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Shifting demographicsA global study on creating inclusive environments for ageing populationsContentsExecutive summary2About this report5Chapter 1: The future challenges of ageing7Bringing attention to ageing preparedness, andmissed opportunities9Chapter 2: The Economist Intelligence Unit SHIFT Index11Chapter 3: Adaptive health and social care systems12Support for healthy ageing14Addressing common risk factors and conditionsassociated with ageing14Multidisciplinary and integrated care15Do we deliver quality health and social care servicesto those who need them?16Availability of health and social care services.17Representation of older people in health systems19Is care affordable to ageing populations?19Chapter 4: Accessible economic opportunity21Financial independence into old age23Productivity into old age: sharing a wealth of experience24Inclusive work environments25Agency to choose when to retire28Chapter 5: Inclusive social structures and institutions31Barriers to participation in society for older people31Social cohesion and participation31Isolation33Access to technology33Provision of a safe and inclusive environment in which to age34Inclusive social institutions35Conclusions36 The Economist Intelligence Unit Limited 20201
2Shifting demographicsA global study on creating inclusive environments for ageing populationsExecutive summaryPeople today are typically living to increasingly older ages. This,however, has created challenges in providing health and socialservices for burgeoning older populations and governments acrossthe globe have been slow to react. What counts now is how societiescan maximise this opportunity and provide effective, inclusiveenvironments in which to age.1This report from The Economist Intelligence Unit (EIU) is based onfindings from the “Scaling Healthy ageing, Inclusive environmentsand Financial security Today” (SHIFT) Index, a benchmarking analysisaround ageing societies, as well as ten in-depth interviews with globalexperts. The SHIFT Index benchmarks against a set of national-levelleading practices in creating an enabling environment supportive oflongevity and healthy ageing for societies in 19 countries comprising theGroup of Twenty (G20)2. The SHIFT Index captures the multifactorialvariables that impact healthy ageing across three domains:(1) Adaptive health and social care systems;(2) Accessible economic opportunity; and(3) Inclusive social structures and institutionsFigure 1: G20 countries and overall EIU SHIFT Index score out of 100.Upper Sector. Score 66.1 to 100Middle Sector. Score 33.1 to 66Lower Sector. Score 0 to 331 The myth of an “ageing society”, World Economic Forum, Andrew Scott (May 29, 2018). See: the-aging-society2 The 20th member—the European Union—was not assessed as part of the SHIFT Index. The Economist Intelligence Unit Limited 2020
Shifting demographicsA global study on creating inclusive environments for ageing populationsIn this foundational index, The EIU establishes a baseline understandingof each country’s enabling environment and identifies several key findings:No G20 country is fully prepared to support healthy, financiallysecure, socially-connected older people. Despite clear progressmade, governments have more work to do to make sure their healthsystems are adaptive to the needs of older adults as they age, while alsofostering inclusion and ensuring individual economic security. Broadly,those countries with a higher proportion of people aged over 50 areimplementing more leading practices to enable inclusive environments(See Fig. 2).Figure 2. Countries with older populations tend to be betterpositionedCorrelation between overall SHIFT Index score and the share of the population overthe age of 50Overall SHIFT Index ia50India40ItalyBrazilMexicoSaudia ArabiaSouth KoreaJapanRussiaArgentinaTurkeyChinaSouth Africa30200%5%10%15%20%25%30%35%40%Share of population aged 50 Enabling adults to age well begins with taking a broad viewof how society supports older members, not just focusing onthe health system. As a whole, the G20 countries perform best inproviding adaptive healthcare systems and worst in providing inclusivesocial structures and institutions, indicating that countries still havework to do to shift the focus towards building more welcoming societiesfor older adults as they age. Countries also have room to grow toprovide more accessible economic opportunities to older workers. The Economist Intelligence Unit Limited 20203
4Shifting demographicsA global study on creating inclusive environments for ageing populationsWealthy countries may find it easier to respond, but wealth is nota prerequisite for providing supportive environments. The bestscoring health systems tend to be high-income countries, but Indonesia(a lower-middle income country) has been making strides to improve itshealth system.Government data collection isn’t yet robust enough to fullydefine and identify the problem and opportunity. There are a lackof data on dedicated health professionals, the extent of isolation andloneliness, as well as mental health.The SHIFT Index identified several priority areas that may form thebasis of policy responses to improve the environment for older adults:1. Collect better data: Countries should collect andpublish detailed, age-disaggregated health and economicdata annually so policymakers can develop evidence-basedprograms and policies.2. Address poverty among older people: Some older adultschoose to work longer, others must. Governments can ensurethe financial health and security of older adults by creating moreinclusive work environments. This starts with removing barriersto working longer that exist in some markets.3. Prevent a care crisis among the elderly: The provision of carefor older adults—both formal and informal—and the accessibilityof, or access to, long-term care is ill-defined and is an area forfurther research.4. Enable older people’s voices to be heard: The views andneeds of older people are not routinely collected and they arenot represented well in policy consultation.5. Address age-related discrimination: Few countriescategorise age-discrimination as a crime outside of employmentpractices. Fighting discrimination as well as physical, emotionaland financial abuse of older adults, will encourage greater socialcohesion across generations.6. Support training and upskilling of older people: Supportingolder people with the skills and help needed to navigateincreasingly complex and digitised health and social caresystems should be an area of focus. The Economist Intelligence Unit Limited 2020
Shifting demographicsA global study on creating inclusive environments for ageing populationsAbout this reportShifting demographics: a global study on inclusive ageing is a report byThe Economist Intelligence Unit, sponsored by Amgen. It considerspolicy efforts to address active and inclusive ageing in 19 countriesbased on a first-of-its-kind index that benchmarks each country’sperformance across accessible and affordable healthcare, socialconnectivity among older adults, and finance security practices andpolicies.The “Scaling Healthy ageing, Inclusive environments and Financialsecurity Today” (SHIFT) Index and the related research programmewhose findings form the basis for this report were informed byextensive research and guided by an international panel of expertsfrom across academia, government, non-governmental organizations(NGOs) and international financial institutions.The following 19 countries (comprising the G20 and excluding the EU)are included in this analysis: Argentina, Australia, Brazil, Canada, China,France, Germany, India, Indonesia, Italy, Japan, Mexico, Russia, SaudiArabia, South Africa, South Korea, Turkey, the UK and the US. Thesewere selected to broadly represent the world: covering roughly 65% ofthe population and 75% of global GDP.The Economist Intelligence Unit extends its gratitude to the followingindividuals (listed alphabetically) who have generously contributedtheir views and insights to the research and development of this report: Martin Baily, chair, Economic Policy Development, Brookings, USA John Beard, director, World Health Organization’s Ageing and LifeCourse Department, Switzerland Elena Glinskaya, lead social protection specialist, World Bank, USA John Morley, professor, St. Louis University’s Division of GeriatricMedicine, USA Brian Kennedy, director, National University Health System Centrefor Health Ageing, Singapore Dorothea K. Vafiadis, director, Centre for Health Living, NationalCouncil on Aging, USA Kanwaljit Soin, consultant orthopaedic and hand surgeon, MountElizabeth Medical Centre, Singapore The Economist Intelligence Unit Limited 20205
6Shifting demographicsA global study on creating inclusive environments for ageing populations Eduardo Sosa-Tinoco, geriatrician, Ministry of Health, Mexico Kenji Shibuya, professor, Department of Public Health, Universityof Tokyo, Japan Nora Super, senior director, Milken Institute Centre for the Futureof Ageing, USA Erwin Tan, director, Thought Leadership, AARP, USAThe SHIFT Index was created by Michael Paterra, Calli Levin andAmanda Stucke of The Economist Intelligence Unit, with analyticsupport provided by Angela Mazimba and Sumer Sharma. Researchwas conducted by: Anant Sharma, Connie Thurlow, Deema AlGhunaim, Eamon Kircher-Allen, Jaekwon Lim, Kevin Alyono, Lian Lin,Lin Fu, Mike Jakeman, Nick Wolf, Peter Laurens, Sastre Consulting, andStan Standish-White. This report was written by Becca Lipman andedited by Jesse Quigley Jones of The Economist Intelligence Unit. TheEconomist Intelligence Unit bears sole responsibility for the contentof this report. The findings and views expressed in the report do notnecessarily reflect those of the sponsor.July 2020 The Economist Intelligence Unit Limited 2020
Shifting demographicsA global study on creating inclusive environments for ageing populationsChapter 1. The future challenges of ageingMore people are living into old age than everbefore. In 2018 The World Health Organization(WHO) predicted that by 2020 there would bemore people aged over 60 years than there arechildren under 5 years.3 This prediction appearson track to be correct,4 and numbers in theolder cohort continue to rise. Low fertility ratescoupled with increasing life expectancy haveresulted in the United Nations estimating thatby 2050 there will be 2.1bn older people—morethan four times the number today.5increase in vulnerability. Less often discussed is‘healthy ageing,’ defined by WHO as “the processof developing and maintaining the functionalability that enables wellbeing in older age.”This definition gives ageing a broader contextthan merely the onset of disease. Anotherwidely used term “longevity” is often usedinterchangeably with ageing. This is a distinct—although interrelated—concept. Longevity refersto a greater duration of life or life expectancy,but offers no qualification on quality of life.In terms of progression, ageing is prominentlydefined by deterioration of function andFor the purposes of our research anddiscussion here, we use the terms “ageing”Defining an era: Ageing vs longevityJust as ageing is not a uniform experience, neither are the many definitions for “ageing”within the academic and political world. In terms of chronological age, ageing is oftenconsidered to start at age 50. However this definition varies significantly across reportsand studies, and is sometimes defined as 55 or 65 . Increasingly sub-categories of agingare used to reflect the various and distinct characteristics associated with old age.In terms of progression, ageing is prominently defined by deterioration of function andincrease in vulnerability. Less often discussed is ‘healthy ageing,’ defined by WHO as“the process of developing and maintaining the functional ability that enables wellbeingin older age.” This definition gives ageing a broader context than merely the onset ofdisease.6 Another widely used term “longevity” is often used interchangeably with ageing.This is a distinct—although interrelated—concept. Longevity refers to a greater durationof life or life expectancy, but offers no qualification on quality of life.For the purposes of our research and discussion here, we use the terms “ageing” and“ageing populations” in their broadest sense to mean those aged over 50 years.3 World Health Organization (WHO). Ageing and health, WHO Factsheet (February 5, 2018). Available at: eing-and-health4 Our world in Data. Age Structure. https://ourworldindata.org/age-structure. Accessed 2020.5 United Nations. World population prospects 2019: Ageing in G20 countries. 2019. events/pdf/other/35/Key%20Findings 28JUNE19.pdf6 World Health Organization (WHO). See the WHO website: https://www.who.int/ageing/healthy-ageing/en/ The Economist Intelligence Unit Limited 20207
8Shifting demographicsA global study on creating inclusive environments for ageing populationsand “ageing populations” in their broadestsense to mean those aged over 50 years.While increased longevity is a majorachievement of science, society andhealthcare, for most, if not all nations, thistrend is presenting challenges. Countries withrapidly ageing populations are seeing theirworking-age population decline relative toretirees, and with it the tax income generatedto fund health and pension systems. Thisphenomenon is illustrated by old-agedependency ratios—that is the number ofpeople aged 65 years or over per 100 personsof working age (15–64 years; see Figure 3). Thecurrent trajectories in G20 countries suggestthat already-strained public pensions andsocial care systems are likely to face challengeswith financial sustainability in the long-term.While on the surface this may seemunavoidable, the socio-economic concernsposed by an ageing population at currenttrajectories are not inevitable. Many areproducts of poor planning by governments,communities, healthcare systems andbusinesses. And each can be significantlyimproved to the social and economicFigure 3. Old-age dependency ratios 1950-2050 in the 19 countries of yIndiaIndonesiaItalyJapanMexicoRussiaSaudi ArabiaSouth AfricaSouth KoreaTurkeyUnited KingdomUnited States20402050ChinaSource: UN Department of Economic and Social Affairs, Population Dynamics 77 United Nations, Department of Economic and Social Affairs, Population Dynamics, “World Population Prospects 2019”, pulation/ The Economist Intelligence Unit Limited 2020
Shifting demographicsA global study on creating inclusive environments for ageing populationsbenefit of ageing individuals, their familiesand their communities, and with positivecontributions to economies via productivityand consumption.Older people represent a growing shareof the workforce and community. TheEconomist Intelligence Unit forecasts thatthe proportion of adults aged 50 in G20countries will range from 15% in India to37% in South Korea by 2030, up from 9%and 18% in 2000, respectively. This hasprompted questions about what policies andinfrastructure are in place to support thispopulation as personal, social and financialneeds change. More often than not, theanswers are unsatisfactory.Furthermore, forecasts that frame an ageingpopulation as a drain on society largely underrecognise the group’s enormous social andeconomic contributions. For example, elderlypeople can be bigger consumers of goodsand services than the young, and thereforean important contributor to global economiesand GDP.8 Their lifestyles and needs—fromhealthcare to leisure-travel—have a significantripple effect through the wider economy andjob market, and are increasingly contributorsto a healthy economy.People are also extending their working lives.In the decade up to 2018, the labour forceparticipation rate of those aged 55-64 roseby nearly 8 percentage points on average inthe OECD area.9 Older people also providea significant share of unpaid activities, suchas caring for children and other adults andvolunteering in the community. A 2004 UKreport found that unpaid contributions byolder people as volunteers or carers arevalued at 270bn per year (or nearly 1.2%of GDP).10 A more recent US report estimatedthe unpaid activity of those aged 50 wasworth US 745bn in 2018, in addition toUS 8.3tn in economic activity.11Bringing attention to ageingpreparedness, and missedopportunitiesTo realise the opportunity presented by olderpopulations, more must be done to maintaingood health and independence into old age.For policymakers, this will require a shiftin the conversation away from unhealthyageing and its costs. Efforts will be betterspent on delivering policies that enable peopleto be healthier, independent and productivefor longer.As this report sets out, there is a broad rangeof policy targets and infrastructure goals thatcan help prepare countries to achieve this andimprove older people’s wellbeing.8 EIU. The Longevity Economy. 2019.9 OECD. 2019. Ageing and employment policies: Working better with age. Available at: https://read.oecd.org/10.1787/c4d4f66a-en?format pdf10 Age UK. 2010. Promoting Mental Health and Well-being in Later Life a guide for commissioners of older people’s services. Available at: in%20later%20life pro.pdf?dtrk true11 EIU. The Longevity Economy. 2019. The Economist Intelligence Unit Limited 20209
10Shifting demographicsA global study on creating inclusive environments for ageing populationsAgeing in context: Vulnerability of older people in thecovid-19 pandemic12The covid-19 pandemic is impacting the global population in drastic ways. In manycountries, older people are facing the most threats and challenges at this time. Althoughall age groups are at risk of contracting covid-19, older people face significant risk ofdeveloping severe illness if they contract the disease due to physiological changes thatcome with ageing and potential underlying health conditions.As of April 2020, over 95% of covid-19 deaths occurred in those older than 60 years, andmore than 50% of all fatalities involved people aged 80 years or older. Reports showthat eight out of ten deaths are occurring in individuals with comorbidities, in particularcardiovascular disease, hypertension and diabetes, but also with a range of other chronicunderlying conditions. The broader societal impacts of covid-19 for older people remainto be quantified, but the need for long-term social distancing and an economic recessionare anticipated to have significant harmful effects.More than ever it is important for older people to lead healthy, independent lives for aslong as possible, avoiding the need for institutional care. Covid-19 may serve as a wakeup call for governments across the globe in providing appropriate environments in whichpopulations can age.12 is-everyones-business The Economist Intelligence Unit Limited 2020
Shifting demographicsA global study on creating inclusive environments for ageing populationsChapter 2: The Economist Intelligence UnitSHIFT IndexThe Economist Intelligence Unit’s SHIFT Indexis an innovative policy and planning analysistool that benchmarks the performance ofthe 19 countries forming the G20 against aset of national-level leading practices aroundlongevity and healthy ageing.The following 19 countries were includedin the index: Argentina, Australia, Brazil,Canada, China, France, Germany, India,Indonesia, Italy, Japan, Mexico, Russia, SaudiArabia, South Africa, South Korea, Turkey,the UK and the US. Collectively, theserepresent the G20 minus the EU.13The SHIFT Index takes a broad definitionof older adults—those aged 50 and older—inorder to capture the environment in whichadults start to plan for later life as they enterthe biological ageing process.The SHIFT Index comprises three categoriesthat create a holistic picture of the factorsthat enable adults to live healthy, engaged anddignified lives as they age. They are:(1) Adaptive health and social care systems;(2) Accessible economic opportunity; and(3) Inclusive social structures and institutionsThe framework contains both quantitativeand qualitative indicators, with data collectedfrom global and national sources. The findingsare presented in an interactive workbook thataccompanies this report. The domains in theSHIFT Index are weighted based on input frommembers of the expert panel. Users can alsocreate customised weightings to test their ownassumptions about the relative importance ofeach indicator.For detailed indicator definitions andthe methodology, see the accompanyingmethodology in the appendix.The G20’s ageing populationThe G20 is an international forum for the governments and central bank governors from19 countries and the European Union (EU). The G20 countries were selected for thisanalysis to achieve a broad representation of the global population and economy: these 19countries represent roughly 64% of the global population and nearly three-quarters (74%)of global GDP.The share of the people aged over 65 years accounts for an average 10% of the total G20population. This includes 28% of the Japanese population on the high end and 3.4% of theSaudi Arabia population on the low end.14 Among the elderly G20 citizens, health trendsare mixed, but mild disability and chronic disease are generally increasing.1513 G20. Participants. https://g20.org/en/about/Pages/Participants.aspx. Accessed 2020.14 United Nations. June 2019. World Population Prospects 2019: Ageing in G20 countries. Available at: events/pdf/other/35/Key%20Findings 28JUNE19.pdf15 WHO. WHO Contribution To G20 2019 Presidency On Health-Related Issues. 2019. https://www.who.int/ageing/g20-feb-2019.pdf The Economist Intelligence Unit Limited 202011
12Shifting demographicsA global study on creating inclusive environments for ageing populationsChapter 3: Adaptive health and socialcare systemsKey findings Preparedness to address the risk factors and conditions associated with ageing isincreasingly common, but multidisciplinary and integrated care is a work in progressfor most countries. A lack of data on ageing-specific specialists and services suggests there are limits toevaluating if societies can deliver quality health services to those who need them. The voice of older people must be represented in the system for both patients(through advocacy and personal autonomy) and their carers. Countries still have workto do on both fronts. Besides geographic availability, access to health services is the foundation forassessing affordable care. For the countries involved, universal or near-universalhealth coverage is the norm, but implementation of these services varies dramatically.Today, due in part to medical advancementsand sanitation, the prevalent infectiousdiseases of the last century have largely takena back seat to non-communicable diseases(NCDs). By 2016, people were living muchlonger and the leading causes of deathswere heart disease, cancer, chronic lowerrespiratory diseases, strokes, Alzheimer’s anddiabetes.16 While this pattern was initially seenin developed nations, developing nations havefast followed suit.These changes affect ageing populationsand economies in new ways. Becausepeople are living longer, there is a greaterchance that they will have more than oneage-related chronic disease at a time, suchas cancer, cardiovascular diseases andneurodegeneration. Typically, these are morecomplicated and expensive to treat and takelonger to cure or manage. Today, about 60%of healthcare spending in OECD countriesgoes to major NCDs such as heart disease andmental health, with the very-old having thehighest per-capita health spend. Money spenton very old people (those aged over 85 years)is as much as six times that of those aged 5559 years.17Effective prevention and management ofchronic diseases not only reduces costs,morbidity and mortality in older people,but also supports a longer and moreproductive life. Healthcare systems nowfind themselves pressured to reduce theincidence of costly NCDs and the prevalence16 Xu, J et al. Deaths: Final Data for 2016.’ National Vital Statistics Reports. 2018. https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67 05.pdf17 OECD. Focus on Health Spending, 2016. -age-and-gender-FOCUS-April2016.pdf The Economist Intelligence Unit Limited 2020
Shifting demographicsA global study on creating inclusive environments for ageing populationsof common risk factors. This will requirefundamental changes to how many systemscurrently operate: instead of focusing solelyon treating illness, more is needed to keeppeople healthy. Success will require a rangeof policy interventions from the societal tothe individual level. Unfortunately, leadingpractices for healthy ageing are inconsistentlyimplemented across countries.To bring clarity to the issue, the first categoryof the EIU SHIFT Index is dedicated to healthyageing and social care systems. It scores eachcountry on proactive measures to addressknown risks and enable multidisciplinary andintegrated health systems for older adults. Thehealth and social care category’s indicatorscover population-based approaches tohealth and risk prevention, such as evidenceof national nutritional guidelines, mentalhealth guidelines, policies to reduce NCDrisk, recommended density of healthcareworkforce per head, health insurancecoverage and more.Overall, the 19 countries collectively score anaverage of 63.2 on a scale of 0 to 100, where100 is the health system most adaptive tothe needs of older adults. Every country stillhas work to do, and there were significantdifferences by country, and wide variations instrengths and weaknesses.SHIFT Index category 1: Adaptive healthand social care systems1United States87.82United donesia74.57Japan73.38Canada72.29France68.910South razil58.414Russia54.815Turkey44.416Saudi Arabia40.517India38.018South Africa37.619China36.5 The Economist Intelligence Unit Limited 202013
14Shifting demographicsA global study on creating inclusive environments for ageing populationsSupport for healthy ageingMuch of ill health in older years is caused byhealth events that could have been avoided byaddressing known risk factors and practicinghealthy behaviours. This section reviewsnational plans and preparedness to preventand manage the most significant risk factors ofchronic conditions in older populations.Generally, two themes arise. First, that somepolicies beneficial to older adults, but alsooften to a wider proportion of the population,have already become widespread, suchas: policies to reduce NCD risk, treatmentguidelines, use of living wills, or even universalhealth coverage. Yet other ideas have still notachieved general adoption but are appearing insome countries, such as policies that recognisethe role of carers, specific disease plansbeyond cancer, care integration and training inmulti-morbidity. These tend to be associatedmore with system reform than policy creation.Addressing common riskfactors and conditions associatedwith ageingCountries which actively manage riskfactors for NCDs may be more successful inpromoting healthier ageing and longevity. Asa bedrock component of healthy ageing, theindex scored countries based on evidence ofguidelines, policies and strategies that addressthe most common risk factors for diseasesprevalent among older adults. These plansare an important starting point because theyshow not only whether governments seethe benefit of prevention, but also if they areprepared to put resources behind it.The finding from this sub-category showsthat health systems are aware of theimportant conditions associated with age andacknowledge that they need to be properlyaddressed. The four leading risk factors forchronic disease development as people ageare physical activity, nutrition, tobacco use,and alcohol abuse. Taken together, theycontribute to the vast majority of chronicdisease, which most often manifests in peopleaged 50 .18The Index also looked for national plans andpublished care guidelines for seven of themost common chronic conditions associatedwith ageing: cardiovascular disease, cancers,osteoporosis, chronic obstructive pulmonarydisease (COPD), diabetes, dementia, andmulti-morbidity. Chronic diseases have majorhealth and economic consequences to ageingpopulations. For example, they are associatedwith lower rates of employment, economichardship and restricted socialisation.19,20,21Prevention is generally believed to be costeffective compared to treatments and longterm care. And, critically, prevention facilitatesthe healthy ageing process, ultimately leadingto economic gains to society and lowerdemands of health systems.18 Peters R, et al. Common risk factors for major noncommunicable diseases, a systematic overview of reviews and commentary: the impliedpotential for targeted risk reduction. 2019. 48/19 Meek KP, et al. Restricted Social Engagement among Adults Living with Chronic Conditions. 2018. 57/20 OECD. Promoting healthy ageing. 2019. https://www.oecd.org/g20/topics/global-health/G
A global study on creating inclusive environments for ageing populations Wealthy countries may find it easier to respond, but wealth is not a prerequisite for providing supportive environments. The best scoring health systems tend to be high-income countries, but Indonesia (a lower-middle income country) has been making strides to improve its
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4 2018 Global Ageing Network Annual Report 2018 Highlights The past year has been filled with new activities and initiatives with our Global Ageing Network members. Below are some of the highlights! The Global Ageing Network at the United Nations The Global Ageing Network continues to support advocacy at the United
