Soonman Aging and Health Policy Asia revised … and Health Policy... · Population Aging and...
Transcript of Soonman Aging and Health Policy Asia revised … and Health Policy... · Population Aging and...
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)
S. Kwon: Aging and Health in Asia
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)
S. Kwon: Aging and Health in Asia
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
S. Kwon: Aging and Health in Asia
• 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
S. Kwon: Aging and Health in Asia
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
S. Kwon: Aging and Health in Asia
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
S. Kwon: Aging and Health in Asia
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
S. Kwon: Aging and Health in Asia
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
S. Kwon: Aging and Health in Asia
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)
S. Kwon: Aging and Health in Asia
0
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20 30 40 50 60 70 80
AgeAgeAgeAge
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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
S. Kwon: Aging and Health in Asia