New Policy Directions

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Global Health Policy

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The University of Tokyo

Global Health Policy

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In this course, learners will become familiar with principles and theories of global health problems, and major challenges and controversies in improving global population health as well as practical applications of quantitative methods to analyze and interpret issues and challenges for policy. Topics will include health and foreign policy, health governance, acute disease surveillance, non-communicable diseases, burden of disease, universal health coverage, health systems strengthening, health financing, and human resources for health and ageing.

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Universal Health Coverage in the Context of Aging

In Module 3, we will introduce the basic concept of universal health coverage (UHC), some technical aspects of health financing, and methods for measuring and improving UHC systems. We will also discuss the challenges to UHC posed by aging and development, including for developing countries. Finally, we will explore policy solutions to aging, and look at new policies being used around the world to improve and strengthen UHC systems.

New Policy Directions12:43

Rencontrer les enseignants

Hiroshi Nishiura
Professor, Graduate School of Medicine, Hokkaido University
(Former Affiliation) Associate Professor, Graduate School of Medicine, The University of Tokyo
Stuart Gilmour
Professor, Division of Biostatistics and Bioinformatics, Graduate School of Public Health, St. Luke's International University
(Former Affiliation) Associate Professor, Graduate School of Medicine, The University of Tokyo
Kenji Shibuya
Professor and Chair
Department of Global Health Policy, Graduate School of Medicine

Okay, so finally let's look at some of the social, economic, and health policy

changes that can and are being made to handle the challenge of aging and

to ensure sustainability and adaptability of universal health coverage systems.

There are essentially three main policy responses to aging itself.

These are natalist policy, which encourages more children.

Immigration policy, which draws working people from other communities.

And productivity policy,

which aims to make changes to the workforce to make it robust against aging.

We'll look at each of these and then we'll look at some of their problems.

And after that, we'll look at some health policies specifically.

So natalist policy is the policy that is most often talked about in response

to the challenge of aging.

Natalist policy is a suite of policies that aim to increase the birthrate.

They include policies such as enhancing the work-life balance,

and introducing systems, such as parental leave.

To enable people to have children and continue to work, or financial incentives

such as tax relief or baby bonuses to encourage people to have more children.

The advantage of Natalist Policy is that it gives domestic control of a population.

It enables a government to control the size of its own population, and

it leverages something that is preexisting in society which is that most

people want children.

However, it has significant disadvantages.

First of all, it takes more than 15 years to take effect

because those children need to grow into the workforce.

It also requires increased births, and

this is going against most trends in most developed nations.

And it also goes against the long term trend in

human history towards lower birth.

And in the short term, it increases dependency

as the population of children who are dependent on parents increases.

So it takes some time to have a full effect.

In contrast to natalist policy, another option to change the dependency ratio,

and to reverse the roll of aging, is immigration policy.

Immigration policies are policies which encourage net migration into a country.

They can be open border polices, such as the EU,

which enable people to move around within the borders of the broader European Union.

Or they can be large migration schemes, such as countries like Australia and

Canada have, and do operate.

The advantages of immigration policy are that it has an immediate affect.

It typically involves young working people moving into the country.

So they immediately bolster the working age population.

It also gives control over the allocation of labor.

With a well designed migration scheme, you can ensure that the people that you add to

your working population are the people that you most need.

However, it has many disadvantages as well.

It can be politically unpopular.

For example, the UK is now considering exiting from the EU

partly as a result of pressures over immigration.

It can be limited by language and culture.

For examples, countries like Japan and

Korea can have difficulty finding migrants who speak their language and

thus have a limited pool of migrants that they can bring in.

And it is also limited by the available pool of young migrants.

As populations age globally, there are a number of young migrants able or

willing to leave a country will decline.

And as big countries such as Japan and China enter the aging period, they and

begin to compete for migrant populations, the number of migrants available for

any one country will decline.

So immigration policy is a short term and potentially limited solution.

A third policy that can enable people to adapt to aging is productivity policy.

This is a series of policies which aim to adapt the workforce to aging

rather than trying to increase its size.

They can range from policies that increase participation, for example by getting more

women into the workforce or encouraging elderly people to work.

They can increase workplace productivity for example by automation or

by introducing new systems.

And they can reorient the workforce so

that for example teachers are retrained to become care workers.

The advantage of productivity policy is that it has an immediate effect, in that

it changes the workplace immediately and it can boost economic growth.

Automation and real orientation of the workforce can induce technology growth.

However, there are many disadvantages to this policy as well.

Obviously, it requires cooperation from six of the society

outside of the government which may not want to cooperate such as corporate and

industrial and union concerns.

And its effectiveness is limited by social economic factors.

The decision to work or not to work is not just a decision of the government control,

and how people work, and which sectors of the workforce they intend to enter,

is not something that governments can easily control.

This slide shows the effect of these different policies in

Japan using a model of the Japanese population which I developed

to model the population out to 2035.

This chart measures on the y-axis.

The old age dependency ratio, that is the number of people aged

over the retirement age divided by the population working.

And the x-axis shows the year.

The yellow line in this chart is

the old age dependency ratio in Japan with no change of policy at all.

The orange line, the jagged line which drops rapidly,

is the effect of chaining of the retirement age from 2010, with

a single year increase in the retirement age every five years up until 70.

The blue line, which is mostly obscured by the other line but

begins to protrude from it and below it, from about 2020,

is the effect of increasing birth rates, to by about 50% from 2015.

So, the current birth rate in Japan is about 1.2 million,

or 1 million babies per year, and I've modeled year increasing that to 2 million.

And finally, the grayish line,

which protrudes from the yellow line earlier on, is the effect of

introducing an extra 500,000 migrants a year into the Japanese population.

You can see, that both the migrant and the birth model, even though they involve

quite large changes, have very little effect on the dependency ratio.

And the birth model takes 15 years to take effect.

The only truly effective short-term intervention

is raising the retirement age.

And this shows that even quite stringent policies,

based on nativism or immigration, may not have a very large effect.

And this shows the difficulty of changing the aging process rapidly.

Aging is defined primarily by what’s called demographic momentum.

Which is the effect of past population build up.

And as we saw in a previous lesson, there is a large bulge of people,

just under the retirement age in Japan.

And they will soon enter this dependency ratio on the top line.

Which is why, it's very hard to change The dependency ratio rapidly in Japan.

Aging is also a health workforce issue and it's through workforce changes that we can

make rapid and sudden changes in this problem.

Aging leads to increased burden of elderly care.

The reduced birth rate leads to an increase in single child families and

a loss of private care workforce,

because single child families cannot care for their own parents.

This leads to increased corporate care needs,

due to the increased elderly population living alone.

There is also an increased density but there is a greater need for

complex chronic care and more need for ancillary staff such as

rehabilitation workers or occupational and speech therapists.

So, the required workforce increases.

There is a direct workforce impact through the reduced number of workers and

increased inflation that arises when there are less workers And

there are financial pressure on the health financing system because

there are less payers and more people taking money from this system.

So also, when we start moving into an aging society,

we begin to focus on healthy aging rather than just on treating healthcare problems.

Healthy aging has the aim to maintain independent living in elderly people.

It aims to benefit individual health and

reduce the burden of those people on the workforce.

If we can develop a healthy aging policy that is sensitive to workforce needs,

then we can reduce the burdens on the workforce.

But policy changes are necessary for healthy aging.

We need health promotion to ensure that as people age, their mobility and

lifestyle is protected.

We need healthcare which is able to manage NCDs and

recognize that they will occur and they need to be managed.

And we also need urban planning and

other social changes which will facilitate autonomy in elderly people.

This requires cross-sectoral changes across many areas of society and

in particular, it needs integrated care policies.

An integrated care policy is a new system of care which takes the healthcare

system away from its traditional focus on curative care and disease-specific care

towards health system which is designed for the epidemiological transition.

So, after the epidemiological transition, we have complex interacting

non-communicable diseases and we also have multiple care agents.

So, someone is trying to live healthfully at an older age in the community,

which means that they're being cared for

simultaneously by their family, by perhaps a cardiologist,

by community nurses, by care facilities, by temporary visiting workers.

There's a wide range of agents involved in their care

rather then a single doctor targeting a single disease.

This means we need to integrate the care at the community level and

streamline health financing to ensure that this system can operate within UHC.

This slide shows an example which is Japan's integrated care policy.

The picture is in Japanese, but I think the image is quite clear.

In the center here, we have the elderly family.

The elderly man and

woman with their grandchild living in a home that is supported by care services.

Up here on the right, we have the care home that they may need to visit at

times when the quality of their care

it needs to be improved beyond that which the family care home can provide.

Over here, we have the doctors in medical services that are providing them with

care, and which are involved in this care-supported home.

And down the bottom, we have a variety of welfare and care services, which enable

these elderly people to continue living happily and autonomously in the community.

The goal of Japan's Integrated Care Policy system is to ensure that all of these

different aspects of the care system work together to as much as possible enable

the cute happy elderly couple to remain living in their home comfortably, for

as long as possible and with as much autonomy as possible.

This is what Integrated Care Policy systems aim to achieve.

And In particular,

they aim to reduce the burden of services on the health care system.

In addition, there is a need to change the health financing organization,

which has traditionally provided financing for UHC.

So in Japan, there is a new system which is the financing system for the old old

which intends to change the financing structures that is more sustainable.

Traditional in Japan, health financing has been around in a prefectures and

in small prefectures have large elderly population,

this is meant that there's been a large burden of cost to the prefectures.

These have traditionally been cross subsidize from younger prefectures and

these subsidies support the care for people aged over 65.

But with a growing elderly population,

there's pressure on this system, which was reformed in 2008.

So, the subsidies are divided up into subsidies for the young old, and

the old old.

The subsidies for the young old were reduced, reflecting the fact that these

people are now healthier and more capable of looking after themselves and

the subsidies to the old old were increased, to reflect the increasing need

to subsidize prefectures with a large proportion of these people.

This was done to ensure the stability of the social insurance based system.

And it's an example of the kind of financing changes that are necessary

in an elderly population.

So in review, there are three policy responses to aging.

Natalist, immigration, and productivity based.

And when considering which policy to use, we need to balance their effectiveness,

their timeliness, and their political and cultural acceptability.

Aging is a workforce as well as a demographic issue.

And when we respond to aging, we need to consider the change in the workforce

composition, and the necessary change in tax base and workforce scale.

And we also need to respond with health system reforms,

which can change the structure and orientation of the system, and

which can introduce new financing methods to support an aging society.

And that concludes our lesson on aging and universal health coverage.

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