Monitoring UHC in the context of population ageing

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Financial protection of older persons in health care in the Kansai region of Japan: Barriers to effective implementation of financial protection policies and programmes

Background

Financial protection against catastrophic or impoverishing health spending is a cornerstone of universal health coverage. Japan has established several policies and programmes to ensure financial protection against impoverishment due to health care costs. This includes universal health insurance, social welfare services, coverage for medical expenses exceeding age- and income-adjusted thresholds, free or low-cost medical care and a public assistance programme. Despite these measures, there is likely to be a growing proportion of older people in Japan who do not receive or forego health services because of their increasing financial hardship, as indicated by the growth of the proportion of older people on public assistance from 1.6% in 1995 to 2.9% in 2015. Financial barriers to health care may be particularly a problem for those in the Kansai region which has some of the highest rates of households on public assistance in the nation, many of which are households with older people.

Goals

To explore the current situation of older people in the Kansai region facing difficulties in paying for health care services when seeing a health professional, receiving a diagnosis, and being treated.
To identify the reasons behind the unmet needs of these older people who could not utilise the existing financial support systems and policies.
To identify the policies that could be better utilised and more effectively disseminated in the Kansai region and across Japan with implications for other countries.

Methods

Use the Behaviour Change Wheel as the theoretical framework to guide the data collection and analysis.
Conduct a literature review of current financial protection policies that apply to older people in Kansai to identify possible gaps in coverage.
Implement a self-administered mail survey of social workers in hospitals, local governments and community-based social welfare and relevant agencies in all six prefectures of Kansai to identify common situations in which older people experience financial hardship in relation to health care use and the challenges that the older patients and health service providers face in utilising financial protection services.
Conduct in-depth interviews with a subset of the survey respondents to explore additional issues that cannot be adequately captured in the survey.

Expected outputs

Peer-reviewed journal articles that describe the financial hardships and unmet health care needs experienced by older people and the obstacles faced by the older patients and health service providers in utilising financial protection services in health in Kansai.
Evidence summary intended for local audiences with implications for policy and practice to strengthen financial protection of older people in relation to health care utilization in Kansai.
Contribution to future Global Monitoring Reports on Financial Protection in Health published jointly by WHO and the World Bank.

Age-disaggregated analysis of national household survey data on financial hardship due to health care utilization

Background

Financial protection is a key dimension of universal health coverage, which is monitored at global, regional and national levels to assess progress towards the 2030 Sustainable Development Goals (SDGs) and WHO’s global impact framework. For the first time, the 2021 WHO-World Bank Global Monitoring Report on Financial Protection in Health compares data on financial protection across households with different age structures. This method will enable some understanding of the different levels of financial protection associated with the age of the person(s) seeking care. This is an innovative analytical approach to apply age-disaggregation to standard measures of financial protection which use households as the unit of analysis. The results can help fill the knowledge gap about financial protection for the care of older people.

Goals

To produce age-disaggregated analysis on financial protection at the national level across WHO Regions to include in the 2021 WHO-World Bank Global Monitoring Report on Financial Protection in Health.

Methods

Identified the most recent nationally representative data appropriate for this analysis, such as household budget surveys, household living standard surveys, household income and expenditure surveys, and household socio-economic surveys.
Estimated incidence of catastrophic and impoverishing health spending prior to the pandemic. This analysis uses the definition of catastrophic spending as health spending exceeding 10% of the household’s total consumption or income, as measured by SDG indicator 3.8.2. Impoverishing health spending is defined as the proportion of the population pushed further below the relative poverty line of 60% of median consumption due to health spending. The analysis was based on the most recent available data from 92 countries across all UN regions except North America and Oceania. These countries account for 53% of the global population in 2017, with lower coverage of populations in lower middle-income countries (43% due to the exclusion of India) and high-income countries (21%). The median most recent estimate available is from 2014 and no data points prior to 2009 were used.
Used a life-course approach to compare results among households with different age structures, specifically: younger households with at least one younger person below 20 years and one adult 20-59; households with only people 20 to 59; multigenerational households with at least one younger person below 20, an adult 20 to 59 and an older person 60 and above; and older households with at least one older person 60 and above and no one below 20 (includes households with only older people).
Conducted country consultations through all six WHO Regional Offices about the analysis results.
Produced statistical summaries along with a narrative synthesis of the regional and global findings in a dedicated section of the 2021 WHO-World Bank Global Monitoring Report on Financial Protection in Health.

Results

Based on the analysis of data from the 92 countries, on average, people living in households with at least one older person 60 and above have the highest incidence of catastrophic spending, as high as 38.3% in upper middle-income countries and in Asia, as compared to the global average of 13.2% of all people.
People living in multigenerational households, which include at least one younger person below 20, one adult 20 to 59 years old, and one older person 60 and above, face the highest rates of impoverishing health spending, as high as 39.9% in upper-middle income countries and in Asia, compared to a global average of 12.7% of all people.

Global Implications

The findings suggest that, globally, households with older people are most likely to spend more than 10% of their total capacity to pay on health care, and that this pattern of spending is most pronounced in Asia. However, this level of health spending is not necessarily impoverishing these households, which implies that the 10% threshold may not necessarily represent an unaffordable level of out-of-pocket health spending for households with older people. Data for this analysis were only available from 92 of WHO’s 194 Member States accounting for only a half of the world’s population, underrepresenting North America and Oceania and high-income countries. A global effort is needed to improve the availability of data from more countries to enable a more comprehensive understanding of how the financial consequences of health care utilization vary by age composition of the household. This type of data can inform better targeting and tailoring of financial protection measures and policies to the actual levels of health care needs and capacity to pay of households. More recent data are also necessary to be able to report on the impacts of the COVID-19 pandemic in the next Global Monitoring Report to be published in 2023.

Implications for Kansai

Households with older people in Kansai may have higher levels of out-of-pocket payments for health care compared to households composed of younger people. It is unclear whether they are experiencing higher levels of impoverishing health spending as a result. Data on health care expenditure alone are insufficient to assess the actual financial impact of health care utilization on households. WKC is carrying out a study that will analyze existing household survey data to identify not only the level of out-of-pocket health care spending but also the financial resources of households to gain a better understanding of the conditions under which health care spending may result in financial hardship among older citizens of Kansai. This information may help local programmes and policies to better identify those households in greatest need of financial protection.

Publications

The findings from this study were the basis for section 1.2. Who experiences financial hardship? A focus on age in the Global Monitoring Report on Financial Protection in Health 2021 (p17-21).

Equity in health care needs and service coverage of older people: a scoping review of the conceptual literature

Background

The global community is advancing the Sustainable Development Goals and target of the progressive realization of Universal Health Coverage (UHC) by 2030. As such, many countries face the challenge of measuring and monitoring their progress in a way that is appropriate to the context of population ageing. The requirements of older people should be considered, including variations in their diversity of needs, as well as the differences in need among older people and other age groups. The objective of this project is to present the evidence on the contributors to equity in health care needs and service coverage for older people to improve monitoring for UHC in the context of population ageing.

Goals

1. To conduct a global scoping review of the conceptual and theoretical literature to determine what should be measured to assess equity of service coverage, particularly for older people.

2. As a secondary goal, to conduct a review of the literature published in Japanese on health care service coverage of older people to understand how equity is conceptualized.

Methods

The conceptual and theoretical literature were searched using a combination of thesaurus and free-text terms for metrics, models/frameworks/theories, older people, equity/disparity and coverage/utilisation/access/need. Databases used to identify relevant published and unpublished (grey) literature included: CINAHL (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), Social Science Citation Index (SSCI) (Web of Science), Global Index Medicus, BIREME, LILACs, SCIELO, CiNii and Ichushi Web. There were no search limitations of date or language.
The evidence base included age-specific frameworks, empirical data or literature that exclusively concerned older people or specific groups of older people and covered social (long-term) care services as well as health care services.
The data were analysed to construct a meta-framework that represents equity, access and need, and what should be considered in any monitoring of equity concerning older populations. The data synthesis also considered how far the findings of the new conceptual framework might be integrated with existing, relevant policy frameworks to determine the policy implications.
For the study of Japanese literature, a search was conducted in domestic bibliographic databases, CiNii and Ichushi Web, as well as in international databases, PubMed and Web of Science. Data charting and synthesis was based on an adapted version of the framework to enable a more nuanced analysis of the literature related to Japan.

Results

The global search retrieved 10,517 citations and 32 relevant articles were identified for inclusion from a global evidence base. A meta-framework was produced based on how equity in health care needs and service coverage of older people have been conceptualized in the literature. The framework identified the following relevant factors: acceptability; affordability; appropriateness; availability and resources; awareness; capacity for decision-making; need; personal social and cultural circumstances; and physical accessibility. The prevalence of multimorbidity, complex care needs, capacity and accessibility issues among older people as a group – and within groups of older people – mean that these factors achieve much greater prominence in our framework than in generic access frameworks.
For the study of Japanese literature, 5,880 citations were identified, and 50 studies were included in the review. The studies were categorized according to the adapted framework which identified nine domains of equity: financial disparity and affordability; availability of services and resources; geographical/regional disparity; cultural and psychological barriers; racial/ethnic disparity; gender disparity; period/cohort disparity; patient capacity to make decisions; and patient knowledge/awareness. The review found that discussions about equity in healthcare access among older people in Japan were focused mainly on issues related to financial barriers, availability of services and geographical/regional disparity.

Global Implications

The measurement of equity in the health care needs and service coverage of older people is under-developed. The framework developed in this study suggest that there is a need to move beyond generic access frameworks when measuring equity in older populations. More accurate frameworks could include indicators for the older person’s capacity for decision-making, their personal and social environment, and complex care needs due to comorbidities. The conceptual framework developed by this research has informed a subsequent statistical study that aims to quantify unmet needs for health and social care among older people across multiple countries.

Implications for Kansai

Few studies examine inequities in health care access and coverage for older people in the Kansai region. However, some studies and databases appear to provide a comparison of prefectures or municipalities in Kansai with those in other regions. Further analysis of such existing studies and data may help improve our understanding of equity in service coverage and health care access in Kansai including for older people. This finding has led WKC to conduct an analysis of several existing national household survey data to better understand the financial impact of health care spending of older people and their unmet needs in Kansai as compared to other age groups and other regions of Japan.

Publications

Carroll C, Sworn K, Booth A, Tsuchiya A, Maden M, Rosenberg M. Equity in healthcare access and service coverage for older people: a scoping review of the conceptual literature. Integrated Healthcare Journal 2022;4:e000092. doi: 10.1136/ihj-2021-000092

WKC Evidence Summary: Key concepts for assessing equity in health care access among older people. Kobe: WHO Centre for Health Development; September 2021. (Download PDF below)

Systematic review and meta-analysis: financial barriers to accessing health services and unmet healthcare needs

Background

The indicators currently used for monitoring financial protection under the Sustainable Development Goals may not capture the extent to which financial barriers keep people from using the health services they need. Low levels of catastrophic and impoverishing out-of-pocket health spending could also result from limited use of services or unmet health care needs due to financial barriers or other factors. This problem of unmet health care needs could be exacerbated for older people who tend to have multiple chronic conditions that require frequent use of health services over a long period. This research aims to synthesize existing global evidence about the levels of and reasons for unmet needs for care among the general population and specifically among the older population.

Goals

To estimate the prevalence of self-reported unmet health care needs in the general population, identify financial and other barriers to health care access, and assess differences in prevalence of unmet needs by population characteristics.
To estimate the prevalence and reasons for unmet needs for health and long-term care (LTC) among people 65 years and older.

Methods

Four electronic databases - PubMed, EMBASE, CINAHL, and Web of Science – were searched using a combination of terms related to forgone care, long-term care, unmet needs, barriers to access and analysis of household surveys. There were no language, date or age restrictions. After screening 3915 articles, 114 studies were included in the review, which covered around 58 million people, mostly adults 30 years and above but also including some children and adolescents, from 56 mainly high-income countries.
The evidence synthesis was performed by using a random-effects meta-analysis to obtain pooled estimates of the prevalence of unmet needs for health care among the populations studied.
Subgroup analysis was performed on people 65 years and above to examine prevalence of unmet needs for not only health care but also LTC. For the subgroup analysis of older people, we focused on the 79 studies that reported data on the population 65 years and older and included an additional 14 studies related to unmet need for LTC.

Results

Survey questions used to measure unmet need for health care varied across studies. In the absence of a standardized definition, the operational definition of ‘unmet need for health care’ used in this study was a negative response to a survey question about whether health care was sought when there was a need for health care in the case of an injury or illness.
Overall, 9.0% of the populations included in the meta-analysis self-reported forgoing or delaying health care when they had a need for health care. The leading reason for unmet health care needs was affordability (20.6%) followed by availability (17.0%), accessibility (12.2%), and acceptability (8.9%). Statistically significant differences were found in the pooled prevalence of unmet health care needs due to cost by education level (primary or less [14.3%] vs higher [7.8%]), self-reported health status (poor [24.6%] vs very good/excellent [15.5%]), insurance status (uninsured [21.9%] vs insured [15.9%]), and economic status (poorest quintile [30.2%] vs richest quintile [8.4%]).
Among the population of older people 65 years and above included in the meta-analysis, 10.4% reported unmet needs for health care, which is greater than the corresponding prevalence of 4.9% among adults 31 to 64 years. The leading reason for unmet needs for health care among the older population was also affordability (31.7%) (mainly the cost of treatment), followed by problems with acceptability (10.4%), accessibility (6.2%) and availability (4.9%). A statistically significant variation in pooled prevalence of unmet health care needs due to cost was found by gender (male [10.9%] vs female [14.4%]), education level (primary or less [13.3%] vs higher [7.5%]), self-reported health status (poor [23.2%] vs good [4.4%]), insurance status (uninsured [27.7%] vs insured [9.0%]), economic status (poorest quintile [28.2%] vs richest quintile [7.1%]), and survey year (2001-2010 [4.3%] vs 2011-2019 [10.8%]).
The measurement of unmet need for LTC was not standardized across studies. For the purpose of this meta-analysis, ‘Unmet need for LTC’ was defined in this study as a negative response to a survey question about whether any assistance has been received to address self-reported limitations in function defined by Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). On average, 25.1% (14 studies) of older people were identified as having unmet needs for LTC. The level of unmet need varied by the older person’s level of function (having problems with ADL [23.8%] vs having problems with IADL [11.0%]) and residential area (rural [51.1%] vs urban [48.0%]).

Global Implications

Global indicators for monitoring progress toward achieving financial protection in health only capture the financial consequences of health care utilization, and completely miss out on people that have low health spending because they have unmet needs. Most countries have little or no data on unmet health needs and even fewer surveys detail the unmet needs among subpopulations such as older people. Integrating measurement of unmet need into existing household surveys may help to fill this knowledge gap. Another challenge is the need for a standardized definition of unmet need for health and long-term care to enable comparison across countries.

Implications for Kansai

Recognizing that there is a lack of information in the published literature about unmet health and long-term care needs of older people in Kansai, WKC’s ongoing research aims to fill this information gap by using available household survey data to produce new estimates of unmet need for health care among older people in Kansai compared to other age groups and other regions. WKC will also qualitatively describe what medical social workers in Kansai perceive as the major challenges that lead to unmet needs for health and social care among older people.

Measuring Universal Health Coverage in Relation to Care for Older People: A Global Scoping Review with an Application to Iran

Background

Population ageing is a global demographic trend which has significant implications for a health system’s ability to progressively attain universal health coverage (UHC) - that is, to ensure that all people can obtain needed health services without experiencing financial hardship. An older population has substantially different health needs and service accessibility challenges compared to a younger population. Iran is among the countries in the WHO Eastern Mediterranean Region which are expected to see a rapid rise in the number of older people over the next decade. It represents a middle-income country where monitoring approaches are needed to guide health system development toward the progressive realization of UHC in the context of population ageing.

Goal

To develop a national framework for monitoring UHC progress with a focus on older people’s care in low- and middle-income countries and assess its relevance and feasibility in Iran.

Methods

Two distinct search strategies were used for global published literature: one aimed to capture measurement and monitoring concepts in relation to UHC and ageing more broadly, and another focused on the UHC targets of service coverage/access, financial protection, equity and quality in relation to older people’s care.
A search was conducted in Scopus, ISI Web of Knowledge, PubMed, Ovid (including Cochrane database of systematic reviews) and ScienceDirect, as well as in the grey literature, with no restriction on date or language of the publication. The main inclusion criteria were that the study must describe both the concept of care needed by older people and the measurement or indicators of UHC relevant to such care. A total of 101 full-text articles were reviewed and 35 met the inclusion criteria for analysis.
The results of the literature review were discussed in two rounds of an expert panel review with Iranian researchers and local and national government officials to examine the relevance and feasibility of measuring the identified themes and indicators in Iran.

Results

Overall, the review found that no existing framework has been published for measuring UHC in the context of population ageing, and that global consensus is lacking on indicators related to monitoring older people’s care.
Of the indicators extracted from the reviewed literature, 25 related to quality of care, 22 related to financial protection, and 10 related to service coverage and access, all pertaining to older people’s care. Others were more generic measures of population health, UHC or equity.
The Iranian expert panel identified several metrics that are not feasible to measure at the national or municipal level either due to the limitations of existing health information systems and surveys or the absence of related programs and structures. They especially noted the challenges of measuring the indicators on long-term care (LTC) when there is no LTC insurance scheme or formal LTC system in the country.

Global Implications

The lack of globally agreed frameworks and indicators for measuring the specific needs of older people may hinder further analysis and the systematic collection of comparable data across countries to assess progress toward UHC. While there are some indicators that could be useful, their applicability across diverse contexts requires further empirical validation. Guidance on the use of available indicators may be needed for countries where formal long-term care systems do not yet exist.

Implications for Kansai

Local governments in Kansai often rely on routinely collected administrative data to assess the performance of their health and long-term care services. However, administrative data tend to be limited to specific aspects of existing policies and programmes, such as service utilization rates, and may not be adequate for assessing the impact of existing policies and programmes or for determining future needs. The indicators identified in this study from the global scientific literature may offer complementary information, and as such, local governments in Kansai may wish to consider adapting them for their own purposes. Consultation meetings with researchers and other local stakeholders could be helpful for local governments to make informed decisions about which indicators to adapt and use.

Conceptual framework with a life-course approach to support universal health coverage monitoring systems

Background

A life-course approach to Universal Health Coverage (UHC) has been proposed to better inform UHC implementation and monitoring. This approach envisions a sustained improvement in human health and well-being across the life span, from birth, the neonatal period and infancy, childhood and adolescence, young adulthood, to older adulthood. All of these stages are shaped by social, economic, and cultural contexts. However, existing indicators for monitoring UHC focus on easily accessible metrics measuring maternal, child and infectious diseases, while metrics for service coverage and related financial protection are needed for countries facing population ageing.

Goal

To provide a narrative synthesis of existing concepts and frameworks related to the life course, population ageing and UHC to inform the development of a framework for monitoring progress toward UHC using a life-course approach.

Methods

The literature search was done in PubMed, Web of Science and Google Scholar, and included grey literature, using search terms related to the life course, ageing and UHC. The search was limited to English publications in the last ten years, between 2009 and 2019.

An initial search identified five existing frameworks on the life course approach to health. These were synthesized into one framework which served as the guiding framework for the second more comprehensive scoping review. This second review focused on evidence to support the various components of the synthesised framework. Additional search terms at this stage included those related to policy/interventions and function/disability to capture literature on the applications of a life course approach that consider not only health but also function as the outcome. This search identified 514 papers of which 84 were included in the final analysis.

Results

While existing conceptual frameworks on the life course approach to health appropriately recognize all stages of the life course and the linkages between them, research on the life course approach to health tends to focus on the earlier life stages. Evidence from the epidemiological studies show that exposures to positive or negative events at an early age (for example, malnutrition or education) have long-lasting effects on health and disability outcomes at an older age. Despite the search for relevant applied research, only nine of the articles were related to policy, and the other 75 were epidemiological studies. The themes extracted from the policy papers emphasized the importance of integrated care that spans the life course, expansion of immunization services to include older people, and age-friendly services. Few studies discussed appropriate metrics for ageing inclusive monitoring or the evaluation of policies or described policies and programs relevance for low- and middle-income countries.

Global Implications

Evidence from epidemiological studies on the life course justify investing in early-life interventions as part of a strategy for improving the health outcomes of future ageing populations. However, there is no evidence to suggest that they should replace investments in later-life interventions that directly respond to the needs of older people. More research is needed to assess the relative impact of interventions at different stages of life to inform the appropriate allocation of resources along the life course. Further research on the practical applications of a life course approach to policies and programmes, especially in low- and middle-income countries, can help generate knowledge about the practical benefits and challenges to adopting this approach.

Implications for Kansai

The life-course concept may be useful as a common framework for local government initiatives to promote cross-sectoral/departmental collaboration for health systems development in the context of population ageing. It could be helpful in highlighting the interrelationships and possible collaborations between departments working on issues that are relevant to different age groups. It may also identify synergies or efficiencies that could be achieved through new inter-sectoral policies or health programmes. It may also help identify segments of the life course that are receiving inadequate attention or investment. In addition, understanding these types of local experiences could inform the development and standardization of key indicators to be monitored along the full span of the life course to assess progress towards UHC in light of population ageing.

Publications

Developing a conceptual framework with a life-course approach to support universal health coverage monitoring systems. WHO Centre for Health Development (WHO Kobe Centre - WKC) Working Paper (#K18021).

Melinda G, Ono R, Tsuboi Y, Chaiyawat P, Kawaharada R, Perrein E, Rosenberg M, Agustina R, Fukuda H. Applying a life course approach to health service coverage monitoring in countries undergoing population aging: A scoping review. - PLOS ONE. Under review.

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