leadership in researching innovative interventions and bringing them to scale, as well as regulating and monitoring existing programs, can help to flatten socioeconomic, gender, and identity-based disparities in quality of life and care and help to ensure greater equity in all facets of the care and protection of older persons. Without sufficient regulation, data, and research, the lives and needs of older people can be marginalized or invisible in broader society, leading to ageism and increasing the vulnerability of older populations. 

Regulation

One indispensable governmental role is to regulate the quality of care for older persons, especially of care providers such as nursing homes and home care, in order to keep people safe and provide consistency in care across geographical locations and socioeconomic statuses, and among providers. In addition to addressing inadequate care, government regulatory bodies can highlight and support high-quality care that meets the needs of older persons. As Katie Smith Sloan, the President and CEO of LeadingAge and executive director of The Global Ageing Network, noted, “There is a need for regulation, but it needs to be regulation with the purpose of incenting quality, as opposed to punishment, which is what most of our regulation [in the U.S.] does at this point.” In this way, regulation can be a tool in the promotion of high-quality care and interventions.

Data collection

While comprehensive, disaggregated data sources on older populations do exist in some contexts, including in Vietnam, India, and Denmark, about 75 percent of countries worldwide collect little to no data at the national level on older adults or on healthy aging specifically. The WHO states that the collection of sufficient, high-quality data “is imperative to shed light on structural and systematic ways in which older persons are left behind . . . [and] data is a prerequisite for informed and successful public policy making as well as for normative action to close existing gaps.” In addition to data disaggregated by age, other key data about older persons disaggregated along racial or ethnic, socioeconomic, subnational geography, and other important identity-based characteristics would help to inform policymaking by highlighting the range of diversity among older persons and help ensure that marginalized populations’ needs are recorded and met. 

About 75 percent of countries worldwide collect little to no data at the national level on older adults or on healthy aging specifically.

Research 

While governments alone may not have the capacity and resources to undertake in-depth research on existing and innovative approaches to healthy aging, governments can set an agenda for non-governmental bodies and researchers to pursue by offering grants and funding to research gaps in support for older persons and pilot interventions that merit further investigation. Successful pilot programs and research conducted in partnership with civil society and the private sector can then be used to inform policy, adjust budget allocation, and scale programs nationally to expand impact. Expert participants in interviews and roundtables identified numerous avenues for further in-depth research that could be undertaken by multi-sectoral partners, including the promising methods to promote age longevity, and how to more effectively mainstream life-long health practices and policies. Governments may also benefit from research into how to more substantively integrate equity and inclusion goals into healthy aging policy, in light of burgeoning research that demonstrates that aging interacts with racism, sexism, and discrimination of all types in a way that contributes to more stressful and rapid biological aging, known as “weathering.”

4. Protection of Human Rights

One central role of government is also to protect the human rights of individuals and groups and define who is “visible” as a rights-holder. For older persons, rights tend to be organized around several themes—the rights to health and health care, to life, and to dignity and a dignified retirement. It is essential, however, to acknowledge that while these rights apply to every person of any age, older persons are a diverse group with varying needs. Some older adults face distinct types of discrimination or challenges that stem from other socioeconomic characteristics, often in a way that interacts with ageism. Women, people experiencing poverty or homelessness, refugees, and people of diverse ethnicities, races, and sexual orientations tend to be the targets of worsened ageism, and structural and individual discrimination based on those characteristics has been found to grow over an individual’s lifetime, exacerbating the effects of ageism. One additional challenge to governments’ ability to protect and promote the rights of older people is the fact that those rights can conflict with measures implemented to protect the population, for example, in the context of COVID-19, most older persons, regardless of health status, have to some extent had their rights reduced in a discriminatory manner. Travel and movement restrictions have been tighter for older persons in most countries than for other age cohorts. While the intent of these restrictions was to protect older persons from spreading or catching the virus, these health measures reduced older persons’ right to free movement and consequently impeded access to social security, work, and health care.

5. International Collaboration and Establishment of Norms

One key opportunity for governments to engage with the healthy aging agenda is by ratifying treaties, including United Nations human rights conventions and by participating in international processes that center on older persons, such as MIPAA reviews. Engaging with other governments and international processes can promote international partnerships and provide opportunities for cross-country learning about healthy aging, particularly about how other countries apply norms or how systems function. While every country has unique history and cultural contexts, there is much opportunity to learn from participation in international forums, as many countries have similar issues and constraints around aging populations. Governments that engage in cross-national learning can then experiment with implementing the best ideas in their own jurisdictions, while being mindful of local, unique realities. To facilitate cross-country learning, and to ensure that all Member States are adhering to agreed-upon standards of care, the Association of Southeast Asian Nations (ASEAN) has implemented a five-year review process during which all members come together to evaluate their health and social care plans—including care for older adults—and lay out their plans for the next five years, in a collaborative environment.

One benefit of such cross-national engagement and participation in international processes is the development of meaningful, shared global definitions, language, and labels, that focus and align policymaking agendas. For example, the “age-friendly” label for cities and communities was first established by the WHO in 2007 and expanded into the WHO Global Network of Age-friendly Cities and Communities (GNAFCC) in 2010. AARP established a U.S. affiliate of the GNAFCC, which has enrolled 573 communities in the United States as “age-friendly.” By laying out explicit definitions and standards to be met for communities accepted into the network, the WHO avoids the risk that language such as “age-friendly” become simply a “tagline instead of a deep and meaningful label,” as Terry Fulmer, president of the John A. Hartford Foundation, noted in an interview. Thus, AARP’s designated “age-friendly” communities strive to meet the same standards as other GNAFCC members from all over the globe.

Health Service Providers: Provision and Promotion of Healthy Aging

Depending on the context, health care providers may be government-led, private sector-owned, or operated on a charitable basis by philanthropic foundations and not-for-profits. These services are key to the implementation and enforcement of healthy aging agendas at the national and international levels. Health care providers can and should be on the cutting edge of health and healthy aging innovation but can often be hindered by workforce and funding shortfalls. However, these organizations and their staffs are on the frontlines of protecting not only older populations’ health, but also the rights to a high quality of life and access to medical care for older persons, through three main roles:

  1. Encouraging Health at All Ages and Abilities
  2. Providing Individualized Care
  3. Providing Accessible Care

1. Encouraging Health at All Ages and Abilities

The WHO’s 2021 resolution on the social determinants of health defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” a statement that acknowledges the need for a holistic, lifelong, and whole-of-society approach to health and healthy aging. This attitude toward health requires health service providers to promote and facilitate a life-course approach to health that works to mitigate and minimize the impacts of individual choices and societal determinants of health, which can affect people into old age. To do so, public and private health service providers can publish resources for individuals to pursue physical fitness and nutrition and deliver services to support smoking, alcohol, and drug cessation. Health service providers also play an important role in supporting older adults with chronic conditions and disabilities. Older adults with chronic diseases and other disabilities often require expanded and specialized care to manage their conditions and can be at risk of ageism if health care providers make assumptions about their needs or priorities. New Zealand’s Better Later Life strategy to support healthy aging, for example, was designed following forums and focus groups with older adults, to ensure that it reflects their priorities. It includes provisions to encourage health at all ages, including through extended support for Maori communities, who typically have worse health outcomes throughout life due to discrimination and poor service provision.

2. Providing Individualized Care

The provision of health care for older adults cannot take a one-size-fits-all approach. Person-centered care was identified by many of the experts interviewed for this report as the future of effective and holistic medical care and a key method for reducing disparities in health outcomes among marginalized groups. Person-centered care allows older adults to identify individualized health goals and emphasizes the primacy of autonomy and the dignity of choice. Individualized care is critical to combatting ageist assumptions that older persons are incapable of making decisions for themselves, which can discourage some older individuals from seeking needed medical care. As such, health service providers seeking to improve health outcomes for older people could benefit from adopting a person-centered approach. Person-centered care should also be a focus in long-term care settings—including palliative and end-of-life care. In long-term care settings, it is critical that providers and case managers work with older adults and, in some cases, their families to establish a plan for care and services. This may include retrofitting accommodations to enable people to age safely in their homes and communities.

CASE STUDY

Age-Friendly Health Systems: The 4Ms

The “4Ms” is a framework for simplifying and streamlining health care for older adults, by identifying four key areas that drive effective health care decision-making, with the aim of promoting health and wellness, as well as preventing disease. Introduced by the Institute for Healthcare Improvement (IHI) and funded by the John A Hartford Foundation, the framework has been adopted by major health care providers in the U.S. and implemented in over 1,000 hospitals as of 2020. 

The 4Ms include:

  • What Matters: Outlining and adhering to individual older adults’ specific health goals and care preferences, including end-of-life care, based on their priorities;
  • Medication: Where possible, ensuring that any necessary medication does not interfere with older adults’ health goals, mobility, or cognitive function, to preserve quality of life;
  • Mentation: Promoting cognitive function by preventing, identifying, treating, and managing dementia, depression, and delirium; and
  • Mobility: Ensuring that older adults can move safely throughout their daily lives to maintain function and do “what matters” to them.

3. Providing Accessible Care

Providing accessible health care requires a multi-pronged and collaborative approach to ensuring that systems and spaces are navigable for older adults. Issues in accessing care may be linked to the physical location of services or may result from discriminatory practices that make older adults feel unwelcome. Facilitating physical access to health care settings requires care providers to provide resources in accessible formats, such as braille and large-print copies of literature, ensure that hospitals and doctors’ offices are accessible for wheelchair-bound and less-mobile individuals, and offer translation services for patients who do not speak the local language. One alternative to physical in-person health care for elderly patients is telehealth, which is becoming increasingly common as a result of COVID-19 and could expand access to certain diagnostic, maintenance, and management of health care post-COVID. Telehealth services enable older adults with low mobility, or those who live in rural or underserved areas, to access health care from the comfort of their homes. However, as telehealth and online booking and payment systems become more common in the health care sector, it is increasingly important to ensure that the country’s infrastructure allows equal access to internet services, regardless of geographic location. Improving older adults’ digital literacy and providing assistance, both financial and educational, for those who need help accessing online resources, is also important for health service providers to consider. 

In seeking to eliminate discrimination in health service provision, accessible and equitable health care delivery can be undertaken on an individual, person-to-person level, or may require systematic intervention to overhaul systems and infrastructures. For example, the New York City Health + Hospitals public care system recently launched a “Medical Eracism” project, which takes a systematic approach to eliminating medical racism across the city’s health care infrastructure by identifying and discontinuing medical tests and assessments that are based on biased and inaccurate assumptions about racial difference. Non-discriminatory health care can also be secured through the recruitment, training, and employment of gerontologists and other medical professionals who specialize in the treatment of older adults, and by sensitizing non-specialized medical professionals in methods of treatment and care that respect the dignity and autonomy of older adults from minority groups.

Civil Society: Accountability and Amplification 

Civil society organizations play a major role in advocating on behalf of older adults, facilitating healthy aging agendas, and convincing policymakers to commit resources to healthy aging agendas and older persons’ needs. Wendy Walker, Chief of the Social Development Thematic Group at the Asian Development Bank, stated that aging is “an invisible issue because of the ways in which societies have traditionally managed the care of older persons in the family, and that they increasingly disappear from visible social life in the workplace, in the community, and otherwise.” Civil society organizations play several central roles in overcoming this societal invisibility:

  1. Advocating for the Needs of Older Adults
  2. Changing Societal Attitudes Toward Aging
  3. Connecting Aging Supporters and Stakeholders

1. Advocating for the Needs of Older Adults

Civil society organizations can advocate for the needs of older persons through high-level campaigns and building political will to support service provision by forming relationships with policymakers and politicians. While this is often a long-term, methodical process requiring high levels of engagement and sustained access to policymakers, civil society organizations can engage policymakers via their personal connections to issues relating to aging, or by presenting compelling stories. Key to advocacy on behalf of older persons are direct interaction and consultation with older persons regarding their individual needs and wants, to avoid inaccurate assumptions, and the amplification of older people’s voices and demands.

CASE STUDY

Coalition of Caregivers and Advocates for the Elderly in Liberia (COCAEL)

During the height of the Ebola outbreak in Liberia in 2014, sixteen registered NGOs formed the Coalition of Caregivers and Advocates for the Elderly in Liberia (COCAEL). The NGOs mobilized around the invisibility of older persons in the Liberian government’s Ebola strategy, which neglected to name older persons as a vulnerable group while identifying women and children as being at risk. Civil society organizations engaging and representing Liberian older people, including COACAEL, were also excluded from the government’s task force to address COVID-19. COCAEL launched advocacy campaigns to bring older people’s needs to the forefront of the public conversation and plans to continue to advocate on behalf of older Liberians through its membership in the National Civil Society Council (NCSCL), which is a coalition of diverse Liberian civil society organizations. In 2021, COCAEL participated in the consultation process for a legislative bill creating a new National Commission for the Elderly in Liberia (NCEL), intended to address the needs of older adults in Liberia.

2. Changing Societal Attitudes Toward Aging

Societal attitudes toward aging can have a significant impact on healthy aging outcomes, as positive self-perception—which generally stems from having a perceived place of value in society as well as positive representation in media—is linked to better health and social outcomes among older adults. To support this and combat ageism more generally, civil society organizations have undertaken information and media campaigns that reframe aging, rejecting ageist stereotypes and highlighting older adults’ economic and contributions to society. These campaigns and initiatives aim to encourage a reassessment of how societal conversations about aging are framed. For example, AARP in collaboration with Getty Images launched the Disrupt Aging Collection, a library of 1,400 images that provide a more accurate portrayal of older people. 

Experts interviewed for this report also highlighted the innovative practice of facilitating cross-generational volunteer work, to improve communication among generations and directly confront ageism among young populations. Ibasho, a project started in Japan following the 2011 earthquake and tsunami, established community housing for older adults, who were then supported to volunteer in the local community through the creation of a café, day care center for local children, and vegetable garden where children learn about nutrition and farming from their elders. Following the initial project’s success, Ibasho has expanded throughout Japan and to communities in Nepal, the Philippines, and Cote d’Ivoire, where projects are tailored to the needs of the local community and the interests of the older adults who volunteer. 

3. Connecting Aging Supporters and Stakeholders

While individual NGOs and civil society organizations can make significant progress on their goals through engagement with policymakers, advocates supporting healthy aging often work in isolation, which can diminish their impact. Wendy Walker, the chief of the Social Development Thematic Group at the Asian Development Bank, noted that, in the case of the Asia Pacific region, “advocacy networks on the ground in many countries are not very well developed or very visible, and that becomes another reason why [older person’s needs] disappear.” However, particularly at the global level, NGOs and civil society taking action on behalf of older adults are beginning to recognize the potential benefit of bridging gaps among these groups in the field through networks. Examples of diverse, international networks of aging advocates include:

  • HelpAge International’s Global Network, comprising 158 organizations across 86 countries that support the goal of helping older persons live safe, healthy, and dignified lives;
  • The International Federation on Ageing (IFA), based in Canada with a network of partners in 75 countries, representing over 80 million older adults around the world;
  • The Global Alliance for the Rights of Older Persons (GAROP), which promotes rights-based approaches for older persons; and
  • The WHO Global Network of Age-friendly Cities and Communities, which aims to connect 1,114 designated age-friendly cities and communities in 44 countries.

These global networks can facilitate the sharing of innovative practices and lessons from programs that civil society organizations have implemented, which may help spur change in new contexts or countries. Building international partnerships can also highlight the areas in which a particular country is falling behind and can encourage organizations to build political will within their own country. For example, in countries with less emphasis on human rights, global networks may be able to collectively apply pressure on national governments to begin prioritizing the protection of rights for all, especially older persons.

The Private Sector: Funding and Innovating 

Private-sector firms, of various sizes and scales, are often integral to the promotion of healthy aging around the world, including in the delivery of care. The private sector can support and expand the work of government, civil society, and health service providers by seeking new technological, medical, and behavioral approaches to promote healthy aging. As such, the private sector plays two pivotal roles in healthy aging promotion:

  1. Driving Innovation
  2. Funding Health Aging Research 

1. Driving Innovation

Innovations for the care and support of older adults, especially technological innovations, often come from the private sector, which can profit greatly from successful new interventions, particularly as populations age and grow wealthier. Examples of such innovative technologies include wearable technologies that alert caregivers about patient falls, advancements in precision medicine, and the development of smart hospitals and smart homes. However, innovations in aging are not limited to digital technologies. As Keren Etkin, founder of The Gerontechnologist, an Israeli company which trains entrepreneurs on aging issues, noted, “It’s not about the technology, it’s about what the technology enables us to do and enables people to do. [If] the technology enables people to be healthier and to age in place for longer, then it doesn’t really matter if it’s VR or AI.” Experts advised that companies can improve the relevance and accuracy of their plans by working directly with gerontologists and older adults themselves, in co-design processes that keep older persons’ needs and experiences central to the development process. For example, iN2L, a technology company that develops tablets and touch-screen devices to support older people’s independence and cognition, worked closely with its target users when designing a program for people with dementia intended to improve memory retention. Product developers worked iteratively, testing each new idea and development on a focus group of older adults with dementia to ensure that it met their needs and was usable by people with a range of digital literacy and mobility abilities.

2. Funding Healthy Aging Research 

Private-sector actors can direct funding and investment toward new and unproven practices with greater ease than government institutions, which can face relatively high levels of bureaucracy and limits on the size and length of grants that can hinder long-term, experimental research processes. Private companies can drive innovation and penetrate markets. Google’s Calico Labs, for example, is a biotech company dedicated solely to the science of aging, in the hope of expanding societal understanding of aging and potential interventions to increase lifespan, conducting research in-house, and awarding grants with few restrictions on research focus. The enterprise is one of several experimental research centers funded and coordinated by Google and its parent company, Alphabet. Experts interviewed for this report noted that private citizens and entrepreneurs may also contribute funding to healthy aging research and innovation, often due to personal interest in the future of aging and longevity or to a desire to contribute to societal improvement. In pursuing a multi-sectoral approach to healthy aging, public-private partnerships can combine private-sector expertise and investment with government data and pathways to scale, avoiding potentially inefficient allocation of resources or duplication of research, while deploying innovative approaches in service of public and societal agendas.

CASE STUDY

The UK Research and Innovation’s “Healthy Ageing Challenge”

The UK Research and Innovation’s “Healthy Ageing Challenge” is a public-private partnership that aims to support healthy aging in the UK. It will provide up to £40 million in funding for large-scale “trailblazer projects” on healthy aging; £2 million for social, behavioral, and design research; and £4 million for social enterprises, in partnership with the UK’s Small Business Research Initiative. Supporting the Healthy Ageing Challenge are five private-sector “investment partners” that will collectively provide up to £39 million in grant funding over a three-year period for small- and medium-sized enterprises (SMEs) to develop innovations for healthy aging. The investment partners are:

Part 4

Key Considerations for Healthy Aging Frameworks and Agendas

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.

Call to Action and Looking Ahead

Supporting global healthy aging will require the concerted effort of all stakeholders in aging rights, services, and care, to close the gaps that remain in the care and treatment of older adults. Governments, civil society actors, the private sector, and health service providers are key to the promotion of healthy aging. They play critical roles providing leadership and setting norms, amplifying the voices and demands of older adults, driving innovation through funding and experimental approaches, and ensuring the smooth and accessible delivery of services. While these four stakeholders are not the sole determinants of the success of healthy aging interventions, they are the fundamental actors without whom aging policies and services would collapse. As such, they are central to the development and expansion of innovative healthy aging practices.

Principles for Innovation in Healthy Aging

Through expert interviews and analysis of current policies, programs, and technologies that support healthy aging, seven main principles have been identified as central to successful innovation in healthy aging promotion. Stakeholders who are committed to healthy aging can adhere to these principles at all stages of the design and implementation process—including new interventions as well as those that are already established and are in need of strengthening.

  1. Participatory Processes and Co-design: Healthy aging policies and approaches benefit from close consultation with older adults themselves as the targets for most intervention. Taking inspiration from the disability rights slogan “Nothing about us without us,” public- and private-sector actors can ensure that new programs and products reflect the needs and priorities of older adults through an iterative co-design process.
  2. Equity and Inclusion: Stakeholders can promote healthy aging for all individuals and communities by acknowledging the diversity of the older population and addressing the social determinants of aging that can cause vulnerable groups to “age faster,” and with less dignity, than their peers. Systemic and individual interventions to support healthy aging benefit from a culturally sensitive and adaptive approach that can evolve as the population’s needs do.
  3. Dignity: Pervasive societal, individual, and internalized ageism still exists across the world, eroding the rights, quality of life, and quality of care of older adults, who may be seen as a burden on families and health care infrastructures. Protecting the inherent dignity and rights of all people—including older people—is therefore essential to the promotion of healthy aging and health at all ages.
  4. Life-Course Approach: Aging begins at birth, as experts noted, thus individuals’ lifestyles and social surroundings will impact their health and well-being as they age. Interventions to support healthy aging should therefore begin earlier in one’s lifetime as well, through a life-course approach that promotes mental and physical health at every age.
  5. Whole-of-Society Approach: Healthy aging is affected by factors across society—not only health care provision, but also social interaction, secure housing, and the ability to contribute meaningfully to society, to name just a few. A whole-of-society approach acknowledges this reality by mainstreaming healthy aging interventions across aging actors, encouraging collaboration among all sectors and levels of government.
  6. Monitoring and Evaluation: Successfully supporting healthy aging necessitates avoiding assumptions of what will and will not work best for a particular population of older adults. Careful monitoring and evaluation practices will benefit new and existing healthy aging interventions and could lead to their expansion and adaptation if proven effective.
  7. Support for Caregivers: Formal and informal caregivers are central to healthy aging, as they are responsible for monitoring and maintaining physical and mental health, following guidance and prescriptions for care, and often providing much-needed social interaction for older adults. Supporting and growing the care economy, and including family caregivers within it, is therefore vital to the success of healthy aging work.

Recommendations for Multi-stakeholder Support for Healthy Aging

A range of key actors are essential to closing the gap inhibiting healthy aging at local and international levels. The promotion of healthy aging across society will necessitate actions by individuals combined with those of the four main aging stakeholder groups—national and local governments, civil society organizations, the private sector, and health care service providers—in order to attain healthy aging goals. Based on in-depth research as well as interviews and roundtable discussions with over 70 experts and practitioners in healthy aging, the following actions could be taken to accelerate progress:

National Governments

  • Improve coordination among actors and sectors to support healthy aging: A whole-of-government and whole-of-society approach to aging services entail high-level coordination by national governments to avoid duplication of work among stakeholders, regulate the quality of services, and allocate funding equitably, including through the provision of private-sector funding for new projects and the development and coordination of comprehensive plans for serving aging people. Frameworks such as Chile’s SENAMA plan or Ireland’s Sláintecare program, featured in the accompanying toolkit, are innovative examples.
  • Incorporate support for specific subgroups of older people into legislation and policy frameworks: Governments can reduce the disparities experienced by members of vulnerable groups by incorporating specific initiatives targeting these groups. Potential actions include prioritizing attention to the experiences of older women, ethnic and religious minorities, displaced peoples, gender- or sexual-identity minorities, persons with disabilities, and persons in specific settings such as fragile states and poverty contexts. The government of New Zealand, for example, has integrated culturally specific needs assessments for Maori people into its plans on aging and mental health.
  • Strengthen the care economy to encourage more people to enter the care workforce: Governments can invest in the care economy by establishing publicly-funded training and education programs for doctors, nurses, and care workers working with older and disabled adults, including geriatric specialists, and by strengthening legal protections for current and prospective migrants.
  • Support informal, unpaid caregivers to provide safe, high-quality care: National governments can implement and enforce legislation to protect family caregivers from economic difficulties, including paid leave for family care, tax credits, housing subsidies, and state-funded respite care and childcare programs. They can also improve standards of unpaid care by providing free training courses to individuals caring for family members. The U.S. government’s RAISE Family Caregivers Act, which became law in 2018, and delivered its first report to Congress on the state of caregiving in September 2021, aims to provide support of this kind to informal family caregivers.
  • Introduce non-contributory or social pensions for people without formal employment: Informal economy workers, as well as individuals such as homemakers and caregivers who are not employed outside their household, may be unable to pay into, and subsequently benefit from, traditional pension plans. Governments around the world can learn from countries with high levels of informal employment, such as India, and from Australia’s means-tested non-contributory Age Pension programs by introducing social pensions that do not require an individual to contribute over their lifetime, to ensure that all older adults maintain a livable income.
  • Monitor and evaluate the impact of aging interventions and collect high-quality data on older adults: Governments can support effective budget and resource allocation by continually monitoring and evaluating existing and new programs to measure their impact on older adults and aging services. Doing so would facilitate the identification of under-performing services and the redirection of resources toward effective interventions. Governments can also take a leadership role in closing the global data gap on older adults, by publishing clear guidance for data collection—such as disaggregating all data by age, sex, race, and ethnicity—and establishing a public data repository that can be accessed by researchers, scientists, and other stakeholders in healthy aging promotion.
  • Participate in international knowledge-sharing exercises to improve global healthy aging outcomes: Countries and regions can learn from each other and adapt innovative practices to be contextually relevant to the needs of local older populations, particularly countries and regions whose populations are beginning to age. They can learn from the successes and failures of those in countries that have already experienced this demographic shift. Regional and global institutions such as the WHO and UN, and international civil society organizations such as AARP, can facilitate the sharing of knowledge and best practices among these regions.
  • Adopt a rights-based approach to confront ageism and encourage older adults’ active participation in daily life: Governments can reduce ageism and lead a shift in social norms and attitudes by explicitly outlining the rights of older adults within national anti-discrimination legislation, including rights in the workplace, communities, and health care. In line with the International Convention on the Rights of Persons with Disabilities, impactful frameworks can be developed in partnership and consultation with older people from a wide range of cultures and subgroups.

Civil Society Organizations

  • Amplify the voices of older people on national and global stages: Civil society organizations that are dedicated to the support of older adults can help combat the “invisibility” that older populations often experience in society, by amplifying the needs and concerns of this group and building political will for healthy aging interventions, through public campaigns and relationships with politicians and policymakers.
  • Tackle ageism by encouraging meaningful engagement between older people and their communities: Civil society organizations can support social norm change and positive attitudes toward aging by demonstrating the positive value that older adults bring to their communities. They may engage in publicity campaigns or create spaces for inter-generational interaction such as volunteer tutoring or free child care programs—such as the Experience Corps program, now run by AARP in 23 U.S. cities—or accessible multigenerational playgrounds, as introduced in Singapore.
  • Act as watchdogs for government healthy aging policies: Civil society organizations play an important societal role as watchdogs for government, holding the powerful accountable for promises made and policies introduced, to ensure that they are enacted fully. In the case of older persons’ rights and needs, civil society groups can monitor the progress and implementation of aging plans, anti-age-discrimination laws, and commitments to improve aging service provision and coordination.

Private Sector

  • Fund innovative research into low-cost healthy aging practices and products: Businesses and entrepreneurs with interests in aging and health and growing markets worldwide can undertake experimental and innovative research that is beyond public-sector project funding. The private sector can invest and innovate to develop new interventions that can be tested, refined, and scaled through adoption by governments and health service providers. Google’s Calico Labs, for example, conducts research in-house and with partners to develop technologies and interventions to promote longevity.
  • Engage in public-private partnerships to develop innovative healthy aging interventions: Private companies can supplement stretched government resources through public-private partnerships, which can “improve the quality and cost efficiency of public services as both parties pool their resources and benefit from each other’s specific qualities.” These initiatives can provide insights and serve as models to be expanded and scaled elsewhere. Initiatives such as the UK Research and Innovation “Healthy Ageing Challenge” use private-sector financing to achieve government strategy goals, thus expanding public-sector resources while maintaining a clear objective.
  • Help to reduce the cost burden of long-term care by supplementing gaps in public-sector service provision: Where governments are unable to extend funding for long-term care infrastructures, the private sector can potentially help underwrite costs, including via the introduction of new innovative long-term care insurance approaches and the establishment of private, employer-provided pension funds, both of which assist people in saving throughout their lifetimes for potentially necessary care in old age. In the U.S., most state governments partner with specific LTC insurers to ensure certain quality standards, such as cost-of-living adjustments to prevent excessive premium inflation.
  • Support older adults who are seeking to remain in the labor force: Private companies can invest in the continued education and training of older adults who wish to remain in active employment later in life, through programs such as the Barclays “Bolder” scheme in the UK, which offers apprenticeships and employment opportunities to people aged 50 and over. Employers can additionally support their older workers through the enforcement of anti-ageism policies in the workplace and the introduction of flexible working arrangements, including teleworking. The Living, Learning and Earning Longer Collaborative, led by AARP, the World Economic Forum, and the OECD, provides a number of examples of how employers can support older employees and create multigenerational workforces.
  • Share anonymized data collected via service delivery and product use: The private sector is well positioned to assist in the collection of age-disaggregated data and fill global data gaps that hinder understanding of the experiences of older adults. In sharing data with local governments, the private sector should protect the privacy of product and service users by anonymizing all datasets.
  • Close the generational digital divide: Private companies can facilitate remote work and learning, telehealth, and greater social interaction through the provision of free or low-cost broadband services for older adults in remote areas, and through investing in digital literacy education. The ability to use digital products such as smart phones and tablets can enable older people to live independently for longer and retain contact with family and friends who may move or migrate away. In Japan, IBM and Apple partnered with the Japanese postal service to provide user-friendly tablets to older adults and teach them how to make appointments and use video conferencing technology, while in the U.S., OATS not only teaches older adults how to use new technologies, but also works with broadband and telecom providers to extend internet services to older adults, particularly in rural areas.

Health Service Providers

  • Professionalize the care workforce through investment in human capital: Health service providers can implement practices to encourage new workers to enter and remain in the care sector, and to work to a high standard of care, including: specialized training in geriatrics, age-friendly health care, and person-centered care; higher pay and better benefits for care workers, including in-home caregivers. For example, Uruguay’s Integrated National Care System (SNIC) provides training for caregivers and regulates working conditions in both elder care facilities and private residences.
  • Integrate formal service provision into the informal care economy: The broad trend toward home-based care around the world requires public and private support to ensure that caregivers and care receivers remain supported, healthy, and safe. Telehealth appointments, mobile care clinics, and regular home visits from medical professionals and social workers give informal caregivers time to attend training sessions or engage in paid work, while providing the opportunity to identify signs of illness, abuse, or neglect that may require professional intervention.
  • Address health care disparities due to race, ethnicity, gender, sexuality, disability, and other factors: Health service providers can work to eliminate historic disparities in elder care and aging service provision by implementing person-centered care as the standard for all interactions with older adults, and through the systematic uncovering of discriminatory medical practices, to support healthy aging for all, regardless of identity or ability. One example of a systematic approach to reducing racial disparities in health and medical care is the New York City Health + Hospitals’ Medical Eracism project.
  • Shift to an integrated care approach that treats all aspects of health in harmony: Integrated health care, which addresses all factors affecting health holistically and thus avoids the siloing of care and information between doctors and specialists, is becoming increasingly common. An integrated approach is thought to promote healthy aging by addressing social determinants of health, and through the early identification of illness, disease, or other forms of poor health, thereby reducing overall health care spending and resource usage by focusing on preventative care. Health service providers can learn from the examples of Thailand and Singapore, where integrated approaches to elder care have been adopted by the state.

Looking Ahead

Across the world, humans are living for longer than ever before in history, but poor health threatens quality of life as people age, necessitating the mainstreaming of policies, practices, and products that facilitate healthy aging. Older adults, both now and in the future, have a right to high-quality, integrated care that allows them to maintain their dignity and autonomy and supports meaningful connections to their communities. Promoting the health and well-being of older adults will therefore require numerous stakeholders—most prominently national governments, the private sector, civil society, and health service providers—to work together to develop and adopt innovative healthy aging practices and to eliminate ageism. As Paul Irving, Chairman of the Milken Institute Center for the Future of Aging, noted optimistically, “If societies can keep their aging populations healthy and engaged, think of how exciting those future years might be.”

This report was produced by FP Analytics, in collaboration with and underwritten by AARP. FP Analytics is the independent research division of Foreign Policy.

FP Analytics would like to acknowledge and thank the many roundtable participants and interviewees who shared their insights and experiences for this study. Specifically, we would like to thank the following experts and practitioners working at the forefront of healthy aging around the world:

  • Abdulrazak Abyad, Middle East Academy for Medicine of Ageing & Middle-East Association on Aging and Alzheimer’s
  • Gretchen Alkema, Vice President of Policy & Communications, The SCAN Foundation
  • James Appleby, CEO, Gerontological Society of America
  • Jane Barratt, Secretary General, International Federation on Aging
  • John Beard, ARC Center of Excellence in Population Ageing Research, University of New South Wales
  • Donald Berwick, Lecturer of Health Care Policy, Department of Health Care Policy, Harvard Medical School; President Emeritus and Senior Fellow, Institute for Healthcare Improvement
  • Robert Blancato, Executive Director, National Association of Nutrition and Aging Services Programs
  • David Blumenthal, President, Commonwealth Fund
  • Bethany Brown, Human Rights Advisor on the Rights of Older Persons, International Disability Alliance
  • Dominic Campbell, Director, Creative Aging International
  • Mathew Cherian, Board Chair, CARE India
  • Catherine Collinson, CEO and President, Transamerica Center for Retirement Studies
  • Daniel Cotlear, Technical Director, Health Financing, The Palladium Group
  • Justin Derbyshire, CEO, HelpAge International
  • Marcus Escobedo, Vice President, Communications and Senior Program Officer, John A. Hartford Foundation
  • Keren Etkin, Founder, The Gerontechnoloist
  • Linda Fried, Dean of Public Health School, Columbia University
  • Terry Fulmer, President, John A. Hartford Foundation
  • Heléna Herklots, Older People’s Commissioner for Wales
  • Paul Irving, Chairman, Milken Institute Center for the Future of Aging
  • Gretchen Jacobson, Vice President, Medicare, Commonwealth Fund
  • Cara James, President and CEO, Grantmakers in Health
  • Alexandre Kalache, President, International Longevity Centre, Brazil
  • Claudia Mahler, UN Independent Expert on the enjoyment of all human rights by older persons
  • Rishi Manchanda, Founder and President, HealthBegins
  • Diane Meier, Professor, Geriatrics and Palliative Medicine, Mount Sinai
  • Susan Mende, Senior Program Officer, Robert Wood Johnson Foundation
  • Adrienne Mendenhall, Director of Business Development, Singapore, Access Health International
  • Colin Milner, CEO, International Council on Active Aging
  • Jim Nicholson, Manager, Healthy Ageing, Community Health System Improvement and Innovation, Ministry of Health, New Zealand
  • Alana Officer, Unit Head, Demographic Change and Healthy Ageing, World Health Organization
  • Jay Olshansky, Professor in the School of Public Health, University of Illinois at Chicago
  • Sue Peschin, President & CEO, Alliance for Aging Research
  • John Piggott, Director, ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales
  • Amal Abou Rafeh, Chief of the UN Programme on Ageing, Division for Inclusive Social Development, UN DESA
  • Paulo Saad, Director, Population Division, United Nations Economic Commission for Latin America and the Caribbean (ECLAC)
  • Ravi Samuel, Cognitive Behavior Psychotherapist, VisionAge India
  • Marcia Scazufca, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, Brazil
  • Andrew J. Scott, Professor of Economics, London Business School
  • Katie Smith Sloan, President & CEO, LeadingAge, Executive Director, The Global Ageing Network
  • Abla Mehio Sibai, Director, Center for Studies on Ageing, American University in Beirut
  • Robyn Stone, Senior Vice President, Research and Co-Director, LeadingAge LTSS Center
  • Cynthia Stuen, Chair/UN Representative, NGO Committee on Aging-NY
  • Edwin Walker, Deputy Assistant Secretary for Policy and Programs, Administration on Aging, U.S. Department of Health and Human Services
  • Wendy Walker, Chief, Social Development Thematic Group, Asian Development Bank
  • Laura Tamblyn Watts, President and CEO, CanAge
  • Diane Whitehouse, EHTEL - Principal eHealth Policy Consultant
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