The UN Decade of healthy ageing: strengthening measurement for monitoring health and wellbeing of older people

Abstract

Over the past 100 years, life expectancy has increased dramatically in nearly all nations. Yet, these extra years of life gained have not all been healthy, particularly for older people aged 60 years and over. In 2020, the World Health Organisation (WHO) and United Nations (UN) member states embraced a sweeping 10-year global plan of action to ensure all older people can live long and healthy lives, formally known as the UN Decade of Healthy Ageing (2021–2030). With the adoption of the UN Decade of Healthy Ageing resolution, countries are committed to implementing collaborative actions to improve the lives of older people, their families and the communities in which they reside. The Decade addresses four interconnected areas of action. Adopting the UN's resolution on the Decade of Healthy Ageing has caused excitement, but a question that has weighed on everyone's mind is how governments will be held accountable? Besides, there have been no goals or targets set for the UN Decade of Healthy Ageing from a programmatic perspective for the action areas, and guidance on measures, data collection, analysis and reporting are urgently needed to support global, regional and national monitoring of the national strategies, programmes and policies. To this end, WHO in collaboration with UN agencies and international agencies established a Technical Advisory Group for Measurement of Healthy Ageing (TAG4MHA) to provide advice on the measurement, monitoring and evaluation of the UN Decade of Healthy Ageing at the global, regional and national levels.

Key Points

• Over the past 100 years, life expectancy has increased dramatically. Yet, these extra years of life gained have not all been healthy, particularly for older people aged 60 years and over.

• In 2020, the World Health Organisation (WHO) and United Nations (UN) member states embraced a sweeping 10-year global plan of action to ensure all older people can live long and healthy lives.

• Adopting the UN's resolution on the Decade of Healthy Ageing has caused excitement, but a question that has weighed on everyone’s mind is how governments will be held accountable?

• Evidence-based guidance on measures, data collection, analysis and reporting are urgently needed to support global, regional and national monitoring of the strategies, programmes and policies that promote healthy ageing.

• To this end, WHO in collaboration with UN and international agencies established a Technical Advisory Group for Measurement of Healthy Ageing (TAG4MHA).

Commentary

Over the past 100 years, life expectancy has increased dramatically in nearly all nations. Life expectancy at birth improved globally from 28.5 years in 1800 to 73.3 years in 2019 [1, 2]. This 3-fold increase in life span reflects the advancement of public health, medicine, and economic and social developments. Additional life years and demographic shifts have profound implications for societies as well as offer unprecedented opportunities for sustainable development [3].

Yet, these extra years of life gained have not all been healthy, particularly for older people aged 60 years and over [4]. Life expectancy at age 60 has increased (from 18.8 years in 2000 to 21.1 years in 2019). Still, the average healthy life expectancy for older people has remained unchanged in many countries, and more than half have not gained more than 1 year of healthy life expectancy in the past 2 decades [5]. While chronic diseases related to ageing continue to hinder health span improvement, there are numerous ways to influence the relationship between chronological age and health [6, 7].

In 2020, the World Health Organisation (WHO) and United Nations (UN) member states embraced a sweeping 10-year global plan of action to ensure all older people can live long and healthy lives, formally known as the UN Decade of Healthy Ageing (2021–2030) [8, 9]. With the adoption of the UN Decade of Healthy Ageing resolution, countries are committed to implementing collaborative actions to improve the lives of older people, their families and the communities in which they reside. The Decade addresses four interconnected areas of action: (i) to change how we think, feel and act toward age and ageing; (ii) ensure that communities foster the abilities of older people; (iii) deliver person-centred integrated care and primary health services that are responsive to older people and (iv) provide access to long-term care for older people who need it [10]. The UN resolution called upon the WHO to lead the Decade’s implementation and monitor and evaluate progress against goals.

The UN Sustainable Development Goals (SDGs) [11], the WHO Global strategy on ageing and health [12], the UN Madrid International Plan of Action on Ageing [13], Report of the Independent Experts on Human rights of Older People [14], European Care Strategy [15] and The Lancet Series on Ageing [16] all recognise the importance of strengthening measurement and data on older persons for monitoring and evaluation of public health programme, policies and interventions. The UN Decade of Healthy Ageing recognises strengthening data, research, and innovation to accelerate implementation [8]. Further, the unprecedented COVID-19 pandemic has provided a sharp reminder of the invisibility of older persons in publically available data [17]. To ensure older persons are not left behind, there is a pressing need to strengthen measurement and address the data gaps. [15].

Making accountability tangible

Adopting the UN's resolution on the Decade of Healthy Ageing has caused excitement, but a question that has weighed on everyone's mind is how governments will be held accountable? In particular, how will the UN and WHO hold governments accountable for improving the lives of older people? A primary purpose of programmes and policies within the Decade is to change tangible and real-life outcomes. For example, to enhance access to employment choices and opportunities, essential health services and long term care, combat ageism, or reduce adverse events. Whether these changes are achieved is a crucial question to public health but is seldom addressed. Often, stakeholders measure inputs, such as how much is spent or how many people are trained rather examining whether policies and programs have succeeded in improving health and wellbeing. With the UN Millennium Development Goals [18] followed by Sustainable Development Goals [11], there is a global trend toward shifting focus from inputs to outcomes and results to track national and international targets to build a strong foundation for transparency and accountability.

Governments use indicators as catalysts for improving public services. As simple as this may sound, what is being measured must be carefully considered, as there can easily be unintended consequences when measuring one outcome over another. Therefore, to provide a picture of progress made by countries and the impact of policies and programmes on the lives of older people, it is essential to develop a balanced set of core indicators across all action areas of the UN Decade of Healthy Ageing. To assist governments, WHO will develop and refine a monitoring and evaluation framework and provide a core set of indicators that stakeholders can use to verify and enhance public health interventions' quality, equity, efficiency and effectiveness at various stages of implementing action areas of the UN Decade of Healthy Ageing. The framework will be aligned with human rights approach, norms, standards and principles [19].

Measuring what matters to older persons

Health in older age is complex. Dynamic interactions between underlying physiological changes, illness and multimorbidity can lead to physical and mental conditions not encapsulated by traditional disease classification. In 2015, the WHO released the World report on ageing and health, which proposed a public health framework for action on population ageing [3]. Central to the Report is a new conceptual model for ‘Healthy Ageing’. Rather than considering healthy ageing from the perspective of the presence or absence of disease, this functioning-based approach is oriented around building and maintaining the ability of older people to be, and to do, the things they have reason to value. WHO proposed that this ‘functional ability’ is determined by the ‘intrinsic capacity’ of the individual, the environments in which they live and the interaction between the individual and these environments. Functional ability is defined as ‘all the health-related attributes that enable older people to be and to do what they have reason to value’. Intrinsic capacity (IC) is defined as ‘the composite of all the physical and mental capacities that an individual can draw on at any point in time’.

Despite the popularity of these concepts, a standard set of measures for collecting data on them has not yet been developed. A series of systematic reviews on the different domains of functional ability (e.g. ability to meet basic needs and ability to be mobile) and of intrinsic capacity (e.g. cognitive capacity and locomotor capacity) currently being conducted by WHO academic partners will provide the basis for developing evidence-based measures of healthy ageing. The findings of these reviews will be appraised and used to create recommendations on valid and reliable indicators and instruments for assessing healthy ageing indicators in the clinical and population settings.

Developing a practical basis for measurement, monitoring and evaluation

The UN resolution invited the Secretary-General to inform the General Assembly about the progress of the Decade of Healthy Ageing based on triennial reports to be compiled by WHO, in collaboration with UN agencies, in 2023, 2026 and 2029. To this end, the WHO’s Department for Maternal, Newborn, Child, Adolescent Health and Ageing and Department of Social Determinants of Health, in collaboration with various other UN and international agencies, have established a Technical Advisory Group for the Measurement of Healthy Ageing (TAG4MHA) to provide advice on the measurement, monitoring and evaluation of the Decade and programmes related to the action areas [20].

The TAG4MHA, in association with UN Steering Committee, was established to align with existing measurement advisory groups, including those overseeing maternal, child and adolescent health [21–23]. Together, these Groups aim to strengthen data and measurement for monitoring health and associated conditions across the life course to ensure progress on accountable action.

The TAG4MHA consists of 20 experts (Appendix 1) selected through an open call and competitive process. Members were selected based on their technical expertise in the significant areas of relevance, such as epidemiology, geriatrics, social gerontology, economics, demography, community development, health policy, psychometrics and statistics and relevant expertise concerning international public health programme evaluation (e.g. monitoring and evaluation of programmes, information systems related to diverse sectors pertinent to the Decade and population surveys or census and digital health). Further considerations in the selection ensured broad expertise across the four main action areas of the Decade of Healthy Ageing, geographic diversity and gender balance. For more information about the TAG4MHA activities, please visit https://www.who.int/news/item/25-01-2022-who-establishes-a-technical-advisory-group-on-measurement-monitoring-and-evaluation-of-un-decade-of-healthy-ageing.

The TAG will offer advice on input indicators and set meaningful outcomes and targets to make accountability concrete. This will promote a strong focus on older persons' outcomes and generate observable measures that make it possible for countries to monitor their progress. Getting accountability right by setting suitable targets for each action area of the Decade of Healthy Ageing will be a high initial priority for the TAG4MHA.

Strengthening countries’ statistical and information systems

A nation's ability to collect, analyse and disseminate high-quality data on ageing and inequalities is crucial for all stages of evidence-based decision-making. These include: (i) indicators for monitoring the situation, (ii) guiding programme design and policy formulation or improvement, (iii) allocating resources, and (iv) informing stakeholders about the impact outcome of policies and programmes. To support countries, with guidance from the TAG4MHA and UN Steering Committee, WHO will be launching a national toolkit for monitoring and evaluating of UN Decade of Healthy Ageing.

More guidance is required on data collection activities aligned with the human rights principle of ‘doing no harm’. All data collection exercises should include means for active and meaningful participation of relevant stakeholders, particularly the most marginalised groups. Disaggregation can, for example, prove very helpful and essential in identifying situations of structural discrimination—ageism—and gaps related to specific age groups. Target respondents should be self-defining and have the option to disclose or withhold, information about their characteristics. When personal data are released, this should only be done with the permission of the older persons concerned (or their appropriate representatives). The respect and protection of personal identity must be central, and data collected must be strictly confidential and used exclusively for statistical purposes.

Concerning data gaps

Nearly 60% of older persons today live in low- and middle-income countries, but fewer than 10% of these countries have a national survey that routinely collects information about healthy ageing [24]. This data gap demonstrates how older people can be invisible. Demographic and health surveys generally do not include women aged 50 and over and men aged 55 and over. Many surveys, even those devoted to older people, do not include older people in institutions, older prisoners or older homeless people. It can be challenging to enumerate older persons because of incomplete or nonexistent information records, traditional household surveys, and gatekeepers. Language barriers, lack of administrative records, physical or cognitive impairments, and remoteness are also factors that exclude specific populations, such as migrants, people receiving home care, people living with dementia, and people living in rural or remote areas. Using proxies to overcome these limitations may not yield accurate results.

Furthermore, there are no reliable tools or survey protocols to measure healthy ageing. Tools used in different countries, or even within the same country, are often heterogeneous [10]. A lack of data comparability between surveys makes monitoring and evaluation very challenging. Due to adverse life circumstances, certain groups of older people may experience declines in physical and mental capacities earlier than their counterparts. Refugees and older people who have been affected by war, conflict, and natural disasters may fall into this category. The existing survey tools aren't designed to cover all the different sub-populations of older people. To address the survey issues, with the advice of the TAG4MHA, WHO will develop valid and reliable survey instruments for population, health facility and policy surveys on ageing. This tool will be validated in a multi-country pilot study in the coming years.

The way forward

Defining successful public health strategies, programs and policies for older adults is difficult without reliable and meaningful data. A fundamental change in methodologies, data collection processes, and tools that can accommodate different subpopulations of older persons is urgently required [25]. To ensure older persons are not left behind, measurement gaps outlined above must be systematically addressed [15]. With the advice of TAG4MHA, WHO along with UN partners will strive to provide governments with tools to facilitate measurement and monitoring to determine whether or not the commitment to the UN Decade of Health Ageing is improving the health and wellbeing of older people.

Declaration of Conflicts of Interest

None.

Declaration of Sources of Funding

None.