We are living in unprecedented times. The covid-19 pandemic is escalating rapidly with more than 173, 300 confirmed cases and over 7,000 deaths in 152 countries and regions (see Figure 1). The majority of cases and deaths are among people aged 60 years and older living in low- and middle-income countries (LMICs) where healthcare resources to treat people and control the epidemic are limited. 

Guidance largely ignores this issue in both high income countries (HICs) and LMICS, the latter of which contain 69% of the global population aged 60 years and over. Their health systems are also weaker, leaving them vulnerable to the worst impacts of covid-19. Limited guidance which is more relevant to HICs has been produced for older people but not for health and social care workers, care homes or day centres. No detailed age-specific data on global cases and mortality has been produced by the World Health Organisation (WHO) even though mortality rates jump sharply in older people, rising from 8% in those aged 70 to 79 years to 15% in those aged 80 and over (see Figure 2 which shows the effect of age on risk of dying from covid-19 from the Chinese outbreak).  

 

 

In the absence of clear comprehensive guidelines for prevention and control of covid-19 among older people, ad hoc policies are emerging. In Italy scarce hospital and intensive care services are being prioritised for younger, otherwise healthy patients over older patients, according to reports. In the UK, people aged 70 and over will be expected to self-isolate themselves for up to four months in the coming weeks.

In LMICs, older people provide an integral economic and social resource to societies, including bringing up grandchildren to support the labour mobility of their adult children and relatives. Beyond grief and bereavement the implications of covid-19 deaths among the older population will be profound, especially when family members working abroad are unable to return home at short notice. 

Increasing numbers of very old people are now being cared for in nursing homes in LMICs. These homes are often unregulated, provide care of very poor quality and may even act as incubators of infection (as do cruise ships, prisons, mines and HIC nursing homes). Outbreaks in LMIC institutions would have serious implications, further underpinning the need for international guidance similar to that issued recently by the International Federation of the Red Cross and Red Crescent Societies, UNICEF and the WHO regarding children and schools.

The ability of health systems to cope with a surge in demand is extremely limited, especially for patients needing intensive care. Health systems in LMICs face severe constraints on capacity at normal times and are unlikely to be able to keep up, especially if the precarious staffing levels—already depleted by migration, low salaries and poor working conditions—and limited gerontological expertise are reduced further by illness. The needs of older people are not being adequately addressed in developing covid-19 policy and practice. Current social distancing policies ignore the precarious existence of many older people and fail to account for the realities faced by those living alone and individuals who are dependent on others. The high levels of illiteracy in LMICs also present a challenge which has yet to be considered in any meaningful way. 

An age perspective needs to be explicitly included in the development of national and global planning for covid-19, and it is increasingly clear that a global expert group should be formed to provide support and guidance for older people, home carers, residential facilities and overburdened hospitals in LMICs. 

 

Shah Ebrahim is an honorary professor of public health at the London School of Hygeine & Tropical Medicine. He would like to thank Peter Lloyd- Sherlock, professor of social policy and international development, University of East Anglia; Leon Geffen, Samson Institute for Ageing Research, Cape Town, South Africa; and Martin McKee, professor of European public health, London School of Hygiene & Tropical Medicine, for contributing to this article. The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the views of The Economist Group or any of its affiliates. The Economist Group cannot accept any responsibility or liability for reliance by any person on this article or any of the information, opinions or conclusions set out in the article. 

 

As China’s economy continues its robust expansion, and as its banking sector finally opens up to foreign competition, the demand for credit is taking off. Local banks have ramped up their operations for the last three or four years in preparation for increased competition from foreign rivals. As their efforts bear fruit, the potential for China’s payment cards market has never looked better.

Nowhere is this more so than in China’s emerging market for debit and credit cards. With more than 200m new cards issued last year alone, China’s total number of plastic cards broke though the one billion mark in 2006, with no sign of the pace abating. While a relatively tiny portion of this total—some 50 million—are currently credit cards, growth rates for the sector (both in terms of spending and transaction volumes) are now much higher than for the mass-market debit cards that form the bulk of cards in circulation. No surprise, then, that foreign banks are now eyeing this space for opportunity.

The main findings of our research are as follows:

Retail banks are very bullish on consumer banking in general—and credit cards in particular... For many of the retail banks surveyed for this report, credit cards are the main priority. When asked what products they believe hold the greatest prospects for China’s personal banking industry, retail bankers were most optimistic about credit cards and bank accounts. Fifty-fivepercent of study respondents believe the prospects for these consumer banking products are ‘highly promising’ over the next three years. Debit cards are seen as the next most promising item (45%), although these are directly linked to the prospects for basic bank accounts, followed by wealth and investment management (40%). In fact, respondents report overwhelmingly positive views for all aspects of the consumer banking sector.  ...But the outlook for profits is less certain. When it comes to profits in the credit card market, our survey respondents are less confident. Forty-three percent agree that it would be difficult to make a profit in the credit card market over the next three years, compared with 36% who remain uncertain and just 21% who believe it is possible. The key issue is tough competition for customers between local banks growing their market share and foreign rivals trying to establish a beach head in China. This competition inevitably leads to lower card fees, which keeps earnings low (or negative). In addition, banks are grappling with low rates of revolving credit on cards, resulting from a cultural aversion to accruing debt, together with low fees and interest rates that issuers are allowed to levy on merchants and card users. Infrastructure is key to growth in the cards market. According to the executives surveyed for this report, improving infrastructure – encompassing both merchants and ATMs—will play the biggest role in encouraging the increased acceptance of card payments in China. Fully 83% of retail bankers polled chose this as an essential requirement. This component scores far ahead of any other criteria, for example better collaboration between key stakeholders such as banks and payment processors (48%) or publicity campaigns (33%). When asked what the Chinese market needs to supporta payments infrastructure, half of the survey respondents selected better availability of consumer credit-history data. Merchant acquisition is a major hurdle. Convincing merchants to accept credit cards is a major challenge for banks. Eight out of ten retail bankers polled for this report say that local retailers’ preference for cash is either a ‘very significant’ or ‘significant’ barrier in operating cards and payment services. In part, this is because retailers don’t yet feel much pressure from customers to provide payment card facilities in a society where cash is traditionally preferred. Despite an opening financial market, much risk remains. More than half (53%) of bankers polled for this report selected political risk, relating to policy and regulation, as the biggest existing or potential risk associated with their firm’soperations in China. Retail bankers in particular listed licensing risk (chosen by 43%) as a major concern, second only to political risk, highlighting the difficulties associated with getting permission to expand into new regions or markets. Along with this, 41% of the respondents expressed a general concern about the outlook for China’s banking industry.

Much work needs to be done to promote a plastic card payment culture in China. More than anything else, a more extensive card network and infrastructure must be rolled out to promote consumer usage. Along with this, databases of consumers’ credit and transaction histories require expansion. In addition, Chinese consumers must be encouraged to make the switch from cash-based transactions to plastic cards. Despite these challenges, growth is already strong. And in cities such as Beijing, efforts to prepare for the 2008 Summer Olympic Games will help create an environment that supports card payments. Although foreign banks entering the market will have their work cut out, the opportunity is simply too big to ignore.

The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.

These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit. 

This paper looks at the ways in which Sweden has implemented VBHC, the areas in which it has faced obstacles and the lessons that it can teach other countries and health systems looking to improve the value of their own healthcare investments.