Aging Caribbean Populations and Implications for Health Management and Financing

Anton Cumberbatch; Charmaine Metivier; Chantal Malcolm; Joslyn Koma and Stanley Lalta HEU, Centre for Health Economics, UWI Presentation at 8TH Caribbean Conference on Health Financing Initiatives Jamaica…November 12th-14th, 2013

2

The Wheels of Life

3

KEY PRESENTATION THEMES • Aging—Demographics

• Aging—Health & Caring • Aging—Financing Considerations

• Conclusions

4

• “We

must be fully aware that while the developed countries became rich before they became old, the developing countries will become old before they become rich”. Dr Gro Harlem Brundtland, World Health Organization (WHO) Director-General, 2002.

• October 1 is International Day of Older Persons

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Aging Demographics--Global Scenario • Elderly may be placed in 4 categories: Pre-Elderly (50-59 years), > Young Old (60-74 years),  Middle Old (75-84 years) > Oldest Old (85 years and older). • In 1950-55,  average life expectancy ..66 and 42 years in Developed/Developing Countries resp.  Elderly 65++ was 8% and 4% of population in Developed/Developing Countries resp. •    

In 2012-15, average life expectancy ..78 and 67 years in Developed/Developing Countries resp. approx. 810 million persons aged 60 years or over in the world (11% or 1 in 9 persons) 1 in 5 persons in Europe; 1 in 9 persons in Asia and LAC and 1 in 16 persons in Africa. majority of older persons are women (84 men per 100 women among all 60++ and only 61 men for every 100 women among 85++

• By 2050,  60++ projected to increase to more than 2 billion (20% or 1 in 5 persons) with 20% of elderly being 80++.  65++ will be 26% and 15% of population in Developed/Developing Countries resp.  older persons will outnumber the population of children aged 0-14 years.

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Trends in Global Ageing (Developed versus Developing Countries) 30% 25%

Percent of Population Aged 65 & Over: History and UN Projection

25% 23% 19%

20% 16%

15%

14%

15%

12%

13%

13%

10%

10% 5%

26%

8%

9%

4%

4%

10% 8%

4%

4%

4%

5%

6%

0% 1950

1970

1990 Developed World

Source: UN (2005)

2010

2030

Developing World

2050

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Aging Demographics--Caribbean Scenario •

The Caribbean has one of the fastest growing older populations in the developing world.

• In the early 1950s: Persons 0-14 years (35% population) outnumbered 60 years ++ (5%)  very few people in the Caribbean reached their eightieth birthday • In 2000: 10% of the population in several Caribbean countries was 60 years ++ with 2% being 80 years ++  highest % found in Puerto Rico (14%), Cuba (14%), Barbados (13%), Netherland Antilles (10%)  lowest found in Haiti and Belize (6%) and the Dominican Republic (7%)  Gender Disparity-The majority of older persons are women • By 2050: 23% of population will be 60 years ++ with 5% being 80 years ++  33% will be 60 years ++ in Barbados, Cuba, Trinidad and Tobago, Guyana and Surinam with 10% or more being 80++ in Cuba and Barbados  There will be more persons (23.9%) in the 80 years ++ group than other elderly groups such as 60-64, 65-69 etc.  Persons 60 years ++ (23% population) will outnumber those 0-14 years (15%)

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Composition of the population of the Caribbean by age groups 1950-2050 60 50

percent

40 o-14

30

15-59 60+

20 10 0 1950

2000

2025

Year

2050

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Age distribution of older population of the Caribbean Medium Variant (Selected years) Age group

1950

60-64

thousan ds 375

65-69

2000 % 35.7

thousan ds 1209

273

26

70-74

192

75-79

2010 % 30

thousan ds 1505

960

23.9

18.3

763

123

11.7

80+

88

Total

1051

2015 % 29.6

thousan ds 1684

1218

24

19

938

527

13.1

8.3

565

100

4024

2050 % 29

thousan ds 2905

% 23.8

1383

23.8

2505

20.5

18.4

1070

18.4

2049

16.7

662

13

768

13.2

1847

15.1

14

766

15

907

15.6

2923

23.9

100

5089

100

5812

100

12229

100

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Population Pyramids for the Caribbean

Source: United Nations Population Division, 2000 Revision

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Ageing—Health and Caring (1) • Ageing is both an achievement and challenge reflecting gains made in nutrition, wealth as well as medical and public health.

• Aging is an economic, social, cultural and biological issue. • Healthy or active aging is seen as being able to maximize independence and function as one grows older. • Many issues faced by older people are due to accumulated social, psychological, and biological problems. Factors such as economic status, health status, social support, and level of education all play major roles in determining whether or not an individual ages successfully.

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Ageing—Health and Caring (2) • For persons 60 years ++--Leading causes of morbidity, disability and premature death (DALYs) are CNCDs mostly : cardio-vascular diseases,  diabetes and complications (eg. renal, neurological, opthalmic),  respiratory conditions  cancers. •   

For persons 75 years ++--Major additional concerns are:physiological/mobility (stroke, arthritis, disability) sense impairment mental illness (depression, dementia, Parkinson’s disease)

• Model of care in Caribbean is too hospital based and doctor centred (‘come to us vs coming to you’) with inadequate attention to healthy aging, primary care, caregiving and caregivers at home • Consider package with resources..‘fair innings’ and capacity to benefit vs doing everything possible

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Leading Causes of Mortality (65+ years) CAREC Member Countries (2004)

Other, 43%

Ischemic heart Disease, 15%

Malignant neoplasma, 4% Influenza and pneumonia, 4% Cerebrovascular disease, 14%

Diabetes, 12%

Hypertensive diseases, 8%

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Determinants of Healthy Ageing Aspects

Key Factors

Behavioural

• smoking, alcohol, exercise, diet, drugs

Environmental

• pollution, home safety, rural/urban location

Socioeconomic

• family, community, income, literacy

Personal

• biology, genetics, coping strategies

Services

• primary care, health promotion, disease prevention, acute care, social support

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Modifiable Illness-Disability Risk Factors Conditions

Risk Factors

Cardiovascular

sedentary life, obesity, lipids, BP, salt, diet,

Pulmonary

smoking, environmental pollution

Neurological

BP, smoking, alcohol, diet,

Diabetes

diet, sedentary life, obesity

Musculoskeletal:

sedentary life, obesity, hormone deficiency

Gastrointestinal

low fibre, alcohol, poor oral hygiene

Urogenital

BP, obesity, hormone deficiency

Cancers

diet, smoking, sedentary lifestyle

Mental Illness

retirement, social isolation, dependency

Accidents

unsafe homes

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Implications for Organization and Management of Care for Aging Populations • Emphasis on more appropriate mix of preventive, primary care and community/home-based care with acute (hospitalisation) and other institutional (residential) care. • More collaboration needed with other sectors to address social, economic and environmental determinants of healthy aging. • Given resource constraints, countries should seek to establish guidelines for ‘health rights’ and access to essential package of care by elderly including the right to refuse care for terminal conditions. • Policies should recognise differential needs of elderly females as well as elderly in urban and rural areas.

males and

• With the private sector as a key player in the healthcare arena, Government should seek to establish and monitor quality standards for care as well as to develop public-private financing options.

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Caribbean Actions on Aging • 1999—CARICOM Regional Charter on Ageing and Health urging governments to provide a coordinated, systematic approach for ensuring health and full participation of older persons. • 2003—LAC countries initiated a regional strategy to implement the 2002 Madrid International Plan of Action on Ageing. However, few countries have since introduced a ‘National Policy on Ageing. • 2004—First Caribbean Symposium on Population was held in Trinidad and Tobago to enhance recognition of impact and policies for ageing of population. • 2005—PAHO/WHO Collaborative Center on Ageing in LAC set up at UWI in Jamaica.

• Specific Chronic Disease Drug Programs: Barbados (Barbados Drug Service, 1980),  Jamaica (JADEP-Jamaica Drug for the Elderly, 1997 and National Health Fund, 2003),  Trinidad and Tobago (CDAP-Chronic Disease Assistance Program, 2003)  Bahamas (National Drug Plan, 2010)

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Elderly--Finding the Cash for Care

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NEEDS AND CAPABILITIES OF ELDERLY (‘x’ s indicate magnitude) Age Category (years)

Health /Medical

Social

Financial

Needs

Capabilities

Needs

Capabilities

Needs

Capabilities

Preelderly> 50--59

x

xxxx

x

xxxx

x

xxxx

Young Old>> 60-74

xx

xxx

xx

xxx

xx

xxx

Middle Old>> 75-84

xxx

xx

xxx

xx

xxx

xx

Oldest Old> 85++

xxxx

x

xxxx

x

xxxx

x

BALANCE OF CARE MODEL Marginal Cost ($)

Domiciliary Residential Hospital

0

Where: • 0A – Efficient Domiciliary Care • AB – Efficient Residential Care • Beyond B – Efficient Hospital Care

A

B

Level of Dependency

Paying for Individual Health Care $

Subsidy needed

Cost of needed care

Subsidy needed Earnings & capacity to pay

0

Age

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Aging and Health Financing Mechanisms Mechanism

Main Features 1.

i) Selffinancing

ii) Insurance

Comments Private (market)

* Individual and family pay for care from cash or property assets e.g. reverse mortgage

•

* Pooling of risks with risk rating to determine package and premiums

• •

•

More responsibility for one’s health and care But inequitable—variable access to care depending on one’s asset base. Actuarially fair But risk-income-illness exclusions limit universal coverage

2. Public i) Gov’t funds

* Tax resources cover spectrum of health care services

• •

Potential access for all But fiscal space constraints so variable range and quality of services

ii) Social Security

* Pooling of risks with graduated contributions based on earnings during work years

•

Equitable with financial protection in accessing care But enforcement issues with selfemployed and informal workers

•

3. Hybrid of 1 and 2

3. Publicprivate mix

* Gov’t or social security covers essential package of care with private ‘top-up’

• •

Cost sharing is established But issues in defining essential package to be available to all.

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CONCLUSIONS 1. We are the next generation of elderly 2. Aging is a natural consequence of improved nutrition; economic capabilities; public health and medical care (and absence of war).

3. Caribbean social values should be kept intact—the elderly are social assets not social burdens. 4. Policies on aging and health should: recognise varying needs and capabilities of different age groups  target actions in pre-elderly years  involve multi-sectoral partners  emphasise healthy aging, primary and home-based care  strengthen cost-sharing with financial protection through social security mechanisms along with targeted support from gov’t. 5. There is need for ongoing research, dev’t of databases, policy monitoring and evaluation (M&E) on aging and health (financing).

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“As for old age, embrace and love it. It abounds with pleasure if you know how to use it. The gradually declining years are among the sweetest in a person’s life.” SENECA