WHAT WE DO

Organization of a global research consortium to advance methods for measuring unmet health and social care needs of older people

Background

The measurement, understanding and monitoring of unmet need for health and social care is important to accelerating global progress towards universal health coverage. It is also important to specifically understand the different needs of older people compared to other age groups, and how these may or may not be met by available health and social care systems. WKC provided seed funding to establish a global research consortium that could collectively address the methodological challenges and produce evidence that can guide policies to be responsive to the needs of people of all ages.

Goals

• To facilitate a global discussion on current practices and future needs related to the measurement of unmet health and social care needs of older people. 
• To establish a global research consortium with a clear research agenda to improve the measurement and understanding of the unmet health and social care needs of older people. 

Methods

1. Conduct a review of grey and white literature to identify key literature, available data sources, and current tools and methods used to measure health and social care needs of older people globally
2. Identify a diverse group of relevant experts through systematic searches of relevant literature and expert databases and snowball sampling 
3. Conduct semi-structured consultations with the identified experts about:
   1. terminology and systems for describing unmet needs of older persons;
   2. measurement criteria, instruments, data, and analytic approaches;
   3. gaps in data, evidence and methods; and
   4. value-add of the research consortium.

Results

1. Established a multi-national research consortium covering all WHO regions, with a research agenda, terms of reference and governance structure.
2. Proposed a global agenda for advancing the measurement and methodology for assessing unmet health and social care needs of older people.
3. Developed a model of care access specific to older people.
4. Compiled the following resources to aid the advancement of the proposed research agenda:
   1. Database of key literature
   2. Database of content and context experts
   3. Database of measures related to unmet care needs in older people
   4. Database of sources of data relating to unmet care need that can be used for secondary analysis
   5. Database of recommended questions to measure unmet care need in older people
5. Created a website to house the resources and facilitate their dissemination.

Global Implications

The research consortium provides a platform for global collaboration on research to improve data and evidence on the health and social care needs of older populations, which can then be used to guide policies and funding allocations to reduce the unmet care needs of older individuals. The consortium will facilitate the exchange of best practices and experiences among different countries and regions and will help build capacity for assessing unmet needs in lower- and middle-income countries. The results are expected to improve the comparability of data on unmet need across different places and time periods, allowing for more accurate monitoring of progress toward universal health coverage.

Local Implications

The research consortium presents an opportunity for Kansai-based researchers and institutions to build their international network and contribute to a global research initiative related to a local health priority. The resources compiled by the consortium could be useful for local research and policies. 

Household survey analysis of financial hardship due to health spending and unmet care needs of older people in Japan with implications for the Kansai region

Background

Protection against financial hardship due to direct payments made for health care is an important element of universal health coverage (UHC). The causes, magnitude and consequences of health spending that exceeds specified thresholds needs to be well understood for designing better policies to prevent impoverishment and improve access to health care in the context of population ageing. Even in countries such as Japan that have achieved some of the highest standards of population health and health system development, population ageing presents a significant challenge to sustain progress toward UHC. Relatively little is known about the extent to which financial hardship due to health care utilization and financial barriers to health care access is a problem for the rapidly growing number of older people in Japan. Much less is understood about subnational/regional variations in this phenomenon. Experiences from Japan could yield helpful lessons for progressing towards UHC to meet the needs of older people.

Goals

To understand the current situation regarding both financial hardship due to out-of-pocket health spending that exceeds 10% of total household consumption and unmet care needs of older people in Japan with specific implications for the Kansai region. 

Methods

1. Secondary analysis of the Japan Household Panel Survey (2004-2020) and the National Survey of the Japanese Elderly (2002-2021) to assess levels of financial hardship due to out-of-pocket health spending greater than 10% of total household consumption and unmet care needs among older people.
2. Consultation with relevant experts and key stakeholders in the Kansai region and analysis of publicly available health statistics to contextualize the research findings.

Results

Based on the analysis of data from the Japan Household Panel Survey:

• In the total sample, during 2004–2020, the incidence of out-of-pocket health spending greater than 10% of total household consumption remained relatively stable, mostly ranging between 8.0%–10.0%, and peaking in 2007 at 12.4%. The incidence was higher among households with older person(s), ≥65 years old (range from 10.9% to 22.9%), than among households with only younger people, ≤64 years old (range from 5.2% to 9.9%). However, during the same period, the incidence of self-reported unmet need due to foregone care remained consistently higher among younger people (range from 6.2% to15.5%) than among those who were older (range from 1.8% to 8.6%).
• The financial consequences of health spending greater than 10% of total household consumption varied by household age structure. Statistical models of the impact of such high health spending in one year on other types of spending in the following year showed that households with older members reduced spending on food and social activities in the year following the high health spending more so than did households with only younger members, which tended to reduce spending on education instead. The results also showed that households with only younger members experienced an income decline in the year following the occurrence of the high health expenditure, while this effect was not found among households with older members. 
• A U-shaped relationship was observed between age and the probability of experiencing unmet health care need where the probability was lowest for 55–60-year-olds and got progressively higher at younger and older ages.

From the pooled analysis of data from Wave 6 (2002) to Wave 10 (2021) of the National Survey of the Japanese Elderly, 60 years old and over:

• Among those reporting limitations in activities of daily living, 15.5% reported a lack of informal and formal care or support, and 62.5% had not yet been certified eligible to receive long-term care (LTC) services. 
• Inequity in public LTC use by education level was observed particularly among women and those 80 years old and above. Those with higher education were more likely to use public LTC services, even after accounting for levels of need based on demographics, health, and functional status.

Based on the sub-analysis for the Kansai region and Hyogo Prefecture:

• The incidence rate of out-of-pocket health spending greater than 10% of total household consumption in the Kansai region was 7% among all households, lower than in other regions. The rates for both households with and without older members were lower than other regions as well (about 11% and 5%, respectively). 
• The prevalence of self-reported unmet health care needs among adults of all ages was about 4%, which ranked in the middle compared to other regions. The rate among people ≤64 was lower (about 5%) but higher among those ≥65 (about 2%) compared to other regions.
• Based on publicly reported data on mortality and disability, the overall population health status of Hyogo prefecture has improved in the past 30 years but the noncommunicable disease burden has increased due to population ageing.

Global Implications

The interpretation and analysis of levels of out-of-pocket health spending as an indicator of financial protection coverage should consider differences by household age structure. Our study suggests that health spending greater than 10% of total household consumption may be more common among households with older persons, but the financial consequence may be greater for younger households that rely on employment-based income. Conversely, households with older people may be more resilient to such levels of health spending because their source of income (e.g., pension benefits) is not affected by their health status and they tend to have more savings. Moreover, it is important to assess the extent of unmet health care needs in addition to levels of out-of-pocket health spending, as health spending only results from health service use. Our study found that people both younger and older than those in the 55-60-year-old group have higher unmet health care needs, potentially due to different reasons. Younger people may forgo care because of their milder symptoms or opportunity costs of seeking care while older people may do so due to the high costs of care for multiple chronic conditions or physical barriers to access care. Thus, age-disaggregated data about unmet needs for health care along with the reasons why they forgo care is essential to more accurately understand and respond to their different needs.

Implications for Kasai

Although Hyogo prefecture compares favourably to many other prefectures in terms of their population health metrics and levels of out-of-pocket health spending and unmet health care need, available health statistics show that the noncommunicable disease burden is increasing with the trend in population ageing. Continued efforts are needed to reduce behavioural risks, such as smoking, unhealthy diet, and insufficient exercise, as well as metabolic risks, such as hypertension, hyperglycaemia, and hypercholesterolemia in the population. Monitoring of household health spending, their impact on household finances, and unmet health care needs will also be important. 

Multi-country cross-sectional and longitudinal studies to quantify unmet needs for health and social care among older people

Background

As the trend toward global population ageing continues, defining and measuring unmet needs for health and social care among older people will be important elements of assessing progress and achievements toward Sustainable Development Goal (SDG) 3.8., Universal Health Coverage (UHC), and WHO’s 13th Global Programme of Work. In the global context, two common challenges exist: lack of a common metric for measuring needs for health and social care among older adult populations; and, little or no access to quality health data in many countries. Populations with care needs that remain unmet or that have foregone needed care will fail to meet the goal of UHC. However, the magnitude of this problem is unclear, even in countries that have taken major strides toward the progressive achievement of UHC, in part because of a lack of standard definitions for the concept of unmet needs and corresponding lack of data.

• To develop an analytical model of unmet needs for health and social care among older people using a theory-based, data-driven approach and a systems perspective that incorporates demand and supply factors.
• To generate empirical estimates of unmet needs among older people by applying the model to existing national-level health survey data from several countries across WHO regions.

• Build on existing theoretical models of health service coverage and access (e.g. Tanahashi and Levesque models) and a synthesis model being developed through research supported by the WHO Kobe Centre that specifically considers equity in service coverage of older people to develop a comprehensive analytical model of unmet needs among older people.
• Identify datasets suitable for analysis from a diverse set of countries at different income levels across different regions, and harmonize and analyze the datasets through local partnerships, especially in low- and middle-income countries. 
• Apply statistical methods informed by existing guidelines and previous research to test the analytical model and produce a composite metric for unmet need.  
• Apply multilevel regression analysis to examine the predisposing, enabling and need factors at individual, group or area, and system level that affect unmet need.

1. Prevalence estimates for unmet health care need and unmet social care need in older adults were generated through secondary analysis of 17 health, social and economic surveys conducted between 2001 and 2019, representing 83 low-, middle- and high-income countries. (*Additional analysis of the European Health Interview Survey (EHIS) Wave 3 collected in 29 countries in 2019 was performed at a later time in 2023. The methods and results of this analysis are reported separately - see Technical Notes and Evidence Summary below). 
2. Large variation was seen in question wording and response categories related to the measurement of unmet need across the different surveys that were analyzed.
3. Based on the responses to direct questions asking about self-reported unmet need, current estimates range from low levels of less than 2% of unmet health care need in adults 60 years and older in some countries to much higher rates of over 50% in others. Similarly, estimates for unmet social care need range from less than 4% to over 40% across countries. Both increasing and decreasing trends in unmet health care need were observed among the few countries where longitudinal data were available. A statistically significant correlation was observed in which the prevalence of unmet health care need among older people was generally lower in countries scoring higher on the UHC Service Coverage Index. 
4. To better quantify unmet health and social care need, a data-driven latent measure of unmet health need among older people was also pursued, using a theoretical model to inform analytical approaches. Each of the models provided some signal on country-specific structures for unmet health need, but the models did not sufficiently converge to develop a universal structure for unmet health need.

Global Implications

An agreed definition of unmet need for health and social care and standardized survey questions would improve current prevalence estimates and their comparability across place and time. The dimensions and determinants of unmet health need are contextual and may be highly localized. Thus, efforts to define and measure unmet need in a way that comprehensively captures their multifactorial nature may be needed before standardization is attempted. Further advancements in defining and measuring unmet need would be required to incorporate this element into monitoring progress towards universal health coverage.

Implications for Kansai

This study identified several ways in which survey questions have been designed around the world to measure unmet need for health and social care among older persons. These could be adapted for use in local surveys. They could also inform debates about how unmet need should be measured in the local context. The prevalence estimates of unmet need produced by this study could also provide comparison data for locally derived estimates of unmet need for health and social care among the older population.

Publications

WHO reports

• Preliminary results were described in Tracking Universal Health Coverage: 2021 Global Monitoring Report (section 1.3.2 Inequalities in unmet health care needs, paragraph 2, page 13). 
• Updated results were featured in Tracking Universal Health Coverage: 2023 Global Monitoring Report (Box 3.2 Aging population and unmet needs, page 56).

Journal articles

• Kowal P, Corso B, Anindya K et al. Prevalence of unmet health care need in older adults in 83 countries: measuring progressing towards universal health coverage in the context of global population ageing. Popul Health Metrics. 2023;21:15. https://doi.org/10.1186/s12963-023-00308-8
• Corso B, Anindya K, Ng N, Minicuci N, Rosenberg M, Kowal P, Byles J. Unmet need for older adults in low-, middle- and high-income countries – lessons in theoretical and analytical model building for monitoring universal health coverage. (submission in progress).

Technical notes 

• Technical Notes: Unmet needs direct survey question analysis - PDF download
• Technical Notes: Unmet social care needs direct survey question analysis - PDF download
• Technical Notes: Prevalence of and reasons for unmet needs for health and social care in the European region - PDF download

Working papers

• Working paper: Prevalence of unmet health care need in older adults in 83 countries - PDF download
• Working paper: Measuring unmet need for older adults: theoretical and analytical model building - PDF download

Evidence summary

• Evidence summary: Inequality in unmet healthcare and social care needs in Europe - PDF download

Measuring financial protection for older persons in Viet Nam

Background

Globally, studies on the impact of out-of-pocket spending on health care tend to be based on country-level data detailing household health expenditures, which gloss over variations in health care utilization and expenditures by population subgroups such as older people. Older people generally have higher rates of chronic conditions and multi-morbidities which may require greater use of health care and putting them at risk of high out-of-pocket payments.

The population in Viet Nam is rapidly ageing. Studies suggest that households with older members are more likely to suffer catastrophic health spending. However, data are lacking to determine the breakdown of spending to understand spending on care and financial coping strategies.

Goal

To study the breakdown of health care spending among households with older members and to identify possible gaps in existing financial protection policies related to health care of older people.

Methods

1. A desktop review and analysis of existing financial protection policies.
2. Twenty in-depth interviews and 28 focus group discussions with policymakers, health managers, health care providers and older people to deepen understanding of current financial protection policies that apply to older people and identify possible gaps in those policies and potential policy solutions.
3. A household survey of 1,536 people 60 years and older with good cognitive function to collect data on their health expenditures and related factors using a multi-stage cluster sampling design in three provinces representing the north, central and south regions of the country.
4. Statistical analysis to describe patterns of health and long-term care utilization by the older person, breakdown of out-of-pocket (OOP) spending for the older person’s care, the financial burden of OOP health expenditure and financial coping strategies.
5. Qualitative data analysis using a grounded theory approach.

Results

• Several limitations in existing financial protection policies were identified through a literature review and focus group discussions with policy makers. These include inadequate level of social assistance benefits; lack of coverage for social care services; and gaps in health insurance coverage among self-employed and low-income older people.
• Of the 1,536 older people interviewed, 82.4% reported having health problems in the preceding 4 weeks, including acute illnesses, injuries, and chronic conditions. The total number of illness episodes reported from the survey sample was 2,355 cases. Nearly all (95%) of older people sampled are covered with health insurance, and this is higher than the reported figure for the total national population (88.1% in 2019). Nonetheless, care was not sought in over 30% of all reported episodes of ill health. These cases resulted in OOP spending for self-medication (mean of 26.7 USD per person per month among those with health care needs). Among the 70% of cases in which care was sought, 93% received outpatient care. Of these, 60.4% resulted in OOP payment (mean of 35.6 USD per month). The majority of OOP spending for outpatient care was related to medicines.
• Among the 70% of cases in which care was sought, 7% (n=115) received inpatient care. Most of these cases (79.6%) resulted in OOP payment amounting to a mean of 188.7 USD per person per month among those with health care needs, which exceeded the average monthly income of 144.6 USD for households with older persons[1]. The OOP payments for inpatient care were mostly for co-payments, buying medicines beyond the health insurance benefit package and indirect costs (travel, meals, etc.) with some regional variation.
• Only 3.5% of older people (n=55) reported using long-term health or social care services at home or in a facility in the previous 12 months, with most (60%)  paying out of pocket (mean of 95.2 USD per person per month). 
• Some 8.6% of the sampled households with older people spent 40% or more of their non-food expenditure on OOP spending for health care including long-term care. Most of this spending was related to the care of the older member(s) of the household. The proportion of households spending 40% or more of their non-food expenditure on OOP health spending was three times as high in households with older members suffering from noncommunicable diseases compared to those with only self-reported healthy older people.
• Some 12.2% of the sampled households had to employ financial coping strategies to pay for the OOP cost of care for older persons. Households borrowed money from relatives/friends (31%), got a loan from individuals/agents (25%) or sold their properties (4%), while the rest (39%) dipped into their savings.

 Global Implications

Disaggregation of health care utilization and expenditure data by vulnerable sub-populations (e.g., by older age groups, chronic health conditions) enables a nuanced understanding of the drivers of OOP health spending in a population, which can inform financial protection policies. Globally, analysis of policies and their health benefits for households with older people or with people with chronic care needs may be a priority for research on financial protection in health, especially in contexts undergoing rapid population ageing. This type of research may help to develop appropriate health policies and intervention programs to achieve fairness in financial protection.  

Implications for Kansai

Prefectural or municipality-level data on health and long-term care expenditures do not provide the information necessary to determine whether households with older persons are experiencing financial hardship due to OOP spending. Special surveys may be required to obtain these data. This kind of data may help to evaluate the effectiveness of policies in reducing financial hardship due to health care utilization or in reducing foregone care among the local population of older people. In the absence of such data, WKC is conducting analysis of existing national household surveys and collecting information from medical social workers in Kansai to better understand the challenges of ensuring financial protection in health for older people in Kansai.   

Adaptation and validation of tools for monitoring the health of older people in Myanmar and Malaysia

Background

Presently, older people comprise a small share of the total population in Malaysia and Myanmar. In both countries, it is projected that this share will double in the next 30 years, which has strong implications for advancing Universal Health Coverage (UHC). For example, as populations age, the capacity of health systems to effectively manage chronic conditions and comorbidity will be essential. Information about the health and social service needs and coverage of older populations will be useful to inform health system development to better meet the needs of an older population. The study aims to adapt the survey instrument of the Japan Gerontological Evaluation Study (JAGES) to facilitate measurement and monitoring of the health and physical functioning of older people in Malaysia and Myanmar.

Goal

To adapt and validate the JAGES survey instrument so that it can be used to measure health and function and assess health inequalities among older populations in Malaysia and Myanmar.

Methods 

• Questionnaire adaptation and validation: In Malaysia, the English-translated version of the JAGES questionnaire was back-translated into Bahasa Malaysian and pilot-tested with 30 older patients visiting an urban primary care clinic in Kuala Lumpur. In Myanmar, the questionnaire was back-translated into Burmese and pilot-tested on 20 older people in the Yangon area. Based on the pilot-test results, the questionnaires were modified to be linguistically and culturally appropriate as well as feasible to administer with older people in each country.
• Sampling: The adapted questionnaires were then used to conduct surveys of the older population in Malaysia and Myanmar, respectively. Multistage random cluster sampling was used to draw representative samples of older people 60 years and above from Hulu Langat and Kuala Selangor districts of Selangor State in Malaysia, and from Yangon and Bago regions of Myanmar.
• Survey administration: Trained surveyors visited the homes of the older residents to administer the survey in person. Persons with severe physical or cognitive impairment were excluded. After obtaining informed consent, an interview was conducted on a range of topics including physical health and functioning, mental wellbeing, health care utilization and social/community engagement. Objective measurements were also obtained from the participants including blood pressure, body weight and height, and grip strength. Each interview took about 45 minutes. Data were collected in December 2018-April 2020 in Malaysia and September-December 2018 in Myanmar.

Results

1. Face validation and content validation: Several of the questions and response options in the JAGES questionnaire were modified so that they were relevant and appropriate to the local context, for example, descriptions of the type of health care services available to them or typical social activities for older people.
2. Data were successfully collected from a total of 2404 older persons (1204 from Malaysia and 1200 from Myanmar) with a 100% completion rate among those who were included in the interview.  
3. Survey findings: Results from Malaysia showed that the majority (74.5%) of respondents report being diagnosed with multiple chronic conditions. Over half of respondents report foregoing care, with women, those with poor perceived health and those with difficulty walking being more likely to forego care. Results from Myanmar showed that women were more likely than men to report poorer health status as well as functional decline, controlling for age and other factors. Some risk factors, such as underweight, were more common in rural areas whereas other risk factors, such as being homebound, were more common in urban areas.

Global Implications

In many low- and middle-income countries undergoing rapid population ageing, there may be a lack of validated survey instruments that can be used to collect data on the health and social service needs and utilization among older people. Adapting and validating existing survey instruments may be an efficient alternative and provide data that are comparable to other countries. This approach can also fill an urgent need for local data on the health of the older population as well as contribute to a global evidence base of comparable data on the health needs and services coverage of older people.

Local Implications

Only a small number of high-level administrative indicators and databases relevant to the provision of health and social care for older people are available that enable comparisons between local governments in Kansai. Participation in existing survey research initiatives could offer a complementary source of information. Until recently, Kobe was the only municipality in Kansai that had participated in JAGES going back to the 2010-11 survey. However, in the latest survey wave conducted in 2019-20, nine other municipalities from Kansai have joined. These municipalities could compare their survey results and their various applications of data to inform local policies and programmes development. They could also help promote the use of research data for policy making in other municipalities of Kansai.  

Publications

1. Shah, S.A., Rosenberg, M., Ahmad, D. et al. Prevalence and determinants of unmet needs for hypertension care among the older population in Selangor: cross-sectional study. Health Res Policy Sys 20 (Suppl 1), 127 (2022). https://doi.org/10.1186/s12961-022-00915-1
2. Nozaki, I., Shobugawa, Y., Sasaki, Y. et al. Unmet needs for hypertension diagnosis among older adults in Myanmar: secondary analysis of a multistage sampling study. Health Res Policy Sys 20 (Suppl 1), 114 (2022). https://doi.org/10.1186/s12961-022-00918-y
3. Shah SA, Safian N, Ahmad S, Nurumal SR, Mohammad Z, Mansor J, Wan Ibadullah WAH, Shobugawa Y, Rosenberg M. Unmet health care needs among older Malaysians. J Multidiscip Healthc. 2021;14:2931–2940. doi: 10.2147/JMDH.S326209. eCollection 2021.
4. Shah SA, Safian N, Ahmad S, Wan Ibadullah WAH, Mohammad ZB, Nurumal SR, et al. Factors associated with happiness among Malaysian elderly. Int J Environ Res Public Health 2021;18:3831. https://doi.org/10.3390/ijerph18073831 
5. Sasaki Y, Shobugawa Y, Nozaki I, Takagi D, Nagamine Y, Funato M, et al. Rural–urban differences in the factors affecting depressive symptoms among older adults of two regions in Myanmar. Int J Environ Res Public Health 2021;18:2818. https://doi.org/10.3390/ijerph18062818
6. Safian N, Shah SA, Mansor J, et al. Factors associated with the need for assistance among the elderly in Malaysia. Int J Environ Res Public Health 2021;18:730. doi: 10.3390/ijerph18020730
7. Win HH, Nyunt TW, Lwin KT, et al. Cohort profile: healthy and active ageing in Myanmar (JAGES in Myanmar 2018): a prospective population-based cohort study of the long-term care risks and health status of older adults in Myanmar. BMJ Open 2020;10:e042877. doi: 10.1136/bmjopen-2020-042877