Title

Background

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

Goal

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

Methods                                                                                                                                                                          

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

Results                                                                                                                                                                             

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

Global Implications                                                                                                                                                                             

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

Implications for Kansai

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