(Editor’s note: This is the second article in a series on “Rights and Dignity: Older People in Conflict and Crisis,” produced in cooperation with Amnesty International USA and HelpAge USA. Read the first article here.)

Aging populations are placing new demands on health systems worldwide, posing a set of historic questions for the United States about whether to adapt its global health priorities to this reality. The World Health Organization estimates that by 2050, the world population of people over 60 will exceed 2 billion, more than double the number in 2019. Most older people live in developing countries — 37 percent in eastern and southeast Asia alone — and those countries are at least partially reliant on the U.S. government and other bilateral and multilateral donors to support their health systems. These donors designed their aid programs decades before longer life expectancy and lower fertility rates fundamentally altered the demographic landscape of the countries they assist.

Because older adults are more prone to multiple chronic conditions or co-morbidities, multiple experts agree that they require integrated care that emphasizes their full personhood. The WHO recommends a continuum of care for older persons that seeks to slow or reverse a range of physical and mental declines commonly associated with aging. These include improving mobility and vitality, preventing cognitive impairment and promoting psychological well-being, preventing falls, maintaining sensory capacity, managing age-associated conditions such as urinary incontinence, and supporting caregivers. The WHO further recommends the adoption of primary care — also known as family medicine — as the model of care best designed to meet the great majority of a person’s health needs along the life course, as opposed to treating individual acute health conditions in a fragmented manner. The U.S. National Academies of Science, Engineering and Medicine similarly concluded in 2022 that “integrated person-centered care is the most effective and appropriate care delivery model for maximizing health, function and well-being across the life span.”

Access to integrated care along the life course can be described as an equity imperative. The burdens of fragmented health care are not felt equally by everyone, falling most heavily on those with multiple chronic conditions and a combination of mental and physical health challenges. For example, people with mental health conditions and substance abuse disorders face a higher risk of chronic diseases such as diabetes and cardiovascular disease. As noted by the U.S. Agency for Healthcare Research and Quality (AHRQ), when these patients are required to see different specialists for their mental and physical health conditions, it compromises their quality of care, compounds their vulnerability, and contributes to social stigma. Added fragmentation and social stigma flow from having to see still more specialists for infectious diseases sometimes associated with substance use, such as HIV and hepatitis C. What AHRQ describes as a “collaborative, patient-centered and whole person” approach to health care is more consistent with normative principles of equity and human rights than fragmented systems.

Integrated Care and U.S. Global Health

The nearly $13 billion that the U.S. Congress appropriated for global health programs in FY23 overwhelmingly supports specific disease programs rather than integrated care. Some of the systems and innovations created for specific disease programs, such as rapid testing to aid in diagnosis and surveillance, can and have been used to respond to other epidemics and benefit health systems more broadly.

Nevertheless, these benefits are an indirect rather than a direct (or intended) effect of congressional earmarks. The required allocations of the U.S. global health account in FY23 included nearly $5.5 billion for bilateral HIV programs, $2 billion for the multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria, $1.3 billion for maternal and child health, just over $1 billion for malaria, and the remainder for family planning, tuberculosis, nutrition, and neglected tropical diseases. Congress allocated an additional $1.5 billon to global health security in FY23, which consists of cross-cutting efforts to respond to infectious-disease threats as a component of national biodefense. These allocations are in stark contrast to a primary care approach, which seeks outcomes that cut across all populations, age groups, and diseases, such as access to a first contact, continuity of care, comprehensiveness of care, coordination between providers, and a person-centered approach.

Aging populations will surely benefit from many of these congressionally earmarked programs. For example, half the people supported on anti-retroviral treatment by the U.S. President’s Emergency Plan for AIDS relief (PEPFAR) are now over 40, and in 2022 almost 10 percent of new HIV-positive tests were in people over 50. This may under-represent the proportion of people living with HIV who are over 50, as the combined stigma of HIV and ageism may prevent older people from being offered HIV tests. Investments in global health security and other infectious-disease programs are also sure to benefit older populations as well as younger ones. The U.S. Agency for International Development’s 2023 Gender Equality and Women’s Empowerment Policy emphasizes a life-course approach, recognizing that the cumulative impacts of lifelong gender disparities can lead to differences in health outcomes among older women.

And yet, the continued focus on HIV/AIDS, other infectious diseases, and maternal and child health—not only in U.S. global health programs, but in development assistance for health more broadly—means that services are necessarily more limited for adults without infectious diseases, including offerings that might provide access to integrated primary care along the life course. In 2020, experts from the University of Washington’s Institute for Health Metrics and Evaluation found that only 9 percent of development assistance for health targets health conditions that impact those 60 or older, despite the fact that this group accounts for 26 percent of the total health burden in low- and middle-income countries. These experts argued that “[t]he aging of the global population demands that the world reconsider this allocation [of funding],” particularly given recent projections that the share of the global population over age 65 will triple by 2100. One way to reconsider this allocation, they argue, is to strengthen the overall performance of health systems in reaching populations of all ages.

Since the U.S. government has a long track record of supporting programs to strengthen health systems (known as health system strengthening or HSS programs) within the authorities set out by Congress, this is a potential way to significantly improve and extend such assistance for populations that currently seem to be underserved.

U.S. Investment in Strengthening Health Systems

The concept of HSS first gained prominence on the global health agenda with the WHO’s publication of the World Health Report 2000 — Health Systems: Improving Performance. The ensuing decade saw a monumental increase in investment in specific disease programs, leading President Barack Obama to launch the Global Health Initiative (GHI) in 2009 with the statement that “We will not be successful in our efforts to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems around the world.” In 2012, the Obama administration issued a paper on HSS as part of the GHI, and USAID’s Office of Health Systems (OHS) began operating as the agency’s HSS focal point. A year later, the Lancet Commission on Investing in Health concluded that structured investments in HSS must accompany all spending on discrete disease interventions to produce sustained impact.

The Western Africa Ebola outbreak in 2014, which claimed more than 11,000 lives, gave further rationale to HSS efforts. It also propelled the Global Health Security Agenda (GHSA), a collaboration established that year linking 70 countries, international organizations, non-government organizations, and private companies to focus on aspects of HSS that contribute to containing infectious-disease threats, such as health information systems needed for surveillance reporting, financing, and a health workforce capable of responding to infectious disease threats.

In 2015, USAID issued the first of a series of vision documents on HSS, providing guidance to their country missions on how to strengthen the overall performance of health systems including the WHO-defined “building blocks” of health governance, financing, service delivery, health workforce, information, and medical products. At the conclusion of the Ebola epidemic in 2016, the U.S. National Academy of Medicine Commission on a Global Health Risk Framework for the Future concluded that “Robust public health infrastructure and capabilities are the foundation of resilient health systems and the first line of defense against infectious disease outbreaks that could become pandemics.” The commission recommended that donors make funding for HSS programs conditional upon a country’s participation in an external assessment of their performance in strengthening public-health infrastructure.

Despite this assessment that HSS is crucial to global health security, the USAID Office of the Inspector General (OIG) concluded in 2019 that HSS remains a “second order priority” compared to congressionally earmarked disease programs, because ultimately it is “one approach of many” that USAID missions can use to achieve the global health goals mandated by appropriations law. Indeed, all that Congress requires in terms of HSS appropriations is that USAID country missions with more than one disease program (e.g. HIV/AIDS and malaria) devote no less than 10 percent of each program to “cross-cutting health system capacity to ensure these systems are affordable, accessible, reliable, and accountable to the people served.”

Congress requires USAID to report annually on this funding, yet while these reports provide useful examples of HSS efforts, the U.S. Government Accountability Office noted in 2023 that these reports contain significant gaps. Fortunately, USAID continues to evolve its approach to HSS and primary care within the authorizations set by Congress, issuing a new HSS vision document in 2021 and launching a pilot program in 2022 to develop primary healthcare action plans with the governments of Cote d’Ivoire, Ghana, Indonesia, Kenya, Malawi, Nigeria, and the Philippines.

Is Health Systems Strengthening the Way to Adapt to Population Aging?

Given this history and funding, how realistic is it that U.S. investments in HSS can be leveraged to help low and middle-income countries adapt their health systems to population aging and demographic change? In 2023, U.S. Senator Benjamin L. Cardin (D-MD) issued a request for information on U.S.-funded HSS programs, asking what actions Congress might take to establish a clearer vision, authority, and set of targets in this area of global health. (Disclosure: I was a Health and Aging Policy Fellow in his office at the time.) Cardin asked, among other things, how Congress can ensure U.S. bilateral global health assistance is adequately responding to the need to strengthen health systems for local populations and that the United States is effectively coordinating with local partners and governments to meet that need. He also asked how Congress can support more effective integration of HSS activities and reduction of health system fragmentation across the full spectrum of global health programming.

These questions create a rare policy opening to explore whether HSS might be an appropriate vehicle for tailoring U.S. global health programs to diverse demographic contexts and promoting the kind of system integration that older adults (and indeed all people) need. To be sure, HSS investments represent only a small fraction of U.S. global health spending, and political momentum for HSS has historically been driven more by the global health security agenda than by the need for primary care along the life course. However, these are powerful investments with the potential to help countries orient their health systems towards the kind of integrated care that people need across the life span. 

Ultimately, it is up to the U.S. Congress to determine the goals and spending of U.S. global health programs, and it has clear opportunities to tailor these goals to the needs of a rapidly aging world. At the most basic level, Congress has an opportunity to explore whether the many agencies of the U.S. government that implement global health programs — such as USAID, the State Department, the Department of Health and Human Services, and the Department of Defense — should develop a unified strategy on HSS, and whether that strategy should adopt a life-course approach that helps development partners orient their health systems towards integrated primary care for people of all ages.

At a further level, Congress could ask whether existing U.S. global health goals, despite skewing towards younger populations and those with infectious diseases, could be as effectively achieved or more so through the adoption of integrated primary care approaches that would benefit people of all ages. This is an important empirical question that might require research or pilot programs that Congress could encourage or authorize.

Finally, Congress has an opportunity to ask whether the existing rationale and scope of U.S. global health diplomacy remains fit for purpose in an era of profound demographic change. Ultimately, an age-inclusive global health policy might require a paradigm shift, or indeed a return to the promise of the Alma Ata Declaration of 1978, which defined primary care as the key to the global goal of health for all and predated the current global health consensus that is rooted in the worldwide response to HIV/AIDS. Whether Congress shows leadership by pushing for answers on these crucial questions and how these elected representatives resolve these questions will have a profound impact on whether having more people living longer lives translates into more people living healthier lives.

IMAGE: Doctors block the entrance to the Parirenyatwa Hospital during a protest march by senior medical doctors in Harare, on December 4, 2019. The doctors petitioned the Zimbabwe Parliament demanding improved working conditions and the reinstatement of 448 junior doctors fired for taking part in a two month long strike over low salaries.  (Photo by JEKESAI NJIKIZANA/AFP via Getty Images)