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Aging and Global Health
Section, Principles, and Drivers of Global Health
Mihajlo Jakovljevic, Ronny Westerman, Tarang Sharma, and
Demetris Lamnisos
Contents
Introduction . . . . . . . . . . ............................................................................. 3
Global Health Impact of Population Aging ...................................................... 3
Increased Early Childhood Survival . . . . . . . ................................................... 3
Worldwide Gains in Longevity and Life Expectancy ........................................ 4
Sexual Revolution and Absorption of Women into Labor Markets ......................... 4
Demographic Evolution during Accelerated Globalization of the 1990s and 2000s . . . . . . . . 5
Political Implications of the Demographic Transition ........................................... 5
Legacy of Colonial Age Leading to a Demographic Transition ............................. 5
Rise of the Emerging Markets: BRICS ....................................................... 7
Occurrence of Geo-Economic World Multipolarity Since 2010s and Impact of New
Silk Road ...................................................................................... 8
Social and Health Policy Reforms Addressing Population Aging .............................. 9
WHO Policies to Combat Population Aging and UN Millennium Goals ................... 9
Global Health Impact of Population Aging ...................................................... 12
Early Childhood Prevention of Infectious Diseases and Maternal Morbidity . . .. . . . . . . . . . . . 12
European Commission Focus on Health Cost and Long-Term Care Projections for All
EU-28 .......................................................................................... 13
M. Jakovljevic (*)
Department of Global Health Economics and Policy The Faculty of Medical Sciences, University of
Kragujevac, Kragujevac, Serbia
e-mail: sidartagothama@gmail.com
R. Westerman
Competence Center Mortality Follow-up, German National Cohort, Bundesinstitut für
Bevölkerungsforschung (BiB), Wiesbaden, Germany
e-mail: ronny.westerman@bib.bund.de
T. Sharma
Evidence to Policy, Copenhagen, Denmark
e-mail: tarangs@gmail.com
D. Lamnisos
Department of Health Sciences, European University Cyprus, Nicosia, Cyprus
e-mail: D.Lamnisos@euc.ac.cy
© The Editors and the World Health Organization 2020
R. Haring et al. (eds.), Handbook of Global Health,
https://doi.org/10.1007/978-3-030-05325-3_4-1
1
Consequences of Migrations for the Demographic Landscape and Survival of Nations . . . 15
Long-Term Medical Care for the Elderly and Family Caregiving ........................... 15
Demographic Data Sources and Their Transnational Comparability ........................ 16
Noncommunicable Diseases .................................................................. 17
Expansion of Morbidity, Compression of Morbidity, and Dynamic Equilibrium ........... 18
Evolution of Mortality Driven by Evolving Lifestyle and Mega-Scale Urbanization .... . . 19
Role of Nutrition and GMO Food . . . . . . . . . . . . . . . . . .. . .. .. . .. . .. .. . . . .. . .. . .. .. . .. . .. .. . .. .. . . 19
Perspectives of 4.0 Industries and Applied Robotics in Home Care for the Elderly
Citizens ........................................................................................ 20
Underlying Factors Contributing to Global Spreading of Demographic Trends . . . . . . . . . . . . 20
Health Expenditure Dynamics Driven by Aging in Contemporary Societies . . . ............ 21
Prominent Role of Dementia and Neuromuscular Disorders in Elderly Age ............... 23
Reform of Social and Health Policy Agenda to Raise Fertility Rates and Exploit Benefits
of Migrations .................................................................................. 24
Disbalance in Historical Roots, Stage, and Speed of Aging Between Rich OECD
and Emerging Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Flagged Emerging Issues ..................................................................... 25
Conclusions . . . . . . . ................................................................................ 26
References ........................................................................................ 27
Abstract
Population aging became a globally widespread phenomenon during the last
decades. Its core underlying causes are extended life expectancy at birth,
improved early childhood survival, education, absorption of women into the
labor markets, and consequences of sexual revolution leading to decreased female
fertility. The scale of this demographic transition is unique in the entire history of
mankind including a profound societal change that is now taking its toll on most
countries, rich and poor alike. Shrinking of capable labor force coinciding with
the expanding share of elderly and retired citizens continues to happen as a long-
term trend. Thus, long-term financial sustainability of public social and health
insurance funds becomes more and more questionable. Health expenditure
growth continues to accelerate worldwide, with increases mostly on demand
side. To a large extent, it is attributable to the needs of elderly citizens for
home-based medical care. Last year of life phenomenon confirmed that almost
entire life span medical consumption of an individual citizen is equal to the last
12 months of costs of treatment of expensive autoimmune, malignant, or vascular
diseases. Most national and transnational authorities seem to be forced to consider
reform of the current healthcare financing pattern inherited from the demographic
growth era. Such exit strategy is necessary to make the financial burden of
population aging bearable for modern-day universal health coverage and retire-
ment policies. Ultimately, without bottom-up rethinking of universal health
coverage and social support legacies, burden of global population aging might
remain virtually unbearable for the most of modern societies.
Keywords
Population aging · Global health · Health expenditure · Demography · Fertility
2 M. Jakovljevic et al.
Introduction
“Silver Tsunami”or population aging is a unique phenomenon in demographic
history of the mankind over the past eight millennia. Traditional societies used to
be young societies with abundance of youth and children dominating proportion of
elderly. This was truth regardless of the dominant ethno-religious pattern or the way
of life of ancient civilizations such as Buddhist, Hindu, Mandarin, Orthodox,
Roman-Catholic and Protestant Christianity, Islam, communism or modern-day
secular, and postindustrial societies. All of these communities had at least 15% of
children younger than 5 years, while the portion of elderly aged over 65 was
significantly less than 5%. In contemporary momentum of 2020, the growing portion
of senior citizens and the decreasing portion of children are meeting a melting point.
As per UN demographic sources, humanity has actually already passed a crossroad
point for the first time ever in history. How could such tremendous change be
possible? The social background matrix and way of life have changed essentially
beginning with the dawn of First Industrial Revolution of the 1740s. The French
nation as a convenient example exposed shy roots of the early female fertility fall
process more than two centuries ago, roughly after the Fall of Bastille back in 1789.
Yet complex demographic transition remained unnoticed almost until the late Cold
War decades. Ultimately serious and stable fall of female fertility was caused by
combined effects of the sexual revolution, female education, and the absorption of
women into the labor markets across the globe. Social circumstances have created
effective financial incentives for women to give birth to fewer children. Innovation
in modern medical technology was raising public demand for advanced diagnostics,
treatment, and rehabilitation procedures. Early childhood survival gradually became
much more successful. It has led to the great extension of human longevity ranging
from Japan to Nigeria. Joint effects of extended life expectancy at birth coupled with
lower fertility led to the increase of median age. In medieval and even during recent
centuries, European agricultural nations had a median population age significantly
beneath 20. Such demographic landscape today is visible among the very few
remaining countries, such as Afghanistan or the region of Sudanese Africa. Such
nations were designated by the United Nations Population and Social Affairs
Division as 18 “demographic outliers.”Unlike these few still juvenile communities,
vast majority of nations around the world belong to the dominant aging pattern. The
process itself began with the earliest historical shift across industrialized Northern
Hemisphere. Now as we speak the median population, age of most contemporary
societies is either approaching or slightly crossing the 40 years threshold.
Global Health Impact of Population Aging
Increased Early Childhood Survival
Major advances in public health measures globally have contributed to increased
early childhood survival in the world. These substantial improvements can be
quantified such that the total numbers of under-5 deaths globally have declined
Aging and Global Health 3
from 12.6 million in 1990 to 5.3 million in 2018. However, still on average, 15,000
children below of age of 5 are dying daily which is an improvement with the under-5
mortality dropping by 59%, from 1990 to 2018. It is essential that there is a provision
of an environment for young children such that they can achieve their full develop-
mental potential which is their fundamental human right and a requirement for
achieving the sustainable development goals.It is critical to give children the best
start in life, and therefore more is needed to ensure this trend continues going
forward. However, with this trend more people are able to reach adulthood than
ever before, which also then contributes to the current public health and demo-
graphic challenges that we see today.
Worldwide Gains in Longevity and Life Expectancy
Life expectancy is increasing almost linearly in most developed countries, and it has
risen by 3 months per year since 1840 (Oeppen and Vaupel 2002). Globally, life
expectancy at birth has increased from 48.1 years in 1950 to 70.5 years in 2017 for
men and from 52.9 years to 75.6 years in 2017 for women (Dicker et al. 2018; Rau
et al. 2008). The largest gain in life expectancy since 1950 was in North Africa and
the Middle East where life expectancy has increased from 42.4 years to 74.2 years.
On the other hand, the smallest gain in life expectancy was in Central and Eastern
Europe and Central Asia where life expectancy has increased by 11.1 years since
1950 (Dicker et al. 2018). Among the 13 counties with a population greater than
100 million in 2017, Russia has the smallest gain in life expectancy since 1950 with
5.7 years net gain for men and 7.7 years for women. The largest gains in life
expectancy among the 13 most populous countries were in Bangladesh with
32.1 years for men and 31.7 years for women and Ethiopia 31.1 years for men and
30.6 years for women. China has also made steady progress since 1950, and in 2017,
life expectancy was 74.5 years for men and 79.9 years for women. Among the
world’s most populous countries, Japan has the highest life expectancy for men and
women since 1963 and continues to do so in 2017. In 2017, the life expectancy at
birth for men in Japan was 81.1 years while for women was 87.2.
Sexual Revolution and Absorption of Women into Labor Markets
The role of women as homemakers has persisted over time, perpetuated through
religious and cultural norms and beliefs. At the end of the Second World War, there
was a substantial increase of women entering the labor market, which was then
further propelled by the sexual revolution of the 1960s and 1970s. The development
of the contraception pill has been attributed to be the public health contribution to
this sexual revolution, which permitted women to delay pregnancy until they chose
it, bringing with it their opportunities to enter and remain longer in the labor market
(Allyn et al. 2016). There is general agreement that the active participation of women
in the workforce brought with its economic growth for the countries (Luci 2009).
4 M. Jakovljevic et al.
However, gender-specific disparities in employment persist, and through empirical
studies, we know that these still have a strong impact on a country’s macroeconomic
growth in terms of GDP per capita (Fortin 2005). There is still a long way to go in
terms of equality in pay for women and the convergence of the gender-pay gap (Blau
1997). Moreover, there persists a clash between traditional family roles and values
and egalitarian perspectives, that is often manifested as an inner conflict for many
women, that is noted as “mother’s guilt,”and which acts as a further obstacle to
gender equality in the labor force.
Demographic Evolution during Accelerated Globalization
of the 1990s and 2000s
Since the 1990s, the global economy entered a new phase of development which was
characterized by an “acceleration of globalization.”This new phase was character-
ized by the rapid spread of information and communication technology (ICT) and a
further increase in global economic integration (Haraguchi et al. 2018). One of the
main characteristics of this era was the economic migration. This economic migra-
tion caused the intra-regional migration from Southern Europe to Northern and
Western Europe (Nicolae-Bǎlan and Vasile 2008), while the USA experienced a
migration inflow from Latin America and Asia (Sintserov 2019). As a result of this,
economic migration was a new population structure. The migration was favored on
one hand by minimizing the global distances due to modern infrastructure and
transportation, of developing communications and Internet, and, on the other hand,
by the development of regulations that facilitate the mobility, such as transfers
between national insurance systems and social and medical assistance (Nicolae-
Bǎlan and Vasile 2008).
Political Implications of the Demographic Transition
Legacy of Colonial Age Leading to a Demographic Transition
World economic history following Renaissance era has led to some established
patterns alongside geographical distribution of development. Out of four consecutive
industrial revolutions, three of them mostly took place among the nations of North-
ern Hemisphere. These were mostly European colonial forces and their descendant
cultures. Aligned with consequences of European conquest of the New World,
Africa and Asia, most of the nations of Global South even today remain among
“developing”or low- and middle-income countries (LMIC) as per World Bank Atlas
measurement of economic productivity. Typical North-South axis meant that goods
and services were manufactured by investors from the North employing skilful,
educated, and affordable labor force of the Global South. Without surprise most
consumers of these same expensive goods or services came back from the Norther
Hemisphere. Economic dominion of Western Europe and its colonial descendant
Aging and Global Health 5
cultures was essentially challenged during nineteenth and twentieth century only by
Imperial Russia and later USSR. Soviet 5-year development plans based on entirely
different economic models were exceptionally successful in terms of economic
output. Real GDP growth rate of USSR as the core indicator of economic produc-
tivity heavily outperformed most of world’s rapidly developing economies during
most of 1928–1971 period (Allen 2005: 315–332). People’s Republic of China much
later adopted 5-year plan strategy, and these plans were clearly one of the corner-
stones of Chinese welfare success story. It is less known fact that during most of the
Cold War era, USSR was ranked the second global economy. This was grounded in
purchasing power parity terms according to the Bretton Woods Financial Institutions
such as International Monetary Fund and the World Bank observing the late 1940s to
early 1980s horizon.
Relying on Agnus Madison’s historical estimates, the USA became the richest
country as per purchase power parity GDP terms around 1875. Surprisingly this
crown was not taken away from the British Empire but instead from Chinese Empire
led by Qing dynasty. Epilogues of both world wars supported further growth of US
share of world economy reaching its peak somewhere in around 1960 with roughly
40% of world’s economic output. Demographic history taught us that US census
population never crossed the 4% threshold of entire mankind population size; thus
the huge scale of such development in North America is better understood. Cold War
era lasted approximately from 1947 to 1991. Accelerated globalization era began
from 1989 and experienced sudden slow down during recession triggered by bank-
ruptcy of Brother Lehman 2008–2016.
Most recently economic globalization even came up to a certain, probably
temporary but unique hold, due to corona pandemic which caused world economic
recession in spring 2020. Through the most of past three decades, Western-Japanese
led multinational companies, inclusive of those typical for the health sector known as
the Big Pharma which harvested most of profit in international arena due to bene-
ficial circumstances.
Yet, there appears to be a significant hidden underlying trend which mostly
passed unnoticed. “Collective or Political West”share in world’s economic output
continued to shrink and contract during the most of 75 post-Second World War
years. Appearance of this profound change was first measured in purchase power
parity terms and far later in nominal terms. This crucial evolution was actually
happening gradually for decades while accelerating rapidly since the late 1990s.
Movement of world’s geo-economic heavy weight from the West toward the East
Asia –Western Pacific Region –appears to be steady but irreversible process. North
American contribution to the world economy was contracting further in the long run,
throughout all the upsides and downs of previous decades. Contemporary US share
is exactly 15.11% in GDP in PPP terms according to the latest data release of 2019.
According to the International Monetary Fund’s“World Economic Outlook,”this
value is going to be at 13.71% in 2024. Convenient to compare, USSR share in
world economy in the same terms during the peak of its power was 16.5%. Even
more surprising results appear if we observe the EU28 (prior to Brexit, as of May
2019) contribution to the world economy. Their joint output on both sides of Iron
6 M. Jakovljevic et al.
Curtain back in 1989, communist and capitalist alike, was around 33%. In the
meantime, geopolitical maps evolved substantially. In last year-ending fiscal 2019,
all these same EU nations (including UK) contributed with only 16.02% to the
global GDP. Most reliable long-term forecasts predict this is going to fall further to
approximately 9% in 2050, regardless of the political landscape that might change.
Macroeconomic global recession 2008–2016 brought upon years of stagnant or
weak real GDP growth in most high-income OECD nations. Serious vulnerabilities
of the neoliberal globalization model became apparent and publicly declared even by
heads of state of G7 nations. Probably a milestone threshold event was the
September 2014 recognition of the People’s Republic of China by the International
Monetary Fund as the largest world economy in purchasing power parity. Deeper
knowledge of Asian economic convinces this is no surprise neither a sudden swift in
tectonic geopolitical movements. Insight into the historical archives reveals that the
roots of today’s world economic order can traced back to where it was a century and
a half ago. Going back to the Medieval Age and Antiquity, we face the very similar
“old world”landscape dominated by either India’s or Chinese imperial statehoods.
Rise of the Emerging Markets: BRICS
Aforementioned explanation of some core drivers of world economic history admits
existence of the “Rich North –Poor South”as during the Colonial Age in terms of
trade and investment flows. Bipolarity of the Cold War effectively ended the legacies
of Western European empires. The Non-Aligned Movement formally established by
India, Egypt, and Yugoslavia was a contributor accelerating this evolution. Promi-
nent Third-World leaders, Mahatma Gandhi, Nelson Mandela, Fidel Castro, and
Patrice Lumumba, played a role in the transformation and fall of classic European
colonialism.
Perestroika was introduced in the USSR in the 1980s, and Deng Xiaoping
Chinese reforms began in 1978, but real profound changes were looming on the
horizon since 1989. Impact of these reforms was not clearly understood when they
happened. Ultimately the Russian recession ended in 1998, and Chinese-accelerated
development was getting its momentum. Goldman Sachs analysts recognized the
rise of “newly established”economies and designated them as the emerging markets.
They had inherited different inner governing practices, but all where located outside
the elite club of traditional high-income, welfare economies of the 1960s. Several
acronyms have been introduced to group them, such as EM7, MIST, Next Eleven,
and others, but the one getting the broadest recognition in academic literature was
the BRICs referring to Brazil, Russia, India, and China. South Africa as a much
smaller member joined BRICS later, which together constituted a formal geopolitical
alliance since 2008. All of these nations were developing much faster before, during,
and after world economic recession 2008–2016. Brookings Institute recently desig-
nated contribution of EM7 nations (BRIC + Mexico Indonesia and Turkey) to the
real GDP growth worldwide (2017–2020 horizon). It has vastly exceeded the share
of G7 (USA, Japan, Germany, UK, France, Italy, Canada) comparing 50% attribut-
able to EM7 to 25% of world’s GDP brought upon by G7.
Aging and Global Health 7
Occurrence of Geo-Economic World Multipolarity Since 2010s
and Impact of New Silk Road
Chinese milestone event on Tiananmen Square in 1989 marked the threshold year
for rapid further development. India and Brazil also changed the traditional North-
South polarity in world economic order. Middle class continues to grow among the
BRICs states (Kravets and Sandikci 2014). This trend is entering its third decade
now in BRICs, with China being the overachiever lifting 800+ million people from
poverty (Jakovljevic 2015). Also, the purchasing power of this middle class is
growing rapidly as well, particularly in rich coastal and industrial areas surrounding
capitals and megacities. The 11th formal meetings of BRICS heads of state took
place in Brasilia in March 2019. Its agenda was largely devoted to the coordination
of health strategies.
One Belt, One Road Initiative appears to be probably the largest scale infrastruc-
tural investment project in mankind history. Chinese Imperial legacy as “the Middle
Kingdom”is actually filled with prominent examples of large-scale coordinated
efforts of huge number of people (Rossabi 1983). Probably among the most well-
known ones are the Great Wall legacy of early statehood of the seventh century BC
and the buildup of a large naval fleet for early Ming dynasty treasure voyages (1405–
1433 AD) exploring the shores of Indian Ocean and Africa. Contemporary China
differs in several core aspects with its historically preceding statehoods in the sense
that it has been long absorbing the dominantly foreign-born knowledge and
technologies.
People’s Republic of China in a much different international circumstances
followed Japanese Meiji 1868 reform example. Modern Chinese development refers
to the successful delivery of social justice in many spheres of life and controlling the
gap between the rich and the poor as measured via Gini index. Socialism with
Chinese characteristics are now well-known as a mega-scale industrialization,
unseen urbanization, and birth of megacities with Shanghai conurbation recently
becoming the largest city on Earth. Probably the most glorious recent examples are
satellite landing on a dark side of the moon and essential technological break-
throughs in 5G cellphone networks. Therefore, Chinese society, academia, and
industry sector alike have clearly developed their ability not only to absorb the
knowledge and reproduce industrial techniques patented by other nations but as well
to move the cutting edge of science creating new authentic knowledge and
technologies.
Yet, brand-new Chinese geo-economic behavior is this new policy of opening to
the world. Society which traditionally perceived itself as the Middle Kingdom had
no essential drive to civilize barbarian tribes across its frontiers like most other
imperial civilizations. This new strategy of building bridges in spirit of mutual
benefit and confidence among primarily the nations of Asia, Africa, and Europe is
indeed a new one. Chinese-accumulated wealth, given the new circumstances in
world trade affairs, needs foreign investment to consolidate its export-oriented
economy. National industrial capacities by far exceed domestic needs, and such an
engagement primarily in surrounding foreign countries and later in Eastern Europe
8 M. Jakovljevic et al.
beyond Russia, Middle East, and Eastern Africa appears to be justified from the
economic point of view.
Chinese economic growth model is now entering a transition period, leading to
the gradual decrease of real GDP growth rates. In year 2019 national GDP was
entering its lowest value over the past 27 years. This was largely attributable to the
trade war with the USA. Inner reforms aim to transform China into a mature
economy driven by domestic consumption, replacing export-based one. This ambi-
tious process is likely to take years to consolidate. Yet the accumulated wealth and
abundance of foreign currency and gold reserves serve as a guarantee of China’s
ability. It is likely to go further beyond ambitious architectural plans alongside many
of the New Silk Road high-speed railway routes, airport terminals, and large naval
capacities intended to serve core ports of Indo-Pacific maritime trade.
The architects of BRI have recently founded the New Development Bank and
Asian Investment Bank surprisingly supported by competitive large Western
European economies. Visible consequence of BRI is induced connectivity among
Asian, European, and African nations of a scale. Collaborative efforts are visible in
terms of huge energy projects, high-speed railways and trade, but also accelerated
access to the 4.0 industries, advanced robotics, and artificial intelligence.
Social and Health Policy Reforms Addressing Population Aging
WHO Policies to Combat Population Aging and UN Millennium Goals
The United Nations (UN) Millennium Declaration was adopted in 2000, where all
world leaders committed to jointly work together to combat poverty, hunger, disease,
illiteracy, environmental degradation, and discrimination against women (World
Health Organization 1999,2017a,b,2018,2020a,b). The United Nations Millen-
nium Development Goals (MDGs) were derived from this declaration and prioritized
eight goals that the UN Member States agreed to try and achieve by the year 2015.
The targets were therefore set for 2015, and indicators were mapped to monitor the
progress from 1990 levels. With many of these goals having a health perspective,
some countries were able to make progress in achieving their targets, but others were
unsuccessful. Some targets were achieved, whereby already by 2010, the MDG
targets for access to safe drinking water were achieved (though the sanitation overall
target was not). Progress was also seen in the nutrition targets of children, whereby in
developing countries, underweight children below the age of 5 years fell from 28%
in 1990 to 17% in 2013. The under-five mortality fell from 12.7 million in 1990 to
6.3 million in 2013. Success was also seen in HIV where new HIV infections
declined by 38% between 2001 and 2013 globally and existing cases of tuberculosis
also declined during this same period. More countries now have high levels of
immunization coverage within 66% of all UN Member States managing at least
90% coverage in 2013.
Some targets were sorely underachieved, despite a significant reduction in the
number of maternal deaths; the rate of decline was less than half the target. When we
unpick it further, though the proportion of women receiving antenatal care at least
Aging and Global Health 9
once during pregnancy was about 83% for the period 2007–2014, the recommended
minimum of four or more visits was only achieved by 64%. From 2000 to 2013, the
incidence of malaria and mortality rates attributed to it fell globally by 30% and
47%, respectively, but the numbers are still high, and there is a long way to go still.
To keep that momentum going, in 2015, all the countries that are members of UN
adopted the 2030 Agenda for Sustainable Development. These are 17 Sustainable
Development Goals (SDGs), which consist of 169 targets, that are now being
monitored (World Health Organization Regional Office for Europe 2020). Once
again, they are drafted to support the end to poverty and inequality globally as well
focusing on improving the health of people and justice and prosperity. The SDGs
versus the MDGs also have targets to protect the planet and are also not only looking
at developing nations but the world globally. This is to ensure that all people are
treated with dignity and are based on values of human rights and equity noting that
new ways of working and innovation will be needed to achieve these. Goal 3 is to
ensure healthy lives and promote well-being for all at all ages, but this is very much
crosscutting, and therefore its progress impacts on other goals as well as other goals
which contribute to goal 3, in promoting and achieving universal health care (UHC).
One of the key elements that are captured by the SDGs is the evolved nature of the
global population since the 1990s. There are many unpredictable health challenges
that emerge; however, one health trend that is certain is that the global population is
rapidly getting older, and this demographic shift to aging is certain. The World
Report on Ageing and Health published in 2015 helped shape the SDGs and
supported the focus on healthy aging globally (Beard et al. 2016). The concept of
“healthy aging”is about creating an enabling environment, i.e., adapting housing,
transportation, public spaces, services etc., as needed to permit maintenance and
preservation of mental and physical capacity, as we age, such that people can
continue do what they value. The WHO developed a global strategy and an action
plan which was adopted by its member states in 2016, which supports this by
creating a policy framework to ensure the lofty ambitions of healthy aging within
the SDGs are met. There are key ten priority areas that the World Health Organiza-
tion (WHO) recommends and are the key priorities to focus on for improving health
of the elderly, and they are summarized in Box 1(World Health Organization
2017c). Health of the elderly is vital to ensure that people at older age have a good
quality of life and that they can continue to make active contributions to society.
Box 1 The Top Ten Priorities for Healthy Aging
Priority 1: Establishing a platform for innovation and change.
Igniting change for healthy aging by connecting people and ideas from
around the world through use of platforms permitting exchange and network.
Priority 2: Supporting country planning and action.
Providing countries with the capacity to get the skills and tools they need to
create evidence informed policies that enable people to live long and healthy
lives.
(continued)
10 M. Jakovljevic et al.
Box 1 The Top Ten Priorities for Healthy Aging (continued)
Priority 3: Collecting better global data on healthy aging.
Focusing on collecting accurate up-to-date and meaningful data on healthy
aging to ensure that we can measure and act to support the initiative.
Priority 4: Promoting research that addresses the current and future
needs of older people.
Researching the questions that are relevant to older people through inno-
vative ways such that we gain valuable knowledge for healthy aging.
Priority 5: Aligning health systems to the needs of older people.
Evolving health systems of countries to ensure that older adults get the
health care they need and where and when they need it in formats that they can
access.
Priority 6: Laying the foundations for a long-term-care system in every
country.
Supporting countries to create equitable and sustainable systems that pro-
vide older people and caregivers the care and the support they need to live with
dignity and enjoy their basic human rights.
Priority 7: Ensuring the human resources necessary for integrated
care.
Creating enabling environments through training and development of
workforce such that people have the skills to deliver quality health and long-
term-care services for older people.
Priority 8: Undertaking a global campaign to combat ageism.
Changing how we think, feel, and act toward age and aging to stigma and
discrimination globally toward the elderly.
Priority 9: Defining the economic case for investment.
Understanding better the costs and opportunities of healthy aging as the
starting point for sustainable, equitable, and effective responses.
Priority 10: Enhancing the global network for age-friendly cities and
communities.
Creating cities and communities around the world that enable older people
to do the things they have reasons to value.
WHO recently put forward their draft proposal for the “Decade of Healthy
Ageing 2020–2030,”which has put the elderly people at the center and brings
together governments, civil society, international agencies, professionals, academia,
the media, and the private sector to improve the lives of older people, their families,
and their communities. It has noted that for the first time in 2020, people above
60 will outnumber children under 5 years, and by 2030 the people above the age of
60 will be 34% higher, and by 2050, there will be twice as many people over 60 as
there are children under 5 years globally. Additionally, by 2050, people over 60 years
will also outnumber adolescents and young people aged 15–24 years. With this pace
of growth, more action is needed to ensure that older people can live with dignity.
Aging and Global Health 11
Already there are more than 1 billion people over the age of 60 globally, with many
living in LMICs, so this has come timely to support countries with a way forward.
Global Health Impact of Population Aging
Early Childhood Prevention of Infectious Diseases and Maternal
Morbidity
There is strong connection between maternal morbidity/mortality and early child-
hood infectious diseases. Regarding maternal mortality only ten countries have
achieved the UN Millennium Development Goal 5 (MDG5) with reducing the
maternal mortality by three quarter between 1990 and 2015 (GBD 2015 Maternal
Mortality Collaborators 2016). Also 24 countries remain on the high maternal
mortality ratio level (per 100 000 live births) greater than 400 in the same time
period. On the other hand, there are global important improvements for the UN
Substantial Development Goals 3.1 like increasing life expectancy, the reduction of
maternal and child mortality, and fighting against leading communicable diseases.
These goals have been realized by 122 of 195 countries. As a highlight the reduction
in child deaths is the major milestone for improving global health, while the annual
global number of deaths of children under 5 years of age (under 5) has declined from
19.6 million in 1950 to 5.4 million in 2017 (GBD 2017 Mortality Collaborators
2018; Burstein et al. 2019). Nevertheless, there are still major challenges for
maternal health during pregnancy that impacts birth outcomes and early childhood
health to continue this success story. Preeclampsia is a pregnancy-related hyperten-
sive disorder that affects 2–8% of all pregnancies and remains a leading cause of
maternal and fetal/neonatal morbidity (Duley 2009). Approximately 12–25% of fetal
growth restriction and small for gestational age infants as well as 15–20% of all
preterm births are attributable to preeclampsia (Jeyabalan 2014). Major prevention
strategies reveal on blood pressure monitoring, medication (low-dose aspirin), and
dietary supplementation with calcium (Gülmezoglu et al. 2016).
Maternal sepsis is associated with pregnancy complications and is still the leading
cause of maternal mortality worldwide. It occurs before or during the delivery and
has directly impact of newborn mortality. Annually about one million of all newborn
deaths are caused by maternal infections. The major prevention strategies focus on
avoiding direct risk factors including unsafe abortion, intrapartum vaginal examina-
tion, and prolonged or obstructed labor (Gülmezoglu et al. 2016). Another strategy is
the improvement of hygienic standards for the delivery. As an example, the global
maternal sepsis study (GLOSS) evaluates criteria for possible severe maternal
infection and maternal sepsis. Important prevention strategies are early identification
and management of maternal sepsis; further understanding of mother-to-child trans-
mission of bacterial infections; the assessment of the level of awareness about
maternal and neonatal sepsis among healthcare providers; and the establishment of
a network of healthcare facilities to implement quality improvement strategies for
12 M. Jakovljevic et al.
better identification and management of maternal and early neonatal sepsis (Bonet
et al. 2018).
HIV infections are remaining global health threats affecting mother and children
via mother-to-child transmission. Antiretroviral therapy (ART) with triple drug
regimens is most effective first-choice medication to prevent vertical mother-to-
child transmission (Ciaranello et al. 2011). In summary, improving hygienic condi-
tions, monitoring blood pressure through delivery, and effective medications are
major prevention strategies to improve mother and early childhood health.
European Commission Focus on Health Cost and Long-Term Care
Projections for All EU-28
The 2018 Ageing Report from the European Commission broaches the issue to
health cost and long-term care projection for all EU-2018 member states. There are
totally 12 different assumption-based scenarios that face at least 1 of 3 main inputs:
(1) demographic structure and the population level, (2) age-related expenditures
profiles modelled as unit cost, and (3) assumptions regarding the development of
unit cost over time with macroeconomic variables. All scenarios estimate changes in
life expectancy, healthcare costs in the last years of life, income elasticity of demand
for health care, different patterns of unit cost development, and the cost-convergence
of age profiles for all EU-2018 member states (EU Commission 2018).
The scenarios one to four remain always on debate for health policy because of
their importance.
With the first scenario known as “demographic scenario,”there will be the
assumption about constant morbidity rates over time. This scenario is also sustained
by the expansion of morbidity hypothesis that assumes all future gains in life
expectancy will be spent in bad health.
The second scenario defined as the “high life expectancy scenario”(a variant of
the demographic scenario) is more optimistic by assuming that the life expectancy at
birth will be higher by 2 years in 2070.
The compression of morbidity hypothesis will be reflected with the third scenario
as “healthy aging scenario.”That scenario implies that the number of years spent in
bad health will be constant over the projection period and all gains in additional life
expectancy are almost spent in good health.
The fourth scenario known as “the postponement in health care spending”
followed as a result of the shift of the excess mortality to higher ages.
The other eight scenarios mostly contain macroeconomic assumptions about
income elasticity, EU-28 cost convergence, labor intensity, sector-specific composite
indexation, non-demographic determinants, increases in healthcare expenditure
AWG reference, AWG risk scenario, and the total factor productivity risks.
As only one example, the “demographic scenario”postulates an increase of the
gross domestic product (GDP) from 6.8% to 7.9% in the period of 2016 to 2070. The
public expenditure on health care will be also increase from 1.0% to 1.7% of the
GDP in the same time period (EU Commission 2018). Again for Germany the
Aging and Global Health 13
projected change in age-related expenditure in health care will be about 4.2% of
GDP. That is accounted as the highest growth in the EU. The two examples support
the main drawback of the assumption-based healthcare projection scenarios because
of its idea of “what if thinking.”Thus, the results must be interpreted with caution
because of the large uncertainty. The EU-28 health cost projection scenario captures
also a long-time period about 54 years that allows also variations of specific indicator
beyond the defined framework (Jakovljevic et al. 2018).
Case “The Great Exemption of India’s Delayed Onset of Aging and Its
Demographic Dividend”
Aging in India has always been defined by increased fatigue and decline in
functional capacity. From the early Hindu scriptures, the concept of retirement
from family life or “Vanaprastha”was prescribed from the age of 50 onward.
The Government of India amended that to be 60 years for retirement from
public service. It is estimated that in the coming one and half decades, 44% of
the total health burden in India will be borne by adults aged 60 and above. This
is a staggering number for which the country needs to prepare for, but one of
the key barriers is that the Indian healthcare infrastructure is dominated by the
private sector, making affordability an issue. This is especially pertinent as it
was established that socioeconomic differences in health and access to health
care are key issues in India. 19% of the elderly population noted health
problems in 2015, with majority being those from a poorer economic back-
ground. Therefore, pro-poor policies that go broader than health are needed to
improve the lives and well-being of the elderly in India.
Case “Latin American Migrations to the USA and Canada”
By the beginning of the new millennium, Latin America is one of the main
regions of population migration to the principal economies of the developed
world (USA, Europe, and Canada). In 2000, there were 19.2 million who lived
in a country outside Latin America (Canales 2011). This Latin American
emigration was driven by the extended economic crisis during the 1980, the
poverty and the lack of economic opportunities in the Latin American coun-
tries (Durand and Massey 2010), as well as the changes in the production
structure and labor markets in the developed economies (USA, Europe,
Canada, and Japan) (Canales 2011). In some cases, such as Mexico, those
who emigrate are drawn primarily from the lower sectors of society, the
workers or peasants (Durand and Massey 2010). In other cases, such as
many South American nations, migrants are drawn mainly from the middle
and professional classes. In general, Latin American migration incorporates
both men and women, although in certain cases, such as Peru, Brazil, and the
Dominican Republic, female migrants dominate (Durand and Massey 2010).
14 M. Jakovljevic et al.
Consequences of Migrations for the Demographic Landscape
and Survival of Nations
A third demographic transition is considered to be underway in Europe and the USA
(Coleman 2006). According to this demographic transition, several population
nations will radically and permanently alter their ancestry as a result of the high
levels of immigration and the persistent sub-replacement fertility (Coleman 2006).
The low fertility combined with high immigration are changing the composition of
national populations and thereby the culture, physical appearance, social experi-
ences, and self-perceived identity of the inhabitants of nations. If current trends
continue, the population of indigenous origin of many countries would be equiva-
lence or even inferior to recent immigrant population or mixed origin (Coleman
2006). According to a demographic forecasting of population projections, the pro-
portions of foreign-origin populations will reach the 45–50% by the 2060s in several
European countries, in the case that the persistent large-scale immigration continues
with the current trend (Lanzieri 2011). That would be an ultimate “replacement
migration”of a kind not previously seen over large geographic areas without
invasion of force. Whether or not this will be the reality depends on the amount
and duration of in-migration as well as the fertility levels of the destination countries.
Long-Term Medical Care for the Elderly and Family Caregiving
One quarter (23%) of the total global burden of disease is attributable to disorders in
people aged 60 years and older. Although the proportion of the burden arising from
older people (60 years) is highest in high-income regions, disability-adjusted life
years (DALYs) per head are 40% higher in low-income and middle-income regions,
accounted for by the increased burden per head of population arising from cardio-
vascular diseases, respiratory, and infectious disorders (Prince et al. 2015). The
leading contributors to disease burden in older people are cardiovascular diseases
(30.3% of the total burden in people aged 60 years and older), malignant neoplasms
(15.1%), chronic respiratory diseases (9.5%), musculoskeletal diseases (7.5%), and
neurological and mental disorders (6.6%). A substantial and increased proportion of
morbidity and mortality due to chronic disease occurs in older people. The hospi-
talization rates among 65 years and older are more than four times their younger
counterparts, while their visits to a GP annually are more than double the rate of
under 65 years old individuals (McPake and Mahal 2017). Healthcare requirements
of the elderly are also more complex because of their high levels of multi-morbidity.
Data from the Australian Health Survey (2014–2015) show that the reporting of
three or more chronic conditions was 29.3% among the age group 65+, and this was
almost double that of the 45–64 age group and nearly 12 times higher than that of the
0–44 age group (McPake and Mahal 2017). The most common cases of multi-
morbidity in the age group 65+ involved some combination of hypertension, hyper-
lipidemia, and osteoarthritis. Disability is also an important issue related to aging
that requires the response of the health system.
Aging and Global Health 15
Family caregiving plays a crucial role in delaying and possibly preventing
institutionalization of chronically ill older patients. When the patient is mildly or
moderately impaired, a spouse or adult children often provide care, but when the
patient is severely disabled, a spouse (usually a wife) is more likely to be the
caregiver (National Alliance for Caregiving and the AARP Public Policy Institute
2015). Approximately 34 million Americans, more than 10% of the US population,
were estimated to have served as caregiver for someone age 50 or older in the year
2015 (National Alliance for Caregiving and the AARP Public Policy Institute 2015).
The amount and type of care provided by family members depend on economic
resources, family structure, quality of relationships, and other demands on the family
members’time and energy. Family caregiving ranges from minimal assistance (e.g.,
periodically checking in) to elaborate full-time care. Caregivers of older adults report
that 63% of their care recipients have long-term physical conditions and 29% have
cognitive impairment (National Alliance for Caregiving and the AARP Public Policy
Institute 2015). Caregiving for older adults with neurocognitive disorders is known
to be particularly intense and burdensome and to have harmful effects on caregivers.
Demographic Data Sources and Their Transnational Comparability
For demographic research there are many data sources available provided by
different stakeholders like the 2019 Revision of World Population Prospects by the
United Nations, WHO Global Health Observatory data repository, and the popula-
tion estimates from the Global Burden of Diseases Study by the Institute of Health
Metrics and Evaluation, University of Washington. The remaining challenges are the
comparability of data collection techniques, the quality of statistical methods for data
preparation, and even the access and data courtesy on very high level. A good
example is the Human Mortality Database that includes all population (countries)
with virtually completed census data and death registration. That scientific endeavor
contains population and mortality data for 37 developed countries and 46 populations
also on sub-national level (Barberie et al. 2015). The HMD has strict selection
criteria for the inclusion of any country. The country’s death registration must be
complete with 99% coverage of all deaths. Furthermore, the HMD process birth
counts as the annual counts of live births by until the available longest time period.
The death counts are available for sex, the completed age, year of death, and year of
birth. For deaths of unknown age, the HMD uses redistributions methods for specific
age range and aggregated deaths. The population size will be captured with census
data as the annual population estimates by sex and age. For data gaps in annual
population estimates, the HMD uses the intercensal survival method that includes
linear interpolation, in case of the territory changes, the period death rates around the
time of a territorial change, and the cohort mortality estimates around the time of the
territory change. The death rates are accounted for periods and cohorts and will be
defined as the ratio of deaths to exposure to risk in matched intervals of age. The
HMD also provides standardized life tables by single calendar year and single year
of age and multi-year and abridged life tables. This allows reliable cross-country
16 M. Jakovljevic et al.
comparisons for life expectancy and age-specific deaths between countries. Another
success story is the Human Fertility Database (HFD) that also refers to official data
on live births and population counts from national statistical offices. As similarity to
the HMD, the HFD also has strict data quality requirements that involve only
countries from developed countries with full coverage of vital statistics. For com-
parability the HFD also plans to include the same countries, territories, or
populations provided in HMD. Currently fertility data for 27 countries and
5 sub-national populations is available with the longest possible continuous time
series (Jasilioniene et al. 2016). Both database show that comparability can be only
achieved with high data quality standards, harmonized methods for data processing,
and even the longtime series with annual data. For the global demographic phenom-
enon, the further efforts should be the accessibility of fertility and mortality data for
less developed countries with lower data coverage less than 99%.
Noncommunicable Diseases
Noncommunicable diseases (NCD) are mostly chronic conditions that account to
more than 80% of all premature deaths. Within NCD there are four top diseases that
excess to premature mortality with cardiovascular diseases (17.9 million deaths
annually), cancers (9.0 million deaths annually), respiratory diseases (3.9 million),
and diabetes (1.6 million) (GBD 2015 Risk Factors Collaborators 2016). The
incidence of NCDs also continues to increase over time and become one of the
most global burden for human health.
The burden of NCD can be reduced with different prevention strategies that must
be implemented in primary healthcare settings. One important factor is education
that essentially should improve the knowledge about certain diseases and their
corresponding risk factors. Beyond the educational programs about primary preven-
tion and a better understanding for behavioral risk factors (e.g., tobacco use, physical
inactivity, unhealthy diet, and the harmful use of alcohol) and the metabolic risk
factors (raised blood pressure, obesity, hyperglycemia, and hyperlipidemia), the
access to effective treatment should be provided for everyone regardless their
socioeconomic status, nationality or ethnic group (Gouda et al. 2019).
Low- and middle-income countries (LMICs) especially in sub-Saharan Africa
currently experience the rapid epidemiological transition as a shift from communi-
cable diseases and childhood illnesses to the increasing predominance of chronic
noncommunicable diseases. Although the burden of communicable, maternal, neo-
natal, and nutritional diseases (CMNN) successfully decreased in sub-Saharan
Africa with essential improvements to healthcare access and successful treatment
with, e.g., antiretroviral therapy for HIV infection, there might be a link to elevated
cardiovascular risks (Triant 2013).
Comorbidities of emerging NCD prevalence with remaining infectious diseases
like HIV or malaria gain more importance for NCD epidemiology in sub-Saharan
Africa. Another example is diabetes mellitus (DM) with increased risk of tubercu-
losis (TB). Individuals with diabetes mellitus have three times the risk of developing
Aging and Global Health 17
tuberculosis. Currently there are more individuals with TB-DM comorbidity than
TB-HIV coinfection. Other chronic infections, for example, with Helicobacter
pylori (H. pylori), human papillomaviruses (HPV), hepadnaviruses (HBV), and
flaviviruses (HCV), are responsible for approximately the 5% of all human cancers
(De Flora and La Maestra 2015). Infection-related cancers can primarily be pre-
vented with avoiding the spread of chronic infections to protect the host organism
with vaccination. A positive example is the national vaccination programs for HPV
during adolescents in Rwanda that mainly contributed to the decline of HPV
infections and dropped the HPV infection-related cervical cancer incidence in
young women.
There are remaining local variations in social and economic development
between rural and urban areas in sub-Saharan Africa that might hinder to embark
on the specific health challenges and outcomes for each country. Some smart
solutions to overcome these regional gaps in the undercoverage of healthcare access
are, for example, people-centered health systems to forward country-specific needs
(Gouda et al. 2019).
Expansion of Morbidity, Compression of Morbidity, and Dynamic
Equilibrium
The theoretical framework behind the epidemiological transition in modern societies
reveals to three competing hypotheses: the expansion of morbidity, the compression
of morbidity, and the dynamic equilibrium. The expansion of morbidity hypothesis
(Gruenberg 1977) postulates that the decreasing mortality level in human
populations will be forced by the systematically drop of the disease-specific fatality
rate with simultaneously increasing prevalence and incidence of that specific dis-
eases. That means living longer with higher morbidity and disability. All medical
interventions will contribute to the longevity with remaining chronic disability
without improving the personal health state. Again, the increased survival means
also higher shares of elderly people being more frailty to chronic diseases. Chronic
diseases may be also additional risk factors for other comorbidities.
The opposite idea is the compression of morbidity hypothesis (Fries 1980; Fries
et al. 1989) that assumes that morbidity and disability will be shifted to higher age of
onset with faster pace than the mortality can excess younger age groups. Fries argued
that the life expectancy is limited by a biological maximum, so the time with diseases
would be compressed into a shorter period at the end of life.
A compromise between the expansion and compression scenario is disclosed with
the dynamic by equilibrium hypotheses by Manton (1982) where healthy life
expectancy grows with the same rate as the total life expectancy. This healthy
aging approach also supposes that the number of years living with diseases remains
constant over time.
Authors tried to replicate all three theories with mixed empirical outcomes and no
clear conclusions about coherence for any hypotheses. While ground-breaking
medical innovations will continuously improve health, the focus about some
18 M. Jakovljevic et al.
diseases might be also changing. High levels of disabling conditions like musculo-
skeletal diseases and dementia correspond with decreasing prevalence rates of
chronic respiratory diseases and cardiovascular diseases at the same time. Thereof
it remains challenging to predict concisely the correct levels of morbidity and the
needed potential demand for health service for the next recent decades.
Evolution of Mortality Driven by Evolving Lifestyle and Mega-Scale
Urbanization
There are three chronic drivers that stimulate the modern evolution of mortality:
stress, physical inactivity, and the consumption of high-caloric food and beverages.
Regarding psychosocial stress, about three or more stressful life events can signif-
icantly increase the risk for mortality in the population (Rutters et al. 2014). That
effect will be strengthening by other coexisting risk factors like smoking, type
2 diabetes, and cardiovascular disease. Chronic stress is present in everyday life
for many people because of the individual challenging motivation to manage family
life with work-related requirements in combination with traffic or job commuting
without any adequate compensation in mental and physical health. Nearly full-time
sedentary lifestyle is also common risk factor for unhealthy behavior and elevated
mortality risks for many modern industrialized societies. That physical inactivity
often corresponds with high-caloric intake of food and beverages like a permanent
high-carb diet that also included high-processed food and high sugar-sweetened
beverages. Such energy imbalance between physical inactivity and poor diet makes
people more susceptible for lifestyle disease like obesity, type 2 diabetes, or cardio-
vascular diseases.
Role of Nutrition and GMO Food
Poor dietary is responsible for more deaths than any other risks globally and is a major
risk factor for noncommunicable diseases worldwide (Afshin et al. 2019). Globally,
in 2017, dietary factors were responsible for 11 million deaths and 255 million
DALYs. The leading cause of diet-related deaths was cardiovascular diseases (11 mil-
lion deaths), followed by cancer deaths (9.1 millions) and type 2 diabetes (3.4 million
deaths) (Afshin et al. 2019). More than half of all diet-related deaths were attributed to
three components of diet, the high intake of sodium, low intake of whole grains, and
low intake of fruit (Afshin et al. 2019). Low-income countries are disproportionally
affected from the diet-related deaths (Afshin et al. 2019).
Aging and Global Health 19
Perspectives of 4.0 Industries and Applied Robotics in Home Care
for the Elderly Citizens
Industry 4.0 is often described as digitization or full-scale automation. It is also
sometimes defined in relation to emerging technologies –advancements in Internet
of things, big data and data analytics, robotics, autonomous systems, sensors and
automation, and production methods, such 3D printing (Stankovic et al. 2017).
Forward-thinking countries like Japan are allocated a significant proportion of the
government’s budget to develop “carebots”which are robots specifically designed to
assist elderly people, and it is an industry with high growth (Muoio 2015). The
global personal robot market, which includes carebots, could reach $US17.4 billion
by 2020, according to a Merrill Lynch report. One example is Honda’s Asimo robot
which is an autonomous, humanoid robot that could help the elderly by getting them
food or turning off lights. The Panasonic Resyone carebot is a robotic device that
transforms from a bed to an electric wheelchair, eliminating the need for multiple
caregivers. Like Resyone, a humanoid robot called Robobear could also eliminate
the need for multiple caregivers by helping transfer seniors from the bed to a
wheelchair. Sales of robots designed specifically to assist elderly people are expected
to increase substantially in the future, according to the Merrill Lynch report.
Apart from the carebots, smart homes, which incorporate environmental and
wearable medical sensors, actuators, and modern communication and information
technologies, can enable continuous and remote monitoring of elderly health and
well-being at a low cost (Majumder et al. 2017). Smart homes may allow the elderly
to stay in their comfortable home environments instead of expensive and limited
healthcare facilities. Healthcare personnel can also keep track of the overall health
condition of the elderly in real time and provide feedback and support from distant
facilities (Majumder et al. 2017).
Underlying Factors Contributing to Global Spreading
of Demographic Trends
The demographic dividend must be seen as “boon and bane”for recent global
demographic trends. This population momentum is accounted with a higher propor-
tion of working-age people (15–64 years) related to lower share of people in the
non-working age (14 years and younger and 65 years and older). While the propor-
tion of working people in the total population is higher, there might be greater
potentials of productivity for the whole population that generates massive growth of
the economy. The demographic dividend is also a chance to improve education over
age structure for seeking higher human capital especially for younger people. These
trends reflect mostly nearly industrialized countries. More pessimistic are the current
trends in the old-dependency ratio for many high-industrialized countries that harm
the monetary inter-generational fairness, while less people in the working ages have
to compensate the welfare and pension for the growing oldest-age group.
20 M. Jakovljevic et al.
The demographic dividend also draws a phenomenon of the “economic refugees”
mostly in low-income countries that force people to leave their home countries to
seek mostly unskilled and low-paid jobs in the new destinations. That brain drain in
the descent countries can potentially result in the “loss of generations”being not
forthcoming for the economic growth and prosperity in these developing countries.
These trends can be only inverted if local governments will systematically improve
the access to job markets with substantial economic policy strategies. That should
create equal income distribution for many people. Consequently, such mechanism
obligates more people to stay in their home country because they are now able to
get along with their living expense there.
Health Expenditure Dynamics Driven by Aging in Contemporary
Societies
Societal need of traditional young communities in health care substantially differs
from the ones in postindustrial old societies. This is easily observed if we compare
exemplary nations of sub-Saharan Africa with Western European ones, such as
Tanzania with Denmark. Thus, we come up to entirely different morbidity and
mortality structures. The first is dominated with mostly curable or preventable
communicable infectious medicines. The latter one is dominated with non-
communicable chronic prosperity diseases, mostly lifetime illnesses very expensive
to treat. This is also visible from different WHO lists of essential medicines for such
countries which refer to the dominant challenges in the sphere of morbidity.
Thus, we come up to the ground economic equations of demand and supply for
medical goods and services in aging nations (Jakovljevic et al. 2016,2017). Today
we well know that labor markets are shrinking. Ever growing share of elderly
citizens mostly retired and with limited work ability presents a challenge for the
pension funds. At the same time, share of work capable young people is narrowing
and therefore tax base of employees capable of paying taxes to support the elderly is
shrinking as well. This combined imbalance has raised the issue of long-term
financial sustainability of national health systems (Jakovljević2017; Ogura and
Jakovljevic 2018; Rancic and Jakovljevic 2016; Reshetnikov et al. 2019).
Since 1893 we had establishment of German Bismarck-style health insurance
system. It is frequently cited as one of the earliest nationwide risk-sharing agree-
ments in Europe. Yet it is important to know that it was actually limited to the very
narrow targeted social layer of industrial workers and their families. At that time
following unification of many monarchies into Germany back in the 1870s, it was
mostly an agricultural society dominated by peasant families and land economy. The
English Beveridge system appeared in 1911 at the eve of First World War although
improved being far from any sort of health insurance for entire population. Surpris-
ingly for scholars less acquainted to economic history, world’sfirst pioneering
universal health coverage for the entire nation inclusive of the poor was the Soviet
Union as early as back in the early 1930s with its renowned Semashko system. Post-
Second World War period was characterized by massive industrialization of a scale,
Aging and Global Health 21
primarily in the USA and Soviet Russia. Much later and to a lesser degree, this trend
was followed by Western Europe throughout the administration of Marshall Plan.
Most of the old EU15 countries, North America and Japan, effectively reached the
welfare state during the 1960s.
Common political approach to fund hierarchical contemporary health system was
to create broad mandatory revenue base. This means to direct the source of financing
toward health insurance funds while sharing burden of contribution among the
employees and employers alike. Either in social insurance based or the general
taxation model, most healthcare funding strategies today rely on a massive pool of
employed citizens. Given the deflation and devaluation of pension-retirement funds,
citizens of working life age are essentially supporting the needs of elderly and retired
citizens.
A variety of such financial strategies were historically established in late nine-
teenth or early twentieth century. European nations were then largely in population
growth mode with fertility rates comparable to Afghanistan or Nigeria today. These
old strategic thinkers and creators of early health financing systems had one crucial
axiom.
Bottom younger floors of the demographic pyramid that sustain the weight of the
heavy upper floors consisting of senior citizens shall always prevail in population
size. To these decision-makers living three to five generations ago, population aging
was virtually unknown and impossible to predict, since it is almost never present in
natural plant and animal communities.
Unfortunately, today we witness putting this assumption to the test. Lower floors
of work-capable citizens are becoming ever thinner and weaker. Simultaneously
upper floors consisting of elderly citizens are becoming more massive. The labor
force is contracting, while the pool of retired pensioners as net receivers consuming
most of available social benefits is expanding.
The second additional determinant refers to testified high medical needs in last
years of life. The seminal literature gives us an abundance of evidence that senior
patients tend to suffer from expensive chronic disorders such as diabetes, cancer,
cardiovascular, autoimmune, or mental diseases. These patients regularly do fre-
quent laboratory testing, imaging examinations, have more outpatient physician
visits, frequent and lengthier hospital admissions, and consume more prescription
and over-the-counter medicines. In a latter step, health economics literature
documented that needs for medical implants, rehabilitation, and psychotherapy are
far greater.
On top of all described medical spending patterns comes the last year of life
phenomenon. This last year of life is unfortunately associated with the oncology
care, intensive care unit admissions, and expensive treatment of autoimmune and
neuromuscular disorders with targeted biological medicines. There is growing body
of academic evidence that this year of consumption usually costs as much as that
individual citizen’s entire lifetime medical consumption.
There is one more cost driver which lies well beyond entire hospital sector. It is
frequently heavily underestimated home-based medical care. Convenient example of
such demand is the pandemic of dementia with prominent case of Ireland. Canada,
22 M. Jakovljevic et al.
Japan, and many Southeast Asian nations expose the same vulnerability because
traditional family caregiving is dying out due to law fertility much beyond simple
replacement levels. This is compensated so far by the professional facilities and
nursing staff at the great social opportunity cost. Faced with similar challenge,
European Commission invests heavily into the robotics research and developments
programs particularly targeted for the medical care of the elderly citizens.
Difficult burden of family caregivers remains hard to properly assess. We know
that commonly reported values are usually only the tip of the iceberg. Israeli example
witnesses the massive pool of citizens taking daily care for a sick or old family
member. At the same time, they remain employed at full-time jobs leading to
personal exhaustion and opportunity costs.
Global health spending landscape is rapidly transforming. Low- and middle-
income countries continue to take over an increasingly growing share of the world’s
health expenditure. Most of these nations face the double burden today. They
continue to struggle with yet non-liquidated pool of communicable infectious
diseases. This burden is coupled with the growing incidence and prevalence of
expensive chronic noncommunicable disease. India and Brazil are probably two
best examples of such deep change. Historical timeline that was needed to double the
portion of citizens aged above 65 from 7% to 14% took place over the 114 years in
France and only 21 years in Brazil. Implications of this huge acceleration of
population aging process worldwide are yet to be seen.
Prominent Role of Dementia and Neuromuscular Disorders
in Elderly Age
Dementia accounted for ten million disability-adjusted life years (DALYs) in older
people in 2010, 44% of the burden arising in low-income and middle-income regions
(Prince et al. 2015). Dementia is characterized by progressively disabling impair-
ment of several cognitive functions. The behavioral and psychological symptoms of
dementia affect the quality of life, and they are an important cause of carer strain
(Prince et al. 2012) as well as a common reason for institutionalization (De Vugt
et al. 2005). Incidence of dementia doubles with every 5.9-year increase in age, from
3 per 1000 person years at age 60–64 years to 175 per 1000 person years at age
95 and older (World Health Organization and Alzheimer’s disease International
2012). Early diagnosis allows patients affected to participate in advanced-care
planning, while they still have capacity to do so (Prince et al. 2011).
Musculoskeletal disorders accounted for 43.3 million disability-adjusted life
years (DALYs) in older people in 2010, 66% of the burden arising in low-income
and middle-income regions, and this is forecast to increase by 70% by 2030. The
main contribution from musculoskeletal disorders arises from low back pain (19.1
million DALYs) followed by osteoarthritis (7.5 million DALYs) (Reveille and
Weisman 2013). The WHO Scientific Group on Rheumatic Diseases estimated in
2003 that 10–20% of the world’s population aged 60 years or older have significant
clinical problems attributed to osteoarthritis (Woolf and Pfleger 2003). Prevalence of
Aging and Global Health 23
osteoarthritis increases with age, since it is progressive and cumulative (Woolf and
Pfleger 2003).
Reform of Social and Health Policy Agenda to Raise Fertility Rates
and Exploit Benefits of Migrations
Among the 201 countries or areas with at least 90,000 inhabitants in 2017, it is
estimated that 83 had low levels of fertility, as the fertility of the population was
below the level required for the long-term replacement of the population (United
Nations 2015). Globally, 28% of governments have adopted policies to raise the
level of fertility. Europe (66%) has the highest proportion of countries seeking to
increase fertility, followed by Asia (38%). Specific measures to increase fertility
include baby bonuses, family allowances, maternal, paternal, and parental leave, tax
incentives, and flexible work schedules. The highest fertility rate in Europe is
observed in France, and this country’s success is partly attributed to the benefits
and facilities provided. In addition to the allowances distributed by French allow-
ance funds, the public authorities also provide direct payments to families for the
care of children and other related benefits. Some of these provisions interconnect
with policies in other areas such as housing, education, employment, and the fight
against poverty. Apart from “classical”family cash benefits, families also cumulate a
number of other advantages under the heading of housing benefits, tax benefits
related to the specificities of the French tax system, and deferred benefits such as
retirement. Moreover, France has adopted early childhood strategies which can be
categorized into three groups: (a) increased child-care facilities (nurseries) and better
financial support for them, (b) increased benefits to provide partial cover of the cost
of child care by registered childminders, and (c) paid parental leave for a parent who
withdraws, either partly or entirely, from the labor market.
Migrants and refugees, including economic migrants, can bring significant ben-
efits to the countries that host them, including improved demographics and height-
ened economic activity and productivity. Moreover, the adaptation of health (and
other) services to make them inclusive and migrant friendly not only ensures that
migrants’health problems are adequately treated but also has positive impacts on the
quality, efficiency, and effectiveness of the services for all in the society
(M8 Alliance expert meeting 2017).
The health of migrants is subject to several risks during their journeys. The
approach to addressing the health needs of migrants and refugees needs political,
strategic, and technical measures that work along two tracks. This first track refers to
the coping with the incoming people and adapting in periods when there are excep-
tionally high numbers arriving at borders. This should include prophylaxis, screen-
ing, and triage at the borders and in reception centers and involve health assessment
and vaccines for people coming from countries affected by endemic infections and/or
because of exposure to infectious agents during their journey (M8 Alliance expert
meeting 2017). The second track refers to providing longer-term equitable access to
health promotion, disease prevention and care, including health care in camps and
24 M. Jakovljevic et al.
transit or detention centers for migrants, as well as provisions for access to health
services in the community (M8 Alliance expert meeting 2017).
Disbalance in Historical Roots, Stage, and Speed of Aging Between
Rich OECD and Emerging Nations
The proportion of the global population aged 60 years or over increased from 8.5%
in 1980 to 12.7% in 2017 (United Nations. World Population Prospects: The 2017
Revision). It is projected to continue to rise over the coming decades, reaching
16.4% in 2030 and 21.3% in 2050. Population aging is a universal phenomenon, and
every country is projected to see an increase in the proportion of people aged
60 years or over by 2050. Population aging is an inevitable consequence of the
declines in fertility and increases in longevity that characterizes the demographic
transition and is usually associated with social and economic development. Europe
was the first region to enter the demographic transition, having begun the shift to
lower fertility and increasing longevity by the late nineteenth or early twentieth
centuries in almost all areas (Jakovljevic and Laaser 2015). As a result, today’s
European population is the most aged, with 25% of the population aged 60 years or
over in 2017. Europe is projected to remain the most aged region in the coming
decades, with 34% of the population projected to be aged 60 years or over in 2050,
followed by Northern America (28%), Latin America and the Caribbean (25%), Asia
(24%), and Oceania (23%). Many countries in Africa remain in the early stages of
the demographic transition; some have begun to see reductions in fertility fairly
recently, while others have yet to see a decline in fertility. As a result, the aging
process is just beginning to emerge in the region, and older persons accounted for
just over 5% of the population of Africa in 2017, but that proportion is projected to
nearly double by 2050.
Flagged Emerging Issues
When we think of older people, the stereotypes are prevalent, whether they are the
ones distorting public opinion or skewing policy debates or becoming an economic
and social burden to society. When we use economic dependency ratios, which
assumes that everyone over the age of 65 years or is unproductive or the use of
disability-adjusted life years which explicitly increases the disability by age, we are
creating a narrative which is negative. Technology provides this sector with new
hope as assistive technologies will possibly play a huge part in care for the elderly in
the future. The changing demographics globally require new innovative ways of
working to create enabling environments for the elderly for their well-being and
quality of life to be sustained. A recent realist review identified potential technolo-
gies that can support the elderly in their daily life difficulties in key three domains of
(i) independent living, (ii) social isolation and dementia, and (iii) medication taking.
One of the key challenges identified was the adoption of these new technologies by
Aging and Global Health 25
the healthcare system and by the elderly people. Therefore, there needs to be
appropriate development of information and communication technologies (ICT) to
create these enabling environments for the elderly to allow for greater independence
and self-determination by the older people in the longer term. That said, with that
comes ethical considerations around gradual loss of privacy with limited knowledge
of what happens with the monitoring data and the pushing of care back to the
individual versus social responsibility which should not be taken lightly.
However, with the introduction of more technology to support care, there comes a
greater possibility to increase health and access inequalities. There already available
assistive technologies, but in some parts of the world, the elderly have minimal or no
access to them. For LMIC only 5–15% people who need them have access to them.
These numbers are expected to grow exponentially in the coming years; therefore
there is a need for a comprehensive, integrated health and social system approach to
increase the current availability of these technologies for aging populations in LMIC.
A critical approach is therefore needed that acknowledges the complex nature and
the uncertainties that persist with self-monitoring and self-care technologies for
people as well as for healthcare providers.
We expect digital health to become a key aspect of contemporary and future
healthcare policies and healthcare delivery systems in the future, but with that comes
a different set of responsibilities and ethical considerations which should be
unpicked and solutions sought before making this mainstream.
Conclusions
Population aging ultimately became a widespread global phenomenon and one of the
landmarks of late twentieth and early twenty-first century. Extended longevity
although desired has led to tremendous growth of medical care demand in most
modern-day communities. From a historical perspective, contemporary health sys-
tems were established relying on demographic growth model. From these roots, it
appears these systems are incapable to combat with exponential tide of medical
expenditures. To a large degree, it remains attributable to the long-term care needs,
expensive last year of life, and family caregiving undergoing extinction in many
modern nations.
Decades long shrinking of purchasing power of middle class in rich OECD
nations raises the affordability line issues. Western European, North American,
and Japanese health spending still remains much higher compared to emerging and
LMICs nations in per capita nominal terms. Affordability of medical services and
pharmaceuticals among the elderly even in high-income nations is getting lower,
while insurance premiums are becoming more restrictive. The new epicenter of
biomedical innovations is steadily moving its frontier toward emerging Asia. “Big
Pharma”seeks her return on investment deriving market access strategies more and
more tailored to suit needs of rich citizen elites in the emerging nations.
Political reality of providing access of aging population to the prescription
medicines, particularly targeted oncology and biologics, brings huge budget impact.
26 M. Jakovljevic et al.
This financial burden is almost unbearable even to the richest of societies with Japan
being prominent example (Ogura and Jakovljevic 2014). To the most of govern-
ments and multilateral agencies, it became obvious that existent social support,
health insurance, and retirement systems are no longer financially sustainable.
They were historically established on a model of demographic growth with peoples
of nineteenth century blossoming in youth and fertility. Today there are entirely
different realities. Medical expenditures, largely driven by needs of expanding share
of senior citizens, are almost twice exceeding the GDP growth rates. The affordabil-
ity frontier of medical services is contracting in the Western Nations and expanding
in the East Asian ones.
As in the examples of France and Russian Federation, fertility gains and certain
degree of rejuvenation seem still to be possible. Yet adoption of policies to support
healthy aging might be able to release some of the financial pressure. Genetically
personalized medicine coupled with innovative pharmaceuticals and home-care
robotic technologies is promising arenas as well. Involvement of cost-effectiveness
criteria in priority allocation of medical resources throughout health technology
assessment framework is already contributing a lot to more effective spending.
Ultimately, without bottom-up rethinking of universal health coverage and social
support legacies, burden of population aging might remain virtually unbearable for
the most of modern societies.
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