By Jinkook Lee
Director of the Program on Global Aging, Health, and Policy,
Center for Economic and Social Research,
University of Southern California
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After falling during the COVID-19 pandemic, global life expectancy has resumed its upward trajectory from previous decades, reaching 73.3 years in 2024.1 As the global population continues to age and enjoy longer lives, one in six people on the planet will be over 60 years old by the end of this decade.
It would be easy to assume — given the younger average age in many low- and middle-income countries (LMICs) — that the coming surge of global population aging will be concentrated in high-income countries (HICs). But by 2030, an estimated 80 percent of the world’s people age 60-plus will live in LMICs.2 And while it took roughly a century for the share of older adults to increase from seven percent to 14 percent in HICs, the same transition will take less than 20 years in many LMICs. This relatively rapid pace of aging — accompanied by rising life expectancy and declining fertility — offers a much shorter lead time for LMICs to prepare for seismic demographic transformations that will ripple through labor markets, health care sectors, and social policies.
For example, declines in the working-age populations pose a challenge to continuing economic growth, spurring concern that LMICs may be “growing old before rich.” The common recommendations in HICs against shrinking labor force — encouraging people to work longer, delaying retirement, and fostering the employability of older workers — may not prove effective in LMICs. Older people in low-income countries often remain in the labor force until old age, and high rates of unemployment and underemployment are widespread in many LMICs. It will be critical to find paths to economic growth that can be achieved even with a shrinking labor force. Increased investment in human capital, physical capital, and technology can help boost productivity. For example, investment in education is one of the primary sources of development of human capital for any nation. As an additional benefit, research on the education-health nexus also suggests that education is the main driver of improved population health, which will help reduce health care needs for the future generations of older adults.
Universal health coverage has been named by the United Nation’s Sustainable Development Goals as a strategy to improve health in LMICs, expanding coverage alone is not certain to improve health outcomes. Improvement is contingent on providing high-quality health care3 — a challenge for many LMICs that face shortages of human, financial, and material resources. A starting point for strengthening health systems in LMICs is the collection and analysis of health data, which will enable accurate evaluation of the effectiveness of health services.
The importance of data cannot be overemphasized, especially in LMICs where the scarcity of data impedes critical assessments and evidence-based policy development.
Social protection coverage, such as pensions that are common in many HICs, also require rethinking to benefit aging populations in LMICs. In these countries, social protection coverage is quite heterogenous because work is often diverse, fluid, and overwhelmingly informal. Significant amounts of employment are unobservable and beyond the reach of the state’s ability to enforce the obligations and benefits of a country’s social contract.4 Employment-based pension policies assume a level of homogeneity and stability in the ways people work, a scenario that reflects reality for a minority of workers in many LMICs. Therefore, it has not been possible to use traditional social insurance associated with formal labor to support post-employment financial needs, highlighting the need for alternative social protection instruments that are not tied to labor contracts. For example, cash transfer programs, not tied to employment but alleviating poverty, have been found to be effective in improving the health and wellbeing of older people in many LMICs, although the magnitude of their impact varies across different program designs.5
Alongside population aging, LMICs have been experiencing changes along multiple other dimensions as well, including epidemiological transition in disease burden and intractable social changes. In addition to the challenges of infectious diseases, non-communicable diseases (NCD) such as heart disease, cancer, and diabetes are a growing threat to health in LMICs. The double burden of communicable and non-communicable diseases puts a major strain on LMICs’ fragile health care systems. The good news is that a population-wide intervention tackling the risk factors of NCDs is possible and can reduce negative NCD consequences. Proactive prevention by primary health care providers rather than reactive treatment by specialists is the best way to address NCDs in these settings.6
Cultural norms are also shifting. Reliance on a family safety net for old age has faded in recent years in many LMICs,7 which can lead to a dearth of care for older people. In most LMICs, formal long-term care is in nascent stages, so the responsibility of care typically falls on families. However, because of smaller family sizes, increased geographic mobility, and increased female labor force participation, families’ capacity for care is diminishing. Even when families can provide informal care, it often comes at the cost of reducing labor force participation of caregivers. Since social attitudes aren’t likely to be reversed, boosting the formal long-term care sector is a more viable alternative. Doing so will create a long-term care workforce, as well as prevent those who are already in the labor market from reducing their labor force participation.
This is a moment of energy and innovation around social protection policy in many LMICs. When COVID-19 struck, many LMICs deployed programs to help to mitigate the impact of the pandemic. As a result of actions taken during the pandemic, as well as weaknesses that the response made evident, many countries are reimagining the design of their social protection systems in ways that may have seemed impossible just years ago. Leveraging innovations in technology and building on the heightened expectations of social protection among policymakers and the population, this new generation of social protection programs may expand rapidly and widely and provide opportunities to effectively address population aging.
Strategic planning and preparation — comprised of investment in human capital, health care infrastructure, technological innovations, and policy and institutional reforms that respond to social shifts — can enable countries to meet the challenges and take advantage of the opportunities presented by population aging. It is inadvisable to extrapolate knowledge and policy recommendations from HICs to LMICs, where labor market characteristics, epidemiological states, socioeconomic resources, and cultures might be very different. Rather, investing in data and research will enable sound policy development suitable for local contexts. It is important to recognize that aging is a process, and what individuals and countries invest in today will shape tomorrow’s global aging society.
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1 United Nations, Department of Economic and Social Affairs, Population Division (2024). World Population Prospects 2024: Summary of Results. UN DESA/POP/2024
2 Goodman-Palmer D et al. Health and wellbeing of older people in LMICs: a call for research-informed decision making, Lancet 2023, Vol 11 Feb, e191-192.
3 Kruk ME, Gage AD, Joseph NT, Dannaei G, Garcia-SAiso S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries, Lancet, 2018, Vol 392, Nov 17: 2203 – 2212. http://dx.doi.org/10.1016/S0140-6736(18)31668-4
4 Torm N, Oehme M. Social protection and formalization in low- and middle-income countries: A scoping review of the literature, World Development, Vol. 181, September, 106662, https://doi.org/10.1016/j.worlddev.2024.106662
5 Richterman et al. 2023. The Effects of Cash Transfers on Adult and Child Mortality in Low- and Middle-Income Countries, Nature, 618, 575-582. https://doi.org/10.1038/s41586-023-06116-2
6 Rajan D, Rouleau K, Winkelmann J, Kringos D, Jakab M, Khalid F, editors. Implementing the Primary Health Care approach: a primer. Geneva: World Health Organization; 2024 (Global report on primary health care).
7 Lee J, Jain U, Govil D, Sekher TV, Lubet A. “Aging in the Global South,” In Ferraro KF, Carr D. (eds) Handbook of Aging and the Social Sciences, the 9th Edition, 2021, Academic Press, 65-82.