Framework on Healthy Ageing

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Regional Framework on Healthy Ageing (2018–2022) ISBN: 978-92-9022-615-4

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Regional

Framework on Healthy Ageing

(2018–2022)

iii

Regional Framework on Healthy Ageing

W

ith better investments in health and advancements in technology, ageing of populations is accelerating rapidly world wide. In 2017, the total population aged 60 years or over in the eleven Member States of the WHO South-East Asia Region is estimated at around 186 million (one fi fth of the global estimate of 962 million). Population ageing and its impact on the economic, social and health situations has been recognized by all the Member States as an important emerging issue that needs attention.

Older persons need to be recognized as active agents of societal development in order to achieve truly transformative, inclusive and sustainable development outcomes. Our region has its own norms and challenges ranging from family values to support networks; from increasing demands for the control and management of noncommunicable diseases to the need for improved integration and coordination of services, from limited social benefi t packages to long-term care for older people to caregivers that require additional support. Improving healthy ageing in our region will require a person-centred perspective on all age-related issues, along with appropriate activities that may be undertaken to promote healthy ageing across the life-course.

In 2012 the Health Ministers of the countries of the WHO South-East Asia Region adopted the “Yogyakarta Declaration on Ageing and Health,” and this led to the development of the Regional Strategy for Healthy Ageing 2013–2018. Since the World Health Assembly in 2016 endorsed the Global Strategy and Plan of Action on Ageing and Health, the existing regional strategy was reviewed and aligned to the global strategy.

The focus of the regional framework, therefore, is not simply to prolong life but also to improve the quality of life and well-being of older people and promote healthy ageing and care of the aged through the life-course. Seven strategic elements have been identifi ed in this Regional Framework on Healthy Ageing. These include health systems, measurement, monitoring, research and sustainable and progressive fi nancing towards universal health coverage. The Framework lays down concrete actions that are anchored in evidence, and are comprehensive and forward-looking, yet eminently practical.

We live in a remarkable world where people live longer and healthier than ever before. In the 2030 Sustainable Development Goals (SDGs) era, addressing healthy ageing is vital. It cuts across the SDG goals on poverty eradication, good health for all, gender equality, economic growth and decent work, reduced inequalities and sustainable cities. This Framework on ageing has the potential to transform the way policy-makers and service-providers perceive population ageing.

I remain fully committed to support Member States in achieving the vision of “Healthy Ageing” in our Region.

Dr Poonam Khetrapal Singh Regional Director

Foreword

v

Regional Framework on Healthy Ageing

List of Acronyms vii Introduction 1

Demographics of Ageing in the South-East Asia Region 2

Rising Ageing Population in SEAR 7

Healthy Ageing Initiatives by WHO in the South-East Asia Region 8

Yogyakarta Declaration on Ageing and Health 2012 9

Rationale 11

Why the Regional Framework on Healthy Ageing? 12

Goal of the Regional Framework 12

Guiding Principles of the Regional Framework 12

Strategic Elements of the Regional Framework 15

Strategic Element 1: Developing an Evidence-based, Integrated Policy

and Plan of Action for Healthy Ageing 16

Strategic Element 2: Developing Age-friendly Environments 17 Strategic Element 3: Aligning Health Systems to the Needs of Older Persons 18 Strategic Element 4: Developing Sustainable and Equitable

Systems for Long-term Care 19

Strategic Element 5: Developing Appropriate Human and Institutional Resources Necessary for Meeting the Health

and Related Care Needs of Older People 20

Strategic Element 6: Improving Measurement, Monitoring and Research for

Healthy Ageing 22

Strategic Element 7: Sustainable and Progressive Financing to Enable a

Path Towards Universal Health Coverage (UHC) 23

Milestones 24

Contents

Annexes 25

Annex-I: Healthy Ageing Activities at the Global Level 26

Annex-II: Regional Initiatives 29

Annex-III: Country Profi les 31

Bangladesh 31

Bhutan 33

Democratic People’s Republic of Korea 35

India 37

Indonesia 39

Maldives 41

Myanmar 43

Nepal 45

Sri Lanka 47

Thailand 49

Timor-Leste 51

References 53

vii

Regional Framework on Healthy Ageing DPR Korea Democratic People’s Republic of Korea

EMRO Eastern Mediterranean Regional Offi ce IPAA International Plan of Action on Ageing

MIPAA Madrid International Plan of Action on Ageing PAHO Pan American Health Organization

SEARO (WHO) South-East Asia Regional Offi ce UHC Universal Health Coverage

UN United Nations

UN-ESCAP United Nations Economic and Social Commission for Asia and the Pacifi c UNFPA United Nations Population Fund

WHA World Health Assembly WHO World Health Organization

List of Acronyms

Introduction

A

geing is a lifelong and inevitable process. It is a progressive change in the physical, mental and social status of individuals, which begins right from the mother’s womb and ends with death. The nourishment and care that the mother and her unborn baby receive determine how the newborn will fare in the world.

An individual’s functional ability continues to grow throughout childhood and adolescence, reaching its peak in early adulthood and declining naturally thereafter. The slope of this decline is determined by several external factors such as food and nutrition; appropriate health care; access to housing; adequate and safe water supply;

education and employment opportunities; a healthy and supportive environment; and the extent of integration of the elderly population into society.

Under nutrition in the womb may lead to disease conditions in adult life, such as overweight/obesity, and cardiovascular, circulatory and endocrine disorders. Obese or overweight children and adolescents run the risk of developing chronic diseases such as diabetes, circulatory disease, cancer and musculoskeletal disorders in adult life and old age. Similarly, exposure to behavioural health risks such as smoking, alcohol consumption, poor diet, a sedentary lifestyle or exposure to toxic substances at work [during a person’s adult life] also infl uence health out comes in older age.

The focus on ageing therefore is not simply to prolong life, but also to improve the quality of life and well being of older people. Healthy ageing is the process of developing and maintaining the functional ability that enables well- being in older age.

186 million

population aged 60 years and above in 2017

in the 11 Member States of the WHO South- East Asia Region (one fi fth of the global estimate of 962 million)

Population ageing and its impact on the economic, social and health situations has been recognized by all the Member States as an important emerging issue that needs attention.

Demographics of Ageing in the South-East Asia Region

Virtually every Member State in the World Health Organization’s Regional Offi ce for South-East Asia is experiencing growth in the number and proportion of older people in their population. Population ageing will have implications for nearly all sectors of society, including labour and fi nancial markets; the demand for goods and services such as housing, transportation and social protection; as well as family structures and intergenerational ties. To ensure progress in development, particularly towards the achievement of global, regional and national goals, there is an urgent need to address the economic and social shifts associated with an ageing population.

3

Regional Framework on Healthy Ageing In 2017, the total population aged 60 years or over in the 11 Member States of the WHO South-East Asia (SEA) Region was estimated at 186 million against a global estimate of 962 million. India with 125 million older persons reported the largest number of older people, followed by Indonesia (22 million), Bangladesh (12 million) and Thailand (11million) (Table1).

Table 1: Total population aged 60 years or over in SEA Region Member States as estimated in 2017, 2030 and 2050 [in thousands]

Country 2017 2030 2050

Bangladesh 12 036 21 681 44 501

Bhutan 59 103 235

DPR Korea 3436 5347 6963

India 125 693 189 137 316 759

Indonesia 22 743 38 241 61 729

Maldives 28 57 164

Myanmar 5043 7732 11 544

Nepal 2569 3577 6510

Sri Lanka 3109 4543 5984

Thailand 11 691 18 687 22 954

Timor-Leste 71 107 162

SEARO – Total 186 478 289 212 477 505

Global 962 263 1402 405 2080 459

Sources: i) World Population Ageing 2017. ii) United Nations Department of Economic and Social Aff airs, Population Division, World Population Prospects, 2017 Revision

By 2030, an estimated 289 million persons in SEA Region Member States will be aged 60 years or over against an estimated global population of 1402 million persons in the same age category. India’s population of persons aged 60 years or over would have increased to an estimated 189 million, followed by Indonesia (38 million), Bangladesh (21 million) and Thailand (18 million). By 2050, the number of older persons in SEA Region Member States would number an estimated 480 million while the global population of persons aged 60 years or over would reach 2 billion. India’s population of older persons would be 316 million, followed by Indonesia (61 million), Bangladesh (44 million), Thailand (23 million) and Myanmar (12 million).

Between the years 2017, 2030 and 2050, the proportion of population aged 60 years or over would continue to increase. While the global average will increase from 12.7%, 16.5% and 21.3% between 2017, 2030 and 2050, respectively, the increase in proportion in SEA Region Member States will be 9.8%, 13.7% and 20.3%, during the same time period. While Thailand will have around 35% and Sri Lanka around 29% of their total populations aged 60 years or over, respectively, by 2050, almost all SEA Region Member States will have 20% to 30% of their total populations aged 60 years or over (Figure 1).

Figure 1: Percentage of population aged 60 years or over

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Global

2017 7.3 7.3 13.5 9.4 8.6 6.3 9.4 8.8 14.9 16.9 5.4 9.8 12.7

2030 11.7 11.3 20 12.5 12.9 11.0 13.1 10.8 21.2 26.8 6.3 13.7 16.5

2050 22 23.7 26 19.1 19.2 28.4 18.5 18 28.8 35.1 6.7 20.3 21.3

40 35 30 25 20 15 10 5 0

Percent (%)

2017 2030 2050

Source: World Population Ageing 2017. United Nations Department of Economic and Social Aff airs, Population Division [Data source: UN (2017). World Population Prospects, 2017 Revision]; SEAR values are weighted means calculated using WPP2017

Member States have been ranked according to percentage point change in the proportion of population aged 60 years or over for the periods 2000–2015 and 2015–2030 (Table 2). Based on the proportion of older persons (aged 60 years or over), between 2000–2015 and 2015–2030, projections indicate that over the next 15 years (2015–2030), the proportion of people aged 60 years or over in the South-East Asia Region will increase from 2.1 to 4.4 percentage points (average). In 2030, Thailand would be among the top ten countries with the most aged populations (27%

population aged 60 years or over) moving from its current 15^th position to the 7^th position. DPR Korea would move up from 82^nd to 39^th position; Indonesia from 119^th to 65^th position and Maldives from 135^th to 71^st position (Table 2).

Table 2: Ranking of countries or areas according to percentage point change in the proportion of the population aged 60 years or over, 2000–2015 and 2015–2030

2000–2015 2015–2030

Global position

Change in % aged 60 years or over (% points)

Global position Change in % aged 60 years or over (%

points)

Bangladesh 122 0.9 97 4.6

Bhutan 113 1.4 113 3.9

DPR Korea 82 2.3 39 6.9

India 97 1.9 120 3.5

Indonesia 119 1.2 65 5.5

Maldives 135 0.7 71 5.3

Myanmar 92 2.0 80 5.1

Nepal 86 2.2 123 3.1

Sri Lanka 44 4.1 52 6.3

Thailand 15 5.9 7 11.2

Timor-Leste 121 1.2 196 -0.2

SEAR - 2.1 - 4.4

Source: World Population Ageing 2017. United Nations Department of Economic and Social Aff airs, Population Division [Data source: UN (2017). World Population

5

Regional Framework on Healthy Ageing

Prospects, 2017 Revision]; SEAR values are weighted means calculated using WPP2017

Between 2017 and 2050, the proportion of populations aged 60 years or over and 80 years or over would increase in all SEA Region Member States. By 2050, it is estimated that around 10% of the population in Thailand, 6.8% in Sri Lanka and 5.3 % in DPR Korea would be aged 80 years or over. This information is depicted in Table 3.

Table 3: Percentage distribution of the population by age groups 60+ years and 80+ years in SEA Region Member States, 2017 and 2050

Country 2017 2050

60+ 80+ 60+ 80+

Bangladesh 7.3 1.1 22.0 3.9

Bhutan 7.3 1.0 23.7 3.7

DPR Korea 13.5 1.5 26.0 5.3

India 9.4 0.9 19.1 2.6

Indonesia 8.6 0.7 19.2 2.3

Maldives 6.3 0.8 28.4 3.9

Myanmar 9.4 0.8 18.5 2.0

Nepal 8.8 0.7 18 2.3

Sri Lanka 14.9 1.6 28.8 6.8

Thailand 16.9 2.4 35.1 10.2

Timor-Leste 5.4 0.4 6.7 1.0

SEAR 9.8 1.0 20.3 3.1

Source: World Population Ageing 2017. United Nations Department of Economic and Social Aff airs, Population Division [Data source: UN (2017). World Population Prospects, 2017 Revision]; SEAR values are weighted means calculated using WPP2017

Life expectancy at birth is an indication of improvements in the health and socio–economic situation. Figure 2 depicts trends in life expectancy at birth for both males and females (combined) from 1990 to 2050 in the 11 Member States.

Figure 2: Life expectancy at birth for both sexes (combined), selected periods

1990-1995 2005-2010 2010-2015 2015-2020 2025-2030 2045-2050 90

80 70 60 50 40 30 20 10 0

Years

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Global

1990-1995 60 55 70 59 64 64 60 56 70 70 51 61 65

2005-2010 69 67 68 66 68 76 64 67 74 73 66 67 69

2010-2015 71 69 71 68 69 76 66 69 75 75 68 68 71

2015-2020 73 71 72 69 69 78 67 71 76 76 69 70 72

2025-2030 76 73.6 74 71 71 80 68 74 78 78 72 72 74

2045-2050 80 77.3 77.5 74 74 84 71 78 81 81 75 75 77

Source: World Population Ageing 2017. United Nations Department of Economic and Social Aff airs, Population Division [Data source: UN (2017). World Population Prospects, 2017 Revision]; SEAR values are weighted means calculated using WPP2017

By 2020, while life expectancy would average at 70 years in SEA Region Member States, Maldives would report the highest life expectancy at birth for both sexes combined (78 years) followed by Sri Lanka and Thailand (76 years) and Bangladesh (73 years). By the end of 2030, estimations indicate a regional average of 72 years of life expectancy at birth. Maldives would report the highest life expectancy at birth (80 years), followed by Sri Lanka and Thailand (78 years), Bangladesh (76 years) and Nepal (74 years).

Table 4 provides information on life expectancy at birth and life expectancy at age 60, for males and females, from the SEA Region Member States for the period 2010–2015.

The average life expectancy at birth for females (70 years) is longer than males (66 years) in SEA Region Member States for the period 2010–2015. Sri Lanka and Thailand reported the longest life expectancy at birth for females (78 years each), followed by Maldives (77 years) and DPR Korea (74 years). Examination of life expectancy at age 60 for the same period 2010–2015, demonstrates that females enjoy longer, or up to 2 years more, life expectancy at age 60 (regional average 19 years) than males (regional average 17 years), with Thailand reporting the longest (23 years) followed by Sri Lanka (22 years), Bangladesh, Bhutan and Maldives (20 years each) for females in the same category.

Table 4: Life expectancy at birth and at age 60 for males and females from SEA Region Member States [2010–2015]

Life expectancy at birth (years) 2010–2015 Life expectancy at age 60 (years) 2010–2015

Female Male Female Male

Bangladesh 72.9 69.8 20.3 18.2

Bhutan 68.9 68.6 20.1 20.2

DPR Korea 74.1 67.2 19.9 14.3

India 69.1 66.2 18.5 17

Indonesia 70.7 66.6 17.8 15.2

Maldives 77.4 75.4 20.1 18.9

Myanmar 68.3 63.7 17.7 15.7

Nepal 70.4 67.4 18.1 16.4

Sri Lanka 78 71.2 21.6 19.1

Thailand 78.4 70.8 23.1 20

Timor-Leste 69.5 66.1 17.7 16.1

SEAR 70.4 66.4 18.9 17.0

Global 73.1 68.6 21.6 18.8

Source: World Population Ageing 2017. United Nations Department of Economic and Social Aff airs, Population Division [Data source: UN (2017). World Population Prospects, 2017 Revision]; SEAR values are weighted means calculated using WPP2017

In Table 5, information on the status of pension coverage, statutory age of retirement and labour force participation of persons aged 65 years or over, is provided. One in four, an estimated 25.6% of the population of the pensionable age receive pension with Timor-Leste and Maldives indicating 100% and 89.2%, respectively, of the eligible population receiving pensions. Thailand (81.7%) and Nepal (62.5%) also have high proportions of their eligible populations receiving pension support. It is assumed that this information relates to those who had been employed in the formal sector and particularly in government services. As such, there is urgent need to establish fi nancial and economic support for all persons reaching the statutory pensionable age in SEA Region Member States.

Average statutory retirement age remains at 59 years for males and 58 years for females in the Member States, with Bangladesh and Maldives reporting the age of retirement for males at 65 years, followed by Bhutan, India and Timor-Leste at 60 years. With rapid increase in life expectancy a fresh look at the statutory retirement age is called for in all Member States.

7

Regional Framework on Healthy Ageing

Rising Ageing Population in SEAR

Regional projections for share of population aged 60 years (%)

Table 5: Statutory pensionable (retirement) age (years) and pension coverage (percentage of persons of statutory pensionable age) in SEA Region Member States

Statutory pensionable (retirement) age (years) [latest available]

Pension coverage (% of persons above statutory pensionable age receiving

an old age pension)

Male Female [2010]

Bangladesh 65+ 62+ 31.7

Bhutan 60+ 60+ 3.2

DPR Korea No information No information

India 60+ 60+ 24.1

Indonesia 55+ 55+ 8.1

Maldives 65+ 65+ 89.2

Myanmar No information No information

Nepal 58+ 58+ 62.5

Sri Lanka 55+ 50+ 17.1

Thailand 55+ 55+ 81.7

Timor-Leste 60+ 60+ 100

SEAR 59+ (avg) 58+ (avg) 25.6

Source: ILO (2014): World Social Protection Report 2014/2014-Social protection for older persons: Key policy trends and statistics; SEAR values are weighted means calculated using WPP2017

[In order to ensure uniformity, comparability and quality of data, only reports of United Nations agencies were consulted

9.8

13.7

20.3

2017

2050

2030

in the compilation of graphs and charts in this section. It must be noted that data on the demographics of ageing in individual Member States may sometime differ from UN reports.]

Source: World Population Ageing 2017. United Nations Department of Economic and Social Aff airs, Population Division. [Data source: UN (2017). World Population Prospects. The 2017 Revision

Healthy Ageing Initiatives by WHO in the South-East Asia Region

The WHO Regional Offi ce for South-East Asia has been taking the lead to put healthy ageing issues on the development agenda of Member States since 1999. Given below is a snapshot of the important events that have occurred till date.

Year Event/Activity

1999 A workshop on Active and Healthy Ageing for mega-countries was organized by the Regional Offi ce.

2004 Regional Offi ce publishes a report, Health of the elderly in South-East Asia: a profi le.

2007 A regional consultation on Active and Healthy Ageing was organized by the Regional Offi ce.

2009 A regional consultation to review a Strategic Framework for Active Healthy Ageing in the South-East Asia Region was organized by the Regional Offi ce in Sri Lanka.

2012 “Ageing and Health” was the World Health Day Theme and celebrated with the slogan, “good health adds life to years”.

The Thirtieth meeting of Ministers of Health of countries of the WHO South-East Asia Region in September 2012 adopted the “Yogyakarta Declaration on Ageing and Health”.

A regional meeting was organized in Sri Lanka which reviewed a Draft Regional Strategy for Healthy Ageing.

2013 An expert group consultation was organized to review the comments and suggestions provided by Member States and fi nalize the document Regional Strategy for Healthy Ageing 2013–2018.

2013 A regional consultation on the ‘Long-term care of the Elderly’ was organized.

2014 A regional meeting on the ‘Health of older women: policy, gender and delivery of service issues’

organized.

2016 A regional meeting was organized to review and revise the Regional Strategy for Ageing and Health (2013–2018) to align it with Global Strategy and Plan of Action on Ageing and Health which was endorsed by the Sixty-ninth World Health Assembly in 2016.

11

Regional Framework on Healthy Ageing

Rationale

Why the Regional Framework on Healthy Ageing?

Population ageing and its impact on the economic, social and health situations have been recognized by all Member States of the World Health Organization’s South-East Asia Region. Member States have established several interventions directed at older people, although the extent of coverage and eff ectiveness of these interventions have not been uniform across Member States. The 2012 “Yogyakarta Declaration on Ageing and Health” urged Member States of the SEA Region to provide leadership and technical support to ensure that the tenets of the Declaration are implemented. The Regional Strategy for Healthy Ageing 2013–2018 was developed in 2014 to guide Member States to translate the Yogyakarta Declaration into plans of action at the country level.

With the launch of the Global Strategy and Action Plan on Ageing and Health (2016- 2020), it is necessary to align the Regional Strategy with the Global Strategy. And in order not to confuse with the global strategy document, it was agreed to title the regional document as the “WHO South-East Asia Regional Framework on Healthy Ageing (2018–2022)”.

Goal of the Regional Framework

To promote Healthy Ageing and care of the aged through the life-course with dignity.¹

Guiding Principles of the Regional Framework

²

01

02

03

04 05

06

07

Rights of Older People

Age-friendly Primary Health Care Long-term

Care

Ageism

Reducing Inequities Gender Equality Adopting a

Multidisciplinary and Multisectoral Approach

1 The global strategy and plan of action on ageing and health has identifi ed two goals: i) fi ve years of evidence-based action to maximize functional ability that reaches every person; ii) by 2020, establish evidence and partnerships necessary to support a decade of healthy ageing from 2020–2030.

2 The guiding principles underpinning the ‘global strategy and plan of action’ are fi ve: progressive realization of human rights including the rights of older people;

gender equality; equality and non-discrimination on the basis of age; equity; and intergenerational solidarity.

13

Regional Framework on Healthy Ageing

1. Rights of Older People

The rights of the older people have been championed by the United Nations since its inception, enshrined in the Universal Declaration of Human Rights and adopted and proclaimed by the General Assembly of the United Nations in 1948. ‘Article 25’ of the Declaration addressed the right to standard of living for the health and well-being of individuals and security of persons in old age. The Second World Assembly on Ageing in Madrid further ensured the rights of older people through the International Plan of Action on Ageing (IPAA) in 2002, which took cognizance of the need to respond to the opportunities and challenges of population ageing in the twenty-fi rst century and which sets out to develop a society for all ages. “Article 5” of the Political Declaration of the MIPAA reaffi rmed the commitment of Members to spare no eff ort in strengthening the rule of law and promoting gender equality. It also emphasized the need to promote human rights and fundamental freedoms of older people, eliminating all forms of age discrimination, neglect, abuse and violence against older adults while enhancing their dignity in society.

2. Gender Equality

Women have longer life expectancy than men, out living men and thereby representing a growing proportion of all older people. Older women are increasingly burdened with non-communicable diseases, which could be prevented if they had access to the right care. Women often face disproportionate diffi culties in obtaining the care they need, a situation that refl ects the gender inequalities encountered by women throughout their life which are particularly exacerbated in old age. In spite of improvements in access to education and their increased participation in the labour market, older women are at higher risk of fi nancial insecurity than older men. The care provided by women to their children and sick family members is often unpaid and unrecognized and further prevents the participation of women in the workforce. This comes at a signifi cant cost to their own well-being and self-suffi ciency in older age, with further risks of insecurity and poverty. The provision of some help by the government for such women should be on the agenda.

Older women are also at higher risk of isolation, which is a key contributor to loneliness, health deterioration, and even premature death. This can be explained by the fact that women tend to outlive their spouses and there is an emerging shift from extended families to single-generation families.

Financial insecurity and vulnerability often make it more diffi cult for older women to protect themselves from abusive relationships, leading to increased abuse and neglect. Fostering the development of interventions that are gender–sensitive and promote gender equality require a clear understanding of the social and economic issues that aff ect the care needs of older women as well as the provision of services for this population group. It also requires a sound understanding of the consequences that result from the lack of provision of gender-sensitive interventions.

3. Reducing Inequities

Participation of older people in society can range from involvement in economic development activities, formal and informal work and voluntary activities as they age, according to their individual needs, preferences and capacities.

Such activities would include older people in the planning, implementation and evaluation of social and economic development initiatives and eff orts to reduce poverty.

4. Ageism

The existence of stereo typing, prejudice and discrimination towards older adults – commonly referred to as

“ageism” – is highly detrimental to the health and well-being of older adults. It also imposes great barriers to developing good policy on ageing as it limits the way problems are framed, the questions that are asked and solutions that are off ered to tackle diff erent issues. Addressing these components of ageism like elderly abuse will require the enactment of suitable legal instruments and administrative measures at the institutional level. Changes to existing customs, discriminatory practices and “age-based categorization” will also be necessary. Global, regional

and national campaigns to combat ageism are also needed. These will be important for messaging and to highlight the actual and potential contributions of older people at home and in society. However, family responsibility for care–giving must be supported by policies that provide respite care, off er quality of care training, and not reinforce gender norms (e.g. the fact that women are caregivers and forego education, employment or other opportunities to provide care).

5. Age-friendly Primary Health Care

Good health is imperative for older people to remain independent and continue to contribute to their families and communities. An eff ective strategy to foster Healthy Ageing will demand that primary care is accessible and appropriate for older people, with care off ered in community settings. It should provide for the creation of primary health care teams with the right mix of skills and responsibilities; the provision of clear guidelines for health promotion and prevention; and the development of advocacy strategies for maintaining minimum standards of care in the primary health-care setting. Similarly, age-friendly primary health care minimizes the consequences of non–communicable diseases through early detection, prevention and quality of care, and provides long-term palliative care for those with advanced disease, both within communities and institutions. Such an approach requires appropriate training of several diff erent categories of health care providers and the provision of aff ordable long-term care to those who can no longer retain their independence, including destitute senior citizens to whom regular fi nancial assistance /aid should be provided by the government.

6. Long-term Care

The World report on ageing and health (WHO, 2015) has defi ned “long–term care” as “the range of activities undertaken by others to ensure that people with or at risk of a signifi cant on-going loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedom and human dignity”.

There are two key principles involved: i) even with signifi cant loss of functions, older people can still maintain a

“normal life”; ii) intrinsic capacity is not static and decline in capacity is part of a continuum which in some cases may be preventable or reversible. The long held assumption that families can alone meet the needs of older people with signifi cant loss of capacity is outdated and neither sustainable nor equitable. Every country needs to have a comprehensive system of long-term care that can be provided at home, in communities or within institutions, taking into account the country’s economic and social context. Reinforcing the cultural norm of looking after older parents and relatives should be an important component of the national plans and strategies. Emphasizing these cultural norms among adolescents and youth would be an important approach. Similarly, messages on inculcating responsibility for taking care of older relatives could be incorporated in the school curriculums. Programmes should be undertaken in schools and colleges in order to strengthen inter-generational bonding.

A key role of the government will be to promote partnerships between diff erent players, including the public and private sector, to build an appropriate system and to ensure that caregivers are given appropriate support, dignity and ensured a better future, too.

7. Adopting a Multidisciplinary and Multisectoral Approach

Older people have varying and complex social and health-care needs. For example, while dementia may be mainly addressed by the health sector, the social and fi nancial insecurities that may co-exist in old age require inputs from the social welfare and fi nance sectors. A multidisciplinary and multisectoral approach, comprising professionals and general staff from several relevant sectors, should be considered as the key mode of care delivery for older people.

15

Regional Framework on Healthy Ageing

Strategic Elements of the Regional Framework ³

3 The ‘Global Strategy and Plan of Action had identifi ed fi ve strategic objectives: i) commitment to action on Healthy Ageing in every country; ii) developing age-friendly environment; iii) aligning health systems to the needs of older populations; iv) developing sustainable and equitable systems for providing long-term care (home, communities and institutions); v) improving measurement, monitoring and research on Healthy Ageing

Seven strategic elements have been identifi ed in the Regional Framework on Healthy Ageing:

1) Developing an evidence-based, integrated policy and plan of action for healthy ageing 2) Developing age-friendly environments

3) Aligning health systems to the needs of older people

4) Developing sustainable and equitable systems for long-term care

5) Developing appropriate human resources necessary for meeting the health and related care needs of older people

6) Improving measurement, monitoring and research for healthy ageing

7) Sustainable and progressive fi nancing to enable a path towards Universal Health Coverage (UHC)

Five of these strategic elements are aligned to the WHO Global Strategy and Action Plan on Ageing and Health, adopted by the World Health Assembly and are relevant to all Member States from the South-East Asia Region. The two additional strategic elements, number 5 and 7, specifi cally emphasize the strategic priorities for the Region’s 11 Member States.

Strategic Element 1: Developing an Evidence-based, Integrated Policy and Plan of Action for Healthy Ageing

Objective

To establish a national policy and plan of action for Healthy Ageing.

Rationale

Investment in the well-being of older people will have significant economic and social returns. The most effective approach will be to develop various health and social policies, legislation, interventions and partnerships around ageing and health. Improving the health conditions and reducing disability among older people demands a commitment and shared responsibility. Lack of adequate political commitment has been a key reason for the absence of an effective policy and plan of action on Healthy Ageing in most Member States. An important impediment to the implementation of programmes for Healthy Ageing has been the lack of orientation among programme providers to age-related problems and interventions as well as a lack of awareness around their significance. The creation of an enabling environment for the formulation of appropriate policies and regulatory frameworks will thus be necessary. Such an environment should place national authorities as the ultimate guardians of older people’s health and well being as it is the Member States who have the responsibility to put in place appropriate policies, financial arrangements and account ability mechanisms, occurring across all sectors and levels of government.

Actions

1. Formulation of an evidence-based national strategy and plan of action that addresses ageing and health.

2. Establishment of an appropriate nodal agency/focal point for the implementation of the Healthy Ageing policy and programme.

3. Formulation and implementation of legal frameworks and mechanisms for maintaining and protecting the inherent dignity and rights of older people and to also protect against ageism.

4. Development of eff ective mechanisms to bridge knowledge into practice, including an appropriate packaging of relevant information for the use of policy-makers.

17

Regional Framework on Healthy Ageing 5. Creation of a national forum consisting of administrative agencies, technical and academic bodies and civil

society that includes representatives of older people among others, to enable continuous policy dialogues that draw together existing evidence and assess its relevance to national priorities.

6. Development of specifi c activities to protect the health and psychosocial well-being of older people in disaster/humanitarian crisis situations.

Indicators

Regional level

1. Number of Member States that have formulated a national policy and plan of action on Healthy Ageing.

2. Number of Member States that have established departments/units for promoting Healthy Ageing programmes in the Ministry of Health and/or other relevant ministries.

National level

1. National policy and plan of action on healthy ageing including legal framework and appropriate indicators for the maintenance, monitoring and assessment of the rights, dignity and entitlements of older people, formulated and operationalized.

2. Department/unit for promoting Healthy Ageing programmes established in the Ministry of Health and/other relevant ministr(ies).

3. Administrative mechanisms for regular monitoring and evaluation of implementation and for assessing multisectoral cooperation in the care of older people, developed.

4. National forum comprising representatives from the national authorities, civil society, academia, private and public care–giving sectors and media, for exchange of knowledge, information and evidence on ageing and health, created.

Strategic Element 2: Developing Age-friendly Environments Objective

To create an enabling environment that addresses the needs and preferences of older people in a comprehensive manner.

Rationale

Age-friendly environments foster Healthy Ageing by i) supporting the building and maintenance of intrinsic capacity across the life-course; and ii) enabling greater functional ability so that people with varying levels of capacity can do the things that they value. Actions to create age-friendly environments can target different situations (home or the community) or specific environmental factors (transport, social protection, housing, health and long-term care) and can be influenced at different levels of the government (national, regional or local).

Engaging all people to live and enjoy a healthy life requires a multisectoral approach with strong engagements from diverse sectors and different levels of government. A high-level national structure or body will be needed to coordinate the plan of action to monitor the implementation of activities and to measure progress.

Actions

1. Adoption and adaptation of the “age-friendly environments” approach through policy issues related to health-care, social services, education and training, labour, housing and transportation, that protects the rights and abilities of older persons.

2. Establishing appropriate mechanisms for implementing accessible and aff ordable social and health-care services, transportation, housing, employment and civic participation, for older persons.

3. Enhancing autonomy of older people and providing them protection from injury, violence and abuse, age-based discrimination through advanced care planning, legislation, access to appropriate assistive devices and raising awareness.

4. Providing administrative and fi nancial support to civil society, in particular organizations of older people, for involvement in the formation and implementation of programmes for the care and support of older persons.

Indicators

Regional level

1. Number of Member States that have adopted/adapted the ‘WHO Global Network of Age-friendly Cities and Communities’.

2. Number of Member States that have enacted legal provisions for the prevention of elder abuse.

3. Number of Member States with nationally representative data on older person’s self-reported knowledge of their rights and involvement in activities that they value.

4. Number of Member States participating in the Global Campaign to combat Ageism.

National level

1. National body empowered with adequate administrative authority, fi nancial resources and monitoring capacity to promote the diff erent aspects of an age-friendly environment created.

2. Number of regulations, acts and incentives introduced for ensuring autonomy of older people.

3. Appropriate legal and administrative mechanisms to protect and support older people from elder abuse.

4. Provision of access to devices from the list of WHO Priority Assistive Products to enhance autonomy of older people.

Strategic Element 3: Aligning Health Systems to the Needs of Older Persons

Objective

To orient health systems to ensure the maintenance of intrinsic capacity and functional ability of Healthy Ageing in older people.

Rationale

As people age, their health needs tend to become more chronic and complex. Health systems and services that address these multi-dimensional needs of older people in an integrated way have been shown to be more eff ective than services that simply react to specifi c diseases independently, often managing health issues in disconnected and fragmented ways. A transformation is needed in the way that health systems are designed to ensure aff ordable access to integrated services that are centred on the needs and rights of older people. This means that each country should identify and select services with the Universal Health Coverage (UHC) schemes, and ensuring that these services are coordinated from a person-centred approach. This will enable older people to build and maintain the best possible functional ability at all stages of life. In order to make this happen, coordination between diff erent services (health included) will remain a crucial issue.

19

Regional Framework on Healthy Ageing

Actions

1. Promoting Healthy Ageing as an essential component of the national primary health care programme for ensuring prompt and comprehensive access of older people to health and related interventions.

2. Strengthening primary health care for the prevention, management and referrals of non-communicable diseases, mobility and functional disorders and mental health problems in older people.

3. Promotion of interventions to improve the access of older people to health and social care services, diagnostic technologies, essential drugs, prosthetics and appropriate assistive technologies, as well as information and communication techniques, as part of UHC.

4. Through administrative, regulatory and promotive mechanisms, ensure the involvement of the private health care sector in promoting ageing and health and the care of older people.

Indicators

Regional level

1. Number of Member States that have developed operational guidelines, procedures and monitoring mechanisms for the age-friendly primary health care initiative.

2. Number of Member States with a national institute/regional centres for ageing and health.

National level

1. Assessment undertaken of the national health system’s responses to an ageing population and plans developed for realignment where needed, for example through provision of benefi t packages (UHC) that support older people’s intrinsic capacity and functional ability.

2. Number of primary health centres that are aligned with the age-friendly approach and operating with an adequate complement of workforce, equipment and resources.

3. Comprehensive assessment undertaken of older people at the time of their engagement with the health system and periodically there after in order to assess intrinsic capacity and functional ability.

4. Number of facilities from the private health-care sector implementing the national policy and plan of action on ageing and health.

Strategic Element 4: Developing Sustainable and Equitable Systems for Long-term Care

Objective

To ensure that all older people in need of care have access to “long-term care” services regardless of age, gender, fi nancial and other considerations.

Rationale

The ageing process, in particular declines in intrinsic capacity, renders older people vulnerable to frailty, and is often accentuated by conditions including malnutrition, cognitive impairment, heart failure and chronic infl ammation/

infection. With advancing age, the disabling impact of chronic diseases also becomes evident with dependence of older people on care provided for all activities related to living. A substantial number of older people have long periods of dependence and need long- term care although the quantum of care would vary from individual to individual. Long-term programmes should be shaped carefully to avoid fragmentation in the provision of care and constructed for a seamless range of health and related care. Moreover, care givers require support.

Actions

1. Design and establishment of a multi-sectoral system including a sound regulatory framework, training and support for caregivers, coordination and integration across various sectors (including the health sector), mechanisms such as accreditation and monitoring to assure quality.

2. Advocacy and communication to recognize that long-term care is an important public health priority, including an acknowledgment of the right of older people with signifi cant losses of capacity to appropriate care and support and that caregivers require support.

3. Ensuring access to long-term care (whether at home, in communities or in institutions) for older people as part of universal health coverage, without the risk of fi nancial hardships to older people, care givers or family, through resourcing and appropriate prioritization.

4. Implementation and adaptation of self-care programmes for the long-term care of older persons, including development of training activities in self-care.

5. Development of programmes to support activities of informal and formal care givers, including the introduction of incentives, training, information and support to those opting to provide long-term care.

6. Promotion of community involvement in the implementation of long-term care programmes to ensure local ownership, sustainability and the ability of older persons to age in a place that is right for them.

Indicators

Regional level

1. Number of Member States that have formulated national programmes on Healthy Ageing comprising management, regulatory, monitoring, resource mobilization and evaluation mechanisms for sustainable long-term care in the formal and informal sectors.

2. Number of Member States that have formulated national standards and training guidelines for long-term care providers in the formal and in formal sectors.

National level

1. National standards, guidelines, protocols and accreditation mechanisms for integrated long-term care provided by the formal and informal sectors have been developed and implemented.

2. Innovative assistive health technologies to improve the functional ability and well-being of people requiring long-term care have been identifi ed.

Strategic Element 5: Developing Appropriate Human and

Institutional Resources Necessary for Meeting the Health and Related Care Needs of Older People

Objective

To ensure a sustainable and appropriately trained, deployed and managed health workforce.

Rationale

Health systems are challenged to provide care and support for older people whose characteristics and needs are diff erent from those of the general population. Older people often experience more than one chronic condition

21

Regional Framework on Healthy Ageing at the same time and can suff er rapid deteriorations in health as a result of a minor acute illness or fl aring up of an existing condition. Similarly, frail older people in particular require timely access to acute and special care such as geriatric care. As such, health care workers of all categories need new competencies that will enable them to meet the health care needs of older people. Involvement of multidisciplinary teams will be there along with competencies to work in the home of older adults in need of care, in community settings and/or in health institutions.

Actions

1. Defi ning the nature, quantity and characteristics needed for the diff erent categories of the health workforce to address the health needs of older people.

2. Preparation and dissemination of appropriate training tools for strengthening the competencies of the diff erent categories of health workforce.

3. Promoting the inclusion of ageing and health issues in under-graduate and post-graduate studies in health and related services.

4. Ensuring the appropriate availability of geriatricians and gerontologists to meet the needs of the population through the establishment of specialized units, training opportunities and promotive career paths for interested health professionals.

5. Utilization of health professionals in the private sector to carry out Healthy Ageing policies of the government, after adequate training and orientation.

6. Creation of an environment for the retention of the health workforce through eff ective policies and models, legal framework and positive career paths.

Indicators

Regional level

1. Number of Member States that have established specialized training in geriatrics and gerontology at the under graduate and post graduate level of study in health.

2. Number of Member States that have produced protocols, manuals and guidelines on training health staff in all aspects of ageing and health.

3. Number of Member States that have established mechanisms for continuous training, incentives and career advancements for the health workforce caring for older people.

National level

1. Number of facilities at the primary, secondary and tertiary health care levels providing health and related care services aimed at older persons.

2. Number of facilities established at the district and community levels to address health and related social care issues of older people.

3. Number of facilities providing training in geriatrics/gerontology to health staff from the formal and informal sectors.

4. Assessment tool to ensure the availability of suffi cient health workforce for eff ective delivery of care to older people.

Strategic Element 6: Improving Measurement, Monitoring and Research for Healthy Ageing

Objective

To measure, analyze and research on trajectories of intrinsic capacity, functional ability, multi-morbidity and eff ectiveness of other interventions on Healthy Ageing across the life-course.

Rationale

The current metrics and methods used in the fi eld of ageing are limited, preventing a comprehensive understanding of the health issues experienced by older persons and the usefulness of interventions to address them. Improving Healthy Ageing will require more research and evidence from a person-centred perspective, on age-related issues, trends and distributions and appropriate activities that may be undertaken to promote Healthy Ageing across the life-course. National statistics and surveillance approaches will need to become inclusive of older people, particularly the oldest age group, and in suffi cient numbers to document their experiences and diverse contexts.

Information will need to assess the presence of co-morbidities and their impact upon the capacity and functional ability of older people. Multi-country and multi-disciplinary studies representative of population diversity, over time, in the Member States are necessary. Also, as evidence builds up, accountability frameworks and mechanisms will be needed to monitor progress.

Actions

1. Collection and use of disaggregated data on the age and socio-economic information on the intrinsic capacities and functional ability of older people for assessing the eff ectiveness of and gaps in existing policies, systems, services and environments in meeting the rights and needs of older people.

2. Development of national databases on all aspects of ageing for timely determination of trends and responses to intrinsic capacities, functional ability and well-being across the life course.

3. Support to academia and research institutions to provide improved understanding of the determinants of Healthy Ageing and evaluate interventions to improve these and the extent to which these are meeting the health and social needs and expectations of older people.

4. Encourage population-based studies at home, in communities and in institutions to identify the levels and distribution of intrinsic capacity and functional ability.

Indicators

Regional level

1. Number of Member States that have established national databases on older people providing disaggregated information on mortality, morbidity, health and socio-economic profi les and Healthy Ageing, as measured by intrinsic capacities and functional ability.

2. Number of Member States that have established regular longitudinal population representative surveys measuring health status and related needs of older people and the extent to which these are being met.

National level

1. National databases including information on population demographics, economic status, income, education, health profi le, housing and ownership, established.

2. Research on identifi cation of determinants of Healthy Ageing and interventions that can improve intrinsic capacities and functional ability.

3. Assessment of multisectoral and intersectoral collaboration to identify actions that foster the best intrinsic capacity and functional ability of older people.

23

Regional Framework on Healthy Ageing

Strategic Element 7: Sustainable and Progressive Financing to Enable a Path Towards Universal Health Coverage (UHC)

Objective

Appropriate services and fi nancial arrangements established to ensure accessibility of older people to Universal Health Coverage (UHC).

Rationale

Population ageing is accompanied by changing health-care needs worldwide as is refl ected by the increasing demands for control and management of non-communicable diseases and for an improved integration and coordination of services to support intrinsic capacities related to long-term care in older adults. As the proportion of older people continues to increase or render more older people vulnerable, Member States will need to align health-care fi nancing to strengthen the service infrastructure for the provision of health care to older people including long-term and end-of-life care. Arrangements should ensure that older people are not denied access to appropriate health care because of their inability to aff ord it. This requires selecting services that meet the needs of older people, within the benefi t packages covered by the country. Moreover, fi nancing mechanisms can be used to encourage the integration of services, include right fi nancial incentives, avoid cost-shifting in the health systems and improve effi ciency.

Actions

1. Establishing sustainable fi nancing mechanisms to address the comprehensive and integrated services required by older people, while also minimizing out-of-pocket expenditures and fragmentation with in the health system.

2. Formulating a collaborative mechanism with the range of services providers, public or private, to ensure that older people have access and can aff ord an essential range of health services (spanning preventive, promotive, curative, rehabilitative and palliative).

3. Integration with national social and economic support programmes to ensure that fi nancial subsidies and benefi ts provided to older people take in to consideration increasing health care costs, evolving technology, increasing demand and the need to meet the right to health irrespective of social or economic status.

Indicators

Regional level

1. Number of Member States that have integrated health system responses to an ageing population in to national policies and plans on ageing and health.

2. Number of Member States that have established eff ective collaboration between the formal and private health-care sectors to provide care for older people.

National level

1. Action taken to select services for inclusion with benefi t packages that specifi cally support intrinsic capacity of older adults (person-centred in addition to condition or disease-based services).

2. Action taken by Member States to ensure the availability of sustainable fi nances for the realignment of programmes, services and systems to promote ageing and health.

3. Action taken by Member States to develop infrastructure and support needed to address long-term care under universal health coverage.

Global Strategy & Plan of Action

• Adoption of fi nalized global strategy and plan of action on ageing and health by the World Health Assembly (May)

• Identifi cation of quantifi able progress indicators for each strategic objective (December)

Global Strategy & Plan of Action

• Contribution to 15-year review of Madrid International Plan of Action on Ageing (February)

• Agreement on metrics and methods to assess Healthy Ageing – whether existing or new (June)

Global Strategy & Plan of Action

• Mid-term report on implementation of strategy, including progress on evidence syntheses on key themes, norms and ‘best buys’. Refi ne direction of strategy based on learning to date (June)

Global Strategy & Plan of Action

• Proposal for Decade of Healthy Ageing discussed in open consultation with Member States, entities representing older people, bodies of United Nations system and other key partners and stake holders (May–September) Global Strategy & Plan of Action

• Proposal for Decade of Healthy Ageing, extending the plan of action from 2020 to 2030, discussed at WHO Executive Board (January)

• Final report on review of strategy, with baseline for Decade on Healthy Ageing (October)

Healthy Ageing : WHO- SEARO [proposed]

• Review of progress

Healthy Ageing : WHO-SEARO [proposed]

• Submission of the Regional Framework on Healthy Ageing to the Regional Committee

• Adoption of the Regional Framework on Healthy Ageing

• Identifying approaches to its adoption /adaptation in Member States

Healthy Ageing : WHO- SEARO [proposed]

• Implementation status of the initiative

‘Decade of Healthy Ageing’ in the Region

2020- 2022

2018

Healthy Ageing : WHO-SEARO [proposed]

• Review of progress

• Formulation of ‘Decade of Healthy Ageing’ initiative in the region

Healthy Ageing : WHO-SEARO [proposed]

• Regional Framework on Healthy Ageing (2018–2022) under formulation

• Regional meeting on the Regional Framework on Healthy Ageing

• Finalization of the Regional Framework on Healthy Ageing

Milestones

2019- 2020

2016- 2017

2019

Annexes