soonman aging and health policy asia revised (unescap ... and heal… · • health systems in asia...

Population Aging and Health Policyin Asia and the Pacific

UNESCAP meeting, Bangkok

July 12, 2016

Soonman KWON, Ph.D.

Chief of Health Sector Group (Technical Advisor)

Asian Development Bank (ADB)

Former Dean, School of Public Health

Seoul National University, Korea

Contents

I. Health of Older People

II. Health System and Policy for Older People

S. Kwon: Aging and Health in Asia

I. Health of Older People

1. Change in the Leading causes and Risk factors of Disability-adjusted Life Years (DALYs) (1990-2010)

• Non-communicable diseases (NCD), e.g., ischemic heart disease, lung cancer, diabetes, chronic kidney disease, showed the highest growth (IHME, 2013).

• 3/4 of NCD deaths occur among persons +60 years (World Bank, 2016)

• Dietary risks were the leading risk factors in most Southeast Asian countries, high BMI and high fasting plasma glucose ranked high in the Pacific; Smoking ranked second or third in Cambodia, Indonesia, Laos, Malaysia, Myanmar, Papua New Guinea, Philippines, Thailand, Timor-Leste, Vietnam (IHME, 2013)


Shifts in Leading Causes of DALYs in East Asia and Pacific, 1990-2010

Source: IHME, 2013

Shifts in Risk Factors of DALYs in East Asia and Pacific for Top 15 Risk Factors, 1990-2010

Source: IHME, 2013

I. Health of older people (continued)

2. Health expenditure

• Health spending was much lower in developing countries (e.g. Myanmar’s 25 USD PPP per capita) compared with developed countries (e.g. OECD average 3,514 USD PPP per capita) (OECD, 2014)

• Growth of health spending has exceeded economic growth in many Asia-Pacific countries (2000-2012) (OECD, 2014)

• “Aging” explains one-third of the health spending growth in developed countries, but it may take greater share in low- and middle-income countries (by increase of health coverage, urbanization) (World Bank, 2016)


Health Expenditure per capita, Public and Private, USD PPP, 2012

Source: OECD, WHO, Health at a Glance: Asia/Pacific 2014

Original source: WHO GHO 2014, OECD Health Statistics 2014.

Determinants of Health Expenditure for Older People

Source: OECD, 2013

Per Capita Health Expenditure by Age Group, Japan (2010)

(Data Source) MHLW, Japan 9

II. Health System and Policy for Older People

1. Health system responses to aging

2. Access to health care with universal health coverage (UHC)

3. Long-term care system

4. Coordination of health care and long-term care

5. Inequality of Health of Older People


• Health systems in Asia are not well placed to respond to an increase in NCDs and aging

• Overreliance on hospital care with very weak gatekeeping and referral systems

• Most countries have no long-term care system, beyond hospitals and the family

• Spending on pharmaceuticals is excessive, due to over-prescription and inefficient procurement (World Bank, 2013) -> Impact on the elderly, who tend to rely more on medication

1. Health System Responses to Aging


Human Resource Issues

Education and training for health professionals has not been re-oriented to respond to the needs of older people, cannot cope with multi-morbiditesand collaboration as a team

Curriculum do not include geriatric health, health promotion, NCD management, functional disability, rehabilitation, and health education for older people

Limited and deteriorating role of primary care and gate-keeping

- Limited role of (public) health centers in risk factor management, screening, education for NCDs

Lack of training of long-term care providers, and support and education program for family care givers


2. Access to Health Care with UHC

Need government commitment to universal access to health care for all people including older people

- Need sustainable financing mechanism or prepaid scheme funded by the (mandatory) public source (government tax or social health insurance)

- Without subsidy to the poor, pure contribution approach faces barriers to UHC

- Extend the benefit package of existing schemes and essential medicines list to cover NCDs and services for older people


Financing Mix and Health Expenditure as a % of GDP

Source: WHO, 2011Source: WHO, 2011Source: WHO, 2011Source: WHO, 2011

Proportion of Countries in which NCD-Related Services and Treatments are generally covered by Health Insurance

Source: WHO, Global Status Report on Noncommunicable Diseases 2010, Geneva: World Health Organization, 2011.

Health Care Financing for UHC

Separate financing mechanism for older people or NCDs is not desirable

- Universal health coverage guarantees access to health care for all, regardless of age

E.g., China: Expansion of coverage to 95% of population, including rural and the unemployed/disabled urban population (Yu, 2015)

- Can use reduced copayment (or copayment exemption or ceiling for accumulated copayment) for older people

-> vulnerable population with higher need and limited capacity to pay

Need to pay attention to the special needs of older people:

e.g., provide additional benefit coverage such as transportation


3. Long-term care system

• Formal long-term care system is not yet established in low- and

middle-income countries (LMICs)

- Many LMICs experience the limitations of traditional informal care:

increased labor participation, change in attitudes for care giving

E.g., Bangladesh: The 2013 Parents’ Care Act

• “children must give parents who live apart from them a monthly income as a

subsistence allowance or violators face a three-month sentence or a fine”

- Building long-term care facilities should be based on need assessment,

assessment of the efficiency of existing providers, and careful planning to

avoid over-reliance on institutional care S. Kwon: Aging and Health in Asia

Long-term Care (LTC)Insurance in Japan and Korea

Public insurance for long-term care, separate from health insurance

- Benefits based on long-term care need (through assessment of physical or mental functions), not targeting the poor

- De-medicalization of LTC, but potential coordination problem between HC and LTC

- Same insurer for HC and LTC:

path dependency, save administrative costs

-> NHIS in Korea, Local governments in Japan


4. Coordination of HC and LTC

Coordination of various policies and programs

- Coordination among the Ministries of Health and Social Welfare

Policy priority between health care vs. long-term care financing:

should consider catastrophic expenditure due to health care vs. long-term care, availability of family care givers, government fiscal capacity, etc.

Coordination between health care and long-term care

-> Continuum of care: overcome discontinuity and fragmentation

among service providers (HC, LTC, rehabilitation, community care, etc.)

Encourage de-institutionalization and

community-based care/rehabilitationS. Kwon: Aging and Health in Asia

PRISMA (Program of Research to Integrate the Services for the Maintenance

of Autonomy)

(Hebert et al., 2003)

5. Inequality of Health of Older People

Expansion of morbidity vs. Compression of morbidity

Compression of morbidity can occur for older people with higher socioeconomic status

Health inequality (across socioeconomic status) increases with age (House et al., 1994; 2005; Miech & Shanahan 2000; Lynch 2003)

- Gap keeps increasing with age (Ross & Wu 1996; Miech & Shanahan 2000)

- Gap increases till their 70s then decreases in their 80s and 90s (House et al., 1994; Beckett, 2000)


0

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0.4

0.6

0.8

1

1.2

20 30 40 50 60 70 80

AgeAgeAgeAge

pro

po

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n w

ith

no

fu

ncti

on

al

lim

ita

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High EducationHigh EducationHigh EducationHigh Education

Medium EducationMedium EducationMedium EducationMedium Education

Low EducationLow EducationLow EducationLow Education

Source: House et al, 1994

Functional Limitation by Age and Education

Inequality of Health of Older People

Why health inequality increases with age (up to their 70s)?

- Differential exposure to health risks across socioeconomic status accumulates with age

- Differential impact of exposure to health risks across socioeconomic status: with age, people become more vulnerable to health risks

Decreased health inequality after their 70s can be due to survival selection bias (Becket, 2000): older people in worse health die early, and health outcome of those with lower socioeconomic status can be overestimated

-> underestimate of health inequality


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