Planning for Aging Societies

As Figure 5 illustrates, the MIPAA and the UN Decade goals broadly relate to promoting social development and protection, ensuring access to quality care, and building enabling environments for older persons.

Figure 5

19 Key Themes in International Frameworks on Aging⁴

Most plans cited MIPAA and the Decade of Healthy Ageing as inspiration for their targets.

Policy Alignment with MIPAA and the UN Decade Themes Is Significant but Incomplete

When accounting for the MIPAA themes and the UN Decade Action Areas, Argentina, Cambodia, Ireland, Lebanon, and Uruguay have the most comprehensive plans of those evaluated, incorporating 14 of the 19 total themes. These plans are both comparatively broad—covering many types of issues that can impact health, enabling environments, and development outcomes for older persons—and relatively robust, as each policy issue includes at least one actionable objective. Plans from Ireland and Jordan cite other plans, including plans from Singapore, New Zealand, and Wales, as sources of inspiration for plan development. These plans are comparatively less broad in scope but have proven effective in implementation.

Figure 6

Themes Mapped by National and Subnational Plan

Across the 15 plans and supporting documents reviewed in this analysis, two nearly universal themes were identified: (1) preventing neglect, abuse, and violence; and (2) improving or providing integrated health care for older persons. In total, 14 of the 15 plans (93 percent) analyzed included at least one policy recommendation or goal related to elder abuse and neglect and at least one related to integrated care (see Figure 7). Ireland’s national plan was the only one analyzed that did not include any targets relating to integrated care, while only Chile’s plan did not include any targets on elder abuse and neglect. Conversely, plans were least likely to address the themes of HIV/AIDS and emergency response and disaster planning: only two of 15 plans (13 percent) addressed HIV/AIDS, and four of 15 plans (27 percent) included targets relating to emergency response. HIV/AIDS is a major health challenge in certain countries, particularly in the Sub-Saharan Africa region; however, many of the countries where HIV/AIDS is of particular concern do not yet have robust aging plans or frameworks as their populations tend to be younger. Additionally, as the United Nations Decade of Healthy Ageing report (2020) highlights, while older people are disproportionally negatively affected by disasters and emergencies, they are often not considered in emergency planning due to ageist attitudes that lead to older persons and their specific vulnerabilities being overlooked.

Figure 7

Alignment of National Plans with International Frameworks

Plans Ensure Older Persons Benefit from Economic Development

The first MIPAA pillar recommends that governments act to ensure that older persons share equitably in the benefits of a country’s economic development. Thirteen of 15 plans reviewed (87 percent) included targets around improving older persons’ financial security and other social protections, providing education and training, and building intergenerational solidarity. The plans tend to reflect the national context and issues of greatest concern and priority. Bulgaria’s plan, for example, the National Comprehensive Strategy for Active Ageing (2016-2030), has a heavy emphasis on employment - particularly on retraining and retaining older adults in the workforce as the country will soon experience the world’s steepest decline in the working-age population. The profiles in the Database provide contextual information specific to each country that has informed each plan’s development and implementation.

Many developing countries, particularly those that are lower-income, have a strong focus on social development and protection, often through filial support laws. These laws require close family members—most often, adult children—to provide financial and material support to aging relatives. Laws that stipulate that family members have a legal duty of care for relatives effectively largely shift the responsibility and funding for care and protection from the state to families. Filial support laws are common in developing countries, particularly in the Asia Pacific and Southeast Asia regions, as policymakers in the 1990s drew upon cultural norms of filial piety and reciprocity to fill gaps in care. Cambodia’s National Ageing Policy 2017–2030, for example, explicitly connects the ideas of filial piety to social development by incorporating “Raising awareness and encouraging adult offspring who are able to provide financial support … in order to fulfill their filial duties” as one of three strategies for that country’s policy social development objective. Cambodia’s National Ageing Policy also identifies intergenerational connection and joint family structures as a hallmark of Khmer society. Some Western countries or jurisdictions also incorporate filial laws into their legal systems of care. As of 2018, 29 U.S. states had filial support laws, although they are rarely enforced. These filial support laws also tie into improving state support for informal caregivers, which is a feature in 11 out of 15 (73 percent) of the analyzed plans, including in Cambodia’s and Singapore’s plans, and is included as a policy issue under MIPAA’s third pillar (called “Ensuring enabling and supportive environments”). Governments have long relied on families to fill gaps in care, and now many are planning or working on providing expanded support to caregivers, as well as acknowledging caregivers as essential stakeholders of healthy aging agendas. Such acknowledgment has driven the inclusion of caregiver support in healthy aging strategies, including Singapore’s Action Plan, which suggests the expansion of training and education for caregivers, respite services, eldercare leave, and improved referral and information services. Several countries have even developed independent strategies, which are not discussed in this report. Examples of independent strategies include New Zealand’s Mahi Aroha – Carers’ Strategy Action Plan 2019-2023, as well as the United States’ 2017–2018 RAISE Act, which directs the development of an independent Family Caregiving Strategy to support informal caregivers.

More Can Be Done to Mainstream Health Targets

Of the three MIPAA pillars, the second pillar, “Advancing health and well-being into old age,” was least prioritized in the sample of 15 plans analyzed in this report. Whereas 12 of the plans reviewed addressed comprehensive assessments for supporting environments, and 11 plans had targets to include older persons in countries’ development processes, only 9 plans addressed more holistic approaches to health. All of the plans have at least one health-related target, but many are not comprehensive across the spectrum of MIPAA’s health-related themes. This trend does not appear to be related to country development status. For example, both the state of California’s and Nepal’s plans address only one aspect of health. However, these gaps may be sufficiently covered in other policy documents beyond the scope of this analysis. Of the plans analyzed, 12 out of 15 plans (80 percent) did include targets to train care providers and health professionals and prevent noncommunicable diseases, respectively. These two themes are the most common MIPAA policy issues to be included in the plans, but such measures are often mere targets that do not offer a policy solution or funding to realize these goals.

Two of the United Nations Decade action areas - improving access to, and quality of (1) long-term care and (2) integrated care - are themes that are relevant to the MIPAA health pillar. Among health-related themes, providing integrated care is the most likely to be included in national plans, with 14 of 15 plans including targets to support the development of better-integrated care. Similarly, 11 of 15 plans target long-term care, particularly through its expansion and improvement. This is important because currently only 5.6 percent of the world’s population lives in countries that mandate full, universal access to long-term care through national legislation. Providing older persons access to long-term care options can reduce the burden of care on families and allow older adults to choose how and where they wish to grow old, which in turn can improve older persons’ well-being.

Creating Age-Friendly Environments Important to Enhance Older Persons’ Quality of Life

The third MIPAA pillar, which corresponds with the fourth United Nations Decade of Healthy Ageing action area, emphasizes the promotion of enabling and supportive environments. Supporting enabling environments for older persons includes access to quality housing and infrastructure as well as tackling ageism, neglect, and abuse - which can shape how older persons function and their overall well-being, both physically and mentally. Among the national plans analyzed, 14 out of 15 (93 percent) reported targets for protection from neglect, abuse, or violence. Elder abuse is prevalent globally, with one in six people over the age of 60 reporting abusive behavior in a nursing home or community setting - and around 64 percent of nursing home or long-term care staff have reported that they had committed some form of abuse in the past year. Abuse also frequently occurs in home care situations, and 11 of the 15 national plans identified the provision of additional support to informal caregivers, many of whom are family members, as a priority to combat caregiver burnout and lessen the incidence of abuse.

Eradicating ageism is another key target to promote an enabling environment for older persons and was included in 11 of 15 plans (73 percent). According to the WHO’s 2021 Global Report on Ageism, roughly half of the world’s population holds ageist attitudes. Additionally, an ageist environment that does not support the needs of older persons is associated with older generations dying 7.5 years earlier, making the reduction of ageist attitudes an important consideration for country plans. The majority of country plans that included a focus on combatting ageism recommended the creation of positive-images-of-aging campaigns as well as legislation that prohibits discrimination based on age. To combat abuse and ageism, many country plans aim to address and improve the quality of life of older persons holistically, as well as focusing on protection of older persons and improving intergenerational solidarity.

Finally, 13 out of 15 (87 percent) of the plans identified improving housing availability, quality, and affordability, and expanding older persons’ access to transport and public spaces as priorities. New Zealand’s Better Later Life Strategy (2019–2034), for example, identifies the creation of functional, safe, and affordable housing for older people as one of five key priorities, with a particular emphasis on providing an option for older persons to remain independent and age-in-place in their home communities. Malta expanded its National Strategic Policy for Active Ageing (2014–2020), to include a free transportation service called the Silver-T, which assists older people in independently conducting daily activities and errands.

While the frameworks provided by MIPAA and the UN Decade of Health Aging provide important indicators against which to benchmark plans, this analysis identified four additional policy considerations that impact the future development and current implementation of national plans. For countries that plan to develop a new plan or update existing plans, it is important to also consider: (1) the engagement of older adults in national plan development through consultative or participatory processes, (2) ensuring successful implementation of stated goals and objectives through measurable outcomes, (3) the impact and implications of the COVID-19 pandemic, and those of future infectious disease outbreaks, and (4) the need to enhance equity and reduce disparities among older populations in healthy aging policies. While the first two factors are critical to the development and implementation of plans both new and old, the latter two represent current policy challenges to healthy aging for nearly every country in the world—developed and developing.

Engaging Older Adults in Plan Development

International frameworks on healthy aging, including MIPAA and the UN Decade of Healthy Ageing, acknowledge the meaningful engagement and empowerment of older persons as critical to developing, implementing, and evaluating healthy aging policies. Plans analyzed in this report utilized a variety of participatory processes to draw on the voices of older people during the development phase of these plans. Such processes included public consultations, social media outreach, public surveys, town hall meetings and forums, webinars, and community roundtables. Several jurisdictions - including Argentina, the state of California, Ireland, Malta, and Wales - consulted experts and civil society organizations representing older persons during plan development. In total, at least 11 of 15 plans analyzed utilized a participatory process that included the voices of older people, or organizations that represent them, during the development process.

Of the plans analyzed for this report, the state of California’s Master Plan on Aging, in which included input and involvement by AARP, and the Age-Friendly Wales strategy, stand out in their use of participatory processes in development. The Welsh strategy, in particular, was heavily informed by input from those aged 50 and over through surveys and forums held in each local authority. This extensive consultation process helped ensure that the strategy was specifically designed around the needs and aspirations of older people in Wales. For example, it identifies improving the availability of public toilets as a priority to improving age-friendly communities; this priority was directly informed by the input of older persons, according to the strategy. The solicitation and incorporation of older adult perspectives is a key component of effective and inclusive strategies.

Monitoring, Evaluation, and Resourcing for Implementation

The implementation of national plans is wholly dependent on the allocation of financial resources by governments toward plan objectives, as well as the application of effective monitoring and evaluation frameworks. While MIPAA briefly identifies the mobilization of resources and the establishment of monitoring and evaluation frameworks as crucial elements of implementation, the GSAP highlights the continued need for improved measuring, monitoring, and reporting systems for healthy aging. Eight plans analyzed in this report recommend the development of indicators to track progress toward the plan’s goals or policy recommendations. At least four of these jurisdictions have published indicators and begun tracking progress related to healthy aging, including the state of California, Ireland, New Zealand, and Wales.

Additionally, Bulgaria and Malta utilize the European Active Ageing Index, a tool developed by the UN Economic Commission for Europe (UNECE) to measure healthy aging. Plans that create specific, actionable targets that are based on data, and then provide sufficient funding to accomplish their objectives, are needed to improve the lives of older persons.

The Active Ageing Index for Europe

The Active Ageing Index (AAI) is a project developed by the United Nations Economic Commission for Europe Population Unit, European Commission Directorate General for Employment, Social Affairs and Inclusion, and the European Centre for Social Welfare Policy and Research in Vienna to measure active and healthy aging. The AAI includes 22 indicators grouped into four domains, which cover employment, participation, independent living, and enabling environments. In its latest 2018 report, the Active Ageing Index compared progress on these indicators across 28 countries in Europe. Since its inception in 2015, the AAI has served as a source of inspiration for countries designing and implementing national aging plans. Several countries, including two outlined in this report, designed plans around the areas of the AAI, and utilize the index as a monitoring and evaluation tool. The creation of a parallel Active Ageing Index is being explored for Asia. 

Active Ageing Index:

Four Areas and 22 Indicators for Measuring Progress

Employment	Participation in Society	Independent, Healthy, and Secure Living	Capacity and Enabling Environment for Active Ageing
Employment rate ages 55–59 Employment rate ages 60–64 Employment rate ages 65–69 Employment rate ages 70–74	Voluntary activities Care to children and grandchildren Care to infirm and disabled Political participation	Physical exercise Access to health services Independent living Financial security (comprised of three indicators) Physical safety Lifelong learning	Remaining life expectancy at age 55 Share of healthy life expectancy at age 55 Mental well-being Use of ICT Social connectedness Educational attainment

However, there is a clear divide between developed and developing countries regarding the resourcing and monitoring of plans. One key barrier to monitoring policies, particularly for lower- and middle-income countries, is limited access to data. Approximately 75 percent of the world’s countries have little to no data on older age groups or healthy aging, meaning that many countries have a limited capacity to monitor existing plan goals or develop future evidence-based policies. Beyond monitoring mechanisms, research revealed that only five plans analyzed for this report were provided with a budget for the plan’s implementation: those implemented by Bulgaria, the state of California, Ireland, New Zealand, and Singapore.

Harnessing Lessons Learned from the COVID-19 Pandemic

The COVID-19 pandemic has exposed gaps in national government protections and global health systems for older adults, highlighting a range of complex challenges that must be addressed in future national plans to prepare for an increased risk of future disease outbreaks and their impacts on care and support for older adults and vulnerable people. At the start of the pandemic, it became clear that older adults are at a higher risk for severe infection. However, the impact of COVID-19 on older adults goes far beyond the risk of infection, affecting older people’s daily routines, the care and support they receive, and their ability to stay socially connected. Additionally, the pandemic has caused widespread economic insecurity among older people and even hastened older adults’ departure from the workforce, reducing their ability to support themselves and their families. In particular, gaps in employment, income, care, and social connection are a result of society’s increased dependence on digital technologies during the pandemic to facilitate work, health care, social connection, and widespread digital illiteracy among older adults.

Due to these profound impacts, national aging plans developed after 2020 increasingly address COVID-19 and the digital divide. Four of the plans examined in this report - those from the state of California, Chile, Jordan, and Wales - address the impacts of COVID-19 on older adults. In addition, New Zealand’s latest four-year Action Plan for the implementation of the Better Later Life Strategy addresses the impacts of COVID-19 on social isolation, digital inclusion, working older adults, and housing. Bulgaria and Singapore are reportedly releasing updated action plans on healthy aging that account for troubling trends produced by COVID-19 and pandemic response measures. Malta also plans to release a new Strategic Policy for Active Ageing, which will incorporate targets related to COVID-19. Countries could identify and aim to cover key gaps that were exposed by COVID-19 including addressing digital inclusion, as they develop their national plans.

Enhancing Equity and Reducing Disparities

Older women, racial, ethnic, and religious minorities, displaced peoples, persons with disabilities, LGBTQ persons, indigenous peoples, and people in specific settings such as fragile states face significant inequities, particularly relating to health and financial security that demand attention in national plans. Ireland’s Positive Ageing Strategy stands out for its attention to Irish Travellers, a nomadic ethno-cultural group that has traditionally faced political and social discrimination and exclusion. As of 2018, the Positive Ageing Strategy includes 14 indicators on healthy aging for Irish Travellers, covering their social and cultural participation, housing, access to health care, and health behaviors. Ireland’s example of collecting and publishing data relevant to an older historically marginalized group reveals the importance of data in making older, marginalized populations more “visible” in policy frameworks, as well as older people in general, which can reduce the impacts of ageism and improve older populations’ resilience. Equity, equality, and non-discrimination are key human rights principles and must apply equally to all people and marginalized groups in a country. Another gap is that MIPAA specifically addresses HIV/AIDS, and yet it is under-addressed in national plans. While this challenge has been diminished in developed country contexts in recent years, it remains a health concern across the developing world.

Looking Ahead

National planning to mainstream aging is a key pathway to protect older populations and facilitate healthy aging. It is also crucial for societies to prepare for and cope with demographic changes. To date, only 128 United Nations Member States have developed some form of policy to mainstream older persons and aging across relevant policy areas, meaning that as many as 65 member states lack any sort of broad strategy or law related to aging at the national or subnational level. For many of these countries, resourcing limitations and data gaps present significant barriers to developing and implementing a plan on aging.

The ‘Return on Investment’ for Prioritizing Aging and Older Persons:

While data availability on older persons and its collection has been identified as a key “enabler” for the UN Decade of Healthy Ageing and prompted significant international work on the issue (see the Titchfield Group on Aging-related Statistics and Age-Disaggregated Data), more research is needed on the economic impact of funding national aging agendas and potential returns on investments in older persons. Although the full economic benefits of mainstreaming aging are still unclear, an independent report commissioned by Public Health Wales explores the potential return on government investments in older adults. The report ‘Living Well for Longer’ estimated that every £1 investment in facilitating active aging can generate between £0.79 and £112.42 in social value within Wales. Other analyses have concluded that investing in the retention of older adults in the workforce can provide significant returns. According to the OECD Promoting an Age-Inclusive Workforce report, building multigenerational workforces could raise GDP per capita by 19 percent by 2050. Preparing health care systems and workforces for an aged population will be critical, particularly in developing countries where fewer plans exist and 71 percent of population aging will occur by 2050. In addition to economic gains from investing in older persons, prioritizing older persons also can lessen ageism, increase intergenerational support, and improve social cohesion across a country’s population, according to a 2017 report by HelpAge International. This shift of perspective can help all generations view older persons as worthy of respect and dignity, and as people who can contribute to society rather than those who are ‘a burden’ on the system. The potential dividends of investing in older persons extend across the economy, health, and social spheres, yet support for healthy aging agendas in multilateral financial institutions remain in preliminary stages.

Developing a national plan is a key opportunity for countries, especially those facing a major demographic shift, to plan for aging populations and improve the health and well-being of older persons. To achieve these goals, policymakers should first consider the themes laid out in international frameworks on aging, including MIPAA and the UN Decade of Healthy Ageing, which are explored in this report’s policy map. Future plans should also consider lessons from the COVID-19 pandemic and address equity concerns for marginalized groups.

The analysis of this report demonstrates the importance of alignment with international frameworks as well as the use of participatory, consultative, and inclusive processes when developing plans. Effective plans are also contextually sensitive and tailored to local realities. Critically, they estimate and allocate financial resources to support implementation and harness data to monitor progress toward stated goals and objectives.

For additional information on these national plans, see the Database of Action Plans for Aging (DAPA), and for additional case studies and resources on Healthy Aging, explore the AARP-FP Analytics Toolkit.