Ageing in Asia Contemporary Trends And Policy Issues 9789813225558, 9813225556

Table of contents :
Intro
CONTENTS
Preface
About the Editors
About the Contributors
Introduction: Regional Trends and Issues
DEMOGRAPHY
ECONOMIC DEVELOPMENT
GENDER AND OLD-AGE ECONOMIC SECURITY
EPIDEMIOLOGY OF NON-COMMUNICABLE DISEASES
ACTIVE AND PRODUCTIVE AGEING
SOCIAL-CULTURAL ASPECTS: FAMILY AND FILIAL SUPPORT
INCOME SECURITY
URBAN ENVIRONMENT
HEALTH AND HEALTHCARE
MENTAL HEALTH
LONG-TERM CARE
PALLIATIVE CARE
TECHNOLOGY AND SOCIAL INNOVATIONS
CONCLUSIONS
Chapter 1 Demography
1.1. INTRODUCTION
1.2. SOURCE OF DATA
1.3. EAST ASIA
1.3.1. Magnitude and Structure of the Aged Population 1.3.2. Speed of Ageing in East Asia1.3.3. Life Expectancy
1.3.4. Remaining Life Expectancy
1.3.5. Median Age and Prospective Median Age
1.3.6. Sex Ratio
1.3.7. Labour Force Indicators
1.3.8. Prospective Old-age Dependency Ratio
1.3.9. Rural-urban Distribution
1.3.10. Health Trends
1.4. SOUTHEAST ASIA
1.4.1. Magnitude and Structure of the Aged Population
1.4.2. Speed of Ageing
1.4.3. Life Expectancy
1.4.4. Remaining Life Expectancy
1.4.5. Median Age and Prospective Median Age
1.4.6. Sex Ratio
1.4.7. Labour Force Indicators
Prospective old-age dependency ratio 1.4.8. Rural-urban DistributionHealth trends
1.5. SOUTHERN ASIA
1.5.1. Magnitude and Structure of Aged Population
1.5.2. Speed of Ageing
1.5.3. Life Expectancy
1.5.4. Remaining Life Expectancy
1.5.5. Median Age and Prospective Median Age
1.5.6. Sex Ratio
1.5.7. Labour Force Indicators
1.5.8. Prospective Old-age Dependency Ratio
1.5.9. Rural-urban Distribution
1.5.10. Health Trends
1.6. CONCLUSION
APPENDIX
Chapter 2 Economic Development
2.1. THE FEAR OF POPULATION AGEING
2.2. ECONOMICS OF POPULATION AGEING
2.2.1. Impacts of Economic Development 2.2.2. Impacts on Economic Development2.3. ECONOMIC DEVELOPMENT BY STAGES OF POPULATION AGEING
2.3.1. Classification of the Stages
2.3.2. Super-Aged, Aged, and Almost-Aged Countries
2.3.3. Early Ageing Countries
2.3.4. Almost Ageing Countries
2.3.5. Young Countries
2.3.6. Very Young Countries
2.4. ECONOMIC DEVELOPMENT AND POPULATION AGEING: STATISTICAL CORRELATION
2.5. CONCLUDING REMARKS
Chapter 3 Gender and Old-Age Economic Security
3.1. INTRODUCTION
3.2. DRIVERS OF FEMALE OLD-AGE ECONOMIC INSECURITY IN ASIA
3.2.1. Education and Income Gender Inequality 3.2.2. Financial Inclusion and Capability3.2.3. Social and Family Support in Old Age
3.2.4. Pension Design
3.3. CASE STUDIES: LESSONS ON OLD-AGE FEMALE ECONOMIC SECURITY FROM KOREA, CHINA, AND INDIA
3.3.1. Korea: Reducing Poverty Does Not Reduce Disparity
3.3.2. China: For Older Women, Health is Wealth
3.3.3. India: Family Ties Can Help or Harm
3.4. CONCLUDING OBSERVATIONS AND POLICYIMPLICATIONS
Chapter 4 Epidemiology of Non-Communicable Diseases
4.1. CHANGING FACE OF NCDs IN ASIA
4.2. NCD AND RISK PATTERNS ACROSS ASIAN COUNTRIES

Citation preview

Ageing Asia in

10585_9789813225541_tp.indd 1

Contemporary Trends and Policy Issues

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World Scientific Series on Ageing in Asia

The series will discuss population ageing and health policy trends in leading countries and societies of Asia, analyze the regional issues and experiences related to these trends and offer lessons to inform wider policy debates of global ageing challenges and eldercare systems development in other regions. More specifically, the books in the series will attempt to address the following questions: 1. What are the forces affecting population ageing and health of the elderly in Asia? 2. How do health and social care systems compare in their responses? 3. Are there policy implications and lessons for health and social care programs? Published: Vol. 1 Ageing in Asia: Contemporary Trends and Policy Issues edited by Phua Kai Hong, Goh Lee Gan and Yap Mui Teng

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World Scientific Series on

Ageing in Asia

Ageing Asia in

Contemporary Trends and Policy Issues

editors

PHUA Kai Hong

Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore

GOH Lee Gan

Yong Loo Lin School of Medicine, National University of Singapore, Singapore

YAP Mui Teng

Institute of Policy Studies, Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore

World Scientific NEW JERSEY

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LONDON

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SINGAPORE

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BEIJING

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SHANGHAI

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HONG KONG

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TAIPEI

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CHENNAI

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TOKYO

4/4/19 10:08 AM

Published by World Scientific Publishing Co. Pte. Ltd. 5 Toh Tuck Link, Singapore 596224 USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601 UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE

National Library Board, Singapore Cataloguing in Publication Data Name(s): Phua Kai Hong, editor. | Goh Lee Gan, editor. | Yap Mui Teng, editor. Title: Ageing in Asia : contemporary trends and policy issues / editors, Phua Kai Hong, Goh Lee Gan, Yap Mui Teng. Other title(s): World Scientific series on ageing in Asia ; vol. 1 Description: Singapore : World Scientific Publishing Co Pte Ltd, [2019] | Includes bibliographical references and index. Identifier(s): OCN 1090808469 | ISBN 978-981-3225-54-1 (hardback) Subject(s): LCSH: Older people--Government policy--Asia. | Older people--Asia--Social conditions. Classification: DDC 362.6095--dc23

British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library.

Copyright © 2019 by World Scientific Publishing Co. Pte. Ltd. All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the publisher.

For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher. For any available supplementary material, please visit https://www.worldscientific.com/worldscibooks/10.1142/10585#t=suppl Desk Editor: Sylvia Koh Typeset by Stallion Press Email: [email protected] Printed in Singapore

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“The demographic destiny of Asia is closely intertwined with how well Asian economies manage their ageing populations. Phua Kai Hong, Goh Lee Gan and Yap Mui Teng have added another important contribution to the growing literature on this issue. They do not just look at the trends of ageing in Asia and the accompanying challenges and risks, but also identify best practices and solutions from around the region that empower the elderly to lead healthy, productive and fruitful years in their old age.” Goh Chok Tong Emeritus Senior Minister and Former Prime Minister

“This book represents a comprehensive approach to the universal issues faced by ageing populations. The editors — a health economist, a family medicine practitioner and a demographer — have provided an essential inter-disciplinary framework for the authors to present a rich picture of issues and policy responses across Asia. As well, there are case studies of ground-up initiatives which may serve as models for other ageing communities. What stands out in this volume of contributions is the role of social and cultural factors in providing a truly holistic health care environment for the elderly. Healthcare as medicine, and healthcare as finance have joined healthcare as social science in this compendium.” Dr Aline Wong Former Professor of Sociology and Former Minister of State for Health and Education

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PREFACE The global phenomenon of ageing populations has posed immense challenges to countries and societies in many ways. Although an ageing population is a celebration of success in overcoming early mortality, governments and international organizations struggle to come up with a coherent and holistic policy framework to deal with the issues of ageing populations. The demographic transition towards an ageing population has profound impacts on the ways health and social care are organized and delivered. Many countries in rapidly developing Asia have undergone an epidemiological transition and entered a stage where the burden of disease comes largely from non-communicable diseases (NCDs). The increased incidence and prolonged nature of chronic conditions are expected to require medical care for extended periods of time thus increasing expenditure. Ageing is also compounded by the presence of co-morbidities, which is the co-occurrence of multiple diseases or medical conditions within one person. The ageing of populations has therefore exerted reform pressures on health and social care systems due in part to the changing patterns of morbidity. The nature of chronic diseases will require complex forms of treatment that is not centered on acute hospitals alone but often require lifestyle interventions and long-term care. Yet existing health and social care systems are often fragmented that see co-morbidities and needs of patients being handled in institutional or departmental silos without complete information about the individuvii

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al’s background, medical history and conditions. The complexity of care-giving to ensure the health of the elderly entails developing “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” — WHO’s official definition of health as adopted by most sources. This goes beyond the traditional understanding of health as a status that is purely physical and requires a look at how models of care need to be put in place to deliver care for the holistic well-being of an individual. In many national healthcare delivery systems, the medical and social services are characterized by professional divisions. There is a persistent cultural, structural and hierarchical divide between medical and social care that often impedes the development of common understanding. The predominance of curative medical services often overshadows preventive healthcare and social care. The perceived prestige of curative medical services that led to its dominating voice has resulted in tension between the health and social care services, considered a threat to realizing developing integrated health and social care services for the elderly. Medical professionals caution against being dismissive of the contributions of social care to the well-being of an individual. It is critical that health systems move from the narrow clinical focus and include their partners in social care to the change the way that care is being delivered to the elderly. The imperative to do so is particularly acute for ageing populations as NCDs associated with old age are often multi-factorial and long-term, and interventions likewise cannot be clinically centered but require a holistic approach for the well-being of the individual beyond institutional walls. The growing longevity of populations has also raised concerns on the financial strain it may pose on national and individual budgets as the lengthened lifespan raises the potential for increasing periods of illness and dependency. This is projected to increase as populations age over the next decades. A potential loss of productivity due to NCDs is significant as chronic disease requires long-term management, thus affecting work performance due to poorer health or disability. The ageing population has thus created demands for reforms of the healthcare system and a huge impetus

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for re-engineering of the ways health and social care are being delivered, financed and regulated. The healthcare models of many developed countries were created for an era when diseases were acute and episodic in nature, however the current model now is challenged by its past success. With the demographic pressure of an ageing population, healthcare systems will have to pay more attention to the prevention and management of NCDs as well as transit from providing care in acute settings to community-based care that will involve multiple stakeholders and entail care beyond the medical dimension but includes the social aspects. This book contains a broad and comprehensive collection of contemporary trends and policy issues across the ageing societies of Asia. The various authors are experts and practitioners who have based their writings on their work or research analysis of available data of regional and country systems from primary and secondary sources. These included academic publications; current information from media, internet and library sources; social care and healthrelated agencies covering the public, private and voluntary sectors; reports of community and international organizations, major meetings and key speeches of policy-makers within the Asian region. The following approaches were taken where information was available: · Comparative trend analysis that will synthesize qualitative and quantitative information into a narrative form that concentrates on the interpretation of policy discourses and discontinuities; emergent changes or innovations; processes and reaction to emergent trends and impact on the aged population group and society at large. · Innovative examples and case studies of policies in ageing societies like Japan, Korea, Taiwan, Hong Kong and Singapore. As these countries are the forerunners of the aged society in Asia, they are at the vanguard of driving important policy reforms to meet the challenges of ageing. They also play an important agenda-setting role in regional responses to various health and social policy issues and therefore offer many lessons to avoid or best practices to be adopted.

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Many rapidly ageing societies in East Asia experienced periods of rapid economic growth compressed in a few decades. Their economic successes have been widely lauded and examined, but the social models of these nations have often been overlooked despite the outstanding performances in health status. Given the enormity of the ageing problem, these countries share the concerns of aged populations, but the approaches undertaken in every country are radically different due to differing contexts. While policy-making in one is characterized by greater political contestation, others may involve debates of social norms and public involvement. Yet there are other calls for rational and evidence-based policy making that considers a whole-of-society approach towards meeting national challenges. The contents of this book had developed from several related research studies and conferences where some preliminary findings were earlier presented. These had included researchers from the region who had earlier agreed to add to the rich and diverse experiences from across Asia. Due acknowledgements should be given to the following who presented papers and participated in the various academic activities: NUS Initiative in Promoting Health in Asia (NIHA) Comparative Study of Health and Social Care for Ageing Populations of Asia (2012–2014) · Phua Kai Hong (Lee Kuan Yew School of Public Policy) · Goh Lee Gan (Division of Family Medicine, Yong Loo Lin School of Medicine) · Yap Mui Teng (Institute of Policy Studies, LKYSPP, NUS) · Thang Leng Leng (Department of Japanese Studies) · Syahirah A. Karim (Lee Kuan Yew School of Public Policy) · Tania Ng (Lee Kuan Yew School of Public Policy) Social Science and Medicine (SSM) Conference on Health Systems in Asia, Singapore, 2015 · Phua Kai Hong (Lee Kuan Yew School of Public Policy, National University of Singapore)

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· Thang Leng Leng (Dept of Japanese Studies, National University of Singapore) · Eng Kiong Yeoh (School of Public Health and Primary Health Care, Chinese University of Hong Kong, Hong Kong SAR) · Soonman Kwon (School of Public Health, Seoul National University, South Korea) · Rachel Jui-Fen Lu (Chang Gung University, Taiwan) Institute of Policy Studies Workshops on Comparative Health and Social Care in Asia, 2015–6 Authors/Co-authors · Phua Kai Hong, Lee Kuan Yew School of Public Policy, NUS · Goh Lee Gan, Division of Family Medicine, Yong Loo Lin School of Medicine, NUS · Yap Mui Teng, Institute of Policy Studies, LKYSPP, NUS · Christopher Gee, Institute of Policy Studies, LKYSPP, NUS · Yvonne Arivalagan, Institute of Policy Studies, LKYSPP, NUS · Fung John Chye and Yeo Su-Jan, School of Design and Environment, NUS · Thang Leng Leng, Department of Japanese Studies, Faculty of Arts & Social Science, NUS · Aris Ananta and Evi Nurvidya Arifin, University of Indonesia · Thelma Kay, Former Director, UNESCAP, Bangkok · Kua Ee Heok, Dept of Psychological Medicine, Yong Loo Lin School of Medicine, NUS · Fong Ngan Phoon, Saw Swee Hock School of Public Health, NUS Advisors and Resource Persons · Kenji Shibuya, Department of Global Health, University of Tokyo, Japan · Paul Ong, WHO Collaborating Centre for Health Sector Development, Kobe, Japan

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Research/Administrative Staff · Marie Nodzenski, Research Associate, Lee Kuan Yew School of Public Policy, NUS · Rachel Hoa Li Fang, Executive, Institute of Policy Studies, LKYSPP, NUS The final form in which the various chapters appear in this book reflects the many additions and modifications as different experts were approached to add to the original list of papers and to fill in the various gaps that were identified to make the book complete. We would like to thank the many research students under the supervision of Dr Phua Kai Hong, who had contributed parts of their research, including Dr Winston Chin who wrote a Master in Public Health dissertation on Long Term Care in Singapore, and Master in Public Policy students who conducted a Public Policy Academic Exercise (PAE) for the Gerontological Society of Singapore, consisting of Jessica Loo, Puttiporn Soontornwipat and Gimhong Gove. We also wish to thank reviewers of the earlier drafts for their feedback, including medical students Victor Shek and Laura Phua. Many complex issues arose to delay the completion of the book since the conclusion of the author workshops in 2015 and 2016. Some of the participants in the earlier comparative studies were naturally reluctant to submit evaluative critiques of their respective health and social systems, while lacking consensus on definite conclusions for policy recommendations on issues of the best forms of health and social care, especially on the existing practices in medical and long term care. In Singapore, the policy debates regarding the financing of long term care had to depend much on critical public consultations and the final release of the ElderShield Review Committee’s full recommendations in 2018. This was soon followed by the announcement of the new CareShield Life scheme to strengthen the long-term care financing system in Singapore in the months of June and July 2018, as premiums had to be computed to be paid fully by withdrawals from Medisave, the compulsory savings scheme for healthcare in Singapore. Even then the longer term

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financing options have yet to be resolved satisfactorily and accepted by major stakeholders. We would like to place on record our appreciation to Emeritus Senior Minister Goh Chok Tong and former Minister of State for Health Dr Aline Wong, (former Chancellor of SIM University, Adjunct Professor of the Lee Kuan Yew School of Public Policy and NUS Professor of Sociology), for writing the messages and lending their support to this publication. Finally, thanks to the publishers, World Scientific Inc, for the editorial assistance provided by Philly Lim, Sylvia Koh and Nuraiziah Johari. A major lesson gleaned in the production of a book of this nature lies not in trying to arrive at a full consensus, as there is no perfect solution to the problems that have arisen. Many of the policies evaluated would become irrelevant and dated with time or changing conditions. We wish that the documentation of the book contents would be read in its proper context and interpreted according to the contemporary issues rising in rapidly ageing countries. The different chapters have provided perspectives of systems undergoing rapid transitions and described examples of best practices and lessons to respond to the changing needs due to population ageing. We hope that the various chapters of this book will be of interest to public policy-makers and practitioners, as well as scholars and students who are interested in development occurring in the leading ageing societies of Asia, a region of great diversity and transformation. Co-Editors Phua Kai Hong Goh Lee Gan Yap Mui Teng

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ABOUT THE EDITORS PHUA Kai Hong is currently teaching Health Economics at the Singapore Management University. He holds adjunct appointments at the Lee Kuan Yew School of Public Policy and the Saw Swee Hock School of Public Health, National University of Singapore, and is Visiting Professor, Graduate School of Public Policy, Nazarbayev University. He was previously Associate Professor and Head, Health Services Research at the Faculty of Medicine, National University of Singapore, and was also Adjunct Senior Fellow at the Institute of Policy Studies, at the Lee Kuan Yew School of Public Policy, National University of Singapore. He graduated cum laude from Harvard University and received graduate degrees from the Harvard School of Public Health (Master in Health Services Administration & Population Sciences) and the London School of Economics & Political Science (PhD in Health Economics). He has produced numerous papers in the field of health policy and management, including the development of health services, population ageing, health economics and financing, comparative health and social policy reforms in the Asia-Pacific region. He is a founding member of the Asian Health Systems Reform Network (DRAGONET), and served as past Chairman of the Executive Board of the Asia-Pacific Health Economics Network (APHEN). He was appointed to many national advisory committees on health and social policy issues in Singapore and is a past Vice-Chairman of the Singapore Red Cross. He has undertaken healthcare consulting xv

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assignments for international organisations including the Asian Development Bank, United Nations Economic and Social Commission for Asia Pacific, World Bank, World Health Organization, and ministries of health in East Asia and the Middle East. He also served as Chairman, Technical Advisory Group on Health Sector Development in the WHO Western Pacific Regional Office (2000– 2005), and moderated several WHO regional meetings on health systems and a Ministerial Round table on Health and Poverty. He delivered the ST Lee Lecture at the Centre for Health Policy, University of Sydney and the Australian National University in 2012, and was a member of the WHO Expert Committee on the Economics of Healthy Ageing (2017–2018). GOH Lee Gan is a Senior Consultant in the Department of Family Medicine, National University Health System, and an Associate Professor in the Yong Loo Lin School of Medicine, National University of Singapore. His contributions are in Family Medicine, Public Health and Internal Medicine in teaching, practice, and research. He was a Past President of the Gerontological Society of Singapore, Past President of College of Family Physicians, Singapore; Past President of Singapore Medical Association; and Past President of Asia Pacific Region, World Organisation of Family Doctors (Wonca). YAP Mui Teng is a Principal Research Fellow at the Governance and Economy Department at the Institute of Policy Studies, Lee Kuan Yew School of Public Policy. She is also an Associate of the Changing Family in Asia Cluster at the Asia Research Institute (ARI), National University of Singapore. She has written and published widely on fertility and family planning, migration, and ageing in Singapore and the region and was formerly a statistician in two government agencies and a researcher in the East–West Center in Honolulu, Hawai’i. Mui Teng has a Bachelor of Social Sciences (Honours) degree from the University of Singapore, and holds Master and PhD degrees from the University of Hawai’i.

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ABOUT THE CONTRIBUTORS Aris ANANTA is an economist-demographer with a multidisciplinary perspective. His regional research interest was Southeast Asia, with a special focus on Indonesia. Since 2015, he has expanded his regional interest into Asia and Africa. The nexus between ageing, population mobility, and development has been one of his research interests. Now, he relates this issue with changes in population com­ position in terms of ethnicity, race, language, and religion. He is Professor at the Faculty of Economics and Business, Universitas Indonesia, West Java, Indonesia. He was a Senior Research Fellow at ISEAS (Institute of Southeast Asian Studies), Singapore, during 2001–2014, after teaching at Department of Economics, National University of Singapore in 1999–2000. Since 1983, after getting his Ph.D. in Economics from Duke University, USA, he has devoted his time to teach, research, and manage aca­ demic institutions at the Universitas Indonesia. Evi Nurvidya ARIFIN is a statistician-demographer, armed with a multidisciplinary inter­est. Working with survey data is one of her passions. She has been working on ageing, migration, fertility/family planning, health, and ethnicity/ religion/ language. Beyond demography, she also works on politics, poverty, and economics. Her regional research interest extends from Indonesia and Southeast Asia to Asia. Currently, she is teaching at the Study Programme on Public Health at the Graduate Programme of the Universitas Respati

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Indonesia, Jakarta, Indonesia; International Special Class at the Faculty of Economics and Business, Universitas Indonesia, West Java, Indonesia; and Master Programme in Economics of Population and Labour at the Faculty of Economics and Business, Universitas Indonesia. She earned her Ph.D. in Social Statistics, spe­cialising in demography, from the University of Southampton, UK, in 2001. She did her post-doctoral programme at the Asian Meta Centre on Population and Sustainable Development in National University of Singapore. Subsequently, she joined the Institute of Southeast Asian Studies, Singapore as a visiting research fellow. She was a post-doctoral fellow at the Asia Research Institute, National University of Singapore, and a visiting research fellow at the University of Oxford and University of Canberra. Yvonne ARIVALAGAN is a Research Associate in the Governance and Economy Department at the Institute of Policy Studies, Lee Kuan Yew School of Public Policy, where she conducts research on population ageing, healthcare systems and family policies. She also has prior work experience in the Ministry of Foreign Affairs, Ministry of Defence and Singapore Press Holdings. She holds a Master’s degree (Distinction) in Development Studies from the Katholieke Universiteit Leuven as well as a Bachelor of Social Sciences (Hons.) in Political Science from the National University of Singapore. Cynthia CHEN is an Assistant Professor at the Saw Swee Hock School of Public Health, National University of Singapore (NUS). She received her PhD in Public Health and Masters in Statistics from NUS. She was subsequently awarded the NUS-Overseas Postdoctoral Fellowship and completed her postdoctoral training in the United States, at the University of Southern California (USC), Schaeffer Center for Health Policy and Economics. At USC, she worked on research projects in the economics of ageing and her projects were supported by prominent private philanthropy in the US. She is also involved in multiple grants in Singapore and the United States

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including the National Institute on Ageing. She plans to continue developing her economics of ageing research and develop models for Singapore and Asia. She will continue to explore health outcomes, health care utilisation and expenditures and evaluate the likely impact of policies. Before graduate school, she served as Policy Analyst at the National Population and Talent Division, Prime Minister’s Office, Singapore. Joelle H. FONG is an Assistant Professor at the Lee Kuan Yew School of Public Policy, National University of Singapore. She holds a PhD in Applied Economics from the Wharton School of the University of Pennsylvania. Joelle’s research interests focus on the economic and health aspects of population ageing, pension economics and finance, public and private insurance markets, longevity risk management, retirement security, and long-term care. Her research has been published in the Journal of Risk and Insurance, North American Actuarial Journal, Journal of Pension Economics & Finance, Scandinavian Actuarial Journal, and Health Services Research. Most recently, she received the 2017 Patrick Brockett & Arnold Shapiro Actuarial Journal award from the American Risk and Insurance Association. Joelle currently serves on the Executive Committee and Board of Governors for the Asia-Pacific Risk and Insurance Association, and is also an Associate Investigator with the ARC Centre of Excellence in Population Ageing Research, University of New South Wales, Australia.​​ FONG Ngan Phoon is currently an Adjunct Associate Professor with the Saw Swee Hock School of Public Health at the National University of Singapore. His responsibilities include teaching undergraduates, and graduate students in promoting healthy ageing, disease prevention, and improving quality of care in healthcare institutions. He is also the Director of the Graduate Diploma in Applied Epidemiology Program of the School. He is also a part-time Consultant with the Ministry of Health of Singapore with the responsibility of auditing Medishield Life claims from community hospitals. From 2000–2007, he was in the senior management of St Luke’s

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Hospital, a 200-bedded voluntary welfare organization community hospital serving the health needs of older persons in the western region of Singapore. He has a medical degree and a Masters of Science (Public Health) from the National University of Singapore. Dr. Fong has extensive experience in managing a community hospital as well as in equipping health professionals in promoting healthy ageing and disease prevention in the community. FUNG John Chye is Director of the Centre for Ageing Research in the Environment (CARE) at the School of Design and Environment, National University of Singapore (NUS), where he is an Associate Professor. Since 1998, he has taught architecture design at the uni­ versity and his research interests include community, housing, ageing, dementia, and healthcare. His publications include Re-Imagining the Nursing Home in Singapore and the Dementia Design Sourcebook. Prof Fung is a professional architect with 30 years of practice experience and was a partner of the firm that he cofounded. He served as a Council Member of the Singapore Institute of Architects (SIA) for many years and has written extensively for the Singapore Architect as its Executive Editor. Loïc GARÇON has been a Technical Officer for the World Health Organization (WHO) Centre for Health Development in Kobe, Japan, since 2008. He is coordinating research on social and technological innovations for healthy ageing. He also has been involved in activities related to second-hand smoke prevention and equity in urban settings. Mr. Garçon holds a PGDip in Global Health Policy, an MA in Social Sciences, and an MBA. Christopher GEE heads the Governance and Economy Department at the Institute of Policy Studies, a research centre of the Lee Kuan Yew School of Public Policy, National University of Singapore. He researches the policy implications and outcomes arising from Singapore’s demographic trends, in particular those aspects relating to housing, health care, and retirement adequacy. He has also co-led studies on the impact of parenthood measures on fertility

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preferences, as well as a multidisciplinary review of the implications of projected demographic scenarios for Singapore. His current research focus is on the policy implications of longevity, inter-generational accounts and transfers, and the “second demographic dividend”. He co-wrote IPS Working Paper No. 24 — The Investment Risks in Singapore’s Retirement Financing System and has published several pieces on strengthening old-age income support and managing healthcare costs for an ageing population. HENG Chye Kiang is the Lum Chang Chair Professor and immediate past dean of the School of Design and Environment, National University of Singapore. He teaches architecture, urban design and planning and has lectured at universities in Europe and Asia. His research covers sustainable urban design, planning, and the history of Chinese cities. He publishes widely; his books include Singapore Chronicles: Urban Planning (2018), 50 Years of Urban Planning in Singapore (2016), Re-Framing Urban Space (2015), On Asian Streets and Public Space (2010), A Digital Reconstruction of Tang Chang’an (2006), and Cities of Aristocrats and Bureaucrats (1999). Prof Heng consults internationally on urban design and planning and is the conceptual designer of several international urban design competition-winning entries in China. He also serves as editorial board member of several international journals and as jury member of many international design competitions in Asia. He is currently senior fellow at Singapore’s Urban Redevelopment Authority Academy and Centre for Liveable Cities and a Board member of the Housing & Development Board, the Singapore Institute of Technology and NAFA. Thelma KAY is the former Chief of the Social Development Division, United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) and also the former Senior Advisor on Ageing Issues, Ministry of Social and Family Development, Singapore. She currently serves as advisor and consultant to governments, United Nations entities and other international organisations on social development issues, focusing on ageing. She has worked on national

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action plans of ageing, social protection and care (especially longterm care), age-friendly cities and active ageing. Ms Kay was educated at the National University of Singapore (NUS) and the London School of Economics and Political Science. She was a faculty member at the Department of Sociology, NUS. She directed UNESCAP’s work on the United Nation’s global and regional mandates on population and development, gender equality, ageing, and disability. She has been a speaker/panelist at national, regional and global events organised by the Asian Development Bank, ASEAN, AARP, International Federation on Ageing, HelpAge International etc., various United Nations entities, and private sector events. She served on the board of the UNESCO International Institute of Education Planning; School of Energy, Resources and Development, Asian Institute of Technology; and the United Nations International Institute for Ageing, Programme for Asia. She is a council member of the Active Ageing Consortium for Asia Pacific. Elaine KEMPSON is Emeritus Professor of Personal Finance and Social Policy Research at the University of Bristol, and a Visiting Professor at Oslo Met University. She has nearly 30 years experience of policy development and research into consumer behaviour and the provision of financial services, working with governments, NGOs, financial services firms and financial services regulators across a wide range of countries. This has included working as a consultant with the Word Bank (2010-2017) and the OECD (20082010) and membership of the European Commission Expert Group on Financial Education (2009-2011). In 2007, she was awarded a CBE in the Queen's Birthday Honours List for services to the Financial Services Industry. Paul KOWAL is coprincipal investigator for the WHO Study on global AGEing and adult health (SAGE); Conjoint Senior Research Fellow at the University of Newcastle’s Priority Research Centre for Generational Health and Ageing in Australia; Courtesy Research Association in the Department of Anthropology, University of Oregon; Consultant with HelpAge International Asia Pacific

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Regional Office (Thailand) and Vantage Health Solutions, Inc. (Myanmar). Dr. Kowal has many years of experience with multicountry studies on aging, health, and well-being, non-communicable diseases, and health systems strengthening. Prior to his public health research, he practiced in the US as a clinical geriatric pharmacist for 4 years. Dr. Kowal obtained his Bachelor of Science in pharmacy practice from the University of Wisconsin–Madison and a Master of Science in pharmacoepidemiology from the University of Minnesota, where he was also a Geriatric Pharmacotherapy Research Fellow. He obtained his doctoral degree from the University of Washington. KUA Ee Heok is the Tan Geok Yin Professor of Psychiatry and Neuroscience at the National University of Singapore (NUS), and Senior Consultant Psychiatrist at the National University Hospital, Singapore. He was trained as a doctor at the University Malaya and received postgraduate training in psychiatry at Oxford University and in geriatric psychiatry at Harvard University. A member of the World Health Organization team for the global study of dementia, he is the previous Head of the Department of Psychological Medicine and Vice-Dean, Faculty of Medicine, at NUS, and a past Chief Executive Officer and Medical Director at the Institute of Mental Health, Singapore. His research interest includes depression, dementia, and alcoholism, and he has written 23 books on psychiatry, ageing, and addiction. The former President of the Pacific-Rim College of Psychiatrists and President of the Gerontological Society of Singapore, he was Editor of the Singapore Medical Journal and Asia-Pacific Psychiatry Journal. He is one of the Editors-in-Chief (with Norman Sartorius) of the new 6-volume series on Mental Health and Illness Worldwide. Marie NODZENSKI is a PhD candidate at the London School of Hygiene and Tropical Medicine. She worked as a Research Associate for the Lee Kuan Yew School of Public Policy (National University of Singapore) from 2012 to 2016. Her research interests include global health governance and diplomacy, global health issues such as

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migrants’ health, health and development in the Asia-Pacific region. Her research at the Lee Kuan Yew School of Public Policy mainly focused on regional health governance in Southeast Asia and on the role of ASEAN as a regional organization to manage transnational health threats, including the growing concern of low-skilled migrants’ health in the ASEAN region which holds potential negative repercussions for economic development and political stability. Nodzenski is the co-author of several publications on these topics. Prior to joining the school, Nodzenski acted as an official representative to the United Nations in Geneva (Switzerland) for a non-governmental organization, specifically working towards the adoption of the Declaration on Human Rights Education and Training by the United Nations Human Rights Council and General Assembly. Nodzenski holds a MA in International Relations from the Brussels School of International Studies (University of Kent, UK). She is currently based in Hong Kong SAR. Paul ONG is a Technical Officer with the Innovations for Healthy Ageing Program at the World Health Organization (WHO) Centre for Health Development in Kobe, Japan. Paul coordinates research into health workforce and political economy of Universal Health Coverage (UHC) issues in light of the challenges brought about by population ageing. He was previously the Global Health Policy Adviser for HelpAge International in London, the specialist global NGO working on ageing and older people’s issues. Paul has an Epidemiology and Health Services Research background. He was both a graduate and a Fellow at Mansfield College, University of Oxford, before entering the sphere of International Development. Donghyun PARK is currently Principal Economist at the Economics Research and Regional Cooperation Department (ERCD) of the Asian Development Bank (ADB), which he joined in April 2007. Prior to joining ADB, he was a tenured Associate Professor of Economics at Nanyang Technological University in Singapore. Dr. Park has a Ph.D. in economics from UCLA, and his main research fields are international finance, international

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trade, and development economics. His research, which has been published extensively in journals and books, revolves around policy-oriented topics relevant for Asia’s long-term development, including middle-income trap, service sector development, and financial sector development. Dr. Park plays a leading role in the production of Asian Development Outlook, ADB’s biannual flagship publication on macroeconomic issues, and leads the team that produces Asia Bond Monitor, ADB’s quarterly flagship report on emerging Asian bond markets. Alex ROSS is a Director for Health Systems and Innovation in the World Health Organization (WHO) Headquarters. From 2011 to 2017, he was Director, WHO Kobe Centre (WKC), a global centre for excellence in research on the consequences of social, economic, and environmental change and its implications for health policies. Ross developed WKC’s new 2016–2026 strategy on universal health coverage, innovation, and ageing populations and oversaw its operational research programme to support countries’ efforts to transform their health and social delivery systems in response to rapid population ageing. He also led the Centre’s earlier work on urbanization and health. Ross has 30 years of experience in domestic and global health, specializing in health systems and policy development, international development, planning, and research for a wide variety of health issues. He received his BSPH and MSPH degrees from the University of California in Los Angeles (UCLA) with specializations in health systems, planning, and policy. THANG Leng Leng graduated from University of Illinois at UrbanaChampaign as a socio-cultural anthropologist. She has research interests in ageing, intergenerational approaches and relationships, gender, and family with a focus on Asia, especially Japan and Singapore. She publishes widely in her areas of expertise and is the author of “Generations in Touch: Linking the old and young in a Tokyo neighborhood”, the first ethnographic study of an age-integrated facility. Her coedited books included “Ageing in Singapore: Service needs and the state” (1996, 2012) and “Experiencing

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Grandparenthood: An Asian perspective” (coeditored with Kalyani Mehta, Springer, 2012). She is coeditor-in-chief of the Journal of Intergenerational Relationships and Vice Chair of the International Consortium for Intergenerational Programs. Besides her base where she is head of the Department of Japanese Studies, she is also coDirector of Next Age Institute, and Honorary Fellow with the College of Alice and Peter Tan, National University of Singapore. Kavita VENKATARAMAN is currently an Assistant Professor at the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. She is a clinician and epidemiologist, with research interests in the areas of cardiometabolic diseases with a specific focus on diabetes and its complications, rehabilitation care, care integration, patient perspectives of care, and patient-reported outcomes. She has authored several articles in reputed international journals and has several competitively funded research projects, completed and ongoing in these areas. She also works closely with the Ministry of Health, Singapore, on diabetes, and post-acute care. Within the school, she is involved in undergraduate medical and non-medical, graduate, and doctoral student teaching on the topics of non-communicable diseases and research methods. Dr. Venkataraman was previously with the WHO Country Office India, working as the National Consultant for Non-Communicable Diseases and Mental Health. YEO Su-Jan is Postdoctoral Fellow in the School of Community and Regional Planning at the University of British Columbia, where she teaches academic modules on urbanisation and urban planning. Her research on cities is positioned at the intersections of culture/ society, built environment, and urban policy. She received her PhD in Architecture from the National University of Singapore, where she also held the position of Research Associate at the School of Design and Environment. Joanne YOONG is a Senior Economist at the University of Southern California’s Center for Economic and Social Research (CESR), and

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Director of CESR’s offices in Singapore and Washington DC where her research interests cover health, finance and social protection. Dr Yoong is also an honorary senior lecturer in Global Health at the London School of Hygiene and Tropical Medicine, and an adjunct economist at the RAND Corporation. She has previously held positions as Associate Professor of Health Systems and Behavioral Sciences at the Saw Swee Hock School of Public Health and the Director of the Center for Health Services and Policy Research at the National University Hospital System. Dr Yoong also served as Director of the Asia Pacific Regional Capacity-Building for Health Technology Assessment (ARCH) Initiative, an APEC-funded multicountry collaboration to promote health technology assessment among member economies, Director of the RAND Behavioural Finance Forum 2012, and co-president of the Singapore Health Economics Association. Dr Yoong received her Ph.D. in Economics at Stanford University as an FSI Starr Foundation Fellow and her AB summa cum laude in Economics and Applied and Computational Mathematics from Princeton University.

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b2530   International Strategic Relations and China’s National Security: World at the Crossroads

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INTRODUCTION: REGIONAL TRENDS AND ISSUES Phua Kai Hong, Goh Lee Gan and Yap Mui Teng

This introduction provides an overview and context to the trends and policy issues described in each of the chapters in this book, “Ageing Asia: Contemporary Trends and Policy Issues”. The main goal of this book is to provide useful comparisons of social care systems undergoing rapid transitions, and to offer some examples of current best practices and lessons to meet changing needs due to population ageing in Asia. Fast-ageing, dynamic industrialising and urbanizing economies in Asia were selected for this regional comparative study — Japan, Korea, China, Hong Kong, Taiwan, and Singapore. Together, they presented a kaleidoscope of experiences learnt in coping with rapidly rising numbers of ageing persons in their midst. These can offer possible solutions to younger nations within and outside Asia, as they transition into the future to become aged and super-aged societies. The lived experiences and trends, together with corresponding public policies to contemporary challenges arising from the growing needs of an ageing population, are examined in a sequence of chapters appearing in the order of the book.

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DEMOGRAPHY In the first chapter, demographic trends of ageing in Asia are described using demographic indicators. These can be grouped into the conventional indicators of measuring magnitude and structure of the aged population, speed of ageing, life expectancy, sex ratio, labour force indicators, and rural-urban distribution. In addition, there are now in existence newer measures of ageing namely, age at which remaining life expectancy is 15 years or less, percent of the population with remaining life expectancy of 15 years or less, prospective old age dependency ratio (POADR), median age, and prospective median age. The demographic trends of three Asian sub-regions — East Asia, Southeast Asia, and Southern Asia, are examined in detail and compared. Close to 80% of East Asians aged 80 or older will be in China by midcentury. The ageing of the older population is also occurring swiftly in other East Asian societies, namely Japan, South Korea and Hong Kong. By mid-century, the growth rate of the 80+ age group in East Asia is set to overtake that of Southeast Asia and Southern Asia together. Singapore will continue to be the Southeast Asian country with the highest proportion of people aged 80 or above. In 2015, 2.4% of Singapore’s population, or 133,000 people, were in this age category and the share is expected to increase to 13.8%, or 921,000 people by 2050. Public policies will thus need to consider the wide-ranging population implications and matters related to ageing.

ECONOMIC DEVELOPMENT  This chapter examines economic and demographic situations of 50 Asian countries by their stages of population ageing. The demographic situation of a country is reflected by the total fertility rate (TFR), life expectancy at birth, and net migration rate per 1,000 population. The so-called Superaged, Aged, and Almost Aged economies are also known as countries that are “money rich, time poor”. These countries benefitted from the post-WWII Baby Boom, but are now the first to experience the challenges of ageing that follows the

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first demographic dividend (which arose from a greater proportion of people at working ages engaged in productive employment relative to those who consume more than they earn, as the result of decreased fertility) and the second demographic dividend (which is due to individuals because they have longer life expectancy, and now have greater incentives to invest in their human capital, especially in health and education). Almost Aged South Korea as the fastest ageing economy and Early Ageing China as the country with the biggest number of elderly people have time-pressured challenges of meeting the ageing infrastructure demands by 2030. Large absolute increase of elderly put significant strain on the country’s elderly healthcare infrastructure. Pre-ageing countries (Almost Ageing and Young Populations) need to grow rich before they grow old. Vietnam, Malaysia, India, Indonesia, and the Philippines have the youngest demographic profiles and are all developing economies with relatively low levels of GDP per capita. They need to establish more sustainable healthcare models, with the opportunity to leapfrog outdated healthcare practices. These countries generally have limited elderly healthcare infrastructure. Many of these nations are still benefitting from the demographic dividend, and the needs of an ageing society may be low on their list of social priorities. Therefore, national policies to cope with ageing due to economic development aim to make the population healthier, more productive and economically independent.

GENDER AND OLD-AGE ECONOMIC SECURITY  Despite impressive economic growth and development in Asia, Asian women remain disadvantaged relative to Asian men. With population ageing, old-age economic insecurity is an increasing regional trend. Tackling the disparities of old-age economic security would require a comprehensive approach which addresses inequalities in the labour market; policies on financial education or financial capability training ageing persons; putting in place gender-sensitive legal and institutional protection systems; and introducing better pension design that balances coverage with incentives. Specifically,

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the following issues would need to be regarded of primordial importance in formulating gender and old-age economic security policies: · Gender gaps in human capital endowments, in both health and education need to be reduced; · Steps and government policies to improve women’s opportunities both during prime and old age, including putting into place maternity leave and other policies to allow women to remain in employment and qualify for pension coverage when young; · Comprehensive financial capability training programmes to raise the financial provision for old age of older and younger adults separately; · Support for the collection and public dissemination of ageingrelated data and research in more Asian countries; and · Pension design and reform to take into account factors like gender differences in financial capability, employment histories, and life expectancies, including eligibility requirements that account for women’s briefer employment histories, joint annuities and survivor’s benefits, minimum pension guarantees or other redistributive mechanisms, appropriate inflation, indexation, statutory retirement age, and means-tested social assistance for widows and elderly women who are ineligible for pension benefits.

EPIDEMIOLOGY OF NON-COMMUNICABLE DISEASES  In this chapter on epidemiology, data on cardiovascular diseases, cancers, diabetes mellitus, and chronic respiratory diseases from Singapore, Malaysia, Japan, South Korea, China, Hong Kong, and India are used to explore the burden and epidemiology of noncommunicable diseases (NCDs) in Asia. The findings are that the burden of NCDs has been rapidly increasing in Asia, driven partly by ageing populations and partly by improved control of communicable diseases. There are substantial variations in disease burden across countries. Also, whilst the incidence rates of these diseases

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tend to be lower in middle and lower-income countries, morbidity and mortality rates tend to be disproportionately higher, suggesting systemic differences in the prevention, diagnosis and management of NCDs by country income levels. There has been a growing recognition in the region for the need for effective policy and practice interventions to tackle the growing NCD burden. Japan has been the leader in designing public health measures to address the twin issues of ageing and NCDs, with a considerable degree of success. Singapore has also rolled out comprehensive strategies to deal with these challenges, which other ageing Asian countries would need to consider for similar approaches.

ACTIVE AND PRODUCTIVE AGEING  Active ageing has evolved from a “deficit model” to the universally recognized World Health Organization active ageing framework which comprises the three pillars of health, security and participation. In recent years, the addition of lifelong learning and functional capacity have enriched the holistic concept of active ageing. For income security, productive ageing with a focus on employability is an important current issue where measures are being taken and explored in many economies. It is necessary that countries in Asia prepare to meet the challenges of ageing populations and the reality of longevity through a range of measures determined by factors such as the level of ageing, the level of development, political economy, culture and tradition.

SOCIAL-CULTURAL ASPECTS: FAMILY AND FILIAL SUPPORT Despite rapid modernization and social-economic cultural changes, contemporary Asian societies still largely expect children to have the moral obligation to care and support for their ageing parents. Cultural ideals of filial piety and family-centric ideas continue to permeate in modernized Asian societies and are proactively promoted in social policies. At least three countries in Asia namely,

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Singapore, India, and China have filial responsibility laws in place that compel the children to maintain their aged parents. Such trends highlight the complexities of promoting filial piety and intergenerational care of the old in the juxtaposition of cultural ideas with social realities of the individualization process in modern Asia. Can Asian governments continue to depend on the family unit to provide care for their family members? Rapid demographic and social-cultural-economic changes have occurred especially in East Asian societies to cause their governments to worry that they will be “turning grey before becoming wealthy”. It is good to note that the family can still be largely depended on to provide for the welfare of its members in “familialism individualization”. Looking forward, in the age of individualism, policies on supporting older persons should regard the family as a valuable resource to be treasured but not to be taken for granted, where policies to support the family in old age care should be comprehensive, along with parallel policies to empower and encourage both independence and generational inter-dependence for a meaningful later life.

INCOME SECURITY Ageing raises many challenges and risks, one of the most prominent being old-age financial protection. The dual challenge of having to set in place strong income support schemes for the elderly, while sustaining economic dynamism, is a reality for many developing countries in Asia today. Growing older may be associated with income insecurity from several causative factors, and in Asia this situation is exacerbated by rising longevity. The factors associated with income insecurity in Asia are a result of prolonged unemployment, lack of adequate pensions, and negative health expenditure. Consequently, individuals are forced to either save harder when young or extend their active working lives into older ages. Also, unlike the advanced countries, emerging Asian nations are experiencing accelerating ageing at relatively low levels of per capita income. This implies that Asia’s next wave of ageing economies may risk growing old before they become rich. The concern is

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that financial and political institutions in these societies may not be adequately prepared to meet the challenges of a demographically ageing population, along with profound gaps that still currently exist in terms of pension provision and long-term care provision for the elderly. Countries in Asia have been moving generally towards multi-pillar pension systems over the past two decades, and can be categorized into five pillars: 1) zero pillar of a basic or social pension which is non-contributory and funded by taxation; 2) mandatory, contributions-based first pillar; 3) mandatory savings-based second pillar (linked to occupational or personal pension plans); 4) voluntary savings-based third pillar; and 5) non-financial fourth pillar comprising access to formal social programmes and informal support. The observed regional trends within Asia are as follows: 1) Firstpillar systems predominate and zero pillar schemes tend to be targeted at specific vulnerable groups rather than being universal in coverage; 2) Second-pillar schemes, with the main example being Hong Kong’s Mandatory Provident Fund (MPF) scheme, which is a typology of old-age income provision in Asia that tended towards a state-regulated partnership between employers and employees, as evidenced in the number of provident funds and defined contribution schemes established in the region, found especially in the former British colonies. Mongolia and China have notional defined contribution (NDC) schemes, which mimic somewhat a defined contribution plan but retain pay-as-you-go (PAYG) financing. Separate pension schemes for civil servants also exist in several Asian countries. These schemes are designed to make a career in the public service more attractive, as well as enable the retirement of older civil servants in a politically and socially acceptable manner. Civil service pension schemes, however, may become financially unsustainable over time because such schemes tend to offer more generous terms and have lower funding ratios than private ones, or to crowd out other pension programmes. Consequently, some countries e.g. Singapore, have begun integrating civil service pension schemes with national schemes. But in less economically developed countries like Bhutan and Cambodia, the civil service pension

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scheme is the only one in existence. Across Asia, the pensionable age for men ranges from 58 years (Indonesia) to 65 years (Hong Kong), whilst for women the range is from 50 (non-public sector female employees in China) to 65 years (Hong Kong). Pensionable and statutory retirement ages are generally rising (Japan, Korea, Singapore), with higher-income countries having equalized the statutory retirement age for men and women. Many of Asia’s retirement-income systems are ill-prepared for the rapid population ageing that will occur over the next two decades as systems for oldage income security need urgent attention to ensure financial sustainability and achieve their primary goal of providing adequate retirement incomes. One way to expand coverage is by increasing the number of effective pillars, and by strengthening existing pillars. The latter may focus on plugging coverage gaps, with evaluations of contribution density especially amongst potentially vulnerable groups. Countries with large informal sectors that are not wellserved by mandatory first and second-pillar schemes may need to develop better regulated voluntary third-pillar schemes to provide those employed in the informal economy more efficient means to build up their retirement savings.

URBAN ENVIRONMENT In the future, two parallel and significant shifts are anticipated in Asia. First, the population of urban dwellers will outpace rural dwellers. It is projected to increase from today’s 48% to 64% by 2050. Second, the population of individuals aged 60 years or over is expected to reach 24%, double the current rate today. Some interesting concepts of future urban planning could be gleaned from the development of housing for ageing populations. These will need to deal with “new town” models of vertical cities and public housing policy to facilitate “ageing-in-place” as well as to identify potential areas for future planning innovations. Public housing in Singapore has developed the “vertical kampung” concept to bring back the community living ideals found in the villages of old, into its housing estates. These are projected to include recent innovations in community-based integrated

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living — consisting of central places for meeting, shopping and eating among the generations; common recreational spaces such as playgrounds, exercise parks and gardens; senior citizens corners and wellness centres offering screening and rehabilitation services, and community clinics for disease prevention and primary health care; etc. — all to further the holistic concepts of healthy, active and productive living. From a social perspective, proper housing and urban design are essential towards supporting more independent living within the community, to mitigate the increasing trends of institutionalization among aged populations. Long-term care facilities and services besides available nursing homes and community hospitals, are conveniently co-located and integrated to put into practice, such ideas like “hospitals without walls”.

HEALTH AND HEALTHCARE With respect to physical aspects of care, elderly people live longer today, but many of them suffer from chronic non-communicable disease. This burden can be prevented or reduced by attention to correcting adverse lifestyle and treating adequately high-risk diseases and complications as they arise. With respect to medical care for the elderly, countries would need to apply the principles of prevention and early detection as a life-course approach as well as deal with facets of medical care that range from medication use of traditional, complementary or alternative medicines, to integrative medicine and use of the successful ageing framework. The socio-cultural aspects in the utilization of traditional medical practices by the elderly, offer lessons of integrating systems of healthcare as well as preventing problems such as polypharmacy among the elderly patients who combine systems of care. The future prospects for ageing in Asia are not doom and gloom, as adapting to population ageing and sustaining the demands of ageing populations are positive areas to work on. There is a need to integrate health and social care, apply the principles adopted by the United Nations’ Madrid International Plan of Action on Ageing, and make Universal Health Coverage for financial sustainability work for ageing people in Asia and worldwide.

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MENTAL HEALTH Mental well-being is a crucial determinant of life satisfaction in old age but yet this is not emphasized in the provision of care of the elderly because of the stigma of mental illness. Although there is a growing interest on dementia research, the commonest mental health problems in late life is depression. As this would not be captured in mortality statistics, but in terms of morbidity however, mental health issues will feature as substantial costs with the ageing population. The future policy issues that need to be dealt with are the implementation of community programmes to deal with depression, as well as prevention of dementia and other agerelated disabilities. Recruitment of more mental health professionals and adequate psychogeriatric services to provide increasing eldercare and adequate support of careers are also major issues.

LONG-TERM CARE While the definition of long-term care (LTC) is debatable, it generally entails a range of services that aim to support elderly with functional and cognitive disability, either in the community or in residential facilities like nursing homes. There is a growing demand for LTC consequent to population ageing. As there is poor alignment of the financing framework between LTC and acute medical care, this generates perverse incentives for hospitalization. LTC services by private for-profit providers are underutilized, and support for informal caregivers are underdeveloped. Current government policies on LTC need to be revisited periodically, with a special focus on service delivery and financing. The affordability of LTC is attempted mainly through financing frameworks such as a combination of taxation and subsidies, insurance in covering catastrophic illness and disability, and in Singapore through innovative financing based on medical savings. Given the wide variety of possibilities and socio-cultural preferences, the different options for LTC in Asia are still being debated and evaluated on achieving an optimum balance

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of the roles of the public, private and people sectors to provide more sustainable models.

PALLIATIVE CARE The modern-day hospice palliative care as a healthcare movement founded by Dame Cicely Saunders has inspired the setting up of hospices around the world in countries far and wide, including Australia, New Zealand, Singapore and Taiwan in the region. In Singapore, her vision inspired the setting up of St Joseph’s Home in 1985, the first modern Asian hospice. In the Asia-Pacific region, the palliative care movement grew and by 2001, the Asia-Pacific Hospice Palliative Care Network (APHN) was formed. This network plays a key role in palliative care development in the member countries and beyond. National policies to support palliative care development is essential as seen in recent shifts in policy, funding and education that are evident in several countries in Asia, as for example, Singapore, China and Hong Kong. Advanced care planning, noncancer palliative care, and home hospice care are growing areas in Asia where policy decisions are encouraged to deliver more costeffective and socially acceptable forms of terminal end-of-life care for the ageing population.

TECHNOLOGY AND SOCIAL INNOVATIONS The last chapter of the book captures regional trends and issues in technology and social innovations: 1) Asian countries as laboratories for innovations in ageing — whether technological and social, innovations are necessary to shift current paradigms and redevelop systems to help older people to remain able despite declining physical function, in ageing Asian countries; 2) Technology and ageing — at the level of day-to-day activities of daily living, current and future advanced technologies are required to improve ability to function of not only individuals, but also populations, at reasonable costs; 3) Health and function in older age — devices and services that address common

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health conditions of older adults have also driven technologies to monitor, manage, and moderate health behaviours, like examples of “smart” homes with devices to maximise functioning; 4) Managing drivers of cost of care — several drivers such as overuse of technology and lack of co-ordination across systems, could be addressed through suitable tools, policies, regulations and incentives. These include health technology assessment (HTA) tools for cost control; co-ordination of care for older populations, supportive information systems, and financing mechanisms to encourage integration of services and technology. In terms of social innovations, three major trends were noted: 1) Pensions and financial security — while many countries in the region may be wealthy before they get “old”, they can benefit from the lessons learnt from the mistakes and successes of pension systems in older wealthy countries, by innovative pension system reforms to harmonise traditional cultural norms such as filial piety with the current realities of ageing in Asia. 2) Universal health coverage and ageing — in Asia, UHC with a nexus on ageing is well illustrated by the example of Japan, which has taken a lead worldwide in social insurance by radically and swiftly shifting its health care system to address a rapidly ageing population. 3) Integrated community care systems — integrated community health systems reduce fragmentation of care by using allied health workers like social workers, care managers, as well as nurses, all working together as a multidisciplinary team. Funding sources from taxation and long-term care insurance have been used normally but sustainability issues are concerned over the limits of financing. Regulation and policy are necessary constructs in the management of appropriate technology and social innovations. Regulation ensures public safety and at the same time, can direct local industries to develop new products and services. Expeditious regulatory reviews would encourage innovations and industry, while maintaining the production of cost-effective and affordable products. The additional regulatory challenges that need to be tackled include: 1) Classification of devices and variations, along with safety and

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performance differences; 2) Servicing and disposal of devices at all steps of the product life cycle; 3) Matching safety and efficacy with intended use; 4) Health technology assessment (HTA) that include clinical trials and pre-market approvals; 5) Government structures to ensure manufacturers take into consideration the whole life-cycle of devices, especially the safe disposal of e-waste. Finally, the point is made of overcoming ageism in Asia as the “largest social innovation” to enable all other innovations and policies to fall into place, and thereby realizing a better world for all older people.

CONCLUSIONS While many aspects of the ageing phenomenon may be universal, there are nonetheless, highly specific and contextualized experiences for all the individual countries throughout Asia. In the ageing person, common problems that pertain to frailty and declining physical and mental functions are usually medicalized, as noncommunicable diseases, vaccine preventable infections, and chronic problems all demand attention. Policies and programmes to change social behaviours for factors like smoking, sedentary lifestyle, obesity, hypertension, and diabetes, are critical in managing age-related conditions. 1) A contextualized and holistic life course approach of ageing forms the personal agenda of action. Each of the societies reviewed in this book has unique experiences to share. Japan is the oldest country in the world and de-facto is the pathfinder in ageing experiences. Korea is acknowledged as the fast-ageing country that experiences similar ageing pressure with China, which is now recognised to be a rapidly ageing country with the largest elderly population in the world. Unlike these three Asian societies, Taiwan is geographically smaller, but Hong Kong and Singapore are cities with dense populations and for these two societies, the shortage of environmental space is a challenge, as in most crowded Asian areas. Here, innovative models of integrated urban living for ageing

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populations under economic limits hold great promise of their transferability to the rest of ageing Asia. 2) Active and productive ageing, ageing in place, and financial sustainability form the components of successful ageing. Ageing successfully for everyone is a pragmatic end in mind and is contingent on the partnership of individuals young and old, supporting families and communities within conducive environments, to be mutually supported by governments to ensure that no one is left behind as ageing takes place. The reduction of loneliness and social alienation remain as challenges within some of the fastest changing societies where traditional support systems are eroding. Living longer and with less disability for the individual can be a real celebration. But how relations will evolve between the individual with the family and the state in providing social support for the aged, are still being played out in the different policies for pensions, healthcare and long-term care financing throughout ageing Asia. 3) Strategies for sustaining ageing populations can come from balancing the demand side due to population ageing with societal responses on the supply side. Compression of morbidity by health promotion is possible in the first place through disease prevention, early treatment of the four high-risk diseases (also known as the deadly quartet) of obesity, high blood cholesterol, high blood pressure, and diabetes. It is also evidence-based that prevention of tooth loss and treating gum infections, will further compress morbidity and prevent disease. All these would have lessons for the reduction of total societal costs related to the care of associated disabilities. Reminiscent of the experiences of the Asian Tigers of the 1960s, Asian economies can excel in the provision of quality services in developing new technologies through artificial intelligence and robotics. Such entrepreneurship and holistic solutions in providing innovative policies, may be the ultimate game changers in sustaining ageing societies in Asia.

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Figure 1.    The Health and Social Policy Matrix for Ageing Populations. Source: Phua KH (2015).

A unifying matrix to meet the challenges of ageing populations can be developed to approach health and social policy issues for ageing Asia (Figure 1). Through a Whole of Society approach, all sectors whether public, private, and people, will need to interact in a coordinated manner at the national, local and individual policy levels, in order to balance the functions of governance, regulation, provision and financing of services for ageing populations.

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b2530   International Strategic Relations and China’s National Security: World at the Crossroads

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CONTENTS Preface About the Editors About the Contributors

vii xv xvii

Introduction: Regional Trends and Issues 

xxix



Phua Kai Hong, Goh Lee Gan and Yap Mui Teng

Chapter 1

Demography1



Yvonne Arivalagan

Chapter 2

Economic Development



Aris Ananta and Evi Nurvidya Arifin

Chapter 3

Gender and Old-Age Economic Security

59 95

 Cynthia Chen, Elaine Kempson, Donghyun Park and Joanne Yoong Chapter 4

Epidemiology of Non-Communicable Diseases



Kavita Venkataraman and Fong Ngan Phoon

Chapter 5

Active and Productive Ageing



Thelma Kay and Marie Nodzenski

125 151

xlv

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Chapter 6

 ocial–cultural Aspects: Family and S Filial Support

177

Thang Leng Leng

Chapter 7  Income Security

Christopher Gee and Joelle H. Fong

Chapter 8

Urban Environment



Fung John Chye, Heng Chye Kiang and Yeo Su-Jan

Chapter 9

Health and Healthcare



Goh Lee Gan and Marie Nodzenski

Chapter 10 Mental Health

203 219 241 265

Kua Ee Heok Chapter 11 Long-Term Care

273

Phua Kai Hong, Winston Chin, Jessica Loo and Puttiporn Soontornwipart Chapter 12 Palliative Care

321

Goh Lee Gan

Chapter 13 Technology and Social Innovations 

359

Paul Kowal, Loïc Garçon, Alex Ross and Paul Ong References389

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CHAPTER 1

DEMOGRAPHY Yvonne Arivalagan

1.1. INTRODUCTION In the 1950s, Asia was among the youngest regions in the world, with just 6.8% of its population aged 60 or older. Having entered the demographic transition towards lower fertility and increasing longevity in the early twentieth century, Europe and Northern America were the world’s oldest regions in the 1950s, with 12.1% and 12.4% of their populations aged 60 or over respectively. However, since the 2000s, Asia has become one of the world’s most rapidly ageing regions, outpacing the rate of ageing in Europe and Northern America. In fact, it will take Asia just 30 years from now to double its percentage of older people, a feat that took Europe and Northern America between 60 and 100 years to achieve (Cheng et al., 2015). As of 2015, about 508 million people in Asia, or 11.6% of the Asian population, were aged 60 or older. This constituted more than half of the world’s older population. Despite these gains, Europe and Northern America continue to be the most aged regions in the world, with about 24% and 21% of their populations aged 60 or over in 2015 respectively. By 2050, 1.3 billion people, or a quarter of the Asian population, are expected to be aged 60 or older and Asia is expected to be the world’s fourth oldest region, behind Europe, Northern America and Latin America, and the Caribbean.

1

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2  Ageing in Asia: Contemporary Trends and Policy Issues

This chapter will provide an overview of the fundamental demographic trends contributing to and resulting from rapid population ageing in Asia from 1950 to 2050. Key indicators used include the size and structure of the aged population, the speed of ageing, total fertility rate (TFR), life expectancy, sex ratio, old-age dependency ratio (OADR), potential support ratio (PSR) and the proportion of older persons in rural and urban areas. Some newer measures of ageing will also be used. Scherbov et al. (2016) argue that traditional definitions of “old” and “dependent” have become increasingly anachronistic, as the roots of the OADR lie in the Bismarckian or early 20th century idea of dependency being linked to pension entitlement, which, in turn, was linked to the onset of decrepitude. The retirement age of 65 thus came to signify the threshold to old age and dependency. However, this notion of dependency is problematic given varying rates of olderage labour force participation in many countries today. Conventional measures of ageing based on chronological age are also insufficient as they assume that a 60-year-old person in the year 1900 was just as “old” as a 60-year-old in 2000 because each has lived the same number of years. However, the 60-year-old in 2000 is likely to have many more remaining years of life. Remarkable improvements in access to healthcare have led to the lowering of mortality in many parts of the word. Life expectancies in many Asian countries and regions, particularly Hong Kong, Macao, Japan, Singapore and South Korea, have exceeded 80 years. The proportion of those aged 80 or older is also rising fast in countries like Bangladesh, Indonesia and Vietnam. These developments call for new measures of dependency that take into account improvements in life expectancy. Sanderson and Scherbov (2005) suggested defining the threshold of old age based upon a fixed remaining life expectancy (RLE), rather than a fixed number of years already lived. RLE is then used to produce a new forward-looking definition of age, called “prospective age”. Everyone with the same prospective age has the same expected remaining years of life. Prospective age has subsequently been used to produce new “old-age” thresholds, new

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proportions of the population who are “old,” new old-age dependency ratios and new median ages. These measures will be included in this chapter. Scherbov and Sanderson (2016) also suggested basing the threshold of old age on an RLE of 15 years as this was the remaining life expectancy of 65-year-olds in many low-mortality countries in the 1960s. The fixed age at which RLE is 15 years or less in any particular country and the proportion of the population at ages with a RLE of 15 years or less are hence useful new tools to measure ageing. From here, it is also possible to calculate the prospective old-age dependency ratio (POADR). The POADR measures the proportion of people above the old-age threshold — the age at which remaining life expectancy is 15 years or fewer — relative to the number of people aged between 20 and the old-age threshold. Lutz et al. (2008) and Sanderson and Scherbov (2007) further proposed the use of the prospective median age (PMA), which accounts for longevity improvements in measuring the median age of the population. While the median age of a population is the age that divides the population into two numerically equal groups, the PMA is defined as the prospective age of a person at that median age. The PMA for any particular country is the age in a fixed base year (usually 2000) where remaining life expectancy is the same as at the median age in the indicated year for the same country. For instance, if the median age of a population in 1950 was 30 and the prospective age of a 30-year-old in that year was 35 (using the year 2000 as a base), then the population’s prospective median age in 1950 would be 35. In general, these new measures of ageing show a slower pace of ageing across Asia. This is particularly significant for East Asian societies like Taiwan, South Korea, Macao, Hong Kong, Singapore and Japan which are expected to age very rapidly in the future under conventional measures of ageing (Lutz et al., 2008; Scherbov et al, 2016). While population ageing will continue to be a feature of their demographic landscape in the 21st century, prospective measures of age suggest that the increases in dependency will be less dramatic than has been implied by traditional measures.

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In addition, this chapter will provide an overview of some health trends in Asia. While life expectancy is rising throughout Asia, it is also important to consider how increasing longevity affects the health status of the elderly. In general, population ageing is contributing to a health transition occurring at different rates around the world, defined as a shift in the global burden of disease from infectious diseases to noncommunicable diseases. The prevalence of non-communicable diseases in the elderly population has thus increased over time. A rise in the prevalence of heart disease, arthritis, diabetes, cancer, and other forms of physical and psychological distress have been reported in many developed ageing populations (Christensen et al., 2009). In this chapter, the prevalence of Alzheimer’s disease and other dementias, cardiovascular diseases1 and cerebrovascular diseases2 among the elderly in Asia will be examined and compared within and between regions as they are among the leading causes of death and disability for older persons (UNDESA, 2015b). The prevalence of tuberculosis, diarrhea, lower respiratory and other common infections3 among the elderly will also be examined and compared. Data on Asian countries generally suggests that the prevalence of non-communicable diseases among older cohorts of seniors aged 70 and above in high-income countries like Brunei, Japan and South Korea is declining compared to lower-income countries. In contrast, older cohorts of seniors in lower-income Asian countries are experiencing an increasingly higher prevalence of these diseases. This is an important consideration given that in many countries with inadequate pension or social security coverage, including several in Asia, older people are more likely to live in poverty than younger persons are (UNDESA, 2015b). However, even in some lower-income countries like Myanmar, Vietnam, Laos and Cambodia, data shows that the prevalence of these diseases among younger cohorts of seniors aged between 50 and 69 is diminishing compared to older cohorts. 1

 This includes rheumatic and ischemic heart disease.  This includes ischemic stroke, haemorrhagic stroke, and hypertensive heart disease. 3  This includes different forms of intestinal infections and meningitis. 2

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In some lower-income Asian countries, the prevalence of infectious diseases such as tuberculosis, malaria, lower respiratory and gastrointestinal infections is still relatively high among older persons, thus contributing to a “double burden” of both infectious and noncommunicable diseases among the elderly.

1.2.  SOURCE OF DATA Unless otherwise stated, population ageing figures for selected countries and regions in Asia, including East, Southeast and Southern Asia, are obtained from “World Population Ageing 1950–2050,” “World Population Ageing 2015,” and “World Population Prospects: The 2015 Revision” all published by the Population Division of the United Nations Department for Economic and Social Affairs (UNDESA 2015a, 2015b). Figures for the age at which RLE is 15 years or less, percent of the population at ages with RLE of 15 years or less, prospective old-age dependency ratio, median age, and prospective median age are based on data produced by the United Nations for the 2012 volume of World Population Prospects (International Institute for Applied Systems Analysis, 2017). Data on the prevalence of Alzheimer’s disease and other dementias, cardiovascular diseases, cerebrovascular diseases, tuberculosis, diarrhea, lower respiratory and other common infections have been obtained from the Global Burden of Disease (GBD) study. East Asia covers China, Hong Kong, Macao, the Republic of Korea, the Democratic People’s Republic of Korea, Japan, Mongolia, and other non-specified areas. Southeast Asia encompasses Brunei Darussalam, Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste, and Vietnam. Southern Asia refers to Afghanistan, Bangladesh, Bhutan, India, Iran, Maldives, Nepal, Pakistan, and Sri Lanka. Data from the 1950–2050 period will be used for all regions and countries except Southern Asia, for which UN demographic records begin from 1980. Tables for the data provided can be found in the appendix. Data from the GBD study will cover the period between 1990 and 2016.

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6  Ageing in Asia: Contemporary Trends and Policy Issues

1.3.  EAST ASIA 1.3.1.  Magnitude and Structure of the Aged Population East Asia is the first Asian sub-region to enter the demographic transition as rapid industrialisation over the last several decades has led to low fertility levels and increasing longevity. As of 2015, three East Asian countries — China, Hong Kong, and South Korea — were among the ten countries with the lowest fertility rates in the world. Japan and Hong Kong were among the ten most aged countries in the world in 2015. In 1950, East Asia was home to about 50 million people aged 60 and above. This number grew to around 270 million in 2015 and is expected to more than double to 578 million in 2050, when just under half of Asia’s population aged 60 and above will be residing in East Asia. The proportion of people aged 60 and above in East Asia has risen from 7.4% of the total population in 1950 to 16.7% in 2015 and is estimated to jump to over a third of the total population, or 36.9%, in 2050. The ageing trends in East Asia have been propelled by declining birth rates and rising life expectancy in the region’s most populous country, China. The total fertility rate (TFR) in China dipped from 3.01 in the late 1970s to 1.55 by 2015, making it one of the largest countries in the world with below replacement fertility (UNDESA, 2015a). Of the approximately 270 million people aged 60 and above in East Asia in 2015, close to 210 million resided in China. By 2050, China will be home to over 490 million people aged 60 or older. They will comprise 84% of the aged population in East Asia. The ageing of East Asia is also fueled by key demographic shifts in Japan; the world’s most aged country. Japan is experiencing a rapidly shrinking and ageing population and is the only country in Asia whose population is expected to decline by more than 15% between 2015 and 2050. Between the late 1970s and 2015, Japan’s TFR fell from 1.83 to 1.40, one of the lowest in the world. In 2015, close to 42 million, or one in three people in Japan, were aged 60 or older as compared to 1950, when just around 6.4 million people were in the 60+ age category. This figure is set to increase to 45.6

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million by 2050, making up close to half, or about 42.5%, of Japan’s total population. Hong Kong has the second highest share of persons aged 60 or older, overtaken only by Japan. Hong Kong’s TFR is also among the lowest in the world, falling from 2.31 in the late 1970s to 1.20 as of 2015. In 2015, over one in five, or 21.7% of Hong Kong’s population was aged 60 and above, numbering close to 1.6 million people. By 2050, it is projected that about 3.3 million people, or about 41% of Hong Kong’s population, will be 60 or older. Older persons in many East Asian countries are also living longer, as is the case in other industrialised nations. While those aged 80 and above comprised just 0.3% of the total population of East Asia in 1950, this figure increased to 2.2%, or 35 million people, in 2015 and is estimated to swell to 9.5%, or about 150 million people, by 2050. Those aged 80 and above comprised about 13% of the 60+ age group in 2015, but are expected to make up over a quarter of this group by 2050. Close to 80% of East Asians aged 80 or older will be located in China by mid-century. The number of persons in this age group in China is expected to rise significantly from around 22 million in 2015 to 120.5 million by 2050. The 80+ age group is also swiftly forming an increasingly large portion of China’s total population, from 0.3% in 1950, to 1.6% in 2015 and to an estimated 8.9% by 2050. The ageing of the older population is also occurring swiftly in other East Asian nations, namely Japan, South Korea and Hong Kong. In Japan, the share of persons aged 80 or older in the total population is higher than in any other country in Asia. About 9.8 million people in Japan are aged 80 or older, comprising 7.8% of the total population. This is up from 0.4% of the population in 1950 and is expected to increase to 15.1% of the total population of Japan in 2050, when 16.2 million people will be aged 80 or older. Similarly, in South Korea, the size of the 80+ age group has increased from comprising just 0.2% of the total population in 1950 to 2.8% in 2015, when there were about 975,000 people in this age category. In 2050, it is estimated that 4.3 million people in South Korea will be aged 80 or older, which will make up close to 14% of the total population. In Hong Kong, the share of the population aged 80 and

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8  Ageing in Asia: Contemporary Trends and Policy Issues

above has risen from 0.3% in 1950 to 4.3% in 2015 and is expected to increase to 15% by 2050, when there will be about 1.2 million people aged 80 or older, up from the current 314,000. 1.3.2.  Speed of Ageing in East Asia East Asia is among the most rapidly ageing regions in the world. Over the next 35 years, the size of the 80+ group is expected to grow faster than the 60+ age group. The annual average rate of population growth for the 80+ age group in East Asia was 4.5% as of 2015 and is expected to increase to 5.8% by 2035 before declining slightly to 4.6% by 2050. By mid-century, the growth rate of the 80+ age group in East Asia is also set to overtake that of Southeast and Southern Asia. In contrast, the annual average rate of population growth for the 60+ age group in East Asia is projected to be decelerating from 4% in 2015 to 1.5% by 2050. Similarly in China, the annual average rate of population growth for the 80+ age group was 4.6% as of 2015 and is expected to rise to 7.4% by 2035 before dropping slightly to 5.4% by mid-century. However, the growth rate of the 60+ age group is estimated to decelerate from 4.6% in 2015 to 1.8% by 2050. In contrast, the rate of growth of the 60+ and 80+ age groups in Japan is declining faster than in East Asia as a whole. In fact, there is expected to be a 0.4% reduction in the size of the 60+ age group in the 2045–2050 period. The growth of the size of the 80+ age group is also expected to slow down significantly, from an annual average rate of increase of 4% in the 2010–2015 period to 0.9% by mid-century. In South Korea, the rate of growth of the 60+ age group is projected to slow down significantly, from about 4% as of 2015 to 0.2% by 2050. The rate of growth of the 80+ age group is also expected to slow, from 7.4% in 2015 to 2.8% by 2050. Similar trends have been estimated for Hong Kong, where the rate of growth of the 60+ age group is set to decline from 4.3% in 2015 to just 0.4% in 2050. The rate of growth of the 80+ age group is likely to decelerate from 5.8% in 2015 to 1.9% by 2050.

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1.3.3.  Life Expectancy The shifting age structure in East Asia is partly due to significant gains in life expectancy across the region in recent years. Average life expectancy at birth in the region has increased from 42.9 years in the period 1950–1955 to 76.6 years in the period 2010–2015. It is projected to rise to 83.1 years by mid-century. Average life expectancy at age 65 has also risen, from 13.7 years in the early 1980s to 16.7 years in the period 2010–2015 and is projected to increase to 20.8 years by 2050. Economic expansion and improvements in healthcare in China throughout the 1990s have led to dramatic reductions in child mortality rates (World Health Organization, Western Pacific Region, 2016; Xi et al., 2014). This has partially contributed to rising average life expectancy in China. In the early 1990s, China’s infant mortality rate4 was 40.5 but has since fallen by about 71% to around 11.6 and is expected to slide further to 3.6 by 2050. The under-five mortality5 has fallen by about 73%, from 50 in the early 1990s to 13.5 as of 2015 and is estimated to fall to 4.3 by 2050. Thus, average life expectancy for a Chinese citizen born in the early 1950s was 40.8 years. It has since risen to 75.4 years between 2010 and 2015 and is expected to increase to 82.5 years by midcentury. Average life expectancy at age 65 has also grown, from 13.1 years in the early 1980s to 15.5 years in the 2010–2015 period and is estimated to rise to 20.2 years by 2050. Partly as a result of a successful universal healthcare system, the Japanese have the world’s highest average life expectancy of 83.3 years (Ikeda et al., 2011). Japanese females are the longest-lived in the world with a life expectancy of 86.5 years. Japan’s average life expectancy rose from 63.9 years in the early 1950s and is expected to increase to 88.1 years by mid-century. Life expectancy at age 65 has risen from 16.9 years in the 1980 to 1985 period to 21.6 years as of 2015 and is projected to increase to 25.1 years by 2050. 4

 Measured as the number of infant deaths per 1,000 live births.  The number of deaths under age five per 1,000 live births.

5

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Life expectancy in South Korea is also among the highest in Asia. Significant declines in infant mortality, from 9.8 in the early 1990s to 2.9 as of 2015, and reductions in some major diseases during the 1980s and 1990s are attributed to the increase in life expectancy (Yang et al., 2010). Average life expectancy at birth has risen from 47.5 years in the early 1950s to 81.4 years as of 2015. It is projected to increase to 87.7 years by mid-century. Average life expectancy at age 65 in South Korea has increased from 13.5 years to 20 years over the last three decades and is expected to rise to 24.2 years in 2050. The gender gap in life expectancy in East Asia is also narrowing, as is expected for more developed regions. This is because while the increase in life expectancy for both males and females in East Asia has been relatively constant since the 1950s, it is estimated that between 2030 and 2050, the increase in the life expectancy of males will be slightly higher than that of females. Between the early 1950s and 2015, the life expectancy at birth for females rose from 44.7 years to 78.6 years, while that for males grew from 41.4 years to 74.7 years. However, between 2030 and 2050, the life expectancy for females is projected to rise by 2.1 years from 82.1 years to 84.2 years, whereas the life expectancy for males is expected to increase by 3.1 years, from 78.8 years to 81.9 years. Similar trends in life expectancy can be observed in China. Between 1950 and 2015, the life expectancy for both males and females in China increased by 34.7 years. Life expectancy for females in China rose from 42.3 years to 77 years and the life expectancy for males increased by from 39.3 years to 74 years. However, between 2030 and 2050, the life expectancy for females in expected to rise by 2.5 years from 80.9 years to 83.4 years while that of males is expected to increase by 3.4 years from 78.3 years to 81.7 years. In contrast, the increase in life expectancy for females is projected to slow down faster than that for males in Japan. Life expectancy for Japanese males and females rose by 18.4 years and 21 years respectively from 1950 to 2015. However, from 2030 to 2050, life expectancy for both males and females is projected to climb by 1.9 years, from 83 years to 84.9 years for males and from 89.4 years to 91.3 years for females.

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1.3.4.  Remaining Life Expectancy In general, the age at which RLE is 15 years or less in East Asia was 67.1 in 2010 and is estimated to rise to 69.6 by 2050. The biggest increases are projected for Hong Kong and South Korea. Between 2010 and 2050, the age at which RLE is 15 years or less is expected to increase from 71.9 to 77.1 for Hong Kong and from 70.2 to 75.9 for South Korea. Under this new definition of “old,” just 8.2% of the population of East Asia was at ages with a RLE of 15 years and below in 2010. This figure is expected to rise to 19.1% by 2050. China and South Korea are expected to see the greatest increases in this respect. 19.2% of China’s population is expected to have a RLE of 15 years or fewer by 2050, as compared to just 7.9% in 2010. 19.8% of South Korea’s population is expected to have an RLE of 15 years or under, up from 7.2% in 2010. 1.3.5.  Median Age and Prospective Median Age The median age in many East Asian societies is expected to increase over the next few decades, although increases in prospective medium age are less rapid. China’s median age is projected to rise from 34.6 in 2010 to 46.2 in 2050, but its PMA is only expected to rise to 42.8 in 2050. Similarly, South Korea’s median age is expected to increase from 37.8 to 53.6 between 2010 and 2050 but the country’s PMA in 2050 is expected to be just 46.6. 1.3.6.  Sex Ratio As women tend to outlive men, older women generally outnumber older men in most parts of the world, including Asia. The sex ratios6 in Asian regions are higher than those in Europe and Northern America. In 2015, the sex ratio among persons aged 60 or older was 91.3 in Asia and 92.0 in East Asia as compared to 73.1 in Europe and 83.9 in Northern America. 6

 Measured as the ratio of males per 100 females.

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The sex ratio among the aged population in East Asia is expected to continue increasing as old-age mortality among males falls at a faster rate compared to females. However, the sex ratio of the 60+ age group in East Asia is expected to increase at a slower pace over the next 35 years than between 1950 and 2015. For those aged 60 or over, the sex ratio rose from 80.1 in 1950 to 92.0 in 2015 and is estimated to hit 94.1 in 2050. The increase in the sex ratio for those aged 80 and above is more accelerated than for the other age groups as the gender gap in life expectancy narrows, growing from 45.1 in 1950, to 66.3 in 2015 and further to a projected 77.6 in 2050. Effects of China’s one-child policy have led to an increase in the sex ratio among the 60+ age group, from 80.3 to 96 between 1950 and 2015. It is expected to climb more gradually to 96.5 by 2050. As men in China are also living longer, the sex ratio for the 80+ age group rose more rapidly, from 43.3 to 74 between 1950 and 2015 and is projected to hit 81.4 in 2050. In contrast, following a sharp increase in the latter half of the 20th century, the sex ratio in Hong Kong is projected to decline from 2015 onwards. The sex ratio for the 60+ age group in Hong Kong more than doubled from 40.5 to 90.6 between 1950 and 2015 but is expected to fall to 67.7 by 2050. Similarly, the sex ratio for the 80+ age group increased from 35.7 to 64.9 between 1950 and 2015 but is expected to fall to 57.6 by 2050. In Japan, the sex ratio among the 60+ age group has increased from 79.2 in 1950 to 79.8 in 2015 and it is expected to increase to 81.9 by 2050. The sex ratio among the 80+ age group is also rising, from 50.4 to 54.5 between 1950 and 2015, to a projected 62.5 in 2050. 1.3.7.  Labour Force Indicators According to the International Labour Organization (ILO), the total labour force participation rate (LFPR)7 of the older population is generally declining in the less developed regions and rising in the 7

 Labour force participation rate is the proportion of the population aged 15 and older that is economically active.

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more developed regions (UNDESA, 2013). In East Asia, which experienced stellar economic growth in the latter half of the 20th century, the LFPR for the 65+ age group declined between 1950 and 1990 because of the diminishing need for older persons to work in later life, but has since been rising gradually. In 2015, about onefifth of those aged 65 or above was economically active, as opposed to 30.4% in 1950. In 2015, this number inched up to 22.3% and is projected to rise to about 25% by 2030. The growth in the LFPR for females aged 65 and above in East Asia was faster than the average rate for the region. Close to 16.3% of women aged 65 and above were economically active in 2015, as compared to 11.8% in 1950 and an estimated 19.6% by 2030. This corresponds to the fall in TFR levels in the region as more women began entering the workforce. On the other hand, while the LFPR for older males is still higher than that for females, it fell from 56.2% in 1950 to 29.1% in 2015 and is projected increase slightly to 31.3% in 2030. Since men outnumber women in the labour force, the total LFPR in East Asia, particularly in the latter half of the 1900s, indicated an overall decrease. The total LFPR for the 65+ age group in South Korea fell from 32.5% to 26.2% between 1950 and 1990 but has since increased and is among the highest in East Asia. It rose to 31.2% in 2015 and is estimated to reach 34% by 2030. The LFPR for older males fell sharply from 66.8% to 39.3% from 1950 to 1990. It has since increased to 42.2% in 2015 and is expected to reach 45% by 2030. In contrast, the LFPR for older females in South Korea has increased continuously, from 8% in 1950 to 23.4% in 2015. By 2030, close to one in four women aged 65 or older in South Korea is expected to be economically active. The LFPR among those aged 65 or older in China also fell between 1950 and 1990, from 29.3% to 19.3%. It grew to 21.9% in 2015 and is expected to pick up and hit 24.3% in 2030. Following a slight decline from 10% to 8% from 1950 to 1990, the LFPR for females in this age category has doubled to 16.1% in 2015. It is expected to increase further to 19% by 2030. In contrast, the LFPR for males aged 65 or older fell by half from 56% to 28.2% between 1950 and 2015, but is projected to increase slightly to 30% by 2030.

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The LFPR of the 65+ age group in Japan has fallen slightly, from 35.4% in 1950 to 21% in 2015, but is expected to rise to 26.4% by 2030. The LFPR for females aged 65 or older has also declined from 21.6% in 1950 to 14.5% in 2015 but it is expected to increase to 20% by 2030. The LFPR for Japanese males aged 65 or older decreased considerably from 54.5% to 29.7% between 1950 and 2015 but is expected to rise to 35% in 2030. The old-age dependency ratio8 in East Asia is expected to soar over the next few decades, as fertility falls and people live longer. It climbed from 7.3 to 15.3 between 1950 and 2015, and is projected to rise sharply to 48.7 in 2050. Correspondingly, the potential support ratio (PSR)9 in East Asia is projected to decline significantly, from 13.8 in 1950 and 6.5 in 2015, to a low of 2.1 in 2050. Japan’s old-age dependency ratio is the highest in the world and is increasing significantly. It rose rapidly from 8.3 in 1950 to 43.3 in 2015 and is projected to rise to 70.9 by 2050. Japan’s PSR is falling fast, from 12.1 in 1950 to 2.3 in 2015 when it had the lowest PSR in the world. Japan’s PSR is estimated to decline to 1.4 in 2050. The old-age dependency ratio in Hong Kong is the second highest in East Asia, although still far behind Japan. Between 1950 and 2015, it increased from 3.7 to 20.6 and is expected to more than triple to 64.6 in 2050. Hong Kong’s PSR has decreased substantially, from 26.9 in 1950 to 4.8 in 2015 and is expected to fall to 1.5 by 2050. The old-age dependency ratio in China is also projected to rise sharply, from a low of 7.2 in 1950, to 13.0 in 2015 and to a further 46.7 by 2050. Similarly, the PSR is expected to decline, from 13.8 and 7.7 in 1950 and 2015 respectively, to 2.1 in 2050. As of 2015, the statutory retirement age is 60 for men and 55 for women in China. In South Korea, it is 60 for both men and women. In Hong Kong and Japan, the statutory retirement age is 65 for both men and women. 8

 The number of persons aged 65 or over per 100 working age persons aged 15–64.  The number of people aged 15–64 per one older person aged 65 or older.

9

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1.3.8.  Prospective Old-age Dependency Ratio While the OADR for East Asia is expected to more than triple from 15.3 to 48.7 between 2015 and 2050, the prospective old-age dependency ratio (POADR) paints a less severe picture. Up from 12.3 in 2010, it is projected to rise to just 31.1 by 2050. While Japan is expected to continue having the highest OADR in East Asia, it is also expected to have the highest POADR in the region. Between 2010 and 2050, Japan’s POADR is projected to increase from 19.5 to 32.3. China’s POADR is projected to rise from 11.9 to 31.4 between 2010 and 2050 and South Korea’s POADR is expected to increase from 10.4 to 31.0 in the same period. 1.3.9.  Rural-urban Distribution In 1980, there was no significant difference in the proportion of older persons living in rural as compared to urban areas in East Asia. Older persons comprised 8.2% of the total population in rural and urban areas. In 2015, the proportion of older persons in rural areas and urban areas doubled to 17.1% and 16% respectively. The share of older females in rural areas jumped from 9.2% to 18% between 1980 and 2015 and the share of older females in urban areas also increased, although slightly more gradually, from 9.3% to 17.2% in this time period. The proportion of older males in rural areas more than doubled from 7.3% to 16.3% in the same period while the proportion of older males in urban areas rose from 7.2% to 14.9%. The share of older persons in rural areas has generally been higher than that in urban areas in China. Between 1980 and 2015, the share of older rural dwellers more than doubled from 8% to 16.7%, while the share of older urban dwellers grew more slowly, from 7.3% to 13.5%. However, while the share of older males in urban areas doubled from 6.5% in 1980 to 12.8% in 2015, the share of older females in urban areas increased more slowly from 8.2% to 14.3%. Rapid urbanisation and a decline in traditional land use in Hong Kong have led to a dramatic decline in the rural population. Hence, the proportion of older persons in rural areas has fallen

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from 9.8% to 0 between 1980 and 2015. The share of older persons in urban areas has increased sharply, from 9.2% to 21.7%. In contrast, the share of older persons in both rural and urban areas in Japan has increased during the 1980–2015 period. The proportion of older people in rural areas more than doubled from 16.5% to 37.7% while urban areas have seen their share of older people almost triple from 11.7% to 32.9%. 1.3.10.  Health Trends Increased longevity in China has been accompanied by a rise in the proportion of older people living in poor health, with disability, and who are dependent on care. In 2012, nearly 80% of deaths among persons aged 60 or over was attributable to non-communicable diseases (WHO, 2012). Chronic non-communicable disease prevalence in China is also expected to rise by at least 40% by 2030. Furthermore, according to the WHO Global Burden of Disease Estimate 2012 (WHO, 2012) nearly 45% of the DALYs in China are attributable to health conditions among those aged 60 or over. China is also experiencing a considerable increase in the share of care-dependent elderly. Between 2010 and 2050, the share of persons aged 60 and above requiring daily care and assistance is expected to almost double from 33.2% to 59.7% of the total population (WHO, 2012). Various studies have also found that the prevalence of hypertension, stroke, Parkinson’s disease, Alzheimer’s diseases and other dementias among persons aged 60 and above increased with age in China. The prevalence of high body mass index (BMI) and obesity among those aged 60 or over, however, decreased with age (SCDC, 2012; NCCNDC, 2012; Chan et al., 2013). The prevalence of cardiovascular diseases, diabetes, and arthritis among older persons in China was found to be higher in urban areas than in rural areas while the prevalence of dementia among older persons was significantly higher in rural areas. Older women were also found to be at greater risk of hypertension, diabetes, arthritis, Alzheimer’s diseases and other dementias than older men.

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Moreover, in 2010, about 19% of those aged 60 or over in China reported difficulties with activities of daily living (ADLs), of whom 6% were completely dependent. A large proportion of older persons requiring assistance with ADLs also live in rural areas (Zhang et al., 2011; WHO, 2012). Data from the Global Burden of Disease study shows that the prevalence of Alzheimer’s disease and other dementias, cardiovascular and cerebrovascular diseases rose among the elderly in China between 1990 and 2016. This increase was faster for older cohorts aged 70 and above compared to younger cohorts in their 50s and 60s. The prevalence of Alzheimer’s disease and other dementias among the elderly in both Japan and South Korea increased from 1990 to 2016, especially among those aged 70 and above. Japanese elderly aged 70 and above experienced a higher prevalence of Alzheimer’s disease and other dementias than the elderly in other East, Southeast and South Asian countries. However, the prevalence of cardiovascular and cerebrovascular diseases among the elderly in Japan and South Korea has declined between 1990 and 2016. This decline has been greatest among those aged 70 and above as compared to those in their 50s and 60s. Ishii et al. (2015) found that treatment rates for chronic medical conditions including ischemic heart disease, diabetes mellitus, hypertension and cerebrovascular diseases in Japan declined significantly between 1996 and 2011. These findings further suggest a decline in the prevalence of these conditions among older persons in Japan. Moreover, the results suggest that younger cohorts of elderly in Japan could be experiencing better health than older cohorts. The authors, who analysed three nationally representative datasets in Japan, also found that disability rates among older Japanese adults aged between 65 and 84 decreased between 2001 and 2013.

1.4.  SOUTHEAST ASIA 1.4.1.  Magnitude and Structure of the Aged Population As of 2015, almost one in ten, or about 59 million people were aged 60 and above in Southeast Asia. This is a six-fold increase from 1950

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when there were around 10.7 million people in this age category. By 2050, it is estimated that Southeast Asia will be home to over 167 million people aged 60 or older, who will comprise one-fifth of the total population in this region. However, there is great variability in the trajectories of ageing within Southeast Asia as it is home to ultralow fertility countries like Singapore, intermediate-fertility countries like Indonesia and high fertility countries such as Timor-Leste. About one-third of those aged 60 or older in Southeast Asia, or 21 million people, lived in Indonesia as of 2015, as opposed to just about 5 million people in 1950. This number is projected to grow to close to 62 million by 2050. The proportion of people in this age category is expected to increase from 8.2% to 19.2% of the total population of Indonesia between 2015 and 2050. Indonesia is also projected to be among the ten most populous countries in the world between 2015 and 2050. It is also considered an “intermediate-fertility” country by the UN, as its TFR has dropped from 5.5 in the early 1950s to 2.5 in 2015 and is projected to fall to 1.91 by 2050. However, the share of older persons is highest in Singapore than any other Southeast Asian country. As of 2015, 17.9% of Singapore’s population was aged 60 and above, numbering about 1 million people, as compared to 1950 when there were just 38,000 people in this age group, comprising 3.7% of the population. By 2050, 2.7 million people, or 40.4% of Singapore’s population, will be aged 60 or older. These trends are fueled by the fact that Singapore had the third lowest TFR in the world and the lowest TFR in Southeast Asia, at 1.23 in 2015. This has fallen from a high of 6.4 in the early 1950s but is expected to pick up slightly to 1.38 by mid-century. The size of the 80+ age group is also rising in Southeast Asia. In 2015, Southeast Asia was home to about 6.5 million people aged 80 or older. By 2050, this figure is set to reach around 27.5 million. Persons in this age category formed 1% of the total population of Southeast Asia in 2015, up from 0.4% in 1950, and are expected to make up 3.5% of the population in 2050. Singapore will continue being the Southeast Asian country with the highest proportion of people aged 80 or above. In 2015, 2.4% of Singapore’s population, or 133,000 people, were in this age category

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and the share is expected to increase to 13.8%, or 921,000 people, by 2050. Thailand has the second highest share of persons aged 80 and above in Southeast Asia. Between 2015 and 2050, this share is expected to increase from 2.1% to 9.9%. The number of people aged 80 or older in Thailand will increase from 1.4 million to 6.2 million in the same period. On the other hand, Cambodia and Laos are the youngest nations in Southeast Asia. Cambodia’s share of persons in the 60+ age group is expected to increase from 6.8% to 17.6% between 2015 and 2050. Its share of those aged 80 or older is projected to rise from 0.5% to 2.6% in the same period. In Laos, the share of persons aged 60 and above is set to increase from 6% to 14.7% in the next 35 years. Those aged 80 and above will comprise 1.6% of the population of Laos in 2050, up from 0.5% in 2015. 1.4.2.  Speed of Ageing Similar to East Asia, the rate of growth of the 80+ age group is higher than the 60+ age group in Southeast Asia. The pace of ageing among the 60+ age group in Southeast Asia is at its peak but is set to decline over the next few decades. The annual average rate of population increase among the 60+ age group was 1% in the early 1950s and 3.8% in 2015. It is expected to fall to 1.5% by 2050. In contrast, the size of the 80+ age group will increase from a rate of 3.3% as of 2015 to 5.7% by 2035, before slowing down to 3.6% by 2050. In Brunei, the annual average rate of population increase among the 80+ age group will double over the next two decades, from 5.2% to 10.1%, before falling to 5.8% in 2050. In contrast, the growth rate of the 60+ age group is expected to slow down considerably, from 7.4% in the 2010–2015 period to 2.2% by 2050. In Southeast Asian countries like Singapore and Thailand which are more advanced in the demographic transition, the growth rates of both the 60+ and 80+ age groups are set to decelerate considerably over the next 3 decades. As of 2015, the 60+ age group in

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Singapore saw an annual average rate of increase of 6.7% but this is expected to plummet to 0.6% by 2050. The rate of growth of the 80+ age group is also expected to fall, from 6.7% in 2015 to 2.7% by 2050. The rate of growth of the 60+ age group in Thailand is projected to fall from 4.3% in 2015 to 0.2% by 2050. The rate of growth of the 80+ age group is also projected to decrease from 5.3% in 2015 to 2.8% by 2050. 1.4.3.  Life Expectancy Average gains in life expectancy in Southeast Asia over the next three decades are expected to be lower than in East Asia and Southern Asia. Average life expectancy at birth in Southeast Asia has increased from 41 years in the early 1950s to 70.3 years as of 2015 and is projected to hit 75.8 years by 2050. Average life expectancy at age 65 has increased from 13.2 years in the 1980 to 1985 period to 14.9 years as of 2015 and is projected to rise to 17 years by 2050. The average life expectancy in Singapore, which is the highest in Southeast Asia, rose sharply from 60.4 years in the early 1950s to 82.6 years as of 2015. It is expected to increase more gradually over the next few decades to reach 88.3 years by 2050, which is even higher than the projected life expectancy for Japan of 88 years. Female life expectancy in Singapore is also expected to outrank most of the world, increasing from 85.6 years in 2015 to a projected 91.2 years by 2050. The estimated life expectancy for Japanese females in 2050 is only slightly higher, at 91.3 years. Brunei has the second highest life expectancy figures in Southeast Asia. In the early 1950s, average life expectancy at birth in Brunei was 60.4 years. It increased to 78.4 years in the 2010–2015 period and is estimated to hit 85 years by 2050. At 65.5 years as of 2015, Laos, which is also the poorest country in Southeast Asia, had the lowest life expectancy in the region. However, over the next 35 years, life expectancy in Laos is expected to increase considerably to 76.6 years, thus overtaking countries like Myanmar and the Philippines. By 2050, Myanmar is estimated to have the lowest life expectancy in Southeast Asia — 70.6 years.

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Unlike East Asia, the gender gap in life expectancy is expected to widen in Southeast Asia. This is consistent with the notion that gains in female life expectancy are expected to be larger than the gains for men in less developed regions. In 1950, male life expectancy in Southeast Asia was 39.9 years whereas female life expectancy was 42.1 years. In 2050, life expectancy for males is expected to rise to 73 years, while that for females is expected to rise slightly faster, to 78.7 years. The widening of the gender gap in life expectancy in Southeast Asia is greatest in the Philippines. Between 1950 and 2050, male life expectancy in the Philippines is projected to rise sharply, from 46 years to 69.1 years. Female life expectancy is expected to rise from 49.6 years to 76.6 years. However, some Southeast Asian countries like Brunei and Thailand are expected to see a narrowing of the gender gap in life expectancy. In Brunei, male life expectancy is expected to increase from 59.6 years to 84.2 years between 1950 and 2050, while female life expectancy is expected to rise from 61.1 years to 85.9 years. In Thailand, male life expectancy is projected to rise from 49.8 years to 77.9 years, while female life expectancy is set to increase from 54.3 years to 82.7 years in this 100-year period. 1.4.4.  Remaining Life Expectancy The age at which RLE is 15 years or less for Southeast Asia lags slightly behind that of East Asia. It is estimated to rise from 65.3 to 68.7 between 2010 and 2050. Singapore is expected to improve faster than other Southeast Asian countries in this respect, with its age at which RLE is 15 years or less projected to rise from 71 to 76.3 between 2010 and 2050. After Singapore, Cambodia is set to be the country with the second highest age at which RLE is 15 years or less, with this figure rising from 72.5 to 76.2 in the same period. Myanmar is expected to have the lowest age at which RLE is less than 15 years, with this figure rising slowly from 62.1 to 63.7 between 2010 and 2050. The share of Southeast Asia’s population at ages with a RLE of 15 years or fewer fell slightly from 6% to 5.3% between 1960 and

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2010 but is expected to more than double to 12.6% by 2050. For a number of Southeast Asian states, this figure is set to increase significantly over the next few decades. At 20.7%, Thailand is projected to have the region’s highest share of persons at ages with a RLE of less than 15 years in 2050. 1.4.5.  Median Age and Prospective Median Age In general, increases in the median age of Southeast Asian countries are not expected to be as rapid as in East Asia. From 2010 to 2050, the median age of Southeast Asia is projected to increase from 27.2 to 38.9. Thailand is set to experience the fastest gains in median age. Thailand’s median age is expected to rise from 35.4 to 51.1 between 2010 and 2050, which will make it the Southeast Asian country with the highest median age in 2050. On the other hand, the prospective median age in Southeast Asia is expected to rise more gradually than the median age. Southeast Asia’s PMA is projected to rise from 27.2 to 34.3 between 2010 and 2050. Under this measure, Vietnam is set to experience the most rapid gains in PMA in this period — from 28.5 to 41.5. Thailand is also expected to have the region’s highest PMA in 2050, with a PMA of 46.2. 1.4.6.  Sex Ratio In contrast to East Asia, the sex ratio among those in the 60+ age group is declining in Southeast Asia. Down from 85.8 in 1950 to 82.2 in 2015, it is estimated to fall to 80.8 by 2050, when it will be lower than the sex ratio for the same age group in East and Southern Asia. On the other hand, the sex ratio for the 80+ age group is becoming more balanced and is expected to continue along this trend until 2050. Rising from 57.2 to 58.9 between 1980 and 2015, the sex ratio for those aged 80 or older is estimated to increase to 61.9 by 2050. The sex ratio among older persons in Brunei is among the highest in Southeast Asia. After declining sharply from 119.9 to 95.3 between 1980 and 2015, the sex ratio for the 60+ age group is

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expected to increase to 101.6 by 2050. For the 80+ age group in Brunei, the sex ratio declined from 82.5 to 77.6 between 1950 and 2015 and is set to rise to 87.3 by 2050. The sex ratio for older persons in Malaysia has also been among the highest in Southeast Asia. For the 60+ age group, the sex ratio fell from a high of 109.8 in 1950 to 95.8 in 2015 but is projected to hit 87.4 by 2050. For the 80+ age category, the sex ratio rose from 99.5 to 123.8 between 1980 and 2015 but is expected to fall to 76.4 by 2050. In Cambodia, the sex ratios for both the 60+ and 80+ age groups are among the lowest in the region, but have been rising quickly. For the 60+ age category, it fell from 82.8 to 67.8 between 1950 and 2015 but is expected to reach 78.6 by 2050. For those aged 80 or older, the sex ratio is projected to drop slightly to 60.0 in 2050, following a decline of 71.9 to 61.8 between 1950 and 2015. 1.4.7.  Labour Force Indicators The average LFPR for those aged 65 and above in Southeast Asia is falling. Between 1950 and 2015, the LFPR fell from 51% to 33.4% and is expected to dip slightly to 33.1% by 2030. This trend is largely driven by the declining LFPR for males in Southeast Asia, as per the general trend observed in less developed regions. Between 1950 and 2015, the male LFPR in Southeast Asia declined significantly, from 74.2% to 44.9% and is estimated to dip to 43.2% by 2030. The female LFPR also fell from 31.6% to 24.6% between 1950 and 2015, but is set to climb slightly to 25.1% by 2030, which is consistent with more women entering the labour market. Cambodia serves as an exception to this general trend in Southeast Asia. Despite the statutory retirement age of 55 for both males and females, the LFPR for older adults in the region has been rising. As of 2015, 64.8% of men and 44.3% of women aged 65 or older were in the labour force, thus forming the highest LFPR figures in the region. This is a significant increase from 1950 when 52.5% or males and 28.9% of females aged 65 and above were economically active. By 2030, it is projected that the LFPR for males in this age category will fall to 55%, while that for females will fall more gradually to 41%.

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In Indonesia, which also has a statutory retirement age of 55 for both men and women, the gap in the LFPR between men and women is higher than in other Southeast Asian countries. In 2015, 54.3% of males and 27.9% of females aged 65 and above in Indonesia were economically active, constituting a difference of 26.4%. This difference is expected to diminish only slightly by 2030, when it is projected that the LFPR for males and females aged 65 or older will be 51.7% and 29% respectively. Both the LFPR as well as the gap in LFPR between males and females in the 65+ age bracket were lowest in Brunei, which has a statutory retirement age of 60 for both men and women. As of 2015, the LFPR for males aged 65 or older in Brunei had plunged to 14.4% from 59.2% in 1950. It is expected to increase only slightly to 15.8% in 2030. For females in this category, who also have the lowest LFPR among older females in Southeast Asia, the figure has decreased from 6.9% in 1950 to 3.8% in 2015 but is expected to rise to 5.5% by 2030. The old-age dependency ratio in Southeast Asia is on the rise, though not as speedily as in East Asia. Between 1950 and 2015, Southeast Asia’s old-age dependency ratio grew modestly from 6.6 to 8.8 and is projected to climb significantly to 24.1 by 2050. The PSR in Southeast Asia is declining, from 13.0 in 1950 to 11.4 in 2015 and is expected to sink to 4.2 by 2050. As the nation with the third lowest TFR and among the highest life expectancies in the world, Singapore had the highest old-age dependency ratio in Southeast Asia in 2015. It has increased from 4.2 in 1950 to 16.1 in 2015 and is projected to see rapid gains in the next three decades, soaring to 61.6 by 2050. The PSR in Singapore is also expected to fall sharply from 6.2 to 1.6 between 2015 and 2050, when it will be the lowest in Southeast Asia. At 6.1, the lowest old-age dependency ratio in Southeast Asia in 2015 belonged to Brunei. It is a drop from 8.3 in 1950. However, Brunei’s old-age dependency ratio is expected to soar to 39.4 by 2050. At 16.4, Brunei’s PSR was also among the highest in Southeast Asia in 2015. This is expected to decline significantly to 2.5 by 2050, by which

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time Singapore and Thailand (which will have a projected PSR of 1.9), will outpace Brunei to have the lowest PSRs in the region. Countries like Indonesia are expected to see more moderate changes in the old-age dependency ratio and PSR. Between 1950 and 2015, Indonesia’s old-age dependency ratio rose slightly from 7.0 to 7.7 and is projected to hit 21.3 by 2050. Indonesia’s PSR fell from 14.4 in 1950 to 13.0 in 2015 and is expected to sink to 4.7 by mid-century. Prospective old-age dependency ratio The gains in POADR for Southeast Asia are more moderate than they are for the OADR. Between 2010 and 2050, the region’s POADR is set to increase from 9.3 to 20.2. Moreover, while Singapore is expected to have the highest OADR in the region by 2050, Thailand is projected to have the region’s highest POADR by 2050. Thailand’s POADR is also expected to increase faster than any other Southeast Asian nations, from 10.5 to 33.2 between 2010 and 2050. After Thailand, countries like Brunei and Myanmar are projected to experience the highest gains in POADR until 2050. 1.4.8.  Rural-urban Distribution The proportion of older persons in both rural and urban areas in Southeast Asia has risen between 1980 and 2015. During this period, the share of older rural dwellers increased from 6% to 9.5% while the share of older urban dwellers grew slightly faster, from 5.5% to 9.1%. Rural areas saw a somewhat greater increase in their share of older females than urban areas as the proportion of older females grew from 6.6% to 10.8% in rural areas but from 6.1% to 9.9% in urban areas. Contrastingly, the share of older males grew marginally faster in urban areas, from 4.9% to 8.2%, than in rural areas, from 5.5% to 8.7%. Thailand is home to Southeast Asia’s largest share of older persons in both urban and rural areas. Between 1980 and 2015, the proportion of older rural dwellers almost tripled from 5.7% to

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16.9%. The share of older urban dwellers also increased significantly from 5.4% to 14.7%. The share of older persons in rural Cambodia has also grown significantly between 1980 and 2015, from 4.8% to 8.6%. The increase in the share of older urban dwellers in Cambodia grew slightly slower, from 4.1% to 7.2%. In contrast, the proportion of older persons in both rural and urban areas in Laos has remained relatively stagnant. Between 1980 and 2015, the share of older persons in rural areas climbed slowly from 5.7% to 6.1%, while the share of older rural dwellers inched very slightly upwards from 5.8% to 5.9%. Health trends According to the Global Burden of Disease data, the prevalence of tuberculosis among the elderly in Southeast Asia is relatively high compared to other Asian regions, although it has generally been declining. In Vietnam, for instance, the prevalence of tuberculosis was 60% for those in their 50s and 60s and 52% for persons aged 70 and above. The prevalence of diarrhea, lower respiratory and other common infections among the elderly in Southeast Asia was higher than that in East Asia but lower than that in Southern Asia, although it has also been generally declining. The prevalence of many non-communicable diseases in Southeast Asia is also increasing, particularly among older cohorts in lowerincome countries in the region. While the prevalence of cardio­vascular, cerebrovascular, Alzheimer’s disease and other dementias have risen among those aged 70 and above in countries like Myanmar, Vietnam, Laos and Cambodia, they have declined among those in their 50s and 60s in these countries. While rising, particularly for older cohorts in lower-income Southeast Asian nations, the prevalence of these diseases has declined among wealthier countries in the region. For example, between 1990 and 2016, the prevalence of cardiovascular disease among those aged 70 and above in Laos rose from about 32% to 34%, but declined among the same group for Singapore, from about 42% to 39%. Furthermore, Brunei is the only Southeast Asian country that has seen a dip in the prevalence of Alzheimer’s disease

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and other dementias in this period, while older cohorts in Laos and Myanmar have seen the greatest increase in this regard.

1.5.  SOUTHERN ASIA 1.5.1.  Magnitude and Structure of Aged Population In 2015, there were about 153.5 million people aged 60 or over in Southern Asia, comprising 8.4% of the total population. By midcentury, it is projected that close to one-fifth of the population, or 460 million people, in this region will be aged 60 or over. The majority of Southern Asia’s older persons live in India. Ageing in India has chiefly been driven by rising life expectancy and a shrinking TFR, which has more than halved from 6.0 in the early 1950s to 2.48 in 2015 and is expected to sink to 1.89 in 2050. Correspondingly, there was a six-fold increase from about 20.1 million people aged 60 or older in 1950 to around 116.6 million people in this age group in India in 2015. By 2050, it is estimated that India will be home to over 330 million people aged 60 and above. In proportionate terms, the share of the 60+ age group in India has grown from 5.6% in 1950, to 8.9% in 2015. By 2050, it is projected that about one out of five people in India will be aged 60 or older. Sri Lanka is in the most advanced stage of ageing in Southern Asia and its share of persons aged 60 or older was the highest in the region in 2015. Not only does Sri Lanka have among the highest life expectancies in Southern Asia, its TFR has fallen sharply from 5.9 in the early 1950s to 2.11 in 2015 and is estimated to decline to 1.8 by mid-century. Between 1950 and 2015, the proportion of persons in the 60+ age group in Sri Lanka rose rapidly from 0.9% to 13.9%. By 2050, estimates suggest that 28.6% of Sri Lanka’s population will be aged 60 or older. The proportion of persons aged 80 and above in Southern Asia is also rising, although it is still lower than that in Southeast and East Asia. Between 1980 and 2015, the share of persons aged 80 and above in Southern Asia grew slightly from 0.4% to 0.8%. It is expected to rise to 2.7% by 2050.

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In India, the proportion of persons in the 80+ age group rose from 0.3% to 0.9% between 1950 and 2015 and is estimated to reach 2.8% in 2050. India also has among the highest number of persons aged 80 or older in the world, at 11.3 million. The share of persons aged 80 or older in Sri Lanka is the highest in Southern Asia. The share of persons in the 80+ age category in Sri Lanka has risen considerably, from 0.9% in 1950 to 1.5% in 2015 and is expected to hit 6.6% by mid-century. 1.5.2.  Speed of Ageing Between 1980 and 2015, the size of the 60+ age group in Southern Asia grew from an annual average rate of 2.8% to 3.5%. During this period, the growth rate of this age group in Southern Asia was more gradual than in East Asia and Southeast Asia. By 2050, the growth rate of the 60+ age group in Southern Asia is expected to decline to 2.7%, but is set to outpace that in East and Southeast Asia. The size of the 80+ age group grew from an annual average rate of 3.4% in the early 1980s to 4.4% in 2015 but is projected to fall to 3.9% by 2050. The growth rate of the 60+ age group will be faster in Bangladesh than in India over the next three decades as compared to the past 60 years. The size of the 60+ age group in Bangladesh grew at an annual average rate of 1.6% in the early 1950s, as opposed to a rate of 2% in India. By the early 2000s, the growth rates of the 60+ age groups in both countries were at par — 2.9% in Bangladesh and 2.7% in India. In 2050, it is projected that the 60+ age group in Bangladesh will be increasing at a rate of 2.9%, while that of India will slow down to 2.5%. By 2050, the growth rate of the 80+ age group is also projected to be faster in Bangladesh than in other major Southern Asian states. The 80+ age group in Bangladesh is estimated to grow at an annual average rate of 5.8% by 2050, as opposed to 3.6%, 3.5% and 2.3% in India, Pakistan and Sri Lanka respectively. In contrast, the growth rates of the 60+ and 80+ age groups in Sri Lanka are expected to decelerate faster than other major countries in Southern Asia. Between the early 2000s and 2050, the growth

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rates of the 60+ and 80+ age groups are projected to fall from 2.8% to 0.5% and 4.6% to 2.3% respectively. 1.5.3.  Life Expectancy Average life expectancy at birth in Southern Asia has risen from 54.8 years in the early 1980s to 67.7 years in the 2010–2015 period. It is expected to rise to 75.6 years by 2050. Average life expectancy at age 65 has also increased from 12 years in the early 1980s to 14.5 years as of 2015. It is expected to reach 17.1 years by 2050. Although the average life expectancy has risen in Southern Asia, it continues to be lower than that in East and Southeast Asia. The average life expectancy in Sri Lanka is among the highest in Southern Asia. Between the early 1950s and 2000s, average life expectancy at birth in Sri Lanka rose from 55.5 years to 72.6 years. In the 2010–2015 period, it reached 74.6 years and is expected to hit 80.7 years by 2050. In contrast, the average life expectancy in India has increased from 38.7 years in the 1950–1955 period to 64.2 years in the early 2000s. It is expected to rise from 67.5 to 75.9 between 2015 and 2050. The gender gap in life expectancy at birth has consistently been narrower in Southern Asia than in Southeast and East Asia, but has been widening slowly. This is because the gains in life expectancy for females are greater than that for males in less developed regions. Male and female life expectancies at birth in Southern Asia grew from 54.3 years and 55.5 years respectively in the early 1980s, to 66.4 years and 69.2 years respectively in the 2010–2015 period and are expected to reach 73.9 years and 77.4 years respectively by 2050. 1.5.4.  Remaining Life Expectancy As of 2010, the age at which RLE was 15 years or less was 63.1 years in Southern Asia. It is estimated to hit 66.6 years in 2050. Bangladesh is expected to see the greatest gains in this regard between 2010 and 2050, during which time the country’s age at which RLE is 15 years or less will rise from 64.6 years to 71.1 years. Both Bangladesh and Bhutan will outrank other South Asian nations on this measure by 2050, with

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an age at which RLE is 15 years or less of 71.1 each. India is expected to see only moderate gains on this measure, with its age at which RLE is 15 years or less increasing from 62.7 to 65.5 between 2010 and 2050. Down from 7% in 1960, the proportion of the population in Southern Asia at ages with a RLE of 15 years or fewer stood at 5.8% in 2010 and is expected to double to 11.3% by 2050. At 7.2% as of 2010, Sri Lanka had the region’s highest share of persons with a RLE of under 15 years. By 2050, this figure is set to surge further ahead of many Southern Asian states to 14.2%. In India, the proportion of people at ages with a RLE of 15 years or fewer is expected to almost double from 6.2 to 12.2 between 2010 and 2050. 1.5.5.  Median Age and Prospective Median Age Similar to East and Southeast Asia, Southern Asia’s PMA is expected to rise more slowly than its median age. Southern Asia’s median age is projected to increase from 24.8 to 36.7 between 2010 and 2050, while its PMA is set to rise to 32.4 in 2050. Southern Asia is also expected to continue having the lowest PMA in Asia. While Nepal is expected to experience the greatest gains in median age between 2010 and 2050, the PMA is projected to rise the fastest in Pakistan in the same period. 1.5.6.  Sex Ratio Between 1980 and 2015, the sex ratio among the 60+ age group in Southern Asia slid sharply from 105.8 to 95.9, unlike in Southeast Asia and East Asia where the sex ratio in this period increased. The sex ratio in Southern Asia is expected to fall slightly further to 92.2 by 2050. In contrast, the sex ratio among the 80+ age group in Southern Asia declined only slightly from 86.7 to 85.7 between 1980 and 2015. It is expected to fall to 81.3 in 2050. The predominance of females in the older age groups in Southern Asia is thus lower than that in Southeast and East Asia. In 2015, Bhutan and Nepal had the highest and lowest sex ratios respectively for the 60+ age group in Southern Asia. The sex ratio for the 60+ age group in Bhutan rose from 79.7 to 128.6 between

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1950 and 2015. It is expected to increase to 128.1 by 2050. In Nepal, the sex ratio for this age group declined from 95.8 in 1950 to 88.6 in 2015 and is expected to fall to 67.5 by 2050. 1.5.7.  Labour Force Indicators The total LFPR for those aged 65 or over in Southern Asia has declined from 33.6% in 1990 to 26.6% as of 2015 and is projected to fall slightly further to 25.5% by 2030. For older females, it has decreased from 13% in 1990 to 11.7% in 2015 and is set to rise slightly to 12% by 2030. As is the trend in other less developed regions, the LFPR for older males in the region also fell, from 53.8% in 1990 to 43.2% in 2010 and to an estimated 40.7% in 2030. However, the LFPR for males in Southern Asia remains significantly higher than that in East Asia, but is expected to be outpaced by growing LFPR among older males in Southeast Asia between 2015 and 2030. Nepal had the highest LFPR in the region in 2015. The LFPR for older males and females in Nepal were 67.6% and 41.6% respectively. Iran had the region’s lowest LFPR among the 65+ age group, at 30.8% for males and just 3.9% for females. The LFPR for older adults in India has declined significantly. The LFPR for males aged 65 or older fell from 71.7% to 43.2% between 1950 and 2015 and is expected to fall to 41.3% by 2030. The LFPR among females in the 65+ age category also fell, but more gradually during the same time period, from 22% to 11.4%, but is expected to increase slightly to 11.9% by 2030. The statutory retirement age is 55 for both males and females in India. It is 65 for males and 62 for females in Bangladesh and 55 for males and 50 for females in Sri Lanka. The old-age dependency ratio in Southern Asia is expected to continue rising, albeit at a slower pace than East and Southeast Asia. Between 1980 and 2015, the region’s old-age dependency ratio climbed from 6.3 to 8.3. By 2050, it is expected to rise to 20. The PSR for the region correspondingly fell, from 15.8 in 1980 to 12.0 in 2015 and is expected to decline to 5.0 in 2050.

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The old-age dependency ratio in India is set to rise faster in the next three decades than it has between 1950 and 2015. It increased gradually from 5.8 in 1950 to 8.6 in 2015 but is expected to soar to 20.5 by 2050. India’s PSR fell from 17.2 to 11.7 between 1950 and 2015 and is expected to decrease to 4.9 in 2050. Sri Lanka is expected to continue having the highest old-age dependency ratio in Southern Asia. However, between 1950 and 2000, Sri Lanka’s old age-dependency ratio dipped from 10.0 to 9.3. In 1975, it reached its lowest point at 6.7. In 2015, it has risen to 14.1 and is projected to increase sharply to 38.0 by 2050. Sri Lanka’s PSR rose from 10.0 in 1950 and peaked at 14.8 in 1975. It has since been declining, reaching 7.1 in 2015 and is projected to hit a low of 2.6 in 2050. 1.5.8.  Prospective Old-age Dependency Ratio Despite declining from 16.4 to 10.8 between 1960 and 2010, the POADR in Southern Asia has been higher than the OADR over the last few decades. However, over the next few decades, the increase in POADR is expected to be more moderate than the rise in OADR. The POADR of Southern Asia is expected to hit 18.2 in 2050. Sri Lanka is expected to have the region’s highest OADR and POADR in 2050. Sri Lanka’s POADR is expected to double from 12.1 in 2010 to 23.4 in 2050. In contrast, India’s POADR is projected to rise more slowly from 11.4 to 19.8 in the same period. Bhutan is expected to have a POADR of 13.8 in 2050, the region’s lowest. 1.5.9.  Rural-urban Distribution The share of older persons in both urban and rural areas in Southern Asia has risen at an equal pace between 1980 and 2015. The proportion of older rural dwellers rose from 6.1% to 8.8%, while the proportion of older urban dwellers grew from 4.9% to 7.5%. The greatest proportionate increase during this period was among older females in rural areas, whose numbers saw a 50% increase from 6% to 9.3% of the total rural population in Southern Asia.

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A similar scenario can be observed in India, where the share of older females in rural areas increased from 6.2% to 9.9% between 1980 and 2015. The share of older females in urban areas in India grew from 5.3% to 8.7%. In contrast, the share of older men in both rural and urban parts of India grew more slowly than for women, from 6% to 8.6% and from 4.8% to 7% respectively. Sri Lanka was among the Southern Asian countries that saw the sharpest increases in the share of older people in both rural and urban areas between 1980 and 2015. During this period, the share of older females more than doubled from 6.5% to 14.4% in rural areas and from 6.7% to 14.6% in urban areas. The proportion of older men also rose significantly, from 7.1% to 12.5% in rural areas and from 6.6% to 11.6% in urban areas. 1.5.10.  Health Trends Older persons in many Southern Asian countries face the “double burden” of both communicable and non-communicable diseases. High numbers of older people continue to live in poverty in Southern Asia and are vulnerable to a number of communicable diseases due to poor nutrition, sanitation, and hygiene. The most prevalent communicable diseases among the elderly in Southern Asian countries were malaria, tuberculosis, pneumonia, gastrointestinal infections and dengue fever. The incidence of these diseases were found to be high in India, Nepal, Pakistan and Bangladesh, while Sri Lanka registered the lowest incidence for these diseases due to effective infection control (Tyagi, 2014). Studies have also found that India’s demographic transition has not been accompanied by a health transition from infectious diseases to non-communicable diseases corresponding to that in developed ageing countries (Dey et al., 2012; Agrawal and Arokiasamy, 2010). Alongside an increase in NCDs such as cardiovascular, metabolic and degenerative disorders among older adults, the prevalence of tuberculosis is higher among elderly individuals than younger ones. While cardiovascular diseases accounted for one-third of elderly mortality, tuberculosis accounted for another 10% and nutri-

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tional, metabolic, gastro-intestinal and genito-urinary infections accounted for under 4% of elderly mortality (Ingle and Nath, 2008). Data from the Global Burden of Disease shows that the prevalence of tuberculosis in India between 1990 and 2016 has grown from 47% to 52% among those aged 50 to 69 and from 39% to 42% among those aged 70 and above. However, the prevalence of tuberculosis among the elderly in other Southern Asian countries is declining slightly. Although also declining slightly over time, the prevalence of diarrhea, lower respiratory and other common infections was still higher among the elderly in Southern Asia compared to other Asian regions. The prevalence of these infectious diseases was highest in Bhutan, where 13% of persons aged 70 and above experienced these diseases in 2016, up from 9% in 1990. In Southern Asia in general, the prevalence of cardiovascular and cerebrovascular diseases is rising among the elderly, particularly for older age cohorts. For example, while the prevalence of cardiovascular disease among those aged 50 to 69 in Bangladesh rose from about 13% to 14% between 1990 and 2016, the prevalence increased from 32% to 38% among those aged 70 and above. In India, the prevalence of cerebrovascular diseases increased from 1.5% to 1.7% among those aged 50 to 69 between 1990 and 2016, while this figure rose from 3.3% to 3.8% among those aged 70 and above. The prevalence of Alzheimer’s disease and other dementias among the elderly in South Asia paints a more mixed picture. In Bangladesh, India, and Pakistan, the prevalence of Alzheimer’s disease and other dementias fell slightly among younger cohorts of seniors aged between 50 and 69, but increased for older cohorts of seniors aged 70 and above. In Bangladesh, for instance, this figure dipped slightly from 0.46% to 0.43% among younger cohorts of elderly, but rose from 4.7% to 5.9% among older cohorts between 1990 and 2016. However, for Bhutan and Nepal, Alzheimer’s disease and other dementias have generally been increasing among the elderly, and at a faster rate among older cohorts. The data also suggests that the prevalence of Alzheimer’s disease and other dementias in South Asia countries is generally lower than that in East and Southeast Asia. In 2016, Indians aged 70 and

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above experienced a lower prevalence of Alzheimer’s disease and other dementias compared to seniors in other South, East and Southeast Asian countries. The prevalence of cardiovascular and cerebrovascular diseases in South Asia is similar to that in middleand lower-income Southeast Asian countries. There is also little variation in the prevalence of these diseases across South Asian countries.

1.6. CONCLUSION As more countries in Asia are set to experience economic growth and social progress over the next few decades, population ageing will become a critical policy issue for the entire region. The pace of ageing in Asia is also unprecedented and necessitates quick thinking and prompt action on the part of governments and policymakers in the region. At the same time, newer measures of ageing suggest that future demographic trends in Asia will be less severe than has been indicated by conventional measures. This bears consideration by policymakers. Significant disparities also exist within sub-regions and countries in Asia in terms of levels and distribution of income, fertility rate, health, causes of mortality, culture, the geographical distribution of the population and many more. As shown in this chapter, the prevalence of major non-communicable diseases is rising among older cohorts of elderly in lower-income countries in Asia. Infectious diseases also continue to affect the elderly in lower-income Asian countries more so than higher-income ones. At the same time, the data also suggests that the prevalence of major diseases among younger cohorts of the aged even in lower-income countries is declining. It is important that policies are sensitive to these differences and effectively cater to different segments of the population. Policymakers must consider ageing-related matters including but not limited to health and social care, income security, employment, urban planning, housing and socio-cultural changes resulting from ageing in different Asian contexts. The following chapters of this book will address these issues.

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APPENDIX Population Ageing in East Asia, 1950–2050 Population aged 60 or over (thousands)

Share of total population (%)

Population aged 80 or over (thousands)

Share of total population (%)

1950

1980

2015

2030

2050

East Asia

49,840.9

—

269,797

435,154

578,414

China

41,572.2

—

209,239

358,144

491,532

—

1,220

4,458

7,333

9,022

73.2

—

1,581

2,670

3,334

Macao

9.1

—

88

185

290

Japan

6,437

—

41,874

44,809

45,636

S. Korea

1,109

—

9,326

16,502

21,003

East Asia

7.4

7.7

16.7

26.4

36.9

China

7.5

7.2

15.2

25.3

36.5

Taiwan

—

6.8

19.0

31.4

44.2

Hong Kong

3.7

9.3

21.7

33.6

40.9

Macao

4.8

12.4

14.8

25.7

34.5

Japan

7.7

12.8

33.1

37.3

42.5

S. Korea

5.4

6.1

18.5

31.4

41.5

East Asia

2,012.5

—

34,956

61,816

149,459

China

1,558.7

—

22,360

41,405

120,571

Taiwan

—

77.5

727

1,227

2,806

Hong Kong

5.7

—

314

514

1,221

Macao

0.8

—

11

22

76

Japan

376

—

9,822

15,197

16,229

S. Korea

45.1

—

1,409

2,924

7,058

East Asia

0.3

0.5

2.2

3.7

9.5

China

0.3

0.4

1.6

2.9

8.9

Taiwan

—

0.4

3.1

5.3

13.7

Hong Kong

0.3

0.7

4.3

6.5

15.0

Macao

0.4

1.9

1.8

3.2

9.0

Japan

0.4

1.4

7.8

12.7

15.1

S. Korea

0.2

0.5

2.8

5.6

13.9

Taiwan Hong Kong

Ministry of Interior. Statistical Yearbook. http://sowf.moi.gov.tw/stat/year/elist.htm#2 Population (end of year) Population Projections for R.O.C Taiwan http://www.ndc.gov.tw/en/cp.aspx?n=2E5DCB04C64512CC (medium variant)

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Demography  37 Speed of Ageing in East Asia, 1950–2050 1950–1955 1980–1985 2010–2015 2030–2035 2045–2050 East Asia China Taiwan Hong Kong Macao Japan South Korea Speed of East Asia China ageing, persons Taiwan aged Hong Kong 80 or over Macao (%) Japan South Korea Speed of ageing, persons aged 60 or over (%)

2.1 2.1 — 6.9 4.1 2.4 1.5 4.6 3.9 — 4.7 -0.5 6.3 13.1

3.0 2.8 5.3 5.4 0.5 3.3 3.9 6.2 6.2 7.6 10.2 -2.5 6.1 4.8

4.0 4.6 4.9 4.3 6.7 1.4 4.0 4.5 4.6 3.7 5.8 1.7 4.0 7.4

2.5 2.7 1.6 1.8 2.6 0.8 2.3 5.8 7.4 7.1 5.8 9.2 1.0 4.6

1.5 1.8 –0.4 0.4 2.1 -0.4 0.2 4.6 5.4 1.6 1.9 2.2 0.9 2.8

Total Fertility Rates in East Asia, 1950–2050 1950–1955 1990–1995 2010–2015 2025–2030 2045–2050 Total fertility rate (TFR)

China Taiwan

6.2

2.0

1.55

1.66

1.74

5.8 (1960) 1.8 (1990) 1.2 (2014) 1.1 (2030) 1.1 (2050)

Hong Kong

4.4

1.24

1.20

1.44

1.63

Macao

5.0

1.41

1.19

1.54

1.74

Japan

2.7

1.48

1.40

1.57

1.69

South Korea

5.4

1.70

1.26

1.45

1.60

*Department of Household Registration, Ministry of the Interior, ROC (2014). Population Projections for R.O.C. (Taiwan): 2014–2060. Total fertility, age-specific fertility rates and sex ratio at birth 1960–2013 [electronic resource]. Taipei City: National Development Council Taiwan. Data downloaded on 17.09.2014 Taiwan: Ministry of Interior: http://www.moi.gov.tw/files/e_moi_note_file/e_moi_note_file_3.pdf Population Projections for R.O.C Taiwan http://www.ndc.gov.tw/en/cp.aspx?n=2E5DCB04C64512CC (medium variant)

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38  Ageing in Asia: Contemporary Trends and Policy Issues Life Expectancy in East Asia, 1950–2050 1950–1955 1980–1985 2010–2015 2030–2035 2045–2050 Total life expectancy (years)

Female life expectancy (years)

Male life expectancy (years)

East Asia

42.9

68.5

76.6

80.4

83.1

China

40.8

67.4

75.4

79.6

82.5

Taiwan

—

73.3 (1985)

79.4 (2010)

82.6

83.7

Hong Kong

61.0

75.6

83.7

86.8

88.7

Macao

54.0

73.4

80.3

84.3

86.5

Japan

63.9

77.0

83.3

86.2

88.1

South Korea

47.5

67.4

81.4

85.5

87.7

East Asia

44.7

70.3

78.6

82.1

84.2

China

42.3

69.0

77.0

80.9

83.4

Taiwan

—

75.8 (1985)

82.6 (2010)

85.9

87

Macao

56.5

75.5

82.5

85.7

87.8

Hong Kong

64.9

78.8

86.6

89.5

91.3

Japan

65.5

79.6

86.5

89.4

91.3

South Korea

49.0

71.7

84.6

88.5

90.7

East Asia

41.4

66.6

74.7

78.8

81.9

China

39.3

65.9

74.0

78.3

81.7

Taiwan

—

70.8 (1985)

76.1 (2010)

79.3

80.4

Hong Kong

57.2

72.4

80.9

83.8

85.6

Macao

51.5

71.1

78.1

82.8

85.1

Japan

61.6

74.1

80.0

83.0

84.9

South Korea

46.0

63.2

77.9

82.4

84.7

National Statistics ROC Taiwan. Life expectation by age and sex http://eng.stat.gov.tw/ public/data/dgbas03/bs2/yearbook_eng/y016.pdf Population Projections for R.O.C Taiwan http://www.ndc.gov.tw/en/cp.aspx?n=2E5DCB04C64512CC (medium variant)

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Demography  39 Sex Ratio of the Elderly in East Asia, 1950–2050 1950 Sex ratio (males per 100 females, aged 60 or over)

Sex ratio (males per 100 females, aged 80 or over)

1980

2015

2030

2050

East Asia

80.1

83.7

92.0

91.9

94.1

China

80.3

86.7

96.0

94.6

96.5

Taiwan

—

137.7

95.5

91.8

97.5

Hong Kong

40.5

73.5

90.6

79.4

67.7

Macao

56.0

63.3

95.6

83.2

81.2

Japan

79.2

74.2

79.8

79.3

81.9

South Korea

80.6

67.1

77.4

83.6

83.6

East Asia

45.1

54.2

66.3

70.1

77.6

China

43.3

55.1

74.0

75.8

81.4

Taiwan

—

71.1

76.5

76.8

74.7

Hong Kong

35.7

32.8

64.9

71.3

57.6

Macao

53.3

22.2

57.4

84.7

67.1

Japan

50.4

57.1

54.5

59.7

62.5

South Korea

59.9

31.7

44.5

57.1

63.4

Ministry of Interior. Statistical Yearbook. http://sowf.moi.gov.tw/stat/year/elist.htm#2 Population (end of year) Population Projections for R.O.C Taiwan http://www.ndc.gov.tw/en/cp.aspx?n=2E5DCB04C64512CC (medium variant)

Old Age Dependency in East Asia, 1950–2050 Old-age dependency ratio (per 100 persons aged 15–64)

Potential support ratio (per persons aged 65+)

1950

1980

2015

2030

2050

East Asia

7.3

8.1

15.3

27.4

48.7

China

7.2

7.6

13.0

25.3

46.7

Taiwan

—

6.3

16.9

35.7

66.9

Hong Kong Macao Japan South Korea

3.7 4.6 8.3 5.5

8.5 12.9 13.4 6.2

20.6 11.5 43.3 18.0

43.7 29.8 53.1 37.6

64.6 45.0 70.9 65.8

13.8 13.8

12.3 13.2

6.5 7.7

3.6 4.0

2.1 2.1

—

14.8

5.9

2.8

1.5

26.9

11.7

4.8

2.3

1.5

East Asia China Taiwan Hong Kong

(Continued)

b3193_Ch-01.indd 39

08-Apr-19 10:19:47 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

40  Ageing in Asia: Contemporary Trends and Policy Issues (Continued) 1950

1980

2015

2030

2050

Macao Japan

21.9 12.1

7.7 7.5

8.7 2.3

3.4 1.9

2.2 1.4

South Korea

18.2

16.1

5.6

2.7

1.5

Population Projections for R.O.C 2E5DCB04C64512CC (medium variant)

Taiwan

http://www.ndc.gov.tw/en/cp.aspx?n=

National Statistics ROC Taiwan http://eng.stat.gov.tw/public/data/dgbas03/bs2/yearbook_ eng/y010.pdf National Statistics ROC Taiwan. General Statistical Analysis Report. http://eng.stat.gov.tw/ public/Data/5428162113SIDMH93P.pdf

Rural and Urban Elderly in East Asia, 1980 and 2015 1980

2015

Total Female Male Total Female Proportion of older persons in rural areas (%)

East Asia

7.3

17.1

18.0

16.3

8.0

8.9

7.1

16.7

17.4

16.0

Taiwan

—

—

—

—

—

—

Hong Kong

9.8

11.5

8.3

0.0

0.0

0.0

Macao

13.3

16.4

10.2

0.0

0.0

0.0

Japan

16.5

18.5

14.4

37.7

40.9

34.3

8.6

10.0

7.2

32.1

36.4

27.7

East Asia

8.2

9.3

7.2

16.0

17.2

14.9

China

7.3

8.2

6.5

13.5

14.3

12.8

Taiwan

—

—

—

—

—

—

Hong Kong

9.2

11.2

7.5

21.7

21.5

21.9

Macao

12.3

15.4

9.4

14.9

14.7

15.1

Japan

11.7

13.2

10.1

32.9

35.6

30.0

5.2

3.0

15.5

17.2

13.8

South Korea 4.1

b3193_Ch-01.indd 40

9.2

China

South Korea Proportion of older persons in urban areas (%)

8.2

Male

08-Apr-19 10:19:48 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  41 Population Ageing Statistics in East Asia, 1960–2050

Age at which remaining life expectancy is 15 years or less

Percent of the population at ages with remaining life expectancy 15 years or less (%)

Prospective old-age dependency ratio

Median age

1960

1980

2010

2025

2050

East Asia

55.1

63.6

67.1

68.1

69.6

China

53.9

63.1

65.7

66.5

68.4

Taiwan

—

—

—

—

—

Hong Kong

63.4

66.8

71.9

73.9

77.1

Macao

62.3

65.3

68.8

70.7

73.5

Japan

62.0

66.5

72.8

74.5

76.9

South Korea

59.5

61.9

70.2

72.5

75.9

East Asia

10.1

6.1

8.2

11.8

19.1

China

10.9

6.0

7.9

11.9

19.2

Taiwan

—

—

—

—

—

Hong Kong

3.4

4.8

8.3

10.2

19.2

Macao

9.2

8.4

5.3

8.8

16.0

Japan

7.5

8.0

13.3

18.2

20.3

South Korea

6.2

5.1

7.2

10.1

19.8

East Asia

23.7

12.4

12.3

17.9

31.1

China

26.4

12.7

11.9

18.3

31.4

Taiwan

—

—

—

—

—

Hong Kong

6.7

8.4

11.3

14.0

29.2

Macao

19.7

15.1

7.0

12.2

24.0

Japan

14.3

13.0

19.5

28.1

32.3

South Korea

14.4

10.3

10.4

14.0

31.0

—

—

—

—

—

21.3

22.0

34.6

39.6

46.2

East Asia China Taiwan

Prospective median age

—

—

—

—

—

Hong Kong

23.2

25.0

41.1

47.2

54.0

Macao

25.3

25.4

36.6

41.9

49.2

Japan

25.5

32.6

44.9

50.2

53.4

South Korea

19.8

22.1

37.8

45.2

53.6

—

—

—

—

—

China

38.2

26.3

34.6

38.4

42.8

Taiwan

—

—

—

—

—

East Asia

(Continued)

b3193_Ch-01.indd 41

08-Apr-19 10:19:48 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

42  Ageing in Asia: Contemporary Trends and Policy Issues (Continued) 1960

1980

2010

2025

2050

Hong Kong

34.5

31.8

41.1

44.8

48.1

Macao

34.9

30.7

36.6

39.5

43.5

Japan

37.5

38.8

44.9

48.2

48.5

South Korea

36.7

33.5

37.8

42.1

46.6

Population Ageing in Southeast Asia, 1950–2050 Population aged 60 or over (thousands)

1950

1980

10,717.7

—

3.8

—

Cambodia

197.4

—

1,052

1,972

3,969

Indonesia

4,952.8

—

21,195

38,956

61,896

81

—

407

685

1,491

Malaysia

447.5

—

2,784

5,196

9,592

Myanmar

976.9

—

4,787

7,981

11,967

Philippines

1,104.3

—

7,321

12,682

20,778

Singapore

38.2

—

1,001

1,969

2,700

Thailand

991

—

10,731

18,355

23,153

Vietnam

1,918.8

—

9,614

18,425

31,432

Southeast Asia

6.0

5.9

9.3

14.7

21.1

Brunei Darussalam

7.6

4.3

7.6

17.1

30.9

Cambodia

4.5

4.7

6.8

10.4

17.6

Indonesia

6.2

5.6

8.2

13.2

19.2

Lao People’s Democratic Republic

4.6

5.7

6.0

8.1

14.7

Malaysia

7.3

5.6

9.2

14.4

23.6

Myanmar

5.5

6.2

8.9

13.2

18.8

Southeast Asia Brunei Darussalam

Lao People’s Democratic Republic

Share of total population (%)

2015

2030

2050

59,101 106,415 33

86

167,320 169

(Continued)

b3193_Ch-01.indd 42

08-Apr-19 10:19:48 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  43 (Continued)

Population aged 80 or over (thousands)

Share of total population (%)

b3193_Ch-01.indd 43

1950

1980

2015

2030

2050

Philippines

5.5

Singapore

3.7

4.9

7.3

10.3

14.0

7.2

17.9

30.7

40.4

Thailand

5.0

5.6

15.8

26.9

37.1

Vietnam

7.0

7.8

10.3

17.5

27.9

Southeast Asia

626.2

—

6,542

10,333

27,483

0.4

—

3

8

34

Cambodia

9.8

—

78

164

577

Indonesia

275.5

—

1,729

2,710

7,417

Lao People’s Democratic Republic

4.5

—

35

54

158

Malaysia

38.7

—

236

546

1455

Myanmar

45.2

—

417

561

1,319

Philippines

72.7

—

596

1,025

2,437

Singapore

4.2

—

133

342

921

Thailand

80.6

—

1,430

2,598

6,171

Vietnam

93.6

—

1,877

2,308

6,974

Southeast Asia

0.4

0.4

1.0

1.4

3.5

Brunei Darussalam

0.7

0.4

0.7

1.4

6.2

Cambodia

0.2

0.2

0.5

0.9

2.6

Indonesia

0.3

0.3

0.7

0.9

2.3

Lao People’s Democratic Republic

0.3

0.3

0.5

0.6

1.6

Malaysia

0.6

0.4

0.8

1.5

3.6

Myanmar

0.3

0.4

0.8

0.9

2.1

Philippines

0.4

0.3

0.6

0.8

1.6

Singapore

0.4

0.5

2.4

5.3

13.8

Thailand

0.4

0.6

2.1

3.8

9.9

Vietnam

0.3

0.8

2.0

2.2

6.2

Brunei Darussalam

08-Apr-19 10:19:48 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

44  Ageing in Asia: Contemporary Trends and Policy Issues Speed of Ageing in Southeast Asia, 1950–2050 1950– 1955 Speed of ageing, persons aged 60 or over (%)

2010– 2015

2030– 2035

2045– 2050

Southeast Asia

1.0

2.8

3.8

3.0

1.5

Brunei Darussalam

3.8

3.4

7.4

4.6

2.2

Cambodia

2.0

3.2

4.4

3.3

2.8

Indonesia

0.0

2.6

3.2

3.3

1.1

Lao People’s Democratic Republic

-0.1

2.6

3.0

3.6

4.5

Malaysia

-1.4

2.5

4.8

3.0

3.0

Myanmar

2.6

2.6

4.0

2.7

1.3

Philippines

1.2

2.5

3.6

2.8

2.3

Singapore

3.2

4.1

6.7

2.6

0.6

Thailand

1.8

3.4

4.3

2.2

0.2

Vietnam

2.5

2.9

4.1

3.2

2.3

1.9

4.9

3.3

5.7

3.6

-3.3

1.6

5.2

10.1

5.8

1.6

4.9

6.0

7.6

4.9

1.7

4.1

0.9

5.0

4.2

-0.4

4.4

2.7

5.4

4.9

Malaysia

0.6

2.3

5.6

5.7

3.7

Myanmar

4.4

4.2

2.2

6.5

3.2

Philippines

3.0

3.4

4.6

4.6

3.7

Singapore

2.7

6.0

6.7

6.9

2.7

Thailand

0.2

4.4

5.3

5.6

2.8

Vietnam

2.5

7.0

3.4

6.6

3.6

Speed of ageing, Southeast Asia persons aged 80 Brunei Darussalam or over (%) Cambodia Indonesia Lao People’s Democratic Republic

b3193_Ch-01.indd 44

1980– 1985

08-Apr-19 10:19:48 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  45 Total Fertility Rates in Southeast Asia, 1950–2050

Total fertility rate (TFR)

1950– 1955

1980– 1985

2010– 2015

2030– 2035

2045– 2050

Brunei Darussalam

7.0

3.28

1.90

1.72

1.69

Cambodia

6.3

5.13

2.70

2.27

1.97

Indonesia

5.5

2.90

2.50

2.14

1.91

Lao People’s Democratic Republic

6.2

5.88

3.10

2.34

1.89

Malaysia

6.8

3.42

1.97

1.79

1.72

Myanmar

6.0

3.20

2.25

1.95

1.79

Philippines

7.3

4.14

3.04

2.59

2.20

Singapore

6.4

1.73

1.23

1.31

1.38

Thailand

6.4

1.99

1.53

1.43

1.58

Vietnam

5.7

3.23

1.96

1.93

1.92

Southeast Asia

Life Expectancy in Southeast Asia, 1950–2050

Total life expectancy (years)

1950– 1955

1980– 1985

2010– 2015

2030– 2035

2045– 2050

Southeast Asia

41.0

61.9

70.3

73.7

75.8

Brunei Darussalam

60.4

70.9

78.4

82.4

85.0

Cambodia

39.4

45.1

67.6

75.3

78.8

Indonesia

37.5

60.7

68.6

71.9

73.9

Lao People’s Democratic Republic

37.8

49.9

65.5

72.9

76.6

Malaysia

48.5

68.8

74.5

77.7

80.1

Myanmar

36.8

55.9

65.6

68.7

70.6

Philippines

47.8

62.9

68.0

70.8

72.7

Singapore

60.4

72.9

82.6

86.2

88.3

Thailand

52.0

65.7

74.1

77.8

80.3

Vietnam

40.4

68.1

75.6

78.5

80.9

(Continued)

b3193_Ch-01.indd 45

08-Apr-19 10:19:48 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

46  Ageing in Asia: Contemporary Trends and Policy Issues (Continued)

Female life expectancy (years)

Male life expectancy (years)

b3193_Ch-01.indd 46

1950– 1955

1980– 1985

2010– 2015

2030– 2035

2045– 2050

Southeast Asia

42.1

64.1

73.2

76.6

78.7

Brunei Darussalam

61.1

72.6

80.4

83.7

85.9

Cambodia

40.8

47.3

69.5

77.4

80.6

Indonesia

38.1

61.8

70.7

74.3

76.5

Lao People’s Democratic Republic

39.2

51.1

66.8

74.7

78.4

Malaysia

50.0

70.5

76.9

79.9

82.0

Myanmar

38.2

58.3

67.7

71.0

73.1

Philippines

49.6

65.4

71.6

74.6

76.6

Singapore

62.1

75.7

85.6

89.1

91.2

Thailand

54.3

68.9

77.6

80.8

82.7

Vietnam

41.8

72.5

80.3

82.4

84.0

Southeast Asia

39.9

59.8

67.5

70.8

73.0

Brunei Darussalam

59.6

69.6

76.6

81.1

84.2

Cambodia

38.1

42.8

65.5

73.0

76.8

Indonesia

36.9

59.5

66.6

69.5

71.5

Lao People’s Democratic Republic

36.5

48.6

64.1

71.1

74.8

Malaysia

47.0

67.2

72.2

75.5

78.3

Myanmar

35.6

53.6

63.6

66.4

68.1

Philippines

46.0

60.5

64.7

67.2

69.1

Singapore

58.8

70.3

79.6

83.1

85.3

Thailand

49.8

62.8

70.8

74.8

77.9

Vietnam

39.1

63.6

70.7

74.6

77.7

08-Apr-19 10:19:48 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  47 Sex Ratio of the Elderly in Southeast Asia, 1950–2050 1950 Sex ratio (males per 100 females, aged 60 or over)

Sex ratio (males per 100 females, aged 80 or over)

1980

2015

2030

2050

Southeast Asia

85.8

81.7

82.2

82.4

80.8

Brunei Darussalam

90.4

119.9

95.3

98.2

101.6

Cambodia

82.8

61.0

67.8

70.5

78.6

Indonesia

94.2

87.2

89.2

87.0

81.2

Lao People’s Democratic Republic

87.5

79.0

81.9

80.9

84.2

Malaysia

109.8

100.8

95.8

84.4

87.4

Myanmar

82.0

79.1

78.3

78.5

80.2

Philippines

61.9

82.9

80.2

78.8

75.2

Singapore

61.9

86.8

87.8

88.5

81.9

Thailand

80.3

83.9

84.9

84.3

84.4

Vietnam

81.8

69.8

66.5

75.6

79.1

Southeast Asia

73.1

57.2

58.9

59.8

61.9

Brunei Darussalam

82.5

95.9

77.6

74.2

87.3

Cambodia

71.9

32.2

61.8

54.2

60.0

Indonesia

87.0

69.5

62.7

61.3

60.0

Lao People’s Democratic Republic

66.6

64.6

67.1

63.5

57.4

Malaysia

99.5

87.3

123.8

87.9

76.4

Myanmar

61.4

58.5

62.0

62.8

59.8

Philippines

51.0

64.4

56.8

56.8

54.8

Singapore

51.0

47.6

57.8

65.2

67.3

Thailand

64.8

62.0

69.9

69.2

68.4

Vietnam

61.4

37.5

43.4

44.2

58.1

Old Age Dependency in Southeast Asia, 1950–2050

Old-age dependency ratio (per 100 persons aged 15–64)

1950

1980

2015

2030

2050

Southeast Asia

6.6

6.9

8.8

14.7

24.1

Brunei Darussalam

8.3

4.9

6.1

16.2

39.4

(Continued)

b3193_Ch-01.indd 47

08-Apr-19 10:19:48 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

48  Ageing in Asia: Contemporary Trends and Policy Issues (Continued)

Potential support ratio (per persons aged 65+)

1950

1980

2015

2030

2050

Cambodia

4.9

4.8

6.4

10.4

19.6

Indonesia

7.0

6.5

7.7

12.4

21.3

Lao People’s Democratic Republic

5.1

6.7

6.2

8.1

13.9

Malaysia

9.4

6.2

8.4

14.5

25.3

Myanmar

5.5

7.0

8.0

12.5

19.6

Philippines

6.8

6.0

7.2

10.3

14.5

Singapore

4.2

6.9

16.1

36.5

61.6

Thailand

5.9

6.6

14.6

29.2

52.5

Vietnam

6.6

9.9

9.6

18.3

34.1

Southeast Asia

15.1

14.4

11.4

6.8

4.2

Brunei Darussalam

12.0

20.4

16.4

6.2

2.5

Cambodia

20.4

20.7

15.6

9.6

5.1

Indonesia

14.4

15.4

13.0

8.1

4.7

Lao People’s Democratic Republic

19.6

14.9

16.1

12.4

7.2

Malaysia

10.7

16.0

11.9

6.9

3.9

Myanmar

18.2

14.3

12.5

8.0

5.1

Philippines

14.7

16.7

13.9

9.7

6.9

Singapore

23.8

14.5

6.2

2.7

1.6

Thailand

16.8

15.2

6.9

3.4

1.9

Vietnam

15.2

10.1

10.4

5.5

2.9

Rural and Urban Elderly in Southeast Asia, 1980 and 2015 1980

2015

Total Female Male Total Female Male Proportion of older persons in rural areas (%)

Southeast Asia

6.0

6.6

5.5

9.7

10.8

8.7

Brunei Darussalam

4.4

4.3

4.6

9.0

9.0

8.9

Cambodia

4.8

5.7

3.8

8.6

9.9

7.3

Indonesia

5.7

6.0

5.3

8.9

9.5

8.2

(Continued)

b3193_Ch-01.indd 48

08-Apr-19 10:19:48 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  49 (Continued) 1980

2015

Total Female Male Total Female Male

Proportion of older persons in urban areas (%)

Lao People’s Democratic Republic

5.7

6.3

5.0

6.1

6.7

5.5

Malaysia

6.0

5.9

6.1

9.6

9.8

9.5

Myanmar

6.3

6.7

5.8

9.2

9.8

8.6

Philippines

5.0

5.5

4.6

7.1

7.8

6.3

Singapore

0.0

0.0

0.0

0.0

0.0

0.0

Thailand

5.7

6.2

5.2

16.9

18.0

15.7

Vietnam

7.9

9.2

6.6

10.7

13.0

8.4

Southeast Asia

5.5

6.1

4.9

9.1

9.9

8.2

Brunei Darussalam

4.2

4.1

4.3

8.5

8.6

8.5

Cambodia

4.1

5.1

2.9

7.2

8.3

6.0

Indonesia

5.3

5.8

4.8

8.3

8.9

7.6

Lao People’s Democratic Republic

5.8

6.4

5.2

5.9

6.5

5.4

Malaysia

5.1

5.2

4.9

8.9

8.8

8.9

Myanmar

6.1

7.0

5.2

8.6

9.9

7.3

Philippines

4.7

5.3

4.1

6.5

7.5

5.6

Singapore

7.2

7.9

6.6

17.0

17.9

16.1

Thailand

5.4

5.9

4.8

14.7

15.7

13.6

Vietnam

7.1

8.3

5.8

9.8

11.2

8.2

Population Ageing Statistics in Southeast Asia, 1960–2050

Age at which remaining life expectancy is 15 years or less

1960

1980

2010

2025

2050

Southeast Asia

59.4

61.9

65.3

66.7

68.7

Brunei Darussalam

61.4

64.0

67.4

69.0

71.8

Cambodia

55.8

53.1

72.5

74.2

76.2

(Continued)

b3193_Ch-01.indd 49

08-Apr-19 10:19:49 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

50  Ageing in Asia: Contemporary Trends and Policy Issues (Continued)

Percent of the population at ages with remaining life expectancy 15 years or less

Prospective oldage dependency ratio

1960

1980

2010

2025

2050

Indonesia

57.9

60.5

63.5

64.8

66.9

Lao People’s Democratic Republic

57.1

58.8

62.6

64.6

68.6

Malaysia

60.0

62.2

64.9

66.5

69.3

Myanmar

57.0

60.1

62.1

62.7

63.7

Philippines

60.8

61.5

62.7

63.8

65.6

Singapore

59.8

63.1

71.0

73.2

76.3

Thailand

62.6

64.5

68.0

69.6

71.8

Vietnam

61.7

65.5

69.7

71.1

72.6

Southeast Asia

6.0

5.0

5.3

7.3

12.6

Brunei Darussalam

5.5

3.1

2.9

6.3

15.5

Cambodia

6.1

8.5

2.6

3.4

6.9

Indonesia

6.6

5.4

5.7

7.9

13.7

Lao People’s Democratic Republic

6.1

6.3

4.6

5.0

7.6

Malaysia

5.3

4.7

4.9

7.1

11.4

Myanmar

7.3

6.2

6.4

9.7

17.4

Philippines

4.6

4.4

4.6

6.3

8.8

Singapore

3.8

5.6

5.5

8.1

15.1

Thailand

4.2

3.9

7.0

10.6

20.7

Vietnam

6.5

5.1

4.9

5.6

13.6

Southeast Asia

13.9

11.7

9.3

11.9

20.2

Brunei Darussalam

12.5

6.6

4.7

9.4

24.6

Cambodia

15.9

21.3

4.9

5.8

10.6

Indonesia

15.1

12.6

10.2

13.1

22.5

Lao People’s Democratic Republic

14.4

16.3

9.9

9.2

11.8

Malaysia

13.2

10.5

8.5

11.4

17.5

(Continued)

b3193_Ch-01.indd 50

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“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  51 (Continued)

Median age

Prospective median age

b3193_Ch-01.indd 51

1960

1980

2010

2025

2050

Myanmar

16.8

14.7

11.0

15.8

29.4

Philippines

11.8

10.6

9.2

11.6

14.9

Singapore

8.6

10.1

7.9

11.1

22.0

Thailand

9.6

8.6

10.5

15.3

33.2

Vietnam

14.1

12.0

7.9

8.2

20.3

Southeast Asia

19.5

19.0

27.2

32.1

38.9

Brunei Darussalam

19.4

20.4

29.5

35.0

43.7

Cambodia

17.1

19.1

23.6

28.7

36.1

Indonesia

20.2

19.0

26.9

31.0

38.4

Lao People’s Democratic Republic

19.0

17.6

20.3

25.3

34.3

Malaysia

17.5

19.6

26.1

32.2

39.8

Myanmar

20.6

19.2

27.8

33.5

40.1

Philippines

16.5

18.0

22.2

25.7

31.5

Singapore

18.8

24.5

37.4

42.0

50.0

Thailand

18.7

19.7

35.4

42.9

51.1

Vietnam

21.8

19.0

28.5

35.7

45.5

Southeast Asia

30.7

25.5

27.2

30.1

34.3

Brunei Darussalam

29.4

25.8

29.5

32.7

38.1

Cambodia

40.1

56.1

23.6

25.9

30.0

Indonesia

33.1

25.6

26.9

29.1

33.7

Lao People’s Democratic Republic

31.5

27.1

20.3

21.6

26.0

Malaysia

26.1

23.9

26.1

29.9

34.0

Myanmar

32.2

24.5

27.8

32.5

37.6

Philippines

20.7

20.2

22.2

24.0

27.1

Singapore

31.6

33.1

37.4

39.6

44.2

Thailand

28.0

25.3

35.4

40.8

46.2

Vietnam

30.7

23.3

28.5

34.0

41.5

08-Apr-19 10:19:49 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

52  Ageing in Asia: Contemporary Trends and Policy Issues Population Ageing in South Asia, 1950–2050

Population aged 60 or over (thousands)

Share of total population (%)

Population aged 80 or over (thousands)

Southern Asia

b3193_Ch-01.indd 52

1980

2015

2030

2050

—

—

153,490

256,153

460,096

2,570.6

—

11,235

21,525

43,492

42.4

—

56

104

235

India

20,098

—

116,553

190,730

330,043

Nepal

522.9

—

2,455

3,572

6,491

Pakistan

3,263

—

12,476

20,672

39,970

Sri Lanka

Bangladesh Bhutan

548.6

—

2,887

4,524

5,951

Southern Asia

—

5.7

8.4

11.9

19.0

Bangladesh

6.2

5.1

7.0

11.5

21.5

Bhutan

5.8

4.3

7.4

11.6

24.5

India

5.6

5.9

8.9

12.5

19.4

Nepal

6.2

5.4

8.6

10.8

17.9

Pakistan

8.2

6.0

6.6

8.4

12.9

Sri Lanka

7.3

6.8

13.9

21.0

28.6

Southern Asia

—

—

15,358

26,828

65,155

100.0

—

1,520

2,679

7,327

Bangladesh Bhutan

2.1

—

7

15

36

922.4

—

11,287

19,977

47,758

Nepal

22.6

—

193

381

853

Pakistan

187.7

—

1,222

1,882

3,904

Sri Lanka

68.2

—

315

691

1,379

Southern Asia

—

0.4

0.8

1.2

2.7

Bangladesh

0.2

0.2

0.9

1.4

3.4

Bhutan

0.3

0.2

1.0

1.6

3.8

India

0.3

0.4

0.9

1.3

2.8

Nepal

0.3

0.3

0.7

1.2

2.4

Pakistan

0.5

0.5

0.6

0.8

1.3

Sri Lanka

0.9

0.5

1.5

3.2

6.6

India

Share of total population (%)

1950

08-Apr-19 10:19:49 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  53 Speed of Ageing in South Asia, 1950–2050 1950– 1980– 2010– 2030– 2045– 1955 1985 2015 2035 2050 Speed of ageing, persons aged 60 or over (%)

Speed of ageing, persons aged 80 or over (%)

Southern Asia

—

2.8

3.5

3.0

2.7

Bangladesh

1.6

2.1

1.5

3.9

2.9

Bhutan

0.9

3.9

3.4

3.8

3.5

India

2.0

2.7

3.9

2.9

2.5

Nepal

1.0

2.8

1.2

0.6

0.3

Pakistan

-0.2

3.4

2.2

3.1

3.5

Sri Lanka

-0.8

3.5

3.8

1.8

0.5

Southern Asia

—

3.4

4.4

4.9

3.9

Bangladesh

4.1

4.8

5.4

2.0

5.8

Bhutan

1.3

5.2

6.7

3.7

5.2

India

1.4

3.2

4.6

5.3

3.6

Nepal

2.7

5.4

3.2

5.1

4.4

Pakistan

4.3

3.4

3.1

2.2

3.5

Sri Lanka

-0.1

5.3

2.8

4.5

2.3

Total Fertility Rates in South Asia, 1950–2050 1950– 1980– 2010– 2030– 2045– 1955 1985 2015 2035 2050 Total fertility rate (TFR)

b3193_Ch-01.indd 53

Southern Asia

—

—

—

—

—

Bangladesh

6.7

4.06

2.23

1.84

1.67

Bhutan

5.9

5.07

2.10

1.69

1.59

India

6.0

3.83

2.48

2.14

1.89

Nepal

5.8

4.97

2.32

1.85

1.69

Pakistan

6.3

5.67

3.72

2.88

2.31

Sri Lanka

5.9

2.38

2.11

1.90

1.80

08-Apr-19 10:19:49 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

54  Ageing in Asia: Contemporary Trends and Policy Issues Life Expectancy in South Asia, 1950–2050 1950– 1980– 2010– 2030– 2045– 1955 1985 2015 2035 2050 Total life expectancy (years)

Female life expectancy (years)

—

54.8

67.7

72.8

75.6

Bangladesh

36.6

54.3

71.0

76.5

78.7

Bhutan

35.2

46.8

68.9

74.5

77.2

India

38.7

54.9

67.5

72.9

75.9

Nepal

36.3

48.3

69.0

74.9

78.0

Pakistan

41.0

57.8

65.9

69.2

71.3

Sri Lanka

55.5

69.1

74.6

78.2

80.7

—

55.5

69.2

74.5

77.4

Bangladesh

34.9

54.5

72.3

77.9

80.0

Bhutan

36.0

46.6

69.1

75.2

78.0

India

38.0

55.1

68.9

74.7

77.8

Nepal

35.8

48.7

70.4

76.5

79.3

Pakistan

39.8

58.4

66.8

70.5

73.0

Sri Lanka

54.7

71.8

78.0

81.0

83.0

Southern Asia

Southern Asia

Male life expectancy (years) Southern Asia

—

54.3

66.4

71.2

73.9

Bangladesh

38.3

54.1

69.9

75.1

77.4

Bhutan

34.5

47.0

68.6

73.8

76.5

India

39.4

54.8

66.1

71.2

74.1

Nepal

36.8

47.9

67.6

73.2

76.3

Pakistan

42.3

57.3

65.0

67.9

69.8

Sri Lanka

56.2

66.9

71.2

75.1

78.1

2030

2050

Sex Ratio of the Elderly in South Asia, 1950–2050 1950 Sex ratio (males per 100 females, aged 60 or over)

Southern Asia

1980

2015

—

105.8

95.9

95.1

92.2

112.3

117.3

104.2

100.2

92.6

Bhutan

79.7

105.7

128.6

132.0

128.1

India

89.9

103.3

94.5

94.3

92.7

134.1

128.9

104.4

98.9

94.4

95.8

77.2

88.6

84.2

67.5

118.5

111.0

79.5

79.4

75.3

Bangladesh

Pakistan Nepal Sri Lanka

(Continued)

b3193_Ch-01.indd 54

08-Apr-19 10:19:49 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  55 (Continued) 1950 Sex ratio (males per 100 females, aged 80 or over)

Southern Asia

1980

2015

2030

2050

—

86.7

85.7

83.2

81.3

100.0

108.5

99.2

95.4

90.5

Bhutan

74.9

96.5

112.4

130.1

125.4

India

98.1

83.3

81.2

80.6

79.4

139.7

111.3

110.3

103.8

89.0

84.0

68.0

77.0

66.9

62.8

111.4

90.6

67.0

65.9

66.6

Bangladesh

Pakistan Nepal Sri Lanka

Old Age Dependency in South Asia, 1950–2050 1950 Old-age dependency ratio (per 100 persons aged 15–64)

Potential support ratio (per persons aged 65+)

1980

2015

2030

2050

Southern Asia

—

6.3

8.3

11.9

20.0

Bangladesh

6.2

5.9

7.6

10.6

23.1

Bhutan

6.3

4.6

7.4

10.8

26.3

India

5.8

6.4

8.6

12.5

20.5

Nepal

6.5

5.9

9.0

10.8

18.0

Pakistan

9.4

7.2

7.4

8.6

12.7

Sri Lanka

10.0

7.3

14.1

23.7

38.0

—

15.8

12.0

8.4

5.0

Bangladesh

16.2

17.1

13.2

9.4

4.3

Bhutan

15.8

21.7

13.4

9.2

3.8

India

17.2

15.7

11.7

8.0

4.9

Nepal

15.5

16.8

11.1

9.2

5.6

Pakistan

10.6

13.8

13.5

11.6

7.9

Sri Lanka

10.0

13.7

7.1

4.2

2.6

Southern Asia

Rural and Urban Elderly in South Asia, 1980 and 2015 1980 Proportion of older persons in rural areas (%)

Southern Asia Bangladesh Bhutan

2015

Total

Female

Male

Total

Female

Male

6.1

6.0

6.1

8.8

9.3

8.3

5.8 4.5

5.4 4.6

6.1 4.5

7.6 9.5

7.3 8.8

7.8 10.2

(Continued)

b3193_Ch-01.indd 55

08-Apr-19 10:19:50 AM

b3193   Ageing in Asia: Contemporary Trends and Policy Issues “9x6”

56  Ageing in Asia: Contemporary Trends and Policy Issues (Continued) 1980

Proportion of older persons in urban areas (%)

2015

Total

Female

Male

Total

Female

Male

India Nepal Pakistan Sri Lanka Southern Asia

6.1 5.5 6.4 6.8 4.9

6.2 5.7 5.8 6.5 5.1

6.0 5.2 6.9 7.1 4.7

9.2 8.5 6.8 13.5 7.5

9.9 8.3 6.7 14.4 8.2

8.6 8.7 6.8 12.5 7.0

Bangladesh Bhutan

5.2 2.0

4.9 2.2

5.4 1.9

6.3 3.6

6.1 3.6

6.4 3.6

India

5.0

5.3

4.8

7.8

8.7

7.0

Nepal

4.9

5.1

4.7

6.8

7.3

6.3

Pakistan

4.6

4.2

4.9

6.4

6.6

6.2

Sri Lanka

6.7

6.7

6.6

13.1

14.6

11.6

Population Ageing Statistics in South Asia, 1960–2050

Age at which remaining life expectancy is 15 years or less

Percent of the population at ages with remaining life expectancy 15 years or less (%)

1960

1980

2010

2025

2050

Southern Asia

56.8

60.4

63.1

64.3

66.6

Bangladesh

60.4

62.8

64.6

67.1

71.1

Bhutan

53.7

58.6

66.6

68.2

71.1

India

55.9

59.8

62.7

63.7

65.5

Nepal

55.5

58.3

62.6

64.3

67.8

Pakistan

61.1

62.8

63.4

63.7

64.4

Sri Lanka

60.4

63.9

65.8

67.5

70.1

Southern Asia

7.0

5.6

5.8

7.4

11.3

Bangladesh

5.2

4.5

4.8

5.0

9.9

Bhutan

7.0

4.9

3.9

4.8

9.4

India

7.5

6.0

6.2

8.1

12.2

Nepal

7.2

6.3

6.1

7.0

10.1

Pakistan

5.8

4.6

5.0

5.8

10.1

Sri Lanka

6.5

4.8

7.2

9.9

14.2

(Continued)

b3193_Ch-01.indd 56

08-Apr-19 10:19:50 AM

“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

Demography  57 (Continued)

Prospective old-age dependency ratio

Median age

Prospective median age

b3193_Ch-01.indd 57

1960

1980

2010

2025

2050

Southern Asia

16.4

12.8

10.8

12.6

18.2

Bangladesh

12.3

11.1

9.0

8.0

14.8

Bhutan

17.0

11.4

7.0

7.5

13.8

India

17.3

13.5

11.4

13.9

19.8

Nepal

16.7

15.0

13.1

12.3

15.8

Pakistan

13.3

11.0

10.2

10.5

16.6

Sri Lanka

15.4

9.9

12.1

16.7

23.4

Southern Asia

20.0

19.6

24.8

29.4

36.7

Bangladesh

18.5

17.5

24.0

29.7

39.9

Bhutan

19.1

18.9

24.4

31.1

40.5

India

20.3

20.2

25.5

29.9

36.7

Nepal

20.2

19.2

21.2

27.1

38.2

Pakistan

19.8

18.2

21.5

26.4

34.1

Sri Lanka

19.1

21.6

30.5

34.6

39.7

Southern Asia

33.1

24.4

24.8

27.6

32.4

Bangladesh

27.0

21.7

24.0

26.7

32.5

Bhutan

39.6

32.7

24.4

28.2

33.9

India

34.0

24.5

25.5

28.2

32.8

Nepal

35.1

29.3

21.2

23.8

31.0

Pakistan

28.5

21.1

21.5

25.7

32.3

Sri Lanka

26.7

24.6

30.5

32.6

34.3

08-Apr-19 10:19:50 AM

b2530   International Strategic Relations and China’s National Security: World at the Crossroads

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“9x6”

b3193   Ageing in Asia: Contemporary Trends and Policy Issues

CHAPTER 2

ECONOMIC DEVELOPMENT Aris Ananta and Evi Nurvidya Arifin

2.1.  THE FEAR OF POPULATION AGEING The current issues on the inter-relationship between population ageing and economic development actually mirror past issues on the relationship between high fertility and economic development in the 1960s and 1970s (Bloom et al. 2011). In the past, issues were associated with the fear of population explosion during the 1960s and 1970s (Kelley 1988, 2001), and currently the fear is related to an explosion of older persons (Onder and Pestieau 2014; Van Der Gaag and de Beer 2015). The issues are concerned with rising dependency ratios, which is the ratio of “unproductive” population to “productive” population. A higher dependency ratio is believed to represent a higher burden for the economy, as one productive person must support a larger number of unproductive persons and vice versa. A shift is observed as the dependency ratio in the 1960s and 1970s referred to the young dependency ratio, while it now refers to the old dependency ratio. The young are often defined as those under 15 years old, said to be already consuming but not yet producing. They are defined as “unproductive”, harmful to economic growth. High young dependency ratio, because of high fertility, is feared to result in much higher spending on “unproductive” expenditure activities such as education, health, and other consumption for the children. 59

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Therefore, it is argued that savings will fall as will investment, resulting in the decline of economic growth. In a similar way, the old are also “unproductive” because they are still consuming but have stopped producing. Then, it is argued that savings will fall, followed by a fall in investment and, then, economic growth. The old are defined as individuals aged at least 60 or 65 years old. This simple model (high consumption–low saving–low investment–low national income) has many shortcomings. The main criticism of this model is that it is still oriented to national income. It has not been oriented to sustainable development, which has been declared by the United Nations as the post-2015 development agenda. Second, the model assumes that declining number and percentage of the labour force, or even working population, is detrimental to economic growth. The model has not paid sufficient attention to the productivity (including health and education) of the labour force. A large labour force will not be good for the economy, and it can even be harmful, if it is of low productivity; a small labour force can be an asset if it is highly productive. Third, the model uses a closed economy, without any relation to the global economy. Actually, almost all contemporary countries in the world are now open economies. Investment no longer depends solely on domestic saving. Foreign direct investment has been commonly used to inject investment when domestic saving is low. Fourth, the model does not consider the possibility of the presence of monetary programmes such as micro-finance, which can help poor households with loans for productive purposes. Fifth, the model also ignores the possibility that high spending for children’s health and education can be productive, as high-quality children will become labour force with high productivity. The model also suffers from measurement problems. Who are the young, unproductive, population? With compulsory education and progress in economic development, the young will continue going to school until finishing high school, and now even aspiring

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to earn undergraduate degrees. That means we should define the young dependents as those below 25 years of age. Then, who are the old, unproductive, population? Why is 60 or 65 years used as the threshold? As detailed in Lee (2000) and Spijker and Maclnnes (2013), many older persons are still working, contributing to the economy, helping the younger generation, and even taking care of their children. Many are even still helping the younger generation financially. The flow of money is not necessarily from the young to the defined “old dependent”. Therefore, Bloom et al. (2011) argued that the “dependency ratio” is actually a “misnomer”. The fear of an explosion of older persons is mostly attributable to the “accounting” framework of analysis. This framework assumes that other things, especially behavioural variables, do not change. It only analyses the number and percentage of older persons, or the working-age population, to the GDP growth, assuming the relationship is constant. Thus, Onder and Pestieau (2014) argued that when the assumptions of constant behaviour are relaxed, population ageing can be an asset to the economy. Furthermore, Prettner (2013) found that the process of population ageing is not necessarily harmful to development. The negative impact of population ageing on economic growth can be reduced, or even avoided, through changes in technology. Behavioural variables may also include changes in labour force participation, delay in retirement age (not only formal-legal retirement ages), changes in productivity (education, skill, health, infrastructure). The concept of Active Ageing, pioneered by WHO (2002), attempts to change behavioural variables, by making older persons independent, healthy, and productive. As a result, older persons will still be able to contribute to the society, and directly or indirectly to the economy. With the success of Active Ageing, older persons can be an asset. With this background, this chapter makes a modest attempt to find an association between population ageing and economic development. This may become the first, important, step to understand

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economic determinants and consequences of population ageing in Asia. To understand this possible association, we conduct both theoretical and statistical discussions. The theoretical discussion examines economic consequences and determinants of population ageing. It elaborates a stylised fact in the association between economic development and population ageing that progress in development is usually accompanied by lower fertility and mortality, resulting in an ageing population. The economy will then suffer from labour shortage. Migrants will flow into the country to sustain its economy. In the meantime, ageing countries also experience rising health expenditure. Bloom et al. (2011 and United Nations (2015a), for example, argued that the process of population ageing is very advanced in high- and very high-income countries. Statistically, this chapter then examines the economic–demographic situation of Asian countries by their stages of population ageing. Economic development has many different aspects. However, in this chapter, we focus on GNI per capita. The classification of GNI per capita follows that of the World Bank (2015). A country is said to be a high-income country if its GNI per capita is above US$12,736. It is an upper middle-income country if at least US$4,125 but below US$12,736; and a lower middle-income country if at least US$1,045 but below US$4,125. In our data, there are no low-income countries, which are defined as having GNI per capita below US$1,045 in Asia. Demographic situation is reflected by total fertility rate (TFR), e0 (Life Expectancy at Birth, which indicates mortality rate), and net migration rate per 1,000 population. The stages of population ageing consist of ageing countries (with percentage of older persons at least 7.0%) and pre-ageing countries (with the percentage below 7.0%). Older persons are those aged at least 65 years old. This discussion is then followed by a statistical correlation analysis, to make a conclusion on the association between economic development and population ageing.

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2.2.  ECONOMICS OF POPULATION AGEING The relationship between population ageing and economic development can be seen from two directions. The first direction is that the economic development affects population ageing indirectly through the three components of population dynamics — fertility, mortality, and population mobility. Understanding how economic development affects population ageing, either through fertility, mortality, or migration, is important in finding policies related to population ­ageing, especially in mitigating the negative aspects of population ageing and promoting the positive aspects of population ageing. The second direction is related to the economic consequences of population ageing or how population ageing affects economic growth, the welfare of the people, employment, and fiscal conditions. The knowledge on the economic consequences can provide policy makers with ways to cope with the situation. The following sub-sections discuss these two directions of relationship between economic development and population ageing in greater detail. 2.2.1.  Impacts of Economic Development The stylised fact of association between economic development and population ageing can be seen through stages of demographic transition (United Nations 2001; Gavrilov and Heuveline 2003). The first demographic transition shows that at the beginning of development, when a country is in its transition from pre-industrial to industrial modern economy, fertility and mortality rates are very high, and roughly in balance. Therefore, population growth is low, assuming there is no migration. With progress in economic development, food supply, and sanitation, there are numerous improvements in public health, which reduce mortality especially among infants and young children. When fertility remains high, this reduction in mortality results in a high population growth rate. Moreover, as the number of infant and children increases, the percentage of older persons declines, resulting in the rejuvenation of the population

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structure. In other words, at this stage, it is possible that reduction in mortality (higher life expectancy) is associated with a lower percentage of older persons. The high population growth rate inevitably generates a population boom which is seen as a barrier for advancement of economy due to high consumption for the young population. As the economy continues to develop, children become expensive as there are more opportunities in the labour market and life as well as norms shift from quantity to quality of children. Combined with government family planning programmes, development is then accompanied by low and very low fertility and mortality rates, and so the percentage of older persons starts to rise. Nevertheless, history has shown that the relationship between development and fertility is not necessarily negative. Sullivan (2013), for example, indicated that some low-income countries can have rapid fertility decline without waiting for the quick progress in economic development. Rapid fertility decline will result in rapid increase in percentage of older persons. If not being accompanied by economic development, these countries will end up “being aged without having high income”. The first demographic transition is completed when fertility reaches its replacement level, usually with TFR around 2.1. Population growth is again very low. Percentage of older persons rises more quickly. During the second demographic transition, when fertility is below replacement level, fertility can even reach a very low level. Maintained for some decades, without in-migration, this belowreplacement level of fertility will result in shrinking of the labour force and population, which can hurt the economy. Changes in social and political norms occur during the second demographic transition, with more accentuation of individual preferences (van de Kaa 1987). During this time, issues regarding the large number and percentage of older persons as well as shortage of labour force rise. People migrate from other countries to fill in the labour shortage. Rising economic opportunities may induce people to keep the fertility even lower, though fertility can

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go up and down depending on economic situation. Economic development will increase longevity and reduce morbidity in old age. Here, a reduction in mortality (an increase in life expectancy) is expected to be associated with a rising percentage of older persons. Population growth remains low and can even become negative. Yet, the rapid increase in the percentage of older persons also implies rapidly rising health expenditure. Financing the growing number and percentage of older persons among the declining labour force becomes the main concern with population ageing. The impact of economic development on migration is more difficult to predict as trends and the future of migration is unpredictable. Migration trends are very sensitive to economic and political changes (Skeldon 2013).1 Economic migration is usually linked to movements of young people and of those having children. Therefore, economic in-migration is likely to reduce the percentage of older persons. This economic in-migration can happen when countries are already ageing, experiencing shortage of labour. Yet, even without the presence of an ageing population, countries can bring in foreign workers to speed up their economic growth. In this case, low percentages of older persons may be associated with high rates of in-migration. On the other hand, economic out-migration may result in an increase of the percentage of older persons. We may also have retirement migration, including return migration, which will increase the percentage of older persons. Retirement migration may be incentivised by favourable, elderly-friendly, conditions in 1

 Development’s impact on population mobility can be very complex. It depends whether it is out-migration or in-migration. It includes transient population, people who move but do not change their residence — the so called non-permanent population mobility. (Migration is permanent population mobility as migration involves with changes of residence). Non-permanent population mobility does not affect the data on demography, but affect the public services such as health, infrastructure of the city, and live in general. The elderly competes more with the transient population in a country or region with a lot and rising flow of transient population.

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the host countries. Consequently, migration can be an important determinant of population ageing and have important economic, social, and political consequences in the host countries. Nevertheless, the consequences are the price to be paid to maintain and even strengthen the economy. As a result, Ananta and Arifin (2009) showed three patterns outside the stylised fact. The first pattern is a “Slowed Ageing Process”. The countries are usually rich, with TFR below replacement level. They need migrants to build the economy. These migrants reduce the proportion of older persons, slowing the process of population ageing. The second pattern is the “Accelerated Ageing Process”. These countries are usually middle-income countries with low fertility because of family planning. The existence of high flows of migration out of the countries, involving mostly young population, accelerated the process of population ageing in these countries. The third pattern is a “Deferred Ageing Process”. These countries experience in-migration even before having low fertility rates and high percentages of older persons. Economic opportunities in these regions are high, despite the relatively high fertility. As a result, the countries are still in early stages of population ageing despite the relatively low fertility in these countries. 2.2.2.  Impacts on Economic Development There are three channels through which population ageing may affect economic development. Two channels are related to macroeconomic conditions, and one channel is concerned with fiscal sustainability (Yashiro and Oishi 1996). The first channel deals with the association of population ageing with the declining quantity and quality of the labour force. The shrinking size of a labour force can also be accompanied by declining productivity of the labour force. As the labour force itself is ageing, the health of the labour force may have deteriorated and skills may have been depreciated. Moreover, as mentioned in Serban (2012), older workers may not be able to adapt to the impacts of globalisation on the labour market.

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Nevertheless, the negative impact of population ageing on the economy can be reduced if older persons become more independent, healthier, and more productive through improvement in health technology and changes toward healthy lifestyles. Spijker and Maclnnes (2013) further showed that the success of Active Ageing can “rejuvenate” the older persons as they are healthier and fitter to work compared to the previous cohort of older persons. The economy can better benefit from this rejuvenation. Perhaps, as discussed by Sanderson and Scherbov (2013) and Yashiro and Oishi (1996), the traditional definition of older person as aged 60 or 65 years old is no longer relevant. They recommend that the definition of older person be extended beyond 65 years. Knapton (2015) chose 75 years old as the new start of being old. Furthermore, the labour force participation rates and productivity for both the young and old can increase too. Delaying retirement rate, as argued by Sanderson and Scherbov (2008), can further improve life expectancy. The second channel of the impact of population ageing on the economy is the aforementioned life cycle consumption–saving investment–economic growth pattern. The fear of population ageing assumes that other things being equal, population ageing will result in lower saving, as the older persons continue to consume but have stopped producing. Therefore, investment declines, but other things do not have to be constant. Onder and Pestieau (2014) showed that as people live longer they can change their behaviour by saving more when they are working and therefore increase investment. As discussed earlier, the fear assumes that it is a closed economy, without possibility of having foreign direct investment. It also assumes that domestic financial institution cannot invest independently of the domestic saving rate. The third channel examines the impact of population ageing on the government budget. Higher life expectancy and large numbers of elderly can mean that the government needs to spend a much higher amount of money if a pension system where the government pays money to the elderly is in place. With a pay-as-you-go pension system, money from the labour force is transferred to the elderly,

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whose number has increased much more than those in the labour force. The explosion of the government expenditure can result in unsustainability of government budgets. Therefore, some countries raised the statutory age at retirement and, at the same time, provided incentives for private saving (United Nations 2015). On the other hand, Thogersen (2015) argued that population ageing in the pay-as-you system can actually result in capital accumulation. The money used by the government to pay for the pension can stimulate economic growth. In turn, the higher economic growth will be able to enlarge government budget. It should also be borne in mind that many developing countries do not have adequate pension systems. Some may have a pension system, but with limited coverage and pension benefits. The family and society will then shoulder the burden of financing the older persons. Therefore, there is a need to create a just and financially sustainable pension system, to guarantee “basic income security” for all people, including older persons. The difficult question is how much is the “basic income security”? It should also be noted that we have not discussed the impact of the ageing population on sustainable development. The discussion is still oriented to economic growth. Some discussions already attempted to relate population ageing with sustainable development (United Nations 2015). They examine the relationship between population ageing, poverty, and economic growth; population ageing and social protection; and population ageing and health and health expenditure. There is no discussion on environmental issues.

2.3. ECONOMIC DEVELOPMENT BY STAGES OF POPULATION AGEING 2.3.1.  Classification of the Stages In this section, we describe countries in Asia based on their stages of population ageing. We define that a country or a region starts ageing when the percentage of older persons, which is defined as the population aged 65 years and above, is at least 7.0% of the total

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population. Among these ageing countries, countries are defined as “super-aged” when the percentage is at least 20.0%. They are called “aged” when the percentage ranges between 14.0% and 19.9%; “almost-aged”, when the percentage is at least 10.0% and less than 14.0%; and “early ageing”, when the percentage is at least 7.0% and less than 10.0%. There are three groups among those with the percentage of less than 7.0%, the pre-ageing countries. The first group is “almost ageing”, the group of countries with percentages of older persons at least 5.0% but less than 7.0%. The second is “young”, consisting of countries with the percentage of older persons at least 3.0% but less than 5.0%. The third, the remaining one, is “very young”, consisting of those with the percentage of older persons at less than 3.0%. With this classification of the stages of population ageing, we examine the stage of population ageing among all 50 Asian countries based on the data presented in the World Population Prospect: the 2015 Revision (United Nations 2015b). As shown in Table 2.1, Asian countries can be found in all stages of population ageing, though the majority of the Asian countries are still in the pre-ageing stage. There are only 15 ageing countries. 2.3.2.  Super-Aged, Aged, and Almost-Aged Countries Japan shows a stylised fact in the relation between development and population ageing. It is also a demographic outlier in the world and in Asia, one of four super-aged countries in the world, followed by Germany, Italy, and Finland (United Nations 2015b). It is a stylised fact, in a very high stage of economic development, with very low fertility and very high longevity, and a small rate of migration (see Table 2.1). As discussed in Akihiko (2006), in 2005, Japan became the first Asian country experiencing population decline because of natural causes. The shrinking population is feared to have its twin, economic contraction. Indeed, as argued in Yoshikawa (2001), Japan economically suffered from a “lost decade” in the 1990s. Furthermore, Muramatsu and Akiyama (2011) argued that with the combination

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70  Ageing in Asia: Contemporary Trends and Policy Issues Table 2.1.    Stages and Demographic Determinants of Population Ageing in Asia.

No.

Country

Life Net Population expectancy migration aged 65+ TFR at birth rate 2015 (%) 2010–2015 2010–2015 2010–2015

Ageing Super-aged 1

Japan (JPN)

26.3

1.40

83.30

0.6

Aged 2

Hong Kong SAR (HKG)

15.1

1.20

83.73

4.2

3

Georgia (GEO)

14.0

1.81

74.64

−14.4

Almost-aged 4

Republic of Korea (KOR)

13.1

1.26

81.43

1.2

5

Cyprus (CYP)

12.8

1.46

79.90

6.2

6

Singapore (SGP)

11.7

1.23

82.64

14.9

7

Israel (ISR)

11.2

3.05

82.07

0.5

8

Armenia (ARM)

10.8

1.55

74.43

−0.7

9

Thailand (THA)

10.5

1.53

74.14

0.3 −0.3

Early ageing 10

China (CHN)

9.6

1.55

75.43

11

North Korea (PRK)

9.5

2.00

69.90

0

12

Sri Lanka (LKA)

9.3

2.11

74.63

−4.7

13

Macao SAR (MAC)

9.0

1.19

80.29

12.5

14

Lebanon (LBN)

8.1

1.72

78.85

49.1

15

Turkey (TUR)

7.5

2.10

74.83

5.3

Pre-ageing Almost ageing 16

Vietnam (VNM )

6.7

1.96

75.56

−0.4

17

Kazakhstan (KAZ)

6.7

2.64

69.08

1.9

18

Malaysia (MYS)

5.9

1.97

74.50

3.1

19

Azerbaijan (AZE)

5.6

2.30

70.64

−0.3 (Continued )

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Table 2.1.   (Continued )

No.

Country

Life Net Population expectancy migration aged 65+ TFR at birth rate 2015 (%) 2010–2015 2010–2015 2010–2015

20

India (IND)

5.6

2.48

67.47

−0.4

21

Timor-Leste (TLS)

5.6

5.91

67.73

−8.9

22

Nepal (NPL)

5.5

2.32

69.01

−2.7

23

Myanmar (MMR)

5.4

2.25

65.64

−1.8

24

Indonesia (IDN)

5.2

2.50

68.59

−0.6

25

Bhutan (BTN)

5.1

2.10

68.88

2.7

26

Iran (IRN)

5.1

1.75

75.06

−0.8

27

Bangladesh (BGD)

5.0

2.23

71.01

−2.8

Young population 28

Maldives (MDV)

4.7

2.18

76.36

−0.0

29

Uzbekistan (UZB)

4.7

2.48

68.24

−1.4

30

Philippines (PHL)

4.6

3.04

67.99

−1.4

31

Pakistan (PAK)

4.5

3.72

65.88

−1.2

32

Brunei Darussalam (BRN)

4.4

1.90

78.44

1.0

33

Kyrgyzstan (KGZ)

4.2

3.12

70.29

−4.0

34

Turkmenistan (TKM)

4.2

2.34

65.39

−1.0

35

Cambodia (KHM)

4.1

2.70

67.61

−2.0

36

Syrian Arab Republic (SYR)

4.1

3.03

69.54

−41.1

37

Mongolia (MNG)

4.0

2.68

68.88

−1.1

38

Lao PDR (LAO)

3.8

3.10

65.51

−3.6

39

Jordan (JOR)

3.8

3.51

73.79

6.5

40

Iraq (IRQ)

3.1

4.64

69.19

3.3

41

Tajikistan (TJK)

3.0

3.55

69.14

−2.9

42

State of Palestine

3.0

4.28

72.65

−2.0 (Continued )

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72  Ageing in Asia: Contemporary Trends and Policy Issues Table 2.1.   (Continued )

No.

Country

Life Net Population expectancy migration aged 65+ TFR at birth rate 2015 (%) 2010–2015 2010–2015 2010–2015

Very young population 43

Saudi Arabia (SAU)

2.9

2.85

74.09

5.7

44

Yemen (YEM)

2.8

4.35

63.51

−0.4

45

Oman (OMN)

2.6

2.88

76.41

65.2

46

Afghanistan (AFG)

2.5

5.13

59.83

3.1

47

Bahrain (BHR)

2.4

2.10

76.37

4.5

48

Kuwait (KWT)

2.0

2.15

74.27

29.8

49

Qatar (QAT)

1.2

2.08

77.94

36.3

50

United Arab Emirates (ARE)

1.1

1.82

76.69

9.3

Notes: Acronym in the parenthesis is a country code. North Korea is officially Democratic People’s Republic of Korea while South Korea is the Republic of Korea. Iran is also known officially as the Islamic Republic of Iran. Source: Compiled from United Nations (2015b).

of population decline and economic shrinkage, Japan also faces the challenges of maintaining its traditions that value working and strengthening social relation. As can be seen in Table 2.1, Japan’s percentage of older persons is very much higher than the second and third highest percentages seen, respectively, in aged Hong Kong and Georgia. However, Georgia is not a stylised fact. Unlike Japan, which has a very high income, Georgia is still an upper middle-income country. Yet, as reported by the UNECE (2015), Georgia also experienced de-­population in 2005, although it had already slowly recovered by 2010. Its de-population was due to a significant out-migration after the collapse of the Soviet Union. Since early 1990s, TFR has been below replacement level and reached 1.8 in 2013, as shown in Table 2.1. Furthermore, up until now, because of few economic opportunities, low income, and unfavourable socio-economic conditions, Georgia remains a migrant sending country with a very large

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net out-migration rate of minus 14.4 per 1,000 population in 2010– 2015. As discussed by CRRC (2007), the migrants are mostly the highly educated, married, and working-age population, which may result in brain drain. As a result, Georgia has been described as being in a “demographic crunch”, hurting the economy. It constitutes an example of a relatively low-income country experiencing accelerated population ageing. Singapore in Southeast Asia is the opposite of Georgia, though both are small countries. Unlike Georgia, a significant influx of migration, attracted by labour shortage and economic opportunities, has slowed down population ageing in Singapore. The magnitude of net migration is similar in both Singapore and Georgia, but with different signs, positive inflow in Singapore and negative outflow in Georgia. Furthermore, Singapore has not been aged, it is still in the almost-aged stage. Hong Kong and Singapore are examples of slowed population ageing. They are migrant-receiving countries where migrants are highly needed for their economic development. Nevertheless, most migrants are on contract basis and return home upon expiry of their contracts. Therefore, when they are old, they are no longer in these two countries and so do not contribute to the population ageing in the two countries. Indeed, migrants have helped to slow down the process of population ageing by increasing the number and percentage of young, working-age population in these two countries.2 Except Israel, all “almost-aged” countries experience low fertility rate of below 1.6. Israel is an anomaly where its high proportion of older persons is accompanied by a relatively high fertility rate, with TFR at 3.0. There was a strong flow of Jewish immigration from many countries in the 1990s. By now, the return migrants are getting older and entering old age. Net migration rate remains positive, but very low at 0.5 per 1,000 population in 2015. In addition, Israelis also

2

 The statistics for the proportion of older persons in Singapore is for the resident population including the citizens and permanent residents only. It does not include the non-residents, who are mostly young population. Including the non-residents, the proportion of older persons in Singapore will be lower than 11.7%.

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enjoy high life expectancy at birth, at 82.1 in 2010–2015, about 1 year longer than South Korea. Israel’s life expectancy at birth is the highest among countries in the West Asia, while others in the region are just below 80.0 years. Therefore, fertility rate will remain the main driver of population growth in the near future of Israel. Fertility rates in Israel will not rapidly decline to reach below replacement level of fertility soon. Israel will then possibly experience rejuvenation of its population when the percentage of older persons declines. These nine countries are located in Southeast, East, or West Asia. Those in Southeast or East Asia are classified as very highincome countries, with GNI per capita of at least US$30,000, except for Thailand, which is a high-income country (Table 2.2). South Korea, the two city-states of Singapore and Hong Kong SAR, as well as Taiwan are the Asian Tigers who have successfully developed at an unprecedented rate from the third to the first world. On the other hand, countries in West Asia are not as rich as those in the former groups. Although Israel and Cyprus are already high-income countries, their GNI per capita are still lower than any of the mentioned Southeast Asian/East Asian countries. Even Armenia and Georgia are still upper middle-income countries. In other words, among the ageing countries, population ageing in West Asia occurs at lower level of GNI per capita than countries in East and Southeast Asia (except Thailand). 2.3.3.  Early Ageing Countries There are only six countries in early ageing stage: China, North Korea, and Macao SAR in East Asia, Sri Lanka in South Asia, as well as Lebanon and Turkey in West Asia. Compared to those almost-aged, aged, and super-aged countries, the GNI per capita of these countries are much lower, except when compared to Georgia and Armenia. Three countries are still in the upper middle-income group, except Lebanon and Turkey, who are already high-income countries. Family planning programmes may have worked in these countries, bringing them to early population ageing.

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Table 2.2.    Stages of Population Ageing and Economic Development in Asia. Country

GNI per capita

Health expenditure

36,747

9.3

Ageing Super-aged 1

 Japan Aged

2

  Hong Kong SAR

3

 Georgia

52,383

—

6,890

9.9

Almost-aged 4

  Republic of Korea

30,345

7.2

5

 Cyprus

26,771

7.4

6

 Singapore

72,371

4.6

7

 Israel

29,966

7.7

8

 Armenia

7,952

4.3

9

 Thailand

13,364

4.1

11,477

5.2

—

—

9,250

3.4

—

—

Early ageing 10

 China

11

  Democratic People’s   Republic of Korea

12

  Sri Lanka

13

  Macao SAR

14

 Lebanon

16,263

6.3

15

 Turkey

18,391

6.7

4,892

6.8

Pre-ageing Almost ageing 16

 Vietnam

17

 Kazakhstan

19,441

3.9

18

 Malaysia

21,824

3.6

19

 Azerbaijan

15,725

5.2

20

 India

5,150

3.9

21

 Timor-Leste

9,674

5.1

22

 Nepal

2,194

5.4 (Continued )

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76  Ageing in Asia: Contemporary Trends and Policy Issues Table 2.2.   (Continued ) Country

GNI per capita

Health expenditure

23

 Myanmar

3,998

2.0

24

 Indonesia

8,970

2.7

25

 Bhutan

6,775

4.1

26

  Iran (Islamic Republic of)

13,451

6.0

27

 Bangladesh

2,713

3.7

10,074

8.5

Young population 28

 Maldives

29

 Uzbekistan

5,227

5.4

30

 Philippines

6,381

4.1

31

 Pakistan

4,652

2.5

32

  Brunei Darussalam

70,883

2.5

33

 Kyrgyzstan

34

 Turkmenistan

35

3,021

6.5

11,533

2.7

 Cambodia

2,805

5.7

36

  Syrian Arab Republic

5,771

3.7

37

 Mongolia

8,466

5.3

38

  Lao PDR

4,351

2.8

39

 Jordan

11,337

8.4

40

 Iraq

14,007

8.3

41

 Tajikistan

2,424

5.8

42

  State of Palestine

5,168

—

52,109

3.7

Very young population 43

  Saudi Arabia

44

 Yemen

3,945

5.5

45

 Oman

42,191

2.3

46

 Afghanistan 

1,904

9.6

47

 Bahrain

32,072

3.8

48

 Kuwait

85,820

2.7

49

 Qatar

119,029

1.9

50

  United Arab Emirates

58,068

3.3

Source: Compiled from UNDP (2014).

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China is the most populous country in the world. It is still in the early ageing stage, but it is already close to entering the almost-aged stage. It is also the 10th oldest country in Asia (United Nations 2015a). China’s population ageing is a result of combination between “One-child policy” family planning programme implemented in 1979 and low mortality. Yet, from the absolute number, as shown in Gu (2016), China’s population aged 65 and above would rank the 11th largest population in the world should they be a country. Furthermore, in a large country such as China, regional variation of population ageing can be very high. Some parts of China have experienced harder challenges because of the more advanced state of ageing. Gu (2016) depicted that in 2010 there were 11 out of 31 regions where the elderly population rate is higher than its national figure. Furthermore, he also showed how Shanghai, as the largest modern city in China, has suffered a decline in its population since 1993 because of its very high percentage of older persons. Yet, economic opportunities have attracted people from less-developed regions in China. Therefore, these migration flows to Shanghai have slowed down the process of population ageing in Shanghai. At the same time, migration from less-developed regions has resulted in an acceleration of the ageing process in the less-developed regions of China. In turn, it results in a “being aged without having high income” phenomenon in the less developed regions. Another success story in family planning programmes is seen in Sri Lanka, making Sri Lanka the oldest country in South Asia, with its percentage of population aged 65 and above standing at 9.3%. In addition, significant net out-migration, at -4.7 per 1,000 population, may have accelerated population ageing in Sri Lanka. Out-migration has been mostly pulled by economic opportunities in other countries and is fully supported by the government as a source of income through the remittances. The Institute of Policy Studies of Sri Lanka (2013) reported that Sri Lankans leave the country seeking job opportunities in countries, such as oil-exporting countries in the Middle East, the Maldives, Singapore, Malaysia, Hong Kong SAR, Romania, the UK, and Australia. Political factors for out-migration only occurred in the 1980s, especially those seeking asylum in other countries.

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On the other hand, as discussed by the Migration Policy Center (2013), Lebanon is a country with a long history of both out-­ migration and in-migration. Lebanon is a country of paradoxes. Economic and political uncertainties have pushed people out of Lebanon. But, currently, economic opportunities also attract temporary workers coming to Lebanon. More importantly, Lebanon has received a huge number of refugees and asylum seekers. These flows of forced migration have social, economic, and political implications in Lebanon. Recently, the net in-migration rate was high, at 49.1 per 1,000 population, meaning that in-migration has much exceeded out-migration. Without in-migration, Lebanon would have been in a more advanced state of population ageing, as its fertility has also been below replacement level. Lebanon is a case where in-migration can reduce the percentage of older persons, and it may bring about social, economic, and political challenges in the country. Lebanon is the only Arab country already experiencing ageing. Lebanon is not as advanced in economic development as most other Arab countries, but it is already a high-income country. Other Arab countries are discussed under the section “very young countries”. In general, countries in this early ageing stage have experienced, and will be challenged with, severe ageing issues when their income is still relatively low. This is in contrast to the super-aged, aged, and almost-aged countries, which experienced ageing while having the necessary economic resources. These countries can be described as “being aged without having high income”, deviating from the stylised fact. 2.3.4.  Almost Ageing Countries There are 12 countries that almost enter the stage of ageing countries with the percentages of older persons reaching between 7% and 10%. They are mostly in Southeast Asia and South Asia. Kazakhstan is the only Central Asian country and Azerbaijan is the only West Asian country categorised within this group. There is a high variation in terms of stages of development consisting of four high-income

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countries (Malaysia, Kazakhstan, Azerbaijan, and Iran), five upper middle-income countries (Timor-Leste, Indonesia, Vietnam, India, and Bhutan), and three lower middle-income c­ ountries (Myanmar, Nepal, and Bangladesh). None of them belong to very high, high, or even low-income country. After China, we have India and Indonesia, two other most populous, upper middle-income countries in Asia. However, unlike China which is already in the early ageing stage, India and Indonesia are still almost ageing countries. As in China, these two countries also demonstrate the importance of paying special attention to domestic regional variation in implementing population ageing policies. There should not be any “one size fits all” policy. A number of provinces and districts have already been aged despite their relatively low stages of economic development in Indonesia (Arifin and Ananta 2016) and India (Dommaraju 2016). Among the almost ageing countries, Kazakhstan and Vietnam have the highest percentage of older persons (6.7%), but have very different stages of economic development. Kazakhstan is a highincome country, with a GNI per capita almost 4 times that of Vietnam, which is an upper middle-income country. Population ageing in Vietnam occurs as its fertility has been below replacement level, in stark contrast to Kazakhstan whose TFR is still above replacement level (2.64) for the same period. Vietnam has high life expectancy at birth, but this is not the case in Kazakhstan (see Table 2.1). Kazakhstan attracted a net migration of 1.9 per 1,000 population to build its economy. The government made immigration a policy as the country used to suffer from a long history of out-migration. On the other hand, out-migration exceeds in-migration in Vietnam. Vietnam has a negative migration rate at 0.4 per 1,000 and benefits from remittance sent by its overseas workers. Apart from Vietnam, in this group, there are three countries with below replacement fertility rates (Iran, Malaysia, and Bhutan). This is different from the majority, which are still above replacement level but already below or at 2.5. As can be seen from Table 2.1, Timor-Leste has the highest fertility rate among Asian

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countries, with a rate of 5.91 for the period of 2010–2015. Despite its very high fertility, Timor-Leste’s percentage of older persons is relatively high in this almost ageing group. A large flow of net outmigration (-8.9 per 1,000 population), due to better economic opportunities abroad, may have resulted in this country being in the almost ageing group. With an economy relying mostly on oil and having an almost ageing population combined with high fertility and net out-migration, Timor-Leste may face difficult challenges in managing its economy. Malaysia and Bhutan are the only two countries with positive net migration among the almost ageing population. Malaysia’s high-income status and low fertility rates have attracted in-migration. The government also promotes the use of migrants to build the economy. In contrast, Bhutan is still an upper middle-income country, already having low fertility, but as described by the Royal Government of Bhutan (2010), it is very reliant on migrants to develop its economy, especially those from India to work in the construction industry. 2.3.5.  Young Countries There are 15 countries, making this group the largest among all groups of population ageing in Asia. Geographically, many of them can be found in each region of Asia, with only one (Mongolia) in East Asia. As indicated in Table 2.1, almost all countries are either upper or lower middle-income countries. Brunei Darussalam and Iraq are the exception. Brunei Darussalam is the richest country, the only very high-income country in this group. The second richest country is Iraq, the only high-income country. Both economies depend mostly on exporting its oil. The poorest country is Tajikistan, a lower middle-income country. Tajikistan is the world most remittance-dependent economy in the world, as reported by the World Bank (Trilling 2015), with remittances contributing to almost half of its GDP. Brunei Darussalam’s GNI per capita is about 35 times that of Tajikistan’s, and yet both of them have young populations.

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As a young population, the fertility rates in this group are still relatively high, with a maximum rate of 4.6. In addition, Brunei Darussalam is the only country with below-replacement level of ­fertility rates, while the Maldives is the only country at replacement level. In contrast, two countries (Iraq and the State of Palestine) have fertility rates greater than 4.0. Tajikistan’s fertility rate is still greater than 3.0. Life expectancy at birth has been relatively high at 69.14, which may indicate a decline in mortality among infants and children. The declining mortality may have rejuvenated the population or at least delayed the rising percentage of older persons. Tajikistan illustrates a case of declining mortality without much progress in its fertility and economy, depending mostly on remittances. It is a case of a country that still faces the issues of large number of younger persons, rather than older persons. Life expectancy at birth among them ranges between 65.4 and 78.4. The lowest life expectancy at birth is found in Turkmenistan. On the other hand, the highest life expectancy in this group is not in the Maldives, where the percentage of older persons is the highest for this group, instead it is in Brunei Darussalam. However, together with Brunei Darussalam, Maldives, Kyrgyzstan, Jordan, and State of Palestine are countries whose life expectancies were relatively high in 1970s. It should be noted that the State of Palestine has the lowest percentage of older persons within this group. Similar to Tajikistan, declining mortality in these countries may be still at the stage of rejuvenating the population through a decline in infant and child mortality rates. Brunei Darussalam has a long history of in-migration, which started in the early 20th century. However, since independence in 1984, the demand for foreigners has increased greatly. The government attempts to diversify its sources of economic growth and to wean its economy from too much dependence on oil and gas, as sources will eventually become exhausted. Therefore, the government of Brunei Darussalam needs people to work in “low skilled jobs” such as in construction and as domestic workers. However, with relatively high education level, Bruneians look down on working such jobs. As a result, the Government implements policies to

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82  Ageing in Asia: Contemporary Trends and Policy Issues

recruit foreigners. On the other hand, there are a lot of economic, social, cultural, and political issues the country has to face because of important inflows of migrants. The economic issue includes Brunei’s over-reliance on foreigners. This is the price to pay to maintain and build its economy (Haji Mohamad 2016). This long history of in-migration, which started long before fertility reached replacement levels, has deferred the population ageing process in Brunei Darussalam. That is the reason why, despite being a very high-income country, Brunei Darussalam is still young, having a low percentage of older persons. After Brunei Darussalam, Iraq is the next high-income country. Though having high income, its fertility is still very high at a TFR of 4.1, much higher than that of Brunei Darussalam. Because of politics and wars, development has not been able to speed fertility decline, and therefore development is not associated with advancement in population ageing in Iraq. People flee the country. Yet, the data show that there is a positive net migration at 2.7 per 1,000 population. This may reflect the flow of returning Iraqis, people coming to Iraq for economic opportunities, and/or the migration of people to Iraq to join the war. The high fertility and flow of in-migration may have resulted in the low percentage of older persons in Iraq. Next to Iraq is Syria, another conflict-torn country. Its GNI per capita is about 5,771, which is much lower than its neighbouring country, Iraq. It has a very large net out-migration rate at -41.1 per 1,000 population. People flee the country. As this kind of outmigration happens at all ages, the impact on percentage of older persons is not clear. As in Iraq, economic development may not be associated with population ageing in Syria. A stylised fact at this stage of population ageing is seen in the Philippines, an upper middle-income country. Fertility is still relatively high, at 3.04, as politics have prevented a smooth implement­ation of family planning programmes. There is a net out-migration for b ­ etter economic opportunities abroad. The Philippines’ economy relies on remittances sent from abroad. Yet, as discussed by Go (2012), after a long history of sending workers abroad, many of the overseas workers return home for various reasons. As the returnees may not be young, this in-migration

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Economic Development  83

may soon increase the percentage of older persons in the Philippines and challenge the Philippines’ economy with ways to cope with the elderly. However, the current relatively low percentage of older persons may have provided an opportunity for the Philippines to grow its economy. Indeed, as reported by ADB (2016), the Philippines’ economy had a solid growth rate at 5.18% in 2015 because of its large domestic demand. 2.3.6.  Very Young Countries There are eight very young countries with a percentage of older persons below 3.0%. This group is in the lowest stage of population ageing. Combined with those having young populations discussed earlier, we find that almost half of the 50 Asian countries are either young or very young. The very young countries represent a clear deviation from the stylised fact. Unlike the structure found in the “young population” group, these six very young countries are even enjoying very high income. They are Arab countries in West Asia: Saudi Arabia, Oman, Bahrain, Kuwait, Qatar, and UAE. Their GNI per capita are similar to the super-aged, aged, and almost-aged countries. Indeed, Qatar has the largest GNI per capita in Asia. The remaining two are lower middle-income countries: Yemen, another West Asian country, and Afghanistan, a South Asian country. Yemen has the lowest income among countries in West Asia. Almost all of these six rich countries also have fertility at or below-replacement level, except Saudi Arabia and Oman. Their life expectancy at birth is at least 74.0 years. Yet, the favourable economic development combined with low fertility and high longevity do not result in an advanced state of population ageing. They have, in this group, the lowest percentages of older persons. Economic opportunities have attracted people to migrate to these countries. Two of the six countries have very high rates of net international in-migration. Oman has the highest net in-migration rate and thus is a migrant country, followed by Qatar and Kuwait. The large international in-migration may have deferred the process of population ageing in these three countries.

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On the other hand, Afghanistan and Yemen follow the stylised fact. Their fertility rates are still very high, with a TFR at 5.0 in Afghanistan and 4.4 in Yemen. Life expectancy at birth is still relatively low, 63.5 for Yemen and 59.8 for Afghanistan, making Afghanistan the country with the lowest life expectancy at birth in Asia. Combined with their low development stage, the high fertility and low life expectancy may have made these countries very young. Furthermore, Afghanistan is the country with the lowest GNI per capita, at US$1,904, in Asia. There are four other Asian countries with GNI per capita less than US$3,000: Nepal (2,194), Tajikistan (2,424), Bangladesh (2,713), and Cambodia (2,805). Nepal, Bangladesh, and Cambodia are already in almost ageing stage, while Tajikistan in young stage. These lower middle-income countries show different stages of population ageing deviating from the stylised fact. Afghanistan is a country with history of out-migration because of conflict, political instability, and low economic opportunity. Most of the migrants from this country since 1980 are refugees. In early 2000s, the government started a repatriation programme. (UNESCAP, 2012). Now, Afghanistan has net positive migration rate, at 3.1 per 1,000 population, which mainly consists of mostly repatriated refugees. Population ageing may not be an urgent demographic phenomenon in Afghanistan today, as its fertility is still high (5.13) and life expectancy is low (59.83). On the other hand, political stability, economic development, and family planning programmes are very urgently needed in Afghanistan.

2.4. ECONOMIC DEVELOPMENT AND POPULATION AGEING: STATISTICAL CORRELATION As mentioned earlier, the stylised fact on the association between economic development and population ageing is that the stage of economic development is negatively correlated with fertility and mortality, and therefore positively correlated with percentage of older persons as a measurement of stages of population ageing. The rising percentage of older persons then results in shortage of

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GNI per capita

y = –62.997x3 + 2638.5x2 – 27948x + 91205 R² = 0.3795

1,40,000 1,20,000

QAT

1,00,000 KWT

80,000

BRN

SGP

60,000 HKG

40,000

JPN

20,000 0 0

5.0

10.0

15.0

20.0

25.0

30.0

Populaon aged 65 and above (%)

Figure 2.1.    Percentage of Older Persons vs. GNI Per Capita in Asian Countries. Source: Drawn by the authors from Tables 2.1 and 2.2.

workers. In turn, in-migration, especially of young people, occurs. The rising number and percentage of older persons also implies rising health expenditure. The preceding section discusses economic–demographic situations in some countries, grouped into several stages of population ageing. This section examines statistically whether there exist such a stylised fact, or any deviation from the stylised fact. Figure 2.1 shows the plot of percentage of older persons against the GNI per capita for all 48 Asian countries.3 The fitted line shows that percentage of older persons has a nonlinear association with GNI per capita, especially in the form of a cubic association. There are two turning points, one is a lower turning point, and another is an upper turning point. The upper turning point occurs when the percentage of older persons is around 20.0%; at any point after 3

 Asian countries consist of 50 countries. Macao SAR and North Korea are missing from the analysis due to the unavailability of their data in the Human Development Report (2014).

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that, a country is called super-aged. This happens at GNI per capita of almost US$80,000. The lower turning point is seen when the percentage of older persons is about 5.4%, at the pre-ageing countries. This point occurs in Cambodia, an almost ageing upper middle-income country. It does not mean, however, that Cambodia is the poorest in Asia. Indeed, Afghanistan is the poorest country with GNI per capita at US$1,904. It should be noted that the upper turning point in Figure 2.1 is simply a statistical “estimate” that the pattern turns negative within the super-aged period. It may reveal that becoming a super-aged is associated with lower GNI per capita. This may reflect a high consumption of older persons who are no longer productive, a common fear of ageing due to high old dependency ratio. Before the lower turning point, the countries have a young and very young population structure. The pattern is that countries with higher percentage of older persons are associated with a smaller GNI per capita. As discussed earlier, most countries in the very young countries category are very high income, oil producing countries which have attracted a lot of migrants. These inflows of migrants may have reduced the percentage of older persons, resulting in very low percentage of older persons among these very high-income countries. Between the two turning points, the relationship between percentage of older persons and GNI per capita is positive, following the stylised fact. The stage of population ageing spans from almost ageing to almost-aged country. An increase in percentage of older persons tends to increase GNI per capita. Population structure within this period is favourable for economic development. However, the figure shows some deviations around the fitted line. For instance, Kuwait (KWT) and Qatar (QAT), two oil producing countries in West Asia, are the cases of “rich before old” in which both are very high-income countries and have very young populations and very low percentage of older persons. On the other end, Japan (JPN) is another deviation as the only super-aged, very highincome country in Asia. Yet, Japan’s GNI per capita is far below the largest GNI per capita in Qatar and some other very ­high-income countries.

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Health expenditure (% of GDP)

y = 0.0412x + 4.4907 R² = 0.0007

12.0 10.0 8.0 6.0 4.0 2.0 0.0 0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Percentage of older persons (65+) Figure 2.2.  Health Expenditure and Percentage of Older Person in Asian Pre-Ageing Countries. Source: Drawn by the authors from Tables 2.1 and 2.2.

Furthermore, Figure 2.2 shows that there is no relation with health expenditure of the government measured as percentage to the GDP in pre-ageing countries in which the R2 is very small. This may simply mean that population ageing is not yet an issue in these countries. On the other hand, among ageing countries, as seen in Figure 2.3, the health expenditure is positively correlated with percentage of older persons, consistent with the stylised fact. This may reveal the fear of population ageing on the economy despite the still positive association between population ageing and economic development, except for Japan. The association of percentage of older persons with fertility and mortality also follow the stylised fact. The association with fertility follows a negative nonlinear relationship as seen in Figure 2.4. Seen from the R2 or coefficient of determination, 39.8% variation in population ageing is explained by the variation in fertility rates. A country with lower fertility rates is associated with a larger

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88  Ageing in Asia: Contemporary Trends and Policy Issues Health expenditure (% of GDP)

y = –0.0112x2 + 0.6351x + 0.5385 R² = 0.3705

12.0 10.0 8.0 6.0 4.0 2.0 0.0 7.0

9.0

11.0

13.0

15.0

17.0

19.0

21.0

23.0

25.0

27.0

Percentage of older persons (65+)

Figure 2.3.  Health Expenditure and Population Ageing Among Asian Ageing Countries. Source: Drawn by the authors from Tables 2.1 and 2.2.

y = –8.058ln(x) + 13.149 R² = 0.3983

Popula on aged 65+ (%) 30.0 25.0 20.0 15.0 10.0 5.0 0 0

1.00

2.00

3.00

4.00

5.00

6.00

Total fer lity rate

Figure 2.4.    Fertility and Percentage of Older Persons in Asian Countries. Note : The correlation excludes Timor-Leste, because its TFR is an outlier, at 5.9. Source: Drawn by the authors from Table 2.1.

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Popula on aged 65+ (%)

y = 0.0051x3 – 1.0748x2 + 74.943x – 1735 R² = 0.5251

30.0 25.0 20.0 15.0 10.0 5.0 0 55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

Life expectancy at birth

Figure 2.5.    Life Expectancy and Percentage of Older Persons in Asian Countries. Source: Drawn by the authors from Table 2.1.

­ ercentage of older persons. The correlation between population p ageing and life expectancy is even stronger, with R2 at 52.5%. It is a positive nonlinear correlation, taking the shape of a cubic relationship as seen in Figure 2.5. Nevertheless, as shown in Figure 2.6, there is no clear relationship between net migration rates and percentage of older persons. As shown in Figure 2.6, the R2 is very weak, 2.8%. Japan (JPN) is a case in point. It is a super-aged country with a very low net migration rate, which is starkly in contrast with Oman (OMN), which is a very young country due to a very large influx of migration. Syria (SYR) is another different case, having a very young population with significant out-migration rates. In some countries, the high percentage of older persons may have attracted in-migration. But migration may have been associated with many social, economic, and political factors, resulting in an unclear relationship with percentage of older persons. Indeed, Figure 2.7 shows that economic development has a tendency to be positively associated with net in-migration rate.

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90  Ageing in Asia: Contemporary Trends and Policy Issues Percentage of older persons (65+)

y = 2E-05x3 – 0.0014x2 – 0.0444x + 6.6428 R² = 0.0285

30.0

25.0

JPN

20.0

GEO

HKG

15.0

SGP

10.0

LBN

5.0

SYR

OMN ARE

0.0 -80.0

-60.0

-40.0

-20.0

0.0

20.0

40.0

60.0

80.0

Net Migraon Rate

Figure 2.6.    Net Migration Rate and Percentage of Older Persons in Asian Countries. Source: Drawn by the authors from Table 2.1.

Net Migraon Rate

y = 8E-14x3 –1E-08x2 + 0.0009x –7.602 R² = 0.3025

80.0 OMN

60.0 LBN

40.0 KWT

20.0

SGP

0 20,000

0

40,000

60,000

BRN

80,000

1,00,000

1,20,000

1,40,000

GNI per capita

-20.0 -40.0

QAT

GEO

-60.0

Figure 2.7.    GNI Per Capita and Net In-migration Rate in Asian Countries. Source: Drawn by the authors from Tables 2.1 and 2.2.

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Economic Development  91

2.5.  CONCLUDING REMARKS The issues on population ageing we face today actually mirror the issues of high fertility we had in the 1960s, 1970s, and even 1980s. The fear is that high consumption because of a large number of unproductive persons will result in low savings, which in turn result in low investment and economic growth. The difference is in the dependency ratio. In the past, we dealt with a young dependency ratio, but now with an old dependency ratio. In the past, babies and younger persons were considered to be the main unproductive group, but now the older persons are the main unproductive one. Fears are driven from the large number and rapid rise of these unproductive population groups, the younger ones in the past and older ones today and in the future. Asia is the home of the world’s three most populous countries. Moreover, several East Asian countries have the oldest populations along with the fastest rates of population ageing. However, not all Asian countries have been experiencing population ageing. Indeed, only 15 out of 50 Asian countries are experiencing population ageing. In addition to the stages of population ageing among Asian countries, this chapter analyses the association between economic development, measured with GNI per capita on one hand and population ageing, measured with percentage of population aged 65 years old and over, on the other hand. The analysis is carried out among both ageing and pre-ageing Asian countries. The stylised fact is that progress in economic development is accompanied by lower fertility and mortality rates. Lower and very low fertility and mortality rates produce high percentages of older persons. In turn, the high percentage of older persons may result in a shortage of young workers in the labour market, hurting the economy. In-migration then occurs to fill in the shortage and build the economy. The rising percentage of older persons is also accompanied by rising health expenditure, feared to create severe economic challenges. This chapter finds that there are two different patterns of relationships. First is among ageing countries where percentage of older

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persons reaches above 7%. The results are very close to the stylised fact. Advanced economic development goes along with low and very low fertility and mortality rates, resulting in higher stages of population ageing. The relationship takes a nonlinear curve. The ageing countries in Asia have already faced the related economic consequences, shown by the rising percentage of government’s health expenditure. However, migration, measured by net migration rates, does not show a clear association with population ageing, but is related to economic development. In particular, countries with high economic opportunities have attracted migrants, rejuvenating the population as a result. On the other hand, those without economic opportunities have been pushed to leave the countries, accelerating the process of population ageing, aggravating the lack of economic opportunities in these countries. Second is among pre-ageing countries which are the majority in Asia. Here, the pattern deviates from the stylised fact. They do not experience the economic consequences of population ageing, such as on health expenditure, because their percentages of older persons are still low and very low. In these countries, economic development is associated with a much lower percentage of older persons. High economic development in these countries has attracted migrants, who are mostly young, and therefore delaying the process of population ageing in these countries. The decline in mortality occurs mostly among infants and children, and thus the decline rejuvenates the population, rather than raising the percentage of older persons. The combination of low percentages of younger and older persons can be an advantage for the economy if the labour force is of high quality, i.e., educated and healthy. The question is whether those currently in the pre-ageing stage will follow the trajectory of the ageing countries. Or, will there be more variation? Will there be new stylised facts, probably with more important roles given to population mobility as the bridge between economic development and population ageing? More importantly, will the fear of population ageing become a reality? Looking at past experiences, of how issues of high fertility were managed, it is very

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likely that we can also manage the issues of population ageing. In the past, family planning programmes were used to reduce the fertility rates. Now, we can reduce the growth and even number of older persons by making them healthier, more independent, and more productive. Therefore, we can “rejuvenate” the older persons, and so the cut-off point of being older can be extended beyond 65 years old, perhaps to 75 years old or 80 years old. Alternatively, we may ban chronological age and define “being old” functionally. The WHO (2016), for example, defined somebody as old when he/she is already at the point when he/she cannot make any meaningful contribution to the family, friends, and/or society. Finally, readers should be cautious in interpreting these results, which simply show association. It is merely an important step to further studies examining causal relationships between economic development and population ageing.

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b2530   International Strategic Relations and China’s National Security: World at the Crossroads

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CHAPTER 3

GENDER AND OLD-AGE ECONOMIC SECURITY Cynthia Chen, Elaine Kempson, Donghyun Park and Joanne Yoong

3.1. INTRODUCTION Due to rapid population ageing, Asian societies now face the challenge of providing economic security in old age. Working-age population shares are set to decline, and traditional family-based support structures are eroding. At the same time, significant gender gaps that disadvantage Asian women persist despite impressive economic growth and development. The interaction of population ageing and gender inequity is significant, and this implies that Asian women have less ability to secure an independent, financially secure old age than Asian men. A further concern is that ageing may exacerbate existing disparity between men and women, compounding inequities experienced in earlier life. In this chapter, we argue that in many Asian settings, women face greater challenges to old-age economic security, driven by differences in demographics, labour force participation, and financial inclusion and capability. Younger women are less able than men to make individual provision due to caregiving burdens, less formal work, and lower earnings. In addition, older women live longer, but work less in old age or retire earlier. Older Asian women (and men) are also rapidly becoming 95

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less able to rely on family provision as family structures change. Although poverty rates are not directly comparable across some countries due to different poverty definitions, within Asian countries where data are available, the results show that older women are at a disadvantage (with the notable exception of the Philippines) (Table 3.1). Table 3.1.    Gender Disparities in Latest Officially Reported Poverty Rates* (%).

Country China1 2

Hong Kong 1

Indonesia

Percentage living below poverty line (%)

Age Group

Year

Overall

Men

Women

60+

2011–2012

22.9

21.8

24.0

65+

2013

27.7

26.4

28.8

60+

2012

12.7

12.5

12.8

2

Japan

65+

2008

22.0

18.4

24.7

Korea2

65+

2008

45.1

41.8

47.2

60+

2009

8.6

7.0

10.0

60+

2000–2012

22.0

22.4

17.4

60+

2004

17.9

16.4

18.9

1

Malaysia

1

Philippines 1

Vietnam

* Poverty rates across countries are not directly comparable due to differences in old-age poverty definition and reporting year. 1  Percentage below individual national or subnationally-defined poverty thresholds. 2  Percentage with incomes less than 50% of median household disposable income (OECD common definition). Sources: · China: National School of Development (2013). Challenges of Population Aging in China: Evidence from the National Baseline Survey of the China Health and Retirement Longitudinal Study (CHARLS). · Hong Kong: Census and Statistics Department. (2014) Hong Kong Poverty Situation Report 2013. · Indonesia: Priebe J, Howell F. (2014). Old-age poverty in Indonesia: Empirical Evidence and Policy Options. A Role for Social Pensions. TNP2K Working Paper. · Korean and Japan: OECD. (2011). Pensions at a Glance 2011. · Malaysia: Saidatulakmal M. (2014). Poverty Issues among Malaysian Elderly. · Philippines: Mapa D, Bersale L.G.S, Albis L.F, Daquis J.C.P. (2011). Determinants of Poverty in Elderly-Headed Households in the Philippines. MPAR Paper No. 28557. · Vietnam: Giang T.L, Pfau W.D. (2008). Determinants of Elderly Poverty in Vietnam. MPRA Paper No. 9927.

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Adequate social protection may be further compromised by pension reforms from traditional defined benefit systems to defined contribution or multi-pillar systems which disadvantage women due to exclusion, limited contribution history, lower savings, and lower benefits (Arza 2015). Pension design and coverage should therefore consider old-age poverty by gender, interactions with social transfers and gaps in coverage, and benefits by gender. Addressing gender disparity in old-age economic security can contribute to both efficiency and equity. Expanding the productive capacity of younger women raises long-term savings, investment, and economic growth. Healthy and independent lifestyles for women in old age reduce health and social care costs and could have other positive long-term inter-generational effects. First, eldercare imposes large opportunity costs on younger women, who tend to assume responsibility for caring for elderly adults. Second, intra-household transfers from older women tend to have positive effects on investments in girls, generating future productivity gains (Duflo and Christopher 2004). Finally, longer life expectancies for women imply the challenges and risks faced by women are faced by the majority of the older population, and hence relate to broader issues of inter-generational and gender equity. This chapter therefore has the following main aims: 1. Examine evidence and drivers of economic security of elderly women relevant to Asia: gender gaps in human capital formation; labour market participation issues, including access to formal sector work; availability of and access to national/mandated pension and social security benefits; and other key issues widely cited in the literature. 2. Analytically review the issue of old-age economic security for women relevant to Asia, based on available data on economic security for elderly women. 3. Identify concrete and specific implications for policymakers, with a focus on policy implications that are especially relevant for female old-age economic security in developing Asia, and propose policy measures that may be applicable to certain types

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of countries, as well as measures that are applicable across the region to support income security of elderly women.

3.2. DRIVERS OF FEMALE OLD-AGE ECONOMIC INSECURITY IN ASIA Countries in Asia are ageing more quickly than any other region in the world (Figure 3.1). With lowered fertility and longer life expectancies, the number and proportion of elders in Asia have been increasing rapidly. The number of older adults (65+) in Asia is projected to triple from 331 million in 2015 to 956 million in 2050 (United Nation 2015). Gender gaps in the region have persisted despite Asia’s rapid economic growth. Summarizing the region’s experience over the last two decades, the 2012 World Development Report (WDR) and its regional companion volume note that there has been some significant advancement, especially in human capital (education and health), where gender gaps have rapidly narrowed or even reversed in favour of women. However, the WDR points out that on issues such as access to productive assets and high-quality employment opportunities, wage equity, and agency for women — all areas with strong implications for lifetime economic security — progress has been slow. (World Bank 2012c) For instance, in terms of formal employment, the status of women in Asia has not only remained low since the early 1990s, but has even decreased relative to the rest of

Figure 3.1.    Percentage Age 0–4 Years and 65 + Years. Source: United Nations Population Division, World Population Prospects: The 2015 Revision.

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Figure 3.2.    Employed Females per 100 Employed Males. Source: World Bank 2012c.

the world (Figure 3.2). Overall, Asia ranked close to last in the regional rankings for the Global Gender Gap Index 2014, above only the Middle East and North Africa (World Economic Forum 2014). Explicit consideration of gender in policy is particularly important since the persistence of gaps suggests that relying on growth alone to mitigate these is not sufficient Targeted policy addressing gender disparities may be particularly important, as economic growth alone does not mitigate gender inequality in societies. At the same time, the aggregate ageing and gender data hide important differences across countries. In 2015, the median age of Asia (30.3 years) is comparable to the global median age (29.6 years), but by 2050, this difference is expected to widen by four years (Asia: 39.9 years vs. World: 36.1 years) (Figure 3.3). However, countries such as Japan, Hong Kong, South Korea, Singapore, and China are ageing at a much faster rate compared to other countries such as India and the Philippines that are still relatively young. Similarly, gender experiences vary widely. For instance, female and male employment is close to parity in North and Central Asia, but the figure is under 40% in South Asia (UNESCAP 2012). In the next section, we explore further commonalities and differences between countries that contribute to challenges to inhibit old-age security for women across Asia. Strikingly, despite the large amount of information on ageing and gender separately, there is a remarkable absence of

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Figure 3.3.    Increasing Median Age (Years). Source: United Nations Population Division, World Population Prospects: The 2015 Revision.

information on gender and old-age economic security in Asia, particularly for comparative purposes (UNESCAP/UNDESA 2014). Our literature review failed to yield any readily available recent cross-country data that document rates of poverty or measures of economic insecurity for elderly women both relative to men and relative to other age–gender sub-groups. In a recent regional survey of ageing data, HelpAge International, Teerawichitchainan and Knodel (2015) reviewed ageing surveys, demographic surveys targeted at women of reproductive age, and census data across 25 Asian countries. They found that survey questions typically address economic security, income, and consumption questions only briefly, with only limited information about family transfers, and even more limited information about the elderly’s own economic activity. 3.2.1.  Education and Income Gender Inequality Table 3.2 shows lower estimated earned income for women throughout Asia, based on the World Economic Forum’s Global Gender Gap Report 2014. In Vietnam, despite having the highest ratio of female to male income, women earn only 80% of male incomes. In highincome Japan and Korea, earned income for women is estimated to be 50% or less compared to men, and in India that figure is less than a quarter.

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Table 3.2.    Labor Market Outcomes. Labor Force % Part time Female wage Ratio of estimated Participation employees as and Salaried female to (% population % total work- Workers (% 15+) force male of females earned employed, income Male Female Male Female MRY 2010–4)

Ratio of Female female to professional male and techni- wages for cal workers similar (% of total) work

China

—

78.2

63.7

—

—

—

52

0.66

Hong Kong SAR

—

51

50.9

11.7

55.5

94.4

42

—

—

—

14.5

—

0.62

India

0.24

78.8

27.2

Indonesia

0.5

83.4

50.3

—

—

33

51

0.67

Japan

0.5

70.5

48.8

10.1

71

88.7

47

0.6

Korea

0.48

73.2

50.2

9.9

56.6

73.6

40

0.54

Malaysia

0.51

80.5

49.5

—

—

74.6

41

0.82

Pakistan

—

—

—

—

—

22.1

26

0.56

Philippines

0.68

—

—

—

—

51.4

61

0.79

Singapore

0.64

76

57.7

—

—

89.5

55

0.81

Sri Lanka

—

75

32.9

—

—

51.2

44

0.74

Thailand

0.78

80.5

63.3

—

—

40.7

48

0.68

Vietnam

0.82

82.1

73.2

—

—

29.4

51

0.66

Sources: WDI, the Gender Gap Index 2014.

This difference is driven by several factors. First, across the region, less than 40% of women aged 15+ were in the formal labour force in 2010 (UNStats 2010). Even in our sample, which has relatively high rates, nationally reported labour force participation rates for women are significantly lower everywhere than for men. Second, even where the gap in participation is less stark (such as Hong Kong, Japan, and Korea), women are more likely to be informal, temporary, or part-time workers. In addition to lower remuneration, this sector lacks protection available to formal employment such as health insurance coverage and mandatory old-age savings (Sastry 2007; Unni 2002).

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Finally, the gender pay gap for similar work universally favours men. This gap is strikingly large and varied across the socioeconomic spectrum. In Pakistan, women earn only 56% of men’s wage, while in Malaysia they earn 80% of male income. The gap also exists in high-income Japan (60%) and Korea (54%). The literature suggests that some of these differences may result from gaps in productivity, for example, in agriculture and entrepreneurship. In agriculture, farms operated by women produce lower yields than men (FAO 2011). Female entrepreneurs tend to manage smaller firms and concentrate in less profitable sectors than male entrepreneurs. In rural Bangladesh, Indonesia, and Sri Lanka, the differences in profitability between femaleowned and male-owned businesses are significant (World Bank 2012b). These unequal outcomes may partly originate from gaps in educational attainment, gender discrimination in labour markets, and constraints on participation, which may all imply less formal, less skilled, and lower paid work for women, which can in turn have sizable consequences for future pension income and eligibility. Progress in women’s educational attainment has been strong, but outcomes are still mixed across the region. Universal primary education has reduced primary enrolment gaps, although outcome inequalities remain. Figure 3.4 shows that for high-income Asian

Figure 3.4.    Literacy Rate, Youth (% Ages 15–24) (Difference: Female-Male). Source: World Bank 2012a.

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Figure 3.5.    Percentage of Adults (25+) who Have Completed Tertiary Education. Source: OECD 2014b.

countries, youth literacy rates are equal, but in lower-income countries, large gaps still favour boys. Interestingly, disparities remain in tertiary education. Among OECD countries, more women achieve tertiary education, but in Asia 4% more men do so (OECD 2014b). These disparities exist in Pakistan and Bangladesh, but remarkably they are biggest in highincome Singapore, Korea, and Japan (Figure 3.5). Labour markets may work against women, especially in sectors where they remain a minority group and lack role models. Employers may hold negative perceptions about women’s abilities, and access to information and support may be limited to male-dominated networks. Underrepresentation of women in certain sectors or occupations can feed discriminatory beliefs among employers, sometimes exacerbated by male-dominated professional/trade networks or mentoring relationships. In addition, career prospects may depend on initial human capital, access to labour and financial markets, and interactions with formal institutions such as legal regimes as well as informal institutions such as social, cultural or religious norms. Furthermore, in many countries, the ability of women to accumulate assets is compromised by discriminatory inheritance laws

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and practices, and property rights (World Bank 2012a). In approximately half of all Asian countries, inheritance rights favour men, and men hold a majority of property and farm titles. (UNStats 2010). This has further adverse consequences for women, since access to credit collateral such as land is limited. External institutional constraints may be further reinforced by gender-based preferences and norms. Despite sizable cultural differences, women in Asia still face remarkably common structural and social pressure to put their children and husbands’ needs before their own. As can be seen from Figure 3.6, some Asian countries’ women have limited control over their own earnings. More importantly, women have even less control over their time and take on disproportionate responsibility for housework and caregiving for children or the elderly. In many Asian settings, women who work outside the home are able to rely on informal childcare arrangements such as neighbours, relatives or a paid live-in domestic worker (Huang et al. 2007), but they still devote more time to care and housework. Differences range from 1 to 3 hours more for housework, 2 to 10 times the time for care

Figure 3.6.    Decisions on Use of Women’s Earnings (Currently Married Women in Employment Aged 15–49). Source: Measure DHS 2010–2013.

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Table 3.3.    Average Hours Spent Per Day in Different Activities (Both Weekends and Weekdays) — Aged 15–64 Years. Japan Average hours spent per day Female Male

Korea

China

Female

Male

Female

India

Male Female

Male

Paid work

2.97

6.25

2.78

4.70

3.80

5.13

2.48

5.30

Routine housework

3.32

0.40

2.30

0.35

2.58

0.80

4.97

0.32

Shopping

0.62

0.27

0.33

0.10

0.42

0.25

0.15

0.23

Care for household

0.43

0.12

0.80

0.17

0.55

0.22

0.62

0.13

Sleeping

7.60

7.87

7.70

7.68

9.07

9.00

8.68

8.90

Personal care

1.37

1.02

1.47

1.38

0.87

0.87

1.15

1.35

Leisure

4.07

4.00

4.47

5.23

3.52

4.13

3.68

4.72

Source: OECD 2013.

(of children, elderly, and the sick), and 1 to 4 hours less for market activities (World Bank 2012c). As a result, in addition to being less likely to seek formal employment, women are also more likely to do so part-time or on an irregular basis. Table 3.3 shows that, for instance, in settings as different as Japan and India, the balance between paid work and household work/care is remarkably similar. 3.2.2.  Financial Inclusion and Capability There are other plausible explanations for women’s lower levels of financial security in old age. Having limited access to formal financial markets may limit their access to financial products and services. Also, their limited financial capability may restrict them from making appropriate financial provision for their old age. Across Asia, there are gender disparities in financial inclusion. As can be seen from Table 3.4, developed economies such as Hong Kong, Japan, Korea, and Singapore enjoy almost universal financial inclusion among individuals aged 15 or over. In contrast, only a small minority in Indonesia, Pakistan, and Vietnam

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106  Ageing in Asia: Contemporary Trends and Policy Issues Table 3.4.    Financial Inclusion (2011). Account at formal financial institution (% 15+)

Saved money in financial institution in past year (% 15+)

Male

Female

Male

Female

China

68

60

32

32

Hong Kong SAR, China

88

89

46

40

India

44

27

28

17

Indonesia

20

19

15

16

Japan

96

97

49

54

Korea, Rep.

93

93

46

48

Malaysia

69

63

41

30

Pakistan

17

3

8

7

Philippines

19

34

11

18

Singapore

98

98

58

59

Sri Lanka

70

67

37

35

Thailand

73

73

43

43

Vietnam

24

19

9

7

Source: Global Findex 2011.

are financially included. In general, gender parity is associated with countries where levels of financial inclusion are high, whereas countries with lower levels of inclusion are associated with greater gender disparities. Looking at levels of saving in a financial institution by gender, again we find wide disparities between countries in the region. As Table 3.4 shows, levels of savings are highest in Hong Kong, Japan, Korea, and Singapore and lowest in Pakistan and Vietnam. There are gender disparities in five of the 13 countries included in the Global Findex. In Hong Kong, India, and Malaysia, women are less likely to save than men, but they are more likely to do so in Japan and the Philippines. However, financial inclusion is only part of the story. Studies of Asian populations in the United Kingdom show greater gender

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disparity compared to the population as a whole (Financial Services Authority 2001). Women with dependent children and women from Indian, Pakistani, Bangladeshi, and Chinese backgrounds were particularly vulnerable. The study also looked at differences in pension-holding and found that the gender gap was smallest for those aged under 25 and widened with age (Financial Services Authority 2001). It was also smaller for single people than for those who were married (or had been) and for those without children. These gaps persisted at all income levels. Although research on Asia is relatively limited, a broader international literature has documented that women and men also differ in key dimensions of financial capability. These include the role they play in managing household finances; their propensity to make financial provision for the future; their interest in and knowledge of financial products; their confidence about buying financial products; their conservatism in the way they select and buy such products; their understanding of financial concepts such as compound interest, inflation, and risk; and their reaction to risk and ambiguity in decision-making. Internationally, there is significant gendering of the roles men and women play in managing household finances. Analysis of World Bank survey data of financial capability across a range of lowand middle-income countries showed that in Mexico, Uruguay, Colombia, Lebanon, Armenia, and Turkey women generally played a lesser role than men in both planning for the future and choosing financial products. This was in contrast to the gendering of day-today money management in some countries — Mexico, Uruguay and Armenia — where women seem to have the main responsibility, and in Lebanon and Colombia, where responsibility was split equally. On the whole, women are less likely to be involved in financial planning and long-term saving. In Singapore, a survey conducted in 2008 by the Housing and Development Board reported that just over half of the elderly residents in public housing planned financially for their old age. Women in particular were significantly less likely to plan for old age. Among women, individuals least likely to plan were

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also most likely to be vulnerable in the future — primarily housewives who depended on their spouses or children for support. This echoes financial capability surveys conducted in Ireland, the UK, and Canada, where women had lower composite scores than men in planning for the future. (Financial Regulator 2009; Financial Services Authority 2006; McKay 2011) This meant that they were less likely to have money put aside for unexpected expenses, to have savings to cover their living expenses should they be unable to work, and to have financial provision for their retirement and old age. In contrast, they were more competent than men at planning and keeping track of their money day-to-day (Financial Services Authority 2001). International surveys also found that women are far less likely to seek the knowledge required to make long-term savings and investments: women are less likely to read the financial pages of a newspaper regularly and are less likely than men to access information about financial products (Financial Services Authority 2001). A number of studies explicitly explore gender differences in levels of knowledge about financial products and services. MasterCard carries out an annual survey that focuses on the Asia-Pacific region, which it publishes as the Financial Literacy Index,1 a score calculated out of the weighted sum of the three components: basic money management (skills related to budgeting, savings, and responsibility of credit usage), financial planning (knowledge about financial products, services, and concepts, and ability to plan for long-term financial needs), and investment (basic understanding of the various risks associated with investment, different investment products, 1

 Some limitations must be noted with the Index: first, it covers only people who are financially included and, secondly, it only covers urban areas. In countries with low levels of financial inclusion, particularly for women, and a predominantly rural population, the results will be unrepresentative of the population as a whole. The Index does not report on the three components separately. Although we are reporting it as indicating knowledge, in practice it covers behaviour, and as a consequence may understate gender differences in levels of knowledge, given the evidence above on the gendering of money management and its weight in the score.

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Table 3.5.    MasterCard Financial Literacy Index for Asia-Pacific region.

Country

Overall index~ 2014

Gender gap* Age 2011# Work status 2011# 2011

2014

Marital status 2011#

Not Unmarried Married 30 Working working 30+ 30+

Asia/Pacific

65

98

98

63

67

67

64

67

67

Australia

69

96

94

63

74

72

68

74

74

China

65

101

100

59

60

62

57

64

60

Hong Kong

70

97

94

65

70

67

70

69

70

India

62

96

100

67

67

63

61

59

62

Indonesia

61

104

99

66

67

66

62

63

67

Japan

55

100

99

53

62

63

57

63

61

Korean Rep

62

100

91

55

56

57

54

53

57

Malaysia

69

97

100

69

65

66

66

61

65

New Zealand

71

93

93

64

74

74

68

71

77

Philippines

66

99

100

71

67

70

66

60

69

Singapore

68

92

94

65

72

70

69

69

73

Taiwan

73

93

97

64

77

71

63

69

75

Thailand

67

101

97

68

70

75

73

76

76

Vietnam

65

105

108

68

71

70

70

71

71

Bangladesh

60

Na

101

Na

Na

Na

Na

Na

Na

Myanmar

66

Na

97

Na

Na

Na

Na

Na

Na

Source : MasterCard Financial Literacy Index 2011 and 2014. ~  for both men and women. * calculated as the ratio of the average score for women and the average score for men. So 100 equates to parity, scores below 100 indicate that women’s scores were lower than men’s. #  for women only.

and skills required). In 2014, women in the Asia-Pacific region as a whole scored marginally lower than men (MasterCard 2014). Across the 16 Asia-Pacific countries, the gender gap was most pronounced in high-income markets, with the exception of Japan (see Table 3.5). Greatest disparity was found in Korea, Hong Kong and Singapore, plus Australia and New Zealand. The countries with least parity were predominantly emerging markets such as Malaysia, Vietnam, Indonesia, and Bangladesh — along with Japan. It may be that as countries develop, financial capability increases but the gender

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gap widens. Within a margin of five percentage points, there does not appear to have been any shift in the gender gap across countries between 2011 and 2014.2 The 2011 survey also allows us to look at the scores of women at different ages, work status, and marital status for women aged over 30 (MasterCard 2011).3 Scores were also higher for women who were working, compared to counterparts without paid work, but it did not vary by marital status. Overall, the body of research confirms that women differ from men in a number of important ways. They are less likely to be financially included; are less likely to be involved in choosing financial products if they live as a couple; are more conservative in their choices; have lower levels of knowledge of financial matters; have a lower level of understanding of key concepts such as inflation and compound interest; and tend to be more risk averse. At the same time, key pieces of evidence challenge these generalisations and suggest that some of them can be explained by the different economic circumstances of women. This serves to illustrate that economic disadvantage may adversely affect their financial planning and using formal financial services to make provision for old age. 3.2.3.  Social and Family Support in Old Age After the transition to old age, economic security depends on the ability of individual and social provision to meet consumption needs. This is not only the result of accumulated physical and financial capital in working years, but also the strength of household/ family support networks, public social security programs, and private pensions. Women live longer than men in every region around the world, and Asia is no exception. Female life expectancy in Asia has 2

 https://esa.un.org/unpd/wpp/Download/Standard/Population/ UN World Population Prospects: Total Population — Both Sexes 3  Sample sizes at this level of disaggregation will be small, and the results for individual countries should be treated with caution as differences of less than 7% points are unlikely to be statistically significant (at the 95% pe level). Across the region as a whole, scores were higher for women aged over 30 than they were for younger women.

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Table 3.6.    Time in Retirement. Life Expectancy at birth(2014)

Statutory pensionable age (excluding early retirement)

Estimated Years in Retirement

Country

Men

Women

Men

Women

Men

Women

China

73.9

76.5

60

55

22.03

29.79

Hong Kong

80.7

86.4

65

65

22.31

26.67

India

64.5

68.0

55

50

21.12

24.21

Indonesia

68.6

72.7

55

55

26.25

29.44

Japan

79.9

86.6

65

65

22.62

27.63

Korea

78.1

84.8

61

61

20.62

25.21

Malaysia

72.6

77.2

55

55

26.49

29.41

Pakistan

65.6

72.1

60

55

19.18

25.69

Philippines

65.2

84.5

60

60

17.42

19.88

Singapore

79.9

77.2

55

55

21.47

24.82

Sri Lanka

71.1

77.6

55

50

26.53

35.61

Thailand

70.9

80.4

55

55

26.29

30.83

Vietnam

71.1

76.5

60

55

23.77

31.37

Source: OECD 2011.

increased dramatically (by 20–25 years in many countries in the past 50 years) (Table 3.6). On average, life expectancy at birth for females in low-income countries rose from 48 years in 1960 to 69 years in 2008, and for males, from 46 years to 65, driven in part by a significant decline in the risk of maternal mortality and fertility rates (WHO 2014). The second half of the 20th century has also seen large improvements in women’s health. At the same time, statutory retirement ages are typically either equal or lower for women than men. For all countries shown in Table 3.6, the OECD estimates that men will spend 10–25% less time in retirement than women. This implies that in addition to having less ability to save given a shorter working life, women are more likely to be in retirement for a longer period of time than men. Although women often depend on their husband’s income for their financial well-being, older women are less likely than men to

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be living with a spouse or partner. Due to shorter life expectancy and the preference for younger wives among men, far more women experience widowhood at some point in their lives compared to men. For example, in Indonesia, Japan, Korea, Malaysia, and Singapore, the percentages of widowed women in the 1980s aged 65 and above were 64%, 61%, 75%, 61%, and 64%, respectively. Mirroring global trends, divorce rates in Asia are also rising. Crude divorce rates have risen from 0.4% in China in 1985 to 1.6% in 2007, and similarly from 0.9% to 2.6% in Korea over the same period (Dommaraju and Jones 2009). Yet, the potential consequences of divorce and widowhood are more severe for women. In addition to loss of income and the social and psychological impact of the transition, women may lose other assets critical to old-age security, especially land or property (Kumar 1994). Even when women have independent financial means, adjustment to singlehood can have serious economic consequences due to the loss of household economies of scale and the reversal of autonomy after death or separation. Some women’s only recourse for economic security may be to return to their extended family or seek out another marriage, although older women’s options to remarry are further limited by men’s preferences for younger wives. In some societies, widows face cultural constraints that limit their ability to achieve a basic standard of living in old age. In much of India, for example, customary restrictions on remarriage, employment, place of residence, and inheritance and ownership of property all limit their abilities to provide for themselves. Yet with the exception of their sons, widows often have little outside economic support (Trivedi 2009; Sebastian and Sekher 2010). In addition to widowhood and divorce, declining family size and out-migration of the young has left the elderly with an increasingly small pool of support. Today, more elderly women than men live alone throughout Asia. For instance, in Vietnam in 2009, almost 12.9% of elderly women live alone, as compared to 4.5% of men (Abalos and Barona 2012). The weakening of extended family ties and competing priorities make elderly women vulnerable even when they live within a large extended family (Berkman et al. 2012).

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Older women, especially very old women, face higher risk of abuse and neglect (Sebastian and Sekher 2010). 3.2.4.  Pension Design While family networks have traditionally been the core of old-age support throughout Asia, most countries now recognise the need for a formal old-age security system and formal safety nets for the elderly. Table 3.7 summarises the key features of pension systems in some Asian countries. Some younger, poorer countries do not yet have a redistributive pillar. High-income Singapore provides only an earningsrelated pension, the Central Provident Fund (CPF), with no government funded component at all. On the other hand, most Table 3.7:  Pension System Features. First-pillar: Redistributive

Country

Basic Means- flat- Minimum tested rate income

Second-pillar: Earnings Related Earnings horizon

Valorisation/ COLA

Defined Contribution Indexation Level

China

—

Yes

—

—

—

—

8%

Hong Kong

Yes

—

—

—

—

—

5–10%

India

—

—

—

Indonesia

—

—

—

Japan

Yes

Yes

—

Lifetime

avg. wage

prices

—

Korea

Yes

Yes

—

Lifetime

avg. wage

prices

—

Malaysia

—

—

—

Pakistan

—

—

Yes

11 years

Prices

prices

—

Philippines

—

Yes

Yes

max(15, Prices lifetime)

prices

—

Singapore

—

—

—

—

—

—

35%

Sri Lanka

—

—

—

—

—

—

20%

Thailand

—

—

—

15 years

to prices

to prices

—

Vietnam

—

—

—

Lifetime

avg. wage

avg. wage

—

11 years —

—

discretionary discretionary —

—

—

—

15.70% 5.70%

23–24%

Source: OECD 2011.

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older countries, including Japan and Korea, have relatively strong multi-pillar systems with some form of social pension in addition to an earnings-based system. Such pensions most commonly take the form of a means-tested transfer such as Hong Kong’s Old Age Allowance or Korea’s Basic Old-Age Pension. Social pensions in the form of universal and unconditional cash transfers for all older citizens are not common in Asia, with a few exceptions such as Brunei. However, formal pension systems may not resolve underlying gender disparities. For instance, in China, pensions are the primary source of income for 57% of retired men in urban areas, but for only 35% of women, who still tend to rely more on family support. Overall, pension participation rates and contribution rates are lower for women than men, for a number of reasons. In employment-based pension schemes, women fare worse since they are more likely to be out of the formal labour market, to participate in irregular or informal employment, or to work for smaller enterprises. In Singapore, CPF is based on individual contributions in the form of payroll-deductions by both employees and employers during working life. Women who are dependents may have their own accounts, but rely on voluntary contributions by their spouses. Pension coverage tends to be higher for the public sector and in large private sector firms. For example, in Pakistan, pension schemes do not cover employees of firms with fewer than five people, the self-employed, or family labour. Even when coverage is universal, women may be excluded due to minimum contribution levels or duration of work. For example, Korea requires at least 20 years of coverage to qualify for full benefits, and 10 years to qualify for early pension. Furthermore, in any earnings-related system, low-income workers, many of whom are women, receive smaller pension benefits. Table 3.8 shows the results of OECD modelling of pensions for men and women at the average wage in selected countries. Although women are expected to accumulate more wealth, this is largely due to a longer expected life span, and net replacement rates are actually generally higher for men than women.

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Table 3.8.  Replacement Rates and Net Wealth (Modeled) by Gender. Net replacement rates at average earnings

Estimated net pension wealth at average earnings (OECD)

Country

Men

Women

Men

Women

China

84.7

66.3

15.2

15.3

Hong Kong

36.8

33.3

6.3

6.6

India

64.1

59.2

9.3

9.6

Indonesia

14.4

13.2

2.6

2.6

Japan

40.8

40.8

5.9

6.8

Korea

45.2

45.2

7.0

8.2

Malaysia

41.0

37.2

7.7

7.7

Pakistan

66.5

58.2

9.3

10.3

Philippines

46.1

46.1

4.4

5.3

Singapore

42.1

37.7

6.8

6.8

Sri Lanka

49.9

33.7

9.2

7.6

Thailand

49.2

49.2

9.8

10.7

Vietnam

69.9

64.2

15.1

19.2

Source: OECD 2011.

Benefit design: Other features of pension schemes also have gender-related effects. Given that women live longer, schemes with benefits designed around unisex mortality tables benefit women. Indexation, especially to wages, benefits the old old at the expense of the young old. Lack of inflation indexation disadvantages women since they live longer and living standards fall disproportionately with age. Even if pensions are indexed to prices not wages, older women’s living standards will fall relative to younger workers. Some pension schemes allow for maternity or caring credits for women, but this is not common in Asia. Provisions for Widowhood and Divorce: Survivor benefits in most countries specify the wife among the first recipients, together with the children. However, survivor benefits are often arbitrarily set and do not acknowledge the loss of economies of scale in household

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costs. Survivors typically receive 50% of the pension, while costs are likely to fall by less. In case of divorce, many women simply lose pensions altogether, although countries such as Japan equally split pension benefits upon divorce, implicitly recognizing non-market household contributions such as childcare. In addition, in India, entitlements stop when women remarry, and in the Philippines, a daughter’s entitlement stops upon her marriage while sons are usually entitled up to a certain age. Current global trends in old age policy and pension reforms may not benefit women. Women have better provision in defined benefit rather than defined contribution schemes, but defined benefit schemes are universally in decline. Schemes that offer flat rate minimum income guarantee to all at a set age may be most equitable, but ageing societies are making this fiscally unsustainable. Universality and auto-enrolment benefit women, but choice has been the mantra of the pensions debate. Many other aspects of pension design also embody critical trade-offs for women. Unisex tables may benefit women, but discourage private insurance companies from covering women. Providing a minimum level of welfare for older women tomorrow may lead to perverse incentives for low-wage female workers today. Means-tested minimum income guarantees can act as a disincentive to female low-wage workers from making their own pension provision. Similarly, adjustment for childcare also risks damaging work incentives and pension contributions. Mandatory levels of contribution or annuitisation may protect women, but may reduce female participation. Given the differences in financial capability, the growing role of individual choice in pension plans may also affect women disproportionately. Research shows that choice overload in pension plan settings may provoke decision paralysis, causing unknowledgeable individuals to rely on poor heuristics or avoid decision-making altogether. Many women hence choose to opt out of pension plans entirely or choose sub-optimal default options (Agnew and Szykman 2005). While these trade-offs are challenging, governments should strive to develop policy with an awareness of

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the need to balance female labour force participation, fiscal sustainability and social protection.

3.3. CASE STUDIES: LESSONS ON OLD-AGE FEMALE ECONOMIC SECURITY FROM KOREA, CHINA, AND INDIA In the previous sections, we were only able to review aggregate country-level statistics. To date, there has been little rigorous in-depth analysis of the health and well-being of elderly populations in Asia, partly due to a lack of systematic and large-scale data. However, in recent years, the worldwide expansion of population survey data on ageing has reached the region. Country-specific population surveys comparable to the original Health and Retirement Study in the United States have been initiated in a few countries. They provide new information on demographics, health outcomes, health behaviour, financial and housing wealth, family structure, employment history, and income. Ageing surveys in Asia include the Chinese Health and Retirement Longitudinal Study (CHARLS), the Korean Longitudinal Survey of Aging (KLoSA), and the Longitudinal Aging Study in India (LASI). CHARLS is a nationally representative longitudinal survey with 17,708 individuals at baseline (including spouses), aged 45 years or older covering 150 county-level units in 28 provinces. Assessments include social, economic, and health circumstances of community residents. CHARLS respondents are followed every 2 years, using face-to-face, computer-assisted personal interviews. KLoSA is also a nationally representative sample, with 10,254 original respondents. Finally, India’s LASI is the most recent addition to the global family of ageing surveys. LASI started in 2010 with a sample of 18,000 interviews, and follow-up interviews will be done every 4 years. The second wave of data collection had started in the fall of 2014 and is currently in the field. In this section, we review current findings from each of these studies that illustrate a different challenge to gender and old- age economic security.

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3.3.1.  Korea: Reducing Poverty Does Not Reduce Disparity Korea has undergone a very rapid demographic transition. The number of Koreans aged 65 and above rose from 3% in 1970s to 11% in 2015, and is projected to increase to 33% by the 2040s (OECD 2014a). The Korean National Pension scheme was first established in 1988 as a public pension funded through contributions. However, few have yet been eligible for benefits since it requires 20 years of contributions. While Korea has experienced rapid economic growth, the erosion of traditional Confucian values has curtailed financial assistance from children to the elderly population, which now faces growing poverty rates. (Kwon 2001). In 2008, Korea further introduced a means-tested basic old-age social pension (BOAP) for those aged 65 and above as a strategy to mitigate old-age poverty. Baseline data from 2006 showed that elderly Korean women experienced many of the vulnerabilities discussed above. They are more likely to be widowed compared to men (22.3% vs. 3.1%), have lower education (measured by having attained at least a high school education) (30% vs. 57%), lower monthly household income (₩1,761,000 vs. ₩2,052,000), less likely to be employed (29% vs. 65%) and more likely to be homemakers (57% vs. 16%). They have more chronic diseases, but are less likely to be disabled compared to men (9% vs. 14%). They also appear to be more mentally resilient than men (Jang et al. 2009). Using two waves of KLoSA data, Lee and Phillips (2011) examined several measures of income and poverty for community-residing adults. Using a relative measure (defined as income less than or equal to 50% of median household income), they find that baseline poverty rates for the elderly in 2006 were 30.4% overall, substantially higher than for other OECD countries. About 31.9% of elderly women, compared to 28.1% of elderly men were living in poverty. By 2008, elderly poverty had fallen by 4%, to 26.5%, an effect that they attribute to the introduction of the BOAP as well as an increase in public pension benefit. Interestingly, they do not find that increases in pension income reduce transfers from children to adults.

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At the same time, the data show that elderly individuals who were older, less educated, living alone, or in poor health did not experience reduction in poverty. All these categories apply disproportionately to women. As a result, the gender gap in old-age poverty remained: 29.0% of women qualified as poor, as opposed to 23.1% of men. The fall in poverty was more pronounced for older men. This illustrates that while introduction of a social pension may reduce poverty, reducing gender disparities requires a broader approach that also addresses cultural mores and practices. 3.3.2.  China: For Older Women, Health is Wealth China has one of the world’s largest elderly populations. With its one-child policy and increase in life expectancy, the population is ageing very rapidly (Smith et al. 2012a). China’s old-age support ratio will fall from 13 to 2.1 by 2050. In addition, the elderly population aged 60 years and above will increase from 10% in 2000 to 30% in 2050 (United Nations 2009). At the same time, economic reform in 1978 has dramatically changed China’s health care system from a centrally planned system to the largest marketoriented health system. China thus faces unique problems in supporting its elderly population. Many recent changes made in social security policies, including the introduction of the New Rural Social Pension, have uncertain implications for the welfare of the elderly. There has also been a rapid expansion in the provision of health insurance, the most successful one being the (NCMS). Recent findings from CHARLS indicate that health status, longevity, and economic security are highly correlated in the elderly population, for women in particular. The CHARLS baseline report (National School of Development 2013; Strauss 2012) showed that women aged 60 and over were significantly more likely than men to live in poverty, and also much less likely than men to be employed. CHARLS data suggest the importance of health in socioeconomic status. At baseline, 26% of men aged 60–74 were in poor or very poor health compared to 31% of women. Equally importantly, at older ages men have significantly

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better performance on both immediate and delayed memory (Zhao 2012). Both these physical and cognitive differences adversely affect women’s capability to remain employed and productive. Critically, Lei et al. (2012) and Smith et al. (2012b) demonstrate that the roots of these disparities can be traced back to childhood education and health status. In particular, Lei et al. (2012) suggest that the cognitive gaps for older women are due to differential investments in education for boys at the expense of girls in poor Chinese communities. This conclusion is further supported by Huang and Zhou (2013), who also use the CHARLS data to analyze the impact of the Great Famine as a natural experiment and trace these cognitive differences back to selective investments in primary schooling; and by Weir et al. (2014). The case of China thus shows the importance of early-life interventions for long-term economic security and highlights the fact that many challenges of old age have their origins in early life. On a more hopeful note, it also suggests that old-age gender gaps in some outcomes are likely to erode over time given that younger female cohorts enjoy more equal educational outcomes. 3.3.3.  India: Family Ties Can Help or Harm While the social position of elderly women in India differs quite significantly from China, they face many of the same issues faced by their Chinese counterparts. By 2050, the population aged 60 and above is expected to more than double from 8% currently to 19% (Arokiasamy et al. 2012). The Indian elderly, who have traditionally relied on family support, now face increasing rates of chronic disease and weakening social ties due to cultural change and rural–urban migration (Bloom et al. 2010). India’s ageing policy is relatively new, with an evolving slate of programs. Fewer than 10% of the population is insured at all. Moreover, the health insurance scheme has a maximum age cut-off of 65. Over 90% have no pension. Since virtually all health expenditures are out of pocket, the role of the family is of paramount importance. As in China, India’s elderly women are disadvantaged

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(Sengupta and Agree 2003). Past data and LASI surveys show that elderly women, especially widows with limited family support, are more likely to report disability of all types. Older women in India, as in China, perform worse than their male counterparts on measures of cognitive ability (Lee et al. 2014). However, unlike China, the LASI data show that education gap cannot account for the extent of this disparity in cognitive health, suggesting that other background factors are important. A key problem that is exacerbated by the poor cognitive ability of older women is the prevalence of elder abuse and neglect. Since the family generally takes on the entire burden of caring for the elderly in India (Berkman et al. 2012; Gupta 2009), older women (especially widows and in the oldest old age group of 80+ years) were more vulnerable to abuse or exploitation by others (Sebastian and Sekher 2011). About 7% stated that they “often” felt abused, while 19% stated “some of the time.” This emerging work, which requires more and better data, highlights the risk that elder abuse, a potential consequence of old-age economic insecurity, poses to old-age well-being and a potential consequence of economic insecurity (Teerawichitchainan and Knodel 2015).

3.4. CONCLUDING OBSERVATIONS AND POLICY IMPLICATIONS In this chapter, we look at the intersection of two key trends in developing Asia — rapid population ageing and persistent gender inequality. Despite impressive economic growth and development, Asian women still remain disadvantaged relative to Asian men. At the same time, the region is experiencing a demographic transition towards older population structures. The confluence of the two trends has brought to the fore the issue of old-age female economic security in Asia. The causes of female disadvantage in old-age economic security are diverse and complex. Our analysis indicates that tackling the disparities requires a comprehensive approach which addresses inequalities in education and the labour market, improves financial education or financial capability training, puts in place

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gender-sensitive legal and institutional protection, and introduces better pension design that balances coverage with incentives. We elaborate further on these below. First, there is a need to reduce gender gaps in human capital endowments, in both health and education, potentially through affirmative action programs as well as group formation and mentoring targeted at women and younger girls. It is critical to put a program of action into place with a view towards understanding longer-term outcomes. An important aspect is communications and social marketing that is gender appropriate and pitched at the right level for the desired citizen. Second, Asian governments should consider steps and policies to improve women’s economic opportunities both during prime and old age, including putting into place maternity leave and other policies to allow women to remain in employment and qualify for pension coverage when young, and reducing age/gender based discrimination in the workplace. Third, designing and putting in place comprehensive financial capability training programs targeting retirement issues would raise the financial provision for old age of older and younger adults separately. Such a program should not be a one-time intervention since reinforcement is necessary to sustain behavioural change, but imparting knowledge alone may be insufficient to bring about behaviour change. The programme should be designed to be accessible, entertaining, and appealing, particularly to its target group of older women, who may have different language requirements and be technology-challenged. Fourth, supporting the collection and public dissemination of ageing related data and research in more Asian countries will allow researchers to have a better grasp of elderly women (and men). At present, most surveys that allow for cross-country comparison are limited to maternal and child health, such as the UNICEF MICS and the Measure DHS, while surveys focused on older adults are limited to a small group of countries. Fifth, pension design and reform must account for gender differences in financial capability, employment histories, and life

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expectancies, including eligibility requirements that account for women’s briefer employment histories, joint annuities and survivor’s benefits, minimum pension guarantees or other redistributive mechanisms, appropriate inflation, indexation, statutory retirement age, and means-tested social assistance for widows and elderly women who are ineligible for pension benefits.

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CHAPTER 4

EPIDEMIOLOGY OF NONCOMMUNICABLE DISEASES Kavita Venkataraman and Fong Ngan Phoon

In this chapter, we will focus on the major non-communicable diseases (NCDs) (cardiovascular diseases, cancers, diabetes mellitus, and chronic respiratory diseases) and their common risk factors (tobacco, alcohol, physical inactivity, and unhealthy diets) to explore the burden and epidemiology of NCDs in the elderly population in Asia. The focus will be on the following countries — Singapore, Malaysia, Japan, South Korea, China, Hong Kong, and India.

4.1.  CHANGING FACE OF NCDs IN ASIA Over the past few decades, the pace of transitions, both demographic and epidemiological, has been most rapid in Asia. The average life expectancy in Asia has increased from 42.1 years in 1950 to 71.6 years in 2015, an addition of almost three decades of life (United Nations 2015). As life expectancies have increased across countries (Figure 4.1), there has been a corresponding sharp increase in the proportions of older populations across most of Asia. In parallel with this, there has been a linked increase in the prevalence of NCDs in the region. This

125

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126  Ageing in Asia: Contemporary Trends and Policy Issues 1990

2013

90 80

YEARS OF LIFE

70 60 50 40 30 20 10 0

Figure 4.1.    Life Expectancy at Birth in Selected Asian Countries, 1990 and 2013 (WHO Global Health Observatory Data Repository 2016).

is partly attributable to the larger pool of populations at risk, given the changing demographics. In addition, this is also due to the reduction in the burden of communicable diseases in many parts of Asia. While the estimated total burden of disease1 in Asia fell from 1.5 billion disability-adjusted life years (or DALYs)2 in 1990 to 1.3 billion DALYs in 2013, the contribution of NCDs to the total burden of disease increased from 44% to 66% in the same time period (IHME 2013). This has been mainly driven by the increased proportion of NCD burden in those aged 50 years and above (Figure 4.2). An esti1

 Disease burden is defined by the World Health Organization (WHO) as the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators. It is often quantified in terms of quality-adjusted life years (QALYs) or DALYs, both of which quantify the number of years lost due to disease (YLDs). 2  DALYs are defined by the WHO as a summary measure used to give an indication of overall burden of disease as mortality does not give a complete picture of the burden of disease borne by individuals in different populations. One DALY represents the loss of the equivalent of 1 year of full health (WHO Global Health Observatory Data).

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DALYs in Asia 1990 6% 13%

56%

25%

NCD DALYs in 70 + years

NCD DALYs in 50 - 69 years

NCD DALYs in other ages

All other DALYs all ages

DALYs in Asia 2013 13% 34% 22%

31% NCD DALYs in 70 + years

NCD DALYs in 50 - 69 years

NCD DALYs in other ages

All other DALYs all ages

Figure 4.2.    Estimated DALYs lost in Asia, 1990 and 2013 (IHME 2013).

mated 461 million DALYs were lost by people aged 50 years and above in 2013 due to NCDs, while the corresponding figure for 1990 was 284 million DALYs (IHME 2013). NCDs are also the leading cause of disease burden in the older population. As can be seen in Table 4.1, NCDs are responsible for 79–96% of the disease burden in people 60 years and older across low-, middle-, and high-income countries in Asia (WHO 2014).

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128  Ageing in Asia: Contemporary Trends and Policy Issues Table 4.1.    Burden of Disease in Persons Aged 60 Years and Above due to NCDs, Selected Asian Countries (WHO 2014). High income

% disease burden due to NCD

Hong Kong (China)

96

Japan

91

Republic of Korea

90

Upper middle-income China

91

Malaysia

87

Mongolia

93

Philippines

79

Vietnam

87

Low-income Cambodia

79

4.2.  NCD AND RISK PATTERNS ACROSS ASIAN COUNTRIES While NCDs are a huge burden on older populations in Asia, there are substantial variations in the magnitude and pattern of NCDs across countries. In terms of absolute numbers, China and India are the biggest contributors to DALYs in Asia, across all ages, and in the elderly. This is natural, considering the huge population sizes in these two countries. When we examine the rates of DALYs across countries in Asia, however, the picture is very different. Figure 4.3 shows DALY rates in people aged 70 years and above across countries in Asia (IHME 2013). As can be seen, Japan, with one of the oldest populations in the world, has the lowest rate, while Mongolia and Afghanistan are at the other end of the spectrum. Similarly, India and China have higher disease burden in the older population group, though the elderly make up smaller proportions of their populations. Singapore, on the other hand, with a rapidly increasing elderly population, does much better in terms of NCD burden. Cardiovascular diseases account for most of the inter-country variations, with greater burden in middle- and lower-income countries

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Afghanistan

India

Indonesia

China

Malaysia

Brunei

South Korea

taiwan

Singapore

Japan



M F M F M

Other non-communicable diseases

F

Musculoskeletal disorders

M

Diabetes, urogenital, blood, and endocrine diseases

F

Mental and substance use disorders

M

Neurological disorders

F M

Digesve diseases

F

Cirrhosis

M F

Chronic respiratory diseases

M

Cardiovascular diseases

F

Neoplasms

M F M F

200000

100000

0

100000

200000

Figure 4.3.    DALY Rates Per 100,000 Population Aged 70 Years and Above across Selected Asian Countries, 2013 (IHME 2013).

like Malaysia, China, India, and Indonesia. Cardiovascular DALY rates in these countries are two to three times the rates observed in Japan. Similar variations, to a lesser degree, are also observable in rates for neoplasms (cancers) and chronic respiratory diseases, while rates for diabetes mellitus are fairly uniform across countries. Much of this variation arises from higher case fatality in the

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Age standardised mortality rate per 100,000

600 2000

2012

500 400 300 200 100 0

Figure 4.4.    Age-standardised Mortality Rates Per 100,000 due to Cardiovascular Diseases, 2000 and 2012 (WHO 2016a).

middle- and lower-income countries compared to the high-income countries. For example, cardiovascular mortality rates are three times higher in China, India, and Malaysia, when compared to Japan, South Korea, and Singapore (Figure 4.4) (WHO 2016a). In addition, mortality rates have substantially reduced between 2000 and 2012 in South Korea and Singapore, making them comparable to Japan where rates were already low, while changes of this magnitude are not observable in the other countries. This suggests that much of the contribution of cardiovascular DALYs in these lowand middle-income countries arises from disproportionately higher mortality rates and is reflective of poorer disease management and less responsive health-care systems in these countries. Figure 4.5 encapsulates the interesting discrepancy between high-, middle-, and low-income countries in Asia in terms of cancer incidence and mortality for some of the most common cancers (IARC 2012). While incidence rates are highest in high-income countries like South Korea, Singapore, and Japan, mortality rates

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Figure 4.5.  Age-standardised Incidence and Mortality Rates from Common Cancers in Women, 2012 (IARC 2012).

are lower or comparable to middle- and low-income countries like China, Malaysia, Philippines, and Indonesia. This is again suggestive of higher case fatality among women in these countries and can be attributed to a combination of differences in screening policies and practices leading to delayed diagnosis, inadequate treatment, and poorer health system capacity to manage cancers. While data shown in both Figures 4.4 and 4.5 are age-standardised and do not directly reflect the burden or mortality from cardiovascular diseases or cancers in the elderly, they are indicative of the systemic issues that affect the management of NCDs in Asian countries, and the challenges in reducing the burden across populations, including the elderly.

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132  Ageing in Asia: Contemporary Trends and Policy Issues 35 Both sexes

Female

Male

30

Years of life

25 20 15 10 5 0

Figure 4.6.    Life Expectancy at Age 60 Years Across Selected Asian Countries, 2013 (IARC 2012).

The effect of the greater NCD burden and poorer outcomes in the older population in middle- and low-income countries compared to high-income countries in Asia is observable in the substantially lower life expectancy at 60 years in the former vs. the latter (Figure 4.6). For instance, a 60-year-old woman in India can expect to live only up to 78 years compared to 89 years for a woman of the same age in Japan, a loss of 11 years. Along with differences in outcomes and survival, the risk for specific NCDs is also likely to be different across countries, based on patterns of risk factor prevalence. Direct comparisons of risk factor levels are difficult across countries due to differences in survey questions, definitions used, coverage of older populations, and reporting. In spite of these limitations, some general comments on patterns of risk factors can be made (Table 4.2) (Wu et al. 2015; MOH 2011; HPB 2010; IPH 2015). A larger proportion of the older population in India is at risk due to smoking habits compared to other countries, while alcohol use appears to be a bigger problem in China.

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Table 4.2.    Prevalence of Common NCD Risk Factors across Selected Countries. China[Wu Singapore et al. 2015] Malaysia[IPH [MOH 2011] (50 yrs & 2015] (60 yrs (60–69 yrs) above) and above)

Common NCD risk factors Daily smoking

India[[Wu et al. 2015] (50 yrs & above)

11.4

26.7

14.4

46.9

3.6

6.3

2.8

0.2

7.2

15.3

14.2

6.4

Central obesity*

36.2

57.4

56.4

78.7

Physical inactivity

40

28.3

46.8

24.9

Insufficient fruit & vegetable intake

76.3[8]

35.6

93.6

90.6

Hypertension

53.4

61.3

69.3

33

Regular alcohol use 2

Obesity (BMI > 30 kg/m )

*Country-specific cutoffs — Singapore: waist-hip ratio (WHR) men > 1.0, women > 0.85; China and India: WHR — men > 0.9, women > 0.85; Malaysia: waist circumference — men > 90 cm, women > 80 cm.

Prevalence of physical inactivity mirrors country income levels, while insufficient intake of fruits and vegetables appears to be the universal default. Interestingly, while obesity prevalence is fairly low in India, abdominal obesity3 appears pervasive. The prevalence of hypertension is also very high in older populations across countries. While the overall profiles indicate significantly higher NCD risk in older people in Asia, the patterns also suggest opportunities for intervention and primary prevention in older people. The associations between risk factors and NCD risk is maintained across ages, though the strength of association may vary due to the higher baseline risks in older people even in the absence of known risk factors (Yusuf et al. 2004; Anand et al. 2008). Effect sizes for most 3

 The 1997 WHO Expert Consultation on Obesity recognised the importance of abdominal fat mass referred to as abdominal, central, or visceral obesity, which can vary significantly within a narrow range of total body fat and body mass index. This constitutes another indicator to identify individuals at increased risk of obesityrelated morbidity (Waist Circumference and Waist-Hip Ratio: Report of a WHO Expert Consultation, Geneva 8–11 December, 2008).

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of the risk factors for cardiovascular disease, for instance, are smaller in older individuals when compared to younger individuals, including for smoking, abdominal obesity, physical inactivity, unhealthy diet, hypertension, and diabetes (Anand et al. 2008). Nevertheless, it is important to recognise that primary prevention is as important in older adults as it is in younger ages to prevent avoidable morbidity and mortality.4 The evidence for the benefits of control of hypertension and dyslipidemia is strong in older individuals as well, as is the evidence for healthy eating and physical activity (Curb et al. 1996; Strandberg et al. 2014; Wen et al. 2011). On the other hand, the association between body weight and mortality in older adults is more complex, with increased risk of mortality at both extremes of weight. This so-called “obesity paradox” means that recommendations on weight management cannot be straightforward. In fact, some researchers suggest that being underweight is a bigger mortality risk than being overweight in older individuals, and therefore weight loss should not be emphasised in the elderly (Oreopoulos et al. 2009; Yerrakalva et al. 2015). This may be especially true for Asian populations where the majority of elderly are in the normal weight range (Murayama et al. 2015; Sharma et al. 2016). At the same time, central obesity seems to confer additional risk on mortality in older adults independent of weight status, and this may be something to worry about in Asia, given the high prevalence of central obesity with normal body weights (Sharma et al. 2016).

4.3. CHALLENGES FOR NCD PREVENTION AND MANAGEMENT IN THE CONTEXT OF AN AGEING ASIA 4.3.1.  Undiagnosed and Undertreated Disease In spite of the known and anticipated high burden of NCDs in older age groups, there are huge gaps in disease diagnosis and appropriate 4

 Morbidity is defined as a diseased state, disability, or poor health, while mortality refers to the number of deaths in a given population.

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management in these populations (Committee on Population, Division of Behavioural and Social Sciences and Education 2012; Wang et al. 2015; Venkataraman et al. 2009). Studies comparing disease prevalence by self-report diagnoses with symptom check-lists or measurements have reported that one-fourth to half of older people with disease on symptom check-list or measured values are undiagnosed (Committee on Population, Division of Behavioural and Social Sciences and Education 2012; Wang et al. 2015; Arokiasamy et al. 2015). The proportion of undiagnosed hypertension ranges from 42% in Malaysia (IPH 2015) to 50% in India (Maurer and Ramos 2015) among older ages. Similarly, the prevalence of undiagnosed diabetes mellitus in individuals aged 60 years and above in Malaysia was 12.8%, 33% of all individuals with diabetes in that age range (IPH 2015). Under treatment of known diseases is an even bigger issue, with proportions of people with known diseases being optimally treated fairly low across countries, irrespective of country income levels. Only one-fourth to one-third of older adults being treated for hypertension had blood pressures lower than 140/90 mm Hg in the multi-country Prospective Urban Rural Epidemiological (PURE) study, which included 7 Asian countries — India, Bangladesh, Pakistan, Iran, United Arab Emirates, China, and Malaysia (Chow et al. 2013). The same study also looked at the use of key secondary prevention drugs after myocardial infarction or stroke. Use of key secondary prevention drugs (aspirin, ACE inhibitors, statins, and beta blockers) was much lower in Asian countries compared to North America and Europe (Yusuf et al. 2011). Interestingly, drug use was higher in those 60 years and above compared to those 60 years and below, and this held across countries. There were significant associations with country income levels for both proportion of well-controlled hypertensives as well as use of secondary prevention drugs, with gradient increasing with income levels. Adoption of healthy behaviours post infarction or stroke was also poor, with half to three-quarters of these individuals continuing to smoke (Teo et al. 2013).

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4.3.2.  Social Determinants of Health and NCDs in the Elderly Health and disease do not occur in isolation; it is now an accepted fact that social, economic, and cultural factors play major roles in the maintenance of health and development of diseases in individuals. Asia, as a whole, is a society under transition, not only demographic and epidemiological, but also socio-cultural. Traditional cultural values and beliefs centre on the primacy of family, filial piety, importance of the larger community over self, the need to maintain harmony, and preserve “face”. Therefore, in most Asian countries, the primary responsibility of caring for older adults lies with their children. However, with increasing globalisation and exposures to other cultures, especially from the West, younger generations are increasingly moving towards a more individualistic cultural orientation (North and Fiske 2015; Xiao et al. 2013). In addition, economic pressures and the need to seek livelihoods are also moving children away from their parents. Rural parts of Japan, China, and India have witnessed a disproportionate rise in the numbers of older adults due to migration of younger adults to urban centres of economic growth (Committee on Population, Division of Behavioural and Social Sciences and Education 2012; Krishnaswamy et al. 2008; Tanaka and Iwasawa 2010; Cai et al. 2012). Greater proportions of the elderly are therefore living alone or with an elderly spouse, with one in three single-person households in Singapore and Japan being headed by an older adult (Koh and Lee 2014; National Institute of Population and Social Security Research 2014). This places the elderly in a position of greater vulnerability, in terms of access to preventive services and care, health-care financing, as well as psychosocial isolation (Courtin and Knapp 2015). This is important in the context of NCDs, as it has been shown that psychosocial factors — depression, stress including financial stress, separation, and family conflict — are more important in the causation of cardiovascular disease in older adults compared to younger adults (Anand et al. 2008). Access to care is also an important determinant of health in the elderly. There are gender and socio-economic differentials in health

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status and access to care among the elderly. The WHO’s Study on global ageing and adult health (SAGE), a longitudinal multi-country study on health and well-being in older populations, includes data on the two Asian giants, China and India, and showcases some of these differences. Older women tend to report worse overall health compared to men of the same age group. For instance, older women in China and South Korea are one and a half and twice as likely to report poorer health, respectively (WHO 2014; Committee on Population, Division of Behavioural and Social Sciences and Education 2012). Similarly, older widows in India are more likely to report morbidities compared to older widowers (Agrawal and Keshri 2014). Women are also less likely to be diagnosed with and treated for disease, with substantial differences in disease prevalence in women based on self-report of previous diagnosis and symptom checklist (Committee on Population, Division of Behavioural and Social Sciences and Education 2012). Education and income levels also play important roles in determining health, with higher education and income associated with healthier NCD risk profiles, smaller proportion of undiagnosed disease, and greater likelihood of receiving treatment (WHO 2014; Committee on Population, Division of Behavioural and Social Sciences and Education 2012; Arokiasamy et al. 2015; Agrawal and Keshri 2014; Finkelstein et al. 2014). There are also differences between rural and urban elderly, in disease and risk factor prevalence, and disease diagnosis and treatment, but the gradients are not always in the direction expected (Arokiasamy et al. 2015; Agrawal and Keshri 2014; Oyebode et al. 2015). Urban elderly tend to have better risk profiles in terms of smoking, vegetable and fruit intake, and leisure-time physical activity, but higher prevalence of overweight and obesity (Oyebode et al. 2015). While there do not seem to be big differences in disease prevalence, rural elderly are more likely to be undiagnosed and untreated (Arokiasamy et al. 2015; Chow et al. 2013). Cost and affordability of care are other major drivers of access to care. This is true for all populations, but even more so for the elderly, most of who are no longer economically active, and therefore dependent either on their lifetime savings or on other family members to cover health-care costs. Availability and affordability of

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appropriate treatments are especially critical for NCDs, both for acute-onset events like myocardial infarction and stroke, as well as long latent-phase diseases like hypertension and diabetes, as time to treatment is an important factor in determining outcomes. In addition, an NCD diagnosis usually calls for long-term treatment, and this makes affordability of medications an important issue. Results from the PURE study showed that availability and affordability of critical secondary prevention drugs for cardiovascular diseases were worse in Asian countries compared to the West (Khatib et al. 2016). There is also great variability in the availability, coverage, and penetration of health insurance, either government-sponsored or voluntary, across Asian countries. Countries like Japan, South Korea, and Singapore have long provided some form of national health insurance cover to all residents, while China is a recent entrant to this pool (Yu 2015). Some countries like India (MOHFW 2015) and Vietnam (Guindon 2014) have, in recent years, introduced health insurance schemes that target the poor. However, there continue to be issues with the reach and targeting of such programmes, including lack of awareness among the eligible poor, inadequate coverage of the most deprived communities, and lack of political and institutional focus on programme effectiveness and efficiency (Thakur 2015; Nandi et al. 2013; Devadasan et al. 2013). The effect of health insurance coverage has also been variable, depending on the level of coverage for inpatient and outpatient care, medications, preventive services, and the conditions covered. Data from China suggests that health insurance coverage has improved care seeking behaviours in the elderly, but without improvements in self-rated health and mortality. There has also been no appreciable change in out-of-pocket expenditures for the insured elderly in China (Cheng et al. 2015). Expanding insurance coverage among the poor in India seems to have reduced mortality and increased utilisation of expensive but underused tertiary hospital services with lower out-of-pocket expenditures (Devadasan et al. 2013; Gupt et al. 2016; Sood et al. 2014), while no change in health outcomes was reported in Vietnam even though inpatient use increased in the covered poor (Guindon 2014).

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4.3.3.  Elderly-specific Issues The elderly face unique challenges in relation to prevention and management of NCDs. Older adults tend to have poorer diets compared to younger peers. In Singapore, older adults tend to have predominantly cereal-based diets, with low intake of vegetables, fruits, meat, and alternatives (HPB 2010). Similar findings have been reported in Older Chinese, who also have largely cereal-based diets and excess intake of oils and salt, with very limited intake of vegetables, fruits, and dairy products (Xu et al. 2015). Dietary choices in the older ages are influenced by the same socio-economic determinants discussed above, as well as issues specific to the elderly, like altered dentition, taste, and smell. The elderly are also less likely to be physically active than younger adults (Wu et al. 2015; Sun et al. 2010). This is in part due to health issues, but also due to physical environments that are difficult to navigate for the elderly. Uneven and slippery surfaces, lack of access to open spaces, and safety issues can all reduce the likelihood that an elderly person will engage in physical activity (King and King 2010). Restrictions on physical mobility and access also affect the elderly’s access to health-care services, including preventive and screening services as well as care services (Bogner et al. 2015; Mahmoudi and Meade 2015). Another challenge with older adults is the increased likelihood of having two or more chronic conditions at the same time. Globally, the prevalence of multi-morbidity5 is 21.3% in those aged 65 years and above, compared to 3.8% for those aged 18–49 years (Afshar et al. 2015). In the SAGE study, prevalence of multi-morbidity in the age groups 60–69 and 70 and above years was 50% and 60%, respectively (Arokiasamy et al. 2015). Multi-morbidity impacts physical functioning, emotional states, and quality of life (Arokiasamy et al. 2015). It also increases the cost and complexity of care for these individuals, and is challenging for health systems to deliver efficiently and effectively (Lee et al. 2015; Palladino et al. 2016). 5

 Multi-morbidity is defined as the coexistence of more than one chronic condition in one individual.

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4.3.4.  Dual burden of Communicable and Non-communicable Diseases The preceding sections have highlighted the burden of NCDs in older populations in Asia. However, it is pertinent to note that many of these countries, like India, China, and Indonesia, are still dealing with unfinished agendas of communicable diseases (Remais et al. 2013). The burden of communicable diseases in the elderly is also not insignificant in these countries (IHME 2013; Committee on Population, Division of Behavioural and Social Sciences and Education 2012; Remais et al. 2013; Lim et al. 2012). In addition, some specific chronic diseases, like cervical and hepatic cancers, have infectious origins, while having an NCD like diabetes can itself increase the risk of infections. It will be important for these countries to effectively tackle the burden of communicable diseases, in parallel to reorienting health systems for NCD management. This is all the more pressing, given the reemergence of certain communicable diseases, and the increasing emergence of drug-resistant strains of infective organisms (De Luca D’Alessandro and Geraldi 2011; Suk and Semenza 2011).

4.4. NCD PREVENTION AND MANAGEMENT FOR SUCCESSFUL AND ACTIVE AGEING — THE WAY FORWARD As populations age, and other causes of disease and death get better controlled, it is inevitable that the burden of NCDs will continue to rise in Asia. However, this does not mean that our elderly populations should continue to suffer disease and disability for much of the silver years. The aim of NCD prevention and management should be to not just help people live longer, but also live healthier for longer. In other words, the goal should be to increase healthy life expectancy6 (HALE) at older ages. While country-specific data on 6

 HALE at birth is a form of life expectancy that applies disability weights to health states to compute the equivalent number of years of life expected to be lived in full health (WHO Global Health Observatory Data).

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HALE at 60 years is not readily available, global summary estimates suggest a loss of about 4 years of healthy life when compared to life expectancy (WHO 2014). We have already discussed in detail the disparities in risk factor prevalence, disease burden, and outcomes between countries and within countries, and the drivers of these disparities in the preceding sections. Addressing these drivers and issues can significantly delay onset of NCDs, limit disability, and extend healthy years of life for older adults. 4.4.1.  Health System Strengthening Over the past few decades, there has been increasing global recognition of the public health burden of NCDs in low-, middle- and high-income countries, and the need for an integrated approach for prevention and management. Several key policy initiatives at the global level, including the Framework Convention on Tobacco Control, the Global Strategy on Diet, Physical Activity, and Health and the Global Action Plan for prevention and control of NCDs 2013–2020, have placed NCDs in the international spotlight. In fact, the theme of the World Health Day 2016 was “Beat diabetes”, with the world health report highlighting the tremendous leap in the numbers of people with diabetes over the last 30 years and calling for urgent action to prevent the disease, as well as diagnose, treat, and care for people with diabetes (WHO 2016b,c). Country capacity to tackle NCDs varies across Asia. In broad terms, the countries under focus in this chapter have NCD-related national policies and systems in place, including the availability of screening and drugs for management. However, capacity to address NCDs is lower in lower middle-income countries like India and Indonesia compared to high-income countries (WHO Global Health Observatory 2016). Table 4.3 shows the availability of national-level NCD monitoring and screening for NCDs at primary health-care level, while Table 4.4 shows the availability of cancer-related equipment, both imaging and radiotherapy units, in selected Asian countries. Even when there are national level policies and facilities available, the level of implementation of these policies and utilisation of

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142  Ageing in Asia: Contemporary Trends and Policy Issues Table 4.3.    NCD-related Monitoring and Screening in Selected Asian Countries, 2013 (WHO Global Health Observatory 2016). NCD monitoring

General availability of screening at the primary health care level

Cancer Breast Cervical Colon Peak flow Total Urine Surveillance registry cancer cytology cancer Diabetes spirometry cholesterol albumin Afghanistan

No

No

Yes

No

No

Yes

No

Yes

Yes

Brunei

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

China

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

India

No

No

Yes

Yes

Yes

Yes

No

Yes

Yes

Indonesia

No

No

No

No

No

Yes

No

Yes

Yes

Japan

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Malaysia

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

South Korea

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Singapore

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Table 4.4.    Total Density Per Million Population of Cancer Equipment in Selected Asian Countries, 2013 (WHO Global Health Observatory 2016). Imaging equipment Magnetic Resonance Imaging

Computed tomography units

Afghanistan

0.1

0.2

Brunei Darussalam

2.39

7.18

Country

Radiotherapy equipment Linear Accelerator

Telecobalt Unit

0

0

China

0.73

0.37

India

0.15

0.26

Indonesia

0.08

0.06 0.5

Japan Malaysia Republic of Korea Singapore

45.94

101.18

6.68

2.89

6.43

1.41

19.99

35.38

2.8

0.2

7.76

8.87

3.33

0.18

the facilities may vary greatly. Effective implementation of NCD prevention and control policies require a whole of government approach, as key implementers of policies on physical activity, diet,

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and tobacco, for example, are not the Ministries of Health, but the Ministries of Planning, Urban and Rural development, Transport, Trade and Industries, etc. This involves a lot of within-government advocacy and a tough balancing act between competing interests. In relation to service utilisation, health system structures, entry barriers, and pricing mechanisms determine how accessible and affordable the services are. As already discussed in the section on challenges, there are barriers to care that operate both across whole populations and specifically determine access and affordability for the elderly. For example, most of the essential medicines for NCD are available in both public and private sectors in India, but one survey noted that the median consumer price ratio for generic drugs in the public and private sectors, respectively, was 33.1 and 86.3, demonstrating a huge price differential in India compared to the international standard pricing (WHO Global Health Obser­ vatory 2016). Such differentials make NCD management unaffordable for large sections of the population, and especially for the vulnerable elderly. Pricing mechanisms and health-care financing systems need to evolve in order to eliminate these issues of access and affordability. High-income countries have their own challenges when it comes to prevention and control of NCDs. Singapore, for instance, has a tiered health system, with acute complex care being provided in public sector hospitals, and primary care largely provided by private general practitioners, along with a limited number of public sector polyclinics (MOH 2014). However, the bulk of chronic disease care at the primary care level is provided by the polyclinics, which places a substantial burden on polyclinics’ capacity and resources. In addition, subsidies for health care are generally larger at the tertiary level, given the anticipated higher costs of care. This means that chronic care at the hospital level may be cheaper for patients compared to the same care at the primary level, and makes step-down care challenging. Singapore has addressed these issues through a variety of health-care innovations over the past few years. Flexible financing like the Chronic Disease Management Programme, which allows the use of Medisave (a compulsory medical savings scheme)

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for chronic disease management (MOH 2015), financial subsidies like the Community Health Assist Scheme, which provides subsidies for care, including chronic disease care, obtained at participating GPs, have helped to increase the affordability of chronic disease care (CHAS 2016). Of particular relevance to older adults is the Pioneer package that was introduced in 2015, which provides even greater subsidies for outpatient care, top ups to their Medisave accounts, and premium subsidies for health insurance to all Singaporeans aged 65 years and above in 2014 (Pioneer Generation Package 2015). The structure of Singapore’s health system has also been evolving over this period, with the introduction of regional health systems to provide seamless care across different levels and providers within a given geographic area (MOH 2014; AIC 2016) and greater support to primary level care providers, especially GPs, for chronic care. This includes the establishment of community health centres, which provide allied health services, like diagnostic imaging, dietetics, nurse counselling and education, diabetic retinal photography, physiotherapy, and diabetic foot screening and podiatry for GPs (AIC 2015). However, there are still challenges, key among which is the issue of trained health manpower availability, especially in the allied health sector.

4.4.2.  Universal Health Coverage The increasing cost of health care is an important issue to address when discussing health system strengthening for NCD prevention and control in the face of population ageing (Table 4.5) (WHO Global Health Observatory 2016). Japan, with one of the oldest populations in the world, now spends 10% of its GDP on health, 80% of which is government expenditure. Health expenditure constitutes 20% of the overall government expenditure in Japan. Government health expenditure is relatively smaller in other countries, constituting around 12% of overall government expenditure in high and upper middle-income countries, and 6% in lower middle- income countries. Correspondingly, out-of-pocket expendi-

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Table 4.5.    Expenditure on Health in Selected Asian Countries, 2013 (WHO Global Health Observatory 2016).

% expenditure % external on health of resources of % of total govern% of GDP % government % private total government total ment expenditure on health expenditure expenditure expenditure expenditure on social security

% out of pocket of total % out of % private plans of private expend- pocket of total total private iture expenditure expenditure

8.1

21.2

78.8

7.1

18.6

0

93.6

73.8

Brunei

2.5

91.9

8.1

7.4

0

0

97.8

7.9

China

5.6

55.8

44.2

12.6

0.1

69.3

76.7

33.9

8

India

4

32.2

67.8

4.5

1.1

6.2

85.9

58.2

4.8

Indonesia

3.1

39

61

6.6

1.1

17.6

75.1

45.8

10.3

82.1

17.9

20

87

80.2

14.4

14

Malaysia

4

54.8

45.2

5.9

1.2

79.9

36.1

16.1

South Korea

7.2

53.4

46.6

11.5

77.8

78.6

36.6

13

Singapore

4.6

39.8

60.2

12.5

11.8

94.3

56.8

Japan

0

0

0 1.1

2.9

3.4

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tures are much higher in these countries. This places undue burden on individuals and families, and as already discussed, can be especially worrying for the elderly, who may lack financial safety nets when dealing with catastrophic illness. Achieving universal health coverage7 is one key way to reduce financial hardship on individuals, families, and communities while effectively providing the promotive, protective, early diagnostic, management and rehabilitation interventions that older people need. Key elements in the design and implementation of universal health coverage include reaching out to and covering the entire population at risk, providing a package of services across the promotion–rehabilitation continuum for a range of health needs, health-care financing to ensure affordability, access to medicines and technologies, and sufficient health manpower capacity; and the ability to deliver these elements vary in individual countries. Globally and within Asia, there is growing recognition of the importance of universal health coverage as a key public health approach and the cornerstone of any country’s health policy (Van Minh et al. 2014; McIntyre et al. 2013). As already discussed in the section on challenges, several health-care financing models are being implemented in different countries to ensure affordability of health care, and coverage has been gradually expanding to include not only acute illnesses but also NCDs. An area that still requires work is health human resource development. Prevention and control of NCDs require a large pool of diversely skilled manpower, and this is an important limitation for service expansion in many countries (Bredenkamp et al. 2015). Even high-income countries like Japan and Singapore are facing a shortage of skilled health professionals to address the twin challenges of ageing and NCDs. Greater strategic thrust to ensure expansion of universal health coverage, planned human resource capacity development,

7

 WHO’s conception of Universal Health Coverage means that all people and communities can use the promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

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increased health financing protection for vulnerable population groups like the elderly, and ensuring coverage of common NCDs and their risk factors can substantially facilitate prevention and control of NCDs in older adults. In Singapore, in view of the ageing population and the increasing prevalence of NCDs, several changes have been made to the health system over the years. As already mentioned, the CHAS scheme has been introduced to subsidise outpatient chronic disease care at private GPs. In addition, the national health insurance scheme has been revamped into a compulsory, life-long coverage scheme, including for pre-existing conditions, to provide greater protection against catastrophic health events. There is also a reconsideration of the level of subsidy between primary, tertiary, and step-down secondary care to facilitate right-siting of care. Greater efforts are also being made to create supportive environments, both built and social, for healthy living across all ages (Lee Hsien Loong 2015). Another important aspect of health systems in Asia is the availability and preference for complementary and alternative systems of medicine for the management of NCDs (Peltzer et al. 2016). There is also need to integrate these alternative systems within the formal health-care structure to assure quality of care and to provide patients with the choice of such care if preferred, on the lines of what the UK NHS has done (NHS 2016). 4.4.3.  Life Course Approach Since the mid-1990s, the WHO has advocated the life course approach to active and healthy ageing (NHS 2016). The life course approach considers the underlying biological, behavioural, and psychological processes that operate across the life course, which is shaped by the environment in which we live. At various stages of an individual’s life course, there are opportunities to build up “health reserve” and promote “functional capacity” as illustrated in Figure 4.7. Recent longitudinal studies have provided evidence that the adoption of healthy behaviours in mid-life increases the odds of

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Figure 4.7.  The life Course Perspective of Ageing (Reproduced from: A Life Course Perspective of Maintaining Independence in Older Age (WHO 1999).

successful ageing (Sabia et al. 2012; Willcox et al. 2006). In the UK-based Whitehall II study, 5,100 British men and women were assessed at baseline in 1985–1988 for 4 health behaviours (regular physical activity, consuming fruits and vegetables daily, drinking alcohol moderately, and never smoking) and followed up to assess if they achieved successful ageing (Sabia et al. 2012). Over a 16-year follow-up, Sabia and colleagues found that the odds for living till 60 years and beyond without chronic disease, disability, or mental illness increased for participants engaging

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Epidemiology of Non-Communicable Diseases   149

in any individual healthy behaviour. They also found that the beneficial impact of healthy behaviours increased linearly, with 33% increased odds for successful ageing for each additional healthy behaviour. Similarly, Willcox and colleagues found that absence of risk factors like overweight, smoking, excess alcohol intake in middle life was associated with increased survival till old age without chronic disease (Willcox et al. 2006). 4.4.4.  Innovative Solutions As we look forward to improving the health of older adults in Asia, it is interesting to examine Japan’s experience with ageing. As already highlighted at the beginning of the chapter and elsewhere, Japan has the greatest life expectancy and the largest proportion of older adults in the world. In terms of NCDs, the Japanese have historically had, and continue to have favourable risk factor profiles, with significantly lower burden of ischaemic heart disease and cancers. Mortality from stroke, which was an important cause of death in Japan, has been reduced through national population-based public health interventions to reduce salt intake and early detection and improved control of hypertension. Key to this health achievement have been universal health coverage, insurance policies, and the literate population. However, challenges remain. Risk factors for NCDs, like smoking, are still not optimally controlled. In addition, as the proportion of older adults in the population rises, the health system is at increasing stress to provide optimal, timely, and quality care, while maintaining financial viability. Further optimisation of care delivery and financing models may be needed to support Japan’s ever-growing older population (Ikeda et al. 2011). Another country experimenting with innovative solutions for an ageing population is Singapore. In 2016, a new Action Plan for Successful Ageing has been introduced which covers the needs of an older population holistically, including not just health and health care, but employment, retirement adequacy, social inclusion, housing, transport, and protection for vulnerable elderly, among others.

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The action plan also follows the socio-ecological model with initiatives focused on helping Singaporeans live long, live well, and age confidently at the individual level, build a cohesive society with inter-generational harmony at the community level, and build an age-friendly city that enables seniors to live actively and age-in-place confidently at the city–nation level. Key health-related initiatives under the action plan include a national seniors’ health programme and workplace health programme to help older adults age healthily by addressing nutrition, physical activity, mental health, and selfempowerment; colocating eldercare and childcare centres to allow greater inter-generational interaction; increasing capacity for community and residential long-term care; progressively making public spaces elder-friendly; and creating active ageing hubs to provide a spectrum of services from wellness promotion to rehabilitation (MOH 2016). In parallel, Singapore has also declared “war on diabetes”, the most rapidly increasing NCD in the country, with a multi-pronged approach starting from promotion and facilitation of healthy lifestyles, screening and early intervention in those at risk, and improved management to slow disease progression and delay complications (Khalik 2016). While both the Singaporean initiatives highlighted are very recent developments, and hence their effectiveness cannot be gauged, it is indicative of the importance of the twin challenges of ageing and NCDs and the country’s seriousness in addressing them, which can be learning points for other countries in Asia.

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CHAPTER 5

ACTIVE AND PRODUCTIVE AGEING Thelma Kay and Marie Nodzenski

5.1.  INTRODUCTION AND DEFINITION Asia is ageing rapidly as a consequence of increasing life expectancy and declining fertility. Geographically, Asia is categorised by the United Nations as East Asia, South East Asia, South Asia, and West Asia. However, with regard to population changes, a different categorisation is more appropriate. This would consist of: (1) Aged societies with over 20% of the population aged 65 years and older - Japan, Singapore, Taiwan, Republic of Korea, Hong Kong, Macau (2) Rapidly ageing societies - Thailand, Vietnam China, Indonesia (3) Societies which are ageing but at a slower pace - all other countries However, population ageing is projected to accelerate in the future. For example, among the 10 ASEAN countries, by 2045 only Cambodia (19%), Lao PDR (12%) and the Philippines (12.4%) will have less than 20% of their population over 60 years of age. The seven other countries are projected to have the following percentage 151

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of population aged over 60 years old: Thailand (35.8%), Singapore (33.9%), Vietnam (27.2%), Brunei Darussalam (26.9%), Myanmar (20.5%), Malaysia (20.4%), and Indonesia (20.0%). To compound the issue, countries at different stages of ageing are also at varying levels of economic development. This would mean that some countries will be getting old before getting rich. Other characteristics include the speed of ageing, giving countries less time to prepare for the implications of population ageing. This is coupled with smaller household sizes and scattered families. Other dimensions are the feminisation of ageing and the increasing number of the older old and the frail and vulnerable. A growing trend is the increasing number of elderly living alone and the single elderly. Smaller family size has also reduced the capacity for care and support from family members, thus necessitating greater independence and self-sufficiency in advancing years as well as the need for non-familial care providers. There has been an increase in life expectancy, with a high incidence of healthy life expectancy1 which has ramifications for post-retirement employment and productive activities. In some countries, low unemployment, the availability of job opportunities, and restricted foreign labour flows have created an environment conducive to economic participation. Furthermore, new cohorts of older persons, who are better educated than previous cohorts and have higher expectations, can avail of these favourable conditions.

5.2.  DEFINITIONS AND CONCEPTS The concept of “active ageing” has been gaining recognition as an important policy tool to address the challenges of population ageing. However, there is some confusion over the meaning of related terms, especially “successful ageing”, “productive ageing”, and “healthy ageing”. 1

 Healthy life expectancy (HALE) at birth is a form of life expectancy that applies disability weights to health states to compute the equivalent number of years of life expected to be lived in full health (WHO Global Health Observatory Data).

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Although the term active ageing is relatively recent, its genesis can be traced to reactions to the early theory of social gerontology which perceived ageing as a period of disengagement, a period of loss and withdrawal of roles and relationships (Cumming and Henry 1961). This narrow and negative perspective of the “deficit model” was challenged by the activity theory which stressed the importance of an active lifestyle. It also formed the root of the three main concepts of successful ageing, productive ageing, and active ageing. Successful ageing was first propounded by Robert N. Butler and reinforced by J.W. Rowe and R.L. Kahn and focused on reducing diseases and disease-related disability, cognitive and physical functional capacity, and the key to successful ageing was propounded to be active engagement with life. However, successful ageing was challenged as an ideal type, which implied that there would be older persons not ageing successfully. Productive ageing was seen as continued participation in paid or unpaid workforce and was seen to be linked essentially to employment and income. Although it signified a departure from the earlier deficit model of illness and disengagement, it was also seen as being too narrowly focused on the economic and utilitarian productivistic approach (Butler 1974; Rowe and Kahn 1987). These approaches are the precursors to the World Health Organization (WHO) definition of active ageing, which covers the three main pillars of health, participation, and security, a conceptual framework that holistically reflected the situation of older persons. The policy framework identified the following determinants: economic, health, and services, behavioural, personal, physical environment, and social, with the overarching factors of culture and gender. This WHO definition, which has gained the most credence in recent years, defined active ageing as “the process of optimizing opportunities for health, participation, and security to enhance the quality of life as people age…” (WHO 2002). Significantly, while other terms convey one-dimensional perspectives like health or economic dimensions, the WHO definition provided a holistic approach to ageing. This comprehensive definition has stood the test of time, and has only recently been further refined with proposed supplementary

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dimensions. A recent addition is the proposal by the International Longevity Centre to include life-long learning as a fourth pillar to reflect the need to adjust to a rapidly changing environment (International Longevity Centre Brazil 2015). Another perspective on active ageing suggests implementing measures to reduce the gap between life expectancy and HALE (which in Asia is around 6–7 years). To amplify the conceptual framework, Alan Walker has identified seven guiding principles of active ageing as follows: (1) include all individual pursuits that contribute to individual well-being e.g. volunteerism, (2) be preventative, involving all age groups, (3) cover all older persons including the frail and dependent, (4) feature inter-generational solidarity, (5) include both rights and obligations, (6) empower with top-down policy actions and also bottom-up action from citizens, (7) respect national and cultural diversity (Walker 2002). In the 2015 World Report on Ageing and Health, the WHO had proposed a framework conceptualizing healthy ageing as comprising intrinsic capacity and functional ability. Healthy ageing is thus defined as “the process of developing and maintaining the functional ability that enables well-being in older age”. Of relevance is the emphasis on maximizing functional ability, which would be achieved by building and maintaining intrinsic capacity and by enabling functional capacity (WHO 2015). The 69th World Health Assembly approved a resolution on the Global Strategy and Action Plan on ageing and health 2016–2020. Five objectives were identified for a long and healthy life: commitment to action on healthy ageing and combating ageism as a key priority; designing age-friendly environment; aligning health systems to the needs of older persons; developing sustainable solutions for long-term care in the home, communities and institutions; improved measurements, monitoring and research on healthy ageing (WHO 2016). A related development is the philosophy and process of reenablement, which is aligned with WHO’s framework of functional capacity and is conceptually a focused and time-limited intervention

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Active and Productive Ageing  155

to address the loss of functioning, facilitating and enabling continued participation in the community. These broadened understandings of active ageing are very useful in the context of ageing in Asia. At the Second World Assembly on Ageing in 2002, the Madrid International Plan of Action on Ageing (MIPAA) was adopted, containing three policy directions: older persons and development; advancing health and well-being into old age; and ensuring enabling and supportive environments. Several policy recommendations pertain to active ageing, particularly on active participation in society and development (priority issue 1 of the first priority direction), health promotion and wellbeing throughout life (priority issue 1 of the second priority direction), and housing and the living environment (priority issue 1 of the third policy direction). MIPAA reflected two very important shifts in the ageing discourse. Firstly, for the first time, there was agreement on the need to link ageing and human rights. Secondly, MIPAA reflected a shift away from viewing older persons as welfare beneficiaries to full and active participants in the development process who also share in its benefits (United Nations 2002). The importance of active ageing was reaffirmed at the Second Asia and Pacific review of MIPAA in 2012 when countries adopted various measures calling for action on active and productive ageing.

5.3.  WHY “ACTIVE AGEING”? The prevailing demographic situation has presented several important challenges which must be addressed, with active ageing being a key measure to cope with these challenges. There is a need to address inadequate income security, especially for low-income workers or non-waged workers (often in the informal and agricultural sectors, widely prevalent in many Asian countries). Countries have various kinds of social security systems. There are countries which provide a non-contributory allowance (social pension) to all citizens above a specified age (e.g. Bangladesh, Brunei, Malaysia, Maldives, Mongolia, Nepal, Thailand, TimorLeste, Vietnam). These schemes are generally quite minimal

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although evaluations done in some countries have attested to their effectiveness. However, some of these schemes have reportedly placed fiscal burden on some governments, which are considering the application of means testing for the current social pension schemes. Some countries also have income support schemes based on broad conditions such as poverty but also include older persons as beneficiaries, such as China’s Five Guarantees Scheme and Minimum Living Standard Guarantee System or India’s National Old Age Pension Scheme of the National Social Assistance Programme. Several countries have contributory pension schemes, but these are usually for the armed forces, civil services, state-owned enterprises, and the private sectors. However, a majority of workers in developing Asian countries are in the informal sectors and are thus excluded from such income support measures. The situation for older women is exacerbated by their disadvantage over the life course through lower education, lower labour force participation, and part-time work or working careers curtailed for care giving, resulting in lower economic independence and inadequate savings for old age. Another important challenge is to address increased medical and welfare costs stemming from changing epidemiology and disease pattern to non-communicable diseases (NCDs), the increasing onset of dementia, the need to close the gap between healthy life expectancy and actual life expectancy, and the challenge of facing expanded morbidity instead of compressed morbidity (especially for older women). Active ageing also helps to combat social isolation, which can have debilitating effects on physical and mental health.

5.4.  ACTIONS BY COUNTRIES FOR ACTIVE AGEING Countries in Asia are becoming increasingly cognizant of the need to address the challenges of ageing and to prepare for ageing populations. A review of development policies of countries in the region shows that several countries have national development plans that

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cover population issues. These have covered ageing issues, usually from a welfare perspective. However, there has been an increasing shift towards recognizing ageing as a development issue, whereby ageing populations can contribute to the development of society as resources and assets.

5.5.  POLICIES/PLANS OF ACTION/LEGISLATION Some countries also have specific national instruments on ageing in the form of policies, action plans, and legislation. These would include policies on ageing such as the Second Bangladesh National Policy for Older Persons, Fiji’s National Policy on Ageing 2011– 2015, the Indian National Policy for Senior Citizens, Malaysia’s National Policy for Older Persons, Mongolia’s National Strategy for Population Ageing, Sri Lanka’s National Charter, and National Policy for Elders, etc. Some examples of plans of action are China’s 12th Five-year Plan for the Elderly, India’s Integrated Programme for Older Persons, the Philippines National Plan of Ageing for Senior Citizens, Singapore’s Action Plan for Successful Ageing, Thailand’s Second National Plan on the Elderly (2002–2021), etc. Legislation has also been enacted such as China’s National Law on Protecting the Rights of Older Persons (1996, revised in 2012), India’s Maintenance and Welfare of Parents and Senior Citizens Act (2007), Nepal’s Senior Citizen Act (2006), Singapore’s Maintenance of Parents Act, etc. The Parliament of Myanmar has approved the Elders Law (2016). Although the promulgation of legislation and regulations are a promising indication of the political importance being increasingly accorded to ageing issues and set boundaries for action, implementation is often a challenge. In recent years, countries have included measures on active ageing in their policies and action plans. Many of these policy instruments include provisions for active ageing. A review of active ageing programmes in several countries in Asia show that such programmes essentially pertain to work/employment, health, and participation, with some countries, also implementing

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pro­grammes on volunteerism, life-long learning, senior centres, and intergenerational activities.

5.6. HEALTH The issue of health funding and health insurance will not be covered in this section as these will be comprehensively discussed in other chapters of this book. Activities in the health sector will thus be focused on those linked to active ageing. One of the most significant shifts in recent years is the epidemiological transition from the predominance of infectious diseases to non-communicable or chronic diseases. Four-fifths of NCD deaths are in low- and middle-income countries, with older people in developing countries particularly at risk. However, the health-care systems of countries have been built and developed to provide acute medical care, often neglecting approaches to prevent or manage chronic diseases. To compound the issue, the social gradient of economic and social disparities within countries often lead to unequal health outcomes. Nonetheless, countries are increasingly undertaking activities in the health sector, especially wellness approaches which are essential to maintain functional independence and to increase elderly’s health span (and not just lifespan). There is increasing recognition of the need for health promotion as a life cycle approach, and a more prioritised and tailored approach to address the health and well-being of older persons. Such an approach has also been considered as “preventive long-term care”. Programmes cover the following gamut: Staying healthy through prevention: This covers health promotion and preventative activities to stay healthy, physically and mentally; nutritional and dietary measures; and wellness programmes. Some health promotion programmes are tailored for local interests such as mindfulness, meditation, tai-chi, and meridian flapping. Some programmes also have multi-functional goals which include building social bonds. Gardening is also being used as a therapeutic and full range of motion activity to achieve specific goals such as motor skills and downshifting. Older persons have been found to spend a

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considerable amount of time on “quiet activities”, especially watching television. While such activities can bring contentment, they should not mask or lead to loneliness, and isolation among older persons, which should be addressed through initiatives towards engagement, including through new technology such as social media and electronic communications, especially in rural areas. Screening for early detection for those at risk: this covers health screening (either from a population approach or a high-risk approach) for physical and mental health, including for depression and dementia, and falls prevention. Management and treatment for optimizing outcomes especially for those with chronic diseases: this covers health management; selfcare; subsidised consultation and medication; and home and community-based support services. Singapore has launched many initiatives. Under the Health Promotion Board, there are some interesting programmes such as Mental First Aid Programme, Health Ambassadors Network, Community Function Screening, and Falls Prevention. Other noteworthy programmes are the National Wellness Programme and Self-care on Health of Older Persons in Singapore (SCOPE). Many other Asian countries also have health promotion and preventative schemes, all falling under the above genre of activities. China has embarked on a massive National Fitness Programme (2011–2015) which puts sports for all as a national strategy and fitness in line with the overall development of the country. Although progress has been made, challenges that remain are the lack of scientific exercise guidance and insufficient sporting venues and facilities. Thailand has interesting programmes in health promotion, funded in part from the Health Promotion Fund and derived from taxes from liquor and tobacco (known as “sin tax”). An important consideration is the need to impart knowledge to meet the needs of ageing populations. For example, while younger persons may benefit from aerobic exercises, older persons will need exercises and resistance training to build muscle mass and maintain balance.

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A dimension of active ageing which bears further scrutiny is the spirituality and religiosity dimension. For example, in multi-cultural Singapore, older Chinese would engage in tai-chi and qi gong. Older Malays would focus on religious activities such as praying, attending religious classes, and ceremonies. For the Indians, spiritual activities would be undertaken according to their religious affiliations. Similarly, in countries like Indonesia, Thailand, and the Philippines, religious activities play an important role in the lives of older persons. In India, it has been reported that women become more housebound as they age, with men outnumbering women in joining associations for older persons. However, older women participate more in religious activities possibly as a result of stereotyped social constructs whereby older Indian women are expected to spend their time in prayer and religious activities.

5.7. PARTICIPATION The importance of participation for active ageing is becoming increasingly recognised. Many countries have community-based platforms such as senior activity centres. Some countries have active old peoples’ associations and old peoples’ clubs such as those promoted by affiliates of Help Age (e.g. Inter-generational Self Help clubs in Vietnam, Old Peoples Self Help group in Myanmar, Older Peoples Organizations in the Philippines, and Older People’s Associations in Cambodia and in Myanmar). In Vietnam, there are currently 2,000 Intergenerational Self Help groups in 17 provinces, and building upon the success of these pilot groups, the Government of Vietnam has recently officially approved the expansion of the Intergenerational Self-help Club model to 65 provinces, establishing targets, allocating budgets, and defining responsibilities for implementation. In countries with a tradition of organised group, it appears that participation rates of the elderly are high. For example, in Vietnam, it is reported in the Viet Nam Aging Survey 2011 that 71.5% of the respondents were members of the Vietnam Association of the Elderly and 82.5% had participated in activities of the association within the last 12 months (VNAS 2011).

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In Thailand, there are approximately 25,000 elderly clubs, located in subdistricts of all provinces. Participation and belonging can also be provided by non-institutionalised and informal groups like neighbours, as evidenced by mutual support provided to Okinawans by their moai social network, and by affinity groups like former classmates, or shared interests, often facilitated by the advent of social media. Life-long learning is becoming an important pillar for active ageing, with the recognition that education which is often front loaded in the earlier part of life will need to be replaced by continuous educational development and life-long learning integrated with the real world and technological development and opportunities. Pro­grammes like those run by the University of the Third Age, the Elder Academy in Hong Kong, the SkillsFuture Initiative and the Silver Academy in Singapore, Elder Schools in Thailand, all providing avenues of older persons to engage in formal and non-formal education. An age-friendly environment facilitates active ageing and enables ageing in place. In this regard, the WHO age-friendly dimensions (transportation, housing, social participation, respect and social inclusion, civic participation and employment, community support and health services, outdoor spaces, and buildings) are a useful framework (WHO 2007). In the Asia-Pacific region, 38 cities from 6 countries have joined the WHO’s Global Network of age-friendly cities and communities. The capital cities of Iran (Tehran) and the Republic of Korea (Seoul) are members, with most of the others being smaller cities and communities. However, some countries have reported that although they are not formal members of the network, they have adopted many of the dimensions of the WHO model of an age-friendly city. Initiatives have been taken by countries to make housing agefriendly. These include priority for multi-generational living, senior priority, and proximity housing support. Enhancement of infrastructure undertaken include barrier free and universal design, and providing support for features to make the house more age-friendly such as Singapore’s Enhancement for Active Seniors Programme (EASE). A study in the United Kingdom has found

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that home adaptations can delay a move into residential care by 4 years and reduce falls requiring medical treatment by 26% (Keall et al. 2015). The environment can also be made more age-friendly through improved walkability and access to transport. Transport can also be made more age-friendly with wheelchair-accessible buses, longer traffic lights, resting benches, etc. A useful measure is the granting of special privileges and discounts (often through proof of identity such as a Senior Citizen card) to senior citizens for transport costs to facilitate enhanced mobility and accessibility.

5.8.  PRODUCTIVE AGEING It is in the area of productive ageing that policies and action have been, and can be expected to, intensify. The elderly of today are not the same as the elderly of the past, often being healthier with fewer physical disabilities and better educated. Measures to enhance the employability and productivity of older workers cover several aspects. One of the most important measure would be the enactment of an enabling legal or regulatory and institutional framework such as the extension of retirement age, and reemployment legislation. With increased longevity and, in some countries, a decrease in the labour supply, extending the retirement age would be a policy option to sustain labour supply and provide older people with income streams. There have also been studies indicating that working older people tend to stay physically and cognitively healthy and active for a longer period of time. Working also provides the environment for social relationships and networks. Studies have shown that the most effective teams are composed of workers of diverse ages (for example, in German automobile factories) without a linear fall in productivity but with complementary outcomes (National Center for Chronic Disease Prevention and Health Promotion 2012; Börsch-Supan and Weiss 2007). Currently, the statutory retirement age of countries in East Asia ranges from 50 to 65 years old. Figures for selected countries (from the World Bank pension database) are as follows: China (50/60), Indonesia (55), Japan (65), Republic of Korea (65), Lao PDR

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(60), Malaysia (60), Mongolia (55/60), Philippines (65), Singapore (62), Thailand (55) Vietnam (55/60) (Pallares-Miralles et al. 2012; World Bank HDNSP Pensions Database). In Singapore, the Retirement and Reemployment Act of 2012 enables workers to work beyond the statutory minimum retirement age of 62–65 and up to 67 (in 2017). Extending retirement age would thus appear, from evidencebased studies, to have positive impact on income security and could also alleviate pressure on the health system. Detractors have, however, pointed out that extension of retirement age would block promotions for younger staff, would incur higher salary costs than new lower paid younger workers, may reduce productivity, and add to the increased health costs for the workplace. Further research is needed to provide a clearer evidence base for policy making on this matter. Another dimension to enable productive ageing is the enhancement of opportunities through employers training programmes, work placement schemes, technology and innovation in the work environment, age-friendly workplaces, job redesign, etc. With the aim of developing competencies and enhancing skills, another important measure would be employability capacity building through skills upgrading and retraining. Other measures include special programmes for female workers, senior entrepreneurship, etc. Institutional mechanisms and platforms have been established in some countries. For example, the Thai Labour Ministry has set up job placement centres for the elderly. The centres match the elderly seeking employment with interested employers. Tax incentives will be provided to businesses to hire older workers. In Singapore, the Tripartite Alliance for Fair and Progressive Employment Practices (TAFEP) was established in 2006 for employees, employers, and the general public to view older workers more positively and to shape a more age-inclusive workplace. The tripartite partners implemented a Work Pro programme, which includes helping employers to redesign processes, practices, and jobs for older workers (also producing a job redesign tool kit). The Ministry of Manpower also takes action against employers

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with discriminatory practices. Under the SkillsFutures scheme, older persons will be provided with opportunities for skills training and subsidies for courses. At the institutional level, a Skills­Future Singapore (SSG) Agency has been established to strengthen a culture of life-long learning and develop a high-quality education and training system. The private sector can also play an active role in productive ageing. OCBC Bank in Singapore has a life-long learning programme for its employees aged 50 and above. The Life Refresh@OCBC initiative covers four areas: digital and financial technology (fintech); financial planning; career planning; and health and fitness. Voluntary welfare organisations/non-governmental organisations have initiated programmes to help in career transition as well as retirement preparation. Social enterprises for older persons also provide jobs or match older persons to available job opportunities. An important aspect about productive ageing is that in many developing countries in Asia, informal and self-employment is more prevalent than formal employment. The extension of retirement age is thus not as important or applicable as measures to boost productivity through training, skills development, and access to finance and credit. This is especially important in countries which have a significant proportion of agriculture in small holdings, farmed by older persons. Older persons are also engaged in productive activities through self-help groups, collectives, or social enterprises. Community groups such as housewives’ associations also engage in producing marketable products, thus generating income for the family. Productive ageing should also cover non-financial activities such as caregiving, including grand-parenting and volunteerism. Grand-parenting is noticeably prevalent in Asia, often in a relationship of reciprocity and social exchange. Grandparents as caregivers often enable the young generation, especially women, to enter the labour force or to engage in income-generating activities. In many Asian countries, grand-parenting has taken on important dimensions brought about by the absence of working parents, migration, and increasingly in divorce and broken families. The role of

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grandparents in raising grandchildren, especially in skipped generations continues to be of great importance in countries where parents leave their children to be raised by grandparents while they migrate. Policies which can be useful in fostering grand-parenting would include family-centric polices like multi-generational housing schemes, family-friendly provisions in tax regimes, and schemes for inter-generational bonding. Caregiving of the elderly is often undertaken by the younger old, especially by a younger or healthier spouse. Volunteerism is another contribution made by older persons. Studies have shown that volunteering can be a way of regaining meaning and structure and belonging especially after experiences of social dislocation such as retirement and bereavement. In Asia, the amount of time spent on volunteerism is low compared to Western countries. However, older persons often play an important role in religious organisations and localised community entities. Furthermore, recent data shows an increase in volunteerism, with higher increase among the younger and better educated old. Volunteerism can take different forms, often informal and not necessarily through organisations or institutions. These can be community-based and centred on mutual help such as gotong-royong in Indonesia, traditional mutual help networks in Japan, and clan or surname associations in Chinese societies. A Republic of Korea — ASEAN project, implemented through HelpAge Korea, trains families and community volunteers in home care for older people. In Thailand, as part of a community-based integrated eldercare system, home help services are provided to elderly villages by two categories of volunteers — elderly care volunteers and village health volunteers. Singapore has started a National Senior Volunteerism Movement, and a Senior Volunteer Fund has been set up to help community organisations better recruit and develop senior volunteers. China has launched the Yin-Ling programme for retired scientists, experts, and professors to participate in volunteer activities. There are also schemes to monetise volunteer services such as payment to trained health volunteers, and also to “pay forward” such as time banks implemented in several countries.

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Grand-parenting, caregiving, and volunteerism are largely uncosted, leading to the non-monetisation and undervaluation of these services. Much can be done to learn from the methodologies applied for measuring the cost of the unpaid work of women.

5.9. GENDER An overarching consideration in a discourse on active and productive ageing would have to include the gender dimension. In Asia, as in most countries in the world, women have longer life expectancy than men (around 5–7 years). However, although women live longer, they have more sick years (shorter healthy life expectancy) and instead of compressed morbidity are more likely to experience expanded morbidity. There are also more women among the older old who are more frail and vulnerable and thus more at risk. Furthermore, women outnumber men among the widowed and single, with implications for care needs. In Asia, women in many countries have lower education levels, lower labour force participation, often being in parttime work or having to curtail their career for caregiving, thus resulting in lower economic independence and inadequate savings for old age. Women also have different health concerns and healthcare needs. The disadvantages of older women are compounded by discrimination and violence through the life cycle. An important gender difference in ageing is the lower life expectancy of men, who have the propensity to indulge in more risk-taking behaviour and lifestyle such as smoking, alcohol consumption, dangerous sports, etc. They also tend to be in more dangerous jobs including combat duties, construction, etc. They are also more likely to die of diseases (such as heart disease), compounded by a higher tendency to not seek medical attention. Furthermore, men are generally less socially connected than women, and this isolation is accentuated upon retirement. These factors of gender disparity can be narrowed through measures such as lifestyle modification and addressing the medical problems.

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5.10. CULTURE Another overarching consideration would be culture, and in the context of Asia, the changing roles of the state, community, and family. The region is experiencing a change in family size, composition, and living arrangements. With diminishing family size, nuclearizing of society, and split (migrant) families, the traditional role of families has been eroded. Some countries have sought to address this issue with legislation, forcing children to provide support to their parents (e.g. Maintenance of Parents Act in Singapore, China, India). However, some factors can also serve to preserve and reinforce filial norms (or piety). For example, even if families are separated and scattered, new and affordable methods of communication like telephone calls, messaging apps, or Skype have enabled regular contact, albeit of a physically indirect nature. Similarly, remittances sent home by migrant workers abroad are important economically in some countries. Examples abound of inter-generational dependence and solidarity including multigenerational living, housing and spaces for inter-generation colocation, and activities to promote inter-generational bonding. Although the traditional role of the family is being eroded, recent studies have found that marriage has positive effects on longevity, regardless of marital quality. A recent study also found that feeling closer to family members and having more relatives as confidants decreased the risk of death for older adults. Another study also found that six out of ten millennials maintain close contact with their family. Thus, the role of the family should not be underestimated, and measures to strengthen familial bonds should be further explored. However, cultural attitudes are not static and can change over time or as a result of policy. For example, in Japan, there has been a distinct shift from the multi-generational family to nuclear family. The National Transfer Accounts project also found that following the change in government policy to shift long-term care subsidies to the family, there has been a concomitant fall in the attitude towards caring for older persons in the family.

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5.10.1.  Technology and the Digital Revolution The advent of technology will be a game changer for active ageing and productive ageing. In the field of health, innovative technology will better enable older persons to be better able to engage in their own health care and well-being such as telehealth, telemonitors, health tracking and sensors, and wearable technology. The process of reabling will be made possible with assistive devices, and technology such as 3D printing, telerehabilitation and the use of exoskeletons. Social media will provide a platform to enhance communication, knowledge acquisition, and sharing and will help combat loneliness and seclusion. The Internet of Things — the interface between the internet and the physical world where “smart” devices are connected — and the sharing (and “gig”) economy will open up new ways of ageing, enabling ageing in place, independent living, and inclusion. The advent of social media has the potential to enable older persons to be linked to a wider world. Examples of promoting digital literacy for older persons can be found in programmes conducted in many countries. In Thailand, digital community centres will provide the facilities for the community to use digital tools for various purposes including e-learning and marketing local products. Some centres are located in temples which are frequented by older persons. However, obstacles still need to be overcome such as the need for cheaper, more affordable, and user-friendly devices, and more ubiquitous internet availability. Another hurdle is digital exclusion in which older persons are not accepting or not availing themselves of the tools of the digital revolution. While technological advances and evolving consumer demand may create new job opportunities, some jobs and occupations may become obsolete. The “future of work” may see several Asian countries at high risk of losing jobs to automation including robotics, or to the wider and more affordable availability of existing technology. The use of new technologies by consumers such as in the news, publishing, and travel industries will also drive employment declines. The ILO has, in a recent study, warned that 56% of the salaried workforce from Cambodia, Indonesia, the Philippines, and

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Vietnam are in the high-risk category for job loss to automation, which can be ameliorated by training to work with digitalised machines. This will render the potential for employment of older workers even more challenging unless requisite skills are made available through retraining and reskilling and life-long learning (Chang and Phu 2016). In addition to technological innovation, there is also social innovation which essentially covers new approaches (ideas, concepts, services, models) that meet social needs through creating new solutions that are more effective, efficient, and sustainable than existing approaches and which serve a social purpose and work for the public good. Simply put, they are innovations that work for solving social problems. Many initiatives can be seen in care giving, such as the integration of social and medical care, the “hospital in a home” initiative, etc. Home care giving is another area where innovations have been introduced or improved upon. Variants of the well-known PACE model have been adopted by some countries, sometimes dubbed PACE-minus with more limited service provision. Innovative practices have also been initiated to encourage more meaningful participation such as the GoodLife Makan, a community kitchen in Singapore to engage older persons and alleviate social isolation. In Japan, many innovative practices for community-based care, retirement communities, and elderly care centres are being implemented. For example, the pioneering “Dream of Mizuumi Centre” in Japan is a model where the elderly in the day care centre can take charge of their own activities, combining rehabilitation, independence and choice, and motivational rewards. There are also good examples in Japan of intergenerational colocation and interaction of eldercare and childcare facilities. Men’s sheds in Australia are proving to be successful in engaging older men in communal activities.

5.11. AGEISM A barrier to active and productive ageing is ageism, first defined as prejudice and discrimination against older persons (Butler 1969). Ageing is a combination of prejudicial attitudes, discriminatory

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practices, and institutional practices and policies that stereotype older persons. A more nuanced definition was proposed where “ageism is defined as a negative or positive stereotype, prejudice and or discrimination against (or to the advantage of) an elder person on the basis of their chronological age or on the basis of a perception of them as being ‘old’ or ‘elderly’” (Iversen et al. 2009). In the context of Asia, this enhanced definition covers the cultural respect for age, although it is generally recognised that ageing often has negative connotations. Ageism is a widely prevalent, pervasive, and prejudicial attitude stemming from the assumption that age discrimination and sometimes neglect and abuse of older persons is a social norm and thus acceptable. It is often expressed in individuals, attitudes, institutions, and policy approaches as well as media presentations that devalue and exclude older persons. They are negative stereotypes and misconceptions and often include cultural and media presentations of older persons. It also affects the framing and stereotyping by society towards older persons and influences policies. Ageism is especially significant as a barrier to employment and productive ageing, and to health care and healthy ageing. In the sector of employment, mandatory retirement age and the reluctance of employers to employ older workers can be perceived to be discriminatory. Furthermore, this is more evident in recent understandings of the ageing process which should be focused on capabilities and functional capacity. Ageism can be combatted through various measures. Foremost among these is the rights-based approach whereby ageism is recognised as an infringement of the human rights of older persons. These rights would cover discrimination and multiple discriminations such as intersection of age and gender; right to social protection, and the right to social security; ageism and social exclusion, and particularly relevant to productive ageing, the right to work, age discrimination, and access to employment. Currently, very few countries have legal protection for older persons against abuse in different settings (especially homes and institutions) and upholding their rights, although there is an increasing trend of

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countries enacting such legal protection. For example, Singapore has enacted legislation for vulnerable persons, covering the elderly and disabled. Very few existing international human rights instruments make specific reference to older persons. In this regard, the ongoing process towards a Convention for the Rights of Older Persons would be useful in securing vital rights for older persons. The Global Sustainable Development Goals promise to be a useful platform for action, especially SDG 3 which endeavours to “ensure healthy lives and promote well-being for all at all ages” (UNDP 2016). At the regional level, there has been some encouraging developments. The Council of Europe has adopted non-binding recommendations on the rights of older persons (2012), the Organization of American States has adopted an Inter-American Convention on Protecting the Human Rights of Older Persons (2015), and the African Union has a protocol to the African Charter on Human and Peoples’ Rights concerning the rights of older persons in Africa. In Asia, human rights frameworks need to be enhanced, building upon political commitments like ASEAN’s “2015 Kuala Lumpur Declaration on Ageing: Empowering Older Persons in ASEAN”. The Asian Forum of Parliamentarians for Population Development has active ageing as one of its priority pillars and can play a useful role in fostering and rallying political will. Action taken to address discrimination on the basis of race (racism) and gender (sexism) especially in the institutionalisation of policies can serve as models which can be learned and emulated to confront and combat ageism.

5.12.  CHANGING MINDSETS Of particular importance to combat ageism is the need to bring about a change in mindsets, especially from the imprinted image of inactive older persons of a bygone generation. Measures undertaken include consciousness raising, changing images of ageing, promoting a positive image of ageing and older persons, creating positive cul-

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tural and media presentations of older persons, and changing the perception of older persons as contributors, not burdens. Activities often cover commemorative events especially International Day of Older Persons, presenting awards to senior citizens and related personnel, and inter-generational activities to bridge the divide among generations. Many countries have age identifiers for privileges and concessionary arrangements for older persons such as discounted prices for goods and services, priority services for health care, transportation, housing, etc. In Singapore, the Pioneer Generation Package was initiated in 2015 to recognise the contribution of the older generation towards nation building. This package consisting essentially of medical subsidies is solely premised upon age, with eligibility limited to those born on or before 1949. A card to avail of privileges has been issued to all citizens aged 60 and above. The media can play an important role in changing images and expectations. For example, heart-warming media productions on respecting the elderly, with videos from several countries such as India, Malaysia, Singapore, and Thailand have been widely disseminated. A very promising initiative is the adoption by the World Health Assembly in May 2016 of the Global Strategy and Action Plan on Ageing and Health which called for a Global Campaign to combat ageism by solidifying commitment of countries and the world.

5.13.  MEASUREMENT AND MONITORING It is generally acknowledged that quantification and measurement is important for implementation. In this regard, effort has been made to measure active ageing. In Asia, after the issuance of the WHO active ageing publication in 2002, researchers from Thailand in 2006 sought to quantify active ageing in accordance with the three pillars of health, participation, and security, using 15 indicators (Haque 2016). This also subsequently gave rise to other efforts at the national level such as a Singapore study which sought to measure active ageing along the lines of the Thai study. The regional

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Shanghai Implementation Strategy was the focus of a set of indicators developed for the Asia-Pacific Region covering the key areas identified in the Madrid Plan of Ageing and the subsequent regional Plan for Asia and the Pacific (UNESCAP 2003). At the global level, the Global Age Watch Index provided a tool to compare indicators around the world, with countries ranked according to income security, health status, capability, and enabling environment. In 2015, out of 96 countries covered in the Index, Japan (ranked 8th) was the only Asian country in the top ten countries, although data gaps precluded the ranking of countries like Singapore (HelpAge 2015). The most recent initiative to measure active ageing is the Active Ageing Index (AAI) of the European Commission and the United Nations Economic Commission for Europe. The AAI is a composite index which comprises 22 indicators across four domains — employment, participation in society, independent, healthy and secure living, and capacity and enabling environment for active ageing. This analytical tool has been used to compute AAI for the 27 EU Member States and is expected to be used to monitor trends in the EU countries. The AAI can serve as a model for other regions and also as a global index with further refinement and adaptation. Another complementary tool is the WHO’s “Measuring the Age-Friendliness of Cities — A Guide to using Core indicators”. This tool has core indicators which focus on equity measures and agefriendly environmental outcomes from accessible physical environments and inclusive social environments (WHO 2015). The National Transfer Accounts project initiated by the University of Hawaii providing estimates of labour income, asset income, public and private transfers, and consumption and savings by age can provide useful insights for policies throughout the lifecycle to respond to population ageing. It is thus important to have improved collection, analysis, and reporting of age-disaggregated data to better understand the experiences, evolving needs, and contributions of people as they age, as well as evidence-based interventions that empower older persons

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and uphold their rights. The use of big data and analytics would be useful in providing deeper insights into key issues. Countries in Asia have strived for active and productive ageing with varying degrees of intensity, range, and success. The level of success can be seen to be associated to the levels of ageing with those with aged populations faring better. These countries, Japan, Republic of Korea, Singapore, Hong Kong, Taiwan, also fortunately have the luxury of affluence to meet the challenges. These countries with ageing populations have a vast array of programmes which can be financed as they have the resources to do so. Some have pointed out that the active ageing programmes of these countries fall short of meeting the criteria for holistic active ageing as they are often only utilitarian, focusing solely on employment and health-seeking behaviour to save on health financing and old age pension and income support. An organizing principle of active ageing categorised into productivist vs. comprehensive has been analyzed by Moulaert and Paris. In the productivist approach, active ageing is mainly focused on work and employment as a response to under employment of older workers. The comprehensive approach calls for participation and involvement of the community to develop policy and government action plans guided by the WHO Age-friendly Cities and Communities framework. The analysis points to the shortcoming of both approaches with a call for further research, which can encompass a more inclusive framework of active ageing (Moulaert and Paris 2013). Active ageing programmes in Asian countries can be categorised into three typologies (Eden Strategy Institute 2014). The first is a very limited one, focused on increasing productivity such as health promotion programmes to increase healthy life expectancy to enable longer working hours. Another set of programmes are multi-faceted and would endeavour to include other activities especially environmental factors. A third typology would be in line with the holistic concept propounded in the active ageing concept of WHO in 2002 and further refined to include life-long learning and

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to broaden the health aspects to embrace WHO’s approach to Healthy Ageing. Alan Walker (2015) has suggested an ideal-type classification of “The Four Worlds of Active Ageing”. These are: • First, a world where governments do not actively support the concept of active ageing (or follow a similar strategy/support a narrow interpretation of active ageing). • Second, a world of active ageing where governments support a broad concept of active ageing but fail to implement it. • Third, a world of active ageing where governments support a broad concept of active ageing (or follow a similar strategy) and, to some extent, successfully implement it. • Fourth, a world of active ageing where governments support a broad concept of active ageing (or follow a similar strategy) and successfully implement it. In the Blue Zones, where high concentrations of centenarians reside, researchers have identified an inter-connected web of factors for their longevity — physical activity, outlooks (purpose, downshift), healthy diet, belonging (social network, religion, family).

5.14.  FUTURE ACTION Countries in Asia have to prepare to meet the challenges of ageing populations and the reality of longevity through a range of measures determined by the level of ageing, the level of development, political economy, culture, and tradition. It is therefore, necessary to analyze the ageing situation in countries individually and to then prioritise solutions and policy measures that would be tailored to the prevailing situation. Action should be taken to: • Link all relevant sectors for a whole-of-government and multisectoral holistic approach.

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• Intensify age-appropriate health-seeking behaviours and behaviour modification measures. • Adapt health systems to the changing epidemiological landscape. • Promote active ageing as preventive long-term care. • Intensify measures for age-friendly environments, guided by resources such as those provided by the World Health Organization • Leverage on, adopt, and adapt new developments and innovations — technological, social, (including the Internet of Things, sharing/gig economy). • Embrace cultural, traditional and, kinship bonds such as filial piety, community-based collective approaches, and social piety where applicable. • Remove barriers and future-proof the challenges of ageing through rights-based legislation and institutional measures to remove ageism and discrimination, and prevent violence/elder abuse. • Change mindsets so that older persons are recognised and acknowledged as contributors and not burdens to society, especially with media and messaging, and the WHO Global Campaign to combat ageism. • Constantly monitor and measure progress, with appropriate tools and methodology including big data and analytics. In summary, the key elements of active and productive ageing would be measures that are holistic, reinforced by technical and social innovation, using the strengths of culture and the realisation of the rights of older persons, through a whole of government and whole of society approach, involving the active role of self, family, community, and the government.

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CHAPTER 6

SOCIAL–CULTURAL ASPECTS: FAMILY AND FILIAL SUPPORT Thang Leng Leng

6.1. INTRODUCTION Policies on the well-being of older persons are universal in their efforts to ensure that individuals are able to age with security and dignity. Implicit in this focus is the concern that without adequate protection to maintain their daily living and rights, older persons who turn frail and could no longer stay employed will be in fear of becoming indigent persons faced with social isolation and neglect. The treatment of the old, though, is said to differ depending on the state of societal development. As what the romanticised “golden age model” belief states, in the “more labor-intensive cultures, old people play more significant roles, that older people are always better valued in stable, pre-literate or primitive societies, and that only in westernised or modernised cultures are they poorly treated” (Eisdorfer 1981, p. xv). The conceptualisation of the relationship between modernisation and the status of the older persons is most commonly represented through the inverse relationship framework first proposed by Cowgill and Holmes (1972) in Modernization and Aging. If the non-westernised cultures are known for its emphasis in the veneration and support of the old, can the inverse relationship between 177

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modernisation and ageing be applied to Asia? Using the case of the most modernised society in Asia at that time, Plath (1972)’s chapter in the same volume gives support to Cowgill and Holmes’ thesis with his somewhat gloomy picture on the status of the old in modernised Japan. This soon led to a rebuttal represented by Palmore (1975, 1985) who in contrast perceives Japan as an exception to the framework, citing the examples of public efforts to promote respect, such as the silver seat on public transport, and the annual Respect of Elders Day as evidence that older Japanese continue to enjoy high status and integration despite modernisation (see Thang 2000). Scholars supporting Palmore’s view also point to modernization and economic advancement as positive attributes making available more resources to maintain the higher status of older persons; and the rapid increase in life expectancy is cited as one positive indicator of the availability of a comprehensive level of welfare in Japan (Nakagawa 1979). But for those who countered the rosy pictures of honourable elders well venerated within the family and the community, public efforts are only to be noted as a representation of an ideal perception of old age in Japan (Koyano 1989). Tobin (1987) even suggests this as the American idealisation of old age in Japan, reflecting more accurately the Americans’ own ambivalence about inter-generational dependence. More than three decades since the initial proposal of Cowgill and Holmes’ thesis, rapid modernisation and social-economic-cultural changes have largely transformed the social landscape of Asia. It is apt to refer to modernisation experienced in Asia over a short period of time as “compressed modernity”, a concept initiated by Chang (2010a) through his close examination of the developments in South Korean modernisation. He defines “compressed modernity” as “a social situation in which economic, political, social and/ or cultural changes occur in an extremely condensed manner with respect to both time and space, and in which the dynamic coexistence of mutually disparate historical and social elements leads to the construction and reconstruction of a highly complex and fluid

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social system” (Chang 2010b, 24). Today, it is typical for writings on ageing in Asia to begin with statements that alluded to the impact of rapid modernisation on the current lower status and problems facing older persons. Instances of elder abuse and neglect in Asian societies occasionally appearing on the news and social media further cause alarm on the decline in moral responsibilities among the young. The increase in the incidences of kodokushi (lone death) in Japan where older persons died in isolation only to be discovered days or even years later is one stark reality of the social disintegration of older persons with the family and community (Danely 2014). Nonetheless, contemporary Asian societies still widely regard children to have the moral obligation to care and support for their ageing parents. Although the incidence of coresidence shows some decline, it still generally remains quite high in Western society standards (Chan 2005; Frankenberg et al. 2002; Ogawa et al. 2006). This remains so for the more economically developed Confucianinfluenced East Asian societies as well which were among the earlier ones in Asia to experience “compressed modernity” (Ikels 2004). In contrast to Chang’s (2010) suggestion that “individuation without individualism” has occurred under such rapid changes, Ochiai maintains that family support still matters and proposes the concept of “familialistic individualisation”, giving evidence of the predominance of familialism1 over individualism in attitudes towards family seen in results of the East Asia Social Survey (EASS) 2006 (Ochiai 2014: 214). This is of course not to assume that the same perceived sense of duty does not exist among Western families, but compared with the more individualistic-oriented values known to characterise the West, ideologies such as “filial piety” and familialism/familism principles regarded to be the essence of Asian culture are said to lay 1

 Esping-Anderson defines “familialism” as the idea where the family should take the greatest welfare responsibility towards its members in both income distribution and care provision, noting that until the 1960s, most welfare states held familialism ideals (2009:80)

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not only the foundation of the family, but also state policies on aged care across Asian societies (Croll 2008). Taking the example of Japan again, although there was a brief period of inclination towards the Western welfare state as exemplified in the 1973 policy to implement free medical and hospital care for nearly all persons who are 70 years and older, the government soon reverted its direction by 1979. To prevent an expanding burden on welfare cost, the ruling Liberal Democratic Party (LDP) instead advocated for a “Japanese-style welfare society” model which essentially means reduced benefits and a return to reliance on the family and the community, drawing on the ideas of the strength of the “traditional Japanese family” as a form of justification (Campbell 1984; Goodman 1998). Even when new health-care system came into being later, such as the 1989 Gold Plan promising a shift from care by the families to society, and the 2000 long-term care insurance said to be a relief for women from their expected role as caregivers for older persons at home — now that care could be purchased with the insurance, insufficient nursing care institutions and hence constrains placed on the eligibility to receive care to those with greater needs have led to the continual reliance on the family. In this chapter, sets in the volume on comparative policies for older persons in Asia, I focus on comparing policies relating to filial support, with the premise that the emphasis on the family and filial responsibility is salient in our understanding of how the socialcultural aspects underscore policies for older persons in Asia. Referring to Ochiai and Chang’s insights on Asian modernisation, my intention is to explore how cultural ideals of filial responsibility in the form of filial piety and similar family-centric ideas continue to permeate in modernised Asian societies and proactively promoted in policies. With the vastness and diversity of Asia, this chapter has limited its focus more on countries where available literature is obtained. By focusing on policies to encourage filial support, I include discussions on relevant filial responsibility law in place in some Asian countries compelling the children to maintain their parents. Certainly, the legal duty to legislate the moral obligation of care for older parents did not originate in Asia; one best-known law

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is probably the 1601 Poor Law of Elizabethan England obligating the children to support their own parents (Chan 2004). The 1601 Law also sets the basis of filial support statutes that exists in slightly over half of the U.S. states today, although it was said to have once existed in as many as 45 U.S. states (Pearson 2012). For many Western countries, improved public welfare support for older persons constitute the main reasons for the lack of filial support laws. The 1601 Poor Law was abolished when England introduced the state welfare by The National Assistance Act in 1948 (Chan 2004: 549), for the U.S., filial support status was repealed in many states when Medicaid came into existence to provide relief for the poor (Pearson 2012: 3). Noting that there is “a global trend away from the enactment and enforcement of filial responsibility laws”2 (Chan 2004: 549), it appears paradoxical that in contemporary Asia, while the demographic pressure, changes in family structures and other social-economic challenges have weakened the family’s capacity to perform filial responsibilities, the Asian governments are instead turning more to the family, moving increasingly towards the promoting of the continuity of filial piety and familialistic responsibility as an ideology and strategy for elderly care provision (Croll 2008). No doubt, turning to rely on the private sphere of the family may be a culturally accepted and cost-effective strategy — provided that the family is still around and in good function, at the same time, more government efforts are in need to address not only the well-being of the older persons, but also that of the families under stress. In the next section, a discussion of the policies in some Asian societies that aim at promoting familial support of the old will be presented, followed by an exploration of the laws relating to filial responsibility in some Asian societies. What are some differences that may characterise the law with similar objective in different societies? How has the juxtaposition of cultural ideals with social realities and the law highlighted the complexities of promoting filial piety and the inter-generational care of the old? 2

 However, most recently in the U.S., concerns are surfacing on the recent use of filial support laws as a collection tool for costly long-term care institutional expenses claiming against adult children in retroactive “support” (Pearson, 2012).

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6.2.  POLICIES TO PROMOTE FILIAL SUPPORT Compared with Western societies, which many had journeyed through the developmental phases of becoming wealthy before turning grey, and thus have more resources in relieving the family from taking sole welfare responsibility of its members; the Asian governments are more likely to worry that they will turn grey before becoming wealthy. Hence, it becomes pertinent that filial support — underlined in the form of filial piety or other related religious and/ or cultural-social notions — continues to remain strong and to be perceived as the most desirable form of support not only by the governments, but more so by the families. Many local terms abound capturing the essence of filial support, such as “xiao” (filial piety in Confucian-influenced cultures, “utang na loob” (debt of gratitude) in Tagalog, “menhormati ibu bapa” (respect one’s parents) in Malay and “mabaapkisevakarna” (serving your parents) in Hindi language. It is common for studies to affirm the presence of filial support in Asian families. At the same time, they recognise the challenges facing population ageing in modernisation and globalisation, such as the strains on the capacity of the young to care for their older members due to the competition for their limited resources and time, the lack of caregivers as labour force participation of women rises, and adult children’s migration from rural to urban areas, and even overseas (Ofstedal et al. 1999; Torres and Samson 2014). 6.2.1.  Financial Subsidy as Public Filial Expression Of the key areas of concerns in the development of national policy of ageing in line with the Madrid International Plan of Action on Aging 2002, social/income security in old age is fundamental in ensuring that the basic needs of older persons are met. Very few Asian governments adopt universal direct financial assistance. In 2009, Thailand introduces universal old age cash payout in the form of the 500 baht universal pension scheme for persons 60 years and above, which has been revised since 2012 to increase the amount slightly and providing a higher amount depending on age

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(Suwanrada 2012). Another example is Hong Kong, which similarly provides universal old age allowance commonly called “fruit money” due to its meagre subsidy to all persons who are age 70 years and above (as well as age 65–69 with income cap). Old age allowance was introduced by the Hong Kong government since 1973 with the idea of performing “filial piety” to appreciate the contributions of older persons in general to Hong Kong society, although for poor seniors, it is regarded as an important form of financial means to support their daily living.3 During the global economic crisis in 2008, when the then Hong Kong Chief Executive Donald Tseng proposed to increase the amount of old age allowance from HKD625 to HKD1000, but restrict recipients through means-testing, the proposal was soon shelved with strong objections from older persons who regarded means-testing as insulting to them because the small sum allowance is perceived to function as a show of respect for elderly (South China Morning Post 2008; Yeung 2013). In Singapore, cash payout to older persons was among the considerations when the government was conducting consultations on the Pioneer Generation Package to be announced in 2015, on the 50th anniversary of the nation’s independence. Finally, the package formulated focuses on helping to finance health-care costs for life without direct cash payout. The package was given without means-testing to Singaporeans who were 65 years and above in 2015 (about 450,000 in total). Similar to the objective of Hong Kong’s old age allowance, the Pioneer Generation Package was introduced to show appreciation to older persons as the nation’s pioneers.4 When referring to the 3

 The current amount is HKD1235 according to the information on website. Old age allowance is divided into Normal Old Age Allowance for those 65-69 years old with proof of income cap eligibility and 70 years and above without need for financial proof. Refer to legal information website for seniors in Hong Kong. Available at http://www.s100.hk/en/topics/Work-and-retirement/Social-Welfare-for-theElderly/Old-Age-Allowance-fruit-money/ (accessed on 20 April 2016). 4  Refer to pioneer generation package website available at https://www.pioneers. sg/en-sg/Pages/Home.aspx (accessed 21 April 2016).

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government’s intention to introduce the Pioneer Generation Package, Minister Chan Chun Sing commented in the occasion of an international conference on Confucius studies that the deeper meaning of the government’s effort is to promote filial piety, hoping that the younger generation will honor the old who have contributed to the prosperity of the nation, and “such a spirit cannot be measured by money” (Lianhe Zaobao 2014). Amidst the lament that filial piety is weakening in the Confuciusinfluenced societies, some governments have taken on more proactive roles in reinforcing and promoting the value of filial piety. In 2012, the Chinese government introduced a new official version of the “24 Paragons of Filial Piety” as guideline to the younger generation in practicing filial piety after a two-year process gathering the opinions of older Chinese (Jacobs and Century 2012). The new filial piety guideline is fairly comprehensive on things to do with/for parents to keep them happy, such as to go home more often, phone them to talk, teach them how to surf the internet, express your love to them, take pictures with them, bring them for regular health check-ups and of course provide them with adequate allowance to spend.5 Intended as a guideline, it has led to much debate and criticisms from the public, which highlighted the practical difficulties of carrying out such filial expectations in today’s stresses in making a livelihood. As practical tips for interacting with one’s older parents, the guideline resonates with popular books published in Japan on practicing filial piety (oyakoko) , such as “55 things to do with your parents before they pass on” published by the Filial piety executive committee (2010). In Singapore, government efforts to reinforce the governing value of filial piety in inter-generational relationships has been consistent, with efforts ranging from publicity campaigns such as the 2010 Thinkfamily campaign by the former Ministry of Community Development, Youth and Sports, promoting awareness 5

 For the guideline, see http://fj.people.com.cn/BIG5/339045/340948/344015/ index.html and Jacobs, Andres and Century Adam, As China Ages, Beijing Turns to Morality Tales to Spur Filial Devotion, New York Times, Sept 5, 2012.

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of filial piety through a series of short films, to policies and law that will be later discussed. Filial responsibility is one of the five core family values promoted as important for the well-being of families and underpin the progress of the nation in Singapore (Tambyah and Tan 2013); survey findings have shown public endorsements of these values, although there are questions as to why homeless older persons could still be seen when the survey shows strong filial responsibilities.6 The government of South Korea has promoted filial piety as a model of loyalty to the state in the 1960s and 70s. Although receiving criticisms that it is an anti-democratic tradition, filial piety has at the same time continues to receive support in the society in the recent times, including active promotion of filial piety by educational organisations, such as the setting up of a Graduate School of Filial Piety in Songsan University, and Filial Piety Cultural Center in Suwon city (Janelli and Yim 2004: 144–145). In all Asian societies, some form of cash relief in the form of public assistance or more targeted assistance for old age7 exist to provide for the basic livelihood of impoverished elderly. They most often come with strict criteria requiring the exhaustion of all forms of financial means, including support from family members before one is eligible to apply, hence serving the function of a “last resort safety net” (MHLW 2015: 353). In Japan, households with persons 65 years and over make up 49.1% of households receiving public assistance in 2015, an increase of almost 300,000 households when compared with 2007 (MHLW 2015: 354). Governments are often concerned with containing spending on 6

 See for example the interview article with a member of the National Family Council about Singapore Family Values published on the website of The New Age Parent (http://thenewageparents.com) focusing mainly on young parents in Singapore. 7  Examples of old age-focused safety net programmes include old-age allowance in Bangladesh (http://siteresources.worldbank.org/BANGLADESHEXTN/Resources/ 295759-1240185591585/BangladeshSocialSafetyNets.pdf), Old-Age Living Allowance introduced in Hong Kong in 2013 providing HKD2390 per month for those age 65 and above who passed means-testing (http://www.swd.gov.hk/oala/index_e.html).

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social safety net programs, Japan, for example, has since 2014 revised the scope of public assistance system to include funding to promote employment and health maintenance with the objective of promoting the capacity of self-reliance of the recipients (ibid., 355). 6.2.2.  Tax Reduction for Providing Filial Support The parent relief/handicapped parent relief provided to working adults, as stated in the website of the Income Revenue Authority of Singapore, has the purposes to promote “filial piety and recognise individuals who are supporting their parents, grandparents, parents-in-law or grandparents-in-law in Singapore.”8 Singapore has come a long way in providing tax relief to working adults for the support of their dependent parents, and over time has expanded coverage to include parents not living together, in-laws, grandparents, and great-grandparents. The amount of relief given is differentiated, in 2015, the tax relief is SGD9000 for dependent older adults (at least 55 years and above) living together, and SGD5500 when living separately, and when the parent/grandparent is handicapped, the relief is increased to SGD14000 living together and SGD10000 when living separately. Only a maximum of two relief could be claimed. The vertical and horizontal extension of the definition of “parent” in this regard to include in-laws, grand, and great-grandparents, and to provide higher relief to those living together is not uncommon in tax relief in Asian societies. It suggests the context of expectations on family care when living together, and family as beyond the nuclear family composition in Asian cultures. In Hong Kong, individuals could similarly claim under “Dependent Parent and Dependent Grandparent Allowance”, and also entitled to “Additional Dependent Parent and Grandparent Allowance” if the dependent parent/grandparent reside with the taxpayer throughout 8

 https://www.iras.gov.sg/irashome/Individuals/Locals/Working-Out-Your-Taxes/ Deductions-for-Individuals/Parent-Relief-/-Handicapped-Parent-Relief/.

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the whole year without paying full cost.9 Japan’s tax relief similarly provides higher allowance (580,000 yen) for the same scope under the category of elderly (age 70 and above) qualified dependents living together. This category falls within the “exemption for dependents” which also has other categories that include “relatives”, defined as “relatives within the sixth degree of consanguinity and relatives by marriage within the third degrees of affinity”.10 Both Japan and Hong Kong only grant tax allowance/exemption of a dependent to one taxpayer. From 2015, Singapore income tax law has revised to allow sharing of the Parent Relief/Handicapped Parent Relief with other claimants. The “sharing of parent relief” reflects and at the same time hope to encourage the children to share in maintaining their parents even if they are not living together. This hopefully relieves some financial burden of the main caregiver adult child. In Hong Kong, there is also provision for a taxpayer paying for a parent or grandparent’s elderly residential care expenses to claim for up to HKD80,000 for tax deduction.11 In contrast, in the Philippines where the Family Code states that “the family has the duty to care for its elderly members”, it was only proposed in 2013 to include parents as dependents qualify for tax deduction.12 In Malaysia, tax relief for filial support is a new provision only provided from 2016, allowing the children to claim for the first time for their parents who are age 60 or older. There is also income restriction like the other societies, and like Singapore, the relief can be shared with other siblings within the limit of the total relief claim for a mother and a father (MYR 1,500 each). This sug9

 For each dependent in dependent parent and dependent grandparent allowance or additional dependent parent and grandparent allowance, the 2015/2016 amount is HKD40,000 (if age 60 or above or is eligible to claim an allowance under the Government’s Disability Allowance Scheme) or HKD20,000 if 55–59 years old. See http//www.ird.gov.hk. 10  2011 income tax guide for foreigners http://www.nta.go.jp/tetsuzuki/shinkoku/ shotoku/tebiki2011/pdf/43.pdf. 11   Deduction for elderly residential care expenses. http://www.gov.hk/en/ residents/taxes/salaries/allowances/deductions/elderly.htm. 12  https://www.senate.gov.ph/lisdata/1611813345!.pdf.

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gests the common scenario of joint caring, especially so for Malay families which tend to have more children. Although the tax relief for filial support only came into existence very recently, the Malaysia tax system already has provisions allowing taxpayers to claim up to RM5000 on the medical expenses of their own parents, a practical relief since medical expenses are the most likely expenditure for older persons. To avoid double claims, the new tax relief could only be claimed by the taxpayer when he does not claim medical expenses incurred by their parents.13 6.2.3.  Housing and other Policy Measures to Promote Family Care of Older Persons Apart from tax concessions and allowances to provide financial support to children who care for their older family members, policies in Asia are also resourceful in encouraging opportunities for eldercare by the family through housing policy and other means. In Japan, policy measures for housing older persons started as early as 1964, besides silver housing especially for older persons, there are also purpose-built larger units for those living with family in public housing design, and other benefits to support family living together or close by, such as priority allocation and preferential interest rates for housing loans. Paired units, in which a standard unit for the nuclear family is located next door or on different levels of the complex were also available to promote close proximity living. The Japan Housing Corporation (later changed to be called Housing and Urban Development Corporation) started the “paired units” system in 1972, but abandoned the scheme two years later because it was unpopular due to “higher rental costs, stricter contract terms and potential difficulties when moving out after the death of the old family member(s).” (Kose and Nakaohji 1988). However, the idea is still much alive in today’s new multigenerational housing concept in Japan represented by the so-called two-generation housing. Such 13

 The new relief is planned to be effective from 1 January, 2016 to 31 December, 2020. See http://www.themalaymailonline.com/malaysia/article/budget-2016middle-class-get-tax-reliefs.

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housing concept promoted by the private housing market helps a three-generation family to build or rebuild from the land of the existing old house a house that is essentially separated in entrance and living spaces affording independent living for both the older persons and the nuclear family (Brown, 2002). The Hong Kong Housing Authority, too, have introduced the Harmonious Families Priority Scheme offering priority to public rental housing to those living together or close by, thereby encouraging care of the old by young family members. With 80% of its population living in public housing, the Singapore government is probably among the most proactive in encouraging extended families to live with or nearby through priority housing schemes and housing grants. If the married children wish to purchase a new flat either living with or near their parents (defined as living in the same town/estate, or within 2 km of each other), they will enjoy priority through Married Child Priority Scheme. When both parents and married children wish to buy their own new flats, they can jointly apply through the Multi-Generation Priority Scheme. Older persons intending to purchase studio apartments especially catered for persons 55 years and above will also receive priority buying it near their married children or their existing home. Since 2013, the Ministry of National Development (MND) has also introduced three-generation (3Gen) flats bigger in size (115 m2) with four bedrooms and three bathrooms (two ensuites) for the nuclear family to include their older parents. It was three times oversubscribed when the first batch of 56 units was offered in end 2014 . It is, however, to be noted that design attempts to provide for three generation family living is not new, in 1987, HDB had attempted the “multi-generational flats” pilot scheme including a studio-apartment adjoined to a four or five room flat (three bedrooms) similar to the paired units in Japan, but did not continue due to poor take up rate. As the Director of estate administration and property department at HDB commented on why these multigenerational units stopped building after about 400 units of them were built. “We found that many buyers did not want to house their parents. They just wanted a bigger flat.” (Tan 2009).

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There are also various CPF (Central Provident Fund) housing grants available with higher amount for first-time families. The preference in these priority schemes and grants to married couples have raised criticisms on fairness as many unmarried children are also providing care and support to their aged parents. In response, higher housing grant also became available for first-time singles purchasing a resale flat to live with their parents. In 2015, MND and HDB (Housing Development Board) introduced a new Proximity Housing Grant where families buying resale flat to live with or near their parents or married child will be able to receive the additional grant, also available for singles buying a resale flat with their parents. Such housing policies play important role in encouraging mutual care and support, and keep families to live in close proximity if not living together. The 2013 Sample Household Survey with about 8,000 HDB households have found slight increase in younger married couples living with or close to their parents (from 35.5% in 2008 to 36.7% in 2013), as well as increase in older persons living with their married children (from 14.3% in 2008 to 19.1% in 2013). In the survey, there is consistent high frequency of visits between children and parents (90% visited each other at least once a month), where those who live in close proximity reporting higher frequency. It should be noted that in housing policies to encourage closer extended family ties, older persons are not necessarily regarded as needing help. With the norm for dual working couples in Singapore, it is common for older parents to assume the role of caregivers for grandchildren while their adult children are at work. This constitutes the background of the Grandparent Caregiver Relief where working mothers are eligible to claim when their parents, grandparents, parents-in-law or grandparents-in-laws help to take care of their children. As with the global trend on caregiving, most family caregivers are female in Asian societies, mostly wives, daughters, and daughters-in-laws. In Singapore, as well as in Hong Kong, Taiwan, and Malaysia, the policy allowing families to employ live-in domestic help/caregivers usually from fellow Southeast Asia and South Asian countries has enabled women to remain in the workforce, as the

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domestic helpers tend to domestic chores of housekeeping, childcare and eldercare. In Singapore, the Foreign Maid Scheme was introduced in 1978, with the main aim of facilitating women’s continued employment, only working women who are married or separated, divorced, and widowed are able to claim Foreign Maid Levy Relief in tax filing. To cater to those who need to hire a foreigner domestic helperto meet care needs, a Foreign Domestic Worker Grant is further introduced for the care of frail elderly and persons with at least moderate disability.14 To keep the employment of helpers only for families who have care needs, the state also provides concessionary levy fees for famililes that have children or grandchildren below 12 years old; or older persons above 65 years old. From 15 September, 2007, the FDW levy concession was extended to FDW’s employers with disability or who have family members with disability and require a full-time caregiver’s assistance in Activities of Daily Living (ibid.). The presence of foreign domestic helpers serving as in-home caregivers is often regarded as an essential strategy allowing for the care of frail older persons at home (Mehta and Thang, 2008). In addition, policies in Japan and other Asian societies to provide for old age pension and social security, to promote long-term care at home, such as tax benefits for the purchase and rental of medical products at home, and subsidies for medical care are also ways helpful to reduce the family burden of eldercare costs (Ting and Woo 2009).

6.3.  LEGAL REGULATION ON FILIAL RESPONSIBILITY As earlier mentioned, legislation obligating adult children to provide for their older parents (or sometimes other family members) are present not only in Asian societies, but also beyond, such as the United States (in 29 states and Puerto Rico), Ukraine, Canada and 14

 See Ministry of Health website for more details. (https://www.moh.gov.sg/content/ moh_web/home/pressRoom/Parliamentary_QA/2016/grant-to-help-families-hireforeign-domestic-workers-to-care-for.html)

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Israel (Pearson, 2012; Ting and Woo, 2009). In Asia, it is varyingly passed as the Maintenance of Parents Act (1995) in Singapore, Maintenance and Welfare of Parents and Senior Citizens Act (2007) in India, placed as elderly rights (e.g. Sri Lanka’s Protection of the Rights of Elders Act (2000)), marriage responsibility, within Family Code (the Philippines) and Civil Code (Taiwan).15 In China, the stipulations to support parents can be found in different laws such as Marriage Law (1950) stating that children should support elderly parents. In the 2001 amendment exacting reciprocity where “Parents shall be under the obligation for the upbringing and educating of their children, and children are also under obligation to support their parents… where any child fails to perform his or her obligations, parents who are unable to work or who are living a difficult life shall be entitled to ask their child to pay aliments (funds necessary to support basic housing and nourishment) (cf. Giles and Mu 2007: 266). The Constitution (1954) also emphasises that children have a duty to support parents (ibid.), similarly, the Law on Protecting the Rights and Interests of Older Persons states the general principals where family members have the duty to take care of their aged parents, including giving financial and emotional support (Ting and Woo 2009: 73). Whether in or outside Asia, filial responsibility law is rarely invoked since Western societies have available generous welfare provisions; in Asian societies where older persons are comparatively less well provided by the state, the notion of “shame” could have pressured the children into conforming, as well as deterring older persons from admitting to their needs (Casey 2008). As filial responsibility law provision is usually very general, some are doubtful if they are effective in protecting the rights of the older parents (Ting and Woo 2009: 73). Perhaps the main objective of such a law is not meant for the parents to start suing their children, but more to serve as a deterrent to remind the children of the need to fulfil their filial responsibility. 15

 See Chen (2015) for comparison of the legal protection of aged parents and inheritance laws in Singapore, India and Taiwan.

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In the discussion below, Singapore’s Maintenance for Parents Act (MPA) will form the basis of comparison with the law in other societies,16 especially India and China (see Table 6.1). India’s Maintenance and Welfare of Parents and Senior Citizens Act (MWPSA) were enacted quite recently in 2007, before this new Act, the Hindu Adoptions, and Maintenance Act (1956) is already in place recognizing that children have the duty to maintain their aged parents, and the parents have the right to maintenance. Under the 1973 Criminal Procedure Code Section 125, parents are able to bring the children to court if they are not provided maintenance. However, such cases are rare, besides the love for their children and fear of stigma, the legal proceedings are often too time consuming and financial draining (HelpAge India17 ). The MWPSA is thus welcomed for providing a simpler and faster means to ensure that older persons get the maintenance they really need (ibid.) The MWPSA bears similarity with MPA, both have in place the system of maintenance tribunals to hear cases, removing the existing judicial system from these actions (Chan 2004). The merit in adopting a tribunal system is that it is not bound by “strict rules of evidence and is able to adopt mediation, rather than adversarial proceedings, as the primary means to resolve the family conflict (ibid. p. 549). The 2011 amendments to MPA places further emphasis on mediation and mending family relationships, requiring that mandatory conciliation at the Commissioner’s Office must first be attempted by the parents before they can file an application to the tribunal. Such a new requirement has led to a decline in legal action taken by the parents with a drop in the number of applications for maintenance (from 199 applications in 2009 to 55 in 2014). The cases that the Commissioner had to deal with increase though, from 17 cases in 2009, to 213 in 2014, showing the success of settlement through conciliation (Lee, 2015).

16

 See Chan (2004) for a comprehensive discussion of the Maintenance of Parent Law in Singapore. 17  http://www.helpageindiaprogramme.org/other/Brochures/Senior_Citizen_ Act_Summary_Folder.pdf.

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Singapore Maintenance of Parents Act

India Maintenance and Welfare of Parents and Senior Citizens Act

China Law on Protecting the Rights and Interests of Older Persons

Scope for parents

Any Singapore resident, 60 years and above, who is unable to maintain himself adequately.

Senior citizens, defined as any person being a citizen of India, who has attained the age of sixty years and above, whether living in India of not. Parent is father or mother even if one is not 60 years yet. Parents and grandparents who are unable to maintain themselves from their own income.

The elderly, referring to citizens at or above the age of 60.

Scope for children

Children, which includes illegitimate, adopted and stepchildren.

Children, whose definition includes son, The elderly shall be provided for mainly daughter, grandson, and granddaughter but by their families, and these does not include a minor. In the case of supporters refer to the children of childless senior citizen, claims may be filed the elderly and other persons who against relatives. Any person being a relative of are under legal obligation to provide a senior citizen and having sufficient means... for the elderly. The spouses of the provided he is in possession of the property of supporters shall assist them in these such senior citizen or he would inherit the obligations. property of a senior citizen (multiple relatives inheriting the property must pay maintenance relative in proportion to the inheritance).

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Maintenance Basic amenities and physical needs including shelter, food, and clothing are provided for, and not linked to parent’s previous standard of living. From 2011, medical cost is taken into consideration.

Maintenance includes provision for food, Providing for the elderly economically, clothing, residence and medical attendance taking care of them in daily life and and treatment, so that parent or senior citizen comforting them mentally, and may lead a normal life. Welfare means attend to their special needs. Ensure provision for food, health care, recreation that the elderly suffering from illness centres and other amenities necessary for the receives timely treatment and care. senior citizen. Properly arrange for housing of the

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Table 6.1.    Key Comparisons of Filial Responsibility Law in Singapore, India, and China.

Not specified

Punishment

Fine not exceeding $5,000 or an imprisonment not exceeding 6 months.

Not specified

Others

From 2011, amendment to “conciliation first” approach where parents must attempt mandatory conciliation at the Commissioner’s Office before filing a claim

Punishable with imprisonment which may extend to 3 months, or fine which may extend to five thousand rupees or with both.

Note: Refer to Law Info China (2015), Ministry of Social Justice and Empowerment, Government of India (2009), Maintenance of Parents (https:// app.maintenanceofparents.gov.sg/Pages/Legislation.aspx).

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Decided by tribunal based on a set Maximum allowance should not exceed ten of criteria including financial thousand rupees per month. needs, earning capacity, expenses incurred and physical health of the parent and children. The claims ca be monthly allowance or lump-sum payment.

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Amount

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elderly and shall not compel the elderly to live in or move to inferior houses. Shall care for mental needs of the elderly, and shall not ignore or cold-shoulder the elderly.

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In contrast, China’s “Law on Protecting the Rights and Interests of Older Persons”, refers in short as “Elderly Rights Law” (ERL)18 goes beyond the safety net principle in providing more general and encompassing aspects of filial support of the old, similarly found in many other Asian societies. The revision in 2013, seeking to meet the emotional needs of older parents have been controversial as would be discussed below. As two big Asian cultures known for the traditional norm of honoring one’s parents, their concerns with filial responsibility reflects societal and attitudinal changes in inter-generational obligations, the awareness of the rising problems of abuse, neglect and abandonment of older persons, and the serious challenges ahead with a fast-ageing population in an era of rapid modernisation and globalisation. 6.3.1.  The Scope of Filial Support Although the scope of filial support seems obvious in a law for the maintenance of parents, like the scope for tax relief of elderly dependents, questions like what constitutes the family and dependents affect who besides the parents are to be included for support and provides a glimpse to the cultural inclusiveness and degrees of what constitutes “family”. The Singapore’s MPA adopts a reciprocal model, restricting the eligible to only one’s own dependent parents, reflecting the “converse duty under existing family law of Singapore” where parents have to provide support to children considered a member of the family (including illegitimate, adopted, step-children), these children also in turn has a duty to support their older parents (Chan 2004: 554). It is also genderneutral, where both sons and daughters, married or unmarried have equal duty to provide for their parents, contrary to the cultural notion in patrilineal norms among the Chinese and Indian families here (ibid.). 18

 http://www.csbnews.com/news/china-law-brings-attention-to-pros-cons-of-caringfor-aging-parent/.

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In China and India, the scope of filial support goes beyond the parents. In China, the “Law on Protecting the Rights and Interests of Older Persons” states that the person who provides care should be the “children of the older persons, and others who have the duty to do so in accordance to the law” and “spouse of the provider should help the provider to fulfill his/her filial duty” (clause 14 in Chapter 219). At the same time, within the scope of filial support of family members, the Law also states that individuals have the duty to provide for their older siblings but qualifies that it is a filial obligation if they were cared for by their older siblings when young, and in cases where they have the means to do so and when the older siblings have no other persons to provide for them (clause 23, Chapter 2). This qualification shows a slightly lower degree of obligation when compared with the expected provision for parents, including in-laws. In India’s “Maintenance and Welfare of Parents and Senior Citizens Act”, an individual is responsible not only for their parents, but also grandparents, and “childless senior citizens” (60 years or older) who can also demand for maintenance from their relatives defined as those who are in possession or would inherit the property of the elderly.20 The eligibility of childless senior citizens to demand their relatives to be; responsible is pragmxatic and probably not unusual in the joint family system to link inheritance with the expectation for maintenance from the relatives. The law provision in fact highlights the implicit understanding that children who receive inheritance have been filial in their duty to provide for their parents. In Taiwan, the cries of unfairness in cases where children who neglected their parents but appeared to demand for inheritance after their passing have led to the proposed legislation prohibiting such unfilial children from claiming their parents’ inheritance. The proposal is said to have gained strong support among the academics and lawyers, a law professor commented that although Taiwan’s Civil Code (Clause 1084) 19

 For full content of the law, see http://www.legalinfo.gov.cn/zhuanti/node_56028.htm.  For details, see http://socialjustice.nic.in/oldageact.php?pageid=1.

20

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has provision stating that children should be filial to their parents, it acts more as a reminder of one’s moral obligation, whereas the proposed legislation would further “operationalise” filial piety in life.21 In a sense, such legislation spells out expectation of reciprocity implicit in the structuring of filial piety, inter-generational care and support in Asian society (Thang 2000). 6.3.2.  Maintaining the Minimum: The Provision of Financial Support — and More As a law in which an older person should seek only as a last resort safety net, the “filial responsibility” in such a law refers basically to financial provision at a minimal basic income security level for parents who are unable to maintain themselves. The MPA, however, operates on the principle of “just and equitable”, as Chan (2004)’s comparison with maintaining a wife or a child shows, the “stark difference” is the “equitable consideration of whether a parent has exhibited an expected degree of care for the child from who he or she is now claiming maintenance” (p. 556), thus the child will not need to provide for the parent even when he can afford it if the parent has shown to neglect the child earlier. Such reciprocal basis of duty is often present in the Western countries which have filial responsibility law, but did not seem to have been much considered in the implementation of the law in other Asian societies. Taiwan, though, has in 2009 made a draft amendment requesting that in the case where adult children had suffered in the past from domestic violence, sexual abuse or abandonment by their parents, they should be exempted (or reduced) from the obligations to maintain their parents.22 Neither childless senior citizens nor children are permitted to appeal against the decision of the maintenance tribunal although this is possible for parents (Parker 2007).

21

 “Proposed change in civic law, children who do not provide support to their parents will not receive inheritance.” Liberty times Net, October 6, 2008. http://news.ltn.com. tw/news/focus/paper/248320. 22  http://news.sina.com.cn/c/2009-11-05/124716559452s.shtml.

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While filial responsibility law is usually concerned with cash payouts to meet financial needs, the 2013 revision of the ERL brings attention on meeting the emotional needs of elderly. Such request for children to provide emotional support may seem reasonable when foregrounding filial piety, often taken to mean “absolute subservience to parents in all aspects of life”, including beyond life in ancestor worship (Goransson 2009: 89). In clause 18 of the law, ways of tending to the emotional needs of the elderly are provided, where “family members who are living apart from the older person should frequently visit or send greetings to the elderly persons” and “companies and work units should give employees enough time off so that they can make parental visits” (Wong 2013). The revised law, more generally referred to as “filial piety law”, has caught widespread attention and attracted controversial reactions when it was announced in July 2013. As reported in The New York Times (ibid.), those that found such a law necessary thought it is a good measure for meeting the emotional needs of elderly that cannot be met by the social welfare system which only provides for material needs. However, those objected to the law found legalizing the expected actions of showing concerns to parents as ridiculous, such as a Chinese novelist who wrote in his microblog with 1.3 million followers, “kinship is part of human nature; it is ridiculous to make it into a law. It is like requiring couples who have gotten married to have a harmonious sex life.” (ibid.) Together with the “New 24 Paragons of Filial Piety” discussed earlier, the state’s assertion of the necessity of such a law highlights the increasing norm of adult children leaving their hometowns for better work opportunities elsewhere,23 consequently leading to isolation and neglect of older persons left behind. Although based on the same premise of providing for the wellbeing of older parents, it will be quite difficult to imagine a similar provision in MPA where the filial responsibility of the children is basically restricted to financial provision. Besides the question of 23

 Rural migration to Chinese cities is said to be rising annually at 4.4 percent, which means nearly 11 million rural migrants would have left their parents behind to work in the cities in a year (Jacobs and Century 2012).

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what constitutes a safety net if emotional needs are to be considered, barriers such as the strained relations between the parents and children being summoned (or with other siblings who may sue the other siblings for not contributing their share) would make it difficult to consider beyond financial provision. Besides, as Goransson (2009), in her study of filial piety among Chinese Singaporeans has found, filial piety is defined quite narrowly to the provision of financial and material support, and “does not automatically involve excessive devotion to parents and acknowledgement of seniority” (p. 89). This parallels what Freedman has observed as early as the 1950s, on the focus on material or economic obligation, rather than excessive deference to parents in the practice of filial piety among Chinese Singaporeans (1957, 58; cf. Goransson 2009: 89). This probably explains why the principle of “just and equitable” is adopted in ensuring reciprocity in MPA. Nonetheless, similar to the opposing voices in the law regulating the meeting of the emotional needs of older parents in China, the MPA was met with controversy when it was proposed in 1994 by the then nominated member of parliament, Professor Walter Woon. Objections were voiced especially from the Chinese-educated community who regarded it inappropriate to regulate filial piety and were concerned that the moral obligation of filial piety would be replaced with legal duty (Chan 2004). In fact, the idea for such a law was already suggested earlier in 1984 by the committee to study the problems of older persons appointed by the Government but did not proceed due to the same concern on filial piety as “a sentiment of the heart which cannot be legislated” (cf. ibid., 2004: 550). When justifying for the proposed law that was eventually passed, Professor Walter Woon argued that the Bill should not be seen as regulating filial piety but to provide a safety net in case filial piety fails (Chan 2004). In the face of increasing burden for the state as population ages in a rapid pace, it will be an ideal scenario for governments when people are mostly supported by their children who regard filial piety as natural and from the “heart”, and filial responsibility law will come into force only to address those who neglect their moral responsibility.

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It seems that, at least in the Confucius-influenced societies, moral obligations of care and filial piety as a matter of the “heart” will continue to affect the debate on the family’s role in filial support. In 1998, when the Hong Kong’s Provisional Legislative Council proposed a similar filial responsibility law, it was voted down with concerns that it will affect family harmony if children are compelled to support their parents unwillingly (Ting and Woo 2009:74).

6.4.  CONCLUDING REMARKS Can the Asian governments continue to depend on the family to provide care for their older members? As a vast continent, Asia is experiencing modernisation at diverse rates, the compressed condition of modernity where rapid demographic and social-cultural-economic changes have happened especially in East Asian societies and increasingly felt by the Southeast and South Asian societies have caused the governments to worry that they will be turning grey before becoming wealthy. Perhaps one consolation out of “compressed modernity” is that the family can still be largely depended on to provide for the welfare of its members, as suggested in the conceptualisation of “familialism individualisation” (Ochiai 2014). However, on the other hand, people could have clung on more to the family because it is the only familiar social resource that one could possibly turn to for protection in the midst of rapid changes. Chang (2010) cautions that family could turn from “social resource” into individual risks with the institutional weakening of the families, and led to “risk-aversive individualisation”. This is defined as “a social tendency of individuals trying to minimise the family-associated risks of modern life by extending or returning to individualised stages of life.” (Chang 2010b: 25). Chang examines the low fertility rate and decline in marriages in South Korea as an evidence of risk-aversive individualisation, and a way to help individuals to buy time before they “prepare or recover material and/or social resources for responsible family relations” (ibid. p. 34). When considering Chang’s thesis in the case of expectations of family care for their older members — a

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belief that most adult children in South Korea would agree that they have the responsibility to provide (Chang 2010: 33), such a responsibility also has the likelihood of becoming a “risk” where individuals are less in control of, thus requiring more concrete support from the state and other sectors. The individualisation process24 in modernisation in Asia as shown in the “familialism individualisation” and “risk-aversive individualisation” tendencies will impact on the expectations of the family in caring for their older members. While the comparative understanding of the policies on some Asian societies may have provided an impression that the governments are placing too much expectations on the family, more Asian governments, especially those caught in rapid ageing demographics, have also been seen introducing new responses that have potential impact on the wellbeing of older persons and their families. Taiwan has implemented a new long-term care insurance in 2016, the third Asian society to do so after Japan and South Korea. Malaysia started tax relief for parents in 2016, and Singapore’s S$3 billion Action Plan for Successful Aging which aims to build a “Nation for All Ages” and empowering older persons to be active in employment, lifelong learning and volunteering has attracted international attention for its proactive human resource approach (Washington Post 2015). Looking forward, in the age of individualisation, policies on supporting older persons should regard the family as a valuable resource to be treasured — and not to be taken for granted, where policies to support the family in old age care should be comprehensive, along with policies to empower and encourage both independence and generational inter-dependence for a meaningful later life.

24

 Beck and Beck-Gernsheim explains that individualisation under Western modernity regards the family more as an elective relationship, a contrast to the pre-industrial society where family was held together by an obligation of solidarity (cf. Chang 2010: 26).

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CHAPTER 7

INCOME SECURITY Christopher Gee and Joelle H. Fong

7.1. INTRODUCTION Ageing raises many challenges and risks, one of the most prominent being old-age financial protection. The dual challenge of having to set in place strong income support schemes for the elderly, while sustaining economic dynamism, is a reality for many developing countries in Asia today. Whether the pension systems in these economies are adequate, effective, affordable, and sustainable, as well as the way in which these systems are financed, are issues of keen interest to scholars and administrators in part prompted by the unprecedented pace of population ageing in the region. Our approach in this chapter is to provide a brief review of current factors contributing to income insecurity among Asian populations, and to indicate some areas where policy reforms are required to bolster retirement security. First, we review evidence on the sources of economic insecurity relevant to older persons in Asia. Second, we describe the current state of pension provision across various economies and draw attention to the most important elements of these pension systems. We also discuss aspects of the systems’ performance such as pension coverage, sustainability, and adequacy. Lastly, we preview a few challenges in old-age income security systems in Asia and explore policy options for the future. 203

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This chapter is primarily about contributory pensions, which we define as government-mandated pension schemes that involve past contributions by the employee, the employer, or both. It also includes civil service pensions. Entitlement to a contributory pension is determined on the basis of how much an individual has accumulated in their individual accounts in the case of defined contribution (DC) plans, or a formula-based retirement benefit in the case of defined benefit (DB) plans. In contrast, non-contributory pensions are targeted transfers to the elderly on the basis of an individual’s circumstances or need. Examples include social assistance schemes, cash transfers to older persons, and minimum income support schemes. 7.1.1.  Sources of Income Insecurity Growing older may be associated with income insecurity as a result of prolonged unemployment, lack of adequate pensions, housing crises, reduced ability to earn an income, diminished savings, and negative health outcomes. In Asia, this situation is exacerbated by rising longevity. Official statistics from the United Nations indicate that the average life expectancy at birth in the whole-of-Asia region has risen considerably over the last 20 years (approximately 60–63 in 1985 to about 70–74 in 2015). Consequently, individuals are forced to either save harder when young or extend their active working lives into older ages. Economic insecurity is closely linked to an individual’s incomeearning capacity. Older persons are especially vulnerable, since they are likely to be viewed as less productive and adaptable than younger workers. For example, the demand for mastery of new skills in an expanding digital economy tends to disadvantage older workers. Older workers may also face direct age discrimination by employers — or oftentimes, discrimination in the form of fewer training opportunities, being passed up for promotions, or being redesignated to lower-level tasks. Asian older women, who on average have less formal education than older men, may find it even more difficult to remain in the labour market (Muhajad 2015). The lack of

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access to gainful employment for the elderly not only poses risks of poverty and dependency in old age, but also wastes a valuable productive resource at the societal level. Another source of income insecurity stems from the lack of adequate pensions. Recent research points to the existence of large informal employment sectors in many Asian countries where working conditions are not regulated, wages are low, and pension coverage is absent (UNESCAP 2014; World Bank 2015). Cambodia and Indonesia are examples of economies characterised by high labour market informality and underdeveloped pension systems. Also, Jütting et al. (2008) noted that a large percentage of people in Bangladesh and India hold informal jobs. In China, rural–urban migrants now comprise a large share of the workers engaged in informal employment in the urban labour market (Wang 2009). A 2014 United Nations report estimates that for some developing countries in Asia, contributory pensions are accessible to only about 10% of the workforce (mainly those in the civil service or large private enterprises). Even in countries where the coverage of contributory pensions is broad, the risk of inadequate pensions may also arise from a variety of factors including macroeconomic conditions (e.g. the 1997 Asian financial crisis); unfunded pension liabilities in pay-as-you-go (PAYG) schemes; poor investment returns from pension monies; non-indexation for inflation of pension payouts; increases in pension eligibility age; and the possibility that future pension benefits may compromise by political instability. While older persons in Asia have traditionally relied on family support and household savings for their economic security, there is evidence to suggest that family-based support for the elderly has weakened in the region over the past few decades due to changing family size and structures, rapid urbanisation, and migration. Adverse health events in old age may also exhaust retirement savings leading to income insecurity. The need for medical care or longterm care tends to increase with age as people grow older and frailer. Not surprisingly, governments in Asia increasingly view health insurance as one of the main components of social protection applicable

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to older persons, in addition to contributory pensions and other income support schemes. Unlike advanced countries in the Americas and Europe, emerging Asian nations are experiencing accelerating ageing at relatively low levels of per capita income. This implies that Asia’s next wave of ageing economies, including China, Thailand, Vietnam, and Malaysia, may risk growing old before they become rich. The concern is that the financial and political institutions in these societies may not be adequately prepared to meet the challenges of a demographically ageing population, along with profound gaps that still currently exist in terms of pension provision and long-term care provision for the elderly. 

7.2. OVERVIEW OF OLD-AGE INCOME SECURITY SYSTEMS IN ASIA Countries in Asia have been moving towards multi-pillar pension systems over the past two decades. According to the World Bank’s classification system by Holzmann and Hinz (2005), a pension system may consist of five pillars: (i) a zero pillar of a basic or social pension which is non-contributory, funded by taxation; (ii) a mandatory, contributions-based first pillar; (iii) a mandatory savings-based second pillar (occupational or personal pension plans); (iv) a voluntary savings-based third pillar, and (v) a non-financial fourth pillar comprising access to formal social programmes and informal support. Within Asia, first-pillar systems predominate and zero pillar schemes tend to be targeted at specific vulnerable groups rather than being universal in coverage (see Table 7.1). Second-pillar schemes are rare; the main example being Hong Kong’s Mandatory Provident Fund scheme (which while called a provident fund is a set of mandatory, fully-funded DC occupational pension plans that is highly state-regulated). The ideal typology of old-age income provision in Asia has tended towards a state-regulated partnership between employers and employees (Ku 2003), as evidenced in the number of provident

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Table 7.1.    Asian Pension System Modalities of Pillars.  

Modality of pillars Pillar 0

Pillar 1

Pillar 2

Asia–Pacific

 

 

 

Bangladesh

Targeted

—

—

Brunei Darussalam

Universal

Cambodia

Provident Fund

—

—

—

—

China

Targeted

Defined Benefit/Notional Defined Contribution

—

Fiji

Targeted

Provident Fund

—

Hong Kong SAR, China

Universal

Indonesia

—

—

Defined Contribution

Provident Fund

—

India

Targeted

Defined Benefit/ Provident Fund

 

Japan

Basic

Defined Benefit

—

Provident Fund

—

Defined Benefit

—

Kiribati Korea, Rep.

— Basic

Lao PDR

—

Defined Benefit

—

Malaysia

Targeted

Provident Fund

—

Mongolia

Universal

Notional Defined Contribution

—

Nepal

Targeted

Provident Fund

—

—

Defined Benefit

—

—

Provident Fund

—

Defined Benefit

—

—

Provident Fund

—

Sri Lanka

—

Provident Fund

—

Thailand

Universal

Defined Benefit

—

Timor-Leste

Universal

Vietnam

Targeted

Pakistan Papua New Guinea Philippines Singapore

Basic

— Defined Benefit

— —

Note : Provident Funds can be considered publicly-managed DC schemes. Source : World Bank Pensions Database 2015.

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fund/DC schemes established in the region, found especially in the former British colonies. Mongolia and China1 have notional defined contribution (NDC) schemes,2 which mimic a DC plan but retain PAYG financing. Separate pension schemes for civil servants also exist in several Asian countries. These schemes are designed to make a career in the public service more attractive, as well as enable the retirement of older civil servants in a politically and socially acceptable manner. Nonetheless, because civil service pension schemes tend to offer more generous terms and have lower funding ratios than private schemes, they may become financially unsustainable or crowd out other pension programmes (Palacios and Whitehouse 2006). Consequently, some countries e.g. Singapore have begun integrating their civil service pension schemes with national schemes. But in less economically developed countries like Bhutan and Cambodia, the civil service pension scheme is the only one in existence. Across Asia, the pensionable age for men ranges from 58 years (Indonesia) to 65 years (Hong Kong), whilst for women the range is from 50 (non-public sector female employees in China) to 65 years (Hong Kong). Receiving a pension is primarily conditional on attaining a specified age, although some countries with DB schemes also specify the completion of a minimum number of years of contributions or service. Pensionable and statutory retirement ages are generally rising (Japan, Korea, Singapore), with higher income countries having equalised the statutory retirement age for men and women. 1

 China has mandatory notional DC schemes for urban enterprise workers and rural dwellers, whilst civil servants have DB plan wholly financed by the government. 2  “Notional accounts are designed to mimic a defined contribution plan, where the pension depends on contributions and investment returns. (For this reason, they are sometimes called ‘notional, defined-contribution’ schemes). Pension contributions are tracked in accounts which earn a rate of return. However, in notional accounts, the return that contributions earn is a notional one, set by the government, not the product of investment returns in the markets” (World Bank’s Pension Reform Primer: a comprehensive, up-to-date resource for people designing and implementing pension reforms around the world).

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7.2.1.  Aspects of Pension System Performance The heterogeneous contributory pension landscape in Asia stems from country-to-country differences in economic development, demographic transition, cultural influences, and political values. Nevertheless, some standard measures exist to provide a basis for such comparison, and these are analyzed in turn for each of the four main performance indicators of pensions systems: coverage, adequacy, sustainability, and efficiency. The level of coverage is defined as the proportion of people either in the working age group3 or in the active labour force covered by mandatory pension schemes. This coverage percentage is a measure of how effectively the pension system is utilised by the preretirement population, and can be used to readily highlight gaps in the system. Amongst high-income economies in Asia, Korea has noticeably lower coverage ratios, especially when compared with the working age population. China, India, Pakistan, and Thailand have comparatively low mandatory pension scheme coverage given their level of economic development (Table 7.2). One common measure of pension adequacy is income replacement rate.4 Table 7.3 shows the net replacement rates for a select group of Asian countries’ mandatory pension schemes. Indonesia stands out with low net replacement rates of 13–14% across the income distribution, a function of its low contribution rates. A number of countries (notably China, India, Philippines, and Singapore) have an element of progressivity in net replacement rates in their pension schemes, with those with lower incomes realizing a higher net replacement rate than those earning more. Singapore’s low net replacement rates for higher income earners notwithstanding high 3

 Typically taken to be of 15–64 years of age.  Gross income replacement rates show the pension benefit as a share of individual earnings, either final earnings before retirement or lifetime average earnings. Net replacement rates are perhaps a better measure of old-age income adequacy, as they take into account personal income taxes paid and social security contributions paid by workers and retirees, especially important as pensioners are often subject to lower rates of taxation. 4

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210  Ageing in Asia: Contemporary Trends and Policy Issues Table 7.2.    Asian Pension Scheme Coverage. Coverage (% of labour force)

Coverage (% of working age population)

66.2%

46.8%

0.5%

0.4%

China (2010)

33.5%

27.7%

Fiji (2006)

36.0%

22.7%

HK SAR (2009)

78.9%

55.4%

Indonesia (2010)

11.0%

8.0%

Korea, Rep. (2011)

Brunei (2005) Cambodia (2010)

79.9%

54.2%

Lao PDR (2008)

1.4%

1.1%

Malaysia (2013)

57.5%

38.5%

Mongolia (2009)

47.2%

29.4%

4.4%

3.3%

Philippines (2011)

26.3%

17.5%

Singapore (2009)

62.1%

44.6%

Thailand (2009)

22.5%

17.7%

Vietnam (2010)

20.7%

17.3%

Papua New Guinea (2009)

Source: World Bank Pensions Database, 2015.

contribution rates are a function of a wage ceiling on contributions (see before), as well as the capacity for pre-retirement withdrawals for non-retirement uses such as to finance housing and health care. Another useful measure of pension adequacy is contribution density.5 Income replacement rates may be inadequate for lowdensity scheme participants even though the benefit formulae may be generous. For example, Singapore’s headline contribution rates for middle-aged workers of 37%6 are the highest in the region, but are subject to a wage ceiling and floor levels that reduce the effective contribution rate for workers above and below the relevant 5

 Contribution density is defined as the share of present value earnings in the active phase of life which the individual contributes to a contributory pension scheme (Valdés-Prieto 2008). 6  Comprising of employers’ contribution of 20%, employees’ of 17%.

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Table 7.3.    Asian Pension Schemes’ Net Income Replacement Rates by Earnings and Gender. Men Individual earnings (% average) China

Women

50

100

200

50

100

200

106.4

84.7

75.5

85.3

66.3

58.7

Hong Kong

36.2

36.8

33.0

33.9

33.3

33.0

India

85.9

64.1

55.2

80.9

59.2

50.5

Indonesia

14.4

14.4

14.6

13.2

13.2

13.5

Japan

54.3

40.8

32.8

54.3

40.8

32.8

Korea

64.8

45.2

26.3

64.8

45.2

26.3

Malaysia

40.3

41.0

42.8

36.6

37.2

38.8

Pakistan

80.8

66.5

33.3

74.9

58.2

29.1

Philippines

57.4

46.1

36.5

57.4

46.1

36.5

Singapore

41.6

42.1

23.8

37.2

37.7

21.3

Sri Lanka

49.9

49.9

51.0

33.7

33.7

34.4

Thailand

48.8

49.2

32.4

48.8

49.2

32.4

Vietnam

72.6

69.9

69.7

66.7

64.2

64.0

Source: OECD, 2013; Pensions at a Glance Asia-Pacific, 2013.

thresholds. In addition, average contribution density falls when selfemployment and informal employment expands and when activity outside the labour force such as domestic production rises (ValdésPrieto 2008). Financial sustainability of a pension system is determined by the level of pension benefits compared with the earnings capacity of all the contributors to the system. An indicator of this might be the required contribution rate, an estimate of the steady-state rate of contributions needed to pay for all promised pension benefits. The Organisation for Economic Co-operation and Development (OECD) notes that based on this required contribution rate many pension systems in Asia are unlikely to prove sustainable in the long term (OECD 2013). China, Vietnam, and Pakistan in particular are highlighted as having required contribution rates above 33% of earnings

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generated from age 20 to the relevant pensionable age, in large part due to high target income replacement rates as well as relatively young pensionable ages for women. Furthermore, this method of assessing financial sustainability may also tend to understate the problem as this measure is calculated for individuals and does not take into account survivorship benefits. The age structure of the population is also not taken into consideration in this measurement, which is especially critical for PAYG pension systems.7 Efficiency, both economic and administrative, is the hardest performance metric to measure. Pallares-Miralles et al. (2012) suggest measures such as the average effective retirement age,8 old-age income security contributions as a share of gross labour costs or the cost of administering public pension schemes as means to assess the efficiency of pension systems. The lack of comparative data in Asia means that useful analysis on the efficiency of pension systems in the region cannot be readily performed.

7.3.  CHALLENGES AND ISSUES Coverage gap is one of the most pertinent challenges facing pension systems in middle-income Asian economies. In these economies, a substantial number of workers are engaged in informal sector enterprises or in informal employment within formal sector enterprises. These workers are not covered by contributory pension schemes, which mainly serve the formal sector, civil servants or military personnel. India, Pakistan, and Timor-Leste are examples of countries with low labour force participation rates and large informal sectors, with women predominantly engaged in care-giving roles outside of the formal economy. In China, an increasing share of the workers 7

 Measures of unfunded pension liabilities as a percentage of GDP could be utilised that take into account the age structure of the population, but this data is not available for any of the pension schemes in the region. 8  This is the average age at which people actually retire given early retirement provisions, and is an important indicator of the way in which a pension system can embed incentives that affect labour force participation and productivity.

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engaged in informal employment in the urban labour market comprise rural–urban migrants. In recent years, several countries such as Vietnam and Indonesia have started to extend pension protection to the informal sector by providing voluntary pension schemes, as well as non-contributory approaches such as social pensions. For richer economies that have achieved wide pension coverage, the challenge of providing adequate, affordable, sustainable income support for their growing elderly populations remains a critical one. Part of this challenge stems from the lack of a systematic approach towards risk management within DC pension plans. DC schemes in Hong Kong (PRC) and Malaysia allow their workers to withdraw their retirement accumulations in a lump sum. Consequently, retirees may run into the risk of outliving one’s retirement savings early in retirement (or longevity risk). An exception is Singapore, which mandated annuitisation under its national pension scheme in 2013. Investment risk — whilst typically pooled in the provident fund schemes in Asia — remains a concern for participants in DC schemes as macroeconomic factors may hugely influence the investment earnings on their individual accounts. Fiscal sustainability poses a major challenge for Asia’s DB pension schemes, even well-established ones. According to a World Bank (2015) report, cash flow deficits are expected to emerge the PAYG schemes of Korea and China over the next two decades. Mongolia’s DB scheme is already running deficits, and Japan has been using budgetary resources to pre-fund their social security benefits. While the social security systems in these countries have thus far largely avoided unsustainable legacy commitments, managing the long-term sustainability of the PAYG pension plans in face of growing fiscal pressure from rapidly ageing populations may call for challenging policy choices and reforms such as cutbacks in benefits and increases in retirement ages. In addition to the risk of financial unsustainability, DB pensioners in developing Asian economies may also be exposed to inflation risk. Specifically, indexation of DB pension payments is not automatic in countries like Thailand, the Philippines, and Vietnam. Adjustments of pension benefits to compensate for

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changes in prices and wages in these countries have historically been ad hoc or discretionary. This is unlike Japan and Korea where basic pension benefits are price-indexed to provide protection against inflation. Price indexation is also almost non-existent for pension benefits paid out under DC pension plans and first-pillar provident funds in Asia. Going forward, this exposure to inflation risk may bear profound implications for pensioners across Asia as life expectancies in the region continue to rise and the reliance on pension payouts extend over a longer time horizon. Continued increases in longevity may ultimately undermine the long-term sustainability of the pension systems, especially DB plans, if left unchecked. A number of income support schemes in Asia face issues of low pension adequacy owing to early withdrawals. Pre-retirement withdrawal schemes currently exist in Indonesia, Malaysia, Singapore, and the Philippines. In Singapore and Malaysia, for example, preretirement withdrawals are allowed for housing, health care, and tertiary education. In India, pre-retirement withdrawals are allowed for medical care and family obligations such as marriage. Where excessive, pre-retirement withdrawals in DC pension systems can inhibit pension contributions from growing with compound interest over time and directly deplete accumulated savings such that pension benefits become inadequate at time of retirement. With few exceptions, most countries in the region have taken a minimalist approach to social welfare, preferring to place more emphasis on creating a legal and fiscal environment that is conducive to economic development. As a result, familial support historically plays the predominant role in old-age income security in many Asian countries. This socio-cultural backdrop has, in large part, influenced the nature and size of formal pension systems that have emerged in Asia (Kwon 2001). Nonetheless, with the weakening of familial support and smaller family sizes, it is not surprising that the elderly populations across Asia are increasingly turning to government support when in need of old-age income and support. Even in “productivist” welfare states such as Hong Kong, Taiwan, South Korea, and Singapore, there has been a gradual movement towards

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universality of social protection and the addition of basic pillars of old-age income security (Holliday and Wilding 2003).9

7.4.  POLICY IMPLICATIONS AND RESPONSES The OECD noted that “many of Asia’s retirement-income systems are ill-prepared for the rapid population ageing that will occur over the next two decades” and that the region’s systems for old-age income security need urgent attention to ensure financial sustainability and achieve their primary goal of providing adequate retirement incomes (OECD 2013). Holzmann et al. (2008) add equity and predictability to the primary yardsticks by which pension systems should be evaluated, over and above the four criteria of adequacy, affordability, sustainability, and robustness set out in earlier work (Holzmann and Hinz 2005). Secondarily, to the extent that pension benefits are claims against future economic output, they point out the need for pension systems to contribute to growth and output by reducing labour market distortions, contributing to savings and facilitating financial market development in their countries.

One way to expand coverage is by increasing the number of effective pillars, and by strengthening existing pillars. Old-age income security in Asia relies heavily on traditional familial sources to provide financial support in old age (the informal fourth pillar in the World Bank framework). These traditional sources of informal support are increasingly coming under strain as a result of rapid demographic transition. The feature of a multi-pillar pension system architecture is that certain pillars are more effective in addressing the needs of different segments of the population. Whilst most countries have both first- and zero-pillar pension systems, the reality is that many have not been able to find the 9

 The most recent example of this is in Singapore which announced a targeted, non-contributory state pension scheme called the Silver Support Scheme implemented in 2016.

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appropriate balance between adequacy, affordability, and sustainability, with many systems either targeting very generous income replacement rates and running the risk of becoming unsustainable in the longer run, or at the other end of the spectrum some systems emphasizing financial sustainability but at the not-inconsequential but harder to measure social welfare impact of financial insecurity and poverty in old-age for some parts of their population. Countries with large informal sectors not wellserved by mandatory first and second-pillar schemes may need to develop well-regulated voluntary third-pillar schemes to provide those employed in the informal economy more efficient means to build up their retirement savings. Existing pillars may be strengthened by focusing in particular on coverage gaps, with evaluations of contribution density especially amongst potentially vulnerable groups such as those employed in the informal economy (disproportionately women, older workers, and increasingly also the young). These groups may need help that can only be provided through the introduction of more comprehensive, tax-funded zero-pillar schemes. Contribution rates for those employed in the formal sector should have the effect of optimizing the incentives to remain in productive employment, but reforms may have to be sensitive to fiscal and economic context of each country as well as the workforce. Although politically challenging, rules around pensionable ages and statutory retirement will need to be reformed, with early pensionable and statutory retirement ages reviewed to reflect rapidly changing healthy life expectancy and expected time in retirement. Early pensionable ages for women in China, Malaysia, Sri Lanka, and Thailand increase the likely time women in these countries spend in retirement whilst reducing the working lifespan and the accumulation phase for their retirement savings. Statutory retirement ages could be made more flexible to reflect advances in healthy life expectancy and the potential extension of working in productive employment at older chronological ages given technological advancements and the evolving nature of the workplace.

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Early withdrawal schemes in some countries’ pension schemes (from the provident funds schemes in India, Malaysia, and Singapore amongst others) can result in depletion of retirement savings well before the statutory age of retirement, or at best raise the risk of not having sufficient savings accumulated upon retirement. Singapore and Malaysia’s provident fund schemes allow for savings to be withdrawn from certain accounts to finance the purchase of housing or for education. Whilst withdrawals for these non-retirement income uses may be for very worthy reasons that improve the welfare of the individual making those withdrawals, there is a risk that in those countries whose pension systems allow retirement savings to be withdrawn to finance housing, retirees find themselves asset-rich and income-poor, or end up overconsuming housing (Low and Aw 1997). The timing of withdrawals can have a significant impact on retirement adequacy. Whilst in most countries in Asia pension payments are received in the form of annuities (payments received at regular intervals until the death of the individual scheme member of their survivors), annuitisation is not mandatory in Indonesia, Hong Kong, Malaysia, and Sri Lanka, whilst only a minimum amount is annuitised in Singapore (and apart from a bequest option, there is no survivors’ benefit in Singapore’s CPF Life annuity scheme). The way that Asia’s old-age income security systems deal with inflation risks will also need to be reformed, with those that provide generous inflation indexation of pension benefits potentially having to reduce the benefits as the financial burden increases, whilst those systems that ignore inflation risks (in particular most DC schemes) pass that risk on to individuals who are not best placed to hedge this risk. It may be that for the former group with overly generous but unsustainable inflation protection that these benefits are scaled down to sustainable levels, whilst for the latter group, some inflation indexation should be introduced in both the accumulation and decumulation phases. Finally, all countries in Asia would do well to consider the effects of rapid demographic transition on especially the informal

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components of each country’s fourth pillar, and to intervene sensitively with the implementation of formal social programmes for health- and long-term care, and housing of the elderly. Programmes that promote life-long learning and the reskilling for older workers could also be implemented that improve the social and economic participation of the elderly.

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CHAPTER 8 URBAN ENVIRONMENT Fung John Chye, Heng Chye Kiang and Yeo Su-Jan

8.1. INTRODUCTION: AGEING AND URBANISATION IN ASIA Human settlements in Asia are ageing as rapidly as they are urbanizing. Today, 48% of Asia’s population live in urban areas. By 2050, it is projected that the proportion of urban dwellers in Asia will rise to 64% — outpacing all other regions in the world (UN 2014a). At the same time, the population aged 60 years or over in Asia is expected to reach 24% by 2050, double the current rate today. As the most populated region in the world, this vast demographic shift in Asia over the next three decades translates to 1.2 billion older persons of which more than 700 million are urban dwellers. In other words, Asia’s elderly population in 2050 would represent 60% of the world’s total aged population of 2 billion people (UN 2014b). A combination of factors is precipitating the rapid pace of ageing and urbanisation in Asia. Here, population ageing is driven by two key phenomena: increasing life expectancy and falling fertility rates, both of which are related to advances in socio-economic development (Phillips and Chan 2002). Concurrently, the key forces driving urbanisation are two-fold: mass rural-to-urban migration towards better economic opportunities in cities and mounting interests by governments to invest in urban growth and development (UN 2015; WHO 2016). It is fitting, then, of our contemporary 219

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times to contextualise ageing within the urban environment given the greater potential for cities to optimise infrastructure and services that support old age. In developed countries, the proportion of older persons residing in cities is projected to increase at par with the younger age cohorts. Developing countries, on the other hand, are demonstrating a larger share of older inhabitants living in urban communities such that the elderly will account for 25% of the total urban population by 2050 (WHO 2007). Indeed, the twin effects of population ageing and urbanisation will have implications for urban communities regardless of the divide between developed and developing countries. In the coming decades, the universal population ascent of urban-dwelling older persons will create new demands and pressures on cities, particularly where infrastructure and services related to health, safety, security, socio-economic well-being, housing, and transportation are concerned. From an urban policy and town planning perspective, the built environment is therefore an essential provision which can help to enhance the quality of life in old age. Given that cities will grow larger in terms of population size — and that this urban population growth will simultaneously include more residents who are elderly — policymakers and town planners are bound to confront the critical question: How can cities enhance quality of life for the elderly? The optimistic viewpoint suggests that cities, being the epicentre of technological, economic, and cultural development, can serve as the grounds for innovative age-friendly urban solutions. Conversely, urban stress from density, noise, and crowding exert a negative effect on the physical and mental well-being of elderly and city dwellers in general. The deep complexity of urban living necessitates the adoption of an ecological approach to human adaptation in the environment as advocated by Lawton and Nahemow (1973). In this chapter, we examine a high-rise high-density development model as an urban strategy which could help to create the kind of city that is not only sustainable but also age-friendly. More specifically, we focus on the role and significance of high-rise housing and high-density towns in enabling the elderly to lead active

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lives and, if they so choose, to age in place. Asian cities, to a certain extent but not always, have higher urban densities than their North American and European counterparts; yet, by the same token, not all high-density Asian cities share similar attributes and proficiencies in terms of planning for their respective ageing populations. Differences in socio-economic development, cultural practice, and political imperative affect the national policy responses to population ageing among the Asian cities. As such, this chapter will highlight some of the novel ageing-related urban policies and initiatives in the more highly-developed economies of Asia, but will refrain from an in-depth comparative study of these examples. Rather, by taking Singapore’s advanced urban planning system as a case study, our aim is to unpack the key principles of Singapore’s long-standing “new town” model and glean insights from the current mode of spatial planning vis-à-vis population ageing. This chapter also explores broadly the impending trends and issues of ageing — such as decreasing household sizes, increasing reliance on institutional care, eroding prominence of filial piety — that may affect Singapore’s social structure in the foreseeable future and, hence, pose new challenges for the urban environment. To this end, we raise fresh considerations towards a more inclusive urban framework that could better accommodate the changes ageing com­munities in Singapore will encounter in the coming decades.

8.2.  VERTICAL ASIAN CITIES AND AGE-FRIENDLINESS The term “age-friendly city” was first developed in 2005 by the World Health Organization (WHO) when it initiated the Global AgeFriendly Cities Project, a global research protocol involving collaborations with 33 cities to identify the essential features of an age-friendly city (WHO 2007). Recurring themes were identified from focus group discussions with respondents aged 60 and above in the participating cities, which included widely varying communities across different world regions, population sizes, and development status (Plouffe and Kalache 2010). The project culminated in the

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WHO (2007) Global Age-Friendly Cities: A Guide with findings structured according to the eight topic areas that informed the focus group discussions: (1) outdoor spaces and buildings; (2) transportation; (3) housing; (4) social participation; (5) respect and social inclusion; (6) civic participation and employment; (7) communication and information; and (8) community and health services. The Guide also includes a Checklist of Essential Features of Age-Friendly Cities, intended as a reference for other communities wanting to implement age-friendly strategies in their jurisdictions. Although all eight topics intersect with the built environment to varying degrees, the greatest urban concerns are the three areas that deal with outdoor spaces and buildings, transportation, and housing. Consequentially, these three physical aspects of the city are also generally most prominent in vertical Asian cities where urban density plays a critical role in influencing the quality of outdoor spaces and buildings, efficiency of transportation, and housing provision for the elderly. The importance of housing, transportation, and the built environment to the national policies on ageing and long-term care of Asia–Pacific countries is similarly articulated in the Macau Plan of Action on Ageing for Asia and the Pacific — Macau POA, ESCAP 1999 (Phillips and Chan 2002). Additionally, other important spatial aspects encompass planning for accessibility to amenities and services (including health-related care) and designing for safety and security against crime in addition to traffic. Vertical Asian cities such as Hong Kong, Seoul, and Singapore share some similar physical characteristics related to urban density that could implicate the age-friendliness of their built environments.1 Firstly, a growing urban population amidst land constraints means that the public commons — streets, parks, open spaces — need to be shared by more and more people. This urban congestion created by pedestrian and vehicular traffic in the city can potentially 1

 We acknowledge that urban density is not necessarily or always a true indicator of the intensity of urbanisation; to better understand the determinants of urbanisation in any particular locale, one would need to analyse the land economics, housing market, urban governance, and development policies on a city-by-city basis.

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compound fears for one’s safety and well-being, especially among the elderly. Secondly, mass transportation provision via a rapid rail network exists primarily because of the critical mass supported by a large urban population; herein rests challenges and opportunities for elder-friendly mobility. Thirdly, high-rise towers are the most common residential development form; in Seoul, 100% of new housing projects on redeveloped sites are high-rise apartments (Ha 2010). This situation is similarly reflected in Singapore and Hong Kong, where residential development also includes a significant stock of government-supplied public housing. About 82% of Singapore’s resident population reside in public housing (HDB 2015), while the figure in Hong Kong is 46% (HKHA 2015). The substantial proportion of public housing dwellers raises considerations for the liveability and affordability of high-rise public housing developments in old age. Issues of safety, security, walkability, accessibility, and connectivity are key preoccupations of planners and urban designers of such residential neighbourhoods. Lastly, from a socio-cultural standpoint, there is an apparent decline of filial piety practices in modern Asian societies (Ng et al. 2002). Today, the tradition of familial inter-dependence — where elderly relatives are provided informal care within the family — is increasingly replaced by long-term institutional support systems. Filial obligations and responsibilities in supporting elderly family members are placed under greater and greater pressure due to converging demographic and socio-economic trends, which include: shrinking family size related to both low fertility and marriage rates; ascension of women (who are customarily the main family caregiver) entering the labour force; higher financial capabilities that enable paid care-giving as an option; globalisation and dispersion of families; and exposure to Western influences regarding notions of individualism (Yoon and Hendricks 2003). It is also important to recognise the diminishing filial piety expectations of elderly parents on their adult children, especially in cities where the high cost of living may leave some adult children financially strained and unable to care for elderly parents with needs. In Hong Kong, for example, there is increasing willingness among

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older persons to live independently and care for themselves as long as they can — a response to the prevalence of adult children who, once they are financially capable, live separately from their parents to start their own nuclear families (Lee and Kwok 2005). Similarly, acts of filial piety in Seoul are being expressed beyond the family network to include non-kin support in the form of neighbours, associations, and institutions (Sung 2001). Indeed, the future elderly are likely to place greater value on privacy and autonomy given their higher levels of education and financial independence; that is, finding ways to meet their social and psychological needs through interactions beyond family relations, described as “shifting social context” by Phillips and Chan (2002, p. 9). Nevertheless, the foundational values of filial piety — respect for elders and reciprocity between parent and child — remain an influential factor in terms of shaping public attitudes and policies towards Asia’s aged population. Changing social structure affects the planning and design of housing types in response to evolving household size, elderly lifestyle choices, and the potential to monetise fixed assets for additional cash for retirement. These trends point to the vital need for urban policies to address ageing-related concerns that encompass not only the physical aspects of the urban environment mentioned earlier but also the social dimensions for enhancing well-being in old age. An integrated ecosystem of community support and health services in the face of modern filial piety practices could help bridge formal and informal sources of old age care, especially where the frail and needy elderly are concerned (Chow 2006). In this respect, vertical Asian cities afford a kind of geographical proximity advantage that could better enable ageing-in-place such that the necessary care and support can be sought without the elderly having to relocate and, thus, severe ties from their familiar environments. Indeed, recent discourse on the making of age-friendly cities has helped to encourage a more inclusive planning and design approach that recognises the participatory and contributory roles of older people in their urban communities (Liu et al. 2009).

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8.3.  A SINGAPORE PERSPECTIVE As a small island-nation, Singapore must contend with the issue of land scarcity given the geophysical limitations of the territory. Paradoxically, being a small island-nation gives Singapore the advantage of effectively coordinating spatial plans and policies driven by a centralised government. Urban planning in Singapore, therefore, is approached with concerted strategic and pragmatic endeavour — strategic in terms of the long-range outlook employed to plan far ahead for future land use needs, and pragmatic in terms of the deep-seated proclivity towards land optimisation to ensure continued economic growth and longterm land availability. In these two ways, Singapore’s urban environment has evolved rapidly in a span of 50 years since independence to become characteristically and recognizably high-rise and high-density. With a population density of 7,736 people per square kilometre of land area, Singapore is the third most urbanised country in the world (World Bank 2016). Evidence of this urban density is largely seen and felt in Singapore’s public housing landscape. The Housing & Development Board (HDB) is a Singapore government statutory board and the national authority on public housing. Since its establishment in 1960, the HDB has formulated housing policies and schemes, master planned estates and towns, and constructed 1,084,119 dwelling units which currently house 82% of Singapore’s resident population (HDB 2015). Presently, 12% of HDBdwellers are aged 65 years and older (DOS 2015a), thus representing a 5% increase of older persons living in public housing since 2000 (DOS 2013). By 2030, it is projected that 1 in every 4 Singaporeans will be an elderly (MOH 2016), thereby consequentially raising the proportion of older persons living in HDB communities. This trend will be most felt in established middle-aged and mature residential estates which have higher ratios of elderly HDB dwellers (e.g. Kallang/Whampoa, 23.5%; Bukit Timah, 16.6%) than the younger towns (e.g. Punggol, 4.8%; Sembawang, 4.1%) (HDB 2013). In Singapore, attention to ageing issues has long been tied to socio-economic and public health policies intrinsic to the ruling party’s political ideology, affecting household structure and giving rise to HDB initiatives such as the “3-Generation (3Gen) Flat”,

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“2-Room Flexi Apartment”, “Multi-Generation Priority Scheme”, and “Proximity Housing Grant’.2 The underlying ethos in planning for an ageing population is Singapore’s “many helping hands” approach where responsibility in caring for the elderly comprises four levels of support: (1) individual; (2) family; (3) community; and (4) national (IMC 1999). As such, these initiatives tend to promote traditional filial roles within a multi-generational family comprising married children and their parents. In the later part of this section, we will discuss some of the emerging trends on ageing that are prompting planners, policy makers, and researchers to reexamine public housing provision for the elderly as a distinct segment in their own right. In recent years, a closer focus on the spatial planning and design of public housing environments has emerged at the forefront of the “active ageing” and “ageing-in-place” initiatives (MOH 2016). In order to better understand the impact of the public housing environment on ageing, we will visit the key planning principles of the HDB traditional “new town” model and its recent variations. Identifying the key trends shaped by an increasingly educated, active, and financially secure future elderly segment in Singapore, we speculate on some potential areas for age-friendly environmental improvements through planning innovation.

8.4. SINGAPORE’S “NEW TOWN” MODEL: KEY PLANNING PRINCIPLES AND TRANSFORMATIONS A “new town” is a fully-planned, self-sustaining urban settlement for a particular population size served by a comprehensive mix of 2

 The “3-Generation (3Gen) Flat” is a purpose-built dwelling unit of 4 bedrooms and 3 bathrooms to accommodate a multi-generational family living under one roof; the 2-Room Flexi Apartment allows elderly residents to monetise their larger flat and move to a smaller unit that may be partly rented out for additional income; the “Multi-Generation Priority Scheme” enables a married child and his/her parent(s) to jointly apply for but separately live in flats within the same building project; the “Proximity Housing Grant” is a monetary subsidy for the purchase of a resale flat that is located in the same town or within 2 km of the married children or parent(s).

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commercial, industrial, and communal amenities. Singapore’s fashioning of public housing in the form of a new town can be traced to the early 1950s — an era of modernist, rational planning. In 1960, when the HDB replaced its predecessor, the Singapore Improvement Trust (SIT), efforts to build homes for the masses were significantly ramped up. Within the first five years of its establishment (1960– 1965), the HDB constructed nearly 55,000 public housing units (HDB 2015), exceeding the SIT’s total of some 23,000 units over its 32 years of existence (Liu 1985). Singapore’s early public housing efforts were achieved by way of two planning strategies: high-rise residential blocks of 10–12 storeys and high-density town development of 280 persons per hectare gross density with up to 880 persons per hectare nett residential density (Ibid.). These early public housing environments revolved around a hierarchical structure comprising a centralised town centre with core services and amenities to support a series of smaller neighbourhoods; each neigh­bourhood, in turn, is served by its own commercial centre to accommodate the daily needs of residents. By distributing amenities at different levels, such matured estates from the nascent phase of HDB are generally more aged-friendly. In the 1980s through to the early 2000s, housing diversification and transit-oriented development led to variations in the new town model. This evolving planning model emphasised qualitative goals such as privacy, identity, greenery, and character of place. Firstly, the 10–12 storey HDB slab block form was augmented by point blocks of 20–30 storeys not only to optimise land and, thus, increase density, but also improve privacy and inject identity and character to residential precincts through new architectural designs. Secondly, such residential precincts, which are now the basic planning unit, were introduced as a third level of the new town hierarchy, providing a local scale for social interaction and improved access to daily amenities and services. Thirdly, the introduction of a mass rapid transit (MRT) rail system, connecting public housing areas to Singapore’s downtown core, created an opportunity for the integration of MRT stations in the planning of new towns. More often than not, however, these MRT stations have been integrated and

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developed together with large enclosed shopping malls at the town centre level. This land planning and development approach has displaced the intimate scale afforded by the local shopping typology, which is originally and deeply embedded in the residential estates. The repercussion is that elderly residents, as with the general public, will need to commute via a public or private vehicle to the shopping malls for some daily necessities and services. In recent years, from the late 2000s to the 2010s, the new town model has evolved again; here, the planning emphasis is on further intensification of land and eco-friendly design features. For example, common open spaces which were once traditionally provided on the ground floor (“void deck”) of a housing block are today elevated above car parks as eco-decks or mid-block as “sky gardens” and “sky terraces” in residential towers soaring 40–50 storeys. Similarly, environmental sensitivities such as building orientation to optimise natural shade and wind which once informed architectural design are today advanced through computer simulations and green technology, and subsequently test-bedded in newer town developments to foster environmentally sustainable living. These transformations to the new town model over the decades, while indicative of a modernising and affluent society, could have enduring implications for mobility, accessibility, and inclusivity related to ageing as we shall later explore.

8.5. AGEING TRENDS AND ISSUES IN SINGAPORE: CHALLENGES AND OPPORTUNITIES IN THE URBAN ENVIRONMENT As a modern and industrialised island-nation, Singapore’s developmental progress has benefited the general population resulting in an educated, cosmopolitan, aspirational, and technology-savvy society. It can be expected, therefore, that the future elderly population will not only generate unique demands but also raise expectations on the provision of infrastructure, services, and amenities for quality ageing. When today’s cohort of adults aged 50–54 years reaches 65–69 years old in the next 15 years, their numbers will add to the projected estimate of 900,000 elderly persons aged 65 and above living

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in Singapore by 2030. Indeed, this cohort of future elderly are statistically more educated compared to their counterpart of existing elderly aged 65 and above; the proportion with a university education is 17.8% for the former and 5.2% for the latter (DOS 2015b). Many within this cohort of future elderly are today participating in the resident labour force at higher rates than their counterparts in previous years, resulting in an 11% participation hike from 71.4% in 2001 to 82.4% in 2015 (MOM 2016). Given the educational and financial background of the future elderly, we may also generalise the increasing exposure of the future elderly to global information and cultural influences through their proficiency and receptiveness in the use of digital technology. From these trends, we can deduce three significant ageing issues that are likely to create challenges and opportunities for urban policy and town planning: I. Independent Living: Housing & Transportation The rate of singlehood has been on the rise since 2000 with both men and women marrying later or remaining single. Con­ sequentially, the population of single elderly is projected to increase more than two-fold from 35,000 seniors living alone in 2012 to 83,000 in 2030 (MOH 2016). Additionally, total fertility rate over the past 30 years in Singapore has continued to fall below the replacement rate of 2.1 (NPTD 2013); in other words, women are having fewer children, if at all. In short, family size is shrinking and the old-age dependency ratio is rising. With the elderly being supported by fewer family members, and as filial piety traditions diminish in today’s contemporary Asian context, the proportion of older persons living independently is expected to rise. Housing and transportation, therefore, are two critical areas where urban policy and town planning can help to enable a safe, secure, and convenient environment for independent living by the elderly. II. Lifelong Learning: Employability & Skills Upgrading In 2015, the Singapore government announced plans to reenact legislation that will enable older workers to gain reemployment

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up to the age of 67 from the previous ceiling of 65. This adjustment responds to the motivation of workers to continue working for as long as they are healthy (Toh 2015). Indeed, the percentage of elderly residents aged 65 years in the labour force has increased from 10.8% in 2000 to 25.2% in 2014 (DOS 2015c) with a previous extension of the reemployment age from 62 to 65 in 2012. The emergence of the “silver market”, first used by the Japanese, could have a positive effect on the economy by enabling the elderly to contribute productively to economic growth which, in turn, creates new service demands and products across various sectors such as health care, wellness, and finance (Kohlbacher and Herstatt 2008). Urban policy and town planning, therefore, will need to consider more carefully the spatial distribution of employment and skills upgrading opportunities that would allow people to work closer to home as one’s mobility diminishes with age. New economic concepts such as sharing economy, collaborative work, social entrepreneurship, and e-commerce are potential job options for the future elderly, particularly with the shifting demographics to an elderly population that comprises increasingly Professionals, Managers, Executives, and Technicians (PMETs). III. Social Inclusion: Community Engagement & Ageing Support A study conducted in 2013 by the HDB on the social well-being of HDB communities reveals that 99.1% of the elderly felt a sense of belonging to their towns/estates and, comparably, 98.9% of the future elderly expressed similar sentiments (HDB 2014). Seen from the perspective of community engagement, the same study shows a significant increase between 2003 and 2013 in the community participation rate of the elderly (excluding the proportion of elderly residents who participated solely in religious activities), from 30.6% in the former year to 42.8% in the latter (Ibid.). Furthermore, combined responses from both the elderly and future elderly in the HDB study indicate that 76.2% of neighbourly interactions occur within the block, followed by 18.1% within the neighbourhood/precinct, and 5.7% within the town (Ibid.). The

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neighbourhood environment, in terms of programming and design, can therefore play an important role in facilitating interactions between the elderly and the community-at-large by increasing opportunities for social inclusion while also providing the infrastructure and services support for ageing-in-place. Independent living, life-long learning, and social inclusion are three central ageing issues that we foresee will characterise the elderly population in 2030. This 12-year time scale is crucial for medium-term policy and planning implementation, which brings us at a timely juncture to question: How effective is the existing new town model in supporting the future elderly towards independent living, life-long learning, and social inclusion? As we highlighted earlier, recent contemporary variations of the new town model demonstrate a propensity towards large commercial developments, residential land use segregation, and centralisation of amenities and services. Rationally, it would seem that such trends might impede active ageing and ageing-in-place by creating longer commuting distances, diminishing street life, and reducing informal albeit meaningful social interactions. In the next section, we point to three spatial/physical principles — mobility, distribution, and integration — and explore how they could be rethought to better enable active ageing and ageing-in-place in a high-rise high-density public housing environment.

8.6. A FRAMEWORK TOWARDS AN AGE-FRIENDLY HIGH-DENSITY URBAN ENVIRONMENT High-rise high-density towns represent a type of urban form which continues to be a topic of wide debate between proponents who, on the one hand, support it as a sustainable and economical approach to development and detractors who, on the other hand, question the liveability and quality of life in extreme vertical cities. Indeed, high-rise high-density towns, when ill-planned, have the potential to create problems related to noise, crowding, and privacy. These problems, in turn, could have downstream repercussions on public

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health, sense of well-being, and social tolerance. Conversely, highrise high-density living environments generate a critical mass that could make public transportation and other essential services viable, in this way potentially reducing car dependency. By encouraging walking and public transportation as the primary mode of travel, high-rise high-density towns could generate vibrant urban life on the streets and in public places. Given the regional and cultural factors which complicate city-to-city comparisons, it is therefore generally agreed that further research and evidence are needed to advance our contextual and applied understanding of high-rise high-density urban development — for either side of the argument. In Singapore, land constraints and an expanding population necessitate an urban form that is high-rise and high-density. Working within these conditions, it is therefore critical that urban policy and town planning for density include not only environmental considerations for sustainable long-term development but also, in view of the impending demographic shift to an ageing population, develop age-friendly solutions towards a better quality of life for all. In this regard, there are three spatial-physical principles — mobility, distribution, and integration — which could help to improve the land use efficiencies and liveability of high-rise high-density towns in Singapore’s public housing landscape. And, learning from planning examples from other high-rise high-density cities in Asia, we explore their potential application or discord in the Singapore context. I. Mobility for Independent Living Over the next 15 years, the demand for public housing typologies catering to smaller household sizes is likely to grow stronger as the number of elderly individuals and couples living alone continue to rise. Such typologies currently include studio units designed for the elderly and purpose-built blocks programmed entirely for seniors (akin to a retirement village). While these living arrangements may give or offer the sense of independent living, their segregating nature would seem to only further isolate the aged from society. There is a significant preference of the elderly to live in regular housing within the community and

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to age in place (URA 2009). Weak social networks exert a higher toll on men living alone, although the combined effect of living alone and a lack of social participation are known to increase depression in both men and women (Chan et al. 2011). Autonomy in old age is the key to many aspects contributing to a good quality of life for the elderly, especially in maintaining daily routines and social interactions.   The future elderly population will not be a homogenous group, and events in the course of life (divorce, death of spouse, physical, and mental impairments) could render some elderly needier than others. The planning and design of residential estates play a crucial role in enabling and supporting the diverse needs of the elderly in maintaining self-reliance and social participation. In Japan, the Cocofump Hiyoshi development in Yokohama and Residence Ajisai-no-oka in Hadano are examples of residential rental properties for the elderly with on-site care services. Both models cater to the elderly in need of long-term care with facilities that include clinics and dispensing pharmacies. Housing an ageing population, therefore, would mean providing a diverse and flexible range of dwelling options rather than a broad-sweeping template. Such innovations in this area might include: allowing non-related older persons to apply for and live in the same flat; ensuring a mix of dwelling types and, hence, diversity of occupants, in a residential block; and integrating eldercare facilities and amenities in a mixed-use residential development. As independence inevitably declines with age, the provision of affordable eldercare for those who require assisted living in old-old age should be located ideally within public housing estates. A seamless housing continuum enables the elderly to not only age in place but also maintain important social connections and support within the community. A high-rise high-density town environment makes the possibility of a seamless housing continuum viable by leveraging on the verticality and proximity afforded by the compact built form.   Indeed, a compact built form supported by an efficient, multimodal, and elder-friendly public transportation system can also

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improve mobility for older persons. In addition to retrofitting the MRT and bus infrastructure with elder-friendly facilities, more could also be done to enhance wayfinding for elderly commuters through means that tap on the cognitive or intuitive understanding of complex transport hubs such as bus terminals and MRT inter-changes. Pathways for other independent modes of travel involving personal mobility device (e.g. walking aids, motorised wheelchairs, scooters, geriatric chairs, etc.) should also be explored in tandem with the overall pedestrian network plan for a public housing town environment. In this regard, and given Singapore’s high-rise setting, more thoughtful design and planning consideration is warranted in aiding movement between different platform levels for individuals, old and young, with mobility impairments. Here, the spatial–physical principle of distribution can play a role in facilitating safe independent movement. II. Distribution of Services and Amenities Close to Home Closely related to mobility is the spatial–physical distribution of services and amenities. When essential services and daily amenities are readily accessible and, as importantly, with affordable options available, the more likely it is for an elderly to leave home and participate in the quotidian activities of community life. Accessibility can be designed into a high-rise high-density town environment in several ways, two of which we will explore here: street block pattern and land use.   Fine-grained street block patterns comprising smaller land parcels, if not larger ones with pedestrian connections, are more conducive for walking (Frank et al. 2006). It has been widely purported that walkable environments help to promote healthy lifestyles and, for the elderly, this includes active ageing (WHO 2016; Nyunt et al. 2015). Indeed, climate is a crucial factor that can affect one’s decision to travel outdoors, particularly in the case of older persons who are more environmentally sensitive. Singapore’s hot, humid, and rainy tropical climate calls for detailed attention to shading, greenery, and shelter — elements

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which can be incorporated into the built urban environment to create micro-climates that minimise the heat island effect. A comprehensive and inclusive pedestrian network plan, therefore, is derived by good understanding of accessibility and pedestrian behaviour while taking into consideration climatic issues.   Land use is another strategy for improving accessibility through the distribution of services and amenities. Distributing everyday services and amenities from the contemporary large shopping centre format to a more decentralised spatial arrangement at the neighbourhood level requires a mixed-use and flexible approach to land planning. Mixing land use zonings with compatible functions in a high-density living environment can help to bring goods and services closer to residents without dependency on private vehicles. When goods and services are made accessible via the ground level of a residential block, for example, it reduces travel time and encourages active use of public space. The residential estates of Upper Ngau Tau Kok in Hong Kong (public housing) and Banpo Xi in Seoul (private housing redeveloped from a previous public housing project) demonstrate the versatility of situating apartment blocks above a podium with ground level access. The podium accommodates commercial facilities and communal amenities for recreation and public gatherings. This building form was a common model for many of Singapore’s earlier HDB developments such as Kreta Ayer Complex, Tanjong Pagar Complex, and Hong Lim Complex to name a few.   Moreover, the affordability of consumer goods and services is generally influenced by real estate economics. In the case of Singapore’s HDB towns, where the government holds the monopoly on land, state-owned commercial property assets could help regulate the rental market, thereby enabling smaller vendors to pass down cost savings to the consumer. For the elderly, such opportunities to engage in the socio-economic urban life of their community present one mode of inclusion which, simultaneously, gives them visibility — this visibility is significant for it can help to increase public awareness, understanding, and tolerance of ageing issues.

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III. Integration of Living and Socio-economic Spaces Research indicates that an active lifestyle which embodies cognitively stimulating leisure activities (e.g. reading, music, gardening, preparing meals, community work, paid employment, etc.) is associated with lowered risks of dementia and Alzheimer’s disease among older adults aged 55 and above (Niti et al. 2008). Additionally, given that the future elderly are keen to continue working long after retirement age, as this would give them the financial ability to lead an active lifestyle, new avenues could be explored through flexible regulations to enable older persons to operate a business within the home or near the home. At the same time, design typologies beyond the basic void deck merit a rethinking in order to introduce new spatial forms for social activities which help to foster community bonding and cohesion. Again, here, a mixed-use approach to land planning could be a mechanism towards a more integrated concept of living. Such a concept would provide spaces for socio-economic activities that are carefully incorporated into the design of residential estates and buildings so as to generate vitality while maintaining peace and privacy.   Enhancing the ability of the elderly to engage in employment close to home while also forging important links with their neighbours through an active social life within the community could potentially result in two strategic outcomes. Firstly, from a physio-psychological health standpoint, the provision of work opportunities at home or near home enables older persons, who may be less mobile yet cognitively able, to extend their years of productivity and economic contribution. Such a geographical work arrangement based on proximity could help to enhance the meaning of a neighbourhood beyond functional living, particularly for the elderly who are likely to become more place dependent as they age. Secondly, from a social perspective, the provision of informal and formal gathering spaces which are inviting to all residents (in terms of universal design) is one way of ensuring that the elderly are included in the social life of their community. These social spaces could be transformed for various activities as and when required, thereby encouraging

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creative utility and empowering residents to take ownership and responsibility of shared facilities. The Japanese “Otagaisama” community tool, for example, is a social capacity-building model based on mutual reciprocity; in this way, facilitating cooperation and sharing of resources between residents, private corporations, and local governments and organisations towards enhancing the well-being of elderly residents in the community (Ogawa 2015, 2016). In this section, we explore a three-principled policy and planning framework for an age-friendly vertical urban environment. The three principles are mobility for independent living, distribution of services and amenities close to home, and integration of living and socioeconomic spaces. Conceptually and by design, these three pillars are inter-connected; in other words, an efficient distribution and integration of land uses improves the state of mobility for the elderly and, conversely, a comprehensive transport network directly determines the comprehensiveness of services and amenities provided at the various scales of a public housing estate. Moreover, in Singapore’s context, urban density and high-rise development are the critical elements and all-pervading characteristics of the built environment. As such, it is necessary that mobility, distribution, and integration be considered along the same plane as these other land use objectives. In time to come, technological advancements could produce aids and tools to intensify the inter-connectedness between the spatialphysical principles of mobility, distribution, and integration. Presently, Singapore has developed a “Smart Nation Platform” which includes the Intelligent Nation (iN2015) Master Plan — a goal-oriented roadmap for harnessing information and communications technology across various sectors in order to build a well-connected society and grow competitively (IDA 2016). It is promising, then, that today’s future elderly are not only knowledgeable but also receptive to novel and sophisticated Smart applications that could improve their everyday lives in terms of practicality, convenience, and personal safety in a vertical urban environment. The intrusion of technology in contemporary society will continue unabated and its intersection with an ageing population would certainly manifest in a number of areas that

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include: assistive devices to augment deficits in functional abilities; sensing and alert systems for enhanced safety; locational systems for wayfinding to compensate for cognitive impairments; autonomous personal mobility to extend the elderly’s travel range; and robotics of all forms to assist, guide, manage, and augment the physical and mental well-being of the future elderly.

8.7. CONCLUSION The significance of urban density and, hence, the impetus for Singapore as a small island-nation to develop in an increasingly high-rise fashion are essential points to address when discussing the topic of urban policy and town planning. When we add to this discussion the factor of an ageing population, it would seem more critical then to question how a high-rise high-density town environment could enhance the quality of life for older persons. By rethinking Singapore’s “new town” model vis-à-vis key issues and trends in ageing, we identify potential areas where policy and planning could work hand-in-hand to derive a vertical urban environment that enables the future elderly to age actively and, if they so choose, to age in place. Here, we explore a framework of three inter-connected spatial-physical principles comprising mobility for independent living, distribution of services and amenities close to home, and integration of living and socio-economic spaces. Firstly, mobility can be an enabler of independent living for the aged. Providing alternative housing typologies and affordable eldercare services in a seamless continuum together with accessible transportation options is advantageous in two ways: it supports those with the desire to age in place and improves physical mobility within and beyond the vicinity of home. Secondly, distribution of services and amenities (e.g. clinics, shops, markets, hawker centres, etc.) close to home encourages walking and use of public transportation over short distances for routine daily needs. Generally, people will become more place-bound in their less active and mobile senior years; hence, it is important to ensure that essential services and amenities are within close reach. Finally, integration of living and

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socio-economic spaces through, for example, the provision of social activity areas and work units within public housing is one way of creating opportunities for social interaction and income generation in the silver years. Theoretically, this three-principled approach aims to enhance the quality of life in ageing by increasing the inclusion of older persons within society. We acknowledge, however, that the implementation of ageing-related policies and elder-friendly planning initiatives towards greater integrated living can be hindered in varying degrees by public resistance. Overcoming the challenges of public resistance — arising from NIMBY (Not In My Backyard) attitudes, age discrimination, misperceptions of the elderly, and other barriers — requires a transformation of the societal psyche. In order to foster greater awareness and empathy towards ageing issues, perhaps it is all the more advantageous to trial new policies and initiatives that not only increase the visibility of older persons within their communities but also illuminate their contributions to society in a positive light. As a land-scarce island-nation, Singapore has generated invaluable lessons with regards to land planning and development. These lessons point to the fundamental strategy of long-term, comprehensive planning for achieving a sustainable high-rise high-density urban environment; however, the transferability of this planning framework to other vertical Asian cities needs to be cautioned. For instance, the deep intrusion of motor-vehicle traffic within HDB estates, albeit introduced with good intentions influenced by a Modernist planning paradigm, is antithetical to the safe, liveable environment conducive to ageing. In this regard and responding to increasing need for sustainability, Singapore is presently moving towards engendering a car-lite urban environment. The contestation between personal mobility devices, pedestrian, and vehicular traffic is another fundamental issue to be resolved. Friction of such a nature is an expected occurrence in a high-rise high-density urban environment that any policy for ageing must consider and ameliorate. More specifically, where day-to-day liveability is concerned, it is important to critically question the effectiveness of the Singapore new town

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model in promoting a good quality of life, especially in light of impending population growth and ageing over the next few decades. These significant demographic trends will have implications for land use and development, thereby creating a necessary prompt for rethinking public housing policies and neighbourhood design in a way that will help to build age-friendly communities that are inclusive, cohesive, and vibrant for all — young and old.

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CHAPTER 9

HEALTH AND HEALTHCARE Goh Lee Gan and Marie Nodzenski

9.1. INTRODUCTION An ageing population has multifaceted and dynamic issues. As such, delivering medical care to the elderly requires us to consider a variety of factors ranging from the physical ailments of the patient himself, the patient’s external environment as well as family and social structures. William Reichel (Reichel et al., 2009) outlines 11 essential principles that should be considered in the care of the elderly patient: · The physician acts as integrator of the biopsychosocial-spiritual model: Medical care has become more complex and specialised, which has resulted in fragmentation of medical thought and care. The ideal model of healthcare will exist when the patient is seen not form a single specialty point of view but with the full appreciation of other organ systems, emotional or psychosocial factors, information based on the continuity of care over time, and knowledge of the patient’s family and community. In considering such factors, the primary care provider is helping the patient to obtain healthcare most consistent with his own preferences and needs. · Continuity of care: optimum healthcare can only be provided to the older adult by an ever-expanding team of professionals, 241

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·

·

·

·

·

·

including primary care and specialty physicians, hospitalists, nurses, therapists and social workers. Particular attention should be paid at transition points in the care of the patient, at which the physician must ensure the patient’s treatment plan, values, expectations and preferences are known and honoured. Bolstering family and home: physicians should be able to recommend services such as home health-aids, day-care, visiting nurses, home-delivery meal programs, etc. Communication skills: critical for good management of elderly care. Increasingly communication will have to be culturally sensitive. Communication involves not only the patient but families as well. Doctor-patient relationship: building a sound relationship requires understanding patient thoroughly. It is also important for the physician to understand family dynamics. The relationship with the patient should be seen as a partnership: both parties should be frank, honest and share information truthfully. Need for thorough evaluation and assessment: It is often difficult to disentangle the physical from the emotional, particularly in elderly populations. Yet, proper diagnosis is essential to make specific treatment plans. Affecting our diagnostic thinking in evaluating an elderly patient would be the consideration of what is physiological versus what is pathological. Even when specific functional capacities change with age, health problems need not be a consequence of ageing. Many of the most common disorders of old age result from pathological processes and not from normal ageing. This constitutes a crucial point as the benefit-risk balance (for medication particularly) is a central tenet in the medical care of the elderly. Prevention and health maintenance: clinicians need to be prepared to discuss the relative risks and benefits of screening tests and preventive medicine in the context of the patient’s overall health status and preferences. Intelligent treatment with attention to ethical decision-making: in the care of the elderly, physicians should attempt to apply the principle of “minimal interference” by resisting the temptation

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to treat a new problem that is poorly understood with still more medications. · Interprofessional collaboration: improvement in healthcare of the chronically-ill elderly requires that health professionals work together for the best interest of the patient. This collaboration will be even more important as more community-based, LTC options involving home care, home hospice care and other services, and care of patients with multiple, complex comorbidities become the norm. · Respect for the usefulness and value of the aged individual. · Compassionate care. While such principles lay the foundations for providing adequate medical care to the elderly, many challenges will arise. We are facing changing times in healthcare. Indeed, in the performance of these essential aspects of care, physicians and care providers may often be distraught, and feel discouraged during this period of costcontainment, evolving pay for performance rule, increased competition, threats of malpractice and other forces in healthcare reform (Reichel et al., 2009).

9.2.  PHYSICAL HEALTH ASPECTS OF AGEING Although seniors are living longer today, many of them suffer from a chronic disease burden, often characterised by co-morbidities complex to treat. Solutions lie in paying attention to chronic disease prevention and treatment (WHO 2000). A direct link exists between 4 high-risk diseases (obesity, hypertension, diabetes, high cholesterol) and commonly known end organ damage (heart attacks, strokes, narrowing in the leg vessels, chronic kidney disease, diabetic eye disease and dementia). This can be prevented by attention to correcting adverse lifestyles and treating high-risk diseases. The disease burden in older adults can be assessed with three measures: Disability Adjusted Life Year (DALY), Years of Life Lost (YLL) and Years Lived with Disability (YLD) (WHO 2006). DALY is a health gap measure that extends the concept of potential years of

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life lost due to premature death (PYLL) to include equiva­lent years of “healthy” life lost by virtue of being in states of poor health or disability. DALYs for a disease or health condition are cal­culated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition (WHO 2006). Diseases such as ischaemic heart disease, lower respiratory tract infection, lung can­ cer, colon and rectum cancer result in short periods of disability but kill faster. Diseases such as diabetes mellitus, anxiety and depression, schizophrenia and strokes do not kill outright but lead to long peri­ ods of disability. In Singapore, the most prevalent conditions are hypertension (52.1%), joint/nerve pain (30.7%) and diabetes (21.8%) while the most disabling conditions are stroke, pelvic/ femo­ ral fractures and osteoporosis (Malhota et al., 2012). See Figure 9.1 (Phua et al., 2009).

Figure 9.1.  Diseases Causing Long and Short Disability-Adjusted Life Years (DALYs) by Broad Disease Group. Singapore, 2004 Burden of Disease Data.

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Functional assessment is thus central in the care of the elderly patient. Indeed, function is the filter through which physicians must view the elderly patient to provide optimal care. The comprehensive geriatric assessment (CGA) is “a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person’s problems” (National Institutes of Health Consensus Development Conference 1988). The multidisciplinary team conducting the CGA will use a systematic approach that incorporates validated assessment tools to assess multiple domains of function, including physical, mental, social, functional and environmental (Gazewood 2009). See Table 9.1a. In assessing the functioning of the elderly patient, Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) usually constitute reliable indicators. ADLs measure basic functioning by rating basic physical function and including Table 9.1a.    CGA Domains and Elements to Assess in the Patient. CGA Domains Physical health

Elements to Assess New diagnosis. Existing diseases. Medication review. Nutrition status. Frailty status. Advanced medical directive.

Mental health

Cognition. Capacity. Mood. Anxiety. Fears.

Social circumstances

Formal and informal careers. Community team involvement. Lasting power of attorney

Functional ability

Activities of daily living (ADL). Instrumental activities of daily living (IADL).

Environment

Housing and place of residence. Safety features (e.g., personal alarms, Telehealth equipment). Equipment (e.g. pressure mattress). Transport facilities.

Source : Blundell A & Gordon A, 2015.

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246  Ageing in Asia: Contemporary Trends and Policy Issues Table 9.1b.    Activities of Daily Living and Instrumental Activities of Daily Living. Activities of daily living (ADL) After Sidney Katz (1)

Instrumental activities of daily living (IADL) After Lawton and Brody (2)

Bathing Dressing Feeding Toilet Mobility Transferring Shopping Housekeeping Laundry Ability to handle finances Responsibility for own medications Food preparation Ability to use telephone Mode of transportation

Source : (1) Katz et al, 1970 (2) Lawton and Brody, 1969.

assessment of communication and cognitive skills for daily functioning. IADLs measure more advanced functions that require intact cognitive and executive function, in addition to intact physical function (Gazewood, 2009). See Table 9.1b. 9.2.1.  Comparative Ageing Policy Developments to Reduce Physical Disability It is noteworthy that as ageing populations in Asia learnt from the experiences of their ageing populations those strategies effective in reducing disease burdens became policy end-points. 1. Japan’s superior population health status. A comparison of the educational differences on physical health, mortality, and healthy life expectancy in Japan and the United States, two long-lived populations, was done. It was found that the education coefficients from physical health and mortality models were similar for both Japanese and American populations, but the older Japanese had better mortality and health profiles. Japan’s compulsory national health service system since April 1961 and living arrangements with adult children

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probably played an important role in its superior health profile compared with that of the United States (Chiu, Hayward, and Saito, 2016). 2. NCD control strategies in Japan and China. A two-country comparison between Japan and China in the experience of NCD control strategies by Wu et al (Wu, Narimatsu, Nakamura, et al, 2017) showed that Japan made great progress in primary prevention of NCDs through strong legislation, the implementation of its “Specific Health Check and Guidance System” and a unique licensed health professional system. China was attempting to improve on its NCD control; and since the New Medical Reform in 2009, China also legislated its NCD control with good results. Wu et al’s paper demonstrated the impact of social policy on healthcare reform in Japan. The results also showed the benefits of countries learning from one another to cope more effectively in lowering the burden of NCDs. 3. WHO’s life course approach in prevention of chronic disease. It is now accepted worldwide that a life course approach of healthy lifestyle is the way to reduce physical disability (WHO, 2017). 4. Fries et al ’s work on reduction of physical disability through healthy lifestyle adoption. Working on several population cohort studies conducted from 1980–2011, Fries et al were able to provide that there was a consistent development of disability with age in elderly patients as their prevailing risk factors increased from a low (0), moderate (1), to high (2–3) number of risk factors (Fries, Bruce, and Chakravarty, 2011). See Figure 9.2. 5. Singapore’s population healthy lifestyle programme. Singapore’s adoption of the healthy lifestyle approach in its population prevention programme was also able to achieve similar results of reduction of physical disability. The comparison of the data from its National Health Surveys of Senior Citizens of 2011 and 2005 showed reduction of mobility limitations (Kang, Yong, and Chan et al, 2016). The takehome message of Fries’ healthy lifestyle studies and Kang’s healthy lifestyle studies is this: a healthy lifestyle can reduce physical disability.

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Figure 9.2    Development of disability with age in seniors after age 68 in subjects with low (0), moderate (1) and high (2–3) risk factors in 1986. Source: Fries, Bruce, and Chakravarty, 2011

6. The importance of oral health proven in Japanese study. Poor oral health results in an increase in the number of years lost to disability (YLD). Preventing tooth loss to retain 20 or more teeth and treatment of gum disease were shown in a cohort study conducted by Matsuyama et al to reduce YLD and compress morbidity (Matsuyama, Aida, and Watt et al, 2017). This is an important discovery. 7. China’s policy announcement of its political will to invest in public oral health. Chinese president Xi Jinping’s keynote speech at the National Health and Wellness Conference on 19 August 2016 showed “the tremendous political will of the Chinese government to invest in public oral health”. Of note, most of the health policies released by the government covered the promotion of oral health (Zhou, Xu, and Li et al, 2018).

9.3.  MEDICAL CARE FOR THE ELDERLY 9.3.1.  Prevention/Early Detection of Disease In caring for the elderly, prevention and early detection of disease will be key. An ideal strategy to reduce the disease burden in the

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elderly will entail three approaches which are not mutually exclusive (Kuh et al, 2014): 1) Reducing risk factors/Lifestyle change (smoking, diet, exercise, weight) 2) Blood pressure control 3) Diabetes Mellitus control and 4) High cholesterol control. A special note on diets for the elderly should be made. Indeed, dietary guidelines for the older adult is necessary (HPB, 2014) (see Tables 9.2, 9.3, and 9.4) as they run the risk of potential dietary insufficiency caused by age-related increases in nutrient requirements combined with a reduction in energy requirements. Health prevention for the older adult should also include immunisations against: · Infection-related cancers e.g., Hepatitis B carrier state and hepatocellular cancer; Human papilloma virus infection and cervical cancer; Table 9.2.    Lifestyle Change. WE CAN • Stop smoking • Diet — go for a healthy diet • Exercise • Weight — aim for BMI below 23 DIET Know the 50%–25%–25% formula for each meal: 50% vegetables, 25% starch, 25% protein • Eat every meal but no snacking; no sweet drinks • Eat 70% full • Choose lower calorie foods to lose weight • Write down everything you eat and drink in a food diary EXERCISE •  Regular physical exercise —- Start low, make it regular. Aim for 30 minutes a day, 5 days a week • Stay active WEIGHT CONTROL •  10% weight loss in 6 months (blood pressure drops 1 mm for each kg of weight reduced) • Continue stepwise, 10% weight reduction every 6 months

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250  Ageing in Asia: Contemporary Trends and Policy Issues Table 9.3.    Blood Pressure Control. ACTIONS TO TAKE • Be physically active to achieve health weight — for every kg weight reduction, BP drops by 1 mmHg • Follow healthy eating plan • Reduce salt in your diet • Take prescribed drugs as directed • Monitor your blood pressure weekly MONITOR BP • Once a week — in your bed clothes — morning when you get up and evening the last thing before you sleep • Record in a booklet • Morning reading should be less than 135/85 mmHg • Evening reading should be less than 120/70 mmHg

Table 9.4.    Diabetes Mellitus. KNOW YOUR TARGETS • HbA1C — Check every 3 months — Goal — below 7 • BP — Check every 3 months — Goal — below 130/80 • Cholesterol (LDL) — Yearly Goal below 2.6 • Cholesterol (HDL) —- Yearly Goal above 1.0 • Triglycerides — Yearly Goal below 1.7 • Weight — Goal — BMI below 23 SEE YOUR DOCTOR REGULARLY • See your healthcare team four times a year —- At each visit check BP, Foot, Weight, Review self-care plan • Four times a year — check your HbA1C test — more often if it is over 7 • Once a year check — Cholesterol, Complete foot exam, dental exam for teeth and gums, retinal photograph for eye problems • At least once in a lifetime get — pneumococcal vaccine

· Influenza; and bacterial pneumonia. Protection against these respiratory viruses and bacteria, respectively, prevents elderly people from suffering secondary complications of pneumonia. Finally, H pylori infection of the stomach in endemic countries like Japan, Korea, and China predisposes one to stomach

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·

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cancer. With the early diagnosis of such infections by endoscopy and biopsy, there has been in a drop of H pylori-related stomach cancer in these three countries (Wu & Lin, 2015). Screening Osteoporosis: all women should be screened starting at the age of 65. Particular attention should be paid to Vitamin D deficiency which is common in post-menopausal women with osteoporosis Hearing: associated with isolation and depression Vision: increased risk of depression, physical disability (falls and hip fractures), poorer performance in ADLs Falls/Injury prevention: risk factors for falling include postural hypotension, use of psychoactive medications, the use of four or more prescription drugs, environmental hazards, balance impairment, muscle strength impairment.

In Singapore, a life course approach to successful ageing has been adopted. It particularly focuses on chronic disease control (lifestyle, high risk disease treatment, complications prevention and treatment), active ageing (physical disability prevention, dementia prevention, loneliness prevention and mental ill-health through paying attention to social connectedness, dementia prevention programme), Mind your head (fall prevention) and health screening. See Table 9.5. 9.3.2.  Polypharmacy and Inappropriate Use of Medication Polypharmacy and inappropriate use of medication is a central issue in the medical care of the elderly. Older patients usually have several pathologies leading to polypharmacy and are thus prone to adverse drug reactions from inappropriate medication. Drug-related incidents are common reasons for acute hospital admission. Optimal drug use includes prescription of appropriate medication as well as avoidance of under-treatment, over-treatment and drug-drug or drug-disease interaction (Ma et al., 2008). A study of 454 residents in three selected nursing homes in Singapore revealed that residents are on an average of 5.32 medications. Polypharmacy and inappropriate medication was seen in 266 (58.6%) and 318 (70%) of residents, respectively (Mamun et al., 2004).

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252  Ageing in Asia: Contemporary Trends and Policy Issues Table 9.5.  Functional Screening Programme for Older Adults of 60 Years and above in Singapore. CONTINENCE

In older women, with age, laxity of tissues may result in leakage of urine when one coughs or laughs. This is called stress incontinence. In older men, enlargement of the prostate may result in overflow incontinence. Both situations are eminently treatable.

MOOD

Changes and losses can result in low mood and sadness. Early detection and treatment result in improvement and cure. A positive mindset helps to maintain a happy mood despite setbacks.

PHYSICAL FUNCTION

Good physical fitness is important in performing daily activities. Much can still be done to improve less than optimal physical function. Try out the Health Promotion Board (HPB)’s Strength Training Programme (STEP).

ORAL HEALTH

Good oral health helps seniors enjoy their food and maintain good nutrition. Maintenance of teeth and gums into ripe old age has its rewards.

HEARING

With age, hearing loss takes place in some. Hearing aids and assistive listening devices are usually able to address the problem.

VISION

Falls and accidents due to poor vision can be prevented. Cataract is a common cause. Regular monitoring of eyesight for changes can help seniors increase their level of independence.

Source: Health Promotion Board, Singapore.

Some reasons for the increased attention to prescribing in the elderly population include: (1) increased sensitivity to drug effects that this patient population experiences secondary to pharmacokinetic and pharmacodynamics changes that naturally occur with ageing (2) the less than optimal medication adherence rates that have been observed within this patient population (3) the current state of not fully following and applying treatment guidelines to these patients (4) the high incidence of both under prescribing and polypharmacy among these patients (Umland et al., 2009).

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9.3.3.  Traditional Medicine and Complementary and Alternative Medicine (CAM) Many elderly patients suffering from chronic diseases and pain may resort to alternative medicine. In the Asian context, traditional and alternative medicine is even more popular, particularly among the elderly. Most of the elderly Singaporeans prefer to consult traditional healers, who are popular because of the accessibility of their service but also because they share same socio-cultural beliefs about illness and health. A powerful therapeutic factor is the rapport between the patient and the healer, who is able to explain the symptoms using the socio-cultural belief system familiar to the patient. It is thus crucial to understand the role that traditional medicine and CAM play in the medical care of the elderly patient. A recent study conducted among elderly Chinese women in Singapore (Chang and Basnyat, 2015) highlights some of the underlying issues and conflicts surrounding TCM and CAM. Medical decision-making is intrinsically linked to personal and cultural understandings of health, medical principles and therapeutic choices in relation to particular life experiences, social bonds and broader environments (Cant and Sharma, 1999). Cited reasons for the use of CAM include dissatisfaction with the limitations of biomedicine (or Western medicine), preference for customised and holistic care and desire for wellness (Dunfield, 1996; McGregor and Peay, 1996). It has been observed that while TCM may be culturally preferred, biomedicine is usually used in the first instance. But this may be explained by medical subsidies for Western medicine. The study reveals a general perception of each practice as limited (Western medicine as being too fragmented and TCM too uncertain), yet institutional tensions between biomedicine and TCM have discouraged the patients from disclosing their medical decisions to practitioners in each system. The reliance on personal judgement from the patient in this context shows the pressing need for more integrative medicine. Some Asian countries (Korea, Taiwan, and China) have

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incorporated TCM in their mainstream health systems and may serve as examples in this regard (Chang and Basnyat, 2015). 9.3.4.  Integrative Medicine Integrative Medicine is defined as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing” (Consortium of Academic Health Centers for Integrative Medicine). Integrative medicine is a developing approach to healthcare that is increasingly in demand and in many ways seeks to return to a system that is personal, supportive, as non-invasive as possible and holistic. True integrative medical clinical practice and research apply and attempt to quantify benefits derived from dietary guidelines, nutritional supplements, stretching/exercise/yoga, stress management techniques, and other approaches followed at the same time (Edman and Herbert, 2009). Integrative medicine (see Table 9.6) may thus include a stronger focus on: 

Nutrition: use of specific dietary guidelines and targeted nutritional supplementation. Elderly are at significant risk for malnutrition and clinical or subclinical nutritional deficiencies  Physical medicine: movement therapies (Tai Chi, Chi gong and yoga: a multicentre study by Emory University found that Tai Chi practiced for an hour twice weekly is the single most effective intervention widely available, reducing falls by 47.5% in people older than 70)  Treatment of chronic pain: main reason why people turn to integrative medicine. The most common pain is due to osteoarthritis. Acupuncture is deemed safe and effective in the treatment of OA. The WHO lists 40 common conditions for which acupuncture should be considered as treatment  Manual therapies: Osteopathic Manipulative Medicine; Chiro­ practic; Therapeutic massage

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Table 9.6.    Classification of Integrative Medicine/CAM Practices with Examples. Dietary, Nutritional Supplement, Herbal and Other Biological Therapies Use of diet and supplementation for therapeutic and preventive purposes Therapeutic diets

Intravenous therapies

Vitamins, minerals, fatty acids…

Aromatherapy

Herbs

Detoxification

Manual Healing Methods Systems that are based on manipulation and/or movement of the body Osteopathic manipulative therapy

Pressure point therapies

Chiropractic

Postural/Movement re-education therapies

Massage therapy

Bioenergetic systems

Mind-Body Interventions Behavioral, psychological, social and spiritual approaches to health Biofeedback

Mindful-based stress reduction

Meditation

Hypnosis and imagery

Yoga

Prayer and mental healing

Tai Chi and Chi gong

Art and music therapy

Alternative Medical Systems Complete systems of theory and practice that have been developed mostly outside of the Western biomedical model Traditional oriental medicine

Naturopathic medicine

Acupuncture

Homeopathic medicine

Ayurvedic medicine

Environmental medicine

Energy medicine Source: Edman and Herbert (2009).



Postural/movement re-education therapies: yoga is useful in pain management  Energy therapy: Reiki  Emotional and spiritual well-being: it is the heart of integrative medicine. Disease is thought to be influenced by stresses, thought processes, emotional factors and one’s spiritual life. Practitioners must therefore look at the physical body but also consider mental and emotional characteristics

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9.4.  WHAT IS SUCCESSFUL AGEING? 9.4.1.  Successful Ageing How can successful ageing be defined? Such a definition surely differs from person to person and culture to culture. Yet, the majority of definitions will have a focus on the absence of disability with lesser inclusion of psychosocial variables (Edmondson and Charmak, 2009). The biological model of successful ageing is based on longevity and the compression of morbidity while psychosocial models will highlight social interaction and well-being as determinants. Rowe and Kahn’s model describes three components of successful ageing: avoidance of disease and disability, maintenance of cognitive capacity and active engagement. Baltes and Baltes’ model (1990) view successful ageing as a process of continuous adaptation to late-life changes (Edmondson and Charmak, 2009). Singapore’s Successful Ageing Strategy (Singapore Ministerial Committee on Ageing, 2015) aims to ensure that all levels of society are well prepared for the challenges and opportunities of an ageing Singapore. This can be achieved at different levels. At the individual level, Singaporeans should be healthy, active and secure and they should lead independent and fulfilling lives (IMC, 1999). At the family level, the objective is to develop strong and caring families based on relationships of interdependence. At the community level, the objective is a strong network of community services and integrated communities providing opportunities for engagement and participation. At the national level, preparedness is key to achieve a competitive economy as well as social cohesion. This strategy consists of four pillars: 

Financial independence (living expenses, medical expenses and housing) to be achieved through continuous training of older workers, continued employability of the elderly

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

Ageing in place (raise awareness of architects, developers and homeowners of the need to create safe home environments for elderly)  Healthcare — Chronic Disease Control (emphasis should be on health promotion and disease prevention- When services are needed, they should reinforce and support the family in its role of caring for elderly members)  Active Ageing (Council of Third Age set up in 2007 — promotion of physical exercise, hobbies, productive pursuits, social activities, educational courses) The Singapore Strategy goes beyond Rowe and Khan’s model (Rowe and Kahn, 1997) as it goes beyond physical, social, mental and cognitive dimensions and addresses important issues like financial independence and ageing in place. 9.4.2.  Ageing in Place In light of increasing longevity and rise in healthcare costs, ageing in place is an important component of successful ageing. To be able to age in place independently, older adults will increasingly make use of assistive devices. As such, healthcare and technology is increasingly becoming a cornerstone of geriatric care. As individuals try to cope with health-related issues such as falls, sensory impairment, diminished mobility, isolation and medication management, they seek solutions that will enhance their lives and allow them to stay at home. The term “gerontechnology” has been coined to describe an interdisciplinary field of scientific research of technological applications (including smart homes) that are directed towards aspirations and opportunities for the elderly person. But as technological advances enable sophisticated home-based solutions, we need to ensure that the design and implementation of informatics applications for older adults are not determined simply by technological advances but by actual needs of end users (Demiris and Hensel, 2008) (see Table 9.7).

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258  Ageing in Asia: Contemporary Trends and Policy Issues Table 9.7.    Categories of Health-Related Smart Home Technologies. Physiological monitoring

Collection and analysis of data pertaining to vital signs (pulse, respiration, temperature, blood pressure) as well as blood sugar level, bladder and bowel output.

Functional monitoring/Emergency detection and response

Collection and analysis of data pertaining to functional measurements such as activity level, motion, gait, meal intake, and other ADLs. Emergency detection enabled through data indicating abnormal situations (such as falls).

Safety monitoring and assistance

Collection and analysis of data pertaining to measurements that detect environmental hazards (fire, gas leak, etc).

Security monitoring and assistance

Measurements that detect human threats such as intruders.

Social interaction monitoring and assistance

Collection and analysis of data pertaining to social interactions (phone calls, visitors, participation in activities, etc). May include technologies such as videobased components that support video-mediated communication, virtual participation in activities, etc.

Cognitive and sensory assistance

Include technologies of automated or selfinitiated reminders and cognitive aids such as medication reminder, lost key locators, etc. Also include task instruction technologies (for appliances, for instance). Aid users with sensory deficits.

Source: Demiris and Hensel, 2008.

9.5.  FUTURE PROSPECTS 9.5.1.  Adapting to Population Ageing in Singapore Three strategies have been put in place in Singapore: 1. Population strategies. 2. Liveability strategies.

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3. Age-friendly strategies: four shifts in healthcare will be necessary to achieve this (Tong 2015): (1) providing more comprehensive support for outpatient treatment in the form of the Community Health Assist Scheme to subsidise treatment for lower or middleclass Singaporeans at private GPs (2) Replacing MediShield with the universal, compulsory health coverage scheme of MediShield Life (3)Right-siting services to give people better, more affordable care in their communities and improving access to GPs and polyclinics (4) encouraging Singaporeans to take care of their health through campaigns promoting healthier food choices, active ageing, and more healthy lifestyle amenities. Moving beyond developing aged care services, the Ministerial Committee will co-ordinate a whole-of-nation effort to put together a coherent national agenda to prepare our population for successful ageing. The masterplan will cover seven diverse areas — lifelong learning for seniors, employment, volunteerism, urban infrastructure, healthcare, retirement adequacy, and research into ageing (Minister Gan Kim Yong, 2014). 9.5.2.  Integration of Health and Social Care Integrated medicine for the elderly would imply better integration of services, of levels of care but also of professionals. Exponential achievements in medical sciences as well as treatment deliveries will empower patients to take greater responsibility for their own care. There will be greater accessibility to medical information, low-cost wearable technology and more supporting social services. The doctor-patient relationship may be re-defined. The role of the doctor will evolve beyond that of traditional ‘medical prescription’ to include social care-giving and case-management. Besides treating illnesses, doctors will help people maximise wellness by their exercising more, eating healthy and building strong social networks. A doctor will assess his patients’ needs and directly match them with the appropriate social support

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services. Doctor’s “social prescription” approach acknowledges the importance of systematically linking patients with a variety of other services that provide more than medicine and promote holistic recovery. Such an approach involves communities and social networks in patient care. We will increasingly witness a close interplay between doctors, patients, social workers and the wider community. Geriatrics remain a newly-developed specialty in Asia and only Taiwan, Japan, Singapore and Hong Kong have developed specific medical programmes pertaining to elderly care. Asian countries tend to lack well-established GP systems and post-acute care service systems, which jeopardises the chances of frail elderly patients to receive sufficient rehabilitation. In this regard, intermediate care stands as a promising development by integrating social and health services close to home in order to promote functional independence and prevent unnecessary hospital re-admissions (Peng and Chen, 2012). 9.5.3.  Sustaining Ageing Populations The UN Foundation launched in 2002 its Madrid International Plan of Action on Ageing (MIPAA) and in 2015 its accompanying Agenda of 17 Sustainable Development Goals by 2030. Together these two initiatives will provide countries worldwide with a roadmap for sustaining ageing populations. Progress on the MIPAA national initiatives in the Asia Pacific countries was reviewed in the MIPAA intergovernmental meeting held in Bangkok, 12–14 Sep 2017 (UN Economic and Social Council, 2017). There are three sets of priority actions for member countries to adopt (UN 2002), (UN 15 Sep 2017). 1. Older persons and development. Active integration of older persons into social and economic development is MIPAA’s first priority area. · In this context, with regards to participation of older persons, China reported that “in 2012, the Government of China initiated a pilot project to strengthen older persons’ associations and their participation”.

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· Two countries, Singapore and Macao, reported increasing employment opportunities for older persons. Singapore has introduced “an extensive set of measures, including legislation and programmes” and facilitation of “employment prospects of older persons”. In Macao, China employment services and vocational training of older persons in the informal sector were being launched. 2. Advancing health and well-being into old age. Initiatives are taking place. · Actions are being taken to reduce the non-communicable disease burden in China, Japan, and Singapore. Chinese president Xi Jinping made it clear at the National Health and Wellness Conference in Beijing in 2016 that health is the prerequisite for people’s all-round development and a precondition for sustainable development in China (Zhou et al, 2018). Singapore has declared war on diabetes (Gan Kim Yong, Minister for Health, Singapore 23 May 2016). · Healthy and active ageing policies and programmes are being launched by China and Singapore. · Measures to enhance mental health services for older persons were being adopted by the government of China; in Singapore, the government introduced a Community Mental Health Master Plan to improve care for “persons with mental health conditions and dementia”. 3. Ensuring enabling and supportive environments. There are two areas of development: · The MIPAA encourages governments to promote ageing in place, independent and self-sufficient living of older persons, which in turn requires age-friendly and disability-free housing designs and public infrastructure, as well as affordable accommodation and transportation. · Older persons who cannot live independently need care in specialised institutions or assistance-living at home, which in turn require quality long-term and/or home-based care options. This also necessitates professional training of care personnel,

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adequate care standards, education and support for households looking after older family members. 9.5.4.  Universal Health Coverage for Financial Sustainability One contemporary strategy to sustain ageing populations is the adoption of universal health coverage (UHC). In this context, “UHC means that all individuals and communities receive the health services that they need without suffering financial hardship. It includes the full spectrum of essential, quality health services from health promotion to prevention, treatment, rehabilitation, and palliative care” (WHO UHC, 31 Dec 2017). All six Asian economies covered in this chapter have adopted UHC albeit with systemic differences. Countries may learn from the experiences of one another as some authors have suggested. 1. Japan. Japan has adopted UHC since 1961. With the percentage of the over 65 years of age population increasing, the sustainability of the financing system is likely to be strained. As such the idea of “community based integrated care system” has been proposed to make it more manageable financially for the government. There are four elements: self-help (Ji-jo), mutual aid (Go-jo), social solidarity care (Kyo-jo), and government care (Ko-jo) (Sudo K, Kobayashi J, Noda S, 2018). 2. Korea. The national health insurance has provided access to healthcare for all since 1969. The corporatist Social Health Insurance system (multiple insurers) introduced in 1977 was transformed into a single-insurer NHI in July 2000. “These changes were influenced externally by globalisation and internally by political democratization, keeping Korea’s private dominant health care provision system unchanged for several decades” (Lee SY, Kim CW, Seo Nam-Kyu, et al, 2017). 3. China. China is moving towards UHC via the social health insurance. He and Wu (2017) noted “China’s remarkable progress in

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building a comprehensive social health insurance system was swift and impressive.” Starting from less than 30% coverage in 2003, it had achieved 98% coverage of its population after only 10 years. Nevertheless, the country’s decentralised and incremental approach towards UHC has created a fragmented SHI. Three negative consequences were noted: “benefit packages vary considerably across schemes”; the “multiple schemes, complicated by massive migration, resulted in weak portability; and “many individuals are enrolled on multiple schemes, causing inefficient use of government subsidies”. In early 2016, the Chinese government announced its blueprint for integrating the urban and rural resident schemes. 4. Hong Kong. Hong Kong is working on a Voluntary Health Insurance Scheme (VHS). “It aims to encourage the middle- and high-income segments of the society to use private services and leave the overloaded public hospitals to serve the low-income needy”. This Scheme is seen to be lacking in coverage, financial protection, and a major challenge in implementation. 5. Taiwan. Taiwan has implemented National Health Insurance since 1995. The system has had its deficiencies. Although it covers 99% of the population, it is not sustainable. It “guarantees “equal access regardless of socioeconomic status and background. A paper by Lee, Ang and Chiang et al, (2018) made recommendations on what the Taiwanese system can learn from mainland China (insurance coverage; medical safety net; medicine price regulation), South Korea (“two step referral system), and Singapore (tripartite insurance model of Medisave, Medishield, and Medifund). 6. Singapore. Singapore adopted UHC in 2015 as a culmination to the multilayer system of protection made up of universal access with co-payment to promote appropriate care, and the tripartite insurance model of Medisave, Medishield, and Medifund (Sim, 2017). See Figure 9.3.

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Figure 9.3.    Multi-layered Health Coverage Singapore. Source: Sim, 2017; MOH Singapore

9.6.  CONCLUDING REMARKS Developing sustainable health and healthcare systems for ageing populations is an important end in mind for an ageing Asia. This in turn is dependent on achieving the following: 1. Recognising the principles of care of ageing populations are multifaceted and are the foundations of elderly care, as described by Reichel et al; 2. Correcting an adverse lifestyle, early treatment of high-risk diseases, and treatment of end organ damage are the keys to reducing chronic disease burden, old-age disability, old-age dependency; 3. Ensuring all levels of society are well prepared for meeting the challenges at the individual, community and societal levels through the successful ageing framework; 4. Putting in place liveability strategies, age-friendly strategies that comprise the whole of government in scope of action, and 5. Integrating healthcare and social care through better integration of services, levels of care, technology, team care approach, as well as integration of traditional medicine and other systems of medicine where relevant and effective.

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CHAPTER 10

MENTAL HEALTH Kua Ee Heok

10.1. INTRODUCTION The mental health of elderly people in Asia is influenced by cultural beliefs and customs. For more than a 1,000 years, Chinese families have worshipped in their homes three deities who personify longevity, happiness, and wealth. Although many may achieve longevity and wealth, it is happiness that is more elusive. Happiness is related to family relationship and care. Embedded in the Asian tradition of filial piety is the expectation that children should take care of their aged parents and provide financial, social, and emotional support. A study by 424 secondary students (from Raffles Institution) provided insight into family care (Ang et al. 2000). Those students who stayed with their grandparents were more likely to expect their children to look after them in the future (p < 0.05, OR = 1.85, 95% Cl 1.03–3.35), wanted to live with their children in the future (p < 0.01, OR = 2.17, 95% Cl 1.21– 3.92), and communicated well with their grandparents (p < 0.001, OR = 3.22, 95% Cl 1.74–5.96). Family support is more crucial, especially when the elderly is afflicted with illness — physical as well as mental disorders. It is important to note that in the WHO report on the burden of diseases

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266  Ageing in Asia: Contemporary Trends and Policy Issues Table 10.1.    Economic Burden of Diseases — Top Five Causes in the World. Rank 1 2 3 4 5

1990 Disease or injury Lower respiratory infections Diarrhoeal diseases Conditions arising during the perinatal period Unipolar major depression Ischemic heart disease

2020 Disease or injury Ischemic heart disease Unipolar major depression Road traffic accidents Cerebrovascular disease Chronic obstructive pulmonary disease

(Murray and Lopez 1996), old people are most vulnerable in all the five leading causes (Table 10.1). All the diseases and injury are associated with depression or dementia. An issue which confronts many countries is the feminisation of the elderly population; women are outliving men at a significantly higher rate. As of 2015, in Singapore, the estimated life expectancy for women is 84.9 years compared to 80.4 years for men. There are more elderly women with dementia — an epidemiological study of dementia in 1999 found the prevalence of Alzheimer’s disease for Chinese women was 1.8% compared to 1.1% for Chinese men. The figures for Malay women and men were 1.5% and 1.2%, respectively (Kua and Ko 1995).

10.2.  LIFE SATISFACTION Life satisfaction is a subjective perception of one’s overall assessment of life quality and general well-being from comparing one’s aspiration to actual life achievement and conditions. It implies a perspective of past, present, and future life conditions. The major determinants of life satisfaction include education, occupation, marital status, health, income, support from primary groups (family and friends), and participation in social and leisure activities. Life satisfaction is multi-factorial and varies with individuals. In a survey of 2325 elderly Chinese in Singapore (Kua et al., 2004), 70.8% expressed their overall satisfaction as “excellent or

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good” and 29.2% as “fair or poor”. The elderly with “excellent or good” life satisfaction were married, lived with their families, and were more likely to exercise, read the daily papers, attend church or temple regularly, look after their grandchildren, and visit community centres or clubs. About 42% stated the main reason for satisfaction was physical comfort, e.g. owning a house, television, refrigerator, radio, washing machine, etc. The second and third reasons were good health and family relationship. Another study of elderly Chinese conducted 10 years earlier (Kua 1994 ) showed that 72% felt satisfied, and in this group, the main reasons were good family relationship (41%), physical comfort (29%), and good health (23%). There is a change of ranking of life satisfaction after 10 years; in the 1994 study, the elderly were mainly immigrants with low income and dependent on their families to take care of them, but in the 2004 study, the elderly were second generation Chinese who were more financially secure and lived in better homes.

10.3. DEPRESSION With the rapid development of industrialisation in recent decades, the social foundations for filial piety and other traditional virtues in Asia have been greatly affected (Chapter 7). This decline in intergenerational cohesion and maintenance of filial obligations has in turn contributed to the older person’s experience of disappointment and sadness. Lim and Ng (2010) postulated a model whereby the relationship between living alone and psychological well-being is mediated by feelings of loneliness in a sample of 1,205 community-dwelling older women (aged ≥60) in Singapore. Living alone was associated concurrently with lack of a confidant, both of which predicted more depressive symptoms and poorer quality of life through the mediation of loneliness. To the elderly Chinese, depressive symptoms like poor appetite, lethargy, or poor sleep are interpreted as due to a “weakness of mental energy”. The traditional healer understands the ethos of the subculture, and consulting one also avoids the stigma of being

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labelled a “mental patient”, as would happen when they see the doctor in the psychiatric clinic. It is generally more acceptable to seek help for physical complaints than emotional problems in traditional Asian societies. The concept of neurasthenia is readily accepted by patients and families in many communities as a non-stigmatizing diagnosis (Chiu 2002). Hence, rather than a somatisation disorder, neurasthenia is a more generic label that allows individuals to use culturally acceptable metaphors of (somatic) symptoms to express the underlying emotional distress. Depressive disorder is the most common psychiatric illness in late life and is often undetected and untreated. It affects the quality of life of the person, increases the economic burden from direct or indirect cost of treatment or loss of employment, and may even lead to suicidal tendency. The underdiagnosis is partly because the elderly or even the doctor may not understand the symptoms and incorrectly attribute them to the ageing process. Because the depressed person is preoccupied with physical complaints of pain or aches, this could mislead the attending doctor. Sometimes the onset is insidious and the doctor may not recognise the symptoms because of the other multiple physical health problems of the elderly. A Taiwan study conducted by Chong et al. (2001) with a sample of 1,500 elderly Chinese (aged ≥65) using the computerised diagnoses system, Geriatric Mental State — AGECAT, reported the prevalence rate of depressive disorders (major and neurotic) to be 21.3%, which is relatively high and comparable to rates reported in some UK studies. In Singapore, where the population is predominantly Chinese (75%), Kua (1992) assessed a random sample of 612 elderly Chinese (aged ≥65) with the Geriatric Mental State- AGECAT and found that the prevalence of depressive disorders to be 4.6%. In a second study, Kua et al. (1997a) surveyed a random sample of 1,062 elderly Chinese (aged ≥65) and reported the prevalence of depressive symptoms to be 16% and depressive disorders to be 6%. Doctors in primary care have observed that many elderly people may have depressive symptoms, but they do not fulfil the Diagnostic and Statistical Manual (DSM) of Mental Disorders criteria from the American Psychiatric Association for depressive

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disorder. The study on elderly Chinese, Indian, and Malay in Singapore (Soh et al. 2008) adds valuable information on the epidemiology of subsyndromal depression.1 The data were from a cohort of 1,092 subjects from a nationally representative multi-ethnic stratified random sample of older adults aged 60 and above. The prevalence of subsyndromal depression was 9.6% (Chinese 10.1%, Malay 8.2%, and Indian 12.6%). In the multivariate analyses, controlling for age, gender, education, ethnicity, and socio-economic factors, both syndromal and subsyndromal depression were significantly associated with medical comorbidities, comorbid dementia, and functional disabilities.

10.4. DEMENTIA The rising tide of dementia is a global concern for it affects both developed and developing countries and will be a major public health issue because it exacts a heavy toll on not only just health services and family life, but also the national economy. In the Japanese or Chinese vocabulary, the term “dementia” implies “stupidity” or “mindlessness” — it is humiliating to elderly people. Consequently, many elderly people are reluctant to seek medical consultation because of the stigma. Recently, there are attempts by the Japanese and Chinese medical communities to agree on a more appropriate word. In India, China, and the surrounding Western Pacific and South Asian countries, there is a phenomenal increase in the number of cases (Table 10.2). Among countries in Asia, there is variation in prevalence rates, and the range is between 3% and 6%. Assessment of memory impairment in late life at the primary care clinic has been difficult because of limitations of assessment instruments. Many existing clinical memory tests lack adequate normative data, reliability, and validity. A brief questionnaire is needed 1

 Subsyndromal symptomatic depression is defined as a depressive state having two or more symptoms of depression of the same quality as in major depression (MD), excluding depressed mood and anhedonia (Sadek and Bona 2000).

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270  Ageing in Asia: Contemporary Trends and Policy Issues Table 10.2.    Prevalence of Dementia In Asian Countries. Country

Prevalence (%)

Singapore (Kua 1992) Taiwan (Lin et al. 1998) Sri Lanka (de Silva et al. 2003) Korea (Jhoo et al. 2008) India (Mathuranath et al. 2010)

2.3 3.7 3.9 6.3 3.7

China (Zhao et al. 2010)

2.9

to screen for cognitive change among elderly people in the community, clinic, and hospital. The Mini-Mental State Examination or MMSE (Folstein et al. 1975) is widely used around the world, but because it will take 20 minutes to administer, the doctors in primary care are reluctant to use it. We have constructed a screening questionnaire called the Elderly Cognitive Assessment Questionnaire or ECAQ (Kua and Ko 1992) for the detection of dementia by the primary care doctor or nurse. The ECAQ is less biased on educational status and can be completed within 5 minutes — it is now used by many primary care doctors in Singapore, Malaysia, and Indonesia. The selectively lower risks of dementia among population groups, such as Chinese and rural Indians are intriguing, and suggest that some possibly unique elements of Asian lifestyles, including traditional dietary patterns, could affect mental health (Kamphuis and Scheltens 2010; Feng et al. 2010). Tea, a beverage originated from China and widely consumed among Chinese, could delay cognitive decline and prevent cognitive impairment in old age (Ng et al. 2008). Environment, family care, and social activities are likely to vary among ethnic groups and contribute differently to the level of cognitive functional reserve which predisposes them to the development of dementia (Kua et al. 2013). Dietary and nutritional factors (e.g. homocysteine, B vitamins) are not extensively investigated (Feng et al. 2006). Playing mahjong games is popular among Chinese individuals and this culture-specific game requires complex ability of cognitive and psychomotor functions. There is

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evidence suggesting that playing mahjong may be helpful in reducing the risk of cognitive decline (Niti et al. 2008). There are very few studies on the natural history of dementia in Asia, and one of the first studies on life expectancy of AD patients is the Japanese Hisayama study reported by Matsui et al. (2009). A total of 828 non-demented elderly aged 65 years old and over were followed-up for 17 years, and the authors found the survival curve of dementia cases aged 65–89 years was significantly lower than that of age and sex matched controls (10 years survival rate, 13.6% vs. 29.3%). A recent report from Korea on survival analyses in AD patients included a large study of 724 consecutive patients from a memory disorder clinic in a tertiary hospital in Seoul (Go et al. 2013). The overall median survival time from the time of diagnosis was 9.3 years. The mean period from the onset of the symptoms to the time of diagnosis was 2.8 years, which means the duration of AD is about 12.1 years. Each phase of the disease presents with different psychological and behavioural symptoms with progressive physical frailty and requires different types of health-care services. The Memory Clinic at the National University Hospital, Singapore, started in 1990 as a base for the WHO global study of dementia (Kua et al. 1997b). There were 77 cases of AD with 24 men and 53 women, and the mean age at onset of symptoms was 71 years. The mean duration of the mild-phase was 5.6 years, moderate phase 3.5 years, and severe phase 3.2 years. The number of survival years from onset of the symptoms was about 12.3 years (Kua et al. 2014, Wu et al. 2013, Rawtaer et al. 2015).

10.5.  FUTURE CHALLENGES A realistic understanding of the challenges of retirement would mean careful planning to deal with them. Preventive measures should include maintaining a healthy lifestyle, including regular exercises, a well-balanced diet, and periodic medical check-up. Financial planning is necessary, and keeping mentally active necessitates developing interests and self-fulfilling activities, e.g.

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reading, hobbies, etc. Social adjustment means a need to disengage or relinquish responsibilities — a new role in the family and seeking other roles in volunteerism for instance. All these strategies could be preventive for depression and dementia (Kua et al. 2013). The mental health of the elderly is linked to their social needs such as community and home support. Public education from talks, books, and mass media on prevention is important to decrease morbidity. Using the internet for information on illness and services should be encouraged. A key feature in the provision of health care of the elderly will be the involvement of the community and community-based organisations. The family and the community will need to be given the necessary support, resources, and knowledge to care for the elderly at home. The focus of psychogeriatric care should be in the community. Ideally, a day hospital or centre in the community can be the nucleus of the service with doctors, nurses, psychologists, and other mental health therapists working as a team. A combined geriatric medicine and psychiatry unit is more appropriate — this will facilitate referral, reduce cost, and allow for integration of the two services. With referrals from the general hospital, the day hospital or centre can provide step-down care programmes, and this will reduce the burden of bed shortage in many acute hospitals (Kua 2010).

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CHAPTER 11

LONG-TERM CARE Phua Kai Hong, Winston Chin, Jessica Loo and Puttiporn Soontornwipart

11.1. INTRODUCTION Asia is facing the challenge of increasing demand for long-term care (LTC) in the face of an acutely ageing population. Current government policies on LTC will need to be examined, with a special focus on service delivery and financing. Most financing frameworks are poorly aligned between LTC and acute medical care, generating perverse incentives for hospitalization. LTC services by private for-profit providers are underutilized, and support for informal caregivers remains underdeveloped. There are also concerns about the affordability of LTC, especially for the middle-income groups, and questions about the effectiveness of many existing or the need for disability insurance schemes. Is there a shift towards the concept of targeted universalism — providing universal subsidies for LTC, targeted towards those with the highest levels of need and based on ability to pay? These subsidies could be portable across not-for-profit and for-profit providers. The system of subsidies could be supported by a common needs assessment tool that divides individuals into different levels of need, and robust infrastructure for care coordination. Finally, future options for severe disability insurance must be explored further, with a discussion of a social insurance model for financing LTC. 273

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11.2.  WHAT IS LONG-TERM CARE (LTC)? The specific health issues of the elderly have necessitated a worldwide paradigm shift away from episodic, hospital-centric care, towards LTC. While the definition of “long-term care” (LTC) is debatable, it generally entails a range of services that aim to support elderly with functional and cognitive disability, either in the community or in residential facilities like nursing homes. In recent decades, much attention has been given to LTC policy, especially the aspects of service organization, delivery, and financing. Faced with economic uncertainty and spiralling government budgetary deficits, many Western developed countries have also been forced to reconsider their approaches to health-care financing to achieve greater fiscal sustainability. For the purpose of this chapter, LTC is defined as a continuum of care services to assist an elderly person1 to function in activities of daily living (ADLs). This is clearly differentiated from the health care an elderly receives in the acute care setting (hospitals). There are various models for providing LTC, including institution-based care such as nursing homes, as well as community-based services such as day-care centres.

11.3.  MODELS OF LONG-TERM CARE According to the OECD classification, countries can be classified into three broad clusters based on two main criteria (Inter-Ministerial Committee on Ageing 1999). The three broad clusters are — universal coverage, the mixed model, and the means-tested model. Nordic countries such as Norway, Sweden, Denmark, and Finland provide universal, tax-funded LTC services. In these countries, LTC is a component integrated into welfare and health-care services for the entire population. The other form of universal coverage is a “stand alone, dedicated social insurance arrangement” for LTC services (Colombo, 2011), which is seen in countries such as Germany, Japan, Korea, the Netherlands, and Luxembourg. 1

 Elderly person aged 65 and above.

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On the other hand, there is the means-tested safety net scheme, employed mainly by United States and United Kingdom (excluding Scotland). In this model, the funding of LTC targets those who are unable to pay for care services only. Lastly, the mixed model is practiced in countries like Ireland, Italy, Spain, and Switzerland. The mixed model is a system where the source of financing is a combination of taxation, insurance, and out of pocket payment. It is observed that there has been a general movement in recent years toward universal coverage with greater risk-pooling of multiple fundings across OECD countries, based on the rationale of fairness and efficiency (Colombo, 2011). 11.3.1.  Japan Definition and System Overview There is currently no clear definition of LTC in Japan (Tsutsumi, 2014). However, we infer from Japan’s Long-Term Care Insurance (LTCI) the two targets groups — (i) elderly individuals aged 65 years old and above who require assistance in daily living and (ii) individuals aged between 40 and 64 years who suffer from agerelated diseases such as cancers and cardiovascular diseases. The Japanese government established LTCI in 2000. The system is operated by municipalities under central government legislation. The program has four main objectives: reducing family burden in taking care of the elderly member, providing comprehensive care through a hybrid of medical and LTC programs, reducing unnecessary hospitalization, and linking benefits to premium costs (Gleckman, 2010). In 2011, the LCTI provided insurance for approximately 29 million primary insured persons and 42 million secondary insured persons at the cost of 8,322,300 million yen (Ministry of Health, Labour and Welfare of Japan, 2012). Delivery Similar to other LTC schemes, the Japanese model provides homecare services and institutional services, while distributing cash grants. The beneficiaries are able to receive in-home services such as

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home-visit nursing care services and out-patient rehabilitation, as well as institutional care services provided by formal health-care providers and community-based services. The good practices in Japan’s LTC system lies in the personalized services provided for each patient. This is made possible via the case management system, which is adapted from the German model. It works such that case managers evaluate the level of assistance needed and act as a contact point between services providers and the beneficiaries. The eligible person is obligated to take health-care assessment supervised by the case manager. The results will be passed onto case conferenced supervised by health-care professionals and municipal LTC council. The beneficiaries will be categorized into six groups based on severity of health status. Each group is entitled for different types of care, care intensity, and fee schedule. This helps to reduce time, costs, and the provision of unnecessary care services for the beneficiaries (OECD, 2013). Regulation The manpower in Japan LTC encompasses many trained and experienced workers, yet the quantity is lacking. To become an entry level caregiver, the individual must undertake 130 hours of training (Ling 1998). The caregivers are required to take state examination and acquire training for 2–4 years or education attainment at college (OECD, 2013). As for case managers, they are seen as sophisticated professionals who have at least 5 years of clinical experience and are responsible for the entire LTC services for each individual, starting from pre-entry assessment to case updates and LTC discharge (OECD, 2013). These demanding requirements of training and comparatively lower wages are causing problems of a shrinking workforce. Financing Unlike other countries, Japan’s insurers bear the major costs. Under the LTCI scheme, the insured person pays merely 10% of the cost of

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services. The programme funding comprises five sources: the primary premium deducted from the monthly income of elderly population age 65 years and above (21%), the secondary premium from the working population aged 40–64 years old (29%), and tax revenue from the central government (25%), prefectural government (12.5%), and municipal government (12.5%) (Ministry of Health and Welfare 2012). This differs from other countries as presented in the OECD study, where major LTC expenses are shared by the private household. The amount varies across countries as follows: Spain (70%), United States (41%), Germany (42%), and Australia (33%). 11.3.2.  Hong Kong Definition and System Overview Hong Kong faces a fast aging population, and the country is expected to have the largest proportion of population aged 65 years and above (42%) in Asia by 2050 (Pham & Yun, 2015). (Suggest use UN sources for proportion of elderly for comparability) This calls for immediate attention to develop a comprehensive and sustainable LTC system. LTC in Hong Kong is described as a continuum of health and social services delivered to individuals with characteristics like “frail with functional disabilities, incapable of self-care, medically stable, but requires multiple and long-term basis of care.” (Chi et al. 2001). Although it is mostly elderly that are frail and in needs of care, LTC in Hong is not confined to just the aged population. It seeks to cover other age groups with disabilities and LTC needs, i.e. the stroke patients. Delivery Currently, LTC services in Hong Kong are split between residentialcare services (RCS) and community-care services (CCS). The community LTC services are predominantly provided by nongovernmental organizations (NGOs) while the RCS are coprovided

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by both NGOs and the private sectors (Ministerial Committee on Ageing 2012). Within the domain of CCS, there are home-based and centrebased services, which include three aspects of enhanced home and CCS, integrated home care services, and day care centres and day care units (Elderly Commission, 2011). These services are mainly provided by NGOs with limited presence of the private sector. The NGOs receive subsidies of up to 80% of the service cost, which is funded chiefly through taxes and partially by user fees. As for RCS, there are hostels for the elderly, homes for the aged, care and attention homes for the elderly, and nursing homes. It is mainly targeted at those aged 65 and above who cannot adequately be taken care at home. However, the younger old, aged in between 60 and 64, may apply for placement as long as there is a proven need. The Hong Kong government provides a substantial amount of subsidies to support the NGOs in the operations of the facilities. However, there is an imbalance between residential and communitybased care in terms of utilization rates and government financing. The institutionalization rates in Hong Kong surpass many other developed countries, reflecting a huge reliance on residential care. The waiting list for a place in a subsidized nursing home is extremely long and can take up to a period of 29 months, while securing a place in a care and attention home can take up to 19 months (Social Welfare Department, 2015). In order to tackle the problem of the long waiting lists, the government introduced the Standardized Care Need Assessment mechanism for elderly service to assess the care needs of the applicants. Regulation The Hong Kong government uses ordinance, code of practice, and licensing to ensure a standardized quality of care services. For instance, the Residential Care Homes (Elderly Persons) Ordinance, which was put in place on 1 June 1996, covers registration, license, appeals, inspection, and operation. The key requirements include

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ensuring building and fire safety, complying with space standards, and having an adequate staffing ratio (Kwong, 2002). The code of practice tries to uniform the standards of operation and management. It lays out principles, procedures, guidelines, and standards for the operators to follow. On the other hand, licensing helps the government to monitor the service standards provided to the elderly. Normally, it is issued, inspected, and renewed by the Social Welfare Department. (Kwong, 2002). Financing As of 2004, the LTC spending level was at 1.4% of GDP (Chung, 2009). Due to the reliance on taxes to finance the LTC system, the government’s fiscal burden has grown drastically with a shrinking working population, along with a growing size of the elderly population. There is no form of means testing, where the charge of a public nursing home is standardized at 1994 HKD per month and a low fee of US$42 to US$47 is charged for CCS users, depending on the facilities used. Recently, a pilot scheme on CCS voucher for the elderly was rolled out (Social Welfare Development, 2015), allowing for elderly individuals to choose CCSs that will match their needs. 11.3.3.  Comparison between Hong Kong and Singapore Hong Kong is often compared because of its many similarities to Singapore. Hong Kong has a population of approximately 7.2 million, compared to 5.4 million in Singapore. Both Singapore and Hong Kong also have high economic growth levels. Being referred to as the Asian Tigers, both Singapore and Hong Kong are well recognized for their highly free-market and developed economy. As a result of economic liberalization and a correspondingly fast development, these two societies now rank among the highest in life expectancy but the lowest in birth rates. Singapore and Hong Kong have become one of the fastest ageing societies, whose populations are ageing vertically in urban environments, i.e. high rise buildings.

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Hong Kong has an ageing population, with 14.2% aged 65 and above (Legislative Council Secretariat, 2014), compared to Singapore’s 11.4%. The ideology of the welfare system in both countries are largely similar, where they are being influenced by traditional Chinese Confucian ideas — such as placing the role of the family above that of the state and the importance of filial piety. This influences the mindset of the population, as well as the policy options undertaken by the state. Up till the 1960s, Singapore and Hong Kong, both ex-British colonies, shared many common features in the organization and financing of the health-care system. The care services in both countries were provided universally without means testing. This system was adopted from the National Health Services. In 1960, under the ruling of the People’s Action Party, Singapore “introduced for the first time a system of user charges, charging 50 cents per attendance at government outpatient clinics and doubling the fee to SGD1 on public holidays” (Lim 1998). This then marked the divergence of the two countries’ policy direction. Hong Kong adopts a dual-track health-care system, with the presence of both public and private health-care service providers. The government is the main provider of health-care services, complemented by the private sector. Public health-care services are financed almost entirely by the government’s tax revenue as compared to Singapore’s reliance on out-of-pocket payments. As such, issues of sustainability have surfaced in recent years due to a continually low tax rate with a growing elderly population. This difference has since stretched into the underpinnings of the LTC system. LTC in Singapore is not provided universally and tax funded like that in Hong Kong. In response to the increasing needs of an ageing population, the Singapore government set up Eldershield in 2002. Later, IDAPE was introduced to help who were not eligible to join ElderShield when it was launched. These two schemes offer help to older adults with a Medisave account and are medically certified by a physician to be unable to perform three or more out of six ADLs. Monthly payout of $400 for up to

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Figure 11.1.    LTC Policy Development and Timeline in Singapore.

72 months could be given under the former, or $150 or $250 per month (dependent on means testing) for up to 72 months given for the latter. Despite their different approaches to health care, Figure 11.1 shows a convergence in the two countries’ policy direction for LTC (putting financing aside). The concept of ageing in place, as put by the Ministerial Committee on Aging (MCA) is to “enable our seniors to age-in-place gracefully and continue to enjoy a high quality of life as they age” (Ong, 2014). The MCA aims to achieve this in two areas by (1) to keep seniors healthy, active, and safe in the community, and (2) to provide good aged care.

11.4.  CASE STUDY: LONG-TERM CARE IN SINGAPORE The example of LTC needs and services in Singapore is presented as representative of many of the issues confronting ageing societies in cities throughout urban and industrialized Asia. As a city–state, it has advantages to respond effectively to the many emerging challenges through responsive and innovative national policies.

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Singapore, like many other developed countries in the world, is facing the challenge of an acutely ageing population, driven by rising life expectancies and declining fertility rates. The proportion of the resident population aged 65 years and over rose from 3.4% in 1970 to 9.9% in 2012 (Singapore Department of Statistics, 2012), and is projected to reach 18.7% by 2030 (Committee on Ageing Issues, 2006). The old-age support ratio (persons aged 20–64 years per elderly aged 65 years and over) dropped from 13.5 in 1970 to 6.7 in 2012 (Singapore Department of Statistics, 2012). Life expectancy has increased dramatically, from 65.8 years in 1970 to 82.0 years in 2011 (Singapore Department of Statistics, 2012). The elderly population has unique health needs, including a high prevalence of chronic diseases like diabetes, heart disease, and stroke; functional disability; and diseases causing cognitive impairment such as dementia. A study in 2005 found that 6.6% of those aged 65 years or older had disability in at least one of five ADL items, higher than previous reported prevalence in Singapore (Ng et al. 2006). It has been projected that the prevalence rate of dementia in Singapore will rise to 1.75% in 2030 from 0.65% in 2010, translating to 92,000 elderly persons living with dementia (Access Economics Pty Limited, 2006). Singapore’s health-care system is based on the key principle that no medical service should be provided completely free of charge without shared responsibilities for its financing. This is in line with welfare principles — family rather than state as the first line of support — and has been extended as fundamentals of the development of the LTC sector. With an increasingly ageing population and demographic shifts, the health-care system has to deal with LTC needs since many elderly individuals who suffer from complex and multiple chronic conditions, requiring coordinated LTC services. It is predicted that the total number of seniors will increase to 18.7% by 2030 (873,300 in absolute terms). This implies increasing efforts are needed to develop our LTC system to deal with this

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“Silver Tsunami”. Evidently, the government has begun by increasing spending levels on the LTC sector. The current spending levels are at 0.1% of Gross Domestic Product (GDP) or 3% of National Health Expenditure. It has grown from 145 million in 2011 to 260 million in 2013 (Ministry of Health, 2014). However, this is still less than the 1–2% of GDP that other developed countries spend on their LTC. 11.4.1.  Background of Long-Term Care Policy in Singapore The Singapore Government’s philosophy on care of the elderly is that the family should be the first line of support. Frail and ill elderly should be cared for by family at home for as long as possible, with institutionalization as a last resort. Community services should support the family in this care-giving role. In addition, older Singaporeans should assume personal responsibility for their health, particularly in living healthy lifestyles and ensuring their continued employability and financial security (Inter-Ministerial Committee on Ageing 1999). For the provision of LTC for the elderly, the government’s strategy is for non-governmental or voluntary welfare organizations (VWOs) to be service providers, while the government plays the role of direction setting, financing, and regulation. The government does not provide any services directly, the rationale being that (1) anything provided by the government is considered a “right”, which leads to increased demand, and (2) such services often require a level of motivation and compassion, and VWOs can also garner voluntary support (Ling 1998). This trend of partnership between government and charitable organizations in the provision of LTC services is also seen in many other countries. Health services for the elderly can be seen as part of a “care continuum”, of which LTC is only one part. Figure 11.2 illustrates the various components of this care continuum, and examples of different facilities catering to specific needs in Singapore. LTC services are provided mostly by VWOs, and some for-profit providers.

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284  Ageing in Asia: Contemporary Trends and Policy Issues Long-Term Care Primary Prevenon

Wellness Program

Health Promotion Board (HPB)

Primary Care

General Practitioners/ Government Polyclinic

Acute Care

Acute hospitals

Step- down care/ Rehabilitaon

Community Hospitals

Community/ Home Care

Palliave Care

Home-based services

Inpatient Hospices

Day care facilities

Home hospice services

Residential Nursing Homes

Figure 11.2.    The Continuum of Care for Elderly. Table 11.1.    Government Assistance to VWOs in the Provision of ILTC Services. Financial assistance

· Up to 90% for capital expenditure · Up to 90% for cyclical maintenance costs for existing building · Up to 50% for operating/recurrent expenditure · Up to 100% rental subsidy for use of government premises or state land · 100% rebate for input Goods and Services Tax (GST)

Manpower assistance

· Secondment of doctors and nurses to work in VWO facilities · Facilitating the allocation of foreign workers permits, and waiving the foreign workers’ levy for VWOs · Training of nursing aides

Others

· Facilitate the allocation of state land and premises · Exemption for Certificate of Entitlement (COE) for vehicles used in providing services run by the VWOs · Issue medical fee exemption cards to needy residents of residential care · Provision of guidelines on nursing home standards and care requirements.

The Government provides various kinds of assistance to VWOs (Ling 1998) (see Table 11.1). To promote integration and continuity of care between different providers, the Ministry of Health set up a statutory board called the Agency for Integrated Care (AIC). AIC assesses individual patients

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and refers them to appropriate providers, and helps acute hospitals coordinate patient discharges to appropriate step-down facilities like community hospitals and nursing homes. In 2012, the Government announced a raft of new measures to boost the capacity of the LTC sector, including increasing nursing home bed capacity by 70%, increasing home-based health care and social services capacity, and increasing day social and rehabilitative care places (Ministerial Committee on Ageing 2012). In addition, it has also announced additional funding to VWO nursing homes to improve staffing ratios, dedicated funds to enable pay increases in the ILTC sector, and investment in initiatives to improve productivity, quality, and professional development (Ministry of Health, 2012). The Community Silver Trust is a dollar-for-dollar donation matching grant provided by the Government to VWOs in the intermediate and LTC sectors. To better support informal caregivers of elderly in the community, it is also working with VWOs and other training providers to develop more caregiver training courses, and has launched a $120 Foreign Domestic Worker Grant for families with a per capita income of up to $2,600, who require the assistance of a foreign domestic worker to care for elderly patients who are permanently unable to perform at least three of the six ADLs (AIC 2017). 11.4.2.  Current Provision of Long-Term Care The Ministry of Health (MOH) and Ministry of Social and Family Development (MSF) are currently responsible for the planning and management of the LTC sector. Singapore’s LTC services are managed as such, the government takes on the role of funding and regulating the services, while the VWOs manage the provision of services. The private sector also provides LTC services although they are not subsidized. The LTC services are split into two main categories — community care and institutional or residential care. As of 2014, the

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distribution between public, private, and VWOs in terms of elderly care services are as follows (Table 11.2): Table 11.2.    LTC Services in Singapore (AIC 2014). Residential Care 1  Community Hospital

Nation-wide 5

2  Voluntary Welfare Organization (VWO) — run Nursing Homes

29

3  Private Nursing Homes

11

4  Private Nursing Homes with Portable Subsidy Beds

21

5  Psychiatric Nursing Homes

3

6  Inpatient Hospice

3

Community-based Care Center-based Care 1  VWO Day Rehabilitation Centers

41

2  VWO Dementia Day Care Centers

11

3  Social Day Care Centers

36

4  Senior Care Centers

1

Home Care 1  VWO providers

34

2  Private providers

12

In general, there have been a growing number of LTC facilities and services over the past 10 years. In order to support the establishment of LTC facilities, the government initiated the Eldercare Fund in 2000, which is an endowment scheme to provide operating subsidies. Compared to 2006, the number of nursing homes (institutional care) increased from 62 to 65 and day-rehabilitation centres (community care) increased from 28 to 38. Efforts are continually being stepped up to develop more aged community facilities in the Housing Development Board towns. As of 2016, there are 56 new senior activity centres (SACs),2 39 new senior care centres (SCCs),3 and 10 new nursing homes to deal with the increased demand. In 2

 SACs allow the elderly to make friends and be involved in social activities.  SCCs provide day care, dementia day care, day rehabilitation services, and basic nursing services. 3

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order to assist with allocating the elderly to the appropriate facilities, the Community Case Management Service and Integrated Care Services (ICS) were developed. The success of the system however remains to be evaluated. For a long time, LTC services in Singapore predominantly focused on residential care. Within this domain, there are nursing homes, community hospitals, and respite care services. For elderly who do not have family members or caregivers to look after them at home, they are placed in nursing homes. Nursing homes could be divided into four types as follows: · Private nursing homes, which are not under the MOH portable subsidy scheme are those that cater to full-paying patients only. · Private nursing homes, which are under MOH portable subsidy scheme are those private nursing homes that set aside some of their beds to be used by patients who are eligible for MOH subsidies and are placed by the ICS. It is important to note that these private nursing homes’ main clients are full-paying patients. · VWO nursing homes, which do not receive MOH subsidies are selffunded by VWOs through fund raising and do not receive any subsidies from MOH. Although patients here are not subsidized by MOH, these VWOs are able to provide the necessary financial and social assistance to patients who are unable to afford the nursing home fees. · VWO nursing homes, which receive MOH subsidies are VWO nursing homes that acquire monetary assistance from MOH, and also provide additional support if the patient requires further financial and social assistance. 11.4.3.  Long-Term Care Financing in Singapore For financing of LTC, the government has continued its twin philosophy of shared responsibility and targeting of government support to the lower-income groups through means testing. The fundamental “3M” system that underlies the entire health-care system (Medisave, MediShield, MediFund) has been reviewed elsewhere (Phua 2002; Lim 2004). Payment for LTC services, as in the rest of the health-care

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system, functions on a copayment basis. Subsidies for LTC services are provided on a means-tested basis, depending on per capita household income per month. Under the latest revised subsidy framework announced in 2012 (Ministry of Health 2012), the qualifying per capita household monthly income was raised from $1,400 to $2,200 for home, community-based, and residential LTC services, covering two-thirds of all households. The degree of subsidy ranges from 20%, up to a maximum of 80% for those with per capita household income less than $600 (Ministry of Health 2017). Subsidies are only available to VWO providers; private providers are not eligible for subsidies, except for a small group of approved private nursing homes that enjoy portable government subsidies. ElderShield, a severe disability insurance scheme, was introduced in 2002 to further help citizens meet expenses incurred in the event of severe disability. It is run by government-appointed private insurers on actuarial principles. Singapore citizens and permanent residents are automatically enrolled on an opt-out basis at age of 40, and pay premiums from their Medisave accounts annually until age 65. Severely disabled persons (defined as limitations in at least 3 of 6 A), receive a monthly cash payout of $300 or $400 for up to 60 or 72 months, respectively (depending on scheme) (Ministry of Health 2016). For those who were not eligible to join ElderShield due to age or pre-existing disabilities, the government has instituted the Interim Disability Assistance Programme for the Elderly (IDAPE), which provides $100 or $150 month for a maximum of 72 months, with a qualifying per capita monthly household income of