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Informal Experts Consultation on Ageing and Health in the Western Pacific Region, Manila,Philippines, 9-10 April 2013 : report

December 16, 2013 World Health Organization

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WPR/DHS/HCF(01)/2013 Report Series No.: RS/2013/GE/16(PHL)

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REPORT INFORMAL EXPERTS’ CONSULTATION ON AGEING AND HEALTH IN THE WESTERN PACIFIC REGION

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Manila, Philippines 9–10 April 2013

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines August 2013

NOTE The views expressed in this report are those of the participants in the Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.

KEY WORDS: Healthy ageing, Older people, Health services, Health promotion, Life cycle, Framework for action

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Members States in the Region and for those who participated in the Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region, which was held in Manila, Philippines from 9 to 10 April 2013.

SUMMARY

Ageing is a key public health challenge confronting Member States in the Western Pacific Region. In almost every country, the population aged 60 years and over is growing faster than any other age group as a result of longer life expectancies and declining fertility rates. Strengthening health systems to provide older persons with seamless access to needed services is an emerging need in developed and developing countries. The WHO Regional Office for the Western Pacific has been strengthening its response to ageing and health. In October 2013, the sixty-fourth session of the Regional Committee for the Western Pacific will discuss ageing and health as an agenda item and in a panel. In preparation, the following analytical work was commissioned to strengthen the evidence base: (1) (2) a comparative study of the health of older people in selected countries in the Region, through secondary analysis of existing survey data; and a review and analysis of policies related to ageing and health in selected countries in the Region.

These activities have informed the development of a draft regional framework for action on ageing and health, to be discussed at a meeting of Member States from 9 to 11 July 2013. The Informal Experts’ Consultation on Ageing and Health for Western Pacific Region brought together 12 temporary advisers and 11 secretariat staff from 9 to 10 April 2013 in Manila to discuss preliminary findings of these analytical studies and obtain advice on next steps with regard to the draft regional framework for action on ageing and health. The objectives of the consultation were: (1) (2) to discuss preliminary findings and recommendations from ongoing analytical work on ageing and health in the Region; and to identify priority actions WHO could take in cooperation with Member States to address the health aspects of population ageing.

Discussions took place according to three main themes, reflecting the three products described above: the health situation of older people in the Western Pacific Region; policies on ageing and health in the Western Pacific Region; and a regional framework for action on ageing and health. Overall, participants welcomed efforts by the WHO Regional Office for the Western Pacific to take forward and strengthen the work on ageing and health, including the development of a regional framework for action on ageing and health. Participants made suggestions during the consultation on core themes and issues to be considered for inclusion in these products. Moreover, participants expressed their appreciation and support of WHO's efforts in this field. Going forward, participants are ready to provide ongoing input in finalizing the regional framework for action on ageing and health and collaborating with Member States on this agenda more broadly.

CONTENTS

1. INTRODUCTION ............................................................................................................... 1 1.1 Background ................................................................................................................. 1 1.2 Objectives .................................................................................................................... 1 2. PROCEEDINGS ................................................................................................................. 2 2.1 Opening session........................................................................................................... 2 2.2 Technical sessions ....................................................................................................... 4 2.3.1 Health situation of older people in the Western Pacific Region.............................. 4 2.3.2 Policies on ageing and health in the Western Pacific Region ................................. 6 2.3.3 Regional framework for action on ageing and health............................................ 10 2.3 Closing session .......................................................................................................... 12 ANNEXES: ANNEX 1 - List of participants ANNEX 2 – Timetable ANNEX 3 - Presentations

Key words:

Ageing and health, older people, health promotion, healthy and active ageing, life-course, age-friendly health system, framework for action

1 1. INTRODUCTION

1.1

Background

Ageing is a key public health challenge confronting Member States in the Western Pacific Region of the World Health Organization (WHO). In almost every country, the population aged 60 years and over is growing faster than any other age group as a result of longer life expectancies and declining fertility rates. Strengthening health systems to provide older persons with seamless access to needed services is an emerging need in developed and developing countries. Advancing health and well-being into old age is one of the three priority directions set forth in the Madrid International Plan of Action on Ageing, adopted in April 2002 at the second World Assembly on Ageing. In May 2012, the World Health Assembly requested the Director-General to support Member States on ageing by adopting Resolution WHA65.3 (Strengthening noncommunicable disease policies to promote active ageing). The WHO Regional Office for the Western Pacific has been strengthening its response to ageing and health. In May 2011, it convened an informal experts’ consultation to advise on the Region’s work on population ageing. In April 2012, on World Health Day, the Regional Office undertook wider efforts to raise awareness on ageing and health, including by disseminating information and convening events at regional and country levels. In October 2013, the sixty-fourth session of the Regional Committee will discuss ageing and health. In preparation, the following analytical work was commissioned to strengthen the evidence base: (1) a comparative study of the health of older people in selected countries in the Region, through secondary analysis of existing survey datasets; and (2) a review and analysis of policies related to ageing and health in selected countries in the Region. These activities have informed the development of a draft regional framework for action on ageing and health, to be discussed at a meeting of Member States in July 2013. An Informal Experts’ Consultation on Ageing and Health for the Western Pacific Region was held from 9 to 10 April 2013 in Manila, Philippines to present preliminary findings from the ongoing analytical work and to discuss their implications and recommendations for action. Twelve temporary advisers and 11 secretariat staff participated (see the list of participants in Annex 1). The informal experts' consultation included technical presentations and discussions. The timetable is attached as Annex 2. 1.2 Objectives (1) (2) To discuss preliminary findings and recommendations from ongoing analytical work on ageing and health in the Region. To identify priority actions WHO could take in cooperation with Member States to address the health aspects of population ageing.

2 2. DINGS PROCEED

2.1

Opening session

Dr Hen nk Bekedam m, Director, Division for f Health Sector S Deve elopment, WHO W gional Offic ce for the Western W Pacific, opened d the inform mal experts' consultatio on by Reg welcoming par rticipants on n behalf of f the Regional Directo or, Dr Shin Young-soo o. He began by highl lighting the growing ne eed to addre ess the issue e of ageing and health. The prop portion of people p aged 60 years an nd over is gr rowing fast ter than any other age group g in th he Region. In particul lar, low- an nd middle-in ncome coun ntries in the Region fa ace a rela atively narro ow window w of time to o prepare for fo populatio on ageing. WHO has been supp porting gov vernments as a they prep pare for pop pulation age eing in thei ir countries. . The Reg gional Offic ce has been strengthening its work k on ageing g and health h, leading to the development of o a draft framework f for action on ageing g and health h. Dr Beke edam uested parti icipants to offer sugge estions on h how best to o take forw ward this are ea of requ wor rk in the Region. R He noted n the complexity c of ageing and health, , which req quires coor rdination and a partner rships across stakehol lders and sectors. He e concluded d by stressing that the t WHO R Regional Office O looke ed forward to advancing the wor rk on ing and hea alth in collab boration wit th partners. agei In her opening rem marks, Dr Susan Mer rcado, Direc ctor, Divisi ion for Building Hea althy Comm munities and d Population ns, WHO Re egional Off fice for the Western W Pa acific, note ed the imp portance of f building healthy co ommunities s and popu ulations for r the obje ective of en nsuring healthy ageing g. She stress sed the nee ed to achiev ve this goal l in a “hea althy way”. The socia al context of o health includes the role of fam mily, commu unity and society, wh hich are par rticularly im mportant for r ageing and d health. Dr r Mercado noted n t the ageing g and health h agenda req quires stron ng partnersh hip across stakeholders s s and that sect tors—for ex xample, in addressing g the health h impact of f rapid urba anization on n the heal lth of older r people. WHO W has an importan nt leadership p role in st trengthening g the capa acity of the e health sect tor to respo ond to popu ulation agein ng. Ageing and health is an area a that chang ges the trad ditional bou undaries of f the health sector and d poses prac ctical chal llenges in relation r to implementi i ing needed interventions. Dr Mer rcado concl luded by s stressing the e need for concrete c and d practical guidance in n stimulatin ng rapid progress on the t ageing and a health agenda. a Figure 1. o introduct tions, Following a round of L Speci ialist, Dr Ritu Sadana, Lead nt for Ag geing and Life Departmen Course, WHO W Gene eva, provid ded a global upd date on age eing and he ealth. She high hlighted the t increa asing proportion n of older people glo obally (see Figure e 1), as wel ll as the speed of population n ageing, es specially in lowand middle e-income co ountries. Ta aking action on ageing an nd health would w b on four key require building dimension ns: (1) pr romoting good

3 heal lth and hea althy behav viours at all l ages (a “l life course” ” approach) ); (2) equip pping heal lth systems s to manage e and mini imize the consequence c es of chron nic diseases s; (3) crea ating physic cal and soci ial environm ments that foster f health h and partic cipation; an nd (4) rein nventing ageing. These e dimension ns were hig ghlighted on n World Health H Day 2012 and would als so form the e basis for a World Report R on Ageing A and d Health, to t be blished in 20 015. pub Ms Anj jana Bhusha an, Technic cal Figure e 2. Offi ficer (Heal lth in Development D t), Div vision fo or Heal lth Sect tor Dev velopment, WHO Reg gional Offic ce for the Weste ern Pacific, , provided a ional update e on ageing g and healt th. regi She e described d some of the agein ngrela ated challen nges and the varyin ng stag ges of the demographic c transition at whi ich different t countries in i the Regio on find d themselves. She sa aid that th he WH HO Regiona al Office's response to agei ing and hea alth include ed organizin ng an I Informal Ex xperts' Cons sultation on Healthy Ag geing in the e Western Pacific P Region in May y 2011 as well w as und dertaking advocacy a an nd raising awareness a on o "Ageing g and heal lth—good health h adds life to year rs" for Worl ld Health Day D 2012. To T strengthe en the evid dence base e, the Reg gional Offi ice has un ndertaken analysis a in ncluding: (1) ( a com mparative st tudy on the e health of older peopl le in selected countrie es in the Re egion (sec condary ana alysis of exi isting datasets), and (2 2) a review and analysis of policie es on agei ing and health in sele ected count tries in the Region. These T forme ed the basi is for development of o a draft regional r fra amework fo or action on n ageing an nd health, to t be cussed by Member M Stat tes at the si ixty-fourth session s of th he Regiona al Committe ee for disc the Western Pa acific in Oct tober 2013. Ms Bhusha an explained d that the ai im of the cu urrent ormal expe erts' consu ultation wa as to disc cuss the preliminary p y findings and info reco ommendatio ons from on ngoing ana alytical wor rk and iden ntify priority y actions WHO W could take in collaborati ion with Member M Sta ates to address the he ealth aspec cts of pulation age eing. She co oncluded by y stressing that t the input of partic cipants wou uld be pop vita al. In the discussions s that follo owed, partic cipants wel lcomed the e efforts by y the WH HO Regiona al Office to o strengthen n this area of work. They T stressed the need d for stren ngthened political p co ommitment, in light of o the curr rent and li ikely increa asing imp portance of ageing a and health for the Region. Participants felt strong gly that effe ective action on agein ng and healt th would also need to i include new w, positive ways w of thin nking ut ageing. The T politica al and econ nomic influe ence of olde er people is s significant and abou grow wing. They y suggested adding a vision v statement to the e draft regi ional framework that t characteriz zed older pe eople as a re esource to society rathe er than a bur rden. the potenti Particip pants also highlighted h ial for othe er broad po olicy agend das to serv ve as potent tial entry points for ad dvancing th he work on ageing and d health, suc ch as non ncommunica able disease es (NCDs), universal health cov verage, and d the post-2015 development ag genda. Poverty and oth her underly ying social determinant d ts of health were hlighted as critical issu ues for age eing and health. Participants welc comed effor rts to high

4 develop a draf ft regional framework k for action n, to provid de guidance and stim mulate broa ader partner rships and options o for implementa i ation. 2.2 Technic cal sessions s

The tec chnical sessi ions were devoted d to discussing d th he following g pieces of work und dertaken by the WHO Regional R Of ffice for the Western Pa acific: (1) (2) (3) a comparative study on n the health h status of ol lder people; a review an nd analysis of o ageing an nd health po olicies; and a draft fram mework for action on ag geing and health. h

ession bega an with sum mmaries of f the work, followed by b presenta ations Each se from m selected experts who provide ed commen nts and add ditional or complemen ntary info ormation. More M exten nsive discu ussions amo ong partici ipants then n followed. . All pres sentations are a available e in Annex 3. 3 f older people in the Western Pacif fic Region 2.3.1 Health situation of Dr Hai i-Rim Shin n, Team Leader, Non ncommunicable Disea ases and Health H motion, WHO W Region nal Office for the W Western Pac cific, chaire ed the mor rning Prom sess sion on the e health situ uation of older o people in the Western W Pac cific Region n. Dr Che erian Vargh hese, Senio or Medical Officer, NCDs, N WHO O Regional l Office for the Wes stern Pacific, chaired th he afternoon n session. Professor Julie Byles, B Direc ctor, Resea arch Centre e for Gend der, Health h and Age eing, Unive ersity of Newcastle, N Australia, presented key findin ngs and policy p imp plications fr rom the comparative study on th he health of o older peo ople in sele ected coun ntries in th he Western Pacific Re egion. The purpose of f the study was to analyse coun ntry- and ag ge-specific population health data a on selected d countries for older pe eople aged d 60 years and a above through t sec condary ana alysis of existing data, to t inform policy p development an nd impleme entation as well as fur rther researc ch on agein ng and healt th. In r and comparativ ve analysis, , a series of o factsheet ts on addition to a summary report pulation age eing was produced p fo or selected countries. Drafts of the report t, the pop coun ntry fact sh heets and re elated data tables t were distributed d as backgro ound docum ments to th he informal experts' consultation. fessor Byles summariz zed the heal lth Prof situation of older o peopl le, includin ng pulation pyramids p in selecte ed pop coun ntries (se ee Figure 3), ag gestan ndardized self-reporte s d health of men n and wom men, as well w as ag gestan ndardized prevalence p of smokin ng and arthritis. Data D sugges st that, whi ile untries in th he the populations in all cou gion are age eing, the spe eed of agein ng Reg is f faster in lo ow- and middle-incom m me coun ntries. The burden of diseas se, Figure e 3.

5 part ticularly fro om NCDs such as ca ancer and diabetes, has h increase ed and pos ses a sign nificant econ nomic burd den for many y countries. . Some coun ntries have very high levels of d disability am mong older age groups s (including g substantia al difference es between men and women). Commentin C ng on the “f feminization n of ageing g”, Professo or Byles po ointed e women in n the West tern Pacific c Region li ive longer than men, they out that while gher rates of f morbidity y and disabi ility and are e particular rly vulnerab ble to experience hig orer health outcomes, o poverty and social isolat tion. Even though t popu ulation agei ing is poo a gl lobal trend, Professor Byles B stress sed the impo ortance of recognizing r g the diversi ity of olde er people, as revealed in i the analysis. L Act ting Depu uty Figure Dr Wang Limin, e 4. Prevale ence of chro onic diseases ector, Dep partment of Disea ase among Dire g the elderly y in China Surv veillance, National Center for f Chr ronic Non Communica C able Diseases Con ntrol and Preventio on, Chinese Cen nter for Disease Control C an nd Prev vention, ma ade a presen ntation on th he heal lth situatio on of and policies for f olde er people in n China. She S describe ed how w ageing wa as accelerat ting in Chin na, and presented findings fr rom a surve ey older peopl le's self-rep ported heal lth of o need ds, includi ing the pr revalence of chro onic diseas se and disability (se ee Figu ure 4). The presentation highlighte ed the close relev vance of chronic and d noncomm municable diseases for the agend da on ing and hea alth. Dr Wang underli ined the growing dem mand for health service es by agei olde er people in i China, which w woul ld require strengtheni ing of the health syst tems, incl luding throu ugh appropr riate health policies p and d other mea asures. Katsunori Kondo, K Prof fessor, Facu ulty of Socia al Welfare, Graduate School S of Health H Dr K and Social Se ervices Man nagement, Nihon Fuk kushi Unive ersity, Japa an, provide ed an rview of the health situ uation of ol lder people in Japan, based b on an analysis of f data over from m the Japan n Gerontol logical Eva aluation Stu udy (JAGES S), one of Japan's ea arliest pop pulation-based gerontol logical surv veys, reachi ing more th han 100 000 0 persons across a 31 municipalit ties with a response rate of 66%. 6 The survey foc cuses on social s erminants of o health, co overing a ra ange of ind dicators on physical p an nd mental health h dete (see e Figure 5), socioecono omic status, , and social and enviro onmental fac ctors. Dr Kondo K also o describ bed the university y's Figure e 5. coll laboration with w the WH HO Centre for f Hea alth Deve elopment on JAGE ES HEA ART, an ef ffort to integrate JAGE ES with h Urban HE EART (the Health H Equi ity Ass sessment and a Respo onse Tool). JAG GES HEAR RT is being continuous sly revi ised and has s fed into WHO's W effor rts to develop d ind dicators for age-friend dly citie es. Altho ough som me researc ch chal llenges rem main, the tool cou uld pote entially als so help str rengthen th he

6 evidence base on ageing and health in other settings and countries. In the discussions that followed, there was strong agreement that strengthening the evidence base on ageing and health to inform effective policy-making was a key priority. Participants highlighted the value of studies such as the WHO-commissioned comparative analysis on the health of older people. WHO has an important role in facilitating information sharing and supporting research and learning on ageing and health. With regards to the content of the comparative analysis, participants suggested including social and mental health issues, including evidence on topics such as social isolation, depression and dementia. Several participants suggested including the issue of older people's expectations about health status, which are important but fluid, reflecting societal values and resources, such as the extent of availability of medicines and assistive devices. The availability and quality of health services in a given country are also relevant, since they vary substantially and could potentially distort a regional comparison of health data. Participants also noted the importance of NCDs and related co-morbidities in relation to the health of older people, which thus merits further analysis. Participants felt that the planned country fact sheets will usefully stimulate policy-related discussions with Member States. Participants' recommendations included using the most up-to-date information available; incorporating policy implications in the comparative study report and country fact sheets; formulating key messages in policy-maker-friendly language; and moving beyond analysis to knowledge translation to informed policy-making. Participants pointed out the various available sources and ongoing efforts by Member States to strengthen information on the health status of older people. Member States can learn from the examples of Japan and China as frontrunners. The group agreed strongly on the need to ensure appropriate disaggregation of data for effective policy-making. The lack of standardization of indicators across surveys and countries limits comparability and is a key priority for action. 2.3.2 Policies on ageing and health in the Western Pacific Region Dr Gulin Gedik, Team Leader, Human Resources for Health, WHO Regional Office for the Western Pacific, chaired the first half of the session on policies on ageing and health in the Western Pacific Region. Dr Xu Ke, Team Leader, Health Care Financing, WHO Regional Office for the Western Pacific, facilitated the second half of the session.

7 Prof fessor Soon nman Kwo on, Dean, Figure 6. Sch hool of Pu ublic Healt th, Seoul National Univ versity, Rep public of rea, provide ed an overvi iew of the Kor revi iew and ana alysis of po olicies on agei ing and health in selected coun ntries in the t Western n Pacific Reg gion. The study s consisted of a desk k review of o documen nts for a broa ad set of f countries s in the Reg gion as well as more in-depth anal lysis based d on key informant i inte erviews and d document t analysis duri ing visits in four countries (Ch hina, Fiji, the t Philipp pines and Viet t Nam). He e summarize ed key chal llenges of population p a ageing in re elation to he ealth, incl luding the rising r dema and for heal lth and long g-term care e, declining family sup pport, and limited fin nancial reso ources (see Figure 6). In this con ntext, he pre esented find dings m analysis on leadersh hip and gov vernance, health h finan ncing, servi ice delivery y and from hum man resourc ces for heal lth. Although specific cs vary sub bstantially across a coun ntries, man ny countries have dev veloped plan ns, policies s and/or ins stitutional arrangement a ts on agei ing and health h issue es. Howeve er, little in nformation is availab ble about their imp plementation n. Low awa areness and d political commitment c t, limited in nformation, lack of f financial resources, we eak institut tional and human h reso ource capac city, and lim mited coor rdination ac cross ministries and pr rogrammes on ageing and health are key bar rriers to a appropriate policy p deve elopment an nd implemen ntation, esp pecially in lo ow- and middleinco ome countr ries in the Region. Lack L of aw wareness, political p wil ll and fina ancial reso ources, incl luding at the t local le evel, often hamper th he develop pment of health h fina ancing arran ngements to o respond adequately to the hea alth needs of o older pe eople. Sim milarly, serv vice deliver ry systems have not yet y reorient ted themse elves as nee eded. Cou untries will need to bala ance between prioritiza ation of hea alth care and d long-term m care, depending on their t local co ontext. In conc clusion, sum mmarizing key k policy recommendations em merging from m the lysis, Profe essor Kwon n highlight ted the imp portance of f political commitmen nt to anal develop and implement appropriate e policies on o ageing and health and increa asing areness abou ut ageing an nd health am mong policy y-makers as s well as the e general pu ublic. awa Mov ving towar rds univers sal health coverage would req quire the developmen d nt of sust tainable and d appropriat te financing g for service es for older people. Par rticular attention wou uld need to o be paid to o equity co onsideration ns so as to avoid wide ening dispa arities betw ween urban n and rural populations p s and higher r and lower r income gr roups. Prof fessor Kwon conclud ded by com mmenting on n the appro opriate link ks between health care e and g-term care e, which cu ut across different elem ments of th he health sy ystem, inclu uding long serv vice deliver ry and fina ancing. Furt ther researc ch on healt th care and d long-term care opti ions for older people is s needed giv ven the rapi id increase in the share e of older pe eople in th he populatio on. Mr Eduardo E K Klien, Reg gional Director, Ea ast-Asia/Pacific Reg gional Dev velopment Centre, HelpAge H In nternational, gave a presentation n on Help pAge Inte ernational's work in th he Region. He underl lined the im mportance of empowering

8 peop ple to age healthily rather than n to Figu ure 7. mer rely live e longer r. HelpA Age Inte ernational's work enco ompasses th hree broa ad areas: (1) ( promot ting spaces s at com mmunity lev vel for self-care, hea althy agei ing, knowledge and practice; (2) developing studies and research; and d (3) porting elopment supp of the deve com mprehensive e care gies. strateg Dev veloping an nd supportin ng older peo ople asso ociations (O OPAs) is a key activity y in the first action area (see Figure 7). Th hese ups comprise a key dimension n of grou both h civil soci iety particip pation and older peop ple's partici ipation, bot th of which h are cruc cial for the ageing and d health age enda. OPAs s' activities cover mult tiple areas, from wom men's partic cipation and d income se ecurity to health h check k-ups, hom me-care and selfcare e. OPAs hav ve the poten ntial to be a great resou urce for cou untries to ad ddress the needs n of it ts older peo ople. In the second s actio on area, HelpAge Inter rnational su upports a number of s studies to st trengthen th he evidence e base on ageing a and health. h Exa amples inclu ude a part ticipatory st tudy on pri imary healt th care for older peop ple in five Asian coun ntries (Cam mbodia, In ndia, Indon nesia, Sing gapore and d Viet Nam m), which frames health h thro oughout the life course e as a huma an right. Wi ith respect to t the third action area a, Mr Klie en highlight ted the imp portance of promoting a continuu um of care, given chan nging fam mily and care e dynamics s in many countries of the Region n. Models of volunteer- and com mmunity-bas sed care (s such as tha at carried out o with th he support of OPAs) hold prom mise for ma any countrie es in the Re egion. Mr Klien K conclu uded by stre essing impo ortant poli icy-relevant t lessons th hat could be e learnt from m existing innovative practices across the Region. Mr Sri inivas Tata a, Chief, Social S Poli icy and Population P S Section, Social velopment Division, D the United Na ations Econ nomic and Social S Comm mission for Asia Dev and the Pacific (UNESCAP), presen nted an ov verview of his organiz zation's wor rk in ation to ageing and hea alth. UNES SCAP serves as an inte ergovernme ental platfor rm to rela develop a regio onal response to popula ation ageing g, share kno owledge and d good prac ctices a it ts challenge es, promote e implement tation of the e Madrid In nternational Plan in addressing of A Action on Ageing A (MIP PAA) and ex xplore the feasibility f of a convention on the rights r of o older person ns. UNESCA AP provide es technical assistance to t Member States to de esign and implement t policies an nd program mmes and to o review MI IPAA imple ementation. . The come docum ment of the e Asia-Pacific review of MIPAA A implemen ntation incl ludes outc seve eral health-r related reco ommendatio ons that can n serve as in nputs to the e global MI IPAA revi iew as well as to the WHO W draft regional r fra amework fo or action. Po opulation ag geing and the health h of older people are e clearly a broad and d complex topic, requ uiring rdination ac cross sector rs, agencies s and levels s of governa ance, as we ell as chang ges in coor behaviours and d mindsets. Opportunit ties for coll laboration include i the NCD and postment agenda as, efforts to o draft a con nvention on n the rights of older per rsons 2015 developm artnerships with civil society, s Uni ited Nations s agencies and a governm ments. and growing pa ighted the need n for rights-based and eviden nce-based action, a inclu uding Mr Tata highli rmative an nd operational initiati ives and contextualiz c zing efforts by advocacy, nor ntries' stag ges in the epidemiolog e gical transi ition and levels of de evelopment t. He coun concluded by stressing th he importan nce of an ap ppropriate health h syste ems respon nse to

9 population ageing, in particular increasing access to needed health technologies and medicine as well as engaging a range of stakeholders. In the discussions that ensued, participants welcomed the review of ageing and health policies in the Region and its emphasis on health systems. Several stated that appropriately strengthening health systems and policies is as important as improving the evidence base on the health of older people to inform policy-making. Numerous countries in the Region have developed laws, policies and programmes on ageing and health. Other countries can learn from these examples and good practices. Participants urged the inclusion of a strong focus on age-friendly health systems in the planned regional framework for action on ageing and health. Participants also recognized the review's focus on four of WHO’s six health systems building blocks and suggested extending the analysis to include the remaining two. Participants emphasized the need to analyse the breadth of existing policies in the Region, which offer a diverse set of options on ageing and health. Further analysis of these policy options and their implementation and effectiveness is needed. On the scope of the review, participants suggested further analysis of certain “grey areas” in health systems, as a stronger basis for the development of the regional framework. For example, clearly differentiating the health and social components of care could strengthen the policy analysis as well as the regional framework for action. Older people typically experience co-morbidities that many health systems are weakly equipped to handle. On service delivery, participants stressed the need to ensure a continuum of care for older people. This requires appropriate coordination and integration of care based on improved understanding of service delivery from the patients’ perspective, as well as from the supply side. Home- and self-care also need to be integrated into the care continuum. OPAs can potentially meet some of these care needs. Further attention is needed to explore community-based care models, given changing dynamics in families, which have traditionally performed this function. On health workforce, participants noted the wide range of health professionals engaged in care, including clinical service providers, those working in health promotion and disease prevention, social care workers and informal careers. Changing demands for different types of health workers would require efforts to strengthen the competencies of all workers in meeting the health needs of older people, including at the primary care level. In addition, increased investment is needed in certain specialities relevant to the health needs of older people. This would require changes in health worker education in terms of technical specialities as well as competencies of health workers. Health worker migration needs attention, given the expected increase in demand for health workers. On health financing, participants agreed that the policy review could highlight examples of effective health financing policies and practices, given the importance of this topic for population ageing. The potential involvement of the private sector is an area that deserves further analysis. Discussions also highlighted the policy links between financial accessibility of health care for older people and broader policy issues related to the retirement age, pensions and social security. In many countries, older people—especially those from low-income households—had little choice but to continue to work, often in the informal sector, due to limited social protection. Society

10 and the media a often fra ame popula ation agein ng as a fin nancial bur rden to soc ciety. ticipants strongly s su upported re-imaging r ageing as a a succ cess story and Part char racterizing older people as a resou urce to socie ety. Particip pants agreed d that medic cines and h health techno ologies had d the potenti ial to subs stantially im mprove old der people's health and d well-being g. However r, in transfe erring and appropriat tely adaptin ng them, the t availab bility, acces ssibility, af ffordability and icines and health h techn nologies wou uld need to be ensured. quality of medi al framewor rk for action n on ageing g and health h 2.3.3 Regiona Mr Sjo oerd Postm ma, Team Leader, H Health Serv vices Devel lopment, WHO W gional Offic ce for the Western W Pac cific, chaire ed the first half of the e session on n the Reg regi ional framework for ac ction on ag geing and health. Ms Anjana A Bhu ushan, Tech hnical Offi ficer (Health h in Devel lopment), WHO W Regional Office e for the Western W Pa acific, faci ilitated the second s half. . Professor AB Dey y, Professor r and Dean n, Departm ment of Ger riatric Medi icine, National Institu ute of Agein ng, All Indi ia Institute o of Medical Sciences, S ga ave an over rview he draft reg gional frame ework for action a on ag geing and he ealth. The objectives o o the of of th draf ft regional framework f for action were w (1) to promote a common understandin u ng of agei ing and hea alth, (2) to address a new w challenges and set prio orities on ag geing and health; h and (3) to stre engthen WH HO’s suppo ort on agein ng and hea alth in the Western Pa acific gion. The fr ramework would w advoc cate for gen nder-respon nsive, equity y-enhancing g and Reg hum man rights-b based actio on on agein ng and health. It wou uld include three pilla ars of action, namely y: promoting g healthy ag geing acros ss the life course; c prom moting univ versal lth coverage e; and stren ngthening th he evidence base. heal Health Po olicy Figu Ms Yuki Murakami, H ure 8. alyst, Orga anization f for Econo omic Ana Coo operation an nd Develop pment (OEC CD), pres sented an overview o of f OECD's work w on ageing a and health. Dat ta from OEC CD, WH HO and ot ther partne ers show that heal lth care cos sts consume e more than n 60% of older peop ple's dispo osable inco ome, luding for those t from households in incl the higher income deciles. She hlighted the e complexiti ies and cost ts of high cari ing for olde er people, and a the need d to coor rdinate bot th the hea alth and so ocial com mponents of f “care”. Lo ong-term ca are is mean nt for those who need assistance on a cont tinuing basi is due to ch hronic impai irments and d reduced in ndependence e in carryin ng out activ vities of da aily living. Different D ty ypes of long g-term care models are available in i the Reg gion and bey yond (see Figure F 8). Care C for olde er people, especially e lo ong-term ca are, is a co omplex issu ue, requirin ng substantial coordina ation and co ollaboration n across sec ctors. All OECD cou untries need d appropria ate policies and arrang gements to provide fo ormal g-term care services, even e though h family an nd other typ pes of inform mal care re emain long

11 traditional backbones. It also has important implications for health systems elements, such as the health workforce. Dr Megumi Kano, Technical Officer, WHO Centre for Health Development, presented an overview of the centre's work. The centre has worked extensively on urban health, including development of the Urban Health Equity Assessment and Response Tool (Urban HEART), to enable local and national officials to identify health inequities and identify appropriate actions to reduce them. The centre's work on metrics for ageing and health equity includes exploratory analyses of intra-urban health inequalities by socioeconomic status among older people in Japan. With the Centre for Well-being and Society at Nihon Fukushi University in Nagoya, Japan, the WHO Centre for Health Development has developed benchmarks to align JAGES with Urban HEART. The centre has also led the development of indicators for age-friendly cities. Innovation for healthy ageing is a new area of focus. A Consultation on Advancing Technological Innovation for Older Populations in Asia, held in February 2013, considered the role of medical and assistive devices in relation to ageing and health. A WHO Global Forum on Innovation for Healthy Ageing is planned for December 2013. In the discussions that followed, participants welcomed the development of the regional framework for action on ageing and health. Participants supported the overall objectives and several suggested including a vision statement, emphasizing older people's experience, skills and wisdom as a resource to society, especially if they are enabled to retain their health and live in environments that promote their active participation. Participants also welcomed the framework's emphasis on the crosscutting issues of gender, equity and human rights, including the participation of older people. On the framework's structure and content, participants generally supported the proposed components as appropriate, especially the focus on promoting age-friendly health systems. WHO could play a valuable role in supporting Member States in this area. They suggested highlighting key health systems challenges with regard to ageing and outlining some suggested actions. Participants also agreed that adequate data collection and knowledge translation are important inputs to inform appropriate policy development and action on ageing and health. The relevant section of the framework should highlight the current situation, potential challenges such as the lack of standardization, and suggested actions. Participants suggested dealing with “promoting healthy ageing across the life course”, in two sections: the first on ageing and health across sectors, stressing the importance of fostering age-friendly environments and the leadership role of the health sector to engage in multisectoral action on ageing and health; and the second on promoting healthy ageing across the life course, recognizing the need for policies and actions to reduce exposure to risk factors for NCDs.

Four pillars of action were proposed for the regional framework for action: (1) (2) (3) (4) foster age-friendly environments through action across sectors; promote healthy ageing across the life course and prevent functional decline and disease among older people; promote universal health coverage through age-friendly health systems; and strengthen the evidence base on ageing and health.

Participants agreed on the usefulness of including a section in the framework on implementation, offering suggestions on advocacy, political commitment and partnerships, and highlighting the importance of engaging with different stakeholders, including older people themselves. 2.3 Closing session

Dr Henk Bekedam concluded the consultation by warmly thanking the experts for their active participation. Their helpful advice would inform finalization of the regional framework for action on ageing and health. The framework would then be presented for further review and input from Member States at a meeting scheduled for July 2013. The final draft would be presented to the Regional Committee at its sixtyfourth session in October 2013. Its endorsement by the Regional Committee would strengthen political commitment and enable WHO to move forward on ageing and health. Dr Bekedam assured participants that WHO stood ready to advance this area of work, in collaboration with Member States and other partners, including the experts participating in this informal consultation.

13 ANNEX 1: List of participants

1. Temporary advisers Professor Julie Byles, Director, Research Centre for Gender, Health and Ageing University of Newcastle University Drive, Callaghan, New South Wales 2308, Australia Tel.: +61 2 4042 0668; Fax: +612 4042 0044; E-mail: Julie.Byles@newcastle.edu.au Dr Aparajit B. Dey, Professor and Head, Department of Geriatric Medicine, All India Institute of Medical Sciences Room No. 3091, Teaching Block, Ansari Nagar, New Delhi 110029, India Tel. + 91 11 2659 3639; Fax: +91 11 2658 8663; E-mail: abdey@hotmail.com Professor Catherine D'Este, Director, Centre for Clinical Epidemiology and Biostatistics and Deputy Head of School (Public Health), University of Newcastle University Drive, Callaghan, New South Wales 2308, Australia Tel.: +61 2 4042 0517; Fax: +61 2 4042 0044; E-mail: Catherine.DEste@newcastle.edu.au Professor Hal Kendig, Professor of Ageing and Public Policy, Center for Research on Ageing, Health and Wellbeing, Australian National University, CMBE/RSPH, Building 62A, Canberra, ACT 0200, Australia Tel.: +61 2 6125 5625; Fax: +61 2 9351 9566; E-mail: hal.kendig@anu.edu.au Mr Eduardo Klien, Regional Director, HelpAge International East-Asia/Pacific Regional Development Centre 6 Soi 17, Nimmanhaemin Road, Suthep, Muang, Chiang Mai, Thailand 50200 Tel.: +66 53 225 440; Fax: +66 53 225 441; E-mail: eduardo@helpageasia.org Professor Josefina Natividad, Director and Professor of Demography, Population Institute 3rd Floor, Palma Hall, University of the Philippines, Diliman 1101, Quezon City, Philippines Tel.: +63 2 920 5402; Fax: +63 2 920 5402; E-mail: jnatividad55@yahoo.com Dr Katsunori Kondo, Professor, Faculty of Social Welfare, Graduate School of Health and Social Services Management, Nihon Fukushi University 5-22-35 Chiyoda, Naka-ku, Nagoya-shi, Aichi 460-0012, Japan Tel.: +81-52-776-5170; Fax: +81-52-776-5170; E-mail: kkondo@n-fukushi.ac.jp Professor David Phillips, Chair Professor of Social Policy, Department of Sociology and Social Policy WYL323, Dorothy Y L Wong Building, Lingnan University, Tuen Mun, N.T., Hong Kong, China Tel.: +85 2 2616 7179; Fax: +85 2 2616 5599; E-mail: phillips@LN.edu.hk

14 Annex 1

Professor Soonman Kwon, Dean, School of Public Health, Seoul National University 1 Kwanak-ro, Kwanak-gu, Seoul 151-742, Republic of Korea Tel.: +82 2 880 2721; Fax: +82 2 762 2888; E-mail: kwons@snu.ac.kr Dr Srinivas Tata, Chief, Social Policy and Population Section,Social Development Division, United Nations Economic and Social Commission for Asia and the Pacific, United Nations Building, Rajadamnern Nok Avenue, Bangkok 10200, Thailand Tel: +66 2 -288-1667; Fax: +66 2 288 1030; Email: tatas@un.org Ms Yuki Murakami, Health Economist/Policy Analyst, Health Division, Directorate for Employment, Labour and Social Affairs, Organisation for Economic Co-operation and Development 2, rue André Pascal, 75775 Paris Cedex 16, France Tel.: +33 1 45 24 93 23, Fax: +33 1 44 30 63 61, E-mail: Yuki.murakami@oecd.org Dr Wang Limin, Professor and Acting Deputy Director of Department of Disease Surveillance, National Center for Chronic and Non-Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention 27 Nanwei Road, Xicheng District, Beijing, China, Tel.: +86 10 8313 6482; +8615010927830; Fax: +86 10 8313 6481, E-mail: wlm65@126.com 2. Secretariat WHO Western Pacific Regional Office Dr Henk Bekedam, Director, Division for Health Sector Development World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +63 2 528 9802; Fax: +63 2 521 1036; E-mail: bekedamh@wpro.who.int Dr Susan Mercado, Director, Building Healthy Populations and Communities World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +6 32 528 9852, Fax.: +63 2 521 1036; E-mail: mercados@wpro.who.int Dr Dale Huntington, Director, Asia Pacific Observatory on Health Policy and Systems, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +63 2 528 9820; Fax: +63 2 521 1036; E-mail: huntingtond@wpro.who.int Mr Sjoerd Postma, Team Leader in Health Services Development, Division for Health Sector Development, World Health Organization Regional Office for the Western Pacific, P.O. Box 2932, Manila 1000, Philippines Tel: +63 2 528 9806, Fax: +63 2 521 1036; Email: postmas@wpro.who.int

15 Annex 1

Dr Gulin Gedik, Team Leader, Human Resources for Health, Division for Health Sector Development, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +63 2 528 9816; Fax.: +63 2 521 1036; E-mail: gedikg@wpro.who.int Dr Xu Ke, Team Leader, Health Care Financing, Division for Health Sector Development, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel: +63 2 528 9711; Fax.: +63 2 521 1036; E-mail: xuk@wpro.who.int Dr Manju Rani, Senior Technical Officer, Health Research Policy, Division for Health Sector Development, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +63 2 528 9048, Fax.: +63 2 521 1036; E-mail: ranim@wpro.who.int Dr Hai-Rim Shin, Team Leader, (Noncommunicable Diseases and Health Promotion), Division for Building Healthy Populations and Communities, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +63 2 528 9860; Fax.: +63 2 521 1036; E-mail: shinh@wpro.who.int Dr Cherian Varghese, Senior Medical Officer (Noncommunicable Diseases), Division for Building Healthy Populations and Communities, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel. No.: +63 2 528 9866; Fax.: +63 2 521 1036; E-mail: varghesec@wpro.who.int Ms Anjana Bhushan (Responsible Officer), Technical Officer (Health in Development), Division for Health Sector Development, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +63 2 528 9814; Fax: +63 2 528 9072; E-mail: bhushana@wpro.who.int Ms Britta Baer, Technical Officer (Gender, Equity and Human Rights), Division for Health Sector Development, World Health Organization Regional Office for the Western Pacific P.O. Box 2932, Manila 1000, Philippines Tel.: +63 2 528 9084; Fax: +63 2 528 9072; E-mail: baerb@wpro.who.int WHO Geneva Dr Ritu Sadana, Lead Specialist, Department of Ageing and Life Course, World Health Organization, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland Tel.: +41 22 791 3250; Fax: +41 22 791 0746; E-mail: sadanar@who.int

16 Annex 1

WHO Centre for Health Development Dr Megumi Kano, Technical Officer, WHO Centre for Health Development I.H.D. Centre Building 9F, 5-1, 1-chome, Wakinohama-Kaigandori, Chuo-ko, Kobe 651-0073, Japan Tel.: +81 78 230 3105; Fax: +8178 230 3178; E-mail: kanom@who.int

ANNEX 2: Timetable INFORMAL EXPERTS’ CONSULTATION ON AGEING AND HEALTH IN THE WESTERN PACIFIC REGION

Time 8:00 08:3010:00

DAY 1 - Tuesday, 9 April 2013 Registration Opening session Opening remarks:  Dr Henk Bekedam, Director (Health Sector Development)  Dr Susy Mercado, Director (Building Healthy Communities and Populations) Introduction of participants Presentation: Global update on ageing and health (15’)  Dr Ritu Sadana, Lead Specialist (Ageing & Life Course), WHO Headquarters Presentation: Regional update on ageing and health (15’)  Ms Anjana Bhushan, Technical Officer (Health in Development) Group photo Break Session 1a: Health situation of older people in the Western Pacific Region Facilitator: Dr Hai-Rim Shin, Team Leader (NCDs and Health Promotion) Presentation: Health situation of older people in the Western Pacific Region – quantitative analysis (15’)  Professor Julie Byles, Director, Research Centre for Gender, Health and Ageing, University of Newcastle (WHO CC), Australia Presentation: Health situation of older people in China (10’)  Dr Wang Limin, Director, Division of Disease Surveillance, Chronic Disease Control Center, China CDC, Beijing, China Presentation: Health situation of older people in Japan (10’)  Dr Katsunori Kondo, Professor, Faculty of Social Welfare, Graduate School of Health and Social Services Management, Nihon Fukushi University, Japan Discussion Lunch Session 1b: Health situation of older people in the Western Pacific Region Facilitator: Dr Cherian Varghese, Senior Medical Officer (NCDs) Facilitated discussion based on guided questions: 1. What are the most important conclusions from the information presented? 2. What further information needs to be collected [what are the gaps] to enable the development of appropriate policy or programmatic recommendations? 3. What are the potential policy/programmatic options based on the report findings? Break Session 2a: Policies on ageing and health in the Western Pacific Region Facilitator: Dr Gulin Gedik, Team Leader (Human Resources for Health) Presentation: Policies on ageing and health in the Western Pacific Region (15’)  Professor Soonman Kwon, Dean, School of Public Health, Seoul National University, Republic of Korea

10:00 10:3012:00

12:00 13:3015:00

15:00 15:3017:00

18 Presentation: Comments and overview of work by HelpAge International (10’)  Mr Eduardo Klien, Regional Representative, HelpAge International, East-Asia/Pacific Regional Development Centre, Thailand Presentation: Comments and overview of work by UNESCAP (10’)  Mr Srinivas Tata, Chief, Social Policy and Population Section, Social Development Division, UNESCAP, Thailand Discussion Informal get-together to welcome participants DAY 2 - Wednesday, 10 April 2013 Session 2b: Policies on ageing and health in the Western Pacific Region Facilitator: Dr. Ke Xu, Team Leader (Health Care Financing) Facilitated discussion based on guided questions 1. What key areas regarding ageing and health are not addressed by the policy review? 2. What is the ‘adequacy’ and ‘appropriateness’ of existing policies (in developed and developing countries)? Are policy gaps the major issue, or policy implementation the major issue, or both? 3. Which are the areas where appropriate policy and programmatic action will lead to maximum gains? Break Session 3a: Regional framework of action on ageing and health Facilitator: Mr Sjoerd Postma, Team Leader (Health Services Development) Presentation: Overview of the Draft Regional framework of action on ageing and health (15’)  Professor A.B. Dey, Professor, Department of Medicine & Nodal Officer, National Institute of Ageing, All India Institute of Medical Sciences, India Presentation: Comments and overview of work by OECD (10’)  Ms Yuki Murakami, Health Policy Analyst, OECD, France Presentation: Comments and overview of work by the WHO Kobe Centre (10’)  Dr Megumi Kano, Technical Officer, WHO Kobe Centre for Health Development, Japan Discussion Lunch Session 3b: Regional framework for action on ageing and health Facilitator: Ms Anjana Bhushan, Technical Officer (Health in Development) Facilitated discussion based on guided questions: 1. Does the draft framework adequately reflect the available evidence on ageing and health? 2. How should the Regional framework for action be used in countries (—as an advocacy tool, helping to inform policy/programmatic options, mobilizing financing)? Does the draft fulfil those expectations? 3. How can WHO support implementation in countries and monitor progress on the Regional Framework for action? Break Closing session: Way forward and next steps Facilitator: Dr Henk Bekedam, Director, Health Sector Development

18:0019:30 Time 8:3010:00

10:00 10:3012:00

12:00 13:3015:00

15:00 15:3016:30

ANNEX 3: Presentations

Proportion of Population Over Age 60, 2012

Global Update on Ageing and Health Informal Experts' Consultation 9 - 10 April 2013 Manila

Dr Ritu Sadana, Lead Specialist Dr John Beard, Director Department of Ageing and Life Course WHO Geneva 2| Global Conference on Ageing 2010

Proportion of Population Over Age 60, 2050

Pace of Ageing - Accelerated

Global Conference on Ageing 2010

Hypertension in people 50 plus - Untreated

Source: SAGE wave 1 2007 – 2010, n = 34,124

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

ANNEX 3: Presentations

3 Approaches to the Challenges of Population Ageing

INACTION Pretend there is no demographic change and continue with current approaches

INACTION REACTION ACTION 7| WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

CONSEQUENCES More developed countries or sub areas – Increasing health and social protection costs with questionable benefit – Marginalisation of older adults and loss of human and social capital

Less developed countries or sub areas – Increasing inequity, reduced productivity due to family burden 8| WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

REACTION Respond by addressing the symptom (e.g. current model yet with reduced health and social benefits) CONSEQUENCES More developed countries – Initial fall in direct commitments, long term increase in indirect costs

ACTION Invest in sustainable health and social systems that liberate the human resource of older populations and enhance socioeconomic development, while also building social protection and responding to health needs. 10 | WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

Less developed countries – Entrench unproductive systems (inefficient, inequitable, injust)

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

Taking Action on Ageing and Health Promoting good health and healthy behaviours at all ages – life course approach Equipping health systems to minimize the consequences of chronic diseases Creating physical and social environments that foster health and participation Reinventing ageing 11 | WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

Linear Lifeplan

0 Age

80 85

Education 12 | Global Conference on Ageing 2010

Work/Family

Leisure

WHO 2012

Thanks to Ken Dychtwald

ANNEX 3: Presentations

Linear Lifeplan “Longevity Bonus”

0 Age

80 85

Education 13 | Global Conference on Ageing 2010

Work/Family

Leisure 14 | Global Conference on Ageing 2010

Cyclic Lifeplan

0 Age

80 85

Education 15 | Global Conference on Ageing 2010

Work/Family

Leisure 16 | Global Conference on Ageing 2010

Thanks to Ken Dychtwald

TAKING ACTION Health policy implications What can the health sector do? What can each health system function do? What can major public health programmes do? What can universal health coverage do? 17 | WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

What level of policy implication? Policy implications: ageing and health Implied questions

Broader policy implications What can government do? What can civil society do? What can regional and global institutions do? What can be done together? What specifically can I do about it?

Legislation can help protect from discrimination, ageism and social exclusion. Health policies should remove barriers to health care access and integrate social services. Labour market, education and family welfare policies should aim to sustain intergenerational solidarity. Interventions to maintain independence and social participation are needed at the individual and the community levels

What sort of legislation? How would they do this? How would they do this? What sort of interventions?

18 |

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

ANNEX 3: Presentations

General Programme of Work 2014-19

Ageing and health work 2014-2015 Support countries to strengthen their own capacities and articulate their own policies Global report on ageing and health, leading to a global plan of action on ageing and health Model and measures for monitoring and quantifying the diverse health needs of older people and whether these needs are met WHO Global and Regional Networks of Age-friendly Cities and Communities strengthened

19 |

IFMSA August 2009

20 |

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

WHO global network of age-friendly cities and communities

Ageing and health work 2014-2015 Technical guidelines on management of frailty, with a focus on low- and middle-income countries Policy options on long-term care – to maintain independence as long as possible, integrate health and social care, offer assistive devices and palliative care Policy options on workforce development – pre service and in service training, not only for chronic diseases Policy options on the health of women across the life course beyond the reproductive age

21 |

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

22 |

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

Need a framework – WHO has some Health policy Classifications & Measures Broader policy

Catalyzing action on ageing and health Knowledge generation with collaborators (data, analysis, research, guidelines, evidence synthesis) – global public goods Knowledge translation in countries (evidenceinformed policy dialogues, identification and implementation of policy options, monitoring impact) – learning and accountability Strengthen expert and institutional networks and collaborations (channel expertise, evidence, experience for Member States) – increasing capacities

23 |

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

24 |

WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

ANNEX 3: Presentations

Ageing and health: updates from the Western Pacific Region

THANK YOU !

Anjana Bhushan, Technical Officer (Health in Development) 25 | WPRO Informal Experts' Consultation, 9 to 10 April 2013, Manila

Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region Manila, Philippines 9-10 April 2013

Ageing-related challenges in the Region 1. Increasing disease burden: health promotion, prevention agenda 2. Weak health systems and services: need for age-friendly health systems 3. Social and economic impacts 4. Equity, gender, human rights issues 5. Inadequate evidence base

Varying demographic transitions Percentage of Men and Women age 60 and over by Countries, WPRO, 2010 Papua NG Solomon Is Brunei Vanuatu Lao PDR Cambodia Mongolia Philippines Samoa Fiji Malaysia Viet Nam Tonga China Singapore R. Korea Hong Kong New Zealand Australia Japan 0 4.2 4.5 4.8 5.2 5.7 6.1 6.4 6.8 7.4 7.9 8 8.8 8.9 12.7 15 15.9 16.1 19 19.9 31.6 5 10 15 20 25 30 35

Women Men

Source: United Nations Dept of Economic and Social Affairs, Population Division, World Population Prospects: The 2008 Revision, 2008.

Time taken for population aged 60 years and above to double, selected countries, Western Pacific Region P o p u latio n a g ed 60 y ears an d a b o ve (% )

Morbidity and disability in older people Top 10 causes of DALYs lost for men, 60-79 years, Western Pacific Region (2004) 3% 4% 4% 31% Cardiovascular diseases Malignant neoplasms Respiratory diseases Sense organ diseases Neuropsychiatric conditions 9% 3% 3% 30%

1940 14%

1950

1960

1970

1980

1990

2000

2010

2020

2030

2040

2050 Philippines

2060

Lao People’s Democratic Republic

Top 10 causes of DALYs lost for women, 60-79 years, Western Pacific Region (2004) 3% 5% 2% Cardiovascular diseases Malignant neoplasms Respiratory diseases Sense organ diseases Neuropsychiatric conditions Infectious and parasitic diseases Digestive diseases Unintentional injuries 16% Musculoskeletal diseases 15% Diabetes mellitus

3% 2%

Hong Kong (China) New Zealand

12%

Infectious and parasitic diseases Digestive diseases Unintentional injuries

7% Australia Japan China Fiji Cambodia Papua New Guinea 14% 21%

Musculoskeletal diseases Diabetes mellitus

14%

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision

Source: World Health Statistics, WHO

ANNEX 3: Presentations

Australia New Zealand

Labor force participation of population 65 years and above, selected countries, Western Pacific Region (2010) 100 90 80

Literacy in population aged 60 years and above, selected countries, Western Pacific Region (2000) Republic of Korea 100 90 80 70 Literacy rate 60 50 40 30 20 10 Men Women Total

China

Singapore Hong Kong (China) Literacy rate

Macao (China) China

Women Men

70 60 50 40 30 20 Men Women Total

Brunei Darussalam Japan Republic of Korea Malaysia Mongolia Fiji Cambodia Viet Nam Papua New Guinea

Total

10 0 60-64 65-69 Age 70+

0 60-64 65-69 Age 70+

Malaysia 100 90 80 70 Literacy rate 60 50 40 30 20 Men Women Total Literacy rate 100 90 80 70 60 50 40 30 20 10 0

Cambodia

Philippines Lao PDR Solomon Islands

Men Women Total

10 0 60-64 65-69 Age 70+

Percentage of population 65 years & above Source: United Nations, Department of Economic and Social Affairs. World Population Ageing 1950-2050

60-64

65-69 Age

70+

Source: United Nations, Department of Economic and Social Affairs. World Population Ageing 1950-2050

Initiating a response • Informal Experts’ Consultation on Healthy Ageing in the Western Pacific Region (05/11) • World Health Day 2012: Ageing and health--good health adds life to years. Press release, RD’s op-ed, video statement; posters, stories; Video: What can you do to have a healthy old age?; data and information sheet; webpages; events in RO, countries

2013 Regional Committee: ageing and health Preparatory work ongoing: • Review and analysis of policies on ageing and health in selected countries in the Region: led by School of Public Health, Seoul National University.

• Ageing, gender and women’s health: – Module on Ageing, Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals – Women and Health in the Western Pacific Region: Remaining Challenges and New Opportunities—chapter on older women

Analysis comprises: – desk review of policies from a larger number of countries – in-depth analysis for 4 countries (China, Fiji, Philippines, Viet Nam), based on country visits Findings include policy implications, presented in policy brief format

2013 Regional Committee: preparations • Comparative study on the health of older persons in selected countries in the Region (secondary analysis of existing datasets): led by Research Centre for Gender, Health and Ageing (WHO collaborating centre), Univ of Newcastle, Australia.

2013 Regional Committee: preparations • Systematic review on needs for assistive devices for older people in selected countries in the Western Pacific Region (WHO Geneva/WHO Kobe Centre) • Draft regional framework of action on ageing and health

Products: – country fact sheets on ageing and health: broader range of countries – report on findings and recommendations from in-depth comparative analysis: smaller set of countries

ANNEX 3: Presentations

Countries included in WHO/WPRO analytical work on ageing Country/Area Comparative study Information sheets In-depth survey data analysis Policy study Desk review In-depth analysis, country visits Medical assistive devices mapping project

Key events 2013 • Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region, 9-10 April 2013, Manila: to discuss findings from analytical work, draft framework of action • Consultation on Ageing and Health in the Western Pacific Region, June 2013 • Regional Committee Meeting, 25-29 October 2013 • Follow-up country support

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands, Commonwealth of the Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna X X X X X X X X X X X X X X X X X X X X X

Informal Experts’ Consultation Objectives: 1. to discuss preliminary findings and recommendations from ongoing analytical work on ageing and health in the Region 2. to identify priority actions WHO could take in cooperation with Member States to address the health aspects of population ageing

Thank you

Your inputs are vital and much appreciated!

http://www.wpro.who.int/topics/ageing/en/

Ageing and health: updates from the Western Pacific Region

Anjana Bhushan, Technical Officer (Health in Development) Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region Manila, Philippines 9-10 April 2013

ANNEX 3: Presentations

Time taken for population aged 60 years and above to double, selected countries, Western Pacific Region P o p u latio n a g ed 60 y ears an d a b o ve (% )

1940 14%

1950

1960

1970

1980

1990

2000

2010

2020

2030

2040

2050 Philippines

2060

Lao People’s Democratic Republic

Women Men

Hong Kong (China) New Zealand

7% Australia Japan China Fiji Cambodia Papua New Guinea

Source: United Nations Dept of Economic and Social Affairs, Population Division, World Population Prospects: The 2008 Revision, 2008.

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision

Morbidity and disability in older people Australia

Labor force participation of population 65 years and above, selected countries, Western Pacific Region (2010)

Top 10 causes of DALYs lost for men, 60-79 years, Western Pacific Region (2004) 3% 4% 4% 31% 6% Cardiovascular diseases Malignant neoplasms Respiratory diseases Sense organ diseases Neuropsychiatric conditions

Top 10 causes of DALYs lost for women, 60-79 years, Western Pacific Region (2004) 3% 5% 2% 3% 3% 30% Cardiovascular diseases Malignant neoplasms

New Zealand Singapore Hong Kong (China) Macao (China) China

Women Men

3% 2%

Brunei Darussalam Japan Republic of Korea Malaysia Respiratory diseases 9% Sense organ diseases Neuropsychiatric conditions Infectious and parasitic diseases Digestive diseases Unintentional injuries 16% Musculoskeletal diseases Diabetes mellitus 15% Musculoskeletal diseases Diabetes mellitus

Total

Mongolia Fiji Cambodia Viet Nam Papua New Guinea Philippines Lao PDR

12%

Infectious and parasitic diseases Digestive diseases Unintentional injuries

14%

21% 14%

Solomon Islands

0 Source: World Health Statistics, WHO

Percentage of population 65 years & above Source: United Nations, Department of Economic and Social Affairs. World Population Ageing 1950-2050

Literacy in population aged 60 years and above, selected countries, Western Pacific Region (2000) 100 90 80 70 Literacy rate Literacy rate

Initiating a response • Informal Experts’ Consultation on Healthy Ageing in the Western Pacific Region (05/11) Men Women Total

Republic of Korea 100 90 80 70 60 50 40 30 20 10

China

60 50 40 30 20 10 0 60-64 65-69 Age 70+ Men Women Total

• World Health Day 2012: Ageing and health--good health adds life to years. Press release, RD’s op-ed, video statement; posters, stories; Video: What can you do to have a healthy old age?; data and information sheet; webpages; events in RO, countries

0 60-64 65-69 Age 70+

Malaysia 100 90 80 70 Literacy rate 60 50 40 30 20 10 0 60-64 65-69 Age 70+ Men Women Total Literacy rate 100 90 80 70 60 50 40 30 20 10 0 60-64

Cambodia

Men Women Total

65-69 Age

70+

Source: United Nations, Department of Economic and Social Affairs. World Population Ageing 1950-2050

ANNEX 3: Presentations

Products: – country fact sheets on ageing and health: broader range of countries – report on findings and recommendations from in-depth comparative analysis: smaller set of countries

Countries included in WHO/WPRO analytical work on ageing

Country/Area

Comparative study Information sheets In-depth survey data analysis

Policy study Desk review In-depth analysis, country visits

Medical assistive devices mapping project

Informal Experts’ Consultation 1. to discuss preliminary findings and recommendations from ongoing analytical work on ageing and health in the Region 2. to identify priority actions WHO could take in cooperation with Member States to address the health aspects of population ageing

Your inputs are vital and much appreciated!

ANNEX 3: Presentations

Thank you

Professor Julie Byles Professor Cate D’Este WHO Collaborating Centre for International Longitudinal Studies of Gender, Ageing & Health Faculty of Health The University of Newcastle

http://www.wpro.who.int/topics/ageing/en/

Population Pyramids Purpose to document and compare population health data on selected WPR countries for persons 60+ to produce a series of factsheets on population ageing for selected WPR countries to compile WPR country and age specific data to inform research, practice and public health policy Lao 57

2010 & 2030

Republic of Korea 58

Population trends in younger and older age groups

Data Sources Obtained World Health Survey (WHS) Australia, China, Lao, Malaysia, Philippines, Viet Nam Multi Country Survey Study (MCSS) - Korea WHO Study on global AGEing and adult health (SAGE) - China SAGE INDEPTH - Viet Nam Not obtained JSTAR - Japan Data request under review National Health Survey - Australia Access granted 26/3/2013 Data not available Cambodia, Fiji

Lao

Republic of Korea

ANNEX 3: Presentations

Age standardised mean years of Education by Gender

Age standardised mean BMI by Gender

Mean years of Education

Mean BMI

Age standardised prevalence of Smoking by Gender

Age standardised Self Reported Health Males

Percentage (%)

Age standardised Self Reported Health Females

Age standardised prevalence of Extreme Difficulty in Moving Around - by Gender

Percentage (%)

ANNEX 3: Presentations

Age Standardised prevalence of Extreme Difficulty with Self Care – by Gender Percentage (%)

Age standardised prevalence of Arthritis by Gender 60 50 40

Percentage (%)

30 20 10 0 Australia China Lao Malaysia Philippines Viet Nam

Men Women

Summary All countries in the region are ageing Low income countries are younger, but ageing at a rapid rate Some countries have very high levels of disability at older ages There are substantial gender differences in disability for some countries

Health situation of older persons in China Wang Limin Professor, Director of Department of Disease Surveillance National Center for Chronic and Non-communicable Disease Control and Prevention (NCNCD) Chinese Center for Disease Control and Prevention (China CDC) 8- April 2013

Contents 1

The situation of ageing in China China is a most populous country in the world with a population of 1.3 billion, which makes up approximately a quarter of the world population. China has entered the aging society Aged ≥ 65 population is about one a hundred twenty million (8.9%) in China, above 15% in some big cities in 2010

The Situation of Ageing in China 2

The Health Policies for Older Persons in China

Public Health System in China Chronic Disease Situation of Older Persons

The economic burden of disease of the elderly is increasing From 1993 to 2011, the economic burden of disease of the elderly increased from 78 billion yuan to 428 billion yuan, the proportion of GDP increased from 2.1% to 3.3%, the price index adjustment, the economic burden of disease of the average annual growth of 12.9%, the treatment costs grown average annual 12.3%.

Challenge and Future Directions 7 1

ANNEX 3: Presentations

Chinese Population pyramid for 2010

The health policies for older persons in China

《 National Benefit Protection Law of Ageing Population 》《The Twelfth Five-Year Development Plan on Aging (20112015) 》《 The Plan for Chinese Chronic Disease Prevention and Control (2012-2015)》《 The Outline for Development Nursing Care in China(20112015) 》《National Specification on Basic Health Services for the Public(2011)》 ……. *Data source: National Census 2010

The measures for older persons health in China The Basic Health Services for the Public is implementing and steadily promoting from 2009 in China Elderly health management is one of important services among the Basic Health Services for the Public in primary health care center provide free physical and medical examination Evaluate lifestyle and health status Management for the hypotension and diabetes patients Health education Improve the primary health care network Strengthen elderly health service capacity

The measures for older persons health in China Consolidate and expand the coverage of new rural cooperative medical, improve the security level of elderly medical Develop the geriatric hospital, rehabilitation hospitals and home nursing Implement monitoring for the health status of older persons

Public Health System in China Ministry of Health Provincial health Departments Prefectural/city health Bureaus China CDC CAMS, NCCVD

Chronic Disease Situation of Older Persons ----method of survey The survey for the situation of older persons health was conducted by NCD and Risk Factor Surveillance in 2010. District : Disease Surveillance Points System (DSPs) covered 161 points in 31 Provinces. Diseases Surveillance Points System(DSPs ) Urban(64) Rural (97)

Provincial CDC

Hospitals, other health facilities

County health bureaus

City CDC

Hospitals, other health facilities

County CDC

Hospitals, other health facilities

Township Health Centers Village clinics Administration Professional guidance Technical cooperation

ANNEX 3: Presentations

Chronic Disease Situation of Older Persons ----method of survey Multi-stage random sampling design 4 • 4 township/street randomly from each county/district of DSP • 3 village/residential community randomly from each township/street

Chronic Disease Situation of Older Persons ----method of survey Contents of the survey

Questionnaire

Physical measurement

Blood test

• 50 household randomly from each village/residential community • 1 resident aged 18 years and above randomly from each household was done the individual questionnaire survey Physical measurements and Blood test. • All ≧50 family members were done family questionnaire survey .

97,200 aded≧18 19,981 aged≧60

Height Family Individual Weight Waist circumference Blood pressure

Fasting glucose OGTT Glycosylated hemoglobin(Hb A1c) Insulin Lipid

1/50

、

84,363 aged≧50 42,660 aged≧60

Chronic Disease Situation of Older Persons ----contents of survey Contents of Family Questionnaire age>=50

Chronic Disease Situation of Older Persons ----contents of survey Contents of Individual Questionnaire, age>=18

，

1. 2.

自报慢病便秘、睡眠障碍及嗅觉异常自报记忆力下降、运动障碍及老年性痴呆和帕金森病患病情况由于认知障碍或运动障碍的护理需求和护理现状

Self-reported chronic constipation, sleep disorder, Olfactory dysfunction Self-reported memory decline, movement disorder, Alzheimer's Disease and Parkinson’s Disease Nursing Demands

1. 2. 3. 4. 5. 6. 7.

吸烟行为饮酒行为身体活动膳食伤害口腔卫生自报高血压、糖尿病、中风及短暂性脑缺血等

1. 2. 3. 4. 5. 6. 7.

Tobacco use Alcohol consumption Physical activity Diet Injury Oral health Prevalence and control of chronic disease : Hypertension : Diabetes, Stroke TIA, etc.

，

Chronic Disease Situation of Older Persons Prevalence of main risk factors in the elderly(aged ≥60)(%)

100.0 90.0 80.0 70.0 87.086.0 84.9

现在吸烟率 (Current smoking) 人群危险饮酒率 Hazards drinking 人群有害饮酒率 Harmful drinking 蔬菜水果不足率蔬菜水果不足率 Insufficient fruit and vegetable intake Never doing exercise

Risk factors

Total 25.2 9.2 11.3

Male 46.5 10.5 13.2

Female 5.0 4.2 3.8

Urban 22.4 8.1 7.4

Rural 26.6 9.9 13.3

60.0 50.0 40.0 46.5

54.4

58.556.5

Male Female 25.2 13.2

（% ）

30.0 20.0

Total 10.5

10.0 0.0

9.2

11.3

5.0

4.2

3.8

56.5

54.4

58.5

49.6

59.8

current smoking

hazards drinking

harmful drinking

从不锻炼率

insufficient never doing fruit and exercise vegetable intake

84.9

87.0

86.0

73.2

92.1

Prevalence of main risk factors in the elderly

ANNEX 3: Presentations

Chronic Disease Situation of Older Persons Prevalence of main chronic diseases in the elderly(aged ≥60)

70 64 60.9 62.5

（%） Urban

Self-reported myocardial infarction(MI) incidence

肥胖率肥胖率 Obesity prevalence 血压升高率 Raised blood pressure prevalence 糖尿病患病率糖尿病患病率 DM prevalence 自报心肌梗死年发生率报心肌梗死年发生率自报脑卒中年发生率报脑卒中年发生率 Self-reported Stroke incidence 慢阻肺

NCD

Total

Male

Female

Rural

12.5 62.5 19.6 1.3 1.7 7.1

9.4 60.9 18.3 1.3 1.9 8.6

15.5 64.0 20.8 1.2 1.5 5.7

16.9 67.7 25.0 1.7 2.2 7.3

10.5 66.5 17.0

（%）

30 20.8 19.6 18.3 15.5 12.5 9.4 8.6 5.7 1.3 1.2 1.3 1.9 1.5 1.7

Male Female Total

1.1 1.4 7.1

7.1 1.2 1.4 1.3 2.3 2.5 2.4

0 Obesity Raised blood pressure DM Self-reported Self-reported Self-reported Self-reported Self-reported MI Stroke COPD AD in Memory PD decline Pop inmovement disorder Pop

Self-reported Chronic obstructive pulmonary prevalence (COPD ) Self-reported AD prevalence in Memory decline Pop

记忆力下降人群中患有老年痴呆下降人群中患有老年痴呆的中患有老年痴呆的比例 Self-reported PD prevalence in

1.3

1.2

1.4

1.3

1.4

运动障碍人群帕金森或帕金森综合症患病率(自报)

Prevalence of main chronic diseases in the elderly 2.4 2.3 2.5 3.7 1.9

老年人群主要慢性病患病情况

Chronic Disease Situation of Older Persons The disability status of elderly in China (aged ≥60)(%)

Chronic Disease Situation of Older Persons Prevalence of main chronic dysfunction in the elderly(aged ≥60) Chronic condition Total Male Female Urban Rural

Disability status

Total

Urban

Rural

Walking disability

行走失能

14.2%

13.1%

14.9%

Hearing disability

听力失能

29.4%

25.1%

31.6%

Language disability

语言失能

自报睡眠障碍患病率 14.2 Self-reported sleep disorder Self 自报嗅觉障碍患病率自报嗅觉障碍患病率 SelfSelf-reported olfactory dysfunction 8.5 自报便秘患病率自报便秘患病率 5.1 Self-reported chronic constipation Self-reported memory decline,

10.7

11.3

13.2 14.7 8.2 8.6 6.1 4.6

7.6 4.3

9.4 5.8

14.5% 30.0%

13.7% 25.3%

15.0% 32.5%

Vision disability Resource

视力失能

自报记忆力下降的自报记忆力下降的比例下降的比例

39.7 36.9 5.7 5.5

42.3

38.3

40.3

：An analysis report of national health services survey in China,2008

Self-reported movement disorder

自报每天出现运动障碍的比例自报每天出现运动障碍的比例

6.0

4.6

6.3

45 35.0% 31.6% 32.5%

42.3 39.7 36.9

40 35

29.4% 30.0% 25.1% 25.0%

30.0% 25.3%

total urba n rural

20.0% 14.9% 14.2% 13.1%

14.5% 13.7%

15%

15.0%

（%）25 20 15 10.7 11.3 9.4 7.6 8.5 5.8 4.3 5.1 5.5 6.0 5.7 14.2

Male Female Total

10.0%

5.0%

10 5 Walking disability Hearing disability Language disability Vision disability 0 Self –reported sleep disorder

0.0%

The disability status of elderly in china Resource

：An analysis report of national health services survey in China,2008

self-reported olfactory dysfunction

Self-reported Self-reported Self-reported chronic Memory decline movement constipation disorder

Prevalence of main chronic condition in the elderly

ANNEX 3: Presentations

45 40 35 30 25

40.3 38.3

Chronic Disease Situation of Older Persons Oral health status in the elderly(aged ≥60) (%) Oral health status Urban

Total

Male

Female

Urban

Rural

（%）

20 15 10 5 0 Self –reported self-reported Self-reported Self-reported Self-reported olfactory chronic Memory movement sleep disorder dysfunction constipation decline disorder

13.2

14.7 8.2 8.6 6.1 6.3

Rural

失牙率 Partially edentulous

74.0 12.6

71.0 10.9

76.8 14.3

70.0 10.0

76.0 13.9

4.6

全口失牙率

Completely edentulous

因牙周疾病失牙率

Edentulous caused by periodontal disease 20

63.3

62.1

64.5

67.0

61.5

Prevalence of main chronic dysfunction in the elderly

真牙颗数﹥ 真牙颗数﹥ Retention of natural teeth﹥20 每天刷牙 Brush teeth every day

51.3 74.4

54.7 86.0

48.1 67.3

58.2 86.0

47.8 67.3

100.0 90.0 80.0

86.0 76.8 71.0 74.0 62.1 64.5 63.3 54.7 48.1 51.3 Male

100.0 74.4

90.0 80.0 70.0 70.0 76.0 67.0 61.5 58.2 47.8

86.0

70.0 60.0

67.3

（%）

50.0 40.0 30.0 20.0

（%） Female Total

60.0 50.0 40.0 30.0 20.0 10.0 10.0 13.9

Urban Rural

10.9 10.0 0.0

14.3 12.6

Partially edentulous

Completely edentulous

Edentulous caused by periodontal disease

Retention of natural teeth 20

﹥

Brush teeth every day

0.0 Partially edentulous Completely edentulous Edentulous caused by periodontal disease Retention of natural teeth 20

﹥

Brush teeth every day

Oral health status in the elderly

Challenge The process of population aging is accelerating in China Higher prevalence of chronic disease and disability among elderly The growing demand for services of elderly health Health policies and measures were still not perfect Level of medical service for elderly needs to be increased

Future Directions • To consolidate and expand medical security • To improve the level of medical service for the elderly • To effectively implement the elderly health management project

of basic health services for the public • To structure indicators of monitoring for the elderly health • To strengthen the surveillance for the elderly health • To enhance data utilization •

Government, public, professional, media, etc.

ANNEX 3: Presentations

Japan Gerontological Evaluation Study

JAGES HEART

Health Equity Assessment and Response Tool

Thanks

A Benchmarking system for older persons’ health Katsunori Kondo, PhD, MD Center for Well-being and Society Nihon Fukushi University and Study Group of “Development of a Benchmark System for Comprehensive Policy Evaluation of Long-term Care Insurance” By Health and Labour Sciences Research Grant (H22-Choju-Shitei-008)

CONTENTS • Overview of the JAGES (Japan Gerontological Evaluation Study) Project • Overview of the JAGES HEART（Health Equity Assessment and Response Tool） 2012 • Challenges of JAGES HEART/AFC (Age Friendly Cities) indicators

Purpose of JAGES benchmark system • To benchmark using multi-faceted indicators for improving health situation and the performance of the public long-term care insurance(LTCI) – Particularly, prevention for functional decline

• Funded by the Ministry of Health, Labour and Welfare, Japan 100

Japan Gerontological Evaluation Study (JAGES) • One of the few population-based gerontological surveys in Japan • Focused on social determinants of health (SDH) and social environment • In 2010/11 questionnaires were sent to 170,000 older people and responded by 112,123 individuals across 31 municipalities in 12 prefectures (response rate: 66.3%)

Survey Items • Health status indicators: self-rated health, chronic conditions, health behaviour, oral health, nutrition/diet, tobacco, alcohol, ADL/IADL, etc • Psychological indicators: depression, subjective well-being, etc • Social indicators: social support, social capital, social participation • Socioeconomic status indicators: income, education, relative deprivation, pension, etc • Environmental indicators: road safety, parks and recreation, accessibility, etc

ANNEX 3: Presentations

JAGES met Urban HEART JAGES：Japan Gerontological Evaluation Study

• Urban HEART (Health Equity Assessment and Response Tool) is a management tool for all ages: modifying to fit for older people • Not only for developing countries but also for developed countries: should be modified for developed counties • Need a version for the older population & developed countries: JAGES HEART

Management Cycle

Set targets by benchmarking Each municipality could find health risks should be tackled http://square.umin.ac.jp/yobou_bm/areadata/13_tokyo.html

Quintiles: Highest ････････････Lowest

Municipality

Find target areas and related factors % of high risk group for dementia

School districts with higher sports-group participation rates show lower rates of fall among the aged 65-74

Dementia risk and participation into community organization JAGES 80 70 60 50 40 30 20 20 40 60 80 100 2

24 municipalities 175 school districts 2 2

Sports group participation rate

R=-0.56

～ 999/km 10001000 - 1499/km 1500/km ～ urban 農村準都市 semi-urban 都市 rural R=-0.54

Population density in habitat area

Older >=75y.o.

n=29,876 Districts with higher rate of participation tend to show lower prevalence of high risk group for dementia 8 community organizations （political, industrial, volunteer, senior, religious, sports, hobby, neighborhood）

R=-0.28

Rate of fall

Rate of fall in the previous year

R=-0.55

% of Participation in community organization http://www.doctoral.sakura.ne.jp/WebAtlas/JAGES_HEART/23000_Chita/Double/atlas.html

Sports group participation

ANNEX 3: Presentations

Hobby group participation & Depression JAGES 2010/11 GDS, Mean

Changes in rate (%) during four years 14

Experiences of fall during the previous year(%)

）

25 municipalities Male, <75 y.o. Male, 75 y.o. ≦ Female, <75 y.o. Female, 75 y.o. ≦

7 municipalities

Depression Score

（

◆2006 ■2010

Municipalities with higher rate of hobby group participation show lower score of depression scale Rate of hobby group participation

4 0 10 20 30

Participation in sports clubs(%)

Future research challenges • Examination – reliability and validity of indicators

Conclusions • WHO Kobe Center (WKC) is developing Urban HEART / Age Friendly Cities (AFC) indicators. • JAGES & WKC develop JAGES HEART for older people in Japan • The importance of inequalities in health and SDH are confirmed. • Many challenges remain

• Refinement and revision – JAGES HEART 2012 to new versions – Fit into the framework of Age Friendly Cities indicators

• Widely accepted and used? – 31 municipalities participated in 2010/2011 Is further expansion in 2013 possible?

• We need more researches and efforts

References Kondo K. ed. Health Inequalities in Japan: An Empirical Study of the Older People. Trans Pacific Press, Melbourne, 2010 2. Chiyoe Murata, Katsunori Kondo, et al: Association between depression and socio-economic Gerontological Evaluation Study(AGES).Health and Place14:406-414,2008 3. Naoki Kondo, Ichiro Kawachi, Hiroshi Hirai, Katsunori Kondo, et al : Relative deprivation and incident functional disability among older Japanese woman and men : prospective cohort study. Journal of epidemiology and Community Health 63 : 461-469, 2009 4. Yukinobu Ichida, Hanibuchi T, Kondo K, et al: Social capital, income inequality and self-rated health in Chita peninsula, Japan: a multilevel analysis of 25 communities. Social Science & Medicine 69(4)： 489-499, 2009 5. Akihiro Nishi, Katsunori Kondo, et al: Cohort Profile: AGES 2003 Cohort Study in Aichi, Japan. Journal of Epidemiology vol.21, No.2:151-157, 2011 6. Hanibuchi T, Murata Y, Ichida Y, et al: Place-specific constructs of social capital and their possible associations to health: A Japanese case study. Social Science & Medicine [Epub ahead of print] doi: 10.1016/j.socscimed.2012.03.017 7. Jun Aida, Katsunori Kondo, et al: Does social capital affect the incidence of functional disability in older Japanese? A prospective population-based cohort study, J Epidemiol Community Health 2013;67:42-47 doi:10.1136/jech-2011-200307 8. Yamamoto T, Kondo K, et al: Dental status and incident falls among older Japanese: a prospective cohort study. BMJ Open 2012;2:e001262 doi:10.1136/bmjopen-2012-001262. 9. Hirai H, Kondo K, et al: Social Determinants of Active Aging: Differences in Mortality and the Loss of Healthy Life between Different Income Levels among Older Japanese in the AGES Cohort Study. Current Gerontology and Geriatrics Research Vol.2012 (2012).doi:10.1155/2012/701583 10. Satoru Kanamori, Yuko Kai, Katsunori Kondo, et al: Participation in sports organizations and the prevention of functional disability in older Japanese: the AGES Cohort Study, PLOS ONE，2012 1.

Policies on Aging and Health in the Western Pacific Region April 9, 2013

Soonman KWON, Ph.D. Dean School of Public Health Seoul National University, Korea 114

ANNEX 3: Presentations

OUTLINE of Presentation I. Challenges of Population Aging II. Health Policy and System for the Elderly III. Policy Recommendations

Challenges of Population Aging

Japan Korea and Singapore China and Vietnam Australia and New Zealand Philippines

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Old-Age Dependency (65+/(20-64)) Rising demand for health and long-term care - Health status, mental health, disability Declining family support - Migration of young workers from rural to urban areas - Increased labor participation of women - Increased number of the elderly living alone Insufficient financial capacity of the elderly - Limited pension and public assistance for the elderly

117 Source: UNDESA (2011)

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II. Health Policy and System for the Elderly 1. National Policy and Governance Many countries have law on aging, national policy and strategy, and national committees related to ageing Social welfare ministry as a focal agency: Instead of broad health care issues for the elderly, most countries target public assistance for vulnerable old people Limited information on the policy impact or effectiveness Awareness on aging is low in many LMICs: transition from high fertility to low fertility and rapidly aging society Kwon: Aging & Health Policy in Asia 119

Policy and Governance China 12th 5-year Development Plan on Ageing (2011-2015) aims - To increase pension coverage for old people - To expand community-based care and nursing homes - To improve the medical care system for the elderly China National Committee on Aging (established 1999): develop policies, coordinate ministerial-level agencies, promotes awareness of aging, supports research on aging, and provides policy recommendations Nat Benefit Protection Law of Aging Pop (revised 2013): states government responsibility for multi-level social security for the elderly (including social pension of 55 RMB) Kwon: Aging & Health Policy in Asia 120

ANNEX 3: Presentations

Policy and Governance Vietnam Law on Elderly (2010) - States the rights and responsibilities of the elderly - the poor elderly are entitled to health insurance,

Policy and Governance Philippines - Senior Citizen’s Act: 20% discount for the elderly - Partial tax exemption for providers - Effects of the policy? - Policy implementation monitored by the Office of Senior Citizens Affairs (OSCA) in local governments Fiji - National Policy on Aging 2011-2015 is the first elderly policy on aging among the Pacific countries - No law on the elderly - Inter-agency committee on aging, but with little activities Kwon: Aging & Health Policy in Asia

medicines, and tools and equipment for rehabilitation National Committee on Aging, chaired by vice PM: - coordinates elderly policy among ministries and

collaborates with national elderly association - 2/3 of provinces have provincial committee on aging Elderly pension of USD 9 per month is for the aged 80+ who do not have retirement pension Kwon: Aging & Health Policy in Asia 121

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Policy and Governance Cambodia: Policy for the Elderly 2003 refers to health promotion and NCD, and addresses the universal health care for the elderly and the need for training of health staff on geriatric health care Lao PDR: In 2005, government approved the First National Policy for the Elderly, which aims to encourage the elderly to participate in social development, health promotion, etc. Mongolia: National Program on Health and Social Welfare of the Elderly (2004-2008) is based on the main principles of the Madrid International Plan of Action Kwon: Aging & Health Policy in Asia

Policy and Governance Barriers to the implementation of the elderly law in LMICs - financial support for the programs - budget allocation and political will of local authorities - human resource capacity - policy coordination among ministries and programs

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2. Financing High-income countries: universal coverage, no specific financing mechanism for the elderly More than half of H expenditure is borne by households in Cambodia, Lao PDR, Philippines, and Vietnam Financial arrangement for the elderly in LMICs: subsidy for H insurance contributions, OOP discount/exemption Role of local governments is important in financing and delivery of health and long-term care -> political and fiscal commitment of the government is key Policy priority on health care vs. long-term care? Kwon: Aging & Health Policy in Asia 125

Health Expenditure as a % of GDP and Financing Mix

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Source: WHO, 2011

ANNEX 3: Presentations

Health Financing and Expenditure Health Expenditure for 65+ in total H insurance exp: 55.4% in Japan (2010), 31.4% in Korea (2009) - Per capita H exp of the elderly is more than 4 times greater than that of the younger in Japan and Korea Japan has separate H insurance for the elderly 75+: government subsidy (50%), contribution (cross subsidy) from health insurance (40%), and premiums from the elderly (10%) Japan and Korea have social insurance for long-term care - de-medicalization of LTC, but potential coordination

Financing China About 90% of pop coverage: Urban Employee Basic Medical Insurance (UEBMI), New Rural Cooperative Med Scheme (NRCMS), and Urban Resident Basic Med Ins (URBMI) - Policy direction: improve risk pooling, extend benefit packages, and reform provider payment systems The retired, who contributed to the employee health insurance for 15 years, do not need to pay contribution - In Shanghai, employee H insurance scheme will pilot benefit package of long-term care for the elderly - Shouzou government provides 450 RMB subsidy for an old person per month for nursing home utilization Kwon: Aging & Health Policy in Asia 128

problem between HC and LTC - Same insurer for HC and LTC: save administrative cost Kwon: Aging & Health Policy in Asia 127

Financing Vietnam H insurance system covers more than 60% of population - Free health insurance is available to those aged 80+ or

Financing Philippines Public insurance (PhilHealth) - Family-based membership along with free insurance card for the poor can benefit the elderly - Low benefit ceiling, ineffective regulation of providers - Plan to extend the benefit package to primary care, including NCDs The retired get H insurance card free if they paid contribution for 10 years: equity? Mandate that 1 % of budget in local government should be allocated for the old or disabled: monitoring? Kwon: Aging & Health Policy in Asia 130

to poor old people who live alone Coverage rate by the social protection system is generally low, and only some specific elderly groups have access to it (UNFPA, 2011) OOP pay is still high even with H insurance card because of limited benefit packages: proportion of H expenditure in living expenditure is 9.3% in rural areas and 9.5% in urban areas in 2008 (Giang, 2010) Kwon: Aging & Health Policy in Asia 129

3. Service Delivery Service delivery system not reoriented to meet the needs of old people in LMICs - geriatric hospital or geriatric ward are rare - most governments have introduced health promotion and NCD management policies, but most of them are non-age specific programs Role of long-term care institutions is minimal in LMICs - tradition of family-based care - Public long-term care facilities target only the poor - governments of LMICs encourage the private sector to build long-term care facilities Kwon: Aging & Health Policy in Asia 131

Service Delivery Australia - Over 175,000 residential care facilities in 2008 (Healy, et al., 2011): 60 % are not-for-profit, 30 % are private forprofit, and the rest are state & local government facilities - National planning benchmark for the year 2011: 88 residential care places per 1,000 people aged 70 years or over, 25 community-based packages per 1,000 for people with high dependency Korea: Over-supply of LTC providers (facilities, providers of home- or community-based care), mainly private, after the since the introduction of LTC insurance in 2008 Kwon: Aging & Health Policy in Asia 132

ANNEX 3: Presentations

Service Delivery China - Government facilities target vulnerable old people with “three no’s (no children, no dependable relatives, and no income or ability to work)” - Government vision: 90% of the elderly cared at home, 7% by community-based care, and 3% by LTC institutions Vietnam and Philippines - Requirement for public hospitals to have geriatric ward is

4. Human Resource Education and training of health professional and longterm care personnel to meet the needs of the elderly is very limited un LMICs - capacity of health and long-term care providers is often quoted as a major bottleneck to reorient the system - limited capacity to work as a team to provide care to elderly patients with multi-morbidities In most LMICs, geriatric health has not been included in the curriculum of health profession, and do not have education and training programs for long-term care providers Kwon: Aging & Health Policy in Asia 134

not fully implemented - Very limited number of public facilities for long-term care - Little information and regulation of private providers Kwon: Aging & Health Policy in Asia 133

III. Policy Recommendations 1. Governance and Leadership

2. Human Resource for Health Education and training for health professionals need to be reoriented to respond to the needs of the elderly, cope with multi-morbidites and collaboration as a team Curriculum needs to include geriatric health, health promotion, NCD management, functional disability, rehabilitation, and health education for the elderly Additional board (specialist) certificate for geriatric medicine or geriatric nursing: pros and cons Strengthen primary care and gate-keeping: continuum of care Training of long-term care providers and support and education program for family care givers Kwon: Aging & Health Policy in Asia 136

Need government commitment to mainstream aging issues and adopt and implement relevant policies Increase the awareness of aging and increase policy priority on the health of the aging population Coordination of various policies and programs across government ministries and agencies - Local government - Coordination among the Ministries of Health and Soc Welf. - Coordination among different components of health system, such as financing, service delivery, and HR Kwon: Aging & Health Policy in Asia 135

3. Financing Need government commitment to universal access to health care for the elderly: sustainable financing mechanism or prepaid scheme funded by the public source Minimize inequity in health care utilization of the elderly between the rich and poor and urban and rural areas: - minimize not only financial barrier but also other types of physical (e.g., transportation) and cultural barriers 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, fiscal capacity, etc Kwon: Aging & Health Policy in Asia 137

4. Service Delivery Service delivery system needs to be re-oriented to meet the health and long-term care needs of the elderly - Coordination between health care and long-term care - Elderly participation in community activities Building more health and long-term care facilities for the elderly should be based on need assessment, assessment of the efficiency of existing providers, and careful planning to avoid over-reliance on institutional care - Geriatric departments and wards, nursing home Public-private partnership: pros and cons, needs effective regulatory policy for private providers Kwon: Aging & Health Policy in Asia 138

ANNEX 3: Presentations

THANK YOU !!! Prof. Soonman KWON

Health and Ageing Consultation with WHO Manila, April 2013

Eduardo Klien

kwons@snu.ac.kr (Seoul National Univ.) http://plaza.snu.ac.kr/~kwons (Homepage) Kwon: Aging & Health Policy in Asia 139

Regional Director HelpAge International East Asia/Pacific

Health and Ageing

Ageing is….

Health status after 60

• • •

Irreversible in nature Condensed in time Comprehensive in scope

5.4 yrs

21.6%

5.1 yrs

38.3% 61.7%

19.6 yrs

78.4%

8.2 yrs

Source: UN DESA (Department of Economic and Social Affairs, Population Division) Population Ageing and development Wallchart 2009.

Some approaches in HelpAge • • • Promoting spaces at community level for healthy ageing, knowledge and practice Studies and research Support to the development of comprehensive Care strategies

Promoting spaces at community level for self-care, healthy ageing, knowledge and practice

ANNEX 3: Presentations

Under the health Component: Self-care (healthy living)

Nutrition

Physical Exercise (10-20 minutes daily/weekly)

Why Multifunctional? Meet the real needs for people Adapt to local context Inclusive Create synergies between activities

(Awareness)

Under the health Component: Homecare (community based volunteer)

Under the health Component: Health care: Checkups, health insurance and access

Health checkup

Volunteer based Homecare (At least 2 visits per week)

Family Care (Monthly awareness) (Every 6 months)

Health Insurance and access (On going)

Healthy Ageing: IEC materials

Replication of the ISHC approach Monthly Monitoring Health Status Weight Reading and Recording Blood Pressure reading and recording

Health Monitoring Booklet

ANNEX 3: Presentations

Replication Tools

Studies and Research

Training Posters (for Older Old)

Some examples • • • • • The situation of older people in Myanmar (2012) Social assistance needs of poor and vulnerable older people in Indonesia (2012) The situation of older people in Thailand (2013) Primary healthcare for older people: A participatory study in five Asian countries (2010)

Study on knowledge and NCDs (SCOPA)

Healthy NCDs Disabled

Overview on Care situation and approaches in the region

Changing needs in Care • • • • • Shrinking family size Increasing migration from rural areas More older persons living alone Lack of institutional care Changing care tradition and lack of relevant skills.

Care

ANNEX 3: Presentations

Care strategies and policies Cost of Care

Continuum of Care

Nursing Home Home for he Aged Short Stay

Day Care

Paid Home Care

Volunteer Home Care Community based care Source: HelpAge Korea

Difficulties of ADL & IADL of OP Institutional care

Thank you

Population Ageing in Asia and the Pacific Srinivas Tata Chief, Social Policy and Population Section Social Development Division UNESCAP

ESCAP – regional arm of UN for AsiaPacific • ESCAP fosters: regional cooperation to promote social & economic development normative, analytical & technical cooperation work of regional nature • Exercises regional intergovernmental convening power • Mandated by ECOSOC to coordinate regional UN system work in economic & social sectors • Focuses on multi-disciplinary responses

ESCAP’s programme on ageing ESCAP serves as an intergovernmental platform to • Develop a regional response to the demographic transition • Share knowledge & good practices in addressing population ageing challenges: long term care, financing, legislation • Explore feasibility of a Convention • Promote the Madrid International Plan of Action on Ageing (MIPAA), identify gaps & regional priorities ESCAP provides technical assistance to Governments to: • Design & implement policies/programmes that empower & protect older persons • Review & appraise the MIPAA implementation

ANNEX 3: Presentations

Asia-Pacific Review of the implementation of the Madrid International Plan of Action on Ageing

Bangkok Statement (health-related outcomes) • Adapt health and social systems in response to the needs of older persons through an integrated continuum of care, including preventive care, acute care, chronic disease management, long-term care and end-of-life care • • Develop policies and models for promoting healthy ageing to support healthy lifestyles, active ageing and the right to health care Develop strategies to meet the rising demand for elderly care, emphasizing especially home and community-based care and to improve the coverage and quality of care in formal and informal settings Allocate adequate resources for the training of caregivers, including informal caregivers and service providers, to address the human resource gaps in meeting the needs of elderly care;

• Bangkok 10-12 September 2012 • Attended by more than 30 countries at senior level • Reviewed progress; identified emerging issues; adopted outcome document • Bangkok statement: Regional input for global review and also regional framework for action

•

Bangkok Statement (health-related outcomes) • Include geriatrics and gerontology in the training curriculum of professionals in the health- and social-care service sectors • Strengthen the primary health-care system to address the health needs of the elderly population and social support systems for long-term care, including through formal and informal capacity-building mechanisms to develop and assist health professionals and social care givers • Encourage community-based and non-profit organizations as well as the private sector to play a major role in the provision of elderly care services and training, in cooperation with government agencies

Health of older persons- the challenge • • • • • • Important issue- where to start Perception as “burden” Diversity among countries Rural and urban Multi-sectoral Who speaks for older persons?

Opportunities • NCD agenda-putting faces to the problems • Post-2015 development agenda • Convention on rights of older persons • Building stronger CSO support • Governments supported by partnerships among UN agencies

Way ahead • Strategy must be rights-based and evidence based • Must contain advocacy, normative and operational elements • Must identify clear entry points for the convention on older persons • Must address countries in different stages of population ageing and development

ANNEX 3: Presentations

Way ahead • Must integrate technology and medicine access • Must link regional framework to nationallevel action • Must engage all stakeholders in a multiagency & multi-sectoral strategyco-sponsor approach? • REMAIN ENGAGED

Thank you

Draft framework of action on ageing and health in the Western Pacific Region Dr A B Dey Dean (Research) Professor & Head, Department of Geriatric Medicine All India Institute of Medical Sciences, New Delhi

Introduction • Enhanced longevity & population ageing: a fact of life • Most countries in the Western Pacific Region are witnessing rapid increase in ageing population • Are the health systems in the region ready to face the challenges of enhanced longevity? • Countries in Western Pacific have only a fraction of time in contrast to Europe and North America to prepare for similar scale of population ageing

Introduction • Population ageing is an important developmental goal as indicator of socio-economic progress • Old age is also: a phase of poverty and economic non-productivity a graveyard of chronic non-communicable diseases a constellation of frailty, cognitive decline and disability a state of dependency and loss of autonomy marked by vulnerability to abuse

ANNEX 3: Presentations

Introduction: Health in Old Age • Inevitable biological decline influenced by genetic make up, environmental exposure and lifestyle across the life course • Result of potentially preventable unhealthy lifestyle • Long term studies have emphasized smoking, obesity & sedentary lifestyle as risk factors for poor health • Poverty and social exclusion in earlier life predict poor outcomes in old age • Healthy living can facilitate active and healthy ageing

Ageing and Health in Western Pacific • Diversity: size of population, cultural, ethnic, economic, political and religious • Commonality: crisis of non-communicable diseases, rapid economic progress, desire for active and healthy ageing Thus a framework of action on ageing and health!

Background to Regional Framework: Evolution of international policies • The First United Nations General Assembly on Ageing in 1982: Vienna International Plan of Action on Ageing – 62-point declaration for action on: health and nutrition, protecting elderly consumers, housing and environment, family, social welfare, income security and employment, education, and collection and analysis of research data. • Adoption of United Nations Principles for Older Persons by the UN General Assembly- 1991 – 18 entitlements for older people relating to their autonomy, independence, participation, care, self-fulfilment and dignity. • International year of the older persons: 1999

Background to Regional Framework: Evolution of international policies • The Second United Nations Second General Assembly on Ageing in 2002 – Madrid International Plan of Action on Ageing (MIPAA), with 3 priority areas: (i) Older persons and development, (ii) Advancing health and well-being into old age; and (iii) Ensuring enabling and supportive environments. • UNESCAP review of the MIPAA recommendations and prioritization of directions for Asia and the Pacific – Shanghai Implementation Strategy- 2002 – Macao Outcome Document- 2007 – Bangkok Report - 2012

Background to Regional Framework: WHO response • Adoption of the concept of “active ageing” – as strategy for implementation of Madrid declaration • World Health Assembly: 2002 - Ageing and health • World Health Assembly: 2005-International Plan of Action on Ageing: report on implementation • World Health Assembly : 2012- Strengthening noncommunicable disease policies to promote active ageing

Initiatives in the Western Pacific Region • 1981 (WPR/RC32.R15): Agreement to develop or strengthen policies and programmes on health care of older people as part of their overall health plans • 1985 (WPR/RC36.R23): Post- First World Assembly on Ageing, WPRO countries resolved to pay increased attention to the health needs of older people in national health policies and programmes. • 1996 (WPR/RC47.R12) and 1998 (WPR/RC49.R11), Member States reiterated to: – formulate and review policies and strengthen programmes to improve the health and quality of life – collect standardized data on ageing and health – strengthen intercountry cooperation – plan for and implement activities to mark the International Year of Older Persons in 1999.

ANNEX 3: Presentations

Initiatives in the Western Pacific Region Informal Experts’ Consultation on Healthy Ageing in WPRO- 2011, for guidance on developing a regional framework of action: Themes for discussion: Advocacy to promote ageing in a more positive paradigm Importance of policies based on a life course approach Inter-sectoral action for healthy ageing Access to evidence base for action Need for standardized set of healthy ageing indicators Identification and adoption of successful models

Emerging issues in old age • Impact of HIV/AIDS: – Care provider of afflicted/ orphaned grandchildren – Living with HIV/AIDS with available strategy • Abuse of older people – Challenge for every society • Vulnerability in natural or man made disasters – Always left out

• • • • • •

Objectives of the Framework for Action 1. Promote common understanding of ageing and health trends of ageing and health implications for the individuals and health systems status of laws, policies and other activities within the diversity of Member States at different levels of development and with different social, institutional and political histories. 2. • • • • •

Objectives of the Framework for Action Address new challenges and set priorities on ageing and health the fastest growing segment of the society narrow window of preparatory time in low and middle income countries new ways of promoting healthy ageing across the life course promoting universal health coverage through agefriendly health systems strengthening the evidence-base.

Objectives of the Framework for Action

Cross-cutting principles 3. Strengthen WHO’s support on ageing and health in the Western Pacific Region more action greater levels of investment greater levels of involvement (Within the core competencies and mandates of WHO)

• Gender sensitivity: biased towards women • Equity: biased towards poor • Human Rights: biased towards rights over welfare

ANNEX 3: Presentations

Components of the framework • Promoting healthy ageing across the life course • Promoting universal health coverage through age-friendly health systems • Strengthening the evidence-base

Situation Analysis: Evidence-base • State of the health of older people in Western Pacific: Limited to high and middle income countries • Limited information on most Pacific island countries: small population, poor access, not so well-functioning health system

Situation Analysis • Information available on – Availability of policy/ institutional provision – Health financing – State of health and disease – Risk factor profile – Functioning of the health system

I. Healthy ageing across the life course • Concept of health promotions through life course approach: well accepted • A temporal relationship between exposures to health risks in critical phases of life to development of chronic diseases in later life • Relationship can extend to exposures across generations in case of cohorts and often in individuals • Impact of social, economic and cultural factors on health and disease: as important determinants in genesis of disease: knowledge expanding

I. Healthy ageing across the life course A life course approach to health or disease can been constructed by relating to exposure to biological, behavioral and psycho-social hazard by an individual during gestation, childhood adolescence, young adulthood and midlife which would lead to accumulation of risk factors of important chronic disease of significance.

I. Healthy ageing across the life course • In the context of old age care; such an approach may have limited current value. However, adoption of life course approach can be of futuristic value for good health of the population. • Interventions for life course approach in the health system can include: – Promotion of reproductive health to ensure safe motherhood – School health programme to protect against malnutrition and infectious disease – Adolescence health programme – Prevention, screening, early detection of metabolic-vascular diseases throughout adulthood • Appear costly and difficult to implement, but have great value in the long run • Concept needs to be included in medical education • Concept needs to be included in overall development agenda

ANNEX 3: Presentations

I. Healthy ageing across the life course: NCD prevention • Risk factor avoidance over life course – Awareness campaign – Legislation/ statutory provision • Screening for common NCDs in primary health care – Inclusion in standard operating procedure of PHCs

I. Healthy ageing across the life course: age friendly environment • Principles of age friendly environment : well accepted • Rights based approach • Implementation requires policy, political, financial intervention • Role of institutions in ensuring age friendly environment – NGOs – Local government – Network of organization

I. Healthy ageing across the life course: health promotion in old age- a primary care intervention • • • • • • • adopting healthy lifestyle practices physical activity and exercise management of cardiovascular risk factors cultivating a positive mental attitude cessation of smoking moderation or cessation of alcohol consumption consumption of food : adequate in protein and calories, rich in fibres, vitamins, minerals, trace elements and antioxidants, low in lipids. • increase in habitual physical activity • improvement of health literacy

II. Age-friendly health systems: Integrated service delivery models to ensure the continuum of care • • • • Primary care Referral services Specialized care Newer biomedical technology: – life support – organ replacements

• Emergency/ acute care • Rehabilitation/ post-acute care • End of life care

II. Age-friendly health systems: Integrated service delivery models to ensure the continuum of care Long term care: care when one is dependent and has lost autonomy • Setting – Home – Institution • Provider – Family – Informal – Formal: health, nursing, social • Components: – Health (acute, chronic, accidents and injuries, emergency) – Nursing – Social care

II. Age-friendly health systems: Integrated service delivery models to ensure the continuum of care Health system Response o o o o Services under primary care Geriatric Medicine Institutions for older patients Integrated with over all health system

• Financing of long term care: a matter of debate

ANNEX 3: Presentations

II. Age-friendly health systems: a health workforce with appropriate skills • • • • Practice of geriatrics is difficult! Health professionals have poor skill in old age care Inadequate curriculum Inclusion of Gerontology/ geriatrics in curriculum of health professionals – Medicine, nursing, paramedical courses

II. Age-friendly health systems: Health financing and health insurance coverage • Financing: out of pocket rights based insurance based • Different models of health financing in Western Pacific • Changing practice in many countries • Need to maintain a cap on out of pocket spending • Need for greater consultation in best practices

• In service training • Post graduation in geriatrics

II. Age-friendly health systems: multi-sectoral intervention • • • • • • •

II. Age-friendly health systems • Role of biomedical intervention Nutritional supplement: micronutrient Vaccines: pneumonia, influenza, tetanus Aspirin, Statins Hormone replacement Screening for early diagnosis Treatment of physical ailments Physiotherapy

• Role of different institutions of the State • Role of private sector in health financing, service provision • Role of NGOs • Role of International Agencies

• Role of technology: aids, appliances & replacements • Telemedicine/ tele-consultation • Use of mobile telephone in health care

III. Strengthening the evidence-base • Need for evidence: dynamics of societal change, new understanding of processes, creation new knowledge in intervention • Authentic / strong evidence base across socioeconomic, geographic and ethnic variations • Cross-national and intra-country surveys at regional level • Need for comparison with global trend.

III. Strengthening the evidence-base • Components: • Demography: proportion and number of people above the age of 60 years; life expectancy at birth and at 60, 70, 80 years; dependency ratio; gender composition. • Economic status: individual and family income; family size; living conditions; health expenditure; and source of income. • Health status: morbidity and disease burden; cognitive status; fitness and activity levels; ability to pursue different levels of ADL (activities of daily living); and causes of health consultation, hospitalization, referral to specialist care and death.

ANNEX 3: Presentations

III. Strengthening the evidence-base • Components: • Health behaviour: attitude towards health, disease and disability; utilization of health services including preventive and promotive services; and perception of health services among users. • Health service availability, utilization by users and quality of care. • Predictors of good health, longevity and disability among both the institutionalized and community-based elderly. • Health-related quality of life in relation to different types of intervention.

III. Strengthening the evidence-base • Data to be used for: – Creation of models of care with regard to type of service, participation of the public and private sectors – Creation of clinical guidelines • Role of Regional Office: technical support in research methodology and facilitation of collaboration between different countries, funding of studies. • Need for active involvement of the Ministry of Health in funding, technical support and human resources. • Involvement of medical schools/research institutions in data collection helps in completing the task on schedule and in maintaining the accuracy and standard of data. • Academic research has a great role in creating the knowledge required for building the evidence base.

Some resources • Typology of countries based on their level of development, and their place in the demographic and epidemiological transitions • Menu of options for action • Model national policy for the health of older people

Typology of Member States • There is need to group member states for prioritization of action • This grouping can be based on: – Income levels (per capita)- World Bank grouping – Proportion of 60+: current and in 2025/2030 & Life expectancy at birth: current and in 2025/2030 – Stage of demographic and epidemiological transitions (?)

Scope for Action • Adoption of regional framework at political level • Time frame: – A decade – 2014- 2023 (for WHO) – Plan periods (for Member States)

Scope for Action: Inter country Activities • Formation of regional advisory committee/ group/ cell for technical support • Preparation of comprehensive/ comparative data base • Networking among organizations, institutions and individuals • Production of training materials • Organization of inter-country collaborative training programmes • Provision of technical assistance to Member-States in implementation of strategies, plans and programmes • Organization of regional consultation for updating the regional action for the decade

• Activities with clearly defines objectives, responsible agency and time frame – Inter country – Country

ANNEX 3: Presentations

Scope for Action: • Organization of national workshop for developing and updating national strategy/plan of action on ageing and health • Conduct of transnational and intracountry surveys for collection of data for creation of evidence-based database • Production of training materials • Strengthening health man power through WHO fellowship programme • Establishment of national programme for training of health professionals in the care of older people • Training in care of older people • Strengthening health system response in primary/ secondary/ tertiary health care system • Organization of national associations of older people • Organization of national association of service providers

Model National Policy The national policy for older people is determined by: country’s demography, impact of population ageing status of the older people in society changing dynamics of family structure state of the economy culture and tradition of the society. • • • • • Constitutional/ statutory mandate Futuristic Inclusiveness Affirmative action Rights based

Model National Policy

Model National Policy (Contd.) • Social security for the vulnerable older people from the state. • Access to affordable and quality health care. • The orientation of health care needs to focus on primary health care along with subsidized specialist care; subsidized drugs, aids and appliances; ambulatory and institutional mental health care; availability of home care and long-term care; availability of affordable health insurance; and health education to enter old age in good health. • Support to the family in caring for older people. • Promotion of civil society involvement in old age care through organizations in nongovernmental sector.

• The principal areas for policy development are as follows. • Financial security in old-age arising out of productivity of working years. • Protection of life and property. • Assuring shelter in age-friendly environment. • Shelters for older people facing destitution. • Availability of scope for training and education for those desiring to be economically productive.

Model National Policy (Contd.) • Emotional support from the institutions of civil society to strengthen coping capacity. • Creation of a good database to plan interventions under the policy. • Training of carers and managers in care of older people. • Use of mass media in influencing society in favour of older people. • Creation of a national association of senior citizens to empower them in influencing policies and programmes meant for them. • Creation of a mechanism to implement and monitor the impact of the policy.

HEALTH AND LONG-TERM CARE FOR OLDER PEOPLE INFORMAL EXPERTS’ CONSULTATION ON AGEING AND HEALTH IN THE WESTERN PACIFIC REGION 9-10 APRIL 2013, Manila Yuki MURAKAMI

ANNEX 3: Presentations

Steep rise in the share of over 80 years old • The probability of needing care increases with age. Less than 1% of those younger than 65 years require long-term health and social care services, while 30% of the women aged 80 years old or over use such services, on average across the OECD. USA Brazil World 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% S

Japan China Korea

EU27 India

OECD Russian Federation

Limitations of daily activities increase with age Limitations in daily activities, population aged 75 years and over, 2009 Limited to some extent Limited strongly 7.7 9.7 8.2 20.8 16.5 8.1 9.6 13.3 12.3 8.7 10.5 19.4 15.4 11.8 14.3 15.8 9.8 16.5 14.0 20.2 16.1 16.8 15.8 19.8 26.6 14.5 14.2 19.1 11.4 18.9 27.5 27.5 24.1 25.2 30.2 29.7 21.3 26.9 30.8 29.1 30.5 36.9 33.8 37.3 31.4 37.5 39.5 42.1 39.1 48.2

Limited to some extent

Limited strongly

Sweden Norway Denmark Iceland United Kingdom Switzerland Ireland Luxembourg Belgium Netherlands Czech Republic Slovenia France Finland OECD Austria Spain Poland Italy Greece Germany Hungary Estonia Portugal Slovak Republic 0 0

16.9 19.1 28.5 8.6 23.0 32.2 34.8 33.9 34.3 41.9 40.4 26.5 33.8 39.2 34.0 34.0 42.6 37.0 44.1 35.5 44.5 42.3 46.6 38.9 37.7

17.1 14.0 16.0 24.2 23.9 13.2 18.2 15.1 20.0 14.9 22.1 29.2 32.2 27.6 26.1 33.6 21.6 29.2 29.8 39.0 30.8 33.2 32.5 37.9 49.9

• Long-term (health) care comprises health and nursing care for patients who need assistance on a continuing basis due to chronic impairments and a reduced degree of independence and activities of daily living (ADL). Long-term care is typically a mix of medical (including nursing care) and social services. • The following items are included in the definition of services of longterm health care: i) palliative care; ii) long-term nursing care; iii) personal care services (assistance with ADL restrictions); iv) services in support of informal (family) care. The following items are included in the definition of social services of long-term care: i) home help (help with IADL); ii) residential (care) services; iii) other social services provided in a LTC context. This basic split between health and social services is not expected to change with the implementation of the 2011 SHA Manual.

% of population aged 65-74 years

% of population aged 75 years and over

Source: European Union Statistics on Income and Living Conditions 2009.

Conceptual framework Well-being of older people

Other factors (i.e. socio-economic determinants)

Health and LTC system performance Quality

Irrespective of financing model, moving towards universal benefits is desirable on access and affordability grounds…

Care Care Patient coordination effectiveness centeredness and integration

Access

Costs

Workforce, living environment, ICT and non-ICT assistive device

1950 1953 1956 1959 1962 1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013 2016 2019 2022 2025 2028 2031 2034 2037 2040 2043 2046 2049

Source: OECD Labour and Demographic database

LTC - health care versus social care

Access and Costs

ANNEX 3: Presentations

Total health expenditure as a share of GDP in WPR, 2010 Total health expenditure as a share of GDP, 2010 10.1 100.0 12.0

Public share of total expenditure on health in WPR, 2000 and 2010 Public share of total expenditure on health, 2000 and 2010 93.4 84.9 83.2 82.5 public 2000 public 2010

9.6

9.5

10.0

90.0

8.7

72.2

71.5

8.6

% total expenditure on health

68.0

80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

70.1

59.8

55.5

55.1

6.9

6.8

% GDP

5.9

5.6

37.8

37.2

5.1

36.3

35.3

4.9

6.0

5.4

53.6

8.0

59.0

4.4

4.0

3.6

2.0

2.8

4.0

3.6

Australia

Malaysia

Asia-16

Brunei Darussalam

Solomon Islands

Viet Nam

New Zealand

OECD (2000-2009)

Papua New Guinea

Korea, Rep.

Cambodia

Singapore

Mongolia

0.0

Australia

Viet Nam

Malaysia

Asia-16

Lao PDR

Papua New Guinea

Brunei Darussalam

Solomon Islands

New Zealand

OECD (2009)

Cambodia

Korea, Rep.

Singapore

Mongolia

Philippines

Source: WHO Global Health Expenditure Database. Source: WHO Global Health Expenditure Database; IMF World Economic Outlook, April 2012.

Private expenditure mainly comes from out-of-pocket spending in WPR, 2010 Out-of-pocket and private prepaid plans spending as a share of private expenditure, 2010 Out-of-pocket Private prepaid plans

… the cost associated with high-care need can account for more than 60% of seniors’ disposable income, including for those from relative high income deciles Share of adjusted disposable income for individuals 65 years and over in different income deciles, mid-2000s Low care needs High care needs

Solomon Islands Papua New Guinea New Zealand Australia Cambodia Fiji Korea, Rep. Lao PDR Malaysia China Japan Philippines Singapore Mongolia Viet Nam Brunei Darussalam 0 10 20 30 40 50 60 % of private expenditure 70 80 90 100

Source: WHO Global Health Expenditure Database. Source: OECD Secretariat calculation based on the OECD Income Distribution and Poverty Database (www.oecd.org/els/social/inequality).

Types of coverage offered Universal coverage within a single programme Means-tested systems • Tax-funded Nordic system; Mixed schemes: • Social LTC insurance in Jap, Kor, NL, Lux, Ger); • as part of health system in Belgium

•

• England social-care system; US: Medicaid

•

Mixed schemes

• Parallel universal benefits (Scotland, Italy) • Progressive universal benefits (Israel, France, Austria, Australia) • Mix universal & means-tested (NK, Canada, Greece)

•

Korea introduced in 2008 a universal LTC system for those aged 65 years and over. With a view to containing cost, elderly Koreans with lower care needs are not eligible to LTC benefits unlike elderly living in countries with more comprehensive systems. For countries that provide for “broader” universality, better targeting within their universal system can represent an avenue to contain future expected cost. For instance, Japan’s public LTC system covers all individuals aged 40 years and older. As part of its 2009-12 planning cycle, and partly to mitigate future cost increases, seniors assessed with the lowest care needs have been moved to a prevention scheme with focus on encouraging healthy ageing. In 2010, Austria further targeted the allocation of benefits under their universal cash allowance (Pflegegeld) by increasing the minimum hours of help per month required to become entitled to an allowance for those with relatively lower levels of care need (level 1 and level 2). Individuals below 65 years of age with age-related (geriatric) disease are also covered under Korea’s universal LTC system.

Philippines

Japan

China

Lao PDR

Japan

Fiji

China

33.3

4.5

ANNEX 3: Presentations

Comprehensive universal systems can be expensive • (Care) needs assessment for effective care planning as well as appropriate benefit allocations (all countries) Define the level of dependency triggering LTC entitlements in line with government’s resources (e.g., Korea versus Japan) Better pooling of financing across generations (e.g., Japan), Broadening of financing sources beyond income earned from work (e.g., Japan) and Elements of pre-funding (private LTCI) Cost-sharing in place (Korea and Japan) In-kind benefits in Korea and New Zealand focus on support for daily living activities (ADL) 7 6 5 4 3 2 1 0

Challenges ahead: Rising prevalence of dementia Prevalence of dementia among the population aged 60 years and over, 2009 % of population aged 60 years and over

•

6.5 6.4 6.3 6.3 6.3 6.2 6.2 6.1 6.1 6.1 5.9 5.8 5.8 5.7 5.7 5.6 5.6 5.6 5.5 5.5 5.4 5.4 5.3 5.3 5.3 5.2 5.1 5.1 5.0 5.0 4.9 4.8 4.7 4.7 4.7 4.2 4.0

•

• •

Source: Wimo et al. (2010).

Caring of older people is complex Fragmented mixed systems can make coordination and evaluation of ‘need’ difficult. – Integrated health and care information systems (e.g. Japan’s care managers) – Functional and service integration – Clinical and professional integration (e.g Australia’s healthplus) – Organisational and financial integration

Providing quality health and social services Asthma hospital admission rates, population aged 80 and over, 2009 (or nearest year) Germany Italy Portugal Hungary Canada Denmark Mexico Netherlands Switzerland Czech Republic Ireland Austria Sweden France United Kingdom New Zealand Poland Belgium Australia Slovak Republic Iceland Norway Slovenia Spain Israel Malta Latvia United States Finland Korea 0

95.18

100

200

300

400

500

600

700

Source: OECD HCQI Data Male Rates per 100 000 population Female Rates per 100 000 population

Uncontrolled diabetes hospital admission rates, population aged 80 and over, 2009 (or nearest year) S… F… P… L… S… M… H… N… C… S… I… U… S… F… S… M… G… U… I… C… P… A… I… B… N… D… K… N… A… I… 0 500 1000 1500 2000 2500 3000 3500 4000

Although family carers are the backbone, all OECD countries need a system providing formal LTC services Male COPD hospital admission…

Source: OECD HCQI Data

3.5 3.5 3.4 3.2 800

ANNEX 3: Presentations

Old-age dependency ratio is increasing 30% OECD 25% EU (27) world

Nurses per 1 000 population, latest year available Japan (2010) Australia (2010) New Zealand (2010) OECD Hong Kong, China (2010) Korea, Rep. (2011) Philippines (2004) 4.3 4.1 3.5 3.4 3.4 2.8 2.4 2.2 1.7 1.6 1.5 1.0 0.9 0.6 0.6 0.5 0.4 4.7 5.6 8.7 10.1 10.1 10.0

20%

Korea, DPR (2003) Brunei Darussalam (2010) Mongolia (2011) Asia-26

15%

Macao, China (2010) Malaysia (2010) Fiji (2009)

10%

Solomon Islands (2009) Singapore (2010) China (2010) Lao PDR (2005)

Viet Nam (2009) Cambodia (2010) Pakistan (2009) Myanmar (2010)

0% 0

8 Per 1 000 population

Source: OECD Labour Force and Demographic Database, 2010. World population projection estimates based on UN World Population Prospects, 1950-2050 (2006 Revision)

Source: OECD Health Data 2012; WHO Global Health Observatory Data Repository, national data sources.

OECD countries at different stages of developing of formal LTC workforce supply nurse personal carer total ltc workforce

Greater staffing challenges in home care? Higher ratio of LTC users per Full-Time Equivalent (FTE) worker in home care than in institutions Users per FTE home care 40 35 30 25 20 15 10 8.0 2.0 2.0 3.4 4.7 1.3 4.7 2.2 5.2 1.3 1.2 2.3 2.4 1.8 2.2 12.9 14.5 9.2 19.6 33.1

LTC nurses and caregivers in institutions per recipients over 65 years, 2008

1.6 1.4 1.4 1.2 1.0 1 0.8 0.6 0.4 0.2 0.2 0 0.2 0.2 0.5 0.5 0.7 0.9 0.7 0.5 0.7 0.9 1.1 1.3

Users per FTE institutional care 39.2

5 0

Source: OECD Health Data 2010

Source: OECD (2011), Help Wanted? Providing and Paying for Long-Term Care, based on OECD Health Data 2010

Social care workers • But

Achieving an adequate supply of LTC workers Secure adequate inflow, valuing work, building careers to Improving recruitment efforts, Improving retention, Increase productivity of LTC workers • • • • • • • New employment, utilization of available workforce or foreign-born workers Enabling LTC workers to work more hours Valuing the LTC profession (Life-long learning and employability and careers in LTC) Competitive wages and benefits Training , initiatives to upgrade job (Jap) Implementing workers-centred workforce policies Work organisation and process

But these requirements vary significantly

ANNEX 3: Presentations

WHO Kobe Centre’s Overview of Work on Ageing and Health

Outline

Background on WHO Kobe Centre: Urban Health Metrics for Ageing and Health Equity Age Friendly Cities Indicators Development Innovation for Healthy Ageing

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Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region 9-10 April 2013, Manila, Philippines

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Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region 9-10 April 2013, Manila, Philippines

Urban Health Equity through Action on SDH

Metrics for Ageing and Health Equity Exploratory studies on health metrics used in Japan – Indicators for public disability prevention programmes – Healthy Life Expectancy indicator

JApan Gerontological Evaluation Study + Urban HEART Analysis of intra-urban health inequalities among older adults by socioeconomic status – SAGE – JAGES

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Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region 9-10 April 2013, Manila, Philippines

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Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region 9-10 April 2013, Manila, Philippines

Age Friendly Cities Indicators Literature review of relevant existing indicators Consultation meeting, August 2012 – Determine indicator selection criteria – Nominate preliminary set of indicators

Piloting, Jan-June 2013 – Obtain inputs from cities and communities

Finalization process, June-Dec 2013 – World Congress of Gerontology and Geriatrics, Seoul – 2nd International Conference of Age Friendly Cities, Quebec Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region 9-10 April 2013, Manila, Philippines

246

http://www.doctoral.sakura.ne.jp/WebAtlas/JAGES_HEART/28100_Kobe/Single/atlas.h tml

ANNEX 3: Presentations

Innovation for Healthy Ageing http://www.who.int/kobe_centre/en/ Consultation on Advancing Technological Innovation for Older Populations in Asia, February 2013, Kobe – Medical and Assistive Devices

WHO Forum on Innovation for Healthy Ageing, 1012 December, Kobe

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Informal Experts’ Consultation on Ageing and Health in the Western Pacific Region 9-10 April 2013, Manila, Philippines

Key facts

Organisation World Health Organization (WHO)

Document type Technical Documents

Adoption date December 16, 2013

Source World Health Organization