Older people are increasingly living in cities, however, urban aging poses a number of challenges: cities are generally not been designed with older people’s needs in mind, people are increasingly disconnected, healthcare systems are failing and baby boomers have very different expectations than previous generations.
While the World Health Organization (WHO) has started a powerful global movement with its Age-friendly Cities program, these intractable programs to be tackled in partnership with private-sector, tech-enabled scalable innovators in particular startups. Connecting startups and age-friendly cities to build ”innovation ecosystems” has the potential to deliver better experiences for older people, lower healthcare costs, and create jobs and economic growth.
Challenges of urban aging
According to Ken Dychtwald, two thirds of all the people ever to reach age 65 are alive today. For older adults, four tensions in particular stand out: urban design being focused on the young and the wealthy; social isolation being exacerbated by digital disconnection; health and long-term care systems being overburdened and failing; and baby boomers delivering new expectations.
Urban planning is focused on the young and the wealthy
Historically, however, cities have not been designed for populations in which a quarter or more of the residents are elderly. The wishes of those with the loudest voices, deepest pockets, and best access to decision makers are often prioritized.
Historically cities have not been designed for populations in which a quarter or more of the residents are elderly
“The wealthy have a disproportionate ability to influence government and therefore urban design. Consequently, the shape and development of cities can often be the result of the needs of the elite, rather than the majority." - The Future of Cities, Future Agenda 2017.
For example, designing urban spaces around those who can’t or don’t want to drive seems to make sense on many levels. Citizen-centric urban planning—inclusive of the needs of all city dwellers and adaptive to their needs as they age—is now needed.
Social isolation exacerbated by digital disconnection
As multigenerational family living becomes rarer, and neighborhood support structures are less reliable, people are becoming increasingly isolated. Further, more and more day-to-day concerns, such as pensions, bill payments, and customer service, are being conducted exclusively online, thus creating challenges for those who are not. An important part of the rollout of “smart cities” will be to ensure they are inclusive of all ages and abilities, important social services are delivered across multiple channels, and social isolation and fraying social structures, particularly among older more vulnerable populations, are recognized.
Health and long-term care systems overburdened and failing
Healthcare costs in the US are among the highest in the world at almost 20 percent of GDP, while the quality of care ranks behind that of other Western countries. And while those other Western nations generally spend only 8 to 12 percent of GDP on healthcare, most of their systems are under significant stress, with populations that generally skew older than in the US. Most health systems were designed for hospital-based acute care rather than for the needs of today’s aging societies, such as with an emphasis on community-based, integrated chronic long-term care systems. In the US, Medicare is managed at the state level, which lets cities off the hook for the health costs of their older inhabitants, thus removing a potential incentive for cities to ensure their inhabitants stay in the best health possible.
Baby boomers change culture and expectations
Baby boomers have reimagined and reinvented culture as they move through society. And as they continue to turn 65 over the next 15 years, they will reimagine aging. The rejection of traditional societal barriers will manifest as "agelessness," removing age as a determining factor in culture, social interactions, employment, housing, leisure, and other areas. This will bump up against deep-rooted and pervasive ageism (along with the semi-acceptable age discrimination—a particularly acute issue in Silicon Valley), resulting in increased cultural stresses. As Stanford professor Laura Carstensen points out, culture hasn’t had time to catch up with the new reality of longer lives and the need to keep older people productive and engaged.
The rise of the "Age-friendly" movement
Over the past decade or so, the WHO has led an "Age-friendly" Cities program, a growing movement that seeks to give voice to older people and ensure the cities and communities around them take their needs into account. A response to the twin trends of urbanization and longevity; it is grounded in asking older people what they want, and built on top of robust theoretical underpinnings.
The program has been embraced by hundreds of cities and implemented at the local level, bringing together stakeholders to address each community’s unique issues. Going forward, there is considerable potential to leverage the age-friendly cities network as a global platform for change at scale. And that’s where startups can come in. Alexandre Kalache launched the idea of age-friendly cities at the 2005 IAGG conference in Rio de Janeiro. Over the following two years, at the WHO in Geneva, he and Louise Plouffe, the director of Research at the International Longevity Centre Canada, led global consultation and research into the concept, asking older adults in 33 cities spanning 23 countries about the advantages or barriers they experienced in eight areas: outdoor spaces and buildings; transportation; housing; social participation; respect and social inclusion; civic participation and employment; communication; and community and health services.
The program has grown rapidly. There are currently 380 cities that have started the process for becoming age-friendly in nearly 40 countries worldwide, reaching approximately 130 million people. In 2010, WHO established the Global Network of Age-friendly Cities and Communities (GNAFCC), which is supported by the web-based platform Age-friendly World. Eleven "affiliates" to the global network support cities and communities on their journey to becoming more age-friendly. One such affiliate, AARP, supports 134 US cities covering over 40 million residents under their age-friendly communities program. The European Union has many age-friendly cities, and has committed 70 billion Euros to innovation as part of the Horizon 2020 program, a large amount of which has been earmarked for healthy aging.
Age-friendly cities + Startups = innovation ecosystems
Delivering better age-friendly cities in the face of considerable and growing challenges around urban aging will require bold vision and strategy together with the ability to deliver radical innovation in an accelerated timeframe. This is not business as usual. It will require a new approach based on public-private cooperation and attracting innovators, in particular technology startups. Tech startups are already making progress introducing innovative new services for older adults in cities, such as transportation, food delivery, social inclusion, and care coordination.
Startups as change agents and job creators
Why should aging innovators care about startups, especially when 90 percent of them seem to be run by people under 25 who are predominantly focused on stuff their mom won’t do for them anymore? Startups matter because they have the potential to deliver impact by doing something new and having the ability to scale it up. They’re also job-creating machines, which are the types of businesses cities should welcome. Startups tend to congregate in startup hubs, which creates a dynamic energy in the areas they are established. According to the Small Business Administration, since 1990, large companies have cut over four million jobs, while small companies have added upwards of eight million positions to the workforce.
Combining the two trends of age-friendly cities and startups holds the potential to deliver scalable impact to meet the needs of older people
Startups making in-roads on aging issues
In the 10+ years since the age-friendly cities project was launched, technology has changed significantly. In particular, the barriers to creating startups have come tumbling down, with new startups proliferating in every walk of life. Many entrepreneurs are now focusing their attention on building on-demand services, many of which are relevant to the older adult demographic. But given the logistical complexities and the need for a critical mass of customers and efficient delivery options, many of these services are only available in larger cities.
Transportation and mobility is one area in particular where we see a high level of interest. Centennial, Colorado (the latest city to join the Aging2.0 Alliance program) also considers this a high priority. In August, the city launched Go Centennial, a public-private partnership with Lyft and Xerox to supply free Lyft Line rides within a three-square-mile service area of the city’s Dry Creek Light Rail Station.
Based on the eight topic areas and associated features highlighted in the original WHO report, below is a selection of startups and tech companies that are addressing the needs of older adults living in cities:
Combining the two trends of age-friendly cities and startups holds the potential to deliver scalable impact to meet the needs of older people. An aging innovation ecosystem brings together all the necessary players to make change happen in aging and senior care—the startups, industry, investors, older adults, governments, and academia—with the tools and ability to make change happen and get things done at scale.
Five Steps to Aging2.0 Innovation Ecosystems
Aging2.0 has built a global social movement of over 15,000 innovators spread across 50 volunteer-run Aging2.0 city chapters in 20 countries. Building an aging innovation ecosystem can be broken down into a five-stage process:
The first step to creating new solutions for people is to engage them in conversations about what needs to change and why—not just assume that we already know the answers. The WHO Age-friendly Cities program did this with a multi-year study involving on-the-ground research with groups of older people in 33 cities. Moving this process online and making it real time and ongoing would be valuable. Models such as the Linkages program in Palo Alto, CA and Iris in Orange County, CA as well as online platforms for engaging in conversations about topics.
With a clear sense of the kinds of issues that need to be addressed and an ongoing communication channel with the people who will benefit from innovation, innovators can engage to develop different solutions. As June Fisher, Aging2.0’s chief elder officer often points out, it’s about designing with—not for—older adults. It requires constructing opportunities to connect designers and developers with the customers themselves. Where possible, the input from the dialogue should be both qualitative and quantitative: stories, case studies, and real-world examples that paint a picture, in addition to data that can be used to discern patterns and gaps.
One example is the travel hackathon Aging2.0 organized last year at Google’s London campus that brought together 10 senior advisors and around 50 technology developers and designers. Other approaches could include collaborative sites such as Quirky.com (which failed) OpenIDEO, IdeaScale, and Skilld.
In most cases, a critical phase of innovation is real-world testing and feedback of the ideas with pilots. Pilots allow the solution creator to test its effectiveness in real-world settings, and the customer to test the solution before deciding whether to make a significant purchase investment. Aging2.0 has spent a great deal of time helping innovators develop pilots, and produced a number of guidelines for innovators, such as 10 Tips for Partnering With Startups. While many innovators get excited about having landed a pilot, care is needed to avoid ending up in "pilot purgatory," wherein precious time and resources are wasted chasing a large deal that never comes.
Conversations with 3,000+ startups over the past five years have shown that one of the biggest obstacles to innovation in the aging and senior care space is a lack of distribution. There are few high street outlets for ‘healthy aging’ products or online portals. Cities in theory have the potential to be the ultimate distribution channels for new products and services - IF there can be collaboration among providers and vendors. The WHO Age-friendly Cities network in turn has the potential to be a channel for innovators to reach millions of older people either directly or via intermediary organizations.
Cities could use an online platform to leverage their scale and allow innovators into an aging market. Within cities, a more joined up approach that allows products to get to end users more effectively is needed. Customer-friendly portals such as Unforgettable.org (based in the UK) are emerging from the private sector to educate and connect people looking for support and products for dementia, and some health plans and insurance companies are starting to become channels for new technologies (such as insurance companies recommending the use of wearable devices to monitor health). The Village to Village model has also been discussed in the context of a distribution channel, and some Villages (such as Ashby Village in Berkeley, CA) are exploring the more active use of technology. Many of the existing platforms used in the public sector to reach large numbers of older adults - e.g. Medicaid programs, local area agencies on aging - don’t seem close to opening themselves up as platforms for innovators, so there is still a long way to go.
Getting to scale requires not only access to a distribution channel, but also a scalable business model and (potentially) external capital from investors (unless growth capital comes from customer revenues, which is often hard for technology businesses).
The impressive size of city budgets is an obvious place to start, however risks and rewards are not well aligned so far. At the recent Sorensen impact investing conference, a panel of mayors talked about the issues that impact them the most. At no point was there any discussion of older adults, so after the event, I broached the subject with a few of the panelists. It quickly became clear to me that most cities are not on the hook for the health outcomes of older adults - their funding and costs were only loosely related to the health outcomes of their residents. Going forward, connecting the massive public health procurement budgets, and those of the cities, holds promise. Citymart has been developing a platform to connect public procurement activities (not just health) with city budgets - introducing the concept of challenges to spark private sector innovators. And new efforts underway by the European Commission to identify leading public health use cases and pool public procurement dollars seems promising.
The situation regarding capital is somewhat similar - there have been a few efforts and isolated private sector support for new technologies, such as caregiving platforms, though these have found it hard to scale without support of the health systems. As a result the healthy aging space is still underfunded compared to its potential impact. The use of regional and infrastructure funds to invest in private sector projects, along with private sector venture investors to ensure high quality due diligence, is one model, and the use of new innovative financing mechanisms that tie investment funding with value delivered, such as social impact bonds, could also be explored here. Either way, there are rich opportunities for impact-minded investors and entrepreneurs to help promising ideas get to scale.
Many of the ingredients are already in place to deliver these. What’s needed is a clear vision with bold leadership at the local level to engage in concrete actions, and a commitment to integrate the previously disconnected worlds of aging, senior care and startups.
Stephen Johnston. CEO & Co-founder, Aging2.0