This is the second of a series of bimonthly reports on the ...



3710305-33210500The impact of COVID-19 on older personsAsia Pacific regional report August 2020left47625This is the second of a series of bimonthly reports on the impact of COVID-19 on older persons in the Asia Pacific region. This series is coordinated by HelpAge International with financial support from UNFPA’s Regional Office for Asia and the Pacific. Accompanying and supporting this regional report produced by HelpAge are eight country briefs. These are for Bangladesh, produced by the Department of Population Sciences, University of Dhaka, on behalf of UNFPA Bangladesh; India, produced on behalf of HelpAge International by Nathan Economic Consulting India; I.R. Iran, produced by Professor Majid Koosheshi on behalf of UNFPA Iran; Japan, produced by the Japan Agency for Gerontological Evaluation Study (JAGES); Republic of Korea, produced by Hanyang University Institute of Ageing Society; and Myanmar, Pakistan and Vietnam, produced by HelpAge International. In a rapidly moving context, these bimonthly reports aim to monitor secondary sources of evidence that illustrate changes in the situation of older people and document how governments and others are responding to the challenges. Given the vast scale and diversity of the region, these periodic reports do not aim to be comprehensive. Rather, they are intended to identify emerging trends across Asia Pacific in broad strokes, with examples.Any parts of this publication may be reproduced without permission for non-profit and educational purposes. Please clearly credit HelpAge International and send us a copy or link. Disclaimer: This document has been produced with financial support from UNFPA. The views expressed herein can in no way be taken to reflect the official opinion of UNFPA. 400000This is the second of a series of bimonthly reports on the impact of COVID-19 on older persons in the Asia Pacific region. This series is coordinated by HelpAge International with financial support from UNFPA’s Regional Office for Asia and the Pacific. Accompanying and supporting this regional report produced by HelpAge are eight country briefs. These are for Bangladesh, produced by the Department of Population Sciences, University of Dhaka, on behalf of UNFPA Bangladesh; India, produced on behalf of HelpAge International by Nathan Economic Consulting India; I.R. Iran, produced by Professor Majid Koosheshi on behalf of UNFPA Iran; Japan, produced by the Japan Agency for Gerontological Evaluation Study (JAGES); Republic of Korea, produced by Hanyang University Institute of Ageing Society; and Myanmar, Pakistan and Vietnam, produced by HelpAge International. In a rapidly moving context, these bimonthly reports aim to monitor secondary sources of evidence that illustrate changes in the situation of older people and document how governments and others are responding to the challenges. Given the vast scale and diversity of the region, these periodic reports do not aim to be comprehensive. Rather, they are intended to identify emerging trends across Asia Pacific in broad strokes, with examples.Any parts of this publication may be reproduced without permission for non-profit and educational purposes. Please clearly credit HelpAge International and send us a copy or link. Disclaimer: This document has been produced with financial support from UNFPA. The views expressed herein can in no way be taken to reflect the official opinion of UNFPA. Executive summary1. Changes in regional context So far, most Asia Pacific countries are faring better than the global average in the fight against COVID-19, though the virus remains a serious threat. The vast majority of confirmed cases are concentrated in a small number of countries. In Asia Pacific, India accounts for over 80 per cent of confirmed new cases, and a handful of countries account for almost all of the rest. Even within countries, the caseload is typically clustered rather than evenly distributed. Public health measures have upended the economy, jobs and everyday life. As the pandemic has expanded from Europe and North America to low- and middle-income countries (LMICs), poverty projections have gone up. There is extensive global speculation on whether the post-COVID world will be worse or represents an opportunity to “build back better” and tackle big challenges. Whatever their outlook, many agree that business as usual is not the goal, especially given alarming risks to the Sustainable Development Goals. 2. Situation of older persons Health and careCOVID-19 has reached only a small fraction of the older population, with their risk closely tied to location. Mortality from COVID-19 increases with age, but younger age groups are a large proportion of deaths in middle-income countries. Older people living in large households are at increased risk of infection. Compared to Europe and North America, household sizes in Asia Pacific are larger, on average, bringing greater risks of within-household transmission. These households face added risks due to the closing and opening of schools in areas where an outbreak is occurring. The secondary impacts of the pandemic on health and health systems affect many older people in Asia Pacific, even in countries with few COVID-19 cases. This is due to reallocation of resources, reduced access to health services, reduced demand for critical health services, and economic impacts on health and nutrition. Other health concerns – associated for example with non-communicable diseases (NCDs) and the need for care support – have a much larger impact on mortality than COVID-19 does at present. Longer term, there are concerns that reduced physical activity, increased social isolation, increased stress and anxiety, and insufficient income may be linked with negative impacts on physical health, functioning, mental health and cognition.Income securityAs the pandemic continues, the resulting economic crisis drives up unemployment and reduces incomes of older people and their households. Most older people in Asia Pacific work in informal or non-standard employment and are therefore highly exposed to the economic crisis. Informal employment tends to provide lower and more irregular incomes, does not provide social protection benefits or ensure health and safety in the workplace. Persons with disabilities are particularly at risk to lose income and participation provided by employment. In some contexts, the return of large numbers of migrant labourers to rural areas can create pressures on older people’s livelihoods. While some migrant workers might send more money to their families who are in extremely difficult circumstances, the global nature of the economic crisis points toward declining remittances over the medium term. Households of older persons or households with no income earner are particularly at risk. In this crisis, access to social protection can be a matter of survival, but some emergency programmes are not accessible to older people. The challenges they face in accessing emergency cash transfers highlight the importance of pension systems to ensure income security, though their coverage remains limited and benefit levels of social pensions are typically inadequate. Social issuesExceptional formal and informal restrictions on movement have left many older people feeling isolated and excluded. With face-to-face social interactions often shut down during the pandemic, older women and men who do not use ICT fluidly are now at a disadvantage. However, it is not yet clear that older people in Asia Pacific, defined by the sole criterion of age, necessarily face exceptional risk of social isolation or loneliness. Much of the global population, of all ages, is suffering from the effects of lockdowns and physical distancing steps. Living arrangements and personal circumstances contribute to variations in social isolation: for example, many of those living in residential care homes or living alone may face severe challenges. For many families, strict lockdowns, school closures and reverse migration may have led to increased social interaction within multigenerational households but disrupted social and religious networks beyond the home. The risk of elder abuse has risen during the pandemic, but evidence of abuse is likely to remain patchy and largely anecdotal. Assessments highlight older people’s fears of increased abuse during the pandemic. The pandemic is another reminder that older women are largely invisible in discussions of gender-based violence (GBV) – and gender as a whole. The pandemic highlights the pre-existing “deficit in reliable and comprehensible data” on women aged 50 and older.3. Responses addressing the older populationDespite the current higher global profile of older people because of their risk from COVID-19, actions directly targeted at older people remain limited in national response plans. GovernmentAmong health and care responses, the most universal government measures are those to prevent transmission of COVID-19 and to protect older people along with the whole population. Just a handful of countries in the region have introduced various forms of support for health insurance as part of their COVID-19 response, such as funding employee contributions, reducing premiums or covering COVID-19 related expenses. Most high-income and upper-middle-income countries are trialling or scaling up telemedicine. One constraint is that telemedicine infrastructure is not widely in place in most countries in the region. As telemedicine is being led by the private sector in LMICs in the region, there are also concerns about health equity. Beyond these issues, there is the question of how ready the public is for telemedicine. Older people on average are more likely than other groups to face challenges accessing telemedicine because of lower rates of Internet access and skills, lower levels of education, and higher rates of disability including hearing, sight, cognitive and speech difficulties. Efforts are being made to address the risks and needs of those who receive care support, though mainly for the minority receiving formal care services. Governments with established formal long-term care systems have established guidelines and support measures to mitigate the spread of COVID-19 within care homes and to support continuity of services, even with physical distancing in place. However, for the vast majority of older people with care needs and their family carers, there has been little government or private support. Social protection has been an integral component of almost every government’s early COVID-19 response. In Asia Pacific, social assistance constitutes 75 per cent of all responses, and about half of those are cash transfers. COVID-19 era cash transfers are relatively generous, especially in contrast to pre-COVID-19 social protection for older people. Most of the emergency cash transfers are of short duration and, without policy changes, may expire between July and September 2020, despite the deepening economic crises. Few new policy announcements have been made in Asia Pacific in June and July 2020. Despite substantial population ageing, only 13 Asia Pacific countries have so far adapted pension systems for older people as a COVID-19 response. The pandemic has demonstrated the value of universal social protection systems. Countries with effective and comprehensive social protection systems are likely to have the institutional capacities and systems in place to scale up programmes relatively quickly. On the other hand, countries that lack robust systems may need to develop their policies and interventions in an ad hoc way and build institutional capacity under difficult circumstances. That approach may lead to delayed or ineffective responses. The recognition that the COVID-19 crisis calls for rapid progress towards universal social protection seems to be shared even by the World Bank and IMF, institutions often associated with advocating for narrow poverty targeting of benefits. Other responses The multilateral development banks continue to provide substantial new financing or redirect existing financing for COVID-19 interventions, including the emergency actions and health system capacity building. Older people benefit, though mostly indirectly, via large international appeals coordinated by UN agencies. Some international bodies are gathering evidence related to older people’s concerns, but to a limited extent. The NGO sector continues to struggle, as public fundraising stalls and donor countries either turn to domestic responses or push their resources through large agencies. CSOs who are part of the HelpAge Asia Pacific regional network are shifting from the distribution of supplies to advocacy, campaigns and rapid needs assessments. Especially where the government response remains limited, established community-based organisations, including those led by older people themselves, often make the local response more effective, coordinated and personal. The private sector is scanning for commercial opportunities arising from the pandemic. The combination of heightened attention to health concerns and the need deliver services from a distance is generating expectations that innovation in the health sector will accelerate. These innovations include transitioning more care outside of hospitals and providing both consumers and health providers with digital tools and new technologies. 4. Selected near-term recommendations The pandemic has stimulated wide public debate about how to move towards a better future for all generations. Those debates are generating important medium- to long-term recommendations that could be transformational, if adopted. For example, they include tackling fundamental societal threats including inequality and sustainable use of the planet’s resources. These in turn could facilitate reforms that improve the situation of older people, such as strengthening inclusive national systems for social protection, health care and long-term care and reducing climate-related threats to health and livelihoods. Rather than attempting to cover all the challenges facing older people, the final section of this report proposes a few achievable priorities for the pandemic period: Gather evidence about older people’s situation in the pandemic. This includes (a)?surveys specifically targeted at older people, but even more productive might be (b) the inclusion of older respondents in more numerous population-wide surveys.Rebalance health system priorities back towards NCD services, given their neglect during the pandemic and high impact on mortality. National COVID-19 response plans should (a) include guidelines to prevent COVID-19 from significantly interrupting NCD health services and (b) ensure that COVID-19 policy responses improve or at least do not worsen exposure to key NCD risk factors. Take action to protect those with care needs, who are among the most vulnerable to COVID-19. (a) In residential care settings, prevent and/or manage the spread of COVID-19; (b) for family carers, expand or introduce financial and psychosocial support and provide information and training on COVID-19 safety. Prioritise universal social pensions as the most effective mechanism to ensure the income security of older people during the crisis. (a) Where social pensions exist but do not reach most older people, their coverage could be expanded. (b) Where social pension transfer levels are too low to provide protection, governments should increase transfer levels at least temporarily.Where emergency cash transfers are implemented for broad segments of the population, they should be accessible, especially for older women and people with disabilities. Although technically eligible, many older people struggle even to register for COVID-19 transfers. Access should be smooth, from outreach and communications to registration and receipt of payments.Consider adding nuance to statements warning of the pandemic’s “risks to older persons”, based purely on chronological age. Such statements not only obscure the diversity of older persons but may also reinforce blanket perceptions of vulnerability and decline in later life. Broad generalisations based on age alone may impede interventions that could be more sharply targeted.AbbreviationsADBAsian Development BankASEANAssociation of South East Asian NationsCOVID-19Corona Virus Disease 2019CSOCivil Society OrganisationESCAPUnited Nations Economic and Social Commission for Asia and the PacificGHRPGlobal Humanitarian Response PlanHICsHigh-Income CountriesICTInformation and communications technologyIDAInternational Development AssociationIMFInternational Monetary FundILOInternational Labour OrganizationITUInternational Telecommunication UnionJAGESJapan Gerontological Evaluation StudyLMICsLow- and Middle-Income CountriesNCDNon-Communicable DiseaseNGONon-Governmental OrganisationOECDOrganization for Economic Cooperation and DevelopmentPPEPersonal Protective EquipmentSAPSocial Amelioration ProgramSDGsSustainable Development GoalsSPRPStrategic Preparedness and Response PlanTHBThai BahtUKUnited KingdomUNUnited NationsUNDPUnited Nations Development ProgrammeUNFPAUnited Nations Population FundUSUnited StatesUSDUnited States DollarsWHOWorld Health Organization1. Changes in regional context COVID-19 disease situation and trendsSo far, most Asia Pacific countries are faring better than the global average in the fight against COVID-19. Scores of countries in Europe, the Americas and Eurasia have higher cumulative tolls than most of Asia Pacific – an important exception being India. Based on data from the first week of August, the US, Brazil and India account for 61 per cent of total new cases and 50 per cent of new deaths in the world. By then, only 19 per cent of countries in Asia Pacific had community transmission compared to 44 per cent of countries in Europe and 60 per cent of countries in the Americas. Most ASEAN countries along with Mongolia, Bhutan, Sri Lanka, and Papua New Guinea are among the list of countries with the lowest cumulative cases and deaths per 1 million population.The vast majority of confirmed cases are concentrated in a small number of countries. In Asia Pacific, India accounts for over 80 per cent of confirmed new cases, and a handful of countries account for almost all of the rest: the Philippines, Iran, Bangladesh, Indonesia, Japan and Pakistan. Cases and deaths per million vary substantially. Per Table 1 below, based on WHO-released data, Singapore has had the most cases per million in the region (but a low death rate), while Iran has had the most deaths per million, in both cases followed by Maldives.Table 1: Highest cumulative cases and deaths per 1 million population in Asia Pacific (as of 7 August 2020)CountryCumulative cases per millionCumulative deaths per millionSingapore9,3254.6Iran3,811214Maldives8,65135Bangladesh1,51620India1,46830Philippines1,09020Nepal74613Indonesia43420Japan34627Even within countries, the caseload is typically clustered rather than evenly distributed. In Indonesia, for example, over half of all active cases are currently on Java, with Jakarta having the highest cumulative cases per 1 million population. In the Philippines, over half of all active cases are in Metro Manila with another quarter of all cases in the provinces of Central Visayas and Calabarzon. In India, 65 per cent of active cases are in just 5 of its 35 states, particularly Maharashtra. Figure 1: Rolling 7-day average of new confirmed cases, selected Asian countriesCOVID-19 will remain a threat to the region, and there are many unknowns. Various countries continue to experience waves and peaks of the virus. Countries such as Bangladesh, India, Philippines, Nepal, Indonesia, and Japan currently present a concern given their continuing high numbers of daily new cases (see Table 1 for details). The COVID-19 data may be just the tip of the iceberg: the actual number of COVID-19 cases and deaths are probably significantly higher, especially where the rate of positive results from testing is high. Data on excess deaths is showing a shocking increase in deaths in places with outbreaks, such as in Jakarta where 50 per cent more deaths (5000+ per month) occurred in March-May, indicating that COVID-19’s impact on mortality may be much greater than what is currently recorded as confirmed deaths., A large unresolved question is the degree to which COVID-19 is spread by pre-symptomatic or asymptomatic cases., Given the ongoing threat, in early August the UN Emergency Committee on COVID-19 warned of a lengthy pandemic duration with far-reaching impact for decades to come, requiring continued efforts from governments, communities and individuals. Socioeconomic trends?Public health measures to curtail spread of COVID-19 are shaping economies and societies. New public health steps have upended the economy, jobs and everyday life. With varying degrees of success, governments have introduced contact tracing, quarantine, physical distancing measures and broad lockdowns to control COVID-19. While national lockdowns, common across much of Asia Pacific in March to May, have eased, local lockdowns are sometimes being reinstated to address outbreaks. For example, Metro Manila went back in lockdown in an attempt to curb the outbreak there. Border closures and international travel restrictions remain nearly universal, impacting tourism and other sectors reliant on global travel. Thailand, for example, has done well in controlling the spread of the virus and has eased its domestic lockdown; but its official GDP forecast is among the worst of the main economies of Asia, partly because its heavy reliance on international tourism. Having downgraded their April forecasts, multilateral agencies remain pessimistic about economic growth prospects. In June the Asian Development Bank (ADB), World Bank and International Monetary Fund (IMF) all sharply reduced their economic growth projections. For example, the ADB cut its forecast for 2020 regional growth from 2.2 per cent to just 0.1 per cent. East Asia is the only subregional economy expected to grow this year (by 1.3 per cent). This projection is dominated by China’s partial rebound, but some of the subregion’s economies (e.g. Malaysia, the Philippines and Thailand) are expected to decline sharply. South Asia is forecast to contract by 3.0 per cent in 2020. Hit first by the pandemic, Asia and the Pacific accounted for approximately 80 per cent of the global reduction in working hours during the first quarter of 2020, and the decline for the second quarter was 13.5 per cent. Economic growth across all subregions is expected to rebound in 2021, but much depends on the trajectory of the pandemic. As the World Bank says: “Even this bleak outlook is subject to great uncertainty and significant downside risks.” As the pandemic has expanded from Europe and North America to low- and middle-income countries (LMICs), poverty projections have gone up. The World Bank estimates that COVID-19 will push 71 to 100 million people into extreme poverty, measured at the international poverty line of USD 1.90 per day, depending on assumptions about economic growth. Even with growth returning in 2021, the World Bank projects that the number of people living in extreme poverty may remain mostly unchanged between 2020 and 2021. This is mainly because countries experiencing the heaviest concentration of extreme poverty, including India, may not have sufficient economic growth to keep up with population growth. (The Special Rapporteur on extreme poverty and human rights believes we aim too low, and criticises the practice of “single-mindedly focusing on the World Bank’s flawed international poverty line.”)48539401477645Many agree that a “return to ‘business as usual’ is unimaginable in a region already off-track” to meet the Sustainable Development Goals.00Many agree that a “return to ‘business as usual’ is unimaginable in a region already off-track” to meet the Sustainable Development Goals.There is extensive global speculation on whether the post-COVID world will be better or worse, but growing consensus that a return to the status quo ante is not the goal. Some observers highlight the threats emerging in the COVID-19 era. Others stress optimistically that the crisis is an opportunity to “build back better” and tackle big challenges such as inequality and climate change. Whatever their outlook, many agree that a “return to ‘business as usual’ is unimaginable in a region already off-track” to meet the Sustainable Development Goals (SDGs)., Seeing the alarming risks to the SDGs due to the pandemic, some UN and other voices have expressed an increasing sense of urgency. Stating that inequality “defines our time”, the UN Secretary General issued a “stinging” call for a “New Social Contract” and a “New Global Deal” to ensure power is shared more fairly at the international level. The United Nations Development Programme (UNDP) has called for a Temporary Basic Income for a staggering 2.7 billion people. The Special Rapporteur on extreme poverty and human rights suggests that the SDGs are failing in key areas and therefore “need to be recalibrated in response to COVID-19, the ensuing recession, and accelerating global warming.” From such perspectives, the main trend to watch may no longer be whether life returns to normal but whether actions by governments and others aim to be transformative.??2. The situation of older persons This section groups both direct and secondary impacts of COVID-19 broadly into three categories: (1) impact on health and care, (2) impact on income and (3) impact on social issues. It builds on the previous Asia Pacific Regional Report, from June 2020, which can be found here.The simple definition of older persons – based on chronological age (years since birth) – hides the diversity among this population group. That diversity in later life – and the wide range of impacts arising from the pandemic – may be illustrated by categorising some of the interrelated factors that determine an individual’s life experience: 394081046990Local environmentNational contextPersonal circumstancesPersonal characteristics00Local environmentNational contextPersonal circumstancesPersonal characteristics(1) Personal characteristics: For instance, a person’s underlying health conditions, functional capacity, gender, ethnicity and the personal imprint of advantages or disadvantages accumulated across the lifecourse, or even inherited characteristics.(2)?Personal circumstances: Interacting with personal characteristics are the individual’s household and immediate circumstances, such as living arrangements; COVID-19 safety practiced by the family; household wealth; and the presence or absence of friends, caregivers or, alternatively, abusive persons. (3)?Local environment: This includes local COVID-19 transmission rates and clusters, local compliance with safeguards, population density, the strength of community services, and accessible environments. (4)?National context: In the pandemic, individuals are also affected by national COVID-19 and other policies and programmes; the existence and strength of healthcare, long-term care, pension and other national systems; and societal attitudes.Depending on the mix of factors, an older person’s experience during the pandemic may be relatively untroubled or severe or – more often – somewhere in between the extremes. Health and care4747895377494Older people living in Thailand, for example, currently have virtually no risk of contracting COVID-19, while those living in India, particularly in an outbreak area, have much higher exposure.00Older people living in Thailand, for example, currently have virtually no risk of contracting COVID-19, while those living in India, particularly in an outbreak area, have much higher exposure.COVID-19 has reached only a small fraction of the older population, with their risk closely tied to location, but indirect effects on health are much more wide reaching. As noted above, most countries in the region have so far escaped worst-case pandemic scenarios. With three million cases in Asia so far across all age groups, it is clear that direct risk of infection for the hundreds of millions of older people living in the region is relatively limited to date. Because of the uneven spread of COVID-19, older people living in Thailand, for example, currently have virtually no risk of contracting COVID-19, while those living in India, particularly in an outbreak area, have much higher exposure. However, the most significant effects on the health of older people are not the direct effects from the virus. The far-reaching social, economic and indirect impacts on health are a bigger concern, as discussed below. The exact effects and their scope are more difficult to discern without more research.Mortality from COVID-19 increases with age, but younger age groups are a large proportion of deaths in middle-income countries. The spread of COVID-19 in countries with younger populations and poorer overall health status has increased the overall proportion of cases and deaths among younger people., Thus, the proportion of older people among COVID-19 cases and deaths is 47688504762595 per cent of confirmed COVID-19 deaths in Japan are among those over the age of 60, while in Indonesia this group accounts for just 40 per cent of deaths.0095 per cent of confirmed COVID-19 deaths in Japan are among those over the age of 60, while in Indonesia this group accounts for just 40 per cent of deaths.lower than original assumptions based on the experience of high-income countries (HICs).,, Increased testing and better contact tracing have increased the number of known asymptomatic, pre-symptomatic and mild cases. Regarding mortality, as a comparison, 95 per cent of confirmed deaths in Japan are among those over the age of 60, while in Indonesia this group accounts for just 40 per cent of deaths., In India as elsewhere, mortality rises with age, yet much less sharply compared to HICs such as Japan. India reports 39 per cent of COVID-19 deaths among people aged 60-74 (who are only 8 per cent of the population) and 14 per cent of deaths among those over the age of 75 (who are just 2 per cent of the population). In the Philippines, 61 per cent of deaths are among those over age 60 and 28.6 per cent of deaths are among those aged 40-59 (see Figure 2 below). Figure 2: Philippines – Cases, recoveries and deaths by age and sexOlder people living in large households are at increased risk of infection., As highlighted in the previous report, Asia Pacific household sizes are larger, on average, than household sizes in Europe and North America. The risks of within-household transmission are high in countries where large extended households are common. These households face added risks due to the closing and opening of schools in areas where an outbreak is occurring. Physical distancing measures within the home have been recommended by countries including the US and the UK, especially for households with members who belong to high-risk groups., Of particular concern are the vast majority of people with care support needs who live at home and receive care from family members, often requiring close personal contact.The secondary impacts of the pandemic on health and health systems affect many older people in Asia Pacific, even in countries with few COVID-19 cases. This is due to reallocation of resources, reduced access to health services, and reduced demand for critical health services. Other unintended effects arise from lockdowns, distancing and other public health measures, resulting in reduced incomes, increased food insecurity, and changes to lifestyle and behaviour. Other health concerns – associated for example with non-communicable diseases (NCDs) and the need for care support – have a much larger impact on mortality than COVID-19 does at present. These challenges interact with pre-existing weaknesses in health systems in countries such as Nepal, India, Myanmar, Cambodia, Indonesia and the Philippines.Some COVID-19 public health measures have the unintended effect of reducing access to health services for issues of concern to older people. Included among these are services for the prevention and management of NCDs, rehabilitation services, hospital care, and semi-essential or non-essential health treatments. In countries where COVID-19 is largely under control, health services are returning to normal, while services in outbreak areas continue to be compromised. A survey of public and private hospitals in seven countries in the second half of June found that hospital in-patient capacity was still significantly affected in India, Indonesia and Philippines, where COVID-19 outbreaks are occurring. Elective and semi-elective but still crucial procedures – such as structural heart, vascular, and lung/pulmonology procedures – are delayed or occurring at significantly reduced volumes across the region. Movement control or travel restrictions and patients’ fear of visiting hospitals due to infection risk also limit access to services, as do limited hospital capacity and government directives. In Thailand and Vietnam, where COVID-19 cases were brought under control, a surge in health care use for chronic and elective procedures, particularly related to NCDs, followed the lockdown. right1080770Disruptions to NCD services are occurring in 122 of the 165 countries surveyed.00Disruptions to NCD services are occurring in 122 of the 165 countries surveyed.A survey of the impact of COVID-19 on NCD services conducted by the World Health Organization (WHO) and Ministries of Health also demonstrated that disruption of health services has been widespread. Of 163 countries surveyed in May, disruptions were occurring in 122 countries. A clear correlation was found between the level of COVID-19 outbreak in the country and the disruption of services including hypertension management and the treatment of diabetes, cancer and cardiovascular emergencies. Similar to the hospital survey discussed above, the WHO survey found the reasons for disruption included cancellation of elective care, closure of population-level screening programmes, movement restrictions, redeployment of staff to provide COVID-19 relief and insufficient personal protective equipment (PPE) available for health care providers. In their COVID-19 plans, 66 per cent of countries have included continuation of NCD services and 17 per cent have allocated additional funding to support NCD health services. The longer-term secondary impacts of COVID-19 on individual health are unknown. There are concerns that reduced physical activity, increased social isolation, increased stress and anxiety, and insufficient income may be linked with negative impacts on physical health, functioning, mental health and cognition.,, It is not clear if these impacts will have any lasting effects on health or health behaviour once lockdowns are lifted. Research has begun on potential long-term health consequences for those who recover from COVID-19: some evidence is emerging about impacts on brain, heart, lungs, kidneys and even dementia.,, On a positive note, at least in the short term, per capital consumption of alcohol and soft drinks in Asia are significantly down due to lockdowns and closures of restaurants, bars, theatres and other large venues.,, Air pollution – linked with NCDs, reduced life expectancy and more severe COVID-19 cases – decreased dramatically during lockdowns.,, One frustration is the typical exclusion of older age groups or the lack of age-disaggregation in the few surveys and studies being conducted on these topics. Until robust surveys are completed, much of what we presume about COVID-19 impacts comes from extrapolation of pre-COVID-19 research, along with smaller studies. As an example, consider the relationship between COVID-19 and dementia. There are reports of COVID-19 cases among people with dementia being severe and that dementia is one of the underlying factors with the greatest links to mortality from COVID-19., There is also the suggestion that the effects of COVID-19 on the brain may lead to increased risk for developing dementia over the long term. A new meta-analysis on modifiable risk factors for dementia concludes that at least 40 per cent of dementias are preventable. Some of those factors like low social contact and low physical activity, and others related to NCDs, are likely worsened by the pandemic crisis and may well lead to the development or acceleration of dementia., The true secondary health impacts of COVID-19 on older people, and future older people, may not be known for some time. But existing evidence is sufficient to guide policy and practice for health systems and COVID-19 recovery plans.Income security474789522035Older people’s economic wellbeing is intimately tied to that of their households and national economies.00Older people’s economic wellbeing is intimately tied to that of their households and national economies.No older person is an island. Evidence on older people’s income security during COVID-19 highlights the following: Whether in paid work or not, their economic wellbeing is intimately tied to that of their households and national economies, and that income security requires comprehensive and well-designed social protection. While age-disaggregated poverty data is lacking, older people’s loss of income from work, struggling families with fewer resources to share, and pension systems with low coverage and benefits mean that many older people will be part of the 71 to 100 million people pushed into extreme poverty, as predicted by the World Bank.As the pandemic continues, the resulting economic crisis drives up unemployment and reduces incomes of older people and their households. In Vietnam, a country that is generally considered to have so far weathered the crisis well, more than half of workers report having been negatively impacted by COVID-19. On average, they experienced a 10 per cent decline in their incomes compared to the same quarter of 2019. Family support represents the biggest source of income for older people in Vietnam, so this decline will likely reduce the ability of households to provide financial support to older people. For about a third of older Vietnamese, however, work remains the most important source of income. About 80 per cent of them work in the informal economy, and informal workers experienced the most significant income decrease (at 8.4 per cent) in the second quarter. In India, a nationwide survey conducted by HelpAge India in June 2020 found that the economic crisis has negatively impacted the livelihoods of 65 per cent of older people. Furthermore, 71 per cent of older people reported that the livelihood of the main income earner in their household has been impacted. In Japan, the jobs crisis disproportionally affects older workers. As the country recorded a decline in employment from March to April 2020, the greatest drop was seen among those aged 65 and older. In previous recessions, older people often were the first to lose their jobs and the last to re-gain employment. Following the 2008 Great Recession, unemployment for older and younger workers skyrocketed everywhere. Many lost stable employment and found themselves in precarious work with lower earnings. However, older workers needed longer to find new work. Evidence from OECD countries further suggests that older workers do not just experience, on average, longer unemployment after a crisis. They are also more likely to face declines in job quality after re-employment, which are more persistent than that for younger workers. The International Labour Organization (ILO) therefore warns that older workers, as well as younger workers and those in less protected and low-paid jobs, will be disproportionately affected by the COVID-19-induced jobs crisis. Most older people in Asia Pacific work in informal or non-standard employment and are therefore highly exposed to the economic crisis. In the region, 86 per cent of older people’s (65+) work takes place in the informal economy, rising to 98 per cent in South Asia. Informal employment tends to provide lower and more irregular incomes, does not provide social protection benefits or ensure health and safety in the workplace. “Non-standard employment” generally means employment that is temporary, facilitated by employment agencies, or part-time. In Japan, the drop in employment in the second quarter of 2020 was mainly among family workers, self-employed, temporary and part-time workers who lost their jobs (see figure below). In most Asian countries, formally employed older people are likely to work in such non-standard employment conditions. A result of older people’s overrepresentation in non-standard employment is that they are often relatively easy to let go during an economic downturn. Figure 3: Change in employment status of workers aged 65 years and above in Japan between the 4th quarter of 2019 and the 1st quarter of 2020Persons with disabilities are particularly at risk to lose income and participation provided by employment. Particularly in ageing societies, disability is increasingly associated with older ages. Workers with disabilities are less likely to be in employment, have decent employment conditions, work in the formal economy and receive social protection as compared to persons without disabilities. In the region, ESCAP research indicates that the difference in poverty rates between persons with disabilities and the general population can be as high as 20 per cent, and persons with disabilities are two to six times less likely to be employed than those without disabilities. This high level of poverty and marginalisation increases both the vulnerability of persons with disability in the COVID-19 crisis and the potential for discrimination. Disability rights organisations in Myanmar, for instance, report that workers with disabilities are often the first to be let go during a downturn and therefore face much greater economic uncertainty during the pandemic. The economic crisis also threatens companies’ disability inclusion activities. In a survey of members of the ILO’s Global Business and Disability Network, one third of companies reported that their disability inclusion activities would be affected.In some contexts, the return of large numbers of migrant labourers to rural areas can create pressures on older people’s livelihoods. In India, more than 100 million internal migrant workers were forced by COVID-19 measures to travel long distances to their rural home villages. This influx of people looking for livelihoods could pose challenges to established livelihoods of older people. For instance, in the Indian state of Kerala, older people (65+) have been excluded from accessing the guaranteed 100 days of employment under the Mahatma Gandhi National Rural Employment Guarantee Act, as implementers expect a surge in demand from younger migrant workers returning to rural areas. While people are legally entitled to receive compensation if work is not provided on demand, such allowance will be given only at the end of the year.right1627632According to the ADB, from the drop in remittances, the “greatest concerns arise among households of older persons or households with no income earner”.00According to the ADB, from the drop in remittances, the “greatest concerns arise among households of older persons or households with no income earner”.Remittances are expected to drop, contributing to reduced incomes of older persons’ households in some countries. Remittance inflows are general considered countercyclical, meaning that migrants tend to send more funds when their families face economic shocks or disasters. COVID-19, however, is different from more localised crises as it is simultaneously hurting migrant source and origin countries. Therefore, while some migrant workers might send more money to their families who are in extremely difficult circumstances, the global nature of the economic crisis points toward declining remittances over the medium term. As the economic crisis threatens the livelihoods of over 91?million international migrants from Asia Pacific, remittances to the region are expected to drop by between USD 31.4 billion and USD 54.3 billion in 2020, equivalent to 11.5 and 19.8 per cent of baseline remittances. According to the ADB, the “greatest concerns arise among households of older persons or households with no income earner”. In the Philippines, for example, the highest prevalence receiving remittances is among senior citizens, at over 21 per cent. Remittance inflows to the Philippines are projected to fall by 23 to 32 per cent in 2020, reducing household spending per capita by 2.2 to 3.3 per cent. The relative increase in remittance inflows in June 2020 in some countries, such as Bangladesh, may therefore not be sustained. Such temporary bumps result from the lifting of lockdowns and the introduction of policies that incentivise transfers by reducing restrictions and transaction fees. In this crisis, access to social protection can be matter of survival, but some emergency programmes are not accessible to older people. A global survey conducted by HelpAge revealed a wide range of challenges for older people to access social protection during COVID-19. In June 2020, HelpAge staff and network members working on social protection in 18 countries worldwide (including India, Pakistan, Bangladesh, Philippines, Sri Lanka, Nepal, Vietnam and Myanmar) were asked whether older women and men, and older people with disabilities, face any challenges in accessing social protection during COVID-19. In broad terms, the challenges identified can be classified into two groups: (1) Those relating to the rapid implementation of large-scale cash transfers to broad segments of a country’s population, which insufficiently consider the needs and capacities of specific groups, such as older people of people with disabilities, and (2) a reliance on ineffective and exclusionary pre-existing programmes as the foundation for a country’s social protection response to COVID-19. Of the latter, the social pensions in India and the Philippines are chronically delayed and therefore do not provide timely protection during this crisis. In the Philippines, for instance, the pay-out of 2019 pension benefits only happened in some regions after three months of lockdown. Various constraints have excluded many older people from the first wave of COVID-19 cash transfers in Asia Pacific. In principle, many older people should be eligible to access emergency cash transfers that are not targeted at particular groups but rather broad segments of populations that have been made poorer by COVID-19. Yet among the countries included in HelpAge’s survey, older people often struggled with digital enrolment and payment systems that rely on Internet access or mobile phone ownership and capacity to use. To be able to access programmes, older people reportedly relied on neighbours and relatives for help, which in some cases opened opportunities for theft. In addition, the need for physical registration and the inconvenient location of paypoints created access challenges for older people, especially those from rural areas or with disabilities. Long queues at banks and welfare offices, lockdowns and lack of public transport, and fear of infection in places without physical distancing also blocked older people from accessing benefits. Finally, respondents reported the lack of a dedicated communication campaign targeted towards for older people and people with disabilities, as well as limited community involvement in outreach. Coupled with eligibility criteria and guidelines that are perceived to be unclear, the lack of accessible and targeted information campaigns left many older people unaware or confused about their eligibility and how to register. Older people’s challenges in accessing other cash transfers highlight the importance of pensions, though benefit levels of social pensions are typically inadequate. While 77 per cent of older people in East Asia receive a contributory or non-contributory (social) pension, only 55 per cent in Asia Pacific as a whole do. In South Asia, coverage is the lowest, with only 23 per cent receiving any pension. The average social pension in Asia has a transfer value of only 12 per cent of citizens’ average income; countries such as China and India (2 per cent) and Thailand (4 per cent) provide much less. The COVID-19 induced economic crises makes this inadequacy apparent. For example, in the Indian state of Odisha, 40 per cent of India’s Old Age Pension recipients spend their entire four-month advance payment in the first weeks after receipt. Social issuesEvidence via government administrative data on social issues such as discrimination, ageism and abuse is limited. Evidence is particularly sparse and slow to emerge for populations in precarious circumstances, such as displacement, statelessness, undocumented migration or proximity to conflict. The evidence may come out only gradually through new research initiatives, which have mostly been disrupted owing to pandemic restrictions. Thus, much of the analysis on the social impacts of the pandemic on older people in Asia Pacific is based on certain assumptions, often reasonable but not fully tested, that draw on historical evidence or data from other contexts or population groups. The pandemic has exposed the fine line between highlighting older people’s social vulnerabilities and reinforcing ageist perceptions. There is a risk that “chronologically-based policies and official statements reinforce old age as vulnerable and dependent, thereby sustaining ageism.” A narrative of decline based simply on chronological age may contribute not only to negative attitudes about later life across society but specifically among older people themselves. right60960The pandemic has sometimes disempowered older people and altered family dynamics.00The pandemic has sometimes disempowered older people and altered family dynamics.Pandemic migration is having multiple impacts on older people in some places, which need further investigation. COVID-19 has resulted in substantial domestic migration (“reverse migration”) in many countries, India prominent among them, and the return home or job loss of international migrants. Regarding international migration, the migrants themselves tend to be younger. In countries with high numbers of COVID-19 cases, persons aged 65 years and older generally represent a lower proportion of international migrants compared to their share in the general population. (India and Pakistan are exceptions.) Yet even if they are not the migrants, older people may be indirectly affected in various ways by both domestic and international migration. This includes impacts associated with migrants’ return to households with older members, including a rise in household expenses combined with loss of remittance income. Aside from economic and other risks, the social impacts of migrant returns (for example, on incidence of social isolation or abuse) are less clear and presumably more variable by circumstances. 47561505308958 per cent of assessment respondents said they feel worried and anxious, and 42 per cent depressed, either all or most of the time because of the COVID-19 situation.0058 per cent of assessment respondents said they feel worried and anxious, and 42 per cent depressed, either all or most of the time because of the COVID-19 situation.Many older people are harmed by social isolation during the pandemic restrictions. Exceptional formal and informal restrictions on movement have left many older people feeling isolated and excluded. As noted above and in the Japan Analytical Brief accompanying this report, isolation can seriously compromise older people’s health. From field observation, HelpAge India reports that the pandemic has sometimes disempowered older people and altered family dynamics, with families controlling their movements outside the house. A petition was even filed against the Government of India’s restrictions on the movement of senior citizens, claiming it could push them into depression. Isolation during the pandemic has indeed affected older people’s psychological state. Older people interviewed in Iran shared their anxiety about the reduction in visits with family, as well as concerns about the health of their children and phobias about the virus stemming from media reports. In rapid needs assessments carried out by HelpAge and its network members in seven Asia Pacific countries, 58 per cent of respondents said they feel worried and anxious, and 42 per cent depressed, either all or most of the time because of the COVID-19 situation. With face-to-face social interactions often shut down during the pandemic, older women and men who do not use ICT fluidly are now at a disadvantage. The digital divide is being examined as a source of inequality in social connectedness, as well as aspects of work (see above) and even safety. On average, although increasing, older people’s usage of ICT is lower than younger people’s. For example, ESCAP analysis of survey data from the International Telecommunication Union (ITU) suggest that less than 10 per cent of older people have access to the Internet in Cambodia, Indonesia, Pakistan and Thailand. Even in a tech-savvy HIC such as Singapore, fewer than half of older people surveyed were comfortable using technologies that are locally ubiquitous, such as having video conversations with family or scanning QR codes. A gender divide is also clear. Women of all ages in LMICs are 20 per cent less likely than men to own a smartphone, and the gender gap in mobile Internet use is 51 per cent in South Asia. Such gaps may also hinder access to services, such as telemedicine or electronic cash transfers.However, it is not yet clear that older people in Asia Pacific, defined by the sole criterion of age, necessarily face exceptional risk of social isolation or loneliness. Much of the global population, of all ages, is suffering from the effects of lockdowns and physical distancing steps. Some global evidence suggests that many active older people are relatively resilient in the pandemic. In the UK, younger groups have reported substantially higher rates of “lockdown loneliness” than older people. Diversity among older people may not be well reflected in blanket statements. Living arrangements and personal circumstances contribute to variations in social isolation. For example, many people living in residential care homes have suffered severely from restrictions that cut off visits from family and others, as the Republic of Korea Analytical Brief (accompanying this report) illustrates. But beyond a few HICs such as Japan, living in care homes is fairly uncommon in Asia Pacific, as noted earlier. Multigenerational coresidence is still more common. Changing living arrangements are an important dynamic. A growing number of older people live alone, although many live nearby family. The Iran Analytical Brief documents how living alone and household headship among older people have increased in recent years. In Singapore, a population-representative monthly survey of people aged 55 to 75 found the general increase in feelings of social isolation in April particularly sharp among those who live alone. Yet for many families, strict lockdowns, school closures and reverse migration may have led to increased social interaction within multigenerational households, but disrupted social and religious networks beyond the home. Research is needed to allow more nuance and disaggregation. The risk of elder abuse has risen during the pandemic, but evidence of abuse is likely to remain patchy and largely anecdotal. COVID-19 has clearly raised new challenges for older people facing abuse, arising for example from the restrictions on movement and the suspension of family visits in care homes. Older people themselves seem aware of the heightened risks. HelpAge’s rapid needs assessments in seven countries (see above) found that most older people feared that abuse had increased during the pandemic, particularly emotional and psychological abuse. In India as well, through an online survey of 5000 older people by Agewell Foundation in June, 71 per cent of respondents said that cases of elder abuse had increased during the lockdown. Such fears may partly reflect media stories of family abandonment of older parents having COVID-19 appearing in Bangladesh, India and other places. WHO suggests a “10x increase in abuse and neglect of older people in some settings” based on data from media reports. Yet experience related to violence against women and children suggests “it is nearly impossible to identify meaningful changes based on simple month-to-month reporting from administrative data”. There is a risk of assuming that Asia Pacific simply mirrors the experience of North American and Europe, where there is more evidence on abuse. For example, British charity Hourglass reported a 25 per cent increase in calls to their confidential helpline relating to neglect, after the lockdown started. But many of these calls were apparently related to neglect in care homes, which in Asia Pacific are much less common. In some parts of Asia Pacific, it is possible that lockdowns, school closures and return migration may actually have temporarily reduced instances of neglect at home but increased other forms of abuse. The situation remains unclear.right43815The pandemic highlights the pre-existing “deficit in reliable and comprehensible data” on women aged 50 and older.00The pandemic highlights the pre-existing “deficit in reliable and comprehensible data” on women aged 50 and older.The pandemic is another reminder that older women are largely invisible in discussions of gender-based violence (GBV) – and gender as a whole. Historical evidence and COVID-19 commentary are reminders that emergencies, especially those that involve quarantine, escalate risks of violence against women. However, it is rarely clear how many of those women are older women, who may be especially cut off because of their heightened mortality risk from the virus. Systematic data collection inclusive of older women is weak. Gender-focused evidence, initiatives and institutions tend to focus on girls and women of reproductive age. Data collection often stops at age 49, including in Demographic and Health Surveys administered in more than 90 countries. The pandemic thus highlights the pre-existing “deficit in reliable and comprehensible data” on women aged 50 and older. In addition, women’s unpaid care responsibilities for older people are often cited, but less often the care roles played by older women themselves. The Vietnam country brief suggests that COVID-19 may have required older women to expand their care role – for example, for grandchildren not in school. The pandemic is fueling debates around intergenerational fairness in North American and Europe, but those divisions seem more muted in Asia Pacific. Medically, the pandemic is having the biggest impact on older generations, but some in the West believe younger generations will pay the biggest economic cost. These public debates appear to be elevating intergenerational tensions in some countries. Such generational framing appears to resonate less well in Asia Pacific. Compared to HICs, in Asia Pacific’s LMICs the combination of a proportionately smaller COVID-19 mortality impact on older people and historically lower social investment in ageing may limit intergenerational tensions. While the patterns in Asian HICs are different, many observers have also highlighted approaches that promote societal cohesion across both HICs and LMICs in many Asia Pacific societies. These approaches may discourage public discussion of generational winners and losers. Nevertheless, where scarce medical resources are under pressure during the pandemic, debates about intergenerational fairness (for example, with triage) may emerge. 3. Responses addressing the older populationResponses to the challenges older people face as a result of the pandemic and its aftermath come from a number of sources. Despite the current higher global profile of older people because of their risk from COVID-19, actions directly targeted at older people have been limited in national response plans. A broad regional overview of emerging responses in Asia Pacific is presented below, grouped by four main types of actors: (1) national governments, particularly in relation to health care and social protection, (2)?multilateral bodies including the UN and development banks, (3) civil society organisations including community-based groups, and (4) the private sector. Given the wide diversity in responses across the region, this is not a comprehensive mapping but a broad overview of some key ernmentHealth/careThe most universal government measures are those to prevent transmission of COVID-19 and to protect older people along with the whole population. With contact tracing, testing and some physical distancing measures still in place, some countries including China, Japan, Republic of Korea, Thailand and Vietnam have been able to resume life more or less as normal, even when small local outbreaks occur. A large proportion of new cases in countries in such situations are from people repatriating and going straight into quarantine. A recognition that migrants, refugees and non-citizens are among the highest at risk of COVID-19 led to free testing and treatment for these groups in some countries including Cambodia, Malaysia, Thailand and Singapore. In countries with ongoing major outbreaks, such as the Philippines and India, governments are struggling to balance public health and economic risks. They have seen acceleration of outbreaks after lifting of stringent lockdowns.Just a handful of countries in the region have introduced various forms of support for health insurance as part of their COVID-19 response. Indonesia, which has been working towards universal health insurance, allocated USD 200 million to fund contributions to the national insurance scheme (Badan Penyelenggara Jaminan Sosial, or BPJS) for 30 million non-salaried workers. The Republic of Korea, the Philippines and Thailand reduced health insurance premiums for individuals who self-contribute. Also, health insurance in the Republic of Korea and the Philippines will cover all COVID-19 health costs for healthcare workers, while Thailand’s covers all medical costs for everyone infected with COVID-19. right824599Several governments, including India and Indonesia, have issued new guidelines on the use of telemedicine during the past few months.00Several governments, including India and Indonesia, have issued new guidelines on the use of telemedicine during the past few months.Most HICs and upper-middle-income countries are trialling or scaling up telemedicine. The promises of telemedicine include increased access to quality health care especially for rural and remote areas. It can also reduce strain on health facilities by resolving many issues through online care. In the time of COVID-19, telemedicine offers a safer way to receive health consultations. Telemedicine use and growth are uneven across the region and led by HICs such as Japan and Singapore, where telemedicine is already part of the health service landscape. Upper-middle-income countries in this region are also seeing a surge in telemedicine because of COVID-19. Several governments, including India and Indonesia, have issued new guidelines on the use of telemedicine during the past few months., Hospitals are increasing telemedicine offerings, and private firms have seen huge increases in engagement and clients across many countries in the region.,,,, But telemedicine has limitations, and many older people are not telemedicine-ready. One constraint is that telemedicine infrastructure is not widely in place in most countries in the region. As telemedicine is being led by the private sector in LMICs in the region, there are also concerns about health equity. Beyond these issues, there is the question of how ready the public is for telemedicine. Readiness includes having Internet access and skills, a further barrier for those with lower incomes and levels of education. Older people on average are more likely than other groups to face challenges accessing telemedicine because of lower rates of Internet access and skills, lower levels of education, and higher rates of disability including hearing, sight, cognitive and speech difficulties. Even in a HIC like the US, a study during the last few months reported that 38 per cent of people over the age of 60 (and 72 per cent of those over age 85) were not ready for video visits and 20 per cent would not be able to use telephone visits. Telemedicine is therefore unlikely to be a full solution to bridging gaps in health services caused by COVID-19 for most older people in the near term, but may over time improve access to health care for many.Efforts are being made to address the risks and needs of those who receive care support, though mainly for the minority receiving formal care services. Governments with established formal long-term care systems such as Japan, Singapore and Republic of Korea have established guidelines and support measures to mitigate the spread of COVID-19 within care homes and to support continuity of services, even with physical distancing in place.,, Countries with mostly private service providers are increasingly expanding government oversight through mandatory testing and/or guidelines for caregivers., In India, guidelines issued in March by the Ministry of Social Justice and Empowerment recommended that caregivers be issued passes to allow them to travel during lockdown. In Malaysia, staff in non-government day care centres have continued support to their clients through video calls and online support. In India, NGOs have developed information and resources for people living with dementia and their caregivers. However, for the vast majority of older people with care needs and their family carers, there has been little government or private support. Some governments initiatives respond to the psychosocial strain of COVID-19. As documented in the India Analytical Brief accompanying this report, India offers a number of examples, often blending government and community action. For example, the Government of Kerala’s poverty eradication and women empowerment mission, Kudumbashree, has mobilised its three-tier structure comprising Neighbourhood Groups, Area Development Societies, and Community Development Societies. These actors raise awareness about care during the pandemic; enlist resource persons to call older people living with family to check on their health; engage community counsellors to provide mental support to older people; and set up community kitchens to ensure cooked meals are available to those who need them most. Social protection Social protection has been an integral component of almost every government’s early COVID-19 response. Between March and mid-July 2020, 200 countries and territories announced a total of 1,298 adaptations and expansions of their national social protection systems to protect livelihoods, people’s wellbeing and national economies from the impact of the pandemic. Total spending on COVID-19 related social protection has stabilised at about USD 589 billion or 0.4 per cent of the world’s GDP since June 2020. Yet almost all of this expenditure takes place in HICs. LMICs account for only about 14 per cent of the total, and low-income countries spend just USD 301 million. Committing USD 167 billion (or USD 137 per capita), East Asia and the Pacific vastly outspends South Asia’s USD 24 billion and USD 3 per capita. Social assistance remains key. Globally and in Asia Pacific, social assistance constitutes 75 per cent of all responses, and about half of those are cash transfers.The East Asia and the Pacific sub-region expanded coverage of cash transfers by twice as much as South Asia. Before the crisis, 16 per cent of the total population in East Asia and the Pacific and 15 per cent in South Asia received a cash transfer, which include social pensions as well as conditional and unconditional cash transfers. In East Asia and the Pacific, governments expanded cash transfers to an additional 44 per cent of the population (reaching 60 per cent in total). South Asia increased coverage to an additional 21 per cent of the population., Figure 4: Asia-Pacific countries with social protection responses to COVID19Figure 5: Number of announced new social protection measures in Asia-Pacific, by monthNote: Colours in Figure 4. range for minimum number of measure (light blue) to maximum (dark blue)Most of the newly introduced cash transfers and expansions of existing ones are of short duration and, without policy changes, will expire soon despite the deepening economic crises. Globally, about 90 per cent of announcements to introduce cash transfers in response to COVID-19 were made between March and May 2020. Available information for 71 cash transfer programmes around the world suggests an average duration of slightly more than three months. Assuming that cash transfers are implemented in the month following the policy announcement, the majority of cash transfers are set to expire between July and September 2020. Their expiry is a concern because few new policy announcements have been made in Asia Pacific in June and July 2020, while the pandemic’s impacts remain severe in many countries. In July, a review found that out of 195 COVID-19 social assistance measures, 72 per cent were ongoing, 13 per cent planned and 14 per cent completed.4260850526902In Thailand, the THB 600 (USD 19) monthly minimum payment for the social pension is a mere 12 per cent of the country’s monthly emergency cash transfer of THB 5,000 (USD 160).00In Thailand, the THB 600 (USD 19) monthly minimum payment for the social pension is a mere 12 per cent of the country’s monthly emergency cash transfer of THB 5,000 (USD 160).COVID-19 era cash transfers are relatively generous, especially in contrast to pre-COVID-19 social protection for older people. Data from 71 countries globally shows that, on average, cash transfers represent 29 per cent of monthly GDP per capita. It is interesting to contrast social pensions and COVID-19 cash transfers. In Thailand, for instance, the THB 600 (USD 19) monthly minimum payment for the social pension is a mere 12 per cent of the country’s monthly emergency cash transfer of THB 5,000 (USD 160). This suggests that the social pension, whose minimum benefit level represents only about 25 per cent of the national poverty line of THB 2,710, has always been inadequate to ensure income security for older people. Despite substantial population ageing, only 13 Asia Pacific countries have so far adapted pension systems for older people as a COVID-19 response. Only Samoa has introduced a new social protection benefit specifically for older people, while Bangladesh, Mongolia, Sri Lanka and Samoa have expanded the coverage of existing social pensions. Ten countries in the region have increased pension benefits, five are advancing pension payments, and four have introduced rules allowing those enrolled in funded pension schemes to prematurely withdraw part of their funds. Table 2: Adaptations to pension systems in Asia Pacific (August 2020),Increased pension benefits Expanded pension coverageAdvancing pension paymentsAllowing access to pension savingsAustralia, Cook Islands, India, Malaysia, Mongolia, Myanmar, Samoa, Singapore, Tonga, ThailandBangladesh, Mongolia, Sri Lanka, SamoaAustralia, Fiji, India, Malaysia, SamoaAustralia, Fiji, Malaysia, SamoaNote: This table does not include the deferring, reducing or waiving of social security contributions as those steps do not provide direct income support for older people. COVID-19 has demonstrated the value of universal social protection systems. Experience from this and previous crises shows that countries with effective and comprehensive social protection systems are much better prepared to protect their citizens from socioeconomic impacts. Such countries are likely to have the institutional capacities and systems in place to scale programmes up relatively quickly. More comprehensive systems also require less scaling-up in the first place, as larger segments of the population are already covered and might require only increases in transfer levels. On the other hand, countries that lack robust systems may need to develop policies and interventions in an ad hoc way and build institutional capacity under difficult circumstances. That approach may lead to delayed or ineffective responses. The Philippines illustrates the challenges of moving rapidly towards a universal COVID-19 response on the basis of a residual system aimed only at the poorest. The country’s emergency social protection response, the “Social Amelioration Program” (SAP), has been massive, introducing one-off, near-universal coverage. The scale of the pandemic-related need pushed the government to go beyond its conventional focus on poverty-targeted social assistance. It therefore largely bypassed the country’s social protection system, which has been in place for over a decade and hailed as an example of shock-response social protection. Needing to develop a system quickly almost from scratch, the implementation of the SAP has been plagued by confusion and delays. For example, senior citizens have been excluded from the SAP because they are already entitled to a social pension. Yet the pension’s monthly transfer levels are far below the SAP levels of P5,000 (USD 102) to P8,000 (USD 163) and had, at the beginning of the lockdown, not been paid in months. right459282The World Bank’s Global Director for Social Protection and Jobs suggested that “COVID-19 highlights the importance of creating universal entitlements to health care and income support, in line with the ‘Universal Social Protection 2030’ goal.”00The World Bank’s Global Director for Social Protection and Jobs suggested that “COVID-19 highlights the importance of creating universal entitlements to health care and income support, in line with the ‘Universal Social Protection 2030’ goal.”COVID-19 is generating fresh appreciation for universal social protection. The recognition that the COVID-19 crisis calls for rapid progress towards universal social protection seems to be shared even by the World Bank and IMF, institutions often associated with advocating for narrow poverty targeting of benefits. In May 2020, the World Bank’s Global Director for Social Protection and Jobs suggested that it will no longer be acceptable for LMIC governments to have “fractured social protection systems where most people fall through the cracks,” and that “COVID-19 highlights the importance of creating universal entitlements to health care and income support, in line with the ‘Universal Social Protection 2030’ goal.” The IMF is even considering the pros and cons of short-term universal transfers to all in response to crisis. Although older workers may be among the most affected by the pandemic, they are often forgotten in the development of employment or recovery policies. While Vietnam, for instance, is implementing a number of economic recovery and employment promotion programmes, none is explicitly targeting older people or people with disabilities. Disability initiatives could point towards innovative solutions. For example, the Bangladesh Business and Disability Network is facilitating job matching services during the crisis for persons with disabilities who lost their job or are looking for their first job, and the Philippine Business and Disability Network is launching a reskilling initiative to help workers with disabilities acquire skills for post-crisis work.Multilateral bodies Financing for broad government responses continues to come from the multilateral development banks. They are providing substantial new financing or redirecting existing financing for COVID-19 interventions, including the emergency actions and health system capacity building. For example, the World Bank Group will provide USD 160 billion in financing globally over 15 months, reaching most LMICs. Of this total, USD 50 billion will be through International Development Association (IDA) channels, in the form of soft loans or grants. The ADB, IMF and other institutions are also providing additional financing to address COVID-19.Older people benefit, though mostly indirectly, via large international appeals coordinated by UN agencies. The three key components of UN response to COVID-19 are the Global Humanitarian Response Plan (GHRP); WHO’s Strategic Preparedness and Response Plan (SPRP); and the UN Socio-Economic Framework led by UNDP. The original USD 2.01 billion GHRP appeal was increased to USD 6.71 billion in early May and then to USD 10.3 billion on 16 July. The GHRP was just over 20 per cent funded as of mid-August. The private sector and philanthropic organisations also make substantial contributions to WHO’s pandemic response in particular. Tencent Healthcare announced a USD 10 million donation to WHO’s COVID-19 Solidarity Response Fund. If the United States withdraws from WHO, as announced, the Bill & Melinda Gates Foundation may become the agency’s top donor. These funding dynamics have raised questions about the influence of parties other than Member States on international health policy and programming directions. Some international bodies are gathering evidence related to older people’s concerns, but to a limited extent. As noted above, WHO’s Department for NCDs conducted a rapid assessment survey of service delivery for NCDs during the COVID-19 pandemic during a three-week period in May 2020. Responses were received from 163 Ministries of Health. UNFPA is conducting some surveys and rapid assessments of the situation of older persons, including in Indonesia, Iran and Vietnam. ILO is tracking pensions and other social protection measures. Others are conducting household surveys that may shed some light on older people’s circumstances. For example, the World Bank is conducting high-frequency phone surveys in a number of Asian countries and will release its datasets. Although not specifically surveys about ageing, they will capture data on older members through household rosters. UN Women is conducting rapid assessment surveys to understand the pandemic’s gendered consequences but has insufficient data to allow disaggregated analysis on older women. Civil society bodiesThe NGO sector continues to struggle. As public fundraising stalls and donor countries either turn to domestic responses or push their resources through large agencies, national and international NGOs are facing sharp cutbacks. For example, a survey of small British charities working in international development (annual income below GBP 1 million) revealed that 45 per cent of them expect to shut down within 12 months. In a UN Women survey of women’s CSOs in Asia Pacific, 71 per cent of respondents said that COVID-19 was affecting them somewhat or very negatively, and 12 per cent have had to temporarily suspend their activities – just when they are most needed. Some humanitarian funds have been channeled through NGOs, but less than in the past. According to UNOCHA, as of 11 July approximately 15 per cent of GHRP funding has gone to NGOs, who typically receive 30 to 40 per cent under Humanitarian Response Plans. One analysis of GHRP disbursement patterns argues that “while the UN’s activities are being robustly funded, civil society and NGOs remain consigned to the periphery”, and suggests that even the 15 per cent figure may be an exaggeration. Particularly during a pandemic crisis, with travel restrictions in place, local government and non-government actors are critical frontline responders who can reach people in need.right682625With travel restrictions in place, local government and non-government actors are critical frontline responders who can reach people in need.00With travel restrictions in place, local government and non-government actors are critical frontline responders who can reach people in need.CSOs who are part of the HelpAge Asia Pacific regional network continue to adapt to the crisis as it unfolds. At the beginning of the pandemic, the distribution of non-food items and protective gear were typical activities of network members. Several months into the pandemic, a majority of network members are involved in advocacy and campaigns. A common advocacy issue has been emergency cash transfers during the lockdown period. They continued information sharing on how to protect older people from the virus through distribution of print and online material, though at a slower pace. Network members took part in various webinars both at regional and national level to share their experience and reflect the voice of older people they are working with. Larger organisations such as HelpAge India and the Tsao Foundation (Singapore) hosted their own webinars. Psychosocial support services were offered by a few network members, sometimes as simple as ensuring that older people are staying connected via phones and can share their concerns with others. As noted above, HelpAge International is also collaborating with several network members to conduct rapid needs assessments in seven countries. Especially where the government response remains limited, community action helps to fill gaps. Community activities vary widely and are largely undocumented, particularly those that are volunteer based. Government programmes target broad categories of people, but local actors are often needed to go the last mile. For example, an older person may be eligible for a national cash transfer but face personal challenges in learning about or registering for the benefit, collecting the money, using the money to buy basic necessities nearby, or fulfilling activities of daily living when money is not the main barrier. With outside assistance often cut off because of lockdowns or other restrictions, established community-based organisations, including those led by older people themselves, often make the local response more effective, coordinated and personal. HelpAge network members regularly receive reports of community activities coordinated independently by older people’s associations during the pandemic. These activities generally fall into several categories. For example (1)?disseminating information to older persons and their families, such as how to stay safe or access government programmes; (2) simply monitoring their status, such as arranging a roster of resource persons to check regularly on older people at risk of isolation; (3) providing basic needs, such as packing and distributing food, PPE or other necessities, donated by community members or provided through government or other external channels; (4) delivering volunteer-based services safely, such as home care, guidance in using technology or counselling for those who need support; or (5) linking older people to formal public services, such as health care, COVID-19 testing or emergency programmes. Private sectorThe private sector is scanning for commercial opportunities arising from the pandemic, to service both consumers and the public sector. Businesses are trying to understand the potential commercial pitfalls and opportunities arising from COVID-19, and how to differentiate consumer demand by age cohort. For example, many market analysts now expect tourism to rebound quickly among younger generations post-pandemic, but for retirees and other older people to remain more cautious about travel for some time. The combination of heightened attention to health concerns and the need deliver services from a distance is generating expectations that innovation in the health sector will accelerate. These innovations include transitioning more care outside of hospitals and providing both consumers and health providers with digital tools and new technologies. (See discussion on telemedicine above.) In light of the digital divide and the public’s increasing dependence on communication technologies for everyday life, smartphone coverage among older consumers may also expand sharply as a result of the pandemic. 4. Selected near-term recommendations The pandemic has stimulated wide public debate about how to move towards a better future for all generations. Those debates are generating important medium- to long-term recommendations that could be transformational, if adopted. For example, they include tackling fundamental societal threats including inequality and sustainable use of the planet’s resources. These in turn could facilitate reforms that improve the situation of older people, such as strengthening inclusive national systems for social protection, health care and long-term care and reducing climate-related threats to health and livelihoods. Rather than attempting to cover all the challenges facing older people, this report proposes a few achievable priorities for the pandemic period: Gather evidence about older people’s situation in the pandemic. This includes (a)?quantitative or qualitative surveys specifically targeted at older people. But even more productive might be (b) the inclusion of older respondents in more numerous population-wide surveys, using methods that allow age- and sex-disaggregated analysis. In particular, older women remain largely invisible during the pandemic. In the absence of recent evidence, we are left with the language of risk (potential harm) rather than impact (actual harm).Rebalance health system priorities back towards NCD services, given their neglect during the pandemic and high impact on mortality. National COVID-19 response plans should include action to accelerate progress on NCD prevention, diagnosis, treatment and palliative care. Specifically, national COVID-19 response plans should (a) include guidelines to prevent new waves of COVID-19 from significantly interrupting NCD health services and (b) be reviewed to ensure that COVID-19 policy responses improve or at least do not worsen population exposure to key NCD risk factors. Take action to protect those with care needs, who are among the most vulnerable to COVID-19. (a) In residential care settings, every effort should be taken to prevent and/or manage the spread of COVID-19; (b) for family carers, expand or introduce financial and psychosocial support and provide them with information and training on COVID-19 safety. Prioritise universal social pensions as the most effective mechanism to ensure the income security of older people during the crisis. Where social pensions exist but do not reach most older people, their coverage could be expanded, for instance by immediately enrolling those on waiting lists (Sri Lanka), making targeted pensions universal in the hardest-hit parts of a country (Bangladesh), expanding geographically, or lowering the eligibility age to reach more older people (Myanmar). Where social pension transfer levels are too low to provide protection, governments should increase transfer levels at least temporarily.Where emergency cash transfers are implemented for broad segments of the population, they should be accessible, especially for older women and people with disabilities. Although technically eligible, many older people struggle even to register for COVID-19 transfers. Access should be smooth, from outreach and communications to registration and receipt of payments.Consider adding nuance to statements warning of the pandemic’s “risks to older persons”, based purely on chronological age. Such statements not only obscure the diversity of older persons but may also reinforce blanket perceptions of vulnerability and decline in later life. While the statistical risk of severe complications or death from COVID-19 infection does rise with age, indirect impacts are much more variable. Broad generalisations based on age alone are sometimes inevitable, as even these recommendations suggest. But they may impede practical interventions that could be more sharply targeted at various population sub-groups.HelpAge International is a global network of organisationspromoting the right of all older people to lead dignified, healthyand secure lives.Published by:HelpAge International, Asia Pacific Regional Office6 Soi 17 Nimmanhaemin Rd., T. Suthep, A. Muang, Chiang Mai 50200 ThailandTel: (66) 53 225400Fax: (66) 53 225441hai@ ................
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