Why and How Have Korean Cities Embraced the World Health Organization’s Age-Friendly Cities and Communities Model?

Introduction

In February 2017, a prominent medical journal – the Lancet – published an article projecting that South Korea will become the first country to break the 90-year barrier in life expectancy by 2030 (Kontis et al., Citation2017). This is a remarkable advancement for Korea, indicative of the nation’s social and economic development, in addition to local advances in public health and medical technology. However, this news is not a rose without a thorn, as Korea also happens to be the fastest aging country in the world. While it has taken 18 years for Korea to move from an aging society to an aged society, it will only take an additional seven years to become a super-aged society (Statistics Korea, Citation2016). While the issue of population aging is particularly acute in Korea, the entire world – particularly Asia – is aging fast. The United Nations (UN) estimates that by 2050 more than a quarter of the Asian population will be over the age of 60 and more than a fifth of the population will be over the age of 80 (UN Economic and Social Commission for Asia and the Pacific [ESCAP], Citation2017).

In light of this rapidly aging world, in 2010 the World Health Organization (WHO) created a network of cities willing to tackle this issue at the metropolitan-city level instead of waiting for central governments to move  (WHO, Citation2009). The WHO defines an “age-friendly” city as a city that “encourages active aging by optimizing opportunities for health, participation, and security in order to enhance quality of life as people age” (WHO, Citation2007). The WHO Global Network of Age-Friendly Cities and Communities (AFCC) is a group of cities committed to using the WHO AFCC guidelines to make their communities more age-friendly. By the end of 2018, the AFCC Network had grown to include 799 cities; however, only 7% of member cities in the Network are in Asia (WHO, Citation2018). This shows that membership in Asia is much lower than the rest of the world even though Asia is the fastest aging region.

Given the short history of the WHO AFCC model, there is a small but growing literature on the subject. Early literature tended to focus on introducing the Network (Barusch, Citation2013; K. Chung, Citation2010; Neal & DeLaTorre, Citation2009), while later publications have included case studies on specific cities or regions (Buffel et al., Citation2014; Chao & Huang, Citation2016; S.-D. Chung & Youn, Citation2014; Garon, Paris, Beaulieu, Veil, & Laliberté, Citation2014; Kendig, Elias, Matwijiw, & Anstey, Citation2014).

Importantly, few or no existing studies on the WHO AFCC are grounded in social policy theory. Two theoretical perspectives appear well-suited to this topic to help understand why and how cities have joined the WHO AFCC Network and how well they have implemented its guidelines. First, John Kingdon’s “multiple streams” agenda-setting model (Kingdon, Citation2011) provides a theoretical framework for understanding the membership and implementation process. Kingdon holds that agenda-setting can be viewed as three independent streams of activities – problem, policy, and political – that converge together to create a “policy window” which then allows the relevant matter to reach government-level agendas (Anderson, Citation2015; Kingdon, Citation2011). Dolowitz and Marsh (Citation1996) define another relevant theoretical framework, policy transfer theory, as “a process in which knowledge about policies, administrative arrangements, institutions etc. in one time and/or place is used in the development of policies, administrative arrangements and institutions in another time and/or place.” Policy transfer theory can help understand the diffusion of the WHO AFCC model from the WHO to its member countries, and also across cities within South Korea.

With respect to specific literature that has informed our current research, Kendig et al. (Citation2014) wrote an Australia-based review on the implementation of the AFCC initiatives, with a focus on Canberra, Sydney, and the state of Victoria. They found that each city had different reasons for joining – from a highly supportive, committed leader’s initiative, to a local government’s follower strategy – and varied implementation experiences; however, a commonality was the problem of financial strain during a time when most nations were aiming for fiscal austerity. Garon et al. (Citation2014) reviewed the collaborative work to encourage implementation effectiveness among age-friendly cities in Quebec, but did not address the process of gaining membership. Buffel and colleagues’ work (Citation2014) is one of very few case studies in which the authors described how the cities decided to pursue membership in the Network. For instance, Manchester’s efforts to make the city more age-friendly started back in 1993 with a working group supporting the European Union (EU)’s year of older people (Buffel et al., Citation2014). These efforts carried over into the 2003 Valuing Older People program and 2009 Manchester Aging Strategy, whose framework matched that of the WHO AFCC, and led Manchester to become the first U.K. city in the Network (Buffel et al., Citation2014). In the case of Brussels, a research project called Belgian Aging Studies helped the city to fulfill the first three steps of the AFCC membership planning phase – a perfect gateway for Brussels to apply for membership in 2009 (Buffel et al., Citation2014).

Conspicuously absent are many studies from East Asia. In a rare case study of Taiwan, Chao and Huang (Citation2016) noted that the WHO AFCC model might not always fit the East Asian context, wherein differences in family values and expected filial piety create a different dynamic from Western countries. These authors called for a uniquely Asian form of age-friendly cities. A more recent study by Chui et al. (Citation2019) used the WHO AFCC model to examine how older adults in Hong Kong perceived the age-friendliness of their community and reported a conflict between the needs of the aging population and the kind of efficiency and commercialization needed in a dense, economically advanced, urban environment. Case studies of South Korean member cities are also very few (e.g., Kim & Kim, Citation2008; Lee & Kim, Citation2017; Lee & Lee, Citation2011, Citation2012), and most represent general assessments by member cities’ research institutes of how age-friendly their respective cities were, according to the WHO AFCC guidelines. The study by Lee and Kim (Citation2017) examined the perception of age-friendliness by older adults themselves in Busan and found that perceptions of age-friendliness varied across the eight domains of WHO guidelines. On the other hand, Chung and Youn (Citation2014) conducted a case study of the age-friendly practices of a member city, comparing a city ordinance passed by Seoul to the WHO AFCC guidelines.

Previous research has contributed to introducing and evaluating the WHO AFCC model; still, there is a concerning lack of research on (a) Asian cities and (b) the process behind membership and implementation, not just the interventions themselves. The current research, drawing on both multiple stream theory and policy transfer theory, seeks to better understand the policy process behind membership and implementation of the WHO AFCC Network in Asian cities in order to address these gaps in the literature. As such, this study aims to explore the interplay of social, political, and cultural forces that have led cities in South Korea to join the WHO AFCC Network as a solution to the social problems caused by population aging, as well as progress with model implementation in each city. Finally, we aim to generate practical policy recommendations for the improvement and sustainability of the WHO AFCC Network in Asia and the broader world.

Methods

Results

From the qualitative analysis, four main themes and ten subthemes emerged (see Table 3).

Discussion

Findings from this study suggest that there is significant political motivation for joining the WHO AFCC Network. In Korea, the leaders of each city and community are under pressure to perform and demonstrate visible proof that they are working for the city on meaningful projects. Gaining membership in a network organized by a prominent international organization such as WHO represents a meaningful achievement to be included among mayors’ and city administrators’ successes.

According to these interviews, the driving force behind the political motivations took several forms, from election year platforms to a new local department that needed to find work projects for itself. Given that population aging has become a widely noted social issue, pursuing and gaining membership in the Network provided legitimacy to a range of key political stakeholders and powerful people in the cities and communities. The findings also suggest that strong leadership was needed not only to apply for the initial membership, but also after membership was gained. This correlates with a previous study by Kendig et al. (Citation2014) where vibrant new age-friendly city initiatives in Australia were attributed to charismatic State Ministers of Health and committed advisors.

The themes and subthemes derived from these interviews are not disparate ideas. They are, in many ways, linked to one another and affect each other, coming together to culminate in a key question: Why has the WHO AFCC Network become such a popular way to approach the issue of population aging in South Korea? Application of a public policy framework may help to answer this question. There is an assumption that public policy agendas are set and chosen as a solution-oriented response to major social problems (Smith & Larimer, Citation2017, p. 93). However, if that were truly the case, then it would be expected that many other Asian cities would also have joined. While there are other East Asian member cities, no other nation has joined with the gusto that Korea has shown. John Kingdon’s multiple streams agenda setting model, which identifies a problem, a policy, and a political stream, provides a theoretical framework to help answer the question. The problem stream is the concern that stakeholders want to affect (Kingdon, Citation2011). Here, the problem stream would be the issue of South Korea’s rapidly aging population. The policy stream consists of solutions for the problem. Given the numerous stakeholders, such as public officers, academics, bureaucrats, etc., Kingdon states that the many possible solutions slosh around in a “policy primeval soup” until they are either selected or killed off (Kingdon, Citation2011). In our case, we already know which policy survives: the WHO AFCC model. Finally, the politics stream is comprised of variables such as public mood, elections results, administration changes, and pressure group campaigns (Kingdon, Citation2011). When these three streams converge and join together, the policy window opens for a short amount of time, and the agenda is set. The hot topic of population aging coupled with the attractive international-organization-led solution, i.e., the WHO AFCC model, in a ripe political climate (usually recent favorable elections), led to the policy window of membership in the Network opening in South Korea.

The significance here is that the final outcome of the agenda setting process was membership in the WHO AFCC Network, not the creation of an age-friendly city. In order to understand the policy process for the implementation of age-friendly practices, the three streams must be considered again. Now, the “problem” is the membership. The policy is a combination of the WHO guidelines, each city’s action plans, and other age-friendly practices. Finally, the politics: it is here that the problem occurs. There is no ongoing favorable political climate. Elections are over, and the key stakeholders involved in pushing the agenda of membership through have been satisfied, so there is no urgency. The first two streams have been coupled, but the last stream has failed to join them, resulting in a lackluster effort toward the implementation of age-friendly city practices.

An interesting and unexpected theme that fell beyond the boundaries of Kingdon’s “multiple streams” model was the role of Seoul as a trailblazer and de facto mentor to subsequent member cities. This particular theme is better viewed within the framework of policy transfer theory. The patterns of WHO AFCC adoption within Korea – with Seoul as the de facto leader – follow traditional policy transfer and diffusion theories. The four main mechanisms in policy diffusion have been identified as competition, learning, imitation, and coercion (Shipan & Volden, Citation2008). While these mechanisms are interrelated, they are also conditional, with certain mechanisms having more influence than others. For example, Shipan and Volden (Citation2008) have found, through a study of antismoking policy choices, that larger cities are better at learning from other governments, less susceptible to economic pressure, and less likely to imitate others. In reverse, smaller cities are more susceptible to economic pressure, learn little from other governments, and most importantly, are more likely to imitate larger cities. In the Korean case, Seoul – being not only the first city to join but also the largest city in the country – has become the city to imitate. As several of the interviews here revealed, subsequent cities joining the Network benchmarked Seoul and its policies. In addition, the interviewee based in Seoul worked to update the WHO AFCC webpage of Seoul in both Korean and English and has made herself available to any other Korean cities that want to join the Network. Having this kind of information and help available locally is very important, particularly since language barriers make it difficult for the project managers to study and learn about the WHO AFCC guidelines on their own.

Seoul has undoubtedly helped many cities in Korea join the Network, but it can only do so much to help other cities; the manager and researcher have other duties and other projects. So far, the interviewee at Seoul has done a fine job of helming the current informal network of cities, which has been able to satisfy current needs. However, policy diffusion studies (Shipan & Volden, Citation2012) have shown that policymakers in the smaller regional cities, who have limited time, little human resource support, and too few experts, will not be able to take full advantage of policy lessons provided by bigger cities who have more time, support, and expertise available. Given the high interest in the AFCC Network and the growing number of members, a more formal network is clearly needed not only for guidance in gaining membership, but also for continuity, encouraging more active participation in the Network, and making better use of lessons learned. Nevertheless, the current basic mentorship model (without a formal domestic network) could be useful for consideration in other Asian countries with cities that have just started to join the WHO AFCC Network. If a member city with significant resources and the wherewithal to provide mentorship was available in each Asian nation, we might see a significant increase in member cities throughout Asia.

Conclusion

Through an interview-based qualitative study with administrators and researchers from South Korean WHO AFCC Network member cities, these findings have contributed to understanding the factors affecting participation in the Network and its implementation in South Korea – one of the leading Asian countries in adopting the WHO AFCC model. Study findings have important implications for the continuity and improvement of current and future Network member cities. The decision to apply for membership among Korean municipalities is often characterized by strong political motivations and strong leadership. Strong leadership needs to continue after initiating membership to ensure successful implementation of Network guidelines and to begin to create age-friendly cities, especially to overcome the shortage of resources that each city faces.

A policy process framework analysis also has revealed that the issue of population aging and the availability of an internationally accredited solution, combined with the right political environment, created the perfect storm for getting membership in the Network on the local governmental agenda. However, lack of political will or a favorable environment after membership has stunted the implementation of age-friendly practices in the cities. Nationally, more resources are needed in order to better achieve policy diffusion through the example and mentoring available from Seoul. Future research is needed both in Korea and throughout rapidly aging Asia, where studies on the cross-national and cross-cultural aspects of the WHO AFCC model are lacking.