Improving metrics, monitoring tools and data
Organization of a global research consortium to advance methods for measuring unmet health and social care needs of older people
The measurement, understanding and monitoring of unmet need for health and social care is important to accelerating progress towards the 2030 UN Sustainable Development Goals and WHO’s Thirteenth General Programme of Work (GPW 13). It is also important to specifically understand the different needs of older people compared to other age groups, and how these may or may not be met by available health and social care systems.
Statistics on unmet health care need are regularly reported for several OECD countries in Europe; otherwise data on unmet need are lacking especially on the need for social care among older people, and for low- and middle-income countries. A study funded by WKC generated prevalence estimates of unmet need for health and social care among older people through secondary analysis of accessible survey datasets. The researchers analyzed 17 health, social and economic surveys conducted between 2001 and 2019, representing 83 low-, middle- and high-income countries, and found large variation across surveys in how unmet need is measured. The results also suggest that the determinants and dimensions of unmet need may be highly contextual and country specific. Thus, an important contribution to this field would be to clarify which aspects of unmet need should be measured through a more standardized approach and which require a more contextualized approach.
To facilitate a global discussion on current practices and future needs related to the measurement of unmet health and social care needs of older people.
To establish a global research consortium with a clear research agenda to improve the measurement and understanding of the unmet health and social care needs of older people.
Analyze and critically review the literature with a focus on current tools and methods used to measure health and social care needs of older people
Identify and map relevant experts and develop a strategy for engagement
Conduct semi-structured consultations with a diverse group of key experts on:
- shared language and systems for describing unmet needs of older persons
- measurement criteria, instruments, data, and analytic approaches
- development of a research agenda
Peer-reviewed journal publication that critically reviews current tools and approaches for measuring health and social care needs of older people
Scientific resources including repository of key publications and database of relevant experts
Concept note and terms of reference for a global research consortium
A new multidisciplinary research consortium of engaged and effective experts from around the world
A research agenda for advancing the measurement of unmet health and social care needs of older people
Regional consultation meetings and global consortium meetings
Household survey analysis of financial hardship due to excessive health spending and unmet care needs of older people in Japan with implications for the Kansai region
Financial protection from catastrophic spending, an important element of universal health coverage (UHC), needs to be well understood for designing better policies to relieve impoverishment and improve access to healthcare in the context of population ageing. As people grow older, they tend to utilize more healthcare. As a result, they may experience financial difficulties associated with health spending or forego care which could cause them to need more care.
Even in countries which have achieved some of the highest standards of population health and health system development, such as Japan, population aging presents a significant challenge to progressively achieve UHC. So far, relatively little is known about the extent to which financial hardship due to healthcare utilization and financial barriers to healthcare access are a problem for the rapidly growing number of older people in Japan. Much less is understood about subnational/regional variations in this phenomenon. Experiences from Japan could yield helpful lessons for progressing towards universal health coverage that sufficiently meets the needs of older people.
To understand the current situation regarding both financial hardship due to excessive health spending and unmet care needs of older people in Japan with specific implications for the Kansai region.
To disseminate lessons learned from Japan on financial protection policies that can help older people receive the care they need without experiencing financial hardship.
Literature review to summarize the latest evidence and information about financial protection policies, financial hardship, and unmet care needs affecting older people in Japan.
Secondary analysis of household survey data from Japan containing samples of older adults to assess levels of financial hardship due to catastrophic health spending and unmet care needs.
Consultation with relevant experts and key stakeholders in the Kansai region to contextualize the research findings.
Statistical estimates of financial hardship and unmet care need among older Japanese people and their determinants.
Policy brief relevant to the Kansai region on mitigating financial hardship of older citizens due to health spending.
Journal articles on financial hardship due to health spending and unmet care needs of older people in Japan.
Multi-country cross-sectional and longitudinal studies to quantify unmet needs for health and social care among older people
As the trend toward global population ageing continues, defining and measuring unmet needs for health and social care among older people will be important elements of assessing progress and achievements toward Sustainable Development Goal (SDG) 3.8., Universal Health Coverage (UHC), and WHO’s 13th Global Programme of Work. In the global context, two common challenges exist: lack of a common metric for measuring needs for health and social care among older adult populations; and, little or no access to quality health data in many countries. Populations with care needs that remain unmet or that have foregone needed care will fail to meet the goal of UHC. However, the magnitude of this problem is unclear, even in countries that have taken major strides toward the progressive achievement of UHC, in part because of a lack of standard definitions for the concept of unmet needs and corresponding lack of data.
- To develop an analytical model of unmet needs for health and social care among older people using a theory-based, data-driven approach and a systems perspective that incorporates demand and supply factors.
- To generate empirical estimates of unmet needs among older people by applying the model to existing national-level health survey data from several countries across WHO regions.
- Build on existing theoretical models of health service coverage and access (e.g. Tanahashi and Levesque models) and a synthesis model being developed through research supported by the WHO Kobe Centre that specifically considers equity in service coverage of older people to develop a comprehensive analytical model of unmet needs among older people.
- Identify datasets suitable for analysis from a diverse set of countries at different income levels across different regions, and harmonize and analyze the datasets through local partnerships, especially in low- and middle-income countries.
- Apply statistical methods informed by existing guidelines and previous research to test the analytical model and produce a composite metric for unmet need.
- Apply multilevel regression analysis to examine the predisposing, enabling and need factors at individual, group or area, and system level that affect unmet need.
- Prevalence estimates for unmet health care need and unmet social care need in older adults were generated through secondary analysis of 17 health, social and economic surveys conducted between 2001 and 2019, representing 83 low-, middle- and high-income countries.
- Large variation was seen in question wording and response categories related to the measurement of unmet need across the different surveys that were analyzed.
- Based on the responses to direct questions asking about self-reported unmet need, current estimates range from low levels of less than 2% of unmet health care need in adults 60 years and older in some countries to much higher rates of over 50% in others. Similarly, estimates for unmet social care need range from less than 4% to over 40% across countries. Both increasing and decreasing trends in unmet health care need were observed among the few countries where longitudinal data were available. A statistically significant correlation was observed in which the prevalence of unmet health care need among older people was generally lower in countries scoring higher on the UHC Service Coverage Index.
- To better quantify unmet health and social care need, a data-driven latent measure of unmet health need among older people was also pursued, using a theoretical model to inform analytical approaches. Each of the models provided some signal on country-specific structures for unmet health need, but the models did not sufficiently converge to develop a universal structure for unmet health need.
An agreed definition of unmet need for health and social care and standardized survey questions would improve current prevalence estimates and their comparability across place and time. The dimensions and determinants of unmet health need are contextual and may be highly localized. Thus, efforts to define and measure unmet need in a way that comprehensively captures their multifactorial nature may be needed before standardization is attempted. Further advancements in defining and measuring unmet need would be required to incorporate this element into monitoring progress towards universal health coverage.
Implications for Kansai
This study identified several ways in which survey questions have been designed around the world to measure unmet need for health and social care among older persons. These could be adapted for use in local surveys. They could also inform debates about how unmet need should be measured in the local context. The prevalence estimates of unmet need produced by this study could also provide comparison data for locally derived estimates of unmet need for health and social care among the older population.
Globally, studies on the impact of out-of-pocket spending on health care tend to be based on country-level data detailing household health expenditures, which gloss over variations in health care utilization and expenditures by population subgroups such as older people. Older people generally have higher rates of chronic conditions and multi-morbidities which may require greater use of health care and putting them at risk of high out-of-pocket payments.
The population in Viet Nam is rapidly ageing. Studies suggest that households with older members are more likely to suffer catastrophic health spending. However, data are lacking to determine the breakdown of spending to understand spending on care and financial coping strategies.
To study the breakdown of health care spending among households with older members and to identify possible gaps in existing financial protection policies related to health care of older people.
- A desktop review and analysis of existing financial protection policies.
- Twenty in-depth interviews and 28 focus group discussions with policymakers, health managers, health care providers and older people to deepen understanding of current financial protection policies that apply to older people and identify possible gaps in those policies and potential policy solutions.
- A household survey of 1,536 people 60 years and older with good cognitive function to collect data on their health expenditures and related factors using a multi-stage cluster sampling design in three provinces representing the north, central and south regions of the country.
- Statistical analysis to describe patterns of health and long-term care utilization by the older person, breakdown of out-of-pocket (OOP) spending for the older person’s care, the financial burden of OOP health expenditure and financial coping strategies.
- Qualitative data analysis using a grounded theory approach.
- Several limitations in existing financial protection policies were identified through a literature review and focus group discussions with policy makers. These include inadequate level of social assistance benefits; lack of coverage for social care services; and gaps in health insurance coverage among self-employed and low-income older people.
- Of the 1,536 older people interviewed, 82.4% reported having health problems in the preceding 4 weeks, including acute illnesses, injuries, and chronic conditions. The total number of illness episodes reported from the survey sample was 2,355 cases. Nearly all (95%) of older people sampled are covered with health insurance, and this is higher than the reported figure for the total national population (88.1% in 2019). Nonetheless, care was not sought in over 30% of all reported episodes of ill health. These cases resulted in OOP spending for self-medication (mean of 26.7 USD per person per month among those with health care needs). Among the 70% of cases in which care was sought, 93% received outpatient care. Of these, 60.4% resulted in OOP payment (mean of 35.6 USD per month). The majority of OOP spending for outpatient care was related to medicines.
- Among the 70% of cases in which care was sought, 7% (n=115) received inpatient care. Most of these cases (79.6%) resulted in OOP payment amounting to a mean of 188.7 USD per person per month among those with health care needs, which exceeded the average monthly income of 144.6 USD for households with older persons. The OOP payments for inpatient care were mostly for co-payments, buying medicines beyond the health insurance benefit package and indirect costs (travel, meals, etc.) with some regional variation.
- Only 3.5% of older people (n=55) reported using long-term health or social care services at home or in a facility in the previous 12 months, with most (60%) paying out of pocket (mean of 95.2 USD per person per month).
- Some 8.6% of the sampled households with older people spent 40% or more of their non-food expenditure on OOP spending for health care including long-term care. Most of this spending was related to the care of the older member(s) of the household. The proportion of households spending 40% or more of their non-food expenditure on OOP health spending was three times as high in households with older members suffering from noncommunicable diseases compared to those with only self-reported healthy older people.
- Some 12.2% of the sampled households had to employ financial coping strategies to pay for the OOP cost of care for older persons. Households borrowed money from relatives/friends (31%), got a loan from individuals/agents (25%) or sold their properties (4%), while the rest (39%) dipped into their savings.
Disaggregation of health care utilization and expenditure data by vulnerable sub-populations (e.g., by older age groups, chronic health conditions) enables a nuanced understanding of the drivers of OOP health spending in a population, which can inform financial protection policies. Globally, analysis of policies and their health benefits for households with older people or with people with chronic care needs may be a priority for research on financial protection in health, especially in contexts undergoing rapid population ageing. This type of research may help to develop appropriate health policies and intervention programs to achieve fairness in financial protection.
Implications for Kansai
Prefectural or municipality-level data on health and long-term care expenditures do not provide the information necessary to determine whether households with older persons are experiencing financial hardship due to OOP spending. Special surveys may be required to obtain these data. This kind of data may help to evaluate the effectiveness of policies in reducing financial hardship due to health care utilization or in reducing foregone care among the local population of older people. In the absence of such data, WKC is conducting analysis of existing national household surveys and collecting information from medical social workers in Kansai to better understand the challenges of ensuring financial protection in health for older people in Kansai.
 Note that the analysis of distribution of OOP excluded cases of cancer and surgery which were outliers due to excessively high costs of treatment compared to the health spending of the rest of the older population.
Adaptation and validation of tools for monitoring the health of older people in Myanmar and Malaysia
Presently, older people comprise a small share of the total population in Malaysia and Myanmar. In both countries, it is projected that this share will double in the next 30 years, which has strong implications for advancing Universal Health Coverage (UHC). For example, as populations age, the capacity of health systems to effectively manage chronic conditions and comorbidity will be essential. Information about the health and social service needs and coverage of older populations will be useful to inform health system development to better meet the needs of an older population. The study aims to adapt the survey instrument of the Japan Gerontological Evaluation Study (JAGES) to facilitate measurement and monitoring of the health and physical functioning of older people in Malaysia and Myanmar.
To adapt and validate the JAGES survey instrument so that it can be used to measure health and function and assess health inequalities among older populations in Malaysia and Myanmar.
- Questionnaire adaptation and validation: In Malaysia, the English-translated version of the JAGES questionnaire was back-translated into Bahasa Malaysian and pilot-tested with 30 older patients visiting an urban primary care clinic in Kuala Lumpur. In Myanmar, the questionnaire was back-translated into Burmese and pilot-tested on 20 older people in the Yangon area. Based on the pilot-test results, the questionnaires were modified to be linguistically and culturally appropriate as well as feasible to administer with older people in each country.
- Sampling: The adapted questionnaires were then used to conduct surveys of the older population in Malaysia and Myanmar, respectively. Multistage random cluster sampling was used to draw representative samples of older people 60 years and above from Hulu Langat and Kuala Selangor districts of Selangor State in Malaysia, and from Yangon and Bago regions of Myanmar.
- Survey administration: Trained surveyors visited the homes of the older residents to administer the survey in person. Persons with severe physical or cognitive impairment were excluded. After obtaining informed consent, an interview was conducted on a range of topics including physical health and functioning, mental wellbeing, health care utilization and social/community engagement. Objective measurements were also obtained from the participants including blood pressure, body weight and height, and grip strength. Each interview took about 45 minutes. Data were collected in December 2018-April 2020 in Malaysia and September-December 2018 in Myanmar.
- Face validation and content validation: Several of the questions and response options in the JAGES questionnaire were modified so that they were relevant and appropriate to the local context, for example, descriptions of the type of health care services available to them or typical social activities for older people.
- Data were successfully collected from a total of 2404 older persons (1204 from Malaysia and 1200 from Myanmar) with a 100% completion rate among those who were included in the interview.
- Survey findings: Results from Malaysia showed that the majority (74.5%) of respondents report being diagnosed with multiple chronic conditions. Over half of respondents report foregoing care, with women, those with poor perceived health and those with difficulty walking being more likely to forego care. Results from Myanmar showed that women were more likely than men to report poorer health status as well as functional decline, controlling for age and other factors. Some risk factors, such as underweight, were more common in rural areas whereas other risk factors, such as being homebound, were more common in urban areas.
In many low- and middle-income countries undergoing rapid population ageing, there may be a lack of validated survey instruments that can be used to collect data on the health and social service needs and utilization among older people. Adapting and validating existing survey instruments may be an efficient alternative and provide data that are comparable to other countries. This approach can also fill an urgent need for local data on the health of the older population as well as contribute to a global evidence base of comparable data on the health needs and services coverage of older people.
Only a small number of high-level administrative indicators and databases relevant to the provision of health and social care for older people are available that enable comparisons between local governments in Kansai. Participation in existing survey research initiatives could offer a complementary source of information. Until recently, Kobe was the only municipality in Kansai that had participated in JAGES going back to the 2010-11 survey. However, in the latest survey wave conducted in 2019-20, nine other municipalities from Kansai have joined. These municipalities could compare their survey results and their various applications of data to inform local policies and programmes development. They could also help promote the use of research data for policy making in other municipalities of Kansai.
- Shah SA, Rosenberg M, Ahmad D, Ahmad S, Safian N, Shobugawa Y. Prevalence and determinants of unmet needs for hypertension care among the older population in Selangor: cross-sectional study – Health Research Policy and Systems. Supplement issue.
Nozaki I, Shobugawa Y, Sasaki Y, Takagi D, Nagamine Y, Zin PE, Bo TZ, Nyunt TW, Oo MZ, Lwin KT, Win HH. Unmet needs for hypertension diagnosis among older adults in Myanmar: secondary analysis of a multistage sampling study. – Health Research Policy and Systems. Supplement issue.
- Shah SA, Safian N, Ahmad S, Nurumal SR, Mohammad Z, Mansor J, Wan Ibadullah WAH, Shobugawa Y, Rosenberg M. Unmet health care needs among older Malaysians. J Multidiscip Healthc. 2021;14:2931–2940. doi: 10.2147/JMDH.S326209. eCollection 2021.
- Shah SA, Safian N, Ahmad S, Wan Ibadullah WAH, Mohammad ZB, Nurumal SR, et al. Factors associated with happiness among Malaysian elderly. Int J Environ Res Public Health 2021;18:3831. https://doi.org/10.3390/ijerph18073831
- Sasaki Y, Shobugawa Y, Nozaki I, Takagi D, Nagamine Y, Funato M, et al. Rural–urban differences in the factors affecting depressive symptoms among older adults of two regions in Myanmar. Int J Environ Res Public Health 2021;18:2818. https://doi.org/10.3390/ijerph18062818
- Safian N, Shah SA, Mansor J, et al. Factors associated with the need for assistance among the elderly in Malaysia. Int J Environ Res Public Health 2021;18:730. doi: 10.3390/ijerph18020730
- Win HH, Nyunt TW, Lwin KT, et al. Cohort profile: healthy and active ageing in Myanmar (JAGES in Myanmar 2018): a prospective population-based cohort study of the long-term care risks and health status of older adults in Myanmar. BMJ Open 2020;10:e042877. doi: 10.1136/bmjopen-2020-042877