Ageing in the Asia-Pacific Region: Issues, Policies and Future Trends (Routledge Advances in Asia-Pacific Studies, Volume 2)

Ageing in the Asia-Pacific Region

The Asia-Pacific region is now clearly witnessing the rapid ageing of many of its nations and Asia is already the region with, relatively, the largest number of older persons. This book focuses on the challenges that this demographic trend poses to economies and societies in the region, and the policies that have evolved to date to meet new demands. It looks forward over the coming decades to consider how societies and economies will deal with ageing and the necessary structural and behavioural changes that this will entail. The book is organized into two main sections. The first introduces the key features, demography, research and long-term care issues of the region, and provides region-wide context and analysis. The second section offers indepth case studies of thirteen countries, including China, Japan, Korea and Indonesia. As well as providing a wealth of original research material, the book also offers valuable comparative analysis: while the larger economies have had to develop policies to maintain their social and economic successes in the face of demographic ageing, developing countries must find ways to build their economies around an ageing population. With contributors drawn from a range of academic and professional disciplines, including many practising social gerontologists, this book will be of interest to scholars in economics, sociology, social policy, health policy, politics and development studies. With its particular emphasis on the future, it will also be an essential reference for anybody with a professional interest in policy-making in the region. David R.Phillips is Director of the Asia-Pacific Institute of Ageing Studies and Professor of Social Policy at Lingnan University, Hong Kong. He was previously Professor of Human Geography, University of Nottingham and Director of the Institute of Population Studies, University of Exeter. His previous publications include Health and Health Care in the Third World, Ageing in the East and Southeast Asia and Health and Development.

Routledge advances in Asia-Pacific studies

1 Environment, education and society in the Asia-Pacific Local traditions and global discourses David Yencken, John Fien and Helen Sykes 2 Ageing in the Asia-Pacific region David R.Phillips 3 Caring for the elderly in Japan and the US Practices and policies Susan Orpett Long 4 Human rights and gender politics in the Asia-Pacific Edited by Anne Marie Hilsdon, Martha Macintyre, Vera Mackie and Maila Stivens

Ageing in the Asia-Pacific Region Issues, policies and future trends

Edited by David R.Phillips

London and New York

First published 2000 by Routledge 11 New Fetter Lane, London EC4P 4EE Simultaneously published in the USA and Canada by Routledge 29 West 35th Street, New York, NY 10001 Routledge is an imprint of the Taylor & Francis Group This edition published in the Taylor & Francis e-Library, 2005. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” © 2000 Editorial matter and selection, David R.Phillips; individual chapters, the respective contributors All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Ageing in the Asia-Pacific region: issues, policies and future trends/edited by David R.Phillips p. cm.—(Routledge advances in Asia-Pacific studies) Includes bibliographical references and index. 1. Aged—Asia. 2. Aged—Pacific Area. 3. Aged—Government policy—Asia. 4. Aged—Government policy—Pacific Area. 5. Aging—Asia. 6. Aging—Pacific Area. 7. Gerontology—Asia. 8. Gerontology—Pacific Area. I. Phillips, David R. HQ1064.A78 A44 2000 305.26'095–dc21 99–087586 ISBN 0-203-46308-0 Master e-book ISBN

ISBN 0-203-77132-X (Adobe eReader Format) ISBN 0-415-22018-1 (Print Edition)

Contents

List of figures List of tables Contributors Preface 1

Ageing in the Asia-Pacific region: issues, policies and contexts

vii ix xii xiv 1

DAVID R.PHILLIPS

2

Demographic dimensions of ageing in East and Southeast Asia

35

KEVIN KINSELLA

3

Research directions in ageing in the Asia-Pacific region: past, present and future

51

GARY R.ANDREWS AND ALBERT I.HERMALIN

4

Long-term care issues in the Asia-Pacific region

82

EDWARD MAN-FUK LEUNG

5

Financing health and long-term care for ageing populations in the Asia-Pacific region

93

PHUA KAI HONG

6

Ageing in Japan: retirement, daily lives, pensions and social security

113

DAISAKU MAEDA AND HISANORI ISHIKAWA

7

Development of long-term care for elderly people in Japan

133

HISANORI ISHIKAWA AND DAISAKU MAEDA

8

Ageing in Hong Kong

158

NELSON W.S.CHOW

9

Singapore’s ageing population: social challenges and responses S.VASOO, TEE-LIANG NGIAM AND PAUL CHEUNG

174

vi

Contents

10

Population ageing in China

194

DU PENG AND GUO ZHI-GANG

11

Ageing and aged care in Taiwan

210

HELEN P.BARTLETT AND SHWU-CHONG WU

12

Ageing in Korea: issues and policies

223

SUNG-JAE CHOI

13

Ageing in Thailand: an overview of formal and informal support

243

JOHN KNODEL, NAPAPORN CHAYOVAN, SIRIWAN GRAISURAPONG AND CHUTIMA SURARATDECHA

14

Ageing in the Philippines: an overview

267

JOSEFINA N.NATIVIDAD

15

Ageing in Malaysia: issues and policies

284

TAN POO CHANG AND NG SOR THO

16

Lansia—elderly people in Indonesia at the turn of the century

299

GRAEME HUGO

17

Ageing, Islam and care for older persons in Brunei Darussalam

322

MARK CLEARY AND HAIRUNI ALI MARICAR

18

Older people in Vietnam amidst transformations in social welfare policy

334

BUI THE CUONG, TRUONG SI ANH, DANIEL GOODKIND, JOHN KNODEL AND JED FRIEDMAN

19

Ageing in Cambodia: tradition, change and challenges

360

ELIZABETH UPHOFF KATO

Index

375

Figures

1.1 1.2a 1.2b 1.3a 1.3b 2.1 2.2 2.3 2.4a 2.4b 2.4c 2.5 2.6 2.7 2.8 2.9 5.1 5.2 15.1 16.1

Forces acting on older persons in most countries of the Asia-Pacific region today: diversity and uncertainty—an interim generation? Asia-Pacific: percentage of elderly population 65+ in 1990, 2010, 2025 Asia-Pacific: percentage of elderly population 75+ in 1990, 2010, 2025 Seven selected countries in Asia-Pacific: expectation of life at birth (years), 1995, 2010, 2025 Nine selected countries in Asia-Pacific: expectation of life at birth (years), 1995, 2010, 2025 Percentage of population aged 60 and over, 1998 and 2025 Speed of population ageing Percentage increase in total, elderly, and oldest-old populations in three countries, 1998–2025 Population, by age and sex in developed and developing countries, 1950 Population, by age and sex in developed and developing countries, 1990 Population, by age and sex in developed and developing countries, 2030 Total fertility rate, 1998 Life-expectancy at age 60 for Japan Elderly support ratios in four Asian nations, 1990–2030 Youth and elderly support ratios in China, 1985–2050 Percentage of women at age 65 in the Republic of Korea with no surviving son Health financing in Singapore Elements of more cost-effective care Malaysia: distribution of population aged 55+ by age group and sex, 1995 and 2020 Indonesia: number of persons aged 65 years or over, 1995

14 15 16 17 18 36 38 39 40 40 41 43 44 46 47 48 109 110 285 300

viii

Figures

16.2 Indonesia: age/sex distribution 1971, 1990 and 1995 and projected distribution 2015 16.3 Indonesia: age dependency ratios by province, 1995 17.1 Brunei: districts, towns and health facilities 17.2 Access to discretionary funds in Brunei 18.1 Population pyramid for Vietnam in the year 2000 18.2 Increase in numbers of Vietnamese 60+ 19.1 Cambodia: aged dependency ratio over time 19.2 Cambodia: older persons’ living arrangements 19.3 Cambodia: percentage involved in income-generating activities by age 19.4 Cambodia: main sources of support of older persons 19.5 Cambodia: choice of treatment when seriously ill

303 308 323 331 336 336 362 363 365 366 369

Tables

1.1 2.1 3.1 3.2 4.1 4.2 4.3 4.4 6.1 6.2 6.3 6.4 6.5 6.6 6.7a 6.7b 6.8 6.9 6.10 6.11 6.12 6.13

Selected examples of national policies on ageing and older people in the Asia-Pacific region 6–12 Rank order of the nine leading causes of death in South Korea, 1966–1994 45 Multi-country studies of ageing in Asia 60–61 Single-country studies of ageing in Asia 66–67 Hong Kong: demand for LTC facilities 86 Provision of LTC places in facilities in Hong Kong 86 Hong Kong: prevalence of chronic illnesses amongst elderly people in community 87 Hong Kong: prevalence of chronic illnesses of elderly people in need of LTC 87 Population of elderly people in Japan: past, present and future 116 International comparisons of the population aged 65+: past, present and future 116 International (non-Asian) comparison of Total Fertility Rates (TFR) 117 Japan: increases in life-expectancy at age 65 117 International comparison of the speed of population ageing 117 Japan’s projected population structure, 1995–2030 118 Japan: increases in the numbers of old people, 1950–1995 119 Japan: increases in the numbers of old people, 1995–2035 119 International comparisons of living arrangements of people aged 60+, 1996 120 Japan: regional differences in proportions of people aged 65+living together with children and living separately, 1995 121 Desired relations with children of persons aged 60+: international comparisons, 1996 122 Opinions of middle-aged persons on their later years 123 Ages of fixed mandatory retirement, Japan 1997 124 Comparison of quartile income distribution of all households, normal households and households whose heads are aged 65+, 1996 126

x

Tables

6.14 Favourite activities of Japanese people aged 65+ 7.1 Japan: development of homes for the aged (when they were public assistance institutions) 1949–1963 7.2 Japan: development of long-term care institutions, 1960–1996 7.3 Japan: Gold Plan (1990) and New Gold Plan (1994) goals for 1999 8.1 Hong Kong: selected demographic characteristics of older population 8.2 Residential and long-term care services for older persons in Hong Kong, July 1999 9.1 Actual and projected working-age persons per older person and index of ageing of the population in Singapore, 1980–2030 10.1 China: percentages of elderly populations by province, 1995 11.1 The growth of the elderly population in Taiwan, 1905–2036 11.2 Self-reported chronic conditions among non-institutionalized elderly people in Taiwan 11.3 Prevalence of functional disability among non-institionalized older people in Taiwan 12.1 Korea: actual and estimated life-expectancy at birth, selected years 12.2 Korea: actual and estimated numbers and proportion of elderly population, selected years 12.3 Korea: beneficiaries of cash-payments under income maintenance programmes 13.1 Demographic trends and projections: Thailand 1970–2030 13.2 Selected indicators of living arrangements among persons 60+ 13.3 Living arrangements in relation to adult children, by place of residence and religion, Thailand 1995 13.4 Intergenerational support from non-co-resident children to elderly parents, by place of residence and religion, Thailand 1995 13.5 Main source of income of persons aged 60+, by place of residence and religion, Thailand 1995 14.1 Selected demographic indicators for the Philippines 14.2 Sources of income of older Filipinos by gender and residence, 1984 ASEAN Survey 14.3 Measures of living arrangements for Filipino older people, 1996 Philippine Elderly Survey 15.1 Malaysia: education level of persons aged 55–64, 1991 and 2020 15.2 Life-expectancy at birth and at age 40 by ethnic group, Malaysia, 1996

126 137 142 148 159 166 177 197 211 213 213 224 225 227 244 256 258 258 260 268 279 280 291 294

Tables

16.1 ASEAN countries: aged populations in 1995 and projection of percentage of population aged 65 and over 16.2 Indonesia: growth of the elderly population, 1971–1995 16.3 Indonesia: sex ratios among the elderly population, 1980–2050 16.4 Indonesia: actual and projected dependency ratios, 1971–2015 16.5 Indonesia: average annual population growth rates of the ‘dependent’ age groups, 1971–1995 16.6 Indonesia: rural-urban distribution of older population, 1971–1995 16.7 Indonesia: labour-force participation among the elderly population, 1980 and 1995 16.8 Indonesia: labour-force participation rates by sex and age, 1971–1995 17.1 Population change in Brunei Darussalam 1911–1996 17.2 Brunei Darussalam age cohorts 1947–1996 17.3 Brunei Darussalam: population projections by age cohort 18.1 Systemic models of social welfare for older persons in Vietnam 18.2 Percentage of Vietnamese elderly people currently receiving the following sources of monthly public support and average amount of payment per recipient 18.3 Reported sources of income for elderly persons by place of residence, Red River Delta 1996 and Ho Chi Minh City and environs, 1997 18.4 Rates of labour-force participation of Vietnamese elderly people by age and occupational sector, Red River Delta 1996 and Ho Chi Minh City and environs, 1997 18.5 Measures of co-residence between persons aged 60+ and their adult children, Vietnam 1994 18.6 Living and support arrangements of older persons in relation to adult children, Red River Delta 1996 and Ho Chi Minh City and environs, 1997

xi

301 302 304 305 305 307 311 311 323 325 326 338 342 346 347 349 351

Contributors

Gary R.Andrews, Centre for Ageing Studies, Flinders University of South Australia, Australia. Helen P.Bartlett, Oxford Centre for Health Care Research and Development, Oxford Brookes University, United Kingdom. Bui The Cuong, Institute of Sociology, Hanoi, Vietnam. Napaporn Chayovan, College of Population Studies, Chulalongkorn University, Thailand. Paul Cheung, Office of the Chief Statistician, Government of Singapore, Department of Statistics, Singapore. Sung-Jae Choi, Department of Social Welfare, Seoul National University, South Korea. Nelson W.S.Chow, Department of Social Work and Social Administration, University of Hong Kong, Hong Kong. Mark Cleary, Department of Geography, University of Plymouth, United Kingdom. Du Peng, Institute of Population Research, Center for Aging Studies, The Renmin (People’s) University of China, People’s Republic of China. Jed Friedman, Population Studies Center, University of Michigan, USA. Daniel Goodkind, US Bureau of the Census, International Programs Center, Washington DC, USA. Siriwan Graisurapong, Health Social Sciences Program, Mahidol University, Thailand. Guo Zhi-gang, Institute of Population Research, The Renmin (People’s) University of China, People’s Republic of China. Albert I.Hermalin, Population Studies Center, University of Michigan, USA

Contributors

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Graeme Hugo, Department of Geographical and Environmental Studies, University of Adelaide, Australia. Hisanori Ishikawa, Department of Social Work, Faculty of Humanities, Japan Lutheran College, Tokyo, Japan. Kevin Kinsella, Committee on Population, National Research Council, Washington DC, USA. John Knodel, Population Studies Center, University of Michigan, USA. Edward M.F.Leung, Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong. Daisaku Maeda, Department of Social Work, Faculty of Humanities, Japan Lutheran College, Tokyo, Japan. Hairuni Ali Maricar, Department of Geography, University of Brunei Darussalam, Brunei Darussalam. Josefina (Joy) N.Natividad, Department of Sociology, College of Social Science and Philosophy, University of the Philippines, The Philippines. Ng Sor Tho, Department of Applied Statistics, Faculty of Economics and Administration, University of Malaya, Malaysia. Ngiam Tee Liang, Department of Social Work and Psychology, National University of Singapore, Singapore. David R.Phillips, Asia-Pacific Institute of Ageing Studies, Lingnan University, Hong Kong. Phua Kai Hong, Department of Community, Occupational and Family Medicine, National University of Singapore, Singapore. Chutima Suraratdecha, School of Economics, Sukhothai Thammathirat Open University, Thailand. Tan Poo Chang, Department of Applied Statistics, Faculty of Economics and Administration, University of Malaya, Malaysia. Truong Si Anh, Institute for Economic Research, Ho Chi Minh City, Vietnam. Elizabeth Uphoff Kato, c/o HelpAge International Cambodia Programme, Phnom Penh, Kingdom of Cambodia. S.Vasoo, Department of Social Work and Psychology, National University of Singapore, Singapore. Shwu-chong Wu, Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taiwan.

Preface

It has been said that ‘the developing world is growing old before it grows rich’, a statement that contrasts the ageing experience of much of the nonWestern world today with that of the historical experience of most Western countries. After crossing the threshold into the twenty-first century, the labelling of countries as developed, developing, First or Third world, seems somewhat archaic, yet there is certainly a grain of truth in the saying above. The Asia-Pacific region is now clearly witnessing the rapid ageing of many of its nations. It is perhaps misleading to term the entire region as ‘developing’, because many of its countries are clearly well advanced in development. Nevertheless, there are important differences in social, economic and political achievement among many countries in the region, which mean that many are still relatively at the emergent phase of development. Yet their concurrent rapid ageing over the past two or three decades does render the saying above applicable to many. Of course, Japan, Hong Kong, Singapore and Taiwan are amongst the wealthiest economies in the world; their current challenge is how to maintain their social and economic successes in the face of demographic ageing of their populations. For many other countries of the region, the challenge may be more fundamental, of how to build economic and social development whilst their populations are generally ageing—a challenge faced by relatively few if any countries in the Western world. The Asia-Pacific region is by and large a very dynamic area of the world, not only economically, socially and politically but also in terms of its demography and population profiles. This book focuses on what has already been identified as a key issue for a large number of counties in the region, the ageing of populations and the associated challenges for economic, health and social policies, and the wider environments. By about 2025, Japan will probably be the most ‘elderly’ country in the world, demographically speaking, and a number of other countries in the region will be in the demographically aged category of countries: Hong Kong, Singapore, Korea, Taiwan and, by weight of numbers, China itself. This presents hitherto unmet challenges in many areas of life: social, economic, political and social infrastructure and environmental planning. At the other end of the scale, demographically speaking, some countries in the region will still be facing policy pressures from youthful populations. Cambodia, for instance, will still

Preface

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have substantial percentages in the younger age groups, and it and many of the less-old countries such as Laos, Burma, Indonesia, Malaysia and Vietnam will still have fewer than 6 per cent of their populations aged 65 years and over by 2010 and probably under 10 per cent by 2025. However, even in these countries with proportionately relatively modest demographic ageing, forces of modernization and especially changes in family ability to provide long-term care and support for older members, combine and raise the need for current and early policy action, especially in the public sector. Ageing conjoined with development has many characteristics that will influence the shape of future social and economic prosperity and even stability of the world and certainly this region. The Ageing and Development Report, published by HelpAge International for the United National International Year of Older Persons in 1999 (Randel et al. 1999), summarizes many features of global ageing, the majority of which are of direct relevance to the Asia-Pacific region and are referred to in various chapters in this book: • • • • • • • • • • •

A global demographic revolution is underway The speed of change is without precedent This demographic shift is certain and its main outlines can be discerned Most of the world’s older people live in developing countries Older people are consistently among the poorest people; poverty and exclusion remain the greatest threats to their well-being Ageing is an increasing female experience Many older persons are resourceful survivors who contribute to the well-being of their families and communities The great enemy of independence and autonomy in old age is not changing family or community values but poverty Many people enter old age in a poor state of health resulting from lifelong deprivations The ageing world is a world of work, especially in developing countries Fifty years on from the United Nations Declaration of Universal Rights, the rights of older citizens are still denied or restricted

Many of these features are to be seen to a greater or lesser extent in the countries of the Asia-Pacific region. As it is the region with the world’s largest number of older persons and as it is also a region of considerable diversity, this book will presage many issues that are also likely to emerge in other developing region countries. The book is structured although not formally divided into two main sections: the first five chapters introduce the main features of research, demography and care of older persons in the region; the subsequent fourteen chapters discuss individual countries. Two chapters focus on Japan, given its special place in the region and world in terms of ageing. The contributors to the book are in the main practising social gerontologists, broadly defined, and

xvi

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drawn from a range of academic and professional disciplines, with specialist knowledge of the countries and issues. Authors were requested not to dwell in great detail on demographic ageing but rather to identify the current issues, problems and challenges facing the countries as a result of current and likely changes in population composition. Hence, chapters do not to follow a rigid, uniform structure since the evolution of interest in ageing, policies and practice is at rather different stages throughout the region. Contributors were in particular invited to look to the future, to identify and discuss policy issues and responses and their adequacy. As a team collection, the chapters present an assessment of ways in which various societies and economies have and will face up to key challenges in social and health care needs, allied areas of longterm care, family changes, income sources and sources of long-term financial support. Comparative demographic data have been used particularly in Chapters 1 and 2 and at appropriate points elsewhere. Excessive reliance on technical demographic measures, such as dependency ratios or older-old ratios, has been generally avoided in the country chapters except for scenesetting, as these data can be of dubious practical and policy significance. Rather, key social, cultural and economic issues have been a focus: for example, the evolving role of Asian concepts of filial piety, intergenerational relations and family care; influences of cultural practices and religious beliefs; and the political pressures and economic realities of ageing populations. The book is a direct successor to Ageing in East and South-east Asia (Phillips 1992) to which many of the current authors also contributed. Almost ten years have elapsed between the writing of the two books and this has been a crucial decade for research and policy in ageing in the region. It is very appropriate for the region that 1999, when the text was principally completed, was the United Nations International Year of Older Persons. Whilst many new texts have appeared on social and political issues in the Asia-Pacific region—whose definition is discussed in Chapter 1—there have been relatively few books that have dealt with the region’s demography, social policy and, certainly, ageing per se. Some notes on terminology are important, especially the terms in which older persons are discussed. A number of researchers have addressed this topic and, although there is not unanimity, it is clear that collective terms such as ‘the elderly’ or ‘the aged’ are not appropriate except in purely technical demographic or policy senses (such as when noting population proportions, for instance). The stereotyping and stigmatizing aspects of language are clear. It is increasingly recognized that older people themselves, if they are to be discussed in group terms, prefer to be referred to as older persons or senior citizens. Whilst fashions may change, group stigmatizing terms are generally now not preferred and authors have avoided these as far as possible in this book. This is particularly so as life-course perspectives and various postmodern views of ageing have made less relevant the traditional boundaries between youth, adulthood and old age. Life courses are more fluid, lifestyles more varied, and more flexible, than earlier

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‘productivity-based’ approaches to understanding ageing would have suggested (Walker and Minichiello 1996). Nevertheless, it is important to be aware that traditional views on ageing and the roles of older persons have been very persistent among many policy-makers and members of the public in many countries in the Asia-Pacific region. As Editor, I should like to thank all authors for their contributions, and many have given much wider advice and suggestions. I should also like particularly to thank John Knodel for very detailed and thoughtful comments on a draft of Chapter 1. It is also my pleasure to acknowledge the help and enthusiasm for the project among my colleagues at the Asia-Pacific Institute of Ageing Studies (APIAS) at Lingnan University, Hong Kong, especially Luk Kit Ling, Billy She and Cindy Man, and Brian Bridges of the Department of Politics and Sociology at Lingnan. The President of Lingnan University, Professor Edward Chen Kwan-yiu, also deserves many thanks for establishing APIAS as a regional research centre on ageing. In the University of Nottingham, Chris Lewis drew most of the maps and diagrams in Chapter 1. Colleagues from a number of organizations in and outside the region were also very generous with information and assistance, including members of the Asian Development Research Forum Ageing Research Network (of Canada’s IDRC, Asian Regional Office, Singapore), HelpAge International (particularly Mark Gorman, Deputy Director, for permission to reproduce extracts from Randel et al. (1999) in Table 1.1 and HAI for material in Chapter 19), the United Nations Economic and Social Commission for Asia and the Pacific (ESCAP), the International Research Center of the US Bureau of the Census, the WHO Centre for Health and Development at Kobe, and various members of the research team at the University of Michigan’s Population Studies Center. References Phillips, D.R. (ed.) (1992) Ageing in East and South-east Asia, Research Studies in Gerontology, Age Concern Institute of Gerontology, London: Edward Arnold. Randel, J., German, T. and Ewing, D. (eds) (1999) The Ageing and Development Report: Poverty, Independence and the World’s Older People, HelpAge International, London: Earthscan. Walker, A. and Minichiello, V. (1996) ‘Emerging issues in sociological thinking, research and teaching’, in V.Minichiello, N.Chappell, H.Kendig and A.Walker (eds) Sociology of Aging: International Perspectives, Melbourne: International Sociological Association Research Committee on Aging. DAVID R.PHILLIPS Director Asia-Pacific Institute of Ageing Studies Lingnan University Hong Kong November 1999

1

Ageing in the Asia-Pacific region Issues, policies and contexts David R.Phillips

Introduction This chapter outlines the context of population ageing in the Asia-Pacific region and key issues and policies currently evident or likely to emerge over the coming decades. The field is maturing and gerontology is establishing itself in many of the countries of the region, supplementing the work of clinicians and biomedical scientists involved with older persons. The decade of the 1990s was a crucial period for research and the evolution of public policy in ageing in the Asia-Pacific region and the early years of the twentyfirst century promise to be yet more important. Nevertheless, in most countries of the region, ageing is still regarded as primarily a family concern, so the changing ability of families to care for and support older members is an issue that permeates many chapters. The book does not, however, start from the often-made assumption that ageing is a problem. Rather, ageing is a positive outcome of combined social, economic and health advances, which have been spectacular in much of the AsiaPacific region. In many ways, the challenge is to transform assumed concepts such as ‘successful ageing’ and ‘active ageing’ into reality (Minichiello et al. 1996), to benefit the citizens and nations of the region. Many countries have begun to address issues in ageing in both practical and philosophical ways and there is much in good and innovative practices to be shared. As Gary Andrews discusses in Chapter 3, whilst increasingly concrete evidence is emerging from research studies across the region, there remains much to be done in research terms, particularly in the translation of research effort to assist policy formulation. Gerontological and geriatrics associations have grown in individual countries and are developing increasing interactions with the international networks in gerontology and Asian regional and sub-regional meetings are thriving. Many policy-makers and practitioners in care and services for older persons are participating in academic and other meetings, so the network of knowledge and contacts is rapidly growing. Whilst there have also been many positive developments, some clouds remain on the horizon. These stem from a mixture of factors not the least of which is the changing climate of economic development in the region. There are also many strong, often contradictory, forces acting on

2

David R.Phillips

families, affecting their ability to fulfil traditional perceived obligations to older members. In addition, there are also changing attitudes amongst some older persons themselves who are less ready automatically to accept family care or inferior quality services. Asia-Pacific: a region with a shared identity? Asia-Pacific is a region variously described by terms that include amongst others Asia(n) Pacific, Pacific rim, East and Southeast Asia (geographically perhaps the most precise) and the Eurocentric term Far East. There are also numerous political and strategic groupings, such as ASEAN and APEC, as well as the individual regionalizations of WHO, E SCAP and other international agencies, that often seem to imply diversity rather than unity. The Asia-Pacific region has evolved as a sub-global system in which many constituent countries have been drawing together in terms of trade and communication, and perhaps shared identity, although this came under strain and differentiation during the late 1990s. Various forces have served to emphasize its regionalization in the global economy whilst others have tended to promote diversity. Certainly, demographic transition, set alongside urbanization and economic change, have been major factors (Maidment and Mackerras 1998; Phillips 1998; Watters and McGee 1997). However, as many chapters of this book show, demographic change and ageing are by no means uniform across the region. The Asia-Pacific region includes the country likely to be the oldest in the world—Japan, which is facing new challenges of slow or negative population growth—but it also has many still predominantly youthful countries such as Cambodia, Laos and Indonesia, in which population policies continue to revolve around family planning and reproductive health. The region’s countries do not share a single, uniform, cultural heritage, but the region’s contemporary cultural mosaic has been shaped under several different civilizations and traditions (Simone and Feraru 1995). East Asian countries have a predominantly Confucian culture which originated and spread from China but which is rather modified in today’s People’s Republic of China. Korea, Japan and parts of the Indochina peninsula came strongly under its influence whereas Buddhism moved east from India, strongly shaping the belief systems of Burma, Siam (Thailand) and Cambodia, with Islam spreading subsequently to become the prevailing religion in Malaysia, Brunei, Indonesia and parts of the south of the Philippines. Overlain across the region is Christianity, from Japan to Indonesia, although it has become a predominant religion only in the Philippines and with significant followers in Korea. The underlying belief systems of the region come from this variety of traditions and, even within individual contemporary countries such as China and Korea, a range of systems has been influential. In addition, Asian belief systems have spread

Ageing in the Asia-Pacific region

3

internationally with migration and international contacts. A common cultural characteristic in the region is the high value placed on family integration and consensus in social relations to maintain harmony among members of groups, with an expectation of community welfare rising above individual interests (Simone and Feraru 1995). At the start of the new millennium, the region remains one of the most economically and demographically exciting in the world. Huge socioeconomic, political and infrastructural changes are being witnessed across the Asia-Pacific region. The economic woes that beset many of the economies during the final few years of the 1990s subsided and positive economic growth resumed although at varied rates (Far Eastern Economic Review 1999). The region nevertheless retains considerable economic diversity. Japan is a key economy, albeit one that was sluggish during much of the 1990s with deflation (especially asset deflation) and very low interest rates, which is important for many older persons who might need to live on investment incomes. Many important internal economic and financial reforms have yet to be carried through and, arguably, Japan’s economic dominance is waning. By contrast, China has emerged as another key economy to future regional long-term growth. The Asian Tiger economies— Taiwan, Korea, Hong Kong and Singapore—fared varyingly during the latter years of the 1990s whilst several other economies emerged in industrial development, including Thailand, Vietnam and the Philippines. Malaysia adopted a largely economic isolationist approach whilst the economy of populous Indonesia remains financially and politically problematic for the foreseeable future. The range of academic and general literature on social, political and economic development in the Asia-Pacific region is fairly extensive. Specific texts on ageing are fewer. Phillips’s (1992) regional overview; a special journal issue focusing on living arrangements of older people in Southeast Asia (Knodel and Debavalya 1997) and certain other special issues of journals have focused on ageing in the region (see, for example, Chan 1999; Kosberg and Chow 1999). The growing interest in this and related topics is clear and it is hoped regional comparisons will increase. A useful review of the health of older persons in the WHO’s Western Pacific Region includes a series of country profiles covering the countries in this book and a number more (WHO 1998). ESCAP (1999a) provides a useful overview of the broader Asian region in terms of data on population and ageing. Issues in ageing: policies, services and facilities for older persons Ageing and policies for older persons in the region are set in a number of contexts, including the complex interrelationships between development and population ageing (ESCAP 1999a). Many involve both long-term and short-term considerations. Long-term considerations relate mainly to

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changing demographic profiles and associated family changes (such as nuclear, smaller families and longer life-expectancy) and the slow nature of change in public and official thinking (which assumes continued reliance on family and children’s care). The immediate effects of demographic factors can be exaggerated in all but a few countries—Japan, Hong Kong, Singapore, perhaps Taiwan and Korea, and China, by weight of numbers. Shorter-term considerations tend to revolve around constraints on the ability to meet the needs and demands of today’s older people, in part associated with shortterm economic uncertainty which makes policy-makers uncomfortable (Arndt and Hill 1999). An erstwhile ebouillient economic region arguably experienced the first major disadvantages of globalization, the problems of rapid acceleration and deceleration in economic growth and the operation of 24-hour financial markets. Greater stability developed in regional economies during 1999–2000, although there is now heightened awareness of the region’s vulnerability and resistance to future shocks. In many ways, for older people, economic crisis had its greatest relevance in the impact effect on families. Unemployment and poverty increased and many families were thrown onto their own resources. Gross domestic product (GDP) fell considerably in many countries between 1997 and 1999, although many did subsequently recover strongly, with the exception of Indonesia. Indonesian families, for example, reduced their expenditures on health care, education and some other important social areas. Indeed, it appears that 25 per cent reductions occurred in average expenditure per household between 1997 and 1998; real wages declined by around 40 per cent and poverty increased (Population Today 1999). This is perhaps one of the more extreme examples of the household impact of economic crisis, although variations have been felt everywhere. Increased unemployment and reduced family incomes have been evident in almost all countries. China, the Hong Kong Special Administrative Region (SAR), Taiwan and Singapore were rather less affected than many but their citizens and economies also felt financial stringency. The political impacts of the crisis led to leadership changes in a number of countries and may potentially lead to greater openness and political reform in many regimes such as those of Indonesia and Korea. Asia-Pacific: the climate for service development for older persons Countries in the Asia-Pacific region are not alone in seeking ways to deal with new welfare demands in general and those of ageing populations in particular. Much of the Western world is also grappling with issues related to service provision for elderly people, often in the context of concerns over impending crises in long-term care (LTC) (discussed further in Chapters 4 and 5). Within the LTC arena in the region, many issues have been identified although rarely tackled, including the nature of suitable models of

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care, the virtues of institutional versus community care, the balance of home and community care and the reliance and reliability of care by informal providers. There is an emerging realization of the potential dangers of overreliance on informal and family sources for long-term care in the region, but it should be remembered that, even in the demographically more mature Western countries where demographic ageing occurred over several generations, appropriate, comprehensive care models have yet to be fully implemented. The extent to which non-Asian solutions can be transplanted to this region is debatable, yet it is helpful to know of the reviews of LTC that have been conducted elsewhere. These include countries such as Germany (Evers 1998) and the 1999 United Kingdom Royal Commission on LTC which made a careful evaluation of alternatives (Royal Commission on LTC 1999). To date, in the region, only Japan—almost as a panic measure—has undertaken a serious review of LTC finance. Hong Kong, Singapore, Taiwan and a few others have considered LTC but mainly in the context of the health sector rather than in its much wider welfare, housing and social care settings. Perhaps, in the Asia-Pacific region, there is room for an ‘Asian way’ in service development for older people which takes account of both limited state provision and the popular strength of Asian family care models, especially the so-called East Asian filial piety based models. Such services that do exist specifically for older persons across most of the region are of relatively recent origins and were mainly developed in a climate of economic growth which all but evaporated in many countries in the late 1990s. Ironically, the financial crisis, which became a primary current constraint on service development, made many Asian countries start seriously to re-evaluate the nature of their social, welfare, health and education programmes and provision. As in many other regions, this has become related to shifts in ideology, often with a view to developing new models of public-private sector participation, cost sharing and individual responsibility. Many of the outcomes of this wider re-evaluation of social expenditure and the overall circumstances surrounding it are inevitably impacting on older people in the region. The Asia-Pacific’s ageing profile may be viewed in the perspective of other developing regions in a wide-ranging overview, The Ageing and Development Report, by HelpAge International (Randel et al. 1999). This stresses the importance of considering the changing environments in which persons are ageing. Whilst modernization theory provides an appealing perspective and exposes the ways in which some older persons are vulnerable to change, it can also overlook the part played by structural factors in the exclusion and impoverishment of older people. This is very important to remember in a fast modernizing region such as the Asia-Pacific where many facets of development may impact on older citizens. The report also provides a valuable comparative summary of national policies on ageing and older

Table 1.1 Selected examples of national policies on ageing and older people in the Asia-Pacific region

Table 1.1 (Continued)

Source: Extracted from Randel et al. (1999) (HelpAge International).

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persons in forty-six countries, several of which are in the Asia-Pacific region. The report also reminds readers that 52 per cent of the World’s population aged 60 and over, and 39 per cent aged 80 and over, live in Asia and a sizeable proportion of these are in the Asia-Pacific countries. By 2020, 57 per cent of people aged 60 or over and 48 per cent aged 80+ will be living in Asia. Table 1.1 summarizes from this report the development of national policies on ageing and older persons in ten countries of the region at the end of the 1990s. Today’s older persons in Asia-Pacific: an interim generation? Many of today’s older persons in the region are in effect an interim generation. They have grown old but are often without substantial personal resources as they had been part of emerging rather than mature economies, so they may well suffer if state and family resources are not available. They are caught between a variety of forces in society, economy and environment, which are summarized in Figure 1.1. These are: 1 2

3

Minimal state provision with continuing dependence on individual or family provision, insurance, savings for care; few countries or individuals have established personal or state pension systems. Uncertain family and community support: potentially reduced by demographic changes, smaller and nuclear families, plus fragmentation and migration; economic crisis impacts on savings and employment. An unfriendly environment in many cities and the countryside in which many older persons live. This is often not improving although there are exceptions in parts of Japan, Singapore and a few pockets elsewhere. Environmental improvement needs interdisciplinary, intersectoral and interdepartmental planning and action, a tradition lacking in most countries.

Today’s older generations are also interim in the sense of political development and advocacy. The situation in most of the region is not as advanced as in, say, Europe or North America. In Europe, for example, Walker and Naegele (1999) point out that the politics of old age have entered a critical phase. There, policy-makers are raising questions about the sustainability of pensions and welfare systems but, in this respect, much of Asia lags behind, although a critical element is rising in policy. In Europe, North America and Australasia, many older persons are becoming increasingly politically active and form significant electorates. In this respect the Asia-Pacific region is also behind, but in some countries such as Japan, Hong Kong, Singapore, the Philippines and others, senior citizens’ rights groups are emerging. In the democracies of the region, there are real possibilities for the coming generations of older persons to become active political forces.

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Figure 1.1 Forces acting on older persons in most countries of the Asia-Pacific region oday: diversity and uncertainty—an interim generation?

Quality of life (QoL) Older persons in the region today are also an interim generation in terms of their quality of life. Their QoL is affected greatly by the above factors and many others, especially the environmental ones discussed below. The availability and affordability of care, the nature of the family and the environment affect all areas of life. It is important to recognize the breadth of factors, and not focus solely on health-related QoL. However, this has rarely been achieved anywhere and very interdisciplinary perspectives are needed to address this topic. The region’s wide variety of ageing experience The Asia-Pacific region is the world’s most rapidly ageing region yet it is very important to realize that there is a great variety of demographic ‘points’ at which countries found themselves at the end of the 1990s (ESCAP 1999a; Knodel 1999; Leete and Alam 1999; Phillips 1995, 1998; West and Kinsella 1998). This is discussed in greater depth in Chapter 2, but the variety very much underlines the relative urgency of action programmes for services for older persons which differ considerably among countries. The range of demographic ageing experience reflects not only the percentages of people defined as elderly in the different countries, but their future prospects for demographic ageing and associated epidemiological changes. Currently, percentages aged 65+ range from 3 per cent to well over 10 per cent and will grow at very different rates over the next few decades. Figures 1.2a and 1.2b show the percentages of people aged 65+ and 75+ at 1990, 2010 and 2025 for most of the countries included in the book. The East Asian countries will almost all experience considerable growth in their elderly populations and most will have over 15 per cent aged 65+ by 2025; Hong Kong and Singapore will have over 20 per cent and Japan over 25 per cent.

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Figure 1.2a Asia-Pacific: percentage of elderly population 65+ in 1990, 2010, 2025.

Expectation of Life at Birth (ELB), whilst a somewhat theoretical figure, shows also a clear Southeast-East Asian division, in which Thailand and Singapore become demographically honorary members of the East Asian geographical group (Figures 1.3a and 1.3b). By contrast, many of the countries in the southeast of the region will have percentages aged 65+ of below 10 per cent well into the next century. Indeed, some such as Cambodia and Laos which are still experiencing growing numbers of young population will actually probably have a smaller percentage of elderly in 2010 than in 1990.

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Figure 1.2b Asia-Pacific: percentage of elderly population 75+ in 1990, 2010, 2025.

A further important feature of the demography of the region is that, with a limited qualification in the case of Japan, there is probably no ‘demographic time-bomb’ set to explode, creating serious short-term problems. Some reseachers, however, do suggest that current projections of future ELB might be considerable underestimates. There is growing evidence of moral panic and popular concern about ageing in many countries. Japan does have a serious problem with percentages and numbers of elderly people, as seen in Chapters 6 and 7, which impact on society and economy in a multitude of ways. China, too, has huge absolute numbers of elderly people—in the late 1990s, only around 7 per cent were aged 65+ but these totalled around 100 million older persons, more than in the major countries of Europe combined. Hong Kong and Singapore follow with fairly impressive percentages but their absolute numbers are relatively small.

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Figure 1.3a Seven selected countries in Asia-Pacific: expectation of life at birth (years), 1995, 2010, 2025.

Varied ageing profiles but some common socioeconomic characteristics The countries may be varied in terms of ‘ageing profiles’ but, as a group, they share some common features which characterize the socioeconomic environments in which ageing and the context of this book are set. Economic growth rather than investment was widely assumed to underpin what limited social security existed in most countries. Only a few of these

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Figure 1.3b Nine selected countries in Asia-Pacific: expectation of life at birth (years), 1995, 2010, 2025.

had much in the way of formal retirement protection. Ironically, China, the largest country and population, spent much of the 1980s and 1990s attempting to undo its extensive cooperatively-based state protection and provision, the so-called ‘iron rice bowl’. This will potentially render many millions of older people bereft of previous support, although new forms of social insurance are currently being experimented with and developed. Almost all countries have recognized the perils of providing denned benefits financed on a ‘pay-as-you-go’ basis, especially in rapidly ageing societies, in

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which costs fall on those currently working whilst people in the often large informal sectors do not pay or receive benefits. Financial security—mainly immature welfare and retirement schemes The extent of retirement protection schemes and benefits has great importance for the nature of services and provision that can be developed and afforded. The depth and reliability of such schemes also have profound importance for the nature and quality of services that can be developed for older persons, others in need of LTC and the families of carers. They are also especially important for those who either have no family at all or have none living close by. The countries of the region differ greatly in the nature of their public and private programmes for elderly service provision, pension schemes and types of support (see for example Asher 1998; ESCAP 1999a; WHO 1998; Randel et al. 1999). They also show considerable variation in the proportions of their national budgets spent on the different economic sectors: health, welfare, education, housing, infrastructure, security and defence. Few countries other than Japan and Singapore have much formal financial support, and China, which previously had some collective financial and support in kind, has largely moved away from such provision and is moving towards individual responsibility. Others, such as Thailand, are attempting to introduce some more comprehensive long-term provision as discussed in Chapter 13. Fragmented occupational structures and fragmented care systems A feature of employment in many countries of the region is that the majority of people working are in the informal sector or in small companies and many remain in rural semi-subsistence activities. These offer few or no retirement schemes and, as a result, many older people continue working full- or parttime. In some countries, such as Japan and Korea, there are striking contrasts in large corporate employers and salaried employees who enjoy a range of employment-related retirement benefits. Hong Kong and Singapore, with their large public sectors, have similar schemes but, even in these countries, there has always been a fairly substantial proportion of persons in less formal employment. Whilst, of course, the formal-informal sector distinction is increasingly recognized as artificial, it does have implications for security of employment with a far greater likelihood of compulsory retirement ages with pension provision in the formal sector. Informal activities and marginal occupations are almost certainly increasing, as is the return of urban-rural migration, which can increase financial insecurity for many people. Remittances to rural areas, where many elderly relatives remain, almost certainly fall in times of economic retrenchment. However, even for employees in large-scale companies, employment is less secure than

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previously. Indeed, some older employees in formal occupations, where age often equates with higher salary costs, can find themselves targeted in redundancies. Changing family structures/contexts: shifting sands in intergenerational relations Family care and filial piety There is widespread and continuing public and private affirmation of the importance of family and community support for older persons across the region. Older persons, in an Asian context even more so than in many other regions, are viewed by many public and policy-makers alike in a family context (Knodel and Chayovan 1997). Confucian, Islamic and Buddhist value systems, among others, uphold this perspective. Indeed, many countries of the region have explicit declarations—sometimes enshrined in law (however unrealistic)—that care for elderly people is a family responsibility, a private affair in which the state has relatively little business. Therefore, anything that affects the ability of families to act cohesively and perform their duties of provision and service may have severe implications. Economic crisis crystallized the difficulties many families were facing even in good times in providing care for multi-generations under the varied effects of modernization. Income reduction, unemployment, economic restructuring and social unrest in some countries have collectively made the traditional task harder although, ironically, these same circumstances may actually strengthen the resolve of many families to support their members. There is nevertheless evidence of a growing practical and philosophical reevaluation of intergenerational relations by all parties concerned and such concepts as parental duty and filial piety may prove more illusory than real. Filial piety can be interpreted in a number of ways. It may be regarded as a fairly straightforward duty (especially in Chinese societies) of children to look after their parents in return for care received when they were being brought up. It can also be much more complex, involving various aspects of obedience, honour and care provision. Clearly, in modern societies today, adult children are far less likely to obey unquestioningly their elderly parents. For some parents and children, this creates tensions, discomfort and a feeling of uncertainty. As Chow notes (Chapter 8), for societies and cultures that have for centuries held dear the values of filial piety, the eroding status of older persons and their poor self-images (discussed below) are causes of considerable misgiving. There are equivalents of filial piety in other cultures in the region. In the Philippines, Natividad (Chapter 14) notes that the maintenance of smooth interpersonal relations and observance of debts of gratitude (utang na loob), especially towards the family, are important, as is avoidance of behaviour that can bring shame (hiya) both individually and on

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the family. Similar codes of parental and child reciprocity and duties are seen in Indonesia, Thailand and Japan among many others. However, it is increasingly recognized that the rigid interpretations of filial responsibility (perhaps without the wider duties of respect and intergenerational linkages) may be negative in terms of the evolution of public policies for older persons. Filial piety may have potentially problematic effects when interpreted solely in its family and not in its wider societal contexts. This is strongly echoed in Chapter 12 by Choi in discussing filial piety in Korea, where its sense of pinning responsibility solely on the family rather than the wider state may even undermine formal welfare developments for older persons. Some authors go so far as to state that, in modern Asian countries, the three-generation family (of grandparents, parents and children) is in an important sense a powerful myth (Hu 1995). The three-generation residence and childrens’ automatic support for older family members have widely been regarded as cultural assets that can combine the best aspects of traditional and modern approaches. However, Hu notes that data such as those on elderly people’s suicide (discussed below) suggest that many older persons, especially elderly women, are currently very vulnerable in view of their socially-constructed total dependence on their children. Many studies confirm this and it may be that the failure of children to provide full care and informal support can lead to great disappointment on the part of the parents and, of course, feelings of guilt on the part of the children. In many societies in the region today, numerous structural factors and those associated with modernization may render this difficult or impossible. Reducing family size with fewer children, practical factors (such as small accommodation units and distance from parents due to work and migration), economic reasons (lack of finance) and many others including intergenerational disputes, often act in combination to render the traditional three-generation residence difficult or impossible. Yet modernization and economic difficulties may, ironically perhaps, also have some positive outcomes such as a re-evaluation of nuclear trends today as families realize that, in times of crisis, the soundest sources of help are from within the family. Nevertheless, in many Asian countries, the reality and practicality of care from such sources is now very much open to question (Ho 1996), as authors in many chapters of this book, including those dealing with Hong Kong, China, Thailand, Korea and others, openly acknowledge. It is widely recognized that family sizes today, and especially in the future, are likely to be much smaller. There will be fewer children to care for increasingly long-lived parents. The long-term impacts of, for example, the one-child policy in China and the exceptionally low fertility rates in places such as Hong Kong, Japan and Singapore might lead to the potential ‘4–2–1’ family structure. In this, a single child can have up to six direct adult relatives as a responsibility (Chapters 6, 8 and 10; Phillips 1998). This may be an extreme situation, and research in Thailand, Vietnam and

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elsewhere suggests that the impact of fertility decline might be less than some sources have anticipated (Knodel and Chayovan 1992; Knodel 1999). Nevertheless, even where larger families are still the norm, as in the Philippines or even in rural China where family planning restrictions have been less rigorously enforced than in urban areas, economic changes mean that children may well be working away from their parental home districts (Joseph and Phillips 1999). Rural-urban migration and international migration illustrate this very well in many countries of the region. The demographic ageing of Asia’s population also means that there will be fewer young workers available to act as formal or informal carers. This may strengthen the importance of older people themselves acting as volunteer or even paid carers, Social participation: stereotypes, self-images and the tragedy of elderly suicides It is clear in many of the countries in the region that a major challenge is to undo or alter the often negative stereotypes of older people among the general population and also the very poor self-images held by many older persons themselves. These images are unfortunate and appear completely at odds with the much-promoted Asian values of respect and reverence for old age discussed above. Negative images are increasingly recognized and are often at the root of conflict between generations. Singapore, for example, has formally addressed this, in March 1999, by establishing working groups under an inter-ministerial committee on ageing to examine all issues in a ‘no sacred cows’ review. The working groups in many ways epitomize the key issues identified in many other settings: financial security, housing and land use policies; employment and employability; cohesion and conflict; social integration; health care. The Singaporean review identifies the need to create a new image of a more healthy, active older person, able to contribute to and not just take from society. In Hong Kong and other countries, this has also been identified along with the need to promote positive and successful ageing. This could accord with the established practice of many older persons in Asia who have been successful in business yet choose to continue working. However, sadly, there remain prevalent poor self-images frequently cited in studies of older people (Chow 1992; Phillips et al. 1999). It may indeed be that new images will emerge but this will not be easy, especially with a continuing media and policy preoccupation with factors such as the rising costs of care for older people and the fear of numerical increases. The development of positive images of active and energetic elderly people and the message that age is not an inevitable barrier to activity is certainly needed. This is crucial if there is to be practical promotion of successful ageing. Fortunately, in some countries, a more positive picture is painted of elderly people active in social and political

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advocacy yet frequently co-residing with, or near to, their children, as in the Philippines and elsewhere. As Natividad notes in Chapter 14, the picture of the majority of older Filipinos is of integration into a family network of children, and very often grandchildren, living together or close by and maintaining daily contact. However, she warns that this apparent ideal can be fraught with tensions for both parties. As a result, in many Asian countries, some older people are making definite decisions to live apart from their adult children. There can be a surprising openness to the idea of living independently and even in an old people’s home (home for the aged) in many of the societies in this book. By contrast, in many other countries such as Brunei and Indonesia, this would be likely to be much less socially acceptable. An improved popular and self-image of older persons should also help to enhance the role of carers, who could be seen as being involved with a worthwhile group in society, rather than a residual and dependent group. The reciprocal aspects of caring—embodied in the tradition Asian model—are surely the key in this respect. Empowerment may be another route in the region. Older people at the top of Asian society have been used to control and power, but the bulk of Asia-Pacific’s elderly population will be poor and often feel disenfranchised. The Philippines again provides an example of older persons having a voice in government but, even then, Natividad notes that the gains senior citizens have made for themselves as a group are relatively modest. Serious policies for the promotion of active ageing and successful ageing will therefore be essential, as elsewhere (Phillipson 1998). In highly economically motivated societies, these will probably involve tax concessions (for employers as well as employees), legislative changes and positive discrimination. It is unlikely that neutral policies or a laissez-faire approach will be successful. Unfortunately, in some countries, notably Japan, older workers in salaried jobs are increasingly targeted as expensive (Chapters 6 and 7). In some countries the temptation to employ younger workers, assumed to be flexible and more appropriately skilled, is increasingly evident in times of unemployment and reduced labour-forces. By contrast, in part because of labour shortages, Singapore has positive plans for the extension of retraining opportunities for older workers as the retirement age is gradually increased (Chapter 9). Suicide amongst older people in Asia-Pacific One of the saddest features of ageing in parts of the region is the high rate of suicide among older people. It is particularly poignant that rates are higher than in most Western countries, in view of the alleged high value placed on age and older people in Asia. Indeed, older persons in many East Asian countries are killing themselves at rates up to five times those of the younger generations and eight times higher than in many Western countries (Hu

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1995). Whilst it should be noted that suicide rates amongst elderly people (men in particular) are also high in the USA and some European countries, for economic, social and many other reasons, suicide rates in much of the Asia-Pacific region appear to be often both high and on the increase. For example, Hong Kong, Taiwan and Singpore, perhaps because of greater willingness than some other countries to record a verdict of suicide, appear to have very high rates. Hong Kong has relatively low youth suicide rates but one of the world’s highest elderly suicide rates (Chi 1997; Li 1998). A review of suicide in the ESCAP region (Ruzicka 1998) identifies a steady increase in suicides with age, a contrast to some other areas in which the young are equally at risk. Suicide rates amongst males aged 75+ in Singapore are recorded as 80 per 100,000 males and at almost 60 per 100,000 among females. In Hong Kong, the corresponding rates are over 60 per 100,000 for males and almost 50 per 100,000 amongst females. In Hong Kong, Singapore, Korea and China, suicide rates amongst the oldest males and females aged 75+ are between two and three times those of middle-aged groups and between four and eight times higher than those in the 15–24 age group. Suicide rates amongst the younger elderly age group (65–74), whilst slightly lower than those in the 75+ group, are still two to three times higher than those of young adults. This pattern, with higher rates amongst the oldest and males, is similar to that reported in the United States, particularly among older white males (at 39 per 100,000) (Hooyman and Kiyak 1999). However, the rate even in this high-risk group in the U SA is still considerably lower than in the same group in Singapore and Hong Kong. Whilst increasing rates of suicide with age are not universal, as Ruzicka (1998) notes, this is clearly a serious social and public health problem in several ESCAP countries and throughout the Asia-Pacific region. It is also possible that elder abuse is prevalent although this has yet to receive detailed research attention and remains a taboo subject to many. Both elderly suicide and abuse clearly require a broad-based response, to bolster the self-esteem, feeling of value and place in society of some older people. Prevention of elderly suicide in particular will involve improved care for those at risk, but also improved economic provision, social support and living conditions. Chi (1997) notes that many elderly people in Hong Kong who killed themselves had previously indicated their suicidal thoughts to family members and others, who had often not taken them seriously. She suggests that, whilst interventions to reduce suicide rates among older persons will be complicated, a multi-stranded policy approach is needed. This could include promotion of awareness of the risks of elderly suicide, strengthening of family life programmes, improved medical and community-based outreach services for older persons and maintaining active lifestyles for isolated older people. At the practical level, assessments of suicide risk should be undertaken among older persons, with intervention strategies, a concomitant requirement being for trained staff and training programmes to include this subject area.

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Appropriate environments for older persons: a major challenge In many respects, the paramount issue in the region is likely to become one of long-term care and the everyday environment, in its broadest sense. If environment and accommodation are appropriate, affordable and flexible, then the whole gamut of community and family care becomes much easier, and formal support, such as it is, more effective. The axiom might be: ‘if the accommodation environment are correct, all other aspects of care will be more effective’. The environment can be broadly envisaged as that internal to the home and the external local environment in which elderly people and their families live, and the interface between the two are crucial. As the experience of many Western countries shows, ageing populations may need new or adapted styles of housing within which they can then often live alone or with minimal support. However, a lack of suitable accommodation and inappropriate, often dangerous, external environments, together form probably the major deficiency in most Asian cities today and even more so in rural areas. Local environments in many Asian cities and rural areas are rarely elderly friendly and especially not to those within any age group who have even a small level of disability. Indeed, many Asian urban and rural areas offer an environment that is in effect hostile to older people; rarely are environments positively elderly friendly. With few exceptions, cities offer a daunting challenge of dense traffic, uneven surfaces, wide roads, stairs and escalators, and various sidewalk obstacles. Often, especially in the poorer countries, an assaultcourse situation exists for people undertaking simple tasks such as shopping, walking the pavement (non-existent or excavated) and attempting to board public transport. The situation in rural areas, where the bulk of the region’s elderly populations live, may be marginally better than the urban areas. However, formal facilities for older people are likely to be fewer. This deficit might be offset by a greater proportion of rural older people living with their families, although social differentiation within the countryside and between country areas themselves can be considerable, as illustrated by Joseph and Phillips (1999) in the case of China. The interface between home and local services and facilities has not been effectively addressed anywhere in the region except in some newer areas of Japan and to a very much lesser extent in Singapore and Hong Kong (Phillips and Yeh 1999). Improving the internal and external environment for older people, their families and carers, presents a huge challenge. The key is to develop practical, integrated planning of a very interdisciplinary nature, acknowledging the essential nature of public-private sector participation. However, a constraint on service development in the short and medium term may be curtailed public expenditure on social as well as infrastructure projects which can impact on older people as well as the wider population.

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Accommodation and long-term care: quality and costs Accommodation initiatives There is a major need throughout the region for the public and private sectors to develop an appropriate mix of accommodation for older people and their families. Some places have begun to address this, and Hong Kong, for example, has an imaginative mix of schemes to cater for older persons in public housing, although supply is insufficient. The private sector remains a long way behind, as it does generally elsewhere in the region. Such policies that do exist in most Asian countries have generally emphasized the importance of maintaining older people, as far as possible, in the community (an exception being the excessive hospitalization of older people in Japan). This means that programmes based in the community that enhance social support at a local level should be an essential part, perhaps the major part, of the service and support networks, both for carers and those in need of care. However, the rhetoric of community care generally exceeds the reality in the vast majority of countries. Therefore, as Chow (1994) and others have noted, community-based programmes and rhetoric must not be seen as total substitutes for institutional care when it is justified. Second, good community-based programmes should assist and act as relief mechanisms for family members and carers, to avoid as far as possible carer fatigue and stress, so commonly identified when adequate long-term help and shorter-term respite care are not available. Long-term care (LTC) The combination of demographic ageing and the deficiencies of accommodation and environmental planning make the provision and development of long-term care perhaps the principal challenge in many AsiaPacific countries. This has to be recognized as comprising much more than institutional long-term care (hospitals, nursing homes and residential care). Today, it should encompass development of a full range of community and home care services. These include home nursing, home helpers, day care services, visiting and meals services, good primary care services accessible to and from the home, and many other services (Phillips 2000). However, in the vast majority of countries in the region, LTC systems, like social security systems, are very immature and consist of fragmented residential care and some limited official and voluntary home and community care. For the most part, they rely (in both popular and official conceptions) on informal care by family members who are rarely supported by community services. In addition, serious standards of inspection, regulation of the formal, institutional parts of LTC are largely non-existent. This lack of standards, high costs and poor quality of LTC form serious shortcomings in many countries but only a few are taking any steps to address the deficiencies.

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The costs of LTC Many Asian countries are expensive for long-term residential care and few have sound, community-based LTC support systems. This is in spite of the fact that it is only recently that profit-making organizations have either grown strongly (as in Hong Kong and Japan) or been allowed to operate at all (as in Korea). It may of course be that as the private market matures and market forces take effect, as supply more nearly matches demand, that prices will stabilize or reduce. However, to date, Japan, Hong Kong, Singapore, Taiwan and Korea are notably expensive. Costs of homes for older people and especially nursing-home-type accommodation are surprisingly high outside the subsidized and limited state sector provision. Some countries such as China, Thailand and Indonesia may be somewhat cheaper but much care remains locally relatively expensive. Some international convergence of costs appears to be happening, perhaps influenced by what the public sector and insurance will support. A comparison of Hong Kong, Britain and Canada in 1999 indicates that a reasonable quality nursing home room in Hong Kong cost (in US dollars) from $800 to 1,800 per month. In Britain, state support for such a room was about $2,000 per month whilst, in Canada, it was estimated at about $1,900. In Hong Kong, as in the other two countries, the costs of higher-level nursing care and good quality single rooms is thus becoming very expensive and arguably unaffordable for many families. Poorer quality shared accommodation is, of course, cheaper but often unsatisfactory. Whilst many countries wish to bolster family ability to provide LTC, they increasingly recognize families’ limitations. However, the reluctance to address this seriously as a societal responsibility can present a major hindrance to policy development, as Choi discusses in the case of Korea (Chapter 12). There are many worthy statements to be seen across the region. The Chief Executive of Hong Kong, for example, has stated that families should not be presented with such a care obligation as to overburden them. The Beijing authorities likewise have announced that it is should not be a source of shame if one’s parents go into a residential home. The key appears to be to achieve public acceptance of residential care as an alternative. In many places, this is accepted by families but often with considerable feelings of guilt, which is not merely an Asian issue but a universal one. For too long the code of filial piety has been ascribed a status and uniqueness that, for practical and other reasons, it no longer has. Some countries actually have in place legal statutes, if rarely used, to enforce filial duties, as in Singapore, Thailand and China. Health and epidemiological transition: ageing and the gender gap For the development of services for older people, variations in the causes of morbidity are very important, arguably more significant than causes of

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mortality (see Chapter 2). New profiles of health status have evolved quite rapidly across the region as epidemiological transition has progressed (Phillips and Verhasselt 1994; Phillips 1998; Phua 1997). The broader concept of health transition is also crucial to the sorts of services likely to be needed, both within the community and in terms of institutional provision (Caldwell 1999). Trends in mental health and dementia in particular are likely to be crucial to the future of long-term care in the region. Unfortunately, data are poor or non-existent at national levels in many of the countries, although there are some useful epidemiological case-studies in a few. The future need for and shape of many welfare and health services (and whether they will be delivered in the community or in institutions) will be strongly influenced by future morbidity patterns. In particular, research is needed to establish whether a compression of morbidity or a pattern of longer life but worsening health is emerging in Asian countries (Ebrahim and Kalache 1996; ESCAP 1999a; Phillips 2000; Robine et al. 1998). There is increasing debate about the nature and linearity of epidemiological transition and it seems clear that protracted and overlapping transitions can occur and that reversals of health gains are possible, especially with the re-emergence of some communicable diseases (Phillips and Verhasselt 1994; Frenk et al. 1996). Transition can also clearly vary considerably between different socioeconomic groups, between rural and urban areas and within urban areas. This is clearly of great relevance to the larger countries in the Asia-Pacific region such as China, Indonesia, Thailand and Vietnam, within which there are great socio-spatial differences in the incidence and prevalence of various causes of mortality and morbidity. Indeed, whether there is a single Western-style progression in transition in the Asia-Pacific region needs to be established; in Europe, for example, a late stage of transition is appearing, with extending lifeexpectancy but reappearance of some infectious diseases. This has important implications for the planning of services for all age groups (Smallman-Raynor and Phillips 1999). Data and investigations are required for the Asia-Pacific region. The social and economic implications of the health status of extended life and the possibility of infectious disease recurrence or new emergence need urgent investigation in much of the region. This is likely to be hindered in many countries, in part because of a lack of data but also because of fragmented responsibilities amongst departments and agencies and a fairly widespread neglect with a few exceptions of ‘strategic social planning’. Data on morbidity must therefore be collected and analysed as a matter of urgency in many countries, as to date there is relatively little certainty of trends in health status beyond the case-study level. There may have to be reliance on spot reporting by ‘sentinel’ units at primary care and outpatient levels. Furthermore, little is known, for example, about the likely impacts of HIV/AIDS morbidity and mortality on family structures and how this will

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affect older people (Caldwell 1999). In some countries, such as Thailand, Burma and the Philippines, as in some African countries, grandparents are likely to become the carers for grandchildren, when adults in the reproductive age have become ill or have died (Gelbard et al. 1999). There is a continuing gender gap in life-expectancy in the region, with females consistently outliving males, often by a good number of years. However, it is unclear whether the gap is narrowing or increasing and, if so, what does it imply for service needs and demand? This is also a potentially very important issue (Chow 1994; Kinsella and Gist 1998; Mehta 1997) with fundamental implications when the male spouse is a key care and financial provider. Poverty amongst older single women is potentially a great problem, one likely to increase, and linked, at least anecdotally, with the high incidence of suicide amongst elderly persons in many countries as discussed earlier. The male-female gap of between 3 to 8 years in expectation of life at birth (ELB) and sometimes yet more in life-expectancy at age 60 shows few consistent trends or signs of narrowing in the 1990s. This implies that many older women will have to live alone and in poverty at the end of their lives (Randel et al. 1999). Data for recent decades show some countries, such as Hong Kong, with a steadily narrowing gap over the years (7.6 years difference in 1971; 5.8 years in 1984). More recently, this has slowed, but in the late 1990s the differential was still estimated as around 5.6 years. In some countries, the gap may even be increasing, although data on this issue are often of only moderate quality in many countries and the conclusions that may be drawn are at best tentative. Apparent increases in the male-female ELB gap in, say, the Philippines, principally from longer female lifeexpectancy and static male life expectancy, may well merely reflect data vagaries. Indonesia seems to have similar trends, albeit at lower ELB levels, but with yet sterner data-quality limitations. At higher ELB levels, Malaysia (ELB 74 for females, 68 for males) and Taiwan (81 for females, 74 for males) also appear to have a more static or even increasing gender differential. Fragmented or non-existent primary health care systems and community care support Primary health care (PHC) is health care that is available to people close by their homes and communities; it is the first point of contact with formal services, often complementing social care (Phillips 1990). Some countries in the region have placed—but recently sadly lost—a strong emphasis on primary care (the Philippines, China and others). An overwhelming case can be made that, if older people are to be able to age within the community and live in their own homes or neighbourhoods, an efficient and affordable PHC system, embedded in a sound social care system, is essential. However, PHC, with a few exceptions, is generally fragmented in Asia-Pacific. It is often spread between the public and private sectors, incorporating Western

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and traditional practitioners, and often provided on a fee-for-service basis which gives little or no encouragement for preventive care and systematic screening and referral to secondary care. A 1999 government-sponsored study in Hong Kong, for example, mentioned but underrated the importance for an ageing population of developing an effective primary health care system with proper referral channels. Instead, the report focused on cost containment (elements of the moral panic associated with ageing populations) and insurance options rather than improving existing systems and educating consumer behaviour and professional practices (Harvard Team 1999). Even where primary health care itself is widespread, it often does not fulfil one of its major roles, which is to direct referrals appropriately to more specialized health services. Many factors militate against good primary care in the region. Private sector physicians in many countries operate as businesses, often working in professional isolation, with little in the way of support from the PHC teams familiar in Britain, some other European countries and parts of Australasia. The PHC providers themselves are often at fault for poor prescribing practices, over-medicalization and over-medication, and a distinct lack of promotive and preventive health care. This is a great deficiency when so many of the hopes for the future are pinned on care in the community. An exception, discussed in detail in Chapter 13, is Thailand. Its free medical programme, in existence since 1989, now covers all people aged 60 and over. It is currently non-means tested and operates via a gatekeeper, a referral system from primary care to higher-level hospitals, so it is potentially a powerful way of providing appropriate coordinated health care to older persons. However, the PHC professionals are not solely to blame, as people’s health-seeking behaviour is poor almost region-wide. There is an habituation to seeking medical care, often inappropriately, and knowledge of healthy lifestyle practices is limited. There is a great need for promulgation of basic promotive health behaviour, especially, but not exclusively, amongst older members. Doctor-shopping is rife in Asia-Pacific and there is a general over-expectation of being prescribed medication. Physicians in many countries both encourage and react to patients’ expectations, in order to survive as businesses. Throughout much of the region, the ineffective prescription of antibiotics for illnesses of probable viral aetiology is routine. There is also considerable inappropriate utilization of hospital outpatient and accident and emergency rooms in many countries. In part, this is because of the deficiencies in PHC, and a good primary care system could avert many unnecessary hospital visits. However, inappropriate utilization can also stem from free or heavily subsidized public hospitals which in itself creates great inefficiencies for the hospital systems and overwhelms facilities for the cases that really require hospital attention. What is the answer? A multi-pronged approach is probably needed,

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involving proper development of primary care teams, perhaps the instigation of patient list-based and publicly supported general practitioners/ family doctors; incentives for health promotion rather than treatment; and public education. Developing proper and integrated primary care referral systems to secondary levels is essential to minimize inappropriate use of hospitals. Variants of managed care and fragmented insurance-based fee-forservice systems will almost certainly not be the most effective way to deal with the needs of ageing populations. However, to improve primary care in the region will require almost total reappraisal of public policies and professional medical practice, and an unrealistically huge change of attitudes on the part of the public in almost every country. Constraints on improving conditions for older persons There are clearly many constraints on improving the conditions of older persons and their families in many parts of the region. As discussed earlier, today’s growing numbers of older persons are in many ways an interim generation. They are often without substantial personal resources, yet public provision is very limited and their living environments often uncomfortable or even hostile. Other constraints are more generic and qualitative in effect, based on changing abilities of families to care for elderly relatives and the inability of any system, even in the strongest economies, to adjust to considerable new demographic and epidemiological demands. The constraints can be social—overt or inadvertent ageist practices; discrimination and poverty amongst elderly people, especially females; negative images of and within the older population. There are also structural constraints, often relating to lack of integration between the programmes of the many agencies and departments involved in housing, local environments and services for the needs of ageing populations. This can be very important in some but not all countries, where traditions of intersectoral and interagency collaboration may not exist and which can be a major hindrance to developing a suitable constellation of services. Other constraints can involve a traditional, deeply imbued belief in the value and ability of ‘the family’ to care, which may in itself provide a mode of self-denial (public and private) of the growing needs of ageing populations. In Korea (Chapter 12), amongst others, this has been identified as an obstacle to the development of modern social policy for older populations. Some social constraints stemmed from the economic crisis in the late 1990s (Atinc and Walton 1999) and many impacted on older persons and their families, although direct evidence is scanty. Heightened prevalence of poverty and incidence of extreme poverty occurred in many countries of the region, with resulting increased unemployment and vulnerability. This is evident in Indonesia (Population Today 1999) and to a lesser extent in other countries. Impacts from broader economic factors such as falling national

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and family incomes and reduced social expenditure for older people remain largely speculative. Most data are guesstimates, and stark: for example, data suggest that two-thirds of Indonesians (the country probably hardest hit by economic and political crisis) would be below the poverty line in 1999 with perhaps 70 million extra people living in poverty (double the previous number). Thai data suggest a perhaps temporary doubling of rural costs of living and even more in urban areas. This is unfortunate because poverty reduction had previously been impressive in Asia-Pacific and hailed to indicate what developing countries and regions can achieve. The social impacts of economic crisis were varied and ranged from the immediate to the slower and more subtle. Immediate impacts included unemployment, distress, retrenched public and private spending on services and health care, and immediate impacts on quantity and longer-term effects on quality of services and care. An important longer-term social impact of economic crisis may be psychological as national confidence of many countries in the regions has been shaken. However, the majority of older persons themselves in the region are both sceptical and stoical, unsurprised at economic changes and often having witnessed far worse in their lives. Conclusions This chapter has set the context for many of the country chapters that follow. There is clearly great diversity in many facets of ageing across the region. However, the chapter has also identified commonalities and features that all countries have to address. Countries are starting to learn from each other and regional policy meetings are increasing (see for example, ESCAP 1999a, 1999b). Research into policy and practice is essential as data and information are patchy and the pace of change is often quickening. References Arndt, H.W. and Hill, H. (1999) Southeast Asia’s Economic Crisis, Singapore: Institute of Southeast Asia Studies. Asher, M.G. (1998) ‘The future of retirement protection in Southeast Asia’, International Social Security Review 51, 1:3–30. Atinc, T.M. and Walton, M. (1999) Social Consequences of the East Asian Financial Crisis, Washington DC: World Bank. Caldwell, J.C. (1999) ‘Good health for many: the ESCAP region, 1950–2000’, Asia-Pacific Population Journal 14, 4:21–38. Chan, A. (1999) ‘The social and economic consequences of ageing in Asia’, Special Issue, Southeast Asian Journal of Social Science 27, 2:1–162. Chi, I. (1997) ‘Elderly suicide: the situation in Hong Kong’, Hong Kong Journal of Gerontology 11, 2:28–35. Chow, N.W.S. (1992) ‘Hong Kong: community care for elderly people’, in D.R. Phillips (ed.) Ageing in East and Southeast Asia, London: Edward Arnold, 65–76.

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——(1994) ‘Elderly women in changing Asian societies’, Asia Pacific Journal of Social Work 4, 2:41–57. Ebrahim, S. and Kalache, A. (eds) (1996) Epidemiology in Old Age, London: BMJ Publishing Group. Economic and Social Commission for Asia and the Pacific (ESCAP) (1999a) Promoting a Society for All Ages in Asia and the Pacific, New York: United Nations. ——(1999b) Macau Plan of Action on Ageing for Asia and the Pacific, New York: United Nations. Evers, A. (1998) ‘The new Long-Term Care Insurance Program in Germany’, Journal of Aging & Social Policy 10, 1:77–98. Far Eastern Economic Review (1999) Review Asia 1999 Yearbook, Hong Kong: Far Eastern Economic Review. Frenk, J., Bobadilla, J.L. and Lozano, R. (1996) ‘The epidemiological transition in Latin America’, in I.M.Timaeus, J.Chackiel and L.Ruzicka (eds) Adult Mortality in Latin America, Oxford: Clarendon Press. Gelbard, A., Haub, C. and Kent, M.M. (1999) World Population beyond Six Billion, Population Bulletin, 54, 1, Washington DC: Population Reference Bureau. Harvard Team (1999) Improving Hong Kong’s Health Care System: Why and for Whom? Printing Department: Hong Kong Special Administrative Region Government. Ho, D.Y.F. (1996). ‘Filial piety and its psychological consequences’, in M.H.Bond (ed.), Handbook of Chinese Psychology, Hong Kong: Oxford University Press. Hooyman, N. and Kiyak, H.A. (1999) Social Gerontology: a Multi-disciplinary Perspective, 5th ed., Boston: Allyn and Bacon. Hu, Y.H. (1995) ‘Elderly suicide risk in family contexts: a critique of the Asian family care model’, Journal of Cross-Cultural Gerontology 10:199–217. Joseph, A.E. and Phillips, D.R. (1999) ‘Ageing in rural China: impacts of increasing diversity of family and community resources’, Journal of Cross-Cultural Gerontology 14:153–68. Kinsella, K. and Gist, Y.J. (1998) Mortality and Health, IB/98–2, International Brief: Gender and Aging, Washington, DC: US Bureau of the Census. Knodel, J. (1999) ‘The demography of Asian ageing: past accomplishments and future challenges’, Asia-Pacific Population Journal 14, 4:39–56. Knodel, J. and Chayovan, N. (1992) ‘The impact of fertility decline on familial support for the elderly: an illustration from Thailand’, Population and Development Review 18, 1:79–102. ——(1997) ‘Family support and living arrangements of Thai elderly’, Asia-Pacific Population Journal 12, 4:51–68. Knodel, J. and Debavalya, N. (1997) ‘Living arrangements and support among the elderly in South-East Asia: an introduction’, Asia-Pacific Population Journal 12, 4: 5–16. Kosberg, J.I. and Chow, N.W.S. (1999) ‘Population aging: social problems and solutions’, Special Issue, Journal of Sociology and Social Welfare 26, 1:3–188. Leete, R. and Alam, I. (1999) ‘Asia’s demographic miracle: 50 years of unprecedented change,’ Asia-Pacific Population Journal 14, 4:9–20. Li, P.W. (ed.) (1998) Older People’s Suicide, Hong Kong Association of Rights of the Elderly, Hong Kong: Humanities Publishing House (in Chinese). Maidment, R. and Mackerras, C. (eds) (1998) Culture and Society in the Asia-Pacific, London: Routledge. Mehta, K. (ed.) (1997) Untapped Resources: Women in Ageing Societies across Asia, Singapore: Times Academic Press.

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Minichiello, V., Chapell, N., Kendig, H. and Walker, A. (eds) (1996) Sociology of Aging: International Perspectives, Melbourne: International Sociological Association Research Committee on Aging. Phillips, D.R. (1990) Health and Health Care in the Third World, London: Longman. ——(ed.) (1992) Ageing in East and South-east Asia, London: Edward Arnold. ——(1995) ‘Experiences and implications of demographic ageing in the Asia-Pacific region’, Hong Kong Journal of Gerontology 9, 1:20–9. ——(1998) Ageing in the Asia-Pacific Region: Trends and Policy Implications, Working Paper 5/98, Asia-Pacific Institute of Ageing Studies, Lingnan College, Hong Kong. ——(2000) ‘Long-term care’, in E.F.Borgatta (ed.) The Encyclopedia of Sociology (revised edition), New York: Macmillan Reference. Phillips, D.R., Luk, K.-L. and Chan, C.-M. (1999) Strangers Sharing Space and Lives: the Housing for Senior Citizens Scheme in Hong Kong, Working Paper 1/99, Asia-Pacific Institute of Ageing Studies, Lingnan College, Hong Kong. Phillips, D.R. and Verhasselt, Y. (eds) (1994) Health and Development, London: Routledge. Phillips, D.R. and Yeh, A.G.O. (eds) (1999) Environment and Ageing, Hong Kong: Centre of Urban Planning and Environmental Management, University of Hong Kong. Phillipson, C. (1998) Reconstructing Old Age, London: Sage. Phua, K.H. (1997) ‘Health transition and health sector reform: perspectives from East Asia’, Proceedings of the International Symposium on Health Transition and Health Sector Reform in Asia, National Institute of Health Services Management, Tokyo. Population Today (1999) ‘Indonesia: coping with crisis’, Population Today 27, 8:4. Randel, J., German, T. and Ewing, D. (eds) (1999) The Ageing and Development Report: Poverty, Independence and the World’s Older People, HelpAge International, London: Earthscan. Robine, J.-M., Mormiche, P. and Sermet, C. (1998) ‘Examination of the causes and mechanisms of the increase in disability-free life expectancy’, Journal of Aging and Health 10, 2:171–91. Royal Commission on Long Term Care (1999) With Respect to Old Age: Long Term Care— Rights and Responsibilities, Cm. 4192–I, London: The Stationery Office. Ruzicka, L.T. (1998) ‘Suicide in countries and areas of the ESCAP region’, Asia-Pacific Population Journal 13, 4:55–74. Simone, V. and Feraru, A.T. (1995) The Asia Pacific, New York: Longman. Smallman-Raynor, M. and Phillips, D.R. (1999) ‘Late-stage epidemiological transition’, Health and Place 5, 3:209–22. Walker, A. and Naegele, G. (eds) (1999) The Politics of Old Age in Europe, Buckingham: Open University Press. Watters, R.F. and McGee, T.G. (eds) (1997) Asia-Pacific: New Geographies of the Pacific Rim, London: Hurst. West, L.A. and Kinsella, K. (1998) ‘Pension management and reform in Asia: an overview’, NBR Executive Insight, no. 11, National Bureau of Asian Research, Seattle, WA. World Health Organization (1998) Health of Older Persons in the Western Pacific Region: Country Profiles, Manila: World Health Organization.

2

Demographic dimensions of ageing in East and Southeast Asia1 Kevin Kinsella

As countries in East and Southeast Asia struggle with ongoing economic uncertainty, issues of employment, labour productivity, and financial restructuring tend to dominate social discourse. With immediate, sometimes day-to-day crises commanding the public spotlight, attention fades from less obvious, longer-term processes involving demographic evolution and changing national health profiles. The effects of these processes, however, will have a substantial, tangible impact on the well-being of today’s and tomorrow’s elderly populations, and will shape the manner in which countries redefine and structure their systems of old-age security. One such long-term process is the demographic ageing of population. The phenomenon of population ageing has been well-publicized in the industrialized nations of Western Europe and North America. What is not as well appreciated is the fact that most countries of East and Southeast Asia are ageing much more rapidly than elsewhere in the world. In the West, there has been increasingly acrimonious debate over the distribution of social resources as the relative balance of older and younger persons changes. Shifting weights of younger and older people have an impact on the implicit social contract, and may strain (or conceivably strengthen) intergenerational solidarity. Social security systems that evolved under one set of demographic circumstances may require substantial restructuring in order to remain solvent and functional for successive generations. The challenge for nations of East and Southeast Asia is to tackle these issues in the context of extremely rapid demographic change. National levels of ageing show wide variation The extent of population ageing in non-Western countries is most commonly expressed as the percentage of all persons aged 60 or over. There are large differences in the level and pace of ageing among the nations of East and Southeast Asia (Kinsella and Gist 1995). With 22 per cent of its population aged 60 or older, Japan currently is the ‘oldest’ of all Asian

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Figure 2.1 Percentage of population aged 60 and over, 1998 and 2025. Source: US Census Bureau, 1999.

nations, and one of the demographically oldest countries in the world (Italy stands as the world’s most aged major country with 23 per cent of its populace aged 60 and over). In contrast, fewer than 6 per cent of all persons are among the ranks of the older persons in the Philippines. Most of the ten other countries in this chapter have one-tenth or more of their populations in the 60-and-over category (Figure 2.1). With the exception of rapidly-ageing Japan, these levels are lower than typically seen in North America and Europe, but generally higher than elsewhere and in other developing world regions. Speed of ageing especially rapid in East Asia During the next three decades, the percentage of older persons is projected to rise substantially in all twelve Asian nations discussed here. By 2025, one of every three Japanese is likely to be at least 60 years old, and the percentage of

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older persons will approach or exceed 25 per cent in Hong Kong (SAR), Singapore, South Korea, and Taiwan. What sets many East and Southeast Asian nations apart from the developed countries of Europe and North America is the speed of the demographic ageing process. Population ageing in the latter has been a gradual process that allowed societies and economies time to adapt to their demographic evolution. For instance, it took 89 years for the elderly (60+) share of total population to rise from 10 per cent to 20 per cent in Sweden. This same increase will be compressed into fewer than 30 years in most countries in this chapter (Figure 2.2), which suggests that Asian nations may not have the luxury of trial and error in terms of social programme design. Fortunately for most countries, the increase in percentage of older people is expected to be relatively modest during the next decade, and then accelerate after the year 2010 as the large cohorts of persons born after World War II enter the ranks of the elderly. Thus, countries throughout the region have a window of opportunity, albeit a rapidly closing one, to plan for the demographic ageing of their population. Planning, of course, involves numbers more than percentages. Regardless of the pace of population ageing in percentage terms, growth in absolute numbers of older persons is a more important barometer to those concerned with factors such as health facilities, pension programmes, and service delivery. In 1998, there were an estimated 191 million persons aged 60 and over in the twelve countries, two-thirds of whom live in China. In the space of only twelve years (1998–2010), the number of older persons is likely to increase by 67 million, i.e. an increase of 36 per cent. By 2025, the twelvecountry elderly total is projected to reach 422 million. China alone will see its 60-and-over population explode from 123 million in 1998 to nearly 280 million by the year 2025. The emergence of the oldest old The term ‘oldest old’ refers here to those persons aged 75 and over. Currently, this group constitutes between 15 and 23 per cent of all elderly people in nine of the twelve nations, with somewhat higher levels seen in Japan, the Hong Kong (SAR) and Singapore. Over the next decade, demographers expect to see an ‘ageing of the elderly’, in all twelve countries, meaning that the 75-and-over component becomes a larger share of the total elderly population. After 2010, the trend is less uniform, although Japan should experience a sustained increase in its oldest-old/elderly ratio; by the year 2025, nearly half of all Japanese older persons are likely to be in the oldest-old category. Although the oldest old represent a small proportion of all persons in a given society, this group typically is the fastest-growing segment of the population. Projections for Indonesia, for example, suggest that the total population size will increase by 35 per cent during the period 1998–2025.

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Figure 2.2 Speed of population ageing (number of years required or expected for percent of population aged 60 and over to rise from 10 per cent to 20 per cent). Source: US Census Bureau, 1999.

The 60-and-over population, however, will increase more than 150 per cent, while numbers of the oldest old will jump by 250 per cent (Figure 2.3). In the twelve nations as a whole, the absolute number of oldest old in 1998 (40 million) is expected to mushroom to 101 million by the year 2025. The numerical growth and increasing socioeconomic heterogeneity of the oldest old challenge social planners to seek further knowledge about this group, since the oldest old consume disproportionate amounts of health and longterm care services (Suzman et al., 1992). The dynamics of population ageing The process of population ageing is primarily determined by fertility (birth) rates and secondarily by mortality (death) rates, so that populations with high fertility tend to have low proportions of older persons and vice versa. Demographers use the term ‘demographic transition’ to refer to a gradual process wherein a society moves from a situation of high rates of fertility and mortality to one of low rates of fertility and mortality. The concept of demographic transition admittedly is a broad one and some would argue that it has many permutations and/or that there is more than one form of

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Figure 2.3 Percentage increase in total, elderly, and oldest-old populations in three countries, 1998–2025. Source: US Census Bureau, 1999.

demographic transition. In general, this transition is characterized first by declines in infant and childhood mortality as infectious and parasitic diseases are eradicated. The resulting improvement in life-expectancy at birth occurs while fertility tends to remain high, thereby producing large birth cohorts and an expanding proportion of children relative to adults. Whole populations begin to age when fertility declines and mortality rates at all ages improve. Successive birth cohorts may eventually become smaller and smaller, although countries may experience a ‘baby boom echo’ as women of prior large birth cohorts reach childbearing age. International migration usually does not play a major role in the ageing process, but can be important in smaller populations. Certain Caribbean nations, for example, have experienced a combination of workingage-adult emigration, immigration of elderly retirees from other countries, and return migration of former emigrants who are above the average population age; all three factors contribute to population ageing. Figures 2.4a–c illustrate the historical and projected aggregate population age structure transition in developing and developed countries. At one time, most if not all countries had a youthful age structure similar to that of developing countries as a whole in 1950 (Figure 2.4a), with a large percentage of the entire population under the age of 15. Given the relatively high rates of fertility that prevailed in most developing countries from 1950 through the early 1970s, the overall pyramid shape had not changed greatly by 1990 (Figure 2.4b). However, the effects of fertility and mortality decline

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Figure 2.4a Population, by age and sex, 1950 (in millions). Source: United Nations and US Census Bureau, 1998/99.

Figure 2.4b Population, by age and sex, 1990 (in millions). Source: United Nations and US Census Bureau, 1999.

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Figure 2.4c Population, by age and sex, 2030 (in millions). Source: United Nations and US Census Bureau, 1998/99.

can be seen in the projected pyramid for 2030 (Figure 2.4c), which loses its strictly triangular shape as the size of younger 5-year cohorts stabilizes and the elderly portion of the total population increases. The picture in developed countries has been and will be quite different. In 1950, there was relatively little variation in the size of 5-year groups between the ages of 5 and 24. The beginnings of the post-World War II baby boom can be seen in the 0–4 age group. By 1990, the baby boom cohorts were aged 25 to 44, and younger cohorts were becoming successively smaller. If fertility rates continue as projected through 2030, the aggregate pyramid will start to invert, with more weight on the top than on the bottom. The size of the oldest-old population (especially women) will increase, and persons aged 75 and over will eventually outnumber any younger 5-year group. The legacy of fertility decline One of the most dramatic demographic developments of recent decades has been the rapidity of fertility decline in many developing countries. The common perception is that below-replacement fertility levels are seen only in the industrialized nations of the Northern Hemisphere. As of 1998, however, the total fertility rate was below replacement level in at least twenty-two other countries, mostly in the Latin American/Caribbean and

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East/Southeast Asian regions (US Census Bureau 1999). Although at first it may seem counterintuitive, past and current trends in fertility often have the greatest impact on the speed of population ageing. Countries with high levels of fertility generally have high proportions of population under age 20. Even if numbers of older persons are increasing over time in such countries, the elderly share of the total population remains relatively small. In countries with low or steadily-decreasing levels of fertility, successive birth cohorts often shrink in size, and older persons come to constitute a growing proportion of total population. Asian countries with large segments of traditionally Islamic or Catholic populations have significantly higher fertility than in other countries of the region. The total fertility rate in 1998 in the Philippines and Malaysia, for example, is about 3.5 births per woman. In stark contrast, seven of the twelve nations in this chapter have a total fertility rate below the natural replacement level of 2.1 children per woman (Figure 2.5). Current levels in Hong Kong (SAR), Japan, and Singapore are among the lowest in the world, and have been below replacement level for many years. Without significant immigration, the persistence of low fertility becomes synonymous with population ageing. Sustained low fertility has important implications in a number of arenas. As noted below, traditional family support mechanisms for older members may no longer function well, because the number of kin (especially children) available to support future elderly generations will be considerably smaller than is true today. Fewer children, coupled with a secular trend toward increased geographical mobility, will in all likelihood increase demand for state and/or private pension availability. Eventual shortages of workers may generate demands for immigrant labour (Peterson 1999), and may force nations to choose between relaxed immigration policies versus pronatalist strategies to raise birth-rates (Kojima 1996). The increasing importance of mortality Although the effect of fertility decline is usually the driving force behind changing population age structure, changes in mortality assume greater weight as countries reach lower levels of fertility (Caselli and Vallin 1990). Among the world’s developing regions, the most dramatic improvements in mortality have been achieved in East Asia, where regional life-expectancy at birth increased from fewer than 43 years in 1950 to more than 70 years in 1995. Singapore’s lifeexpectancy at birth rose 30 years in barely one generation, from 40 years in 1948 to 70 years in 1979. Japan presently enjoys the highest life-expectancy of the world’s major countries—the average Japanese born in 1998 can expect to live a full 80 years. Women live longer on average than do men in all jurisdictions in this chapter, with the gender differential in life-expectancy at birth ranging from 2.8 years in China to 7.6 years in South Korea.

Demographic dimensions of ageing in East and Southeast Asia

Figure 2.5

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Total fertility rate, 1998.

Source: US Census Bureau, 1999.

As infant and childhood mortality reach low levels, which is the case with most of the jurisdictions in this chapter, improvements in average lifeexpectancy are achieved primarily by declines in mortality among older segments of the population. Although reliable historical data on mortality are not widely available in Asia, rapid declines in old-age mortality have been recorded in several nations. In Taiwan and Singapore, for example, the deathrate for persons aged 65–69 has dropped by more than half in the post-World War II period. The decline in Japan has been steeper still; the female mortality rate at ages 65–69 in 1994 was less than one-fourth the level in 1950. Major reductions can be seen at older ages as well. As a consequence of these changes, life-expectancy at older ages has increased markedly. Figure 2.6 shows the 30-year change in life-expectancy at age 60 in Japan; under the mortality conditions of 1995, the average Japanese woman aged 60 years could expect to live an additional 25 years, and the average Japanese man more than 20 years. Given the low death-rates among young-old population, and the aforementioned extraordinary growth in oldest-old population, some Asian countries are approaching the time when subsequent improvements in overall life-expectancy will derive from changes not merely amongst the elderly population, but primarily amongst the oldest old. It is now well-documented that old-age mortality in low-mortality countries has reached much lower levels than ever before recorded, and that the decline has tended to accelerate in recent years (Kannisto 1994). In Europe and parts of Asia, these mortality reductions have caught many

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Figure 2.6

Life-expectancy at age 60 for Japan (years of life remaining for those who reach age 60).

Source: Government of Japan, Japan Statistical Yearbook 1998.

demographers and policy planners by surprise. And while there is considerable debate as to the extent of future mortality changes and the limits to human lifespan (see, for example, Vaupel and Jeune 1995), the fact remains that in the world’s longest-lived nations, life-expectancy at birth and at older ages continues to increase. Past estimates of the size of elderly and oldest-old populations have proved too low, and the mortality assumptions underlying current estimates may also prove to be conservative. Such assumptions have poorly served policy planners and businesses concerned with health care costs and delivery systems, pension scheme development, housing design, and other issues related to greying populations. Epidemiologic change will affect old-age security As improved child survival and fertility declines lead to population ageing, growing numbers of older persons shift national health patterns in the direction of more continuous and degenerative ailments. Data from South Korea in Table 2.1 exemplify the typical shift in causes of death. The relative importance of infectious and parasitic diseases, which dominated South Korean mortality in the mid-1960s, has lessened over time while that of chronic and degenerative diseases has increased. By 1981, cancers had become the number one killer. In 1994, the overall cardiovascular disease category—cerebrovascular (stroke) plus hypertension plus other circulatory— accounted for about 30 per cent of all deaths. This epidemiologic transition characterizes all twelve nations in this chapter. As countries age, they will experience a growing burden of chronic diseases and the costs associated with treating such diseases (Murray and

Demographic dimensions of ageing in East and Southeast Asia Table 2.1

45

Rank order of the nine leading causes of death in South Korea, 1966 to 1994

Sources: National data as reported in Ehn Hyun Choe (1989), Population Ageing in the Republic of Korea, UNESCAP Asian Population Studies Series, No. 97, New York; and as reported to the World Health Organization.

Lopez 1996). Much of the demand for old-age economic security will be driven by escalating health care costs. This suggests not only greater demand for expanded pension coverage, but a plethora of marketing opportunities vis-à-vis health care, health insurance, residential care and facilities, devices to assist living, and so forth. Elderly support ratios to rise throughout Asia Broad changes in a nation’s age structure are reflected in changing societal support ratios. One commonly used measure of potential social support is the elderly support ratio (sometimes called the elderly dependency ratio), denned here as the number of persons aged 60 and over per 100 persons aged 20 to 59. Other factors being equal, a rise in this ratio implies that there are fewer economically productive persons per every person of retirement age. The elderly support ratio will rise in all twelve countries over the next three decades. However, the rate of increase will vary considerably, due in large part to past and current levels of fertility. Where birth cohorts have been shrinking for many years (e.g. in Taiwan, Japan and Singapore), numbers of new labour-force entrants also eventually shrink, and older people become an increasing proportion of total population. Where fertility decline has been slower, (e.g. Brunei, Malaysia, Indonesia and the Philippines), large numbers of young adults continue to enter the prime economically active ages and offset the concomitant growth in the older population. In the Philippines, for example, the elderly support ratio will rise only gradually during the next thirty years, whereas South Korea will experience a sharp increase, particularly after 2015 (Figure 2.7). In Hong

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Figure 2.7

Elderly support ratios in four Asian nations, 1990–2030 (persons 60+ per 100 persons aged 20–59).

Source: US Census Bureau, 1999.

Kong and Japan, the elderly support ratio will leap to 59 and 67, respectively, by the year 2025. The situation in the People’s Republic of China illustrates the potential effect that rapidly declining fertility may have vis-à-vis population ageing. In 1979, China established an official one-child-per-family policy aimed at curbing growth in the world’s most populous nation. While the policy was relaxed somewhat in subsequent years, it has drastically lowered China’s total fertility rate, to an estimated level of 1.8 children per woman in 1998. As a result, China will age sooner and more quickly than most developing countries. China’s age profile in 1998 contains two large ‘bulges’ consisting of persons aged 18 to 29 and 34 to 40. The oldest persons in these age bulges will be entering their sixties just prior to the year 2020. This population momentum will produce a rapid ageing of the Chinese population in the second and third decades of the twenty-first century. Recent analyses of 1995 sample census data from China suggest higher old-age mortality than had been previously estimated, resulting in lower numbers of projected elderly persons. Nevertheless, the number of Chinese aged 65 years and over is now projected to increase from 74 million in 1995 to 187 million in 2025, and further to 311 million in 2050. Short of a catastrophic rise in adult mortality or massive emigration of an unprecedented scale, we can be reasonably certain that this growth will occur, because the elderly members

Demographic dimensions of ageing in East and Southeast Asia

Figure 2.8

47

Youth and elderly support ratios in China, 1985–2050 (youth ratio: persons 0–19 years per 100 persons 20–64 years; elderly ratio: persons 65 years and over per 100 persons 20–64 years).

Source: US Census Bureau, 1999.

of the middle decades of the twenty-first century are already born. One analysis (Kinsella and Velkoff 2000) of China’s projected youth and elderly support ratios, using slightly different age categories than in this chapter, suggests that the ratios are likely to converge (Figure 2.8). Family ability to care for older members may be decreasing Since most physical, emotional and economic support for older individuals is provided by family members, the demography of population ageing is increasingly concerned with understanding and modelling kin availability. Kin availability refers to the number of family members that will potentially be available to elderly individuals if and when various forms of care are needed. While reduced fertility and smaller families obviously imply fewer potential caregivers, this is offset to some extent by increased longevity. Modelling is further complicated by the fact that while demographic forces impose constraints on family, household, and kin structures, these structures also are determined by social and cultural factors (Myers 1992). For example, it remains to be seen if the high rates of divorce observed in some Western nations will result in a lack of kin support for persons in older age, and whether ‘blended’ families and other forms of social arrangements will, in the future, provide the types of care and support that are common today.

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Figure 2.9

Percentage of women at age 65 in the Republic of Korea with no surviving son.

Source: Lee, Yean-Ju and Alberto Palloni, 1992, ‘Changes in the Family Status of Elderly Women in Korea,’ Demography, 29, 1:69–92.

The consensus to date foresees a declining biological kinship support network for elderly persons in developed and many developing countries. The issue of kin availability has become especially important in the context of East and Southeast Asian countries, driven in large part by the rapid declines in fertility that have greatly reduced the average family size of young-adult cohorts. The complex interplay of demographic and cultural factors is illustrated by the case of South Korea. There, two-thirds of older persons are economically dependent on their adult children (Korea Institute for Health and Social Affairs 1991), and cultural norms dictate that sons provide economic support for elderly women who have lost their spouses. Lee and Palloni (1992) have shown that declining fertility means that there will be an increase in the proportion of Korean women with no surviving son (Figure 2.9). At the same time, increased male longevity means that the proportion of elderly widows also will decline. Thus from the elderly woman’s point of view, family status may not deteriorate significantly in the coming years. From society’s perspective, however, the demand for support of elderly women is likely to increase. The momentum of rapid population ageing means that the fraction of the overall population that is elderly women (especially sonless and childless widows) will increase among successive cohorts. Given the strong trend toward nuclearization of family structure in South Korea, and the traditional absence of state involvement in socioeconomic support, the future standard of living for a growing number

Demographic dimensions of ageing in East and Southeast Asia

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of elderly widows is tenuous. A similar prospect looms in Taiwan and Japan (Hermalin et al. 1992; Jordan 1995). Simulations of kin availability in rural China (Jiang 1994) are more optimistic, suggesting that, in spite of relatively low fertility, improvements in mortality will ease the future burden on the family support system. Only a very small percentage of rural households will have to support two or more elderly parents, while at the same time, relatively few older people will be childless. Note 1

Portions of this chapter appeared previously in Loraine A.West and Kevin Kinsella, 1998, ‘Pension Management and Reform in Asia: An Overview’, NBR Executive Insight, No. 11, The National Bureau of Asian Research, Seattle, WA. The opinions expressed here are solely those of the author, and do not necessarily reflect the views of either the US National Academy of Sciences or the US Census Bureau.

References Caselli, G. and Vallin, J. (1990) ‘Mortality and aging’, European Journal of Population 6, 1:1–25. Hermalin, A.I., Ofstedal, M.B. and Chi, L. (1992) ‘Kin availability of the elderly in Taiwan: who is available and where are they?’, Comparative Study of the Elderly in Asia 92–18, Ann Arbor: University of Michigan Population Studies Center. Jiang, L. (1994) ‘Parity and security: a simulation study of old-age support in rural China’, Population and Development Review 20, 2:423–48. Jordan, M. (1995) ‘Japan nearing crisis in care of elderly’, The Washington Post, October 31: A8. Kannisto, V. (1994) Development of Oldest-Old Mortality, 1950–1990: Evidence from 28 Developed Countries, Odense: Odense University Press. Kinsella, K. and Gist, Y.G. (1995) Older Workers, Retirement, and Pensions. A Comparative International Chartbook, Washington: US Census Bureau. Kinsella, K. and Velkoff, V.A. (2000) An Aging World 2000, Washington: US Census Bureau. Kojima, H. (1996) ‘Aging in Japan: population policy implications’, Institute of Population Problems Reprint Series 25, Tokyo: Ministry of Health and Welfare. Korea Institute for Health and Social Affairs (1991) KIHASA Bulletin 21, Seoul: Korea Institute for Health and Social Affairs. Lee, Y.-J. and Palloni, A. (1992) ‘Changes in the family status of elderly women in Korea’, Demography 29, 1:69–92. Murray, C.J.L. and Lopez, A.D. (eds) (1996) The Global Burden of Disease, Geneva: World Health Organization. Myers, G.C. (1992) ‘Demographic aging and family support for older persons’, in H.L.Kendig, A.Hashimoto and L.C.Coppard (eds) Family Support for the Elderly, Oxford: Oxford University Press. Peterson, P.G. (1999) ‘Gray dawn: the global aging crisis’, Foreign Affairs 78, 1: 42–55.

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Suzman, R.M., Willis, D.P. and Manton, K.G. (1992) The Oldest Old, Oxford: Oxford University Press. United States Census Bureau (1999) International Data Base, Washington, DC: International Programs Center. Vaupel, J.W. and Jeune, B. (1995) ‘The emergence and proliferation of centenarians’, in B.Jeune and J.W.Vaupel (eds) Exceptional Longevity: From Prehistory to the Present, Odense: Odense University Press.

3

Research directions in ageing in the Asia-Pacific region Past, present and future Gary R.Andrews and Albert I.Hermalin

Introduction Countries in the Asia-Pacific region were among the earliest to respond to the research and policy implications of the UN World Assembly on Ageing (United Nations 1983), as embedded in paragraphs 84 and 85 of the Plan of Action: Para. 84. The Plan of Action gives high priority to research related to developmental and humanitarian aspects of aging. Research activities are instrumental in formulating, evaluating and implementing policies and programmes: (a) as to the implications of the ageing of the population for development and (b) as to the needs of the ageing. Research into the social, economic and health aspects of ageing should be encouraged to achieve efficient uses of resources, improvement in social and health measures, including the prevention of functional decline, age-related disabilities, illness and poverty, and co-ordination of the services involved in the care of the ageing. Para. 85. The knowledge obtained by research provides scientific backing for a sounder basis for effective societal planning as well as for improving the well-being of the elderly. Further research is required, for example (a) to narrow the wide gaps in knowledge about ageing and about the particular needs of the ageing and (b) to enable resources provided for the ageing to be used more effectively. There should be emphasis on the continuum of research from the discovery of new knowledge to its vigorous and more rapid application and transfer of technological knowledge with due consideration of cultural and social diversity. As described by Andrews (1992), during the 1980s there was a stream of research and conferences dealing with facets of population ageing despite the fact that as of 1990 only two countries in the region—Japan and Hong Kong— had 10 per cent of their population at ages 60 or older.

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This precociousness on the part of policy-makers and researchers is a credit to their recognition of the rapid declines in fertility and mortality that were ongoing in much of the region and of the rapid social and economic developments which were putting pressure on existing social arrangements for ensuring welfare of older persons. Given these dynamics, research and policy have focused on the twin issues noted in paragraph 84 above: What are the implications of population ageing for national social and economic development, and what are the implications of the underlying changes for the well-being of the older population? Within the region, recognition of these issues and initial research was more notable in East and Southeast Asia in keeping with their generally earlier demographic and socioeconomic changes, but in recent years recognition of population ageing as a critical social, economic, and developmental issue has strengthened throughout the region, and was clearly expressed in the 1998 Macau Declaration and Plan of Action on Ageing (ESCAP 1998). This chapter seeks to provide an overview of the research undertaken and some of the broader issues confronting research and its utilization for policy. The following section addresses the various types of research that have been employed and their main uses, followed by a review of specific examples of national and cross-national research. This sets the stage for a discussion of the challenges facing future research and policy formation and several recommendations for enhancing future work in the region. Types of research on population ageing and their primary uses Research in the broadest sense can mean any systematic attempt to gather and analyse either primary or secondary data in order to extend knowledge of population ageing and its consequence. From this standpoint a very wide range of efforts can be included, extending from aggregate analyses of international or national datasets, through primary or secondary analyses of specially designed or appropriate surveys, to ethnographic and qualitative studies. Each of these approaches have been employed in studying some facet of population ageing and this section briefly outlines the key characteristics associated with each strategy. Aggregate analyses of census, vital statistics and other data Many countries in the region have a long tradition of censuses and many countries conduct regular household surveys to measure labour-force rates, migration patterns, or other basic social and economic parameters. Registration of vital events is also ongoing throughout the region, although accuracy and completeness vary considerably. Each of these sources can be used to provide important basic information about the characteristics of

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older persons and fairly simple changes to their data collection and/or reporting procedures can greatly enhance their value. Censuses provide data on the age structure of the population and on key characteristics (education, residence, labour-force activity) of each age group. Particularly valuable, given the emphasis on the support arrangements of elderly people, are the data on household structure which reveal who older persons are living with and, often, the size and conditions of the dwelling place. Censuses are also important because they provide small area data, which can be important in assessing the needs of the older persons in each community and for developing appropriate local programmes. Hermalin and Christensen (1992) have shown how individual censuses and cohort data embedded in two or more censuses can be used to study important transitions occurring to the elderly and near elderly and to project the characteristics of the future elderly. The potential of the censuses can be greatly enhanced through the addition of a few strategic questions and the development of public use micro-samples, as discussed further below. The regular household surveys conducted by many countries in the region vary a great deal in their emphasis but often the subject matter is relevant to the study of the older population as well as other age groups. This is particularly true of those which focus on labour-force dynamics, as they can reveal the level and type of economic activity undertaken at older ages as well as the reasons for not working (retirement vs inability to find work) and other relevant dimensions. Many household surveys, in addition to their emphasis on a particular topic, cover a number of basic socioeconomic characteristics, which can be used to advantage to study patterns and trends among older persons. It is worth noting that in many cases, these surveys start out with a representative sample of households and ascertain the basic characteristics of everyone in the household, providing additional information about the living arrangements of older persons. In addition to surveys undertaken by individual governments, several international household survey programmes, like the World Fertility Survey, the Demographic and Health Surveys, and the Living Standard Measurement Survey, have similar structures and can be used to investigate various facets of population ageing within countries and comparatively (Martin and Kinsella 1994; De Vos 1995). Data from vital registration of deaths are potentially of great value for studying the mortality patterns and trends at older ages and causes of death among older persons. Together with the census data they provide the basis for the calculation of mortality rates and expectations of life, and are important ingredients for projecting future population size and age structure. Accurate data on causes of death are also valuable adjuncts to other health data in assessing the status of older persons and the emerging demands on the health infrastructure from population ageing. In many countries, vital

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registration of deaths is still incomplete and inaccuracies in reporting the age and cause of death hamper their analytic potential. Nonetheless, greater utilization of the data available, along with attempts to strengthen the overall system, can pay good dividends as discussed further below. Cross-sectional and longitudinal surveys of the older population Aggregate data from censuses and other sources are limited in the range of information collected about the older population and in the ability to manipulate the data on an individual basis in order to study the level of association across characteristics and to test hypotheses in a careful manner. To overcame these gaps, special household surveys are often undertaken of the older population (and occasionally other relevant age groups, like children or caregivers) which allow researchers to collect a wide range of traits, behaviours, and attitudes about each individual. Surveys of this nature have been undertaken in the region both through national and international auspices. In the latter case, as discussed further below, these efforts provide an opportunity to compare populations across countries, but even surveys restricted to one country allow for important comparisons across racial-ethnic groups, and by regional or urban-rural location. In addition, since many surveys elicit similar data on the traits and characteristics of older persons, comparisons across countries on several key items may be possible, with due caution, even when an explicit comparative design has not been employed. Many of the surveys undertaken in the region have been prompted by the awareness of the policy-makers of the importance of population ageing, described above, and in turn the results of the surveys provide policymakers, planners and practitioners with information and insights important to the execution of sound policies and programmes. In addition, the early utilization of surveys focused on older persons within the region has contributed to the development of a cadre of trained researchers who are increasingly sophisticated about the special issues and challenges confronting high-quality research on this topic, and has generated important baseline data against which later changes and developments may be gauged. Although survey research strategies for studying older persons share much in common in terms of design and content with surveys of other age groups, a number of special considerations arise, which have not as yet received sufficient attention throughout the region. These include the following: 1

Whether to restrict the sample to elderly living in households or to attempt to study the institutional population as well. Most survey designs rely on selecting households and although the institutional population tends to be a very small proportion of older persons in the

Research directions in ageing in the Asia-Pacific region

2

3

4

55

region currently, omitting them can cause some distortions in gathering data for advanced age groups and for studying certain health conditions. For elderly in households, procedures for deciding whether they are well enough in terms of understanding, hearing, health, to be interviewed needs to be anticipated. For those not eligible, how to select a proxy and what portions of the questionnaire to ask the proxy must be decided. Although high non-response rates pose a problem for all surveys, special cautions must be exercised for those focusing on older persons. If sufficient callbacks are not made, it is all too easy to find the less well and oldest old at home and miss those who are working and/or active, thereby distorting the overall picture of the elderly population. Limiting questionnaire and interview length can pose a problem. As listed below, there is a wide range of issues that can be profitably studied and for many of these, one wishes to learn not only the current situation but considerable history as well. For example, in addition to knowing whether the respondents are currently employed, one often wishes to know something about the jobs they had in the past, the duration of each, and various aspects of each activity. Although some elderly people will have ample free time, for others a long interview can be taxing and it may be difficult for them to recall all the detail asked about.

Surveys may be designed to test a number of well-specified hypotheses in which case the content often contains considerable depth on a limited number of topics; or the goals may be broadly descriptive, seeking to develop baseline information across a broad spectrum of characteristics. Given the relatively recency of concerns with population ageing within the region, almost all the studies fall into the latter category, although there often are priority topics such as health or intergenerational support, within the broad range covered. The topics often touched on to some degree in a typical survey are enumerated below, although few surveys will cover all or most of them systematically. • • • • • • •

Basic demographic and social-demographic characteristics (age, education, marital status, urban-rural residence, etc.), Family structure and living arrangements including family size, Social activities and relationships in the community and the family, Formal and informal support patterns and social security, Labour-force participation and retirement, and leisure activities, Physical and mental health status including history of chronic illness, impairments, disabilities and handicaps, and self-perceived health status, Utilization of health and other social facilities in the community, including alternative, traditional health services,

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• • •

Behavioural habits such as smoking, alcohol consumption and exercise, nutrition and eating habits, economic well-being, accommodation, housing, and environmental conditions, beliefs, attitudes and aspirations; life satisfaction, significant life events, and level or morale.

•

In addition to the foregoing considerations, surveys among older persons, like other studies, must decide whether they will be nationally representative through the use of probability sampling techniques, or whether they will be limited geographically and/or employ purposive selection methods. In the latter case the results obtained cannot be assumed to represent all the country’s elderly and the potential for comparisons over time or with other countries will be highly limited, as will some of the policy implications, as discussed further below. Another major design element coming to the fore in surveys of older persons is what to do over time. Should the same survey be repeated with a new sample periodically in a series of cross-sections, or should a panel design be employed in which the same respondents are followed every few years. Many of the questions of prime interest in studying the older population can only be addressed through longitudinal data. These include the ability to measure accurately the many transitions older persons face, such as the transition from independent living to living with children or others, the transition from full employment to retirement, and the transitions among various health statuses. In addition, key questions cannot be pursued without such data. For example, as Hermalin (1997a) has noted: It is obvious that the income of older people can affect their health, and that labor force activity will have an impact on income. But the system is complex and there are subtle problems of cause and effect. Income can affect health; but to what extent does poor health affect income and asset accumulation? Coresidence with children may promote physical and emotional health, but poor health may be a cause of coresidence. To develop sound policy it is important to understand these and other subtle interrelationships. To understand these interrelationships, and develop sound policy, there is a need for longitudinal data and given the subtlety of the information needed, this usually points to a panel design with re-interviews rather than reliance on retrospective reporting of complex histories. It is possible to combine panel studies with repeated cross-sections by adding new birth cohorts as the original panel ages, and this design is being employed in the Health and Retirement Survey in the United States (Juster and Suzman 1995) and in Taiwan (discussed below).

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Qualitative data in ageing research Anthropologists have long been attentive to the ways that various age-strata relate to one another in different cultures, and their insights from participant observation about the role of older persons have been influential. As noted at the outset, concerns about the well-being of older persons in many developing and newly industrialized countries stem not only from the rapid demographic shifts but from the equally rapid social and economic changes. Understanding how basic family and other aspects of culture respond to these shifts is critical for anticipating the effects of these changes on older persons. Qualitative approaches ranging from participant observation, case studies, in-depth interviews, and focus group discussions can assist other forms of data collection and analysis in providing a coherent picture of societal arrangements and the changes underway. A number of studies undertaken in Asia have combined qualitative strategies with survey and other data toward these ends. Qualitative approaches can be employed at many stages of a research project. Focus group discussions or in-depth interviews can be employed at the initial stages of a survey to assist in the development of a questionnaire that will be meaningful to the intended respondents’ frames of reference about particular topics. Qualitative approaches can also be used to follow up survey analysis to tap into the normative and cultural shifts underway that are difficult to capture in the usual questionnaire structure. These follow-up studies are sometimes held with a subset of those interviewed and sometimes with an independent sample or a special group, like the primary caregivers of older persons. Overall, their versatility in addressing a number of the more subtle interpersonal dynamics and feelings make them a valuable tool in ageing research (Sankar 1989). Review of completed and ongoing multi-country studies of ageing There is no single source for identifying all the country and multi-country studies of ageing ongoing in the region. Several past attempts to review research in the region have relied on studies presented in journals and conferences or personal knowledge and these include Andrews (1992), Martin and Kinsella (1994), and Hermalin (1997b). The amount of detail available from published sources varies considerably. In an attempt to provide a more comprehensive overview and with more uniform coverage, the authors distributed a brief questionnaire to a select list of researchers known to them to be working on major country or multi-country studies of ageing in the region, requesting basic information, such as size, design elements and topics covered. The replies received plus information in papers and websites, and the previous reviews form the basis of the overview presented here. We first cover the multicountry projects and then describe a number of major country efforts. The

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boundary between multi-country projects and single-country studies is not hard and fast. Several multi-country projects have employed surveys which vary in design and content across countries, at the same time that several individual country studies have been influenced by the same investigators and have employed similar questionnaires. Thus the opportunity for cross-country comparisons exist both through explicit multi-country projects and through judicious selection of single-country studies. It must be stressed that we make no claim to completeness and there are undoubtedly a number of important studies omitted. Readers aware of other relevant studies are urged to communicate information of the type presented here to the authors so that a more complete and comprehensive guide to research in the region can be developed and disseminated through appropriate channels. Table 3.1 presents the major elements of the multi-country studies identified by the authors and for which sufficient detail could be obtained. They are presented in approximate chronological order. In addition to the title and sponsor or primary organization, the table identifies the countries involved, the geographic coverage (whether national or restricted to certain regions), the years in which the surveys were conducted, the size of the sample, and age groups involved. The last column also gives some indication of the type of survey and sampling design employed. Surveys using purposive selection at each stage are so identified; those using purposive selection for some stages (e.g. the selection of districts) but random selection of respondents, are called ‘mixed’. Studies using a panel design are so identified. Surveys using known probabilities of selection at each stage are identified as ‘representative’. The type of design employed for those without any notation were often probability samples, but in some cases the design elements are not known in sufficient detail. A brief narrative report based on Table 3.1 follows, providing additional information about each project, and relevant references. Health and social aspects of ageing (WHO) One of the first of the multidimensional cross-national studies of ageing in the region to be published was the World Health Organization Regional Office for the Western Pacific (WHO/WPRO) Four-Country Study carried out in Fiji, the Republic of Korea, Malaysia and the Philippines (Andrews et al. 1986). This project was carefully designed to provide cross-national comparative data. Reviews of existing country data were undertaken and a household survey of samples of the population aged 60 years and over were conducted using standardized survey instruments. The survey data were supplemented by the conduct of a series of case reports on selected respondents. The findings were compared with the selected results from developed countries that had participated in an earlier WHO sponsored eleven-country European study.

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There were notable differences in the findings of the Western Pacific and European studies and also many similarities. In particular, subjects in all four of the Western Pacific countries were much more likely to be living in extended family situations, mostly with children, than was the case in the European countries. On the other hand, many of the classic age-related phenomena of widowhood, declining social participation, loneliness, decline at advanced ages in health and function were similar. These data are now archived and a number of independent analyses have examined such things as patterns of morbidity and function (Manton et al. 1987), living arrangements (Martin 1989), economics (Agree and Clark 1991), family support (Esterman and Andrews 1992) and measures of healthy life-expectancy (Lamb and Andrews 1991; Lamb and Myers, in press). Socioeconomic consequences of the ageing of populations (Association of Southeast Asian Nations (ASEAN)) In 1984 a series of studies funded by the Australian government under the general title ‘Socioeconomic Consequences of the Ageing of the Population’ was initiated as a component project of phase III of the ASEAN Population Programme in five ASEAN countries (Indonesia, Malaysia, the Philippines, Singapore and Thailand). In these studies a core questionnaire was developed to gather information on household structure, housing, economic resources, living support, health and social activities. Some secondary data analysis was undertaken and existing policies and programmes on ageing in the countries were examined and evaluated. The project, which was coordinated from Singapore, gave its main objective as the raising of awareness of policy-makers and planners to the issues of ageing throughout ASEAN. A key finding of this study, noted in its cross-national report, was the potential stress which could be placed on family members by continued reliance on family support by the elderly population (Chen and Jones 1989). The authors argued that increased urbanization and social mobility, smaller families, and the tendency for married women to enter the paid workforce all suggest the possibility that parents will not be able to assume that their children will care for them in their old age. Emerging issues of the ageing of populations (ESCAP) The ESCAP secretariat with financial support from the United Nations Population Fund (UNFPA) initiated a cross-national study in 1986 to examine the impact of population ageing in selected countries (ESCAP 1989). Countries participating in this series of studies included the People’s Republic of China, Republic of Korea, Malaysia and Sri Lanka. The plan was to collect information in several stages. Data available from censuses and other sources were analysed first. In the second part of the study a

Table 3.1 Multi-country studies of ageing in Asia

c

still in the field.

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sample survey was conducted gathering information from older people and resident care providers. Finally, a review of existing policies and programmes concerning the elderly was undertaken and evaluated. The principal objective was to provide a set of policy and programme recommendations to address the issues of an ageing population as well as the individual needs of older persons and their careers. Several final country reports have been published (Arshat 1989; China National Committee 1989; Ch’oe 1989; Perera 1989). The report of a cross-national seminar to review the results notes that most of the problems of the aged identified in the study are related to poverty and decreasing availability of care for the aged (ESCAP 1989). Social support systems in transition (United Nations University) The United Nations University, based in Tokyo, has been responsible for the planning and initiation of a series of studies on social support systems for the elderly in seven developing nations including the Asian countries of India, Republic of Korea, Singapore and Thailand. These studies were designed to collect data in several different ways. An historical survey of formal and informal support systems was undertaken. An ethnographic study of communities using participant observation techniques was included; household surveys covering demographic information, family relationships, current and potential future needs and sources of social support as well as several other domains were conducted and, finally, more detailed case-study material was also obtained from selected respondents. The overall objective of the project is to delineate the balance of formal, informal and personal resources that may best promote social welfare in countries undergoing rapid social and demographic change, at ‘an appropriate cost’ and taking into account differing sociocultural settings. In the first cross-national report on findings, Hashimoto (1992) demonstrated that older persons appear to maintain co-residence with children despite changing socioeconomic and demographic conditions. Variation between different countries was noted in the chosen living arrangements and the extent to which these appeared to be influenced by socioeconomic and individual characteristics. The life and attitudes of the elderly (Office of Prime Minister and Office of Management and Coordination, Japan) In the period from 1981 through 1990, ministries in Japan sponsored a series of household surveys of the elderly in several developed and developing countries, using survey organizations within each country and a standardized questionnaire. In 1981, the countries included were Japan, Thailand, the United States, the United Kingdom, and France. In 1986,

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surveys were conducted in Japan, Thailand, the United States, Denmark, and Italy. In 1990, the countries included Japan, Korea (South), the United States, the United Kingdom, and Germany. Thus several countries were represented two or three times over this period. The questionnaires employed were quite standardized and focused on family, work, housing, social life, public and private services, values and religion. Reports from these studies from the sponsoring ministries have appeared only in Japanese (Japan, Office of the Prime Minister 1982; Japan, Office of Management and Coordination 1987; Japan, Office of Management and Coordination 1992). Extension of health and social aspects of ageing (WHO) The WHO-sponsored Four-Country Study in the Western Pacific approach was extended to the South East Asian Region of the WHO where a similar set of surveys were undertaken during 1990 in Indonesia, North Korea, Myanmar, Sri Lanka and Thailand. Based on the earlier experience, the South East Asian studies used larger (1,200), more nationally representative samples of persons aged 60 years and over, an extended and improved survey instrument and in three of the countries (Sri Lanka, Myanmar and Thailand) performance-based measures of physical function were employed. Greater attention has been given in these later surveys to such questions as the well-being of older persons, intergenerational exchange, contributions of older persons particularly to family and the community and the issue of caregiving burden (Andrews and Hennink 1992). Local-level policy development to deal with the consequences of population ageing (ESCAP) With support from the United Nations Population Fund, ESCAP initiated a study in six countries in the region to study the characteristics of older persons in several local areas with emphasis on their skills and potential economic contribution. The aims were to relate these findings to the nature of the local areas and their potential for integrating older persons more fully into their economies, and to investigate policies and programmes that would assist the fuller utilization of the economic skills of older persons. Six reports based on these studies have been published (Afzal 1994; Gokhale 1994; Kabir 1994; Phalakornkule 1994; Thu 1994; Wirakartakusumah 1994) Changing society and quality of life (Waseda University, Japan) In the period 1993–5, Waseda University sponsored studies in selected cities of Japan, South Korea, and Taiwan to further understanding of how the rapid changes underway in these societies were affecting the quality of life of older persons, in terms of economic, social and leisure activities. Reports

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from each country were presented at a symposium along with other presentations and published by Waseda University (1997). Rapid demographic change and the welfare of the elderly (University of Michigan) With support from the National Institute on Aging, the Population Studies Center of the University of Michigan has engaged in a 10-year collaborative project with the Philippines, Taiwan, Thailand, and Singapore to study a broad range of topics related to the well-being of older persons in the face of rapid social and economic change. The topics investigated include the availability and location of kin, living arrangements, exchanges and intergenerational support, resource allocation and division of labour within the household, income and assets, labour-force and retirement patterns, differentials in health and health behaviours, use of and satisfaction with existing services. To accomplish these aims a wide variety of data have been employed, including existing census and administrative data, available ASEAN surveys for the three south-eastern countries, an extensive series of focus group discussions among the elderly and younger adult groups, and new nationally representative surveys in each country. In Taiwan, the first survey was conducted in 1989 and a panel design was adopted with major re-interviews in 1993 and 1996. In 1996, there was also a new sample of those 50 to 66 interviewed, to create a representative sample of those 50 and over for that year. The focus group discussion transcripts have been archived and can be assessed by contacting [email protected] for additional information. Other data are in the process of preparation. The project has published fifty-four research reports, which can be ordered or reviewed at http://www.psc.isr.umich.edu/pubs/series.html. In addition, special issues of the Journal of Cross-Cultural Gerontology (1995) and the Asia-Pacific Population Journal (1997) have appeared. The first presents results from the focus group discussions and the second on survey findings of support arrangement. Other analyses have focused on economic wellbeing (Hermalin et al. 1999), and on transitions in functional status (Zimmer et al. 1998) in Taiwan. Household structure and the elderly (ESCAP) In 1996, ESCAP, with the financial support of the United Nations Fund for Population Activities, undertook studies in six countries in the region with the major objective of assessing the impact of changing family structure on the situation of older persons. The questionnaire topics included: household composition and structure, demographic characteristics of older persons, economic status, health status, kinship availability, support exchanges, and caregivers. The design employed involved a purposive selection of one

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urban and one rural locality from each country and interviewing 200 elderly from each locality. A small number of caregivers of older persons were also to be interviewed. The publications based on these data include ESCAP (1999a, 1999b). Review of major country studies of ageing Table 3.1 has focused on multi-national studies which contain two or more countries within the Asia-Pacific region, but several have also included countries outside the region. In addition to those shown in Table 3.1, several studies have had as their major focus a comparison of one country in the region with one or more outside the region. Japan, as a major industrialized country with distinctly different cultural arrangements regarding old-age support than other industrialized nations, has been of particular interest in this regard. Hashimoto’s study (1996) compares a city in the United States with one in Japan on the helping arrangements and support systems for older persons. It uses intensive interviews, participant observation as well as small-scale surveys to understand how society and culture shape the ideas of deserving help and of giving. Liang et al. have conducted a series of surveys in Japan closely modelled after those in the United States in order to compare the two countries on several dimensions of population ageing. The characteristics of these Japanese surveys are treated with the single-country studies, although their comparative intent should be kept in mind. Table 3.2 presents several key elements of major studies of ageing completed or underway within Asia-Pacific countries since the late 1980s. The table does not attempt to capture the pioneering surveys carried out in a number of countries more than ten years ago, and it omits the large number of local biological, behavioural, and clinical ageing studies ongoing throughout the region. Many of these are represented in the proceedings of the International Association of Gerontology Congresses (see, for example, International Association of Gerontology Asia/Oceania Region 1991, 1995, 1999). Even with these caveats, it is likely that important surveys have been overlooked and the authors would welcome being informed about these. Although the emphasis has been on large-scale nationally representative studies, studies of particular cities or areas have been included where special design features are noteworthy. Appendix 3.1 presents some additional detail about several of the studies, including references, website locations, and information on data availability. An overview of Tables 3.1 and 3.2 indicates that, with few exceptions, most countries in East and Southeast Asia has been the subject of at least one survey of the older population and many have had multiple studies undertaken. In South Asia, although the major countries have been covered to some degree, the density and the scope of surveys appears lighter than elsewhere in the region. China, not surprisingly, given its size,diversity, and

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Table 3.2 Single-country studies of ageing in Asia

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Table 3.2 Continued

Note:

a Through partial financial support provided to the Population Studies Center of the University through the Fogarty International Center and the Mellon Foundation.

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dramatic demographic dynamics, is the subject of many surveys relevant to population ageing and the studies shown represent only a portion of the many specialized studies underway. But several countries in Southeast Asia, like Thailand, Malaysia, and Indonesia, have been involved in a large number of multi-country or single-country studies, thereby accumulating a large body of relevant information over the 1980s and 1990s. Hong Kong (not tabulated) has recorded several studies by academic units and the government, on health, quality of life and long-term care needs, the findings of many having been published internationally and in the SAR’s own journal, The Hong Kong Journal of Gerontology. A comparison of Tables 3.1 and 3.2 (and the related information) suggests that the single-country studies have generally employed larger sample sizes than the multi-national efforts, have often been more focused as to their objectives, and have more often used longitudinal or other innovative designs. These differences arise in part because of limitations for funding multi-national efforts as well as the fact that many of the multi-national studies were carried out at earlier time points when research into population ageing was just getting underway. With these differences in mind, the next section reviews some of the methodological issues suggested by this array of studies. Methodological and policy issues The broad mandate of research implied in the UN World Assembly on Ageing’s Plan of Action outlined at the outset, and the response within the region brought to the fore at an early stage a number of methodological and strategic issues. The issues range from more specific aspects of data collection techniques to broader dimensions of how to coordinate the efforts of the different disciplines involved in ageing research and how to utilize the research conducted for policy and programme development. Some of these issues were addressed at a 1987 conference in Singapore (East-West Center 1987) and are reviewed briefly in Martin and Kinsella (1994). As is often the case with a rapidly developing field, several of the earlier problems—like how to define old age in developing countries—appear less pressing, while new ones have emerged. In this section we review the more narrow methodological issues related to ageing research, reserving for a later section a discussion of the broader strategy questions concerned with policy, auspices and coordination of efforts. Data collection strategies should, of course, follow from research goals and the large number of possible objectives bring to the fore many different procedures and questions. Hermalin (1998) has suggested that, in the near term, three types of research should receive priority: anticipating the characteristics of future cohorts of elderly; understanding the adjustments and accommodations that families make in response to the changing demographic and socioeconomic

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conditions; and studying the well-being of current older persons and the transitions they undergo in terms of health, support and living arrangements, economic status, and work and retirement. Each of these objectives relies on different data collection strategies, involving census and other ongoing data collection efforts, qualitative approaches and special household surveys, respectively. We review some key issues associated with each strategy stemming from these recommendations, as well as from the reviews of existing research. Improving ongoing data collection efforts A number of low cost steps can greatly enhance the value of the censuses, vital registration data, and regular household surveys that many countries undertake. Perhaps the simplest step is to increase the number of older-age categories shown in most tabulations so that distinctions can be made, for example, among those 65–69 as compared to those 70–74 years of age, etc. Too many published tabulations on key characteristics end at 65 and over (and sometimes even younger), depriving researchers of the ability to study differences across older-age cohorts and to undertake useful trend and cohort analysis. More refined age categories are most clearly important for characteristics closely associated with ageing, like health measures, mortality, household structure, and labour-force participation. Improving vital statistics at older ages is particularly important for projecting the future number of ‘oldest old’. A second promising step would be to add a few key questions that can greatly enhance the value of an existing data collection mode for ageing research. For censuses, for example, distinguishing the nominal head of a household from the economic head would assist in measuring the economic status of older persons and knowing how long each person lived in the household would be of value in studying living arrangements. The addition of a few health questions centering around the existence of disabilities can produce valuable data at low cost. Similar opportunities to enhance regular labour-force and other household surveys should be exploited. Another important low-cost step is to make available micro-samples of census data so that individual-level analyses can be carried out on the information collected, enabling analysts to go beyond the published tables to develop nuanced descriptions of older persons and to test various hypotheses. Improving special data collection efforts Some of the problems associated with special surveys are clear from a review of Table 3.1. Many of the surveys undertaken are characterized by small sample sizes and/or non-representative sampling designs. These drawbacks

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greatly limit their utility. If a survey is not representative of a given country or a region it can hardly be the basis of comparison with another country, and it can be misleading as a basis for policy-making or programme development. Other methodological issues not apparent from the table centre around the topics to be covered and the specific wording of the questions. Even the simplest plan to gather descriptive information on ageing populations may involve complex issues of conceptualization, definition, and measurement. If questions are adopted from existing Western questionnaires, they may not make sense within the level of economic development of another society. Even where they appear to fit, comparability may be defeated by poor or inadequate translation, and questions (or answers) may not have the same meaning across cultures even when careful translation has been employed. As noted by Martin and Kinsella (1994) this may be particularly the case in exploring the health status of respondents. A few of the studies covered in Table 3.1, and several in Table 3.2, have utilized standardized biomedical measurements and simple performance-based testing of function, and greater utilization of these approaches, when adequately standardized and applied, may enhance cross-cultural and cross-national comparability (Guralnick et al. 1989). The advantages have already been touched on of longitudinal surveys, particularly through panel designs, for addressing a number of key questions difficult to pursue from isolated cross-sectional surveys. Though panel surveys are attractive, they tend to be costly and difficult to execute and accordingly should not be approached lightly. As example, it is important to minimize attrition due to non-response in successive waves, as well as have high response rates at the outset and this requires high-quality fieldwork with multiple callbacks. Given the inevitable losses in the panel due to mortality or serious illness, a sufficiently large sample size should be provided for at the outset, also contributing to high costs. The panel design also puts a premium on planning far enough ahead so that question wording of the same concepts does not vary over rounds, which can invalidate or weaken measures of change. At the same time, panel studies contain considerable flexibility in some respects. Important information not obtained in one round may be included in a subsequent questionnaire, and it is possible to reserve a portion of the questionnaire for experimental items or special topics. A discussion of the main features of panel studies may be found in Scott (1995). As noted above, a variety of qualitative approaches can be used to advantage in studying older persons, particularly in trying to assess the ongoing social changes that influence intergenerational relations and support patterns. In relation to Table 3.1, the University of Michigan undertook a systematic set of 18–26 focus group discussions in each of the four countries with older adults as well as adults representing the ages of their children. In addition, several of the studies reviewed in Tables 3.1 and

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3.2 included individuals critical to the elder’s well-being, like children or caregivers, often using in-depth interviews to assess a range of dynamics less amenable to regular survey approaches. It appears that there is more room for qualitative data as an adjunct to other types of analyses, as well as more systematic presentation and analysis of the data collected in this manner. The next section outlines a number of projects underway or planned for the region as a backdrop for a discussion of how to enhance the value of these studies and their utilization in policy-making and programme development. International inter-governmental agency activities planned or underway The 1999 International Year of Older Persons launched on 1 October 1998 provided a significant impetus to many organizations including the intergovernmental agencies in the undertaking of population ageing related activities including data collection, analysis and research across a wide range of areas. Some of the more significant endeavours within the Asia-Pacific Region are identified below. The World Health Organization (WHO 1997) through its headquartersbased Programme on Ageing and Health has pursued a series of activities aimed at promoting the ideas of ‘healthy and active ageing’. A project concerned with development of a research agenda for healthy ageing was initiated, but there has been no direct promotion or sponsorship of research activities per se at this point, although an effort is being made to undertake some meta-analysis of a range of population-based study data sets including several originally generated in the Asia-Pacific region. At the regional level, the Western Pacific Regional Office of WHO has produced a comprehensive review of basic data on ageing in all of the countries of the region. It has drawn on past research and data collection activities to develop guidelines for policy development and planning of health care services and programmes for older persons. The United Nations Population Fund (UNFPA) has continued to focus on its primary mission of reproductive health and population and development issues. However, some increasing attention is being given to ageing and in its State of the World Population Report 1998: The New Generations, (United Nations Population Fund 1998) ageing is a primary theme. Some support has been provided for research oriented activities in the region including a project in the People’s Republic of China for ‘Development of Research on the Aged for Policy Formulation Purposes’ being conducted by the China Research Center on Aging. In addition community-based projects have been supported in Thailand and the Republic of Korea. The UNFPA has stated its intention of promoting the gathering of sound data and research in support of policy formulation particularly in developing countries.

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The United Nations Commission on Human Settlement (HABITAT) is developing a research project as a contribution to the International Year of Older Persons in Asia entitled ‘Living Conditions of Older Persons in Urban Communities’, jointly with the Institute of Public Administration in the USA. The International Labour Organization (ILO) has pursued some research activity in the region related to social security provision. In this regard, assistance has been provided to its membership in the region to explore alternative schemes of social security and the adaptability and suitability of various options to the differing circumstances and traditions of individual countries. The Economic and Social Commission for Asia and the Pacific has been an active player in development of research and policy review in the region. The Commission has sponsored multi-country research efforts, has commissioned position papers and hosted a series of Expert Group Meetings and policy forums (ESCAP 1996). The United Nations programme on ageing has now initiated an exercise aimed at ‘The Development of a Research Agenda on Ageing for the Twentyfirst Century’. This project will extend over a three-year period beginning with the formulation of an initial research agenda framework developed by an expert consultative group that met early in 1999. The initial meetings were sponsored by the International Association of Gerontology on behalf of the UN and are being supported by the Novartis Foundation for Gerontology. The expert consultative meeting identified key priorities for research necessary to guide future policy directions and organizations, agencies and individuals that can pursue in-depth consideration of each of the areas of priority. The results of the initial consultation and the further development of key areas will be widely disseminated for further debate and consideration before the final formulation of the agenda. This will be undertaken by a second expert consultation early in 2001 for the ultimate consideration and endorsement of the General Assembly of the UN and formal transmission to member states for consideration and action. The production of the Agenda for Research is intended to gain the commitment of governments, international agencies, research foundations and researchers to examine the critical questions on ageing and its implications that are identified during the process. The overall vision of the Research Agenda on Ageing is one that will foster global cooperative endeavour between the scientific community, governments, nongovernmental organizations and other partners in ageing-related research, in an innovative approach that will ‘make a difference’. The outcome is expected to be a significant investment in research on ageing, at least during the first decade of the coming century (Andrews and Clark 1999). Interrelating research and policy An underlying theme of this review is that the impetus for much of the research on ageing throughout the region was motivated by awareness of

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policy-makers and others that rapid demographic and socioeconomic changes necessitated appropriate research to inform planning and programme development. Many of the studies undertaken in the region have an explicit policy-related objective. It is thus appropriate to inquire how well this objective has been met and how the policy relevance of future research can be strengthened. The relationship between policy and research is complex and it is well to recognize that there is no simple one-to-one relationship between the two, although there are, and should be, many points of intersection. Hermalin (1999) has traced some of these connections, noting that research on ageing can serve policy in the following ways, utilizing the range of research strategies outlined in previous sections: 1 2

3

4 5

Provide estimates of needs, preferences, and costs. Provide knowledge of interrelationships useful for policy formation and programme refinement: a identifying target audiences and key geographic areas for specific services; b measuring attitudes toward services, likely reactions to potential incentives, emerging preferences and needs. Providing the database for projections and simulations of costs and needs: a utilizing estimates of future characteristics of older persons to project changing needs; b utilizing trends on changing norms to anticipate the types of programmes needed in the future. Using comparative research to study social-cultural context and variations in programme preference. Using research to evaluate programme performance and generate needed changes.

Hermalin (1999) goes on to point out the many dimensions that must be addressed in developing programmes and policies, which involve both broad political philosophy and detailed bureaucratic considerations, for which research can provide only limited assistance. It is difficult to generate an overall appraisal of how well the research undertaken in the region has served policy and programme development. This clearly varies across specific studies and countries. Some deficiencies in the multicountry studies, partially applicable to several of the single-country studies, can be noted. Many have employed small non-representative samples which limit comparisons within countries (among socio-demographic groups) and across countries; and often the comparative potential has not been exploited with careful comparative analysis. Several important topics have received limited attention, including information on the income and wealth of older persons and

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the dynamics of work and retirement (Martin and Kinsella 1994; Hermalin 1997b). Conversely, there has probably been undue attention paid to the living arrangements of older persons with too much stress on the formal structure and too little on the functions that go on within the household, the availability of kin outside the household but nearby, and details of the support and exchange arrangements in which older persons take part (Hermalin 1998). It should also be recognized that studies in population ageing are complex, involving many subject matters and disciplines. Accordingly it is important that researchers with different orientations work cooperatively to make sure that the economic, social, and physical well-being of older persons are properly measured and analysed (Martin and Kinsella 1994). Despite these problems, several of the multi-country efforts have generated important benchmark and comparative data on a variety of health-related measures, providing useful inputs for policy-makers considering the health needs of older persons and possible new or expanded health insurance and other programmes. A number of the cross-cultural studies have also provided important data on living arrangements and sources of support of older persons, which provide benchmark levels against which future changes may be gauged. Aside from health, these probably constitute the major emphasis of the research to date. The findings from these studies of living arrangements and intergenerational support of older people within the region do indicate that, generally, a high proportion of older people are residing with their children, or have children nearby, and that family members are still frequently providing physical, financial and material support in accord with the needs of older persons. Hermalin (1997a) has noted that this is an important ‘policy’ result, in demonstrating that there is no quickly evolving crisis that requires immediate attention. This means that policy-makers and researchers have an opportunity to build on past efforts to develop a more systematic research programme that will address emerging issues and meet the intermediate and longer-term needs of their populations. In tackling this task, the following steps should enhance the policy relevance of the research undertaken: •

•

Establishing effective communication between policy-makers and researchers both before studies are undertaken, to insure that policy and programme needs are reflected, and after the data are in, to insure that the results are conveyed to policy-makers in useful terms. Provision of sufficient research support to insure that high-quality, thoughtful studies are carried out to provide a base of knowledge, and data for both basic science and policy. Comparative analyses based on carefully executed standardized surveys as well as comparative analyses of existing and planned social welfare programmes are two important sources of knowledge for sound policy development. Appropriate comparisons will include not only countries within the

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region but developing countries elsewhere, as well as the experience of the more industrialized countries (Hermalin 1997a; Binstock 1986). Developing a sufficiently flexible stance toward research and policy strategies to allow for new and experimental approaches as conditions warrant. This might involve greater use of administrative records in tandem with survey data to understand how new programmes are being utilized; or better integration of survey and qualitative studies to anticipate better how people are responding to rapidly changing socioeconomic environments.

The awareness of policy-makers in many parts of the region to challenges posed by population ageing and the early start on research, reviewed in this chapter, are very positive developments that bode well for future dialogue and cooperation, and a strengthened research profile in the years ahead. Conclusion Countries in the Asia-Pacific region still have time to assess demographic projections and future needs and to formulate appropriate programmes and policies in response to the prospects for substantial population ageing. There is a need to go beyond some of the past efforts that have been aimed at collecting purely descriptive data and for more exploration of ways of building a developmental dimension into research on population ageing. Thus, more research is needed into aspects of healthy and successful ageing, and into the positive contribution of older persons to their families, societies and national economies in the context of population ageing that is occurring concurrently with social and economic development. Issues such as work, retirement and social security provisions require greater attention. Special consideration needs to be given to questions related to gender, poverty and extreme old age. The past decade has seen substantial groundwork laid down in terms of the surveys and studies already carried out. However, much more can done and the very dynamic social and economic environment of the region offers unparalleled opportunity to study the many critical dynamics and changes associated with population ageing in the region. New policies and programmes currently under consideration and the social, and economic pressures that create the need for them, call for timely and appropriate research that can effectively inform policy-makers and underpin decisions made on policy options for the future. Acknowledgement The authors appreciate the assistance of Sela Panapasa in collecting the data and preparing the tables, and the help provided by Ingrid Naaman and Mary Beth Ofstedal with various aspects of the manuscript.

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Juster, T. and Suzman, R. (1995) ‘An overview of the health and retirement study’, Journal of Human Resources 30 (Supplement 1995):S7–S56. Kabir, M.H. (1994) Local Level Policy Development to Deal with the Consequences of Population Ageing in Bangladesh, Asian Population Studies Series, No. 131–A, Economic and Social Commission for Asia and the Pacific, New York: United Nations. Lamb V.L. and Andrews, G.R. (1991) ‘Healthy life expectancy of the elderly in developing countries’, in Fourth Work-Group Meeting REVES, International Research Network for Interpreting of Observed Values of Healthy Life Expectancy, Leiden, June 1991. Lamb, V.L. and Myers, G.C. (in press) ‘A comparative study of successful aging in three Asian countries’, Population Research and Policy Review. Liang, J., Bennett, J.M. and Maeda, N.A. (1991) ‘The structure of self-reported physical health among the aged in the United States and Japan’, Medical Care 29: 1161–80. Manton, K., Myers, G.C. and Andrews, G.R. (1987) ‘Morbidity and disability in four developing nations: their implications for social and economic integration of the elderly’, journal of Cross-Cultural Gerontology 2:115–29. Martin, L.G. (1989) ‘Living arrangements of the elderly in Fiji, Korea, Malaysia and the Philippines,’ Demography 26:627–43. Martin, L.G. and Kinsella, K. (1994) ‘Research on the demography of aging in developing countries’, in L.G.Martin and S.H.Preston (eds) Demography of Aging, Washington, DC: National Academy Press. Perera, P.D.A. (1989) Emerging Issues of Population Aging in Sri Lanka, Asian Population Studies Series, No. 98, Economic and Social Commission for Asia and the Pacific, New York: United Nations. Phalakornkule, S. (1994) Country Policy Development for the Elderly at the Local Level in Thailand, Asian Population Studies Series, No. 131–E, Economic and Social Commission for Asia and the Pacific, New York: United Nations. Sankar, A. (1989) ‘Gerontological research in China: the role of anthropological inquiry’, journal of Cross-Cultural Gerontology 4:199–224. Scott, J. (1995) ‘Using household panels to study microsocial change’, Innovation 8, 1:61– 73. Thu, Dang (1994) Local Level Policy Development for Integrating the Elderly into the Development Process in Viet Nam, Asian Population Studies Series, No. 131–F, Economic and Social Commission for Asia and the Pacific, New York: United Nations. United Nations (1983) ‘Vienna International Plan of Action on Aging’, World Assembly on Aging (Vienna, Austria, 1992), New York: United Nations. United Nations Population Fund (1998) The State of the World Population: The New Generations. New York: UNFPA. Waseda University (1997) Aging People in Transition. Papers of International Symposium on a Comparative Study of Three Cases in Asia: Korea, Taiwan and Japan, Tokorozawa, Japan: Advanced Research Center for Human Sciences, Waseda University. Wirakartakusumah, M.D. (1994) Local Level Policy Development on Consequences of Ageing: Indonesia Case, Asian Population Studies Series, No. 131–C, Economic and Social Commission for Asia and the Pacific. New York: United Nations. World Health Organization (1997) Special Programme for Research on Aging— Description of Programme (SPRA), Copenhagen: WHO. Zimmer, Z., Lin, H.-S., Hermalin, A.I. and Chang, M.C. (1998) ‘Educational attainment and transitions in functional status among older Taiwanese’, Demography 35, 3:361–75.

Research directions in ageing in the Asia-Pacific region Appendix 3.1 Details of studies

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* Through the National Archive of Computerized Data on Aging (NACDA), a program within the Interuniversity consortium for Political and Social Research (ICPSR) located within the Institute for Social Research at the University of Michigan. The website is www.icpsr.umich.edu/NACDA.

4

Long-term care issues in the AsiaPacific region Edward Man-fuk Leung

Introduction Most countries in the Asia-Pacific region are no exception to the phenomenon of global ageing of the population. However, as noted in Chapters 1 and 2, a particular point about the region is that countries have different rates of population ageing and are at various stages of economic development. The region now has the highest number of elderly people of any in the world and it is expected that with successful population control in most countries in the region, the rate of population ageing will continue to be faster than in the West. Although there are shared cultural values amongst most countries which favour the family as the centre for care, especially for its older people, the pace of industrialization, urbanization and migration mean that changes are occurring and expected in living patterns, notably in the smaller size of households and families living apart. With the ageing of the population, there are increasing numbers of older persons, some of whom will suffer from ill health and disabilities resulting in the need of care and support by others. In the past, when the traditional extended family was in place, the care of the older relatives was in the hands of their younger family members, especially women. Today, however, it is much more common for family size to be smaller and for women to be working outside the home, reducing the capacity of the family to look after its older members. This process has occurred in most Western countries over more than one hundred years; the countries in the Asia-Pacific region will take somewhere around twenty to thirty years to complete a similar process (Choi 1999). More seriously, most countries in the region are not prepared to cope with the increasing need for government intervention in the care and support of older persons. In order to prepare for the challenge of the ageing population, governments need to examine the examples of other countries in the care and support of older people especially the development of long-term care. There are many issues related to the needs of long-term care for elderly people including sources of funding, programmes, regulation and monitoring of standards of care. With these issues in mind, this chapter

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examines the development of long-term care in the region. Reference will be made from a range of countries and the evolution of policy in Hong Kong in particular. The need for the development of long-term care in the region Long-term care (LTC) is very broad, as discussed in Chapter 1, and has been defined as care delivered to individuals who are dependent on others for assistance with the basic tasks necessary for physical, mental and social functioning over a sustained period of time (Kane and Kane 1989). It is clear that the provision of nursing homes or other LTC institutions varies considerably among different countries (Phillips 2000). As the health status of elderly people correlates strongly with age, the need for LTC for elderly people is much higher than in the rest of the population. Research in the United Kingdom indicates that as many as 38.8 per cent of those elderly people over 80 had severe incapacity requiring care (Alber et al. 1991). Similarly, it was estimated in the European countries that the need for nursing care increased sharply with age; in the age group of 80 and above, one in every three persons needed daily care. In another study carried out in the United States, it was found that the per capita spending for those 85 or above was two and a half times that at between 65–69 of age (Waldo et al. 1989). Experience in aged societies has demonstrated that population ageing is associated with a general increase in frailty in the population over time. Many frail elderly people are in need of long-term care, which means that their chronic ill health and functional limitation makes them rely on others for care and support. The need for LTC, especially institutional care rather than home support, usually centres around the period of frailty associated with advanced old age compared with younger old. Therefore the need would be mostly concentrated in people older than 75 and there can be a rapid increase in severe incapacity beyond the age of 70. The need for care and support may be concentrated on frailty at the end of life although not exclusively so, of course. In Western countries, the need for long-term institutional care (as opposed to non-institutional LTC) is roughly around 5 per cent for those over 70 years old. A study in United States has shown the rate of admission to nursing homes will increase with age, and admission rates to nursing homes in the United States increased exponentially from age 65 through age 90. At age 65, the admission rate to nursing homes was 1 per cent, for 85 it was 10 per cent and for 90 it reached 14 per cent (Freeman 1996). In terms of cost, some US$70 billion has been spent on nursing-home care and for each nursing-home resident it costs an average of US$3,200 per month, with the United States government paying for more than 60 per cent of nursing-home expenditures (Levit et al. 1994). The positive association

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between old age and the prevalence of disability means that population ageing creates a growth in the need for care as well as associated costs. In the Asia-Pacific region, the ageing phenomenon will become most prominent in the first two decades of the twenty-first century. In Asia, only 8 per cent of the population were over the age of 60 in 1975; by the year 2000, this will increase to 11.5 per cent, which will further rise to about 20 per cent by the year 2025. In absolute numbers, there were 167 million elderly people in Asia in 1980, and this will increase to 291 million by 2000 and 616 million by 2025. There were 62 million people aged 70 and over in 1980, and this is expected to rise to 115 million in 2000 and 243 million by 2025. The above figures indicate that the number of elderly people over age of 70 will approximately double every twenty years in the region as a whole. The growth in the number of older-old individuals and the rate of ageing has drawn particular concern from some of the newly developed countries in the region, especially Hong Kong, Singapore and Japan. The number of elderly people over the age of 70 in Hong Kong was 181,000 in 1980 and will rise to 435,000 in 2000 and 750,000 in 2025. In Japan, the same age group was 6,429,000 in 1980, 11,886,000 in 2000 and will be around 18,908,000 in 2025. For Singapore the rate of increase will be yet more rapid. In 1980, there were only 63,000 people aged 70+ which will increase to 138,000 in 2000 and 344,000 in 2025. If disability and need rates were very stable, the above figures would allow the forecast of need for long-term care. The figures suggest that this need will approximately double every twenty years in countries around the region. More significant is the growth of those over 85. In Hong Kong, for example, elderly people over the age of 85 will increase more than fourfold between 1986 and 2006. Even if health is improving among the older populations, a big question and without much data to support it one way or another, the most significant aspect of the growth of percentages of elderly people will be the increase in those aged 85 and over. Among this group is generally a large number of people who are severely impaired physically or mentally, or both. Hunter (1992) and others have pointed out that demand for health and social care rises sharply with age: for example, 1 per cent of those aged 75–79 have severe disabilities compared with 41 per cent of those aged 85 and over. The increase in the very old population will pose an increasing burden to society and prove particularly challenging for the maintenance of high-quality care of old people. In view of the rapid rate of ageing in the region, steps must be taken to prepare, in public policy terms, for the LTC needs of ageing populations, and the timescale is the next twenty years or sooner. The need for long-term care in Asian populations The extent of physical, functional and mental impairment is one of the major determinants of need for LTC (especially institutional care) for older

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persons. The demand for long-term institutional care could be reflected by the number of people on the waiting list for the facilities and the number who have been already admitted to nursing homes. Data are not abundant for the Asia-Pacific region but this chapter draws on the example of Hong Kong, where government-funded care and attention homes (see also Chapter 8) have been established since the early 1970s and a central waiting list has been created for those applying for LTC institutions. This enables some evidence of demand to be gauged, although it is not perfect unless all on the waiting list are assessed (which is currently being undertaken in Hong Kong). Demand for LTC facilities as evidenced by the number on the waiting list for care and attention homes and medical infirmary places has been rising steadily in the past ten years. This may be regarded as especially serious as Hong Kong faces a disproportionate increase in the number of elderly people aged 75 years and over. For example, the number on the waiting list for care and attention homes increased from 8,900 in 1992 to 19,278 in 1998 (117 per cent increase). The number on the waiting list for infirmary places increased from 5,964 in 1993 to 7,171 in the year 1997 (Table 4.1). A by-product of these long waiting lists has been the growing demand for places in profit-making private sector and other residential homes to meet the shortfall. Most have to wait between three and five years for a place and, indeed, a high proportion of people on the waiting list never gain entry to these institutions as they have died by the time a vacancy occurs for them. This rapid growth in demand and the by-product of growth for private LTC provision in the absence of public provision is an important aspect of the Hong Kong case and no doubt also in other countries. A review of the provision of government-funded care and attention places and medical infirmary places in Hong Kong show that these have fallen well behind demand. By 1997–8, there were only 9,211 places in care and attention homes and 1,915 medical infirmary beds by contrast with the long waiting list mentioned above (Table 4.2). This has fuelled a rapid growth in the private market and the number of private home beds rose from 8,870 in 1991 to over 22,000 by 1998, a growth rate much faster than in the publiclysupported sector. Unfortunately, most private homes have been of substandard quality and run by non-medical or nursing trained persons. The rise in the number of private home beds reflects the inadequacy of the current health care and support system for older persons in need of longterm care. However, if community care could be further strengthened, the demand for residential care might be much reduced. In 1997, there were over 33,500 elderly people living in various types of care homes in Hong Kong. The proportion of people aged 70 and above institutionalized in Hong Kong was around 7 to 8 per cent for the period 1993–1997. This indicates that demand for institutional care in Hong Kong is at a level very similar to that of many Western countries.

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Table 4.1 Hong Kong: demand for LTC facilities (number on waiting list)

Table 4.2 Provision of LTC places in facilities in Hong Kong (numbers of places)

Health status of elderly people in Hong Kong Although people in Hong Kong enjoy a very long life-expectancy, the health of elderly people is not necessarily better than elsewhere. One study in 1996 showed a high prevalence of chronic illness among elderly people (Leung and Lo 1997). About one-third of older persons had hypertension and rheumatism, 17 per cent had suffered from fractures and about 10 per cent had diabetes (Table 4.3). Another survey in 1995 found that elderly people on the infirmary and care and attention home waiting list had a much worse health status than others, with a much higher proportion of people suffering from stroke, dementia and Parkinsonism (Ngan et al. 1996) (Table 4.4). The same study found that a high proportion of elderly people on the waiting list were admitted to private homes, reflecting the difficulties being faced by families in caring for elderly people awaiting institutional care. The prevalence of dementia amongst older persons in Hong Kong is similar to that of most Western countries, again illustrating that dementia will also be an important determinant of long-term care in similar Asian countries. The provision of long-term care As discussed above and illustrated by the Hong Kong example, the health status of older persons in many newly industrializing countries is likely to develop a profile similar to that of Western countries. As there will be

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Hong Kong: prevalence of chronic illnesses amongst elderly people in community

Source: Leung and Lo 1997

Table 4.4 Hong Kong: prevalence of chronic illnesses of elderly people in need of LTC

Source: Ngan et al. 1996

significant growth in the elderly population, especially in the old-old population, there is a need to plan for better provision of LTC. As discussed in Chapter 1 and in many others in the book, past experience suggests that the region has a predominant belief that family can or should provide care for older persons requiring care and support. Governments usually plan mainly for those who do not have any family members. However, with a number of factors affecting the development of the region, this remains a dubious strategy without intervention from the government. Researchers from Japan and Korea amongst others have pointed out that state intervention is necessary to provide long-term care, otherwise other areas such as hospital and medical expenditure will be affected. Sung (1999) notes that the pace of public service developments in Korea has lagged behind that of

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economic growth. Korea needs to push for full-scale development of public services (Choi 1996 and Chapter 12). Sung further notes that even those elderly persons who are living with their children need services, such as adult day care, financial aid, home health care, social services, counselling and training for caregivers. Maeda (1999) also points out that Japanese political leaders have erroneously believed that traditional family care will continue to function well into the future and have thus neglected the possible growth in need for public long-term care services. Indeed, shortage of public long-term care services, especially institutional care services, will continue to cause the unnecessary hospitalization of many older persons (Chapters 6 and 7). This can result in the misuse of public medical expenditure as well as the abuse of precious hospital facilities and medical manpower. The above observations have been confirmed in Hong Kong by Ngan et al. (1996). They note that the provision of LTC services in Hong Kong has far lagged behind the growth of the elderly population as a result of the assumption that the community will be able to provide the necessary care for elderly relatives. They found that most older people waiting for publicfunded institutional care eventually ended up in profit-making homes. The experience of Japan, Korea and Hong Kong demonstrates that detailed planning is required for the provision of LTC services for older persons and should not be left solely to the family. As noted in Chapter 1, this has also been accompanied by observations that the status of elderly people is no longer high in Hong Kong (Chow 1999) and it is probably similar elsewhere. Chow notes that a change that has occurred in Hong Kong is that elderly people must often learn to be more independent in order to keep pace with the tempo of modern society. In this respect, the provision of LTC for elderly people would strengthen their role and status. The organization of long-term care Before the actual occurrence of rapid increase in the old-old population, countries need to plan for the provision of LTC. In order to develop longterm care, planning must form an essential part of the government’s role as it cannot be left ad hoc to the private sector. The key elements to consider in the organization of LTC include the following broad areas: The national policy for long-term care The provision of LTC for older persons should be well planned. It should be based mainly on the number of old-old population to project the need in the community. Individual countries should monitor the prevalence of chronic illnesses and disabilities across different age groups. The making of national policy in the provision of LTC should help to address the balance and provision of various forms of caring facilities. It has been suggested that a

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comprehensive LTC system must include four elements (Estes and Harrington 1985): 1

2 3

4

First, it must be comprehensive, including a full range of health and social services covering the long-term care continuum from communitybased care to institutional care. It must also include preventive and restorative services as well as treatment and illness management. Second, it must provide incentives for providers to keep costs at a reasonable level, to prevent over-utilization and to promote the use of appropriate services. Third, it must have a financing system that provides protection from impoverishment to individuals who need LTC and that allows for the combining of private and public resources to assure protection for individuals before they become ill. Fourth, it must ensure access to those who need the services regardless of financial ability to pay or other characteristics; clients must have access to the services regardless of age or disability.

Components of LTC In order to protect the well-being of frail elderly people, a full range of longterm care services should include a mix of institutional and communitybased facilities and programmes. The necessary components comprise institutional care, including inpatient care, skilled nursing facilities, rehabilitation care, psychiatric services and nursing homes; and community services, including respite care, day care, home health and nursing care, transportation and escort services and foster care. Balance between formal and informal care As noted above, policy-makers in the region commonly believe that older persons will best be looked after by family members. However, the situation in Japan, Korea and Hong Kong has demonstrated that families—the principal providers of informal care—can no longer bear sole responsibility for the care of their elderly members. Families in modern societies have many restraints that limit their capacities of caring for older persons. Therefore, the demand for public LTC (formally-provided) will continue to grow in the region. However, it is already apparent in Western countries that the balance between formal and informal care should be carefully designed. As the burden of care for frail elderly people continues to rise, the heavy reliance on formal care would not be sustainable. Therefore, policy should be designed to enhance the caring capacity of the family to look after sick elderly members within their own homes, thereby reducing the demand of formal services especially institutional care. It appears that in most countries

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in the past, efforts have been placed on residential care rather than developing community services. This often resulted in unopposed demand or the assumption that residential care was what frail elderly people needed. The proper development of community-based health and care services will reduce the need for institutionalization and also increase the capacity of the family to look after older members at home. The financing of LTC This is a major issue, touched on in several other chapters in the book. Elderly people in need of ETC are often likely to be in a poor financial situation and, in the Asia-Pacific region, as discussed in Chapters 1 and 5, there are rarely mature financial support systems in place as yet for this age group. Even in Western welfare states, a substantial proportion of elderly pensioners live in poverty (Sinclair et al. 1990) or at a very low level of basic income. Many tend to become poorer as they get older and it is amongst this group of people that the requirement for care becomes greatest. It is difficult to expect them to be able to purchase the care services they need from their own resources—savings or current income. Therefore, in developing LTC services, the proper financing mode needs to be carefully planned. A wide variety of models is possible although rarely are any totally satisfactory. LTC could be funded through general revenue like in many Western countries such as Australia or the United Kingdom at present, although with means testing or other forms of rationing in many. Alternatively, LTC insurance and social insurance could be a financing option. A mixed economy of provision? It is well recognized that the provision of LTC services soley within the publicly-funded sector can result in slow response to changes in demands for services and hence an inappropriate selection or mix at any point in time. Publicly-funded programmes tend to be more conservative in their planning, and hence lack much flexibility towards the provision of care services amongst others. Therefore, a trend has been to encourage a mix of providers in LTC. The care could be provided through state-supported agencies, nonprofit-making organizations as well as profit-making organizations. However, in many countries of the region, services for profit have only recently entered this area. Perhaps only by offering competition can improvements in the provision of LTC be achieved. Regulation and quality of long-term care The encouragement of both private and public provision of LTC might improve the quantity of such services. However, with the growth in numbers

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and types of services, it is clear that issues relating to regulation of the quality of LTC need to be addressed and this is still in general at an early stage in the region. In some countries, older people have been abused during their stay in private (and public) residential homes. The state’s role in setting standards in regulating the quality of long-term care services is crucial in maintaining the well-being of elderly people receiving those care services (Phillips 1996). Training for long-term care In general, LTC services are essentially care services that require knowledge and skills amongst workers involved. The personnel involved in provision of LTC are broad and include health care professionals such as medical practitioners, nurses, social workers and rehabilitation professionals. Undergraduate training for health care professionals is therefore important in these groups, to instil a positive outlook on caring for the frail elderly people at initial training stages. In addition to health care professionals, a majority of care and assistance is provided by unskilled or semi-skilled workers, including of course family members. In-service training for these workers is therefore very important to both establish and maintain good quality care for older persons being served and to maintain the ethos of care, and to update workers and others on good practice. The provision of training to family caregivers is also important in enabling them to provide the best appropriate care, reduce their stress, often associated with lack of knowledge of how to care, and to lessen their burden in day-to-day care of older family members. References Alber, J., Guillemard, A.-M. and Walker, A. (1991) Social and Economic Policies and Older People, Commission of the European Communities, p. 32. Choi, S.J. (1996) ‘The family and ageing in Korea: A new concern and challenge’, Ageing and Society 16:1–25. Choi, S.J. (1999) ‘Approaches to elderly housing and accommodation in Korea’, Proceedings of Asia-Pacific Regional Conference for the International Year of Older Persons, vol. 2:278–85, Hong Kong: Hong Kong Council of Social Services and Social Welfare Department. Chow, N. (1999) ‘Diminishing filial piety and the changing role and status of the elders in Hong Kong’, Hallym International Journal of Aging 1:67–77. Department of Community Services and Health (1986) Nursing Homes and Hostel Review, Australian Government Publishing Services. Estes, C.L. and Harrington, C. (1985) ‘Future directions in long-term care’, in Harrington, C., Newcomer, R.J. and Estes, C.L. (eds) Long Term Care of the Elderly— Public Policy Issues, Newbury Park, CA: Sage. Freeman, V.A. (1996) ‘Family structure and nursing home risk’, Journal of Gerontology: Social Science 5IB, 2:561–9.

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Hunter, D.J. (1992) ‘The prospects for long-term care: current policy and realistic alternatives’ in Gormally, L. (ed.) The Dependent Elderly: Autonomy, Justice and Quality of Care, Cambridge: Cambridge University Press. Kane, R.L. and Kane, R.A. (1989) ‘Transitions in long-term care’, in M.G.Ory and K.Bond (eds) Ageing and Health Care: Social Science and Policy Perspectives, London: Routledge. Leung, E.M.F. and Lo, M.B.N. (1997) ‘Social and health status of elderly people in Hong Kong’, in S.K.Lam, (ed.) The Health of the Elderly in Hong Kong, Hong Kong: Hong Kong University Press. Levit, K.R., Sensenig, A.L., Cowan, C.A., Lazenby, H.C., McDonnell, P.A., Won, D.K., et al. (1994) ‘National health expenditures 1993’, Health Care Financing Review 16:247– 94. Maeda, D. (1999) ‘Perspectives on health and long-term care’, paper presented at the 6th Asia/Oceania Regional Congress of Gerontology, Seoul, Korea. Ngan, R.M.H., Leung, E.M.F., Kwan, A.Y.H., Yeung, D.W.T. and Chong, A.M. L. (1996) A Study of Long Term Care Needs, Pattern and Impact of the Elderly in Hong Kong, Hong Kong: City University of Hong Kong. Phillips, D.R. (1996) ‘Issues in inspection’, in E.M.F.Leung et al. (ed.) ‘Total care of the elderly: a multi-disciplinary approach’, Hong Kong Journal of Gerontology, Supplement to vol. 10:281–4. Phillips, D.R. (2000) ‘Long-term care’, in E.F.Borgatta (ed.) The Encyclopedia of Sociology (revised edition), New York: Macmillan Reference. Sinclair, I., Parker, R., Leat, D. and Williams, S.T. (1990) The Kaleidoscope of Care, National Institute for Social Work, London: HMSO. Sung, K.T. (1999) ‘Ideals and practices of family support in Korea: Cross-cultural perspectives’, Keynote Address, 6th Asia/Oceania Regional Congress of Gerontology, Seoul, Korea. Waldo, D.R., Sonnefield, S.T., McKusick, D.R. and Arnett, R.H. (1989) ‘Health expenditure by age group, 1977 and 1987’, Health Care Financing Review 10, 4: 111–20. United Nations (1985) The World Aging Situation: Strategies and Policies, New York: United Nations.

5

Financing health and long-term care for ageing populations in the Asia-Pacific region Phua Kai Hong

Introduction Demographic variables which interact with social, economic and cultural factors must all be considered to assess their impact on the health services (WHO 1982). Shifts in basic demographic characteristics such as age distribution, sex composition, family formation and life-expectancy of the population would also have considerable effects on the economy and the social structure of a country. Some of these effects are increasingly being felt in countries whose populations are rapidly ageing and the implications are immense for social and support services—health care, housing, welfare and income security, among others. The pace of social and economic transformation could also accentuate the problems of older persons, especially those who are sick or destitute and without family support. Factors such as rapid urbanization, housing development and resettlement, industrialization and labour-force participation, especially of women, may also contribute to the weakening of the extended family structure and traditional support system for older people. A shift away from care provided in the home and community may potentially lead to growing demands elsewhere, as well as creating stresses on existing public services and the use of limited resources available. Whilst it is important to avoid the ‘moral panic’ often associated with discussion of social and financial costs of providing for ageing populations, it is also sensible to review the options available in the public and private sectors (Fine and Chalmers 2000). Financing the care of older citizens, in particular the increasing costs of their health and long-term care, has nevertheless surfaced as a critical issue in many of the economies in the Asia-Pacific region. This chapter discusses various options for the funding of such care and focuses on short- and longer-term aspects. It takes as examples the cases of Japan and Singapore, whose broader demographic and ageing circumstances are discussed in subsequent chapters. This chapter concentrates on how these two countries have approached the potential problems of sustainable funding of health and

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long-term care and the various combined approaches they are implementing. A wider discussion of the issues, potential and shortcomings of the approaches is also provided. Demographic trends in Japan and Singapore: implications for financing care Many countries of the Asia-Pacific region experienced an extended baby boom following the conclusion of the Second World War in the mid-1940s. The ageing of these ‘Baby Boomers’, together with the rapid fertility declines and increased longevity since the 1960s, mean that many if not all countries will see a ballooning of the elderly segments of their populations in the early part of the next century, as discussed in Chapters 1 and 2. Whilst many Asian countries will experience ageing much later than countries in the West, their ageing populations are nonetheless, increasingly surpassing that of their Western counterparts. Asia is expected to account for about 58 per cent of the world’s total population of older people by the year 2025, with both Japan and Singapore leading the pack in the ‘global ageing’ race (WHO 1995). It is estimated that the peak of population ageing will occur around 2025 in Japan (when older people are expected to exceed 25 per cent of the total population) and around 2030 in Singapore, when older persons will comprise 26 per cent of the entire population. Declining mortality and lower (or stagnating) fertility rates have also meant that older people are becoming an integral part of these and many other societies in the region. The governments of Japan and Singapore both recognize that a large proportion of their citizens is fast approaching the age of retirement, and acknowledging the implications ageing would have on policy-making and government expenditures. Additionally, there is concern about maintaining the health and vitality of older members of the population as lifespan increases, so that they do not become an unduly heavy financial and social burden on society (and to mitigate the potential ‘moral panic’ discussed in Chapter 1). A viable family structure that is able to provide love, care and support for its elderly members is arguably crucial (and many feel most ideal) if both societies wish to keep formal support systems for the elderly to a minimum. Nonetheless, potential or traditional caregivers—the family and predominantly female members—are in turn increasingly stressed due to the onslaught of modernization and urbanization, despite or even because of many Asia-Pacific countries’ Confucian traditions. Demographic changes such as decreases in household and family size and related trends such as changes in marital status (declining marriage rates and increasing divorce rates) might increase the need for alternatives to family care. In spite of the recognized limitations in their interpretation, elderly dependency ratios (the ratio of elderly to working-age population) are also projected to increase dramatically in both countries, especially after 2010–15.

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The elderly dependency ratio suggests (subject to differences in definitions of working age) that more old people will have to be supported by a proportionately smaller number of the working population. This can have drastic implications for issues concerning labour supply, financial security and the provision of social services, especially health care. This is because the incidence of many diseases and disabilities generally increases with age (Chapter 1 and 2). On the other hand, in part as a result of decreasing fertility and family size, there will be more older persons with fewer family members to care for them. Trends in the sex ratio, marital status and family formation also have a bearing on the care of older persons at home. Population shifts due to housing and employment patterns can likewise exacerbate the situation, where a higher proportion of the elderly population already require increasing external assistance for their well-being (Ministry of Health, Singapore 1984). Other demographic features in Singapore and Japan will also impinge on the provision and costs of care. In particular, sex ratios in the older population can be very important. As women generally outlive men, and mortality rates are falling faster among females than males in Singapore, for example, the net result is a growing sex imbalance in the population especially with increasing age (Shantakumar 1994). The health problems of ageing populations are consequently increasingly reflected in the conditions and needs of a larger proportion of older women. In general, women are also likely to utilize health services more than men, so the differential demands may be expected to become increasingly pronounced with the changing sex ratios. It could nevertheless be argued that declining trends in male-female ratios per se over age do not automatically or necessarily lead to a higher demand for social sendees. This would depend on the family structure and marital status of those affected. In Singapore, for example, in the 1990 population census, although females constituted 53.5 per cent of the aged population, widows comprised 29 per cent. Over 54 per cent of all aged women were widowed as compared to about 19 per cent of aged men. As the common pattern is for an older male to be cared for by a younger spouse or female member of the family, this would not automatically pose more problems for the care of older men, although it has obvious implications for the care of older women. However, the earlier deaths of men, usually husbands and fathers who are, in this generation especially, usually the breadwinners, would typically result in widowhood, one-parent (maternal) and one-person (female) households, usually associated with reduced income, increased poverty and enhanced risks of ill-health for the survivors (Siegel and Hoover 1982). This has an effect of enhancing the importance of financial security issues in ageing populations. Financial security and health care: issues from Singapore Surveys of senior citizens have found a majority of older persons in favour of raising the retirement age in Singapore (Ministry of Social Affairs 1983). The

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main reasons for not continuing to work indicate either sufficiency in financial support or ill health; financial problems and boredom have also been cited as major difficulties during retirement (Ministry of Health et al. 1996). In the 1995 survey of Singapore, 2.1 per cent of the senior citizens studied found their incomes usually inadequate for their expenses and a further 8.7 per cent found their income occasionally inadequate. The most common reason stated was the high cost of living (57.7 per cent) although a sizeable minority (16.5 per cent) also cited high medical costs. High medical costs are also one of the factors (9.4 per cent) contributing to feelings of financial insecurity for the future. Prolonging the period of employment should not only alleviate some of these problems but also maximize the productive capacity and capitalize on the experiences of older workers. It would enable financial and social independence and provide the economic means to lead an active healthy life in the community. As improvements in life-expectancy continue, there will be a greater need to raise the age of retirement and to extend the working life of the older population. Various forms of inducements need to be devised to encourage employers to retain older workers in active employment for as long as possible. In the Asia-Pacific region, in general, only the more developed countries have public programmes set up for the expressed objective of providing financial security in old age or due to permanent disability among the working population, although most of these are limited (Chapter 1). There are still sections of the workforce that are not covered by these formal systems and these usually include the self-employed, family employers, casual workers and others who work outside of permanent employment. Depending on the extent of savings or private insurance coverage among these workers, they can lack financial security, which potentially could pose problems in the future (Advisory Council on the Aged 1989). The lack of financial security among the present generation of older people in most countries of the region (the ‘interim generation’ as described in Chapter 1) has certain implications concerning health care especially as their levels of dependency are likely to be high and even increase in the foreseeable future. It also means that the present employed generation will have to bear the increasing costs for the support of this interim group, who are largely without personal savings, until later cohorts with adequate savings appear in larger proportions. Health care needs of older persons: evidence from Singapore The health needs of older persons, either unmet or expressed in actual utilization of health services, are on average much greater than those of the rest of the population (Chapter 4). This expected rise in demand for health care is intensified by both the increasing proportion of older people and by the ageing of the older population itself, driven by the growing number of older persons who are living longer. Older people, especially the very old,

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are particularly vulnerable to chronic debilitating diseases, severe disability and an inability to manage activities of daily living (ADLs) so they are more likely to need long-term care. This is unlikely to change in the foreseeable future, even if direct epidemiological evidence in the region is scanty. It therefore becomes necessary to plan for the appropriate levels and types of services required by older populations. Hence, there is the urgency for innovative approaches to the organization and financing of health care against the rapidly ageing population trends. In the rapidly developing countries of Asia-Pacific, even though statistics indicate that the general state of health of older persons is generally improving, it must be borne in mind that, potentially, the situation could become more critical, given demographic trends and changing patterns of disease. However, the prevalence and severity of reported conditions are uncertain for the future, since they will be affected by lifestyles, social acceptance of disease and disability in old age and cultural adjustments, in addition to supply factors such as technological developments in medical practice and the evolution of social care. In the 1995 National Survey of Senior Citizens in Singapore (Ministry of Health et al. 1996), about 7 per cent of people aged 55 and above reported that they had been hospitalized in the past one year. The percentage hospitalized increased with age, from 5.5 per cent among those in the 55–64 age group, to 8.2 per cent (65–74) and 9.2 per cent among those aged 75+. Nearly 30 per cent of senior citizens studied also indicated that they had been receiving regular treatment from doctors for some long-standing illness. The medical problems reported, in descending order, were high blood pressure (52.2 per cent), diabetes (31.7 per cent), heart conditions (16.7 per cent), rheumatism and arthritic conditions (10.9 per cent) and stroke (3.0 per cent). The extent of medical benefits provided by employers, and whether these cover retirees, pensioners or aged dependents of employees, can have considerable implications for the utilization of and expenditure on health care. If the level of subsidy through public programmes and the prevailing prices of health care is insufficient, this can mean that a larger safety net is needed. This is to avoid the situation when older people and their families do not have sufficient income and savings to pay for their increased medical needs, especially chronic long-term care and catastrophic events requiring potentially high costs. The apparently inexorable rise in health care costs implies a corresponding demand either for health insurance in the private market or public pressure for government subsidies and social insurance. Health insurance in Japan Japan is a country that has addressed but not yet solved many of the financial and other implications of its extreme ageing profile (see Chapters 6 and 7). Its medical care system is very much a pluralistic social insurance

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system, with compulsory enrolment based on employment or residence, and financed through premiums proportional to income. Inequalities in income levels and individual needs are compensated for by subsidies to groups, not to individuals. The costs for the elderly are paid from a fund of pooled contributions from all the insurance plans. This direct subsidization of the old by the young, in addition to budget subsidies and income-pro-portional premiums, makes the Japanese system distinctively egalitarian. Nonetheless, the government recognizes that despite the need to maintain a minimum standard of living for all, this level should be kept below that of the lowest income group in order to discourage people from opting for the easiest way out. This explains why the government is determined to provide only the minimum needs to all elderly people and has always tended to relegate the care of older persons to the sphere of the family. State-funded welfare and security schemes, which include the elderly as a beneficiary group, have been implemented on a limited basis since the 1920s (see Chapter 7 on the history of the development of LTC services in Japan). It was held that any services beyond this level should be provided by the private sector and paid for by consumers themselves. Since older people in Japan today are relatively well-off and demand quality services, the so-called private sector ‘Silver Industry’ is encouraged to enter the health and welfare market. Although the Japanese health care model resembles the Scandinavian and German models in many aspects (in terms of welfare and egalitarianism), the government is very much aware that high taxes and insurance premiums (for subsidizing the elderly groups) can act as disincentives for young people to contribute to the economy. The first health insurance scheme was implemented in 1927 and, subsequently, several more were introduced along industrial and regional groupings. However, until 1961, when national health insurance was implemented, health insurance coverage was rather limited. Due to this historical circumstance, multiple insurance systems are independently operated and the resulting system is complex. For employees in large companies and their dependents, employees’ insurance is managed by associations established either in a single company or organized by a group of companies, whereas in smaller firms, employees’ insurance is coordinated by the government. Universal coverage was achieved in 1961; two-thirds of the population is insured through the household head’s employment and the remaining one-third through the municipalities where the family resides. Although premium rates and benefits differ slightly according to geographical variations, payments to all physicians and health care institutions are determined by a uniform fee schedule set by the central government. Under this health insurance scheme, every citizen and legal resident is entitled to affordable medical care. Tight control on the fees has also kept health care costs at a relatively low level; its ratio to the gross domestic product in 1993 was 7.3 per cent. Universal health insurance has

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been achieved at relatively low costs and the Japanese system has proven itself in delivering equitable health care. Yet, this very low-cost nature of the system is going to be one of the major obstacles to future structural reforms in the implementation of the public long-term care insurance or kaigo hoken. Meanwhile, the average length of hospitalization in Japan is by far the longest in the world and relates to the so-called ‘social hospitalization’ of older people, without good medical cause (Chapter 7, LTC). The correlation between low hospitalization costs and length of hospitalization is by no means coincidental. The problem of overtreatment of older persons has historically been due to the relative lack of LTC care and nursing homes. With the provision since 1972 of very low-cost medical care for the elderly, many private hospitals have become de facto long-term care facilities for the elderly. To illustrate this, until 1991, hospitalization fees for elderly patients (inclusive of all medicines, food and services) were only ¥400 (US$3.50) per day. Although fees have now been increased to ¥600 (US$5.50) per day, it is still considered cheaper to be hospitalized than to be institutionalized. Moreover, norms in the Japanese value system, which permit and even glamorize the act of hospitalization, make the act of hospitalization socially and personally acceptable. On the other hand, an elderly person can hire a home helper from private service at a minimum rate ¥700 (US$6) per hour. If eight hours of care are needed, a person would need to pay at least ¥2 million (US$18,000) per year for using that service. In monetary terms, it then appears more economical to hospitalize an elderly person rather than seek more appropriate forms of care. The booming ‘Silver Industry’ since the 1980s aims at providing a wide range of goods and services to older persons, such as specially designed housing, home help, visiting nurses and the selling/renting of special beds and bathtubs. No doubt, this booming ‘Silver Industry’ would be capable of serving a minority of older people who can afford it. However, the cost of these services renders them inaccessible to the majority of the elderly population. Differences in the level of care that an elderly person can receive might potentially create social cleavages rather than mutual help and solidarity. To exacerbate the problem, it appears that Japan is not yet ready to look after all its elderly residents and formal social support has remained inadequate. The existing infrastructure gives priority to those with low income and lacking in family support. Due to high demand in the public sector and priority given to lower income groups, individuals who require LTC might have to rely on private service instead. However, alternatives are increasingly reduced if one belongs to the middle or lower-middle income groups. This has placed stress on these groups who, out of economic necessity, have to maintain dual-income households. Yet, by the very same token, they are unable to engage alternative means of care and, in the meantime, home care of older members becomes an increasingly less viable option when both partners need to work. Even in government-funded nursing homes and hospitals, the shortage of

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nursing staff (let alone well-trained ones) and helpers threatens the quality of LTC, exacerbated by the low pay of home helpers. Currently, quality care is maintained by high morale and the dedication of a small number of administrators and caregivers but these standards cannot be sustained for long. The amount of reimbursement that service providers and caregivers receive is similarly an area of concern. Moreover, to obtain home help or to be admitted into these nursing homes, application has to be made to the municipal welfare office and applicants undergo a means test. Sometimes, individuals merely forgo help in order to avoid the tedium of such tests. The Gold Plan and New Gold Plan In its efforts to clear the hurdle of fiscal containment, Japan implemented the ‘Ten-Year Gold Plan for the Promotion of Health and Welfare Services for the Elderly’ in early 1990 (revised in 1994) to increase LTC facilities and services within a decade from 1990 to 1999 (discussed in detail in Chapter 7). According to this plan, the number of beds for the very frail and seriously impaired elderly is to be increased approximately three-fold by the year 2000, from 189,830 in 1989. The pace of development of community and care services will also be substantially accelerated to assist elderly people while allowing them to live independently in their accustomed homes and communities. These goals were revised upward in the 1994 New (Revised) Gold Plan and increased funding has been made available in the form of grants and subsidies despite the difficult fiscal situation. In total, more than ¥9 trillion (US$80 billion) will be invested during the 10-year period which has already started in 1989 (Ministry of Health and Welfare 1996). Both the Gold Plan and New Gold Plan paved the way for future reforms in the fundamental characteristics of health care in Japan, but it is evident that, in order for these plans to work, more large-scale investments in LTC infrastructure will be insufficient. It appears that such efforts have generated only limited effects. Nursing homes and health care facilities for the elderly might have increased in absolute numbers under the Gold Plan but nursing homes still cannot cope with the incessant heavy demand. Quality LTC for older persons requires more than just expensive infrastructure and the government must adopt a two-pronged approach by training more qualified caregivers and educating the public. In addition, there are concerns that dramatic increases in funding for LTC might merely be a political manoeuvre to sweeten the effect of introducing an unpopular consumption tax in 1996 and to win the support of female voters. Long-term care insurance: the Japanese experience Japan provides an example of one of the few countries in the region that has at least attempted a thorough review of the future funding of LTC, even if the

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results have been subject to considerable debate and criticism. The Public Long Term Care (LTC) Insurance Act, passed in 1997, should be implemented in the year 2000 (see Chapter 7). Half the costs will be paid by premiums that will be levied on all those who are 40 years old and above and the other half will be covered by general taxation. The monthly payment will initially be ¥2,500 with a 10 per cent co-payment at the point of service provision. Both are subjected to deductions/waivers for those from the very low-income group. The insurers will be the municipalities since they are the carriers of the health insurance programmes and are responsible for the provision of social services. Due to the wide differences in the demographic structure, there will be a pooling mechanism at the national level to allocate resources equitably. Benefits and eligibility Benefits from the scheme will include institutional care, short-term respite care, day care, home-help, visiting nurses and the loan of equipment. However, ambulatory care in physicians’ offices and hospitals, physicians’ home visits, as well as acute care in general will continue to be covered by the current health insurance scheme. All residents of Japan aged 40 years and above who have paid or are paying LTC premiums will be potentially eligible, but eligibility for those between 40 and 64 will be determined according to criteria of ‘age-related diseases’. What exactly fits into these criteria has yet to be determined. Conditions such as the early stages of dementia, Alzheimer disease and cerebrovascular disorders are most likely to be included and these limitations on eligibility in the 40–64 age group were a result of political compromise to control costs. Yet no matter how these ‘age-related diseases’ are denned, there will always be justifiable complaints from individuals having diseases not included in the category. Those aged 65 years and above would automatically be eligible. Eligibility status will be classified into six levels by assessment of the patient’s functional and cognitive status and the assessment can take place either in the community or in institutional care settings. Reassessment will be periodically made every 3–6 months after commencing LTC. The onsite assessment will be performed using a 71-item form that measures activities of daily living (ADL), cognitive and sensory status, excluding the degree of medical supervision required. However, the extent of home-based informal care available is not taken into consideration in determining the eligibility status. This means that the provision of formal services will become an entitlement regardless of how much family support the person has. The total amount of reimbursement is then decided by the degree of disabilities that the elderly person has. While the current consensus might be in favour of this programme (for example, surveys in 1995 showed that 82 per cent of those polled were in favour of its introduction), support might decline if costs were to escalate or

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if the benefits were deemed inadequate. As the plan for elderly care was designed in the latter half of the 1980s during the economic bubble of Japan’s economy, no-one had really anticipated the severe repercussions of the increasing unemployment rate and current depression and deflation in the Japanese economy. An increasing number of Japanese working adults over the age of 35 years are in danger of losing their jobs as a result of the ongoing trend of company restructuring. As the economy seems unlikely to pick up substantially within the near future, the likelihood of retrenched workers finding steady employment again seems low. Consequently, people over the age of 40 are going to find it difficult and may be unwilling to pay the premium for the long-term care insurance. Coupled with increased income tax in the late 1990s, there is concern that this group of people might be reluctant to reduce personal consumption just to finance the insurance system, which basically does not cater for their current needs. While the Japanese government hopes that part of the increased spending would be offset by a reduction in health care costs, physicians, on the other hand, wish to expand their role in the expanding field of LTC. In addition, new services such as diaper changing could incur additional costs. If not handled properly, this programme could be endangered by a clash of interests between the two parties. In addition, unlike acute care, ‘need’ determination can be rather subjective because the wishes of patients and their families and not the physician’s professional judgement are the most important factor in deciding what kind of services should be provided. Unless the government can devise explicit mechanisms to objectively measure and limit eligibility, the probability of risk escalation is very high. The government would in turn need to resolve the problem by raising premiums and taxes, which would generate dissatisfaction amongst voters as well as further the economic problems of low consumer spending. The difficulties in implementing this programme have been held to have been compounded by methodological flaws in the proposed system. One criticism is of the eligibility classification. The fact that the amount of medical need/supervision is excluded from the 71-item assessment criteria would mean that levels of dependency could not be translated into meaningful, clinical definitions. As such, the absence of an objective yardstick for dependency level is likely to make it difficult to account for the change in a patient’s eligibility status and, consequently, the amount of benefits to which he or she is entitled. Another area of concern is the fact that the government has yet to disclose the number of people requiring LTC eligible to be placed in the six categories of classification. This is especially sensitive when the government is cautious of making this appear like a quota system which would negate the rational of displacing the current form of social provision that is strictly controlled by the budget. The new system is designed on the basis of individual need without taking into consideration the fiscal limitations of the

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municipal LTC insurance fund. Hence, the government is caught in the dilemma of providing LTC to as many people as possible and having to balance the accounts. A further potential defect lies in the inadequate attention given to maintaining the integrity of the assessment process. Under the current plan, it would most likely be the frontline LTC clinicians who decide the form and quantity of care a patient needs. This is an opportunity when the system could potentially be abused as the both clinicians and patients have the incentive to place the patient in the highest possible level of eligibility. Furthermore, there are no checks and balances to prevent clinicians from developing care plans that might channel most of the entitlement money to procure services from their institutions. Since a patient is free to choose between institutional and home care, and among the different types of facilities that provide institutional care, there is a high likelihood that patients would go for the most expensive form of care available within their eligibility category. Apart from the compulsory 10 per cent co-payment, there are basically no other economic disincentives to stop them from doing so. Similarly, a distinction needs to be drawn between the existing health insurance system and the new LTC insurance. Unless regulations are set, institutions who are in the position of suggesting and providing LTC may try to maximize revenue by getting the most out the two systems. Unfortunate as it may be, care managers may not always come up with care packages that are in the best of the recipients’ interests. The initial home care services provided by the new system would be limited compared to the wider variety of services provided by the current tax-based system. For example, the new system would not include the delivery of meals, a definite inconvenience to older persons who are either bedridden or non-ambulatory. Those who need additional care would have to spend their own money—an almost impossible feat for the much poorer senior citizens, given the high cost of private care services. The present direction of the LTC insurance plan seems to follow the United States model of fee-for-service payment. The quality of service is then dependent on what one can afford to pay. Yet, it should be borne in mind that policy reforms and changes in the fundamental characteristics of the Japanese health care system need not necessarily go in tandem. The concept of competition in managed care that is so prevalent in countries such as the United States has not really taken root in Japan. It will be interesting to watch how this will be played out in Japanese society, with its social and economic complexities discussed in Chapters 6 and 7. Medical savings and health insurance in Singapore Meeting the costs of health care and hospitalization due to rapid population ageing will be a major challenge in many Asia-Pacific countries and

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especially in the urban areas. For example, in Singapore, people aged 65 and over comprised 7 per cent of the population but accounted for 17 per cent of all hospital admissions and 19 per cent of outpatient poly clinic visits in 1995. Their average length of hospitalization was 11.3 days, substantially higher than the average of about 5 days for the overall population. Older persons appear generally to consume a disproportionate share of health care due to increased prevalence of diseases that are chronic and more severe (Ebrahim and Kalache 1996). Such demographic and epidemiological demand factors will exert economic pressures that are also likely to be aggravated by supply factors such as the introduction of life-sustaining but costly medical technologies. This calls for innovative ways of providing costeffective health care for an expanding elderly population and more sustainable methods of financing care within an old-age security system. In some Asian countries such as Singapore, there is the official policy of enlarging the scope of mandatory savings to cover other areas that would be consistent with the social objectives of providing old age security. One of these areas identified by the policy-makers is health care coverage, especially to protect the older population against the high costs of hospitalization. Since health care needs and expenses are expected to rise dramatically with ageing, mechanisms to protect older persons against expected medical costs could be built into old-age security schemes as well. Traditional health care financing through taxation or personal payments are generally held to be inadequate to pay for good quality health care. Therefore, prior savings have had to be enforced to meet the anticipated rising costs of medical care for the future. These considerations form the underlying basis for the National Health Plan of Singapore formulated in 1983, whose key proposal, the Medisave Scheme, attempts to impose compulsory savings and to re-structure the then existing system of medical care financing. The main objectives of the National Health Plan are, first, to secure a healthy, fit and productive population through active prevention and promotion of healthy lifestyles and, second, to improve cost-efficiency in the health services. In addition to promoting individual responsibility for maintaining good health, it aims to build up financial resources so as to create the means to pay for medical care during illness, especially in old age (Ministry of Health 1983). Medisave can be allowed to pay for the hospital expenses of immediate family members. This accords with the concept that the basic social and economic unit should naturally be the family nucleus, in which caring for the welfare of its ill and aged members is first and foremost, a family responsibility. The aim is to preserve certain values held to be desirable, such as filial piety, which could enhance the stability of an essential societal structure amidst rapid changes. Where there are genuine difficulties in the case of the entire family being unable to share in the medical expenses of its sick and elderly, only then does the state step in to subsidize costs from public taxes (Phua 1986).

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The 1995 National Survey in Singapore has shown that Medisave has become the most important provision relied upon by senior citizens aged 55 and above to finance their health care. More than half (55 per cent) depended on their children’s Medisave to pay for their medical expenses while 17.9 per cent depended on their own Medisave and 2 per cent on their spouse’s Medisave. Medisave funds accounted for nearly three-quarters (74.9 per cent) of the health care financing provisions of senior citizens aged 55 and above although the older groups of senior citizens relied on the Medisave of their children more than their own. Proportionately more women (65 per cent) than men (43.8 per cent) depended on their children’s Medisave. As men were likely to have accumulated more Medisave over their working life, the proportion of men (30.1 per cent) depending on their own Medisave for financing their health care was higher than that of women (6.9 per cent). However, there was a group (7.9 per cent) of senior citizens who had not made any financial provisions for health care. Nearly 42 per cent of this group indicated that they were not able to do so because of unemployment or low income to accumulate Medisave or personal savings. A similar proportion had also not done so because they felt that they could rely on their children to pay their medical bills if required (Ministry of Health et al. 1996). In the past, Singapore has sought to balance supply factors in the health sector by deliberate manpower and facilities planning and, on the demand side, by mobilizing individual savings through the Medisave scheme within the existing Central Provident Fund (CPF) (Asher 1998). Therefore, demand has been rationed implicitly through consumer purchasing power in the market. Such social policies have been necessary to avoid the problems in maintaining the balance between demand pressures and supply capacity. The situation is even more acute for the small population in Singapore, whose rising expectations for a higher quality of services have surfaced with growing affluence (Phua 1987a; Lee 1999). In anticipation of future demands and needs emerging from demographic trends in Singapore, the Committee on the Problems of the Aged chaired by the Minister of Health was convened in 1983 ‘to recommend measures to prevent, ameliorate or deal with such problems’ (see Chapter 9—Singapore). Among the recommendations in its 1984 report were included a national policy for the elderly, covering aspects of employment, financial security, health and recreational needs, social services and institutional care, and family relations (Ministry of Health 1984). These were followed by the Report of the Advisory Council on the Aged in 1989, which recommended, among others, the development of community-based programmes for maintenance of good health, prevention of disease, and rehabilitative and social support for the elderly. Alongside this were other related developments such as the implementation of the National Health Plan and the Medisave Scheme. These reflected an integrated and consistent policy of ensuring that savings through

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the CPF mechanism, would form the backbone for viable long-term financing of increasingly expensive health care of the elderly in Singapore. This was further strengthened by Medishield as a back-up catastrophic illness programme and Medifund for support of the indigent. The latest 1999 InterMinisterial Committee Report on Health Care for the Elderly has concluded that the best option for the future of LTC financing should be along the lines of the Medishield scheme. Like the Medishield scheme, the LTC Insurance Scheme should be voluntary, based on an opting out approach, and have the features of deductibles and co-insurance to discourage over-consumption and over-servicing (Ministry of Health 1999), although this has certain potential problems, discussed below. There is general belief that the system of cost-sharing with medical savings has contributed to more effective health care spending by reducing wasteful and unnecessary consumption. Indeed, Singapore has enjoyed a lower rate of growth in health care spending relative to GNP than many places elsewhere. In essence, Medisave serves as an additional source of personal financing for medical expenditure to be borne by individual families. With this shift in public cost-sharing, government tax revenue would hence be freed to meet other priorities and to contribute towards better targeting of subsidized health services. It is also hoped that Medisave, acting as a substantial health financing and payment scheme, could also control effective demand through the price mechanism. Payment and reimbursement Under the Medisave scheme, payment for health care would be made more at the point of consumption. It is intended that this tangible nexus between payment and utilization would reflect the real costs of health care and would discourage over-utilization. Medisave should also be able to cater for different consumer preferences over a range of ward accommodation either in the public or private hospitals. It could therefore be used to provide complete coverage for lower-priced wards with the basic essential services, or to subsidize the more expensive hospital charges if preferred, but within certain limits. Through Medisave, reimbursement for private hospitalization is pegged to rates set by the more pervasive public hospital sector, which is subject to strong budgetary controls on the supply side. With the imposition of permissible limits on daily charges, and the type of procedures performed, potential abuse could be prevented for excessive Medisave withdrawals. However, with such price caps put in place, would there be incentives on the part of providers to increase the volume or quality of services provided? There is also the question of whether the withdrawal limits need to be adjusted periodically to reflect rising costs as, otherwise, the balance in charges would have to be borne from increasing out-of-pocket payments which would hurt the lower income groups. Similarly, could withdrawal

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limits be adjusted to take into consideration the higher differential costs of medical care for older people? Fine-tuning and revisions could be implemented towards improving the reimbursement method as it evolves locally, for example, the introduction of case-mix funding and fee schedules based on relative value scales for health care providers. This is necessary so that the issue of ‘balance-billing’—extra charges additional to the rates set— would not become serious. Easing a financial burden? Unlike social insurance and tax-based financing, the savings approach should not place an unduly heavy burden on the proportionately decreasing number of the young and productive, and should free public expenditure from the vagaries of economic cycles. The present generation of wageearners is obliged to save for the future, instead of relying on the uncertain taxes of the next generation for support later. This is in line with official policy to promote financial independence among older people, whose medical needs are expected to increase in the years ahead. However, this could also mean that both employees and employers have to be squeezed hard to make contributions, on top of rising wage costs that would be subtracted from private incomes and profits. In addition, the present cohort of wage-earners could be doubly affected, since they not only have to save for their own old age but also have to provide for the existing number of elderly dependents without substantial savings (Phua 1987b). Compulsory versus voluntary contributions Given the still popular assumptions in Singapore and other countries in the region that the family is the main caregiver for older persons and that the state provides a safety net as a last resort, many people might remain myopic and not see the need to save for their old age. When faced with unpleasant realities (such as catastrophic illness and long-term debilitating conditions), a common response is denial. Therefore, unless steps are taken to increase public awareness of the costs of eldercare, the probability of people opting out of the new insurance scheme remains fairly high. Perhaps governments should mandate that citizens contribute the moment they start working so that they only need to pay low monthly premiums. Since most caregivers tend to be women, they also tend to sacrifice their financial independence, losing out in terms of paid employment, in order to fulfil their unpaid obligations as housewives or caregivers. Therefore, non-earners such as home-makers should be encouraged to join the scheme by allowing them to pay lower premiums or by using their spouses’ income. As women are likely to form a large proportion of the future aged population, it makes sense to start saving now before they reach old age or the death of their spouses.

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Policy issues and implications The socioeconomic implications of a rapidly ageing population in relation to a disproportionately reduced working population can be significant. Governments would be strained to finance ever-increasing public spending from a shrinking tax base. Amidst demands from increasingly vocal and ageing electorates to provide more and better public services, many governments have found it unpopular to ration and cut back on existing social programmes. This is also compounded by poor economic conditions, unemployment and mounting public expenditure in many countries in the region, which all add to the difficulties of financing social security schemes supported by a declining number of contributors. Some countries have resorted to various cost-containment measures and critical re-examination of existing systems of financing social programmes, especially health care. Countries with indirect health care financing through social insurance or taxation have removed many restraints on individual demand and thus ration services by intervening mainly on the supply side. Whatever the method of financing adopted, it will not diminish the necessity to improve delivery and utilization of health care for the elderly population through efficient, equitable and cost-effective means. The expanded use of health insurance can, in fact, emphasize the need for even greater vigilance in monitoring cost and quality, which should include strengthening utilization review and medical audit within the health care systems of Asia. It is probably desirable that there are financial incentives and control measures to encourage doctors and patients to utilize health care at the most appropriate level and at a cost that a country can afford. In view of anticipated demographic, epidemiological, social and economic trends, existing tax-based health care financing would have to support growing needs. The Singapore model attempts to avoid the problems of increasing the tax burden on the productive, including employers and employees and does not subject social expenditure to the vagaries of economic cycles. Present generations of younger wage-earners are mandated to save for their own inevitable health care needs in old age, instead of relying on the uncertain taxes of future generations. By such a multi-layered health care financing system, together with varying levels of cost-sharing and subsidy in a public-private mix of health services, it is hoped that the future economy with a much larger proportion of elderly population, will be able to withstand increasing burdens of health care costs, as well as providing a sustainable degree of social security (Asher 1998; Phua et al. 1996). Singapore has embarked on a policy of health reform by restructuring its health care financing system through a scheme of compulsory savings as part of a Central Provident Fund for the working population (Figure 5.1). This mandatory Medisave scheme can be used to cover dependent family members, consistent with the traditional values of filial piety and extended

Financing health and long-term care for ageing populations

FINANCING METHOD • Compulsory savings Family savings • Catastrophic insurance Long-term care insurance • Endowment • Taxation

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3-M SYSTEM • MEDISAVE •

MEDISHIELD

•

MEDIFUND

Figure 5.1 Health financing in Singapore.

family support. The Medisave scheme for basic health care coverage is augmented by a back-up Medishield insurance scheme for catastrophic illness. The latter Medishield Plus schemes provide for optional coverage of additional high-cost benefits. Similarly, the impending long-term care insurance scheme would be integrated with these schemes to offer more protection for care provided outside hospitals. For the needy and indigent without adequate Medisave or Medishield funds, public subsidy is supplemented from a medical endowment fund. The Medifund Scheme is built up during periods of high economic growth and would further relieve the dependency on traditional taxation as the primary means of financing social welfare for the poor (Phua 1997). Conclusions Against the background of rapid economic growth, demographic and health transitions leading to issues of population ageing, concerns over health care and income security have surfaced with considerable alarm in some Asia Pacific countries (ESCAP 1991, 1996). Growing attention is being paid to the wider issues of social care, which include the living arrangements, family and community support, formal and informal sectors of care, and their interrelations with other welfare needs (see for example Figure 5.2). Of particular interest is the status of elderly people in the societies undergoing rapid changes. There will be related social costs and policy implications for support systems, which thus present new challenges for the development of innovative and cost-effective models (Phillips 1992). The World Bank Policy Research Report on Averting the Old Age Crisis: Policies to Protect the Old and Promote Growth has also sounded the alarm about the potential crisis facing many old-age security systems. Whilst the whole issue of ‘moral panic’ over increased numbers of older persons has been questioned (Chapter 1), nevertheless, as life-expectancies increase and birthrates decline, the proportion of old people is expanding and could threaten

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• • • • •

Avoid hospitalization and institutions Provide substitutes and alternatives such as day care, home nursing, hospices Develop community-based services Strengthen family support and home care Improve housing and living arrangements

Figure 5.2 Elements of more cost-effective care.

the financial security systems supported principally by the young. In many industrialized countries, escalating costs in public pension plans have been accused of impeding economic growth and such formal systems appear to be both unsustainable and difficult to reform. In developing countries, urbanization and increased mobility are eroding extended family networks and traditional means of support. Newly industrializing countries that are developing old-age security systems risk repeating the costly mistakes of many older economies. Therefore, a mix of three systems or ‘pillars’ may be considered to support the basic functions of old-age security systems— redistribution, savings and insurance. The first is a mandatory publiclymanaged and tax-financed system, the second a mandatory privatelymanaged and fully-funded savings system, and supplemented by a third voluntary system of occupational or personal saving plans. Together, these three pillars coinsure against risks of old age while not impeding growth in ageing societies (World Bank 1994). Given that health care needs are expected to be greater as populations in this region age, should not the same requirements be met for health care financing systems? The three basic functions of redistribution, savings and insurance are just as applicable for financing health care as for old-age security. Even though the relative risks and uncertainties may be different for health care needs, a similar mix of financing methods can still be recommended to offer greater protection while promoting growth in countries with ageing populations. These considerations have formed the basis for the existing integrated systems of old-age security and health care financing in Singapore. Comparable innovative means of financing need to be explored to guarantee the cost-effectiveness of providing other essential services for older persons, straddling the full range of types and levels of health care in various settings (acute or chronic care; nursing-home, residential or home care; preventive, curative and rehabilitative care). In the varied forms of care for the elderly, more economic checks and balances are almost inevitable in response to potentially increasing expenditure and competition for scarce resources available. Of particular relevance is likely to be the introduction of acceptable methods of cost-sharing or cost-containment aimed at balancing forces of supply and demand.

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References Advisory Council on the Aged (1989) Report of the Advisory Council on the Aged, Singapore, January. Asher, M. (1998) ‘The future of retirement protection in Southeast Asia’, International Social Security Review 51, 1:3–30. ESCAP (1991) Population Ageing in Asia, Asian Population Studies Series, No. 108, Economic and Social Commission for Asia and the Pacific, Bangkok, and Japanese Organization for International Cooperation in Family Planning Inc., Tokyo. New York: United Nations. ——(1996). Population Ageing in Asia and the Pacific, Economic and Social Commission for Asia and the Pacific, Bangkok, and Japanese Organization for International Cooperation in Family Planning Inc., Tokyo, New York: United Nations. Ebrahim, S. and Kalache, A. (eds) (1996) Epidemiology in Old Age, London: BMJ Publishing Group. Fine, M. and Chalmers, J. (2000) ‘“User pays” and other approaches to the funding of long-term care for older people in Australia,’ Ageing and Society 20, 1: 5–32. Lee, K.M.W. (1999). ‘Income protection and the elderly: an examination of social security policy in Singapore’, Journal of Cross-Cultural Gerontology 13, 4:291–307. Ministry of Health (1983) Blue Paper on the National Health Plan, Singapore, February. ——(1984) Report of the Committee on the Problems of the Aged, Singapore, February. ——(1999) Report of the Inter-Ministerial Committee on Health Care for the Elderly, Singapore, February. Ministry of Health et al. (1996) The National Survey of Senior Citizens in Singapore 1995, Ministry of Health, Ministry of Community Development, Department of Statistics, Ministry of Labour, and the National Council of Social Service, November. Ministry of Health and Welfare (1996) Trends in the Nation’s Welfare (Kousei Tokei Kyokai), Tokyo, Ministry of Health and Welfare of Japan. Ministry of Social Affairs (1983) Report on the National Survey of Senior Citizens, Singapore, May. Phillips D.R. (ed.) (1992) Ageing in East and South-east Asia, London: Edward Arnold. Phua, K.H. (1986). ‘Singapore’s Family Savings Scheme’, World Health, May. ——(1987a). ‘Saving for Health’, World Health Forum, 8:38–41. ——(1987b) ‘Ageing: socio-economic implications for health care in Singapore’, Annals Academy of Medicine, Singapore 16, 1:15–23. ——(1997) ‘Medical savings accounts and health care financing in Singapore’, in G. Schieber (ed.) Innovations in Health Care Financing: Proceedings of a World Bank Conference, March 10–11, 1997, World Bank Discussion Paper No. 365:247–55. Phua, K.H., Seow, A. and Lee, H.P. (1996) ‘Issues and challenges of public health in the 21st Century in Singapore’, in Y.Khairuddin, Y.L.Low and S.N.Zulkifli (eds) Issues and Challenges of Public Health in the 21st Century, Kuala Lumpur: University of Malaya Press. Shantakumar G (1994) The Aged Population of Singapore, Census of Population 1990, Monograph No. 1, Singapore.

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Siegel, J.S. and Hoover, S.L. (1982) ‘Demographic aspects of health of the elderly to the year 2000 and beyond, World Health Statistics Quarterly 35, 3/4:140–1. World Bank (1994) Averting the Old Age Crisis: Policies to Protect the Old and Promote Growth, New York: Oxford University Press. WHO (1982) World Health Statistics Quarterly, 35, 3/4, Special Issue on Public Health Implications of Ageing. ——(1995) World Health Report 1995—Bridging the Gaps, Geneva: WHO.

6

Ageing in Japan Retirement, daily lives, pensions and social security Daisaku Maeda and Hisanori Ishikawa

Introduction Japanese elderly people in their seventies and eighties have lived through one of the stormiest periods in their country’s long history. When they were born, Japan was one among the many underdeveloped countries of Asia and most citizens were employed in agriculture and fishing. Japan was following a national policy of centralization of power and strengthening its military forces to catch up with the advanced countries of the Western world. When today’s elderly people were in their teens, they experienced the Great Depression, with both economic and psychological suffering. Many were compelled to forgo a higher education and instead worked to help their parents. Some were forced to lives of deprivation, because of their father’s unemployment. Then came the war against China, and later the Second World War which brought painful experiences on the battlefield and the loss of family members. During these long years, Japan gradually advanced toward an ultra-nationalistic and totalitarian society. This has greatly influenced the way of thinking of today’s older people. After the Second World War came defeat and a completely opposite national policy based on decentralization, liberalism and internationalism. Thus, it may be said that elderly persons of today have experienced a political and cultural revolution since their younger days. During their lifetimes, the Japanese economy has made great progress. Despite its serious setbacks in the Great Depression and its later collapse after the Second World War, between 1900 and 1970, Japanese manufacturing industry expanded 150 times. In comparison, during the same period, that of the United States expanded fourteen times, Italy seventeen times, Germany nine times and France six times. Economic growth has been especially conspicuous since 1955 and in the fifteen years 1955 to 1970, Japan’s industrial production expanded 6.7 times (Oouchi et al. 1971). Therefore, Japanese people who are now in their seventies experienced these economic changes when they were between 20 and 40 years old. This means it was they who really created the rapid economic development of the nation.

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Industrialization seems inevitably to bring about urbanization, and the speed of urbanization in Japan has been rapid since the late 1950s. This is illustrated in the rapid growth of the urban population by contrast with a decrease in the rural population. According to the national censuses of 1950 and 1985, the urban population increased from 31 to 93 million, while the rural population decreased from 53 to 28 million. If the decrease in the proportion of the labour-force engaged in primary industries (agriculture, forestry and fishing) is taken into consideration, the change becomes yet more significant. In 1950, five years after the end of the Second World War, as much as 48 per cent of the labour-force was engaged in primary industrial activities, which had fallen to only 7.9 per cent by 1983 (G MCA, Department of Statistics 1989). These two factors, rapid industrialization and urbanization, caused a drastic change in Japanese life, sometimes referred to as the ‘Westernization of life’. It deeply affected both the social and economic life of all people in both rural and urban communities. Thus, Japanese older persons of today have lived under two completely different sets of national goals and ideologies. They have also experienced very rapid changes in standards of living with the shift from an agricultural to an industrialized country. Their unique life experiences should always be kept in mind when the problems of ageing in Japanese society are considered. Characteristics of ageing in Japan A Western social gerontologist was once told that three out of four elderly persons lived with their children in Japan. She reacted by asking ‘Why do you have to study our social services for the elderly, then? You don’t need them!’ This seems to be a typical example of the oversimplifications persons tend to make about other countries. Indeed, Plath (1972), an American anthropologist, once rightly noted that ‘Ageing in Japan, as elsewhere, is a matter for deep human ambivalence’. In fact, because of the above rapid and drastic social changes, two contradictory factors coexist within the many aspects related to ageing in Japan. For example, although respect for the elderly is still regarded as one of the essential virtues, social services for the elderly, which are indispensable for their well-being, are much less developed compared with those in many countries of the Western world. Similarly, although there are many elderly persons, sometimes over 80 years old, at the head of large firms, the compulsory retirement age of most large firms is low (usually at 60 years). Furthermore, although there is a psychological tendency for Japanese elderly people to assume a stance called inkyo, which literally translated means ‘living in hiding in one’s old age’ (having delivered the responsibility of daily life, and living a quiet and peaceful life), many very old politicians do not retire. Therefore, it is very difficult to give a clear picture of ageing in Japanese society. In this respect, as in many others, Japan may be regarded as a society of contradictions.

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Definition of old age in Japan Japanese people used to define old age as meaning those aged 60 years and over, as in most societies under the influence of Chinese culture. In ancient China, the calendar year was named with the combination of the two sets of Chinese characters; one consisted of twelve characters and the other of five characters. Therefore, when a person became 61 years old, the name of that year was the same as the year of birth. For this reason, the 61st year after birth is called Kanreki (return of the calendar) and carries a special meaning in a person’s life. This custom is also observed in some countries of Southeast Asian (Cowgill 1972). Kanreki was often regarded as the beginning of one’s second childhood and, in Japan, many people used to hold a passing rite to mark it. At the time of the Kanreki ceremony, the person becoming 61 was presented by their children and relatives with a red vest designed to signify the coming of the second childhood. Thus, Japanese people of 60 years of age and over were permitted to be dependent on others, mainly on their adult sons and daughters and, in general, they were not obliged to work to earn money. In other words, Kanreki signified a social sanction, permitting entry into inkyo ‘retired life’, if this was desired. In reality, however, most Japanese older people continued to work, either for money or for the satisfaction of continuing to have a meaningful role in life. However, the concept of old age now has changed greatly. According to nationwide research conducted in 1986, only 21 per cent of the proportion of respondents aged 60 and over thought that the beginning point of the late life was 60 years of age or younger. Indeed, 45 per cent thought that it was 70 years of age or over (GMCA, Section on Policy for the Elderly 1987). Japanese gerontologists, in common with their professional colleagues in most Western countries, also tend now to use age 65 as the divide between middle age and old age. The main reason is that the proportion of the population aged 65 and over seems to be appropriate for considering social programmes for the elderly. In many actual programmes, however, people aged 60 and over are generally treated as old people and, in fact, the pensionable age of the largest public pension programme, Kohseinenkinhoken (Welfare Pension Insurance Program), is 60, five years younger than the average pensionable age of many Western industrialized countries. However, as discussed in more detail later, following the Pension Reform of 1994, the right to receive Japan’s public pension will be gradually raised to 65 by the year 2013. Demographic features In 1997, the number of older persons aged 65 and over was 19.8 million, 15.7 per cent of the total population (Table 6.1). This percentage is very similar to that in many other industrialized countries such as Sweden, Germany, France and Great Britain (Table 6.2). The age structure of Japan’s

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Table 6.1

Population of elderly peope in Japan: past, present and future

Source: National Institute of Population and Social Security Research, Ministry of Health and Welfare (1997).

Table 6.2

International comparisons of the population aged 65+: past, present and future (percentages)

Source: Health and Welfare Statistics Association (Kohsei Tohkei Kyohkai) (1998a) p. 27.

population was quite stable from the beginning to the middle of the twentieth century. The very high birth-rate, promulgated by national policy, offset the gradual increase of the aged population resulting from advances in medicine and public health and general improvements in the standard of living. However, since 1950, five years after the end of the Second World War, the birth-rate decreased very sharply from 32 per 1,000 in 1930, 17 per 1,000 in 1960 and 9.5 per 1,000 in 1997. Japan now belongs to the lowest birth-rate group in the world (Table 6.3) and the low birth-rate is combined with a very high extension of life-expectancy of old people (Table 6.4). This tendency is expected to continue and it is estimated that elderly people aged 65+ will reach approximately 28.0 per cent of the population in the year 2030 (Table 6.1). At that time Japan is likely to be the most aged country in the world. Table 6.5 shows an international comparison of the rate of population ageing among five industrialized countries with respect to the year when the proportion of people aged 65+ reached the 10 per

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Table 6.3 International (non-Asian) comparison of Total Fertility Rates (TFR)

Source: Health and Welfare Statistics Association (Kohsei Tohkei Kyohkai) (1998b) p. 44.

Table 6.4 Japan: increases in life-expectancy at age 65

Source: Health and Welfare Statistics Association (Kohsei Tohkei Kyohkai) (1998b) p. 443.

cent level and the year it will attain the 20 per cent level. The rapidity of population ageing in Japan is very impressive. The number of years needed for the proportion to increase from 10 per cent to 20 per cent will be only twenty-one years in Japan, notably shorter than many other countries. This is remarkable given that Japan’s aged population was the last among many industrialized nations listed in Table 6.5 to have reached the 10 per cent level (in 1985), while she will be the first among them to reach the 20 per cent level. Table 6.5 International comparison of the speed of population ageing

Source: Based on data in Japan Aging Research Center (1998) Table 7, part IV, p. 291.

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The world’s longest average lifespan and a great increase in the very old population A prime feature of Japan’s population ageing is the fast and conspicuous extension of the average lifespan (expectation of life at birth, ELB). In 1996, Japan’s average life-expectancy was 77.01 years for men and 83.59 years for women, then the longest in the world. Half a century ago, when Japan started population ageing, ELB was only 59.6 for men and 63.0 for women (1950–52). A further important characteristic is the sharp decrease in the younger population. The gap in numbers between younger people and old people will steadily widen in the future. In 1995, the proportion of the young population at ages 0–14 was 15.9 per cent whilst that of those aged 65 and over was 14.5 per cent (Table 6.6). Throughout the projected period, the percentage of young people will continue to decrease, reaching 12.7 per cent by 2030, but the older percentages will increase continuously to 28.0 per cent by 2030. With regard to population ageing in Japan, the impact of a great increase in the very old population cannot be overemphasized. As shown in Table 6.7a, during the forty-five years between 1950 and 1995, the number of older persons aged 80 and over increased more than ten times to 3,881,000. It is estimated that this number will continue to expand and exceed 12 million before 2035 (Table 6.7b). This means that the size of very old population (80+) will increase further by almost four times during the forty years between 1995 and 2035. Undoubtedly, such an enormous increase in the very old population will exert an immense impact on patterns and levels of demand for medical care and social welfare services. An inevitable result of these demographic changes will be a sharply growing total dependency ratio. This ratio will be relatively low until the turn of the century. In the next century, however, the index is expected to Table 6.6 Japan’s projected population structure, 1995–2030

Sources: National Census for 1995; National Institute of Population and Social Security Research, Ministry of Health and Welfare (1997). Note: Total Dependency Ratio=the sum of population aged 0–14 and 65+ divided by the population aged 15–65, multiplied by 100.

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Table 6.7a Japan: increases in the numbers of old people, 1950–1995 (thousands)

Table 6.7b Japan: increases in the numbers of old people, 1995–2035 (thousands)

Source: Based on data in National Institute of Population and Social Security Research, Ministry of Health and Welfare (1997).

increase sharply and will reach a peak of 68.6 in 2030 (Table 6.6), which will also be one of the highest of the world at that time. The impact of population ageing on Japanese society In parallel with the ageing of the population and the accompanying socioeconomic changes, it is predicted that the Japanese tradition of family care for aged parents cannot avoid considerable weakening or, indeed, total loss. Accordingly, in the near future, Japan will be simultaneously confronted with two difficult problems: the rapid increase in the number of elderly people (especially the very old and those needing special care) and weakened family support and care. This means that Japan must make every effort to achieve a fast expansion of public support and care services for its rapidly increasing very old population. Another important feature of the changing population composition is the prospect of the ageing of the labour-force. According to official estimates of the Ministry of Labor, the age composition of the labour-force will change significantly during the ten years 2000 to 2010. Although the age group between 15 and 54 will decrease by 8.5 per cent, the age group between 60 and 64 will grow by as much as 41.4 per cent. The number of workers aged 55–59 will, however, remain about the same. This change will greatly influence the future social and economic conditions in Japan. For example, while an increasing number of younger workers will be needed for expanding the manufacturing industries vital to support a rapidly increasing older population, the number of such workers will decrease considerably. Many more workers will also be needed for the personal care services

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catering for the expanding number of very old people and other physically dependent persons. A further key demographic feature of an ageing population is its geographical distribution. Currently, the proportion of the population aged 65 or over is much greater in rural areas than in the large metropolitan areas, mainly as a result of the enormous migration of younger people from rural areas to industrialized areas. In 1995, for example, the proportions of persons aged 65 and over in Tokyo and Osaka, the two largest metropolitan areas of Japan, were 13.0 per cent and 11.0 per cent, respectively. By contrast, there were certain rural prefectures in which the proportion of the 65+ age group already exceeded 20 per cent (National Census 1995). It is predicted that this discrepancy will continue or even grow in the future. It is feared that the development of services for rural older populations may be very difficult because many more old people will be scattered over wide areas whilst the population of younger people able to provide services for them will be limited. Living arrangements One of the most conspicuous differences between the lives of older people in Western countries and those in Japan, or many other Asian countries, can be seen in their living arrangements. Table 6.8 shows this difference. While more than 40 per cent of elderly persons aged 60 and over in Japan live with their married children, only fewer than 5 per cent in the United States and Germany live with married children. There is also a great difference in the proportion of elderly persons living alone. In Japan, only about 8 per cent of elderly persons aged 60 and over live alone, compared to about 40 per cent in the United States and Germany. In many Western countries, however, about half of the older people living separately from their children live geographically close to them (Shanas et al. Table 6.8

International comparisons of living arrangements of people aged 60+, 1996 (multiple answers) (percentages)

Source: General Management and Coordination Agency of the National Government (GMCA), Section for Policy for the Elderly (Kohrei-shakai Taisaku-shitsu) (1996).

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1968). If this is taken into consideration, the difference with Japan becomes significantly smaller, although a considerable gap still remains. In addition, it is important to realize that two generations living together in Japan in the same house very often maintain two economically independent households. Moreover, the number of older persons living independently but close to their children in the same community seems to have increased in recent years. What factors may be influencing the particular forms of living arrangements of Japanese elderly persons today? An hypothesis can be readily constructed that Japanese elderly persons live with their children because of housing shortages. It is certainly true that, in large metropolitan areas, there is still a serious shortage of housing. However, a closer examination reveals that the proportion of elderly people living separately (living alone or only with spouse) is significantly higher in metropolitan areas than in smaller cities and rural areas (Table 6.9). In other words, elderly persons live together with their children even in localities where the shortage of housing is not so serious. It appears that, in Japan, housing problems even tend to promote separate living rather than cohabitation. This seems to be shown by the higher percentage living separately in large cities, probably as a result of the limited size of available houses. Why, then, do so many Japanese elderly persons live with their children? Generally speaking, Japanese culture expects the eldest son to live with his parents, to support and take care of them. If elderly persons and their children live separately, the situation is often interpreted by others as meaning either that the parents are disliked by their children or there is something wrong on the part of the children. To the average older parents (except for highly educated and/or Westernized persons), living separately from their children will bring shame on them. On the other hand, in Western society most older parents want to live separately and independently for as long as their health permits. In other words, independence, a highly esteemed virtue in Western societies, is not necessarily regarded so in Table 6.9

Japan: regional differences in proportions of people aged 65+ living together with children and living separately, 1995 (percentages)

Source: Ministry of Health and Welfare (1997).

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Japanese society. Indeed, it might not be too much to say that Japanese elderly persons are not only allowed but are also expected to be dependent on their children, rather than to be too independent or stubborn. In fact, a very popular proverb runs ‘When old, obey your children’. This attitude is clearly shown by a recent international comparative study on the opinions of older persons (Table 6.10). According to this study, 54.2 per cent of Japanese people aged 60 and over think that ‘it is desirable to live together always’. The same study shows that only 4.0 per cent of elderly people think so in the United States and 13.4 per cent in Germany. The attitude of younger Japanese people is, however, changing gradually, as shown in Table 6.11 which describes the outcomes of the national survey on the opinions of middle-aged persons on life in their later years. More than 50 per cent of Japanese middle-aged men and women are thinking of living separately from their children in their later years. The proportion of persons who would prefer to live separately is greater among the younger generation, suggesting that the living arrangements of Japanese older people will change gradually and probably significantly in the future. Another interesting fact about the family life of the Japanese elderly is that, unlike many Western societies, most live with their son, especially the eldest son, whenever possible, a characteristic of both Japanese and Korean families. In most parts of China, too, old parents usually live with their son, but not necessarily the eldest son (Aoi 1976). In other parts of East and Southeast Asia, however, customs differ. For instance, in Thailand, as in many Western societies, most ageing parents live with their daughters, Table 6.10 Desired relations with children of persons aged 60+: international comparisons, 1996 (percentages)

Source: General Management and Coordination Agency of the National Government (GMCA), Section for Policy for the Elderly (Kohrei-shakai Taisaku-shitsu) (1996).

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Table 6.11 Opinions of middle-aged persons on their later years (men and women aged 30–59) (percentages)

Source: Prime Minister’s Secretariat, Public Relations Office (Koh-hoh-shitsu) National Opinion Survey on Image of Late Life (1993). Note: National representative sample (3,000) of middle-aged men and women aged 30–59; DK=Do not know; NA=No answer.

especially with the youngest (Cowgill 1972). Thus, in Japan one of the most serious family problems elderly persons have to face is the conflict between an old mother and her daughter-in-law, instead of the son-in-law problem more recognizable in Western societies. The burdens that the family members have to bear when elderly persons living with them become very frail or seriously impaired are very heavy due to the shortage of institutional and community care services. This is really one of the most important social problems that ‘ageing Japan’ is facing today. Work and retirement Japanese society has some unique characteristics in terms of its employment and retirement system, in particular a fixed mandatory retirement age, a seniority wage system and an expectation of lifetime employment. These characteristics have also an impact on the employment and retirement of older persons. The most important feature for rapidly ageing Japanese society is the early fixed mandatory retirement age applied in most large firms, including national and local governmental agencies. In Japan, 94.5 per cent of all enterprises having 30–99 employees and almost all enterprises having more than 100 employees had adopted a fixed mandatory retirement age (Japan Aging Research Center 1998). In 82 per cent of enterprises having such a system, the mandatory retirement age is 60 (Table 6.12). This is significantly younger in comparison with many other highly industrialized countries and also low in the light of the present average life-expectancy of middle-aged and old-aged Japanese. For government employees, the fixed mandatory retirement age is presently set at 60 by law, although many of those at higher positions retire even earlier.

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Table 6.12 Ages of fixed mandatory retirement, Japan 1997 (percentages)

Source: Japan Aging Research Center (1998) p. 124.

For the majority of Japanese people, the fixed mandatory retirement age of 60 is premature because, generally speaking, their children have not yet finished high school or college. Japanese men usually marry in their late twenties or early thirties. Therefore, their last child may be born when they are around 35 or later. College education is generally expected for middleclass children. If parents are forced to retire before 60, their last children will still be in college or, in some cases, the child may even be in high school. One of the main obstacles to raising the mandatory retirement age relates to the unique Japanese seniority wage system, under which the postponement of retirement age leads to greater expenditures on higher salaries for employees. Because of the ageing of the workforce, however, many businesses have been gradually modifying the seniority-based wage system by introducing ability-related elements. Work for elderly people As noted above, when a person is forced to retire at age 60 or before, in many cases his or her children are still financially dependent and, therefore, the majority will try to find another job when they first retire. With a few exceptions (very high government officials and senior executives of private enterprises), jobs taken after the first retirement offer a much smaller income and lower social status. In addition, they are often unstable and/or irregular but, nevertheless, in 1995, 78.9 per cent of older men aged between 60 and 64 were still working as were 41.9 per cent at the age of 65+. This is far higher than comparable figures for the USA, Denmark, France and Germany (Japan Aging Research Center 1998). The major reason for the higher rates of participation in the labour-force by Japanese old people is a lack of income. This suggests that, in the future, when the mandatory retirement age is postponed to age 65, deemed unavoidable if the productivity of the nation is to be maintained in light of the rapidly shrinking younger population, the participation rate of older persons in the labour-force will be reduced significantly. Another factor that

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influences the labour-force participation of elderly persons is the availability of acceptable and suitable jobs. According to the 1995 National Census, 31.6 per cent of Japanese elderly persons 65 and over (men and women working gainfully) were engaged in primary industries (agriculture, forestry and fishing). This proportion is much greater than 6.1 per cent of the total population (National Census 1995). In addition, 47.1 per cent of older men (65+) in the labour-force are self-employed (GMCA, Department of Statistics 1995), again a much greater proportion than that of the total population (15.1 per cent). However, these figures do not necessarily mean that elderly persons change their jobs, move into primary industries or become self-employed. Rather, it is reasonable to assume that most of those who were engaged in these industries have continued in them. Another reason is that, generally speaking, primary industry jobs may be more appropriate for elderly people to continue than are those in other industries such as manufacturing and mining etc. What, then, will be the labour-force participation of Japan’s elderly in the future, when the retirees from primary industries or self-employed jobs have adequate incomes from public pensions? Most Japanese social gerontologists admit that this will also exert a strong influence towards the reduction of labour-force participation rates among older persons, along with the raising of the fixed mandatory retirement age noted previously. The economic life of Japanese elderly people It is difficult to give a clear and concise picture of the economic life of Japanese elderly people. This is principally because many live with their adult children and form a single economic unit with regard to earnings as well as consumption. It is especially difficult to identify precisely the income of individual elderly people who live with self-employed children because, in most cases, they also contribute to the work of the children’s family. In most cases, however, their incomes are officially regarded as nil, so there are no national statistics on the income of individual elderly people in Japan. The statistical data generally cited are those on the income of households, classified by the age bracket of the household head. Needless to say, the household income includes that earned by younger household members. Indeed, the average per capita income of households whose heads are 65 and over is only a little less than that of all households (2,065 thousand yen in 1996, compared to 2,257 thousand yen for all households) (Ministry of Health and Welfare 1996). In other words, as far as average per capita income is concerned, the economic conditions of elderly people in Japan do not seem particularly miserable. It should be mentioned, however, that there are great disparities between the income of high-income elderly persons and the low-income elderly. Table 6.13 shows a comparison of the quartile income distribution of all

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Table 6.13 Comparison of quartile income distribution of all households, normal households and households whose heads are aged 65+, 1996 (percentages)

Source: Ministry of Health and Welfare (1996).

households, normal households and households whose heads are older persons (65+). Although the average income of the households whose heads are aged 65+ is not particularly small, the reality is that, while there is a small number of very rich elderly persons (3.5 per cent), the overwhelming majority of older persons are in the lowest quartile (62.4 per cent). The daily lives of retired persons It was noted earlier that the proportion of elderly people still in the labourforce is higher in Japan than in most other industrialized countries. It is also true, however, that the majority of men and women over 65 years of age are retired and not working for income. How, then, do they spend their time? According to an international comparative study in 1996, the proportion of Japanese older persons who are engaged in active religious activities, social gatherings, community volunteer activities, and group activities is significantly smaller than in most other industrialized countries. The study indicates that Japanese elderly people in general are perhaps surprisingly less active in comparison with other countries. The favourite hobby among Japanese elderly people is watching television (Table 6.14). It appears that, Table 6.14 Favourite activities of Japanese people aged 65+ (multiple answers) (percentages)

Source: General Management and Coordination Agency of the National Government (GMCA), Section on Policy for the Elderly (Kohrei-shakai Taisaku-shitsu) (1994).

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on average, Japanese elderly people spend more time working to earn income, doing activities with the children’s family with whom they live, and watching TV. Generally speaking, they spend much less of their time in more positive types of hobbies than do those in other advanced countries, because they simply do not have the array of such hobbies. Pensions, social security and social services for older persons Japan’s pension schemes As Watanabe (1996, 1999) notes, the Japanese system for providing retirement income has three pillars: social security, private pension plans and individual savings schemes. The history of public retirement pension insurance programmes in Japan dates to the 1940s. Since then, its coverage has gradually broadened and, in 1962, it had come to cover all Japanese aged 20 and over, including the self-employed. Japan’s retirement pension insurance system is very complex but it may be summarized as follows. In 1985, it became a two-tiered system; the reform was so drastic that it was called the ‘New Retirement Pension’ for several years thereafter. The first tier is a flat benefit related to years worked but not to earnings, whilst the second tier is related both to years worked and earnings. First, all enrollees contribute to a Basic Pension programme (Kiso Nenkin). In 1999, the amount of contribution per month to the Basic Pension programme was 12,800 yen (approximately US$116). In addition to the participant’s contribution, the national government contributes one-third of the participant’s contribution to the Basic Pension fund. (Those who belong to the programmes for employees pay their contribution through the programmes to which they belong, making no direct contribution to the Basic Pension programme.) The second tier involves programmes for employees. There is a Public Retirement Pension Insurance Program for the Employees of Private Enterprises (Kohseinenkin Hoken), the Public Retirement Pension Insurance Programs for the Employees of Central and Local Governments and two small special programmes for the employees of semi-public organizations such as private formal schools (Kyohsai-nenkin Hoken). The amount of contribution to these two programmes (Kohsei-nenkin Hoken and Kyohsai-nenkin Hoken) is decided according to the income of the employees. The contributions are divided equally between the employers and employees. The retirees from these programmes receive two pensions, one from the Basic Pension programme and the other from the programmes for employees. In the late 1990s, the average amount of pension for those retirees who had contributed forty years (based on the 1994 revision of the regulations in 1999) was: Retired individuals, Basic Pension only: 65,000 yen a month (approximately US$590) Retired couple, Basic Pension only: 130,000 yen a month (approximately US$1,180)

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Retired couple (husband a private enterprise employee; the wife economically dependent on her husband) Basic Pension for husband and wife: 65,000 yen each Benefit from the second tier programme: 100,983 yen Total: 230,983 yen a month (approximately US$2,100) There is also a second tier system for the self-employed but, as it started in 1991, no-one is as yet receiving payments under this system. As it is not compulsory, (the number of enrollees) is still very small, fewer than one million as of 1997 or only about one-thirtieth of the number of enrollees in the Basic Pension only. The number of the enrollees was approximately 69.66 million in 1996, which includes self-employed, employees in private enterprises, employees of central and local government and employees enrolled in other minor special programmes, such as that for teachers in private schools; it also includes the economically dependent spouses of employees enrolled in their programmes. The breakdown of 69.66 million is: Basic Pension only Programmes for employees in private enterprises Programmes for employees of central and local government Special programmes

31.3 million 33.0 million 4.46 million 0.90 million

The raising of the age of eligibility of men for full benefits from the National Retirement Pension Insurance for Employees of Private Enterprises (Kohseinenkin-hoken) and other Public Retirement Pension Insurances for Employees was referred to earlier and will start very slowly from 2001. Every three years, the age of eligibility will be raised by one year; to reach 65 in the year 2013. For women, the increase will be started five years later, from 2006, and the goal (65 years) will be reached in 2018. However, the revision of eligibility is for full benefit and between the age 60 and eligibility age, a partial pension will be paid. Its amount will be decided in accordance with the income of the retiree. Private pension schemes In addition to the public compulsory pension system, lump sum payments at the time of resignation or retirement, a kind of private pension, are very popular in Japan. Except for very small-scale firms (with fewer than about thirty employees), virtually all Japanese firms have private pensions with fairly substantial lump sum payments at the time of retirement (Watanabe 1996). For example, a person whose final position was secondary administrative and has worked for, say, forty years for an average firm, usually receives something in excess of 10 million yen (approximately US$91,000), In addition to lump

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sum payments, there are several types of private pension plans in Japan with quite large numbers of employees and self-employed persons participating. Even if traditional informal lump sum payment at the time of resignation or retirement are excluded, as well as so-called contract-out plans (privately administered public pension insurance for the employees of private firms— Kohsei-nenkin Hoken) the number of participants in formally established and/or publicly approved private pension plans is estimated to be 17.6 million of Japan’s total workforce of approximately 67 million. However, as the public sector retirement pension for employees is reasonable in Japan at present, the significance of private pensions is comparatively small. Nevertheless, because of the progress of ageing, a reduction in the average amount of public retirement pension in the future appears inevitable. Therefore, there is much discussion of private pension plans, altered tax regulations and the like. Union leaders, the Ministry of Labor and the Ministry of Health and Welfare, which is mainly responsible for social security, are not very interested in the hasty development of private pension plans for employees. In the long run, however, it is likely that private pension plans will become increasingly important and it might be said that Japan is now preparing for their sound development. Social security and social services As far as the public pension system and public sickness insurance system are concerned, Japan is almost on the same level as most other advanced countries of the Western world. Educational and recreational services for older people are also well developed. However, Japan’s social services for frail and impaired elderly people are significantly less well developed than in other advanced countries, mainly due to the very fast increase in the older population, especially that of the very old as noted earlier. In brief, the structure of the social security and social services for elderly people in Japan may be summarized as follows: Basic legislation Japanese social policies for elderly citizens are planned and implemented in accordance with the principles laid down by the Fundamental Law on Policies for the Aging Society of 1995. In accordance with this law, the government is to establish a policy statement on the ageing society and renew it when necessary. The current statement was adopted in 1996, the year following the enactment of the law. Social security Japan has a universal public retirement pension insurance system that covers all adult citizens including those who are self-employed. Public sickness insurance also covers all Japanese from infants to the elderly. For persons aged 70 and over,

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a special programme has been established for promotive, preventive and rehabilitative services, as well as for the alleviation of the burden of co-payment. Long-term care services One of the shortcomings of Japanese social policies for the elderly is the long overdue development of long-term care services for frail and impaired older persons. The overview of the long-term care services in Japan is discussed in detail in the next chapter of this book, as is the 1997 Long-term Care Insurance System Act. Educational and recreational services A variety of educational services for senior citizens is provided in all municipalities, including towns and villages, with subsidies from the Ministry of Education. In general, they are provided as a part of the adult education programme. Some prefectural governments as well as local governments have special programmes and/or facilities for this service. Among them, InaminoGakuen (the Inamino School for Senior Citizens) of Hyogo Prefecture is renowned for the excellence of its programmes and facilities. In addition to educational programmes, the large majority of municipalities have community welfare centres for the elderly, whose purpose is to provide recreational and educational services for senior citizens and many centres also provide counselling services. In addition to the community welfare centres, there are quite a number of small-scale neighbourhood welfare centres for the elderly (Rohjin Ikoino le—literally translated, Rest and Relaxation House for the Elderly). These serve as places for older persons to meet and enjoy a range of recreational activities. One feature of the Japanese public programmes for elderly people is the national subsidy for the establishment and operation of old people’s clubs, of which there were 134,000 in March 1997, spread throughout Japan. About 8,840,000 people were members (approximately 33 per cent of the older population aged 60 and over). Programmes to provide opportunities for gainful employment As already noted, generally speaking, Japanese older people, especially men, want to continue to work as long as possible both for a meaningful life as well as for extra income. In an attempt to meet these needs, the following services are provided through a national subsidy. Information centres for the development of vocational ability of older persons (Kohreisha Nohryoku Kaihatsu Joh-hoh Sentah) The main purpose of this kind of centre is to help find adequate jobs for unemployed older persons. They also serve as information and advice centres about various issues and problems faced by older persons.

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Silver Manpower Centers Silver Manpower Centers are intended to find opportunities for light, parttime gainful work for older persons. These centres are to be run by notfor-profit organizations of retired older persons themselves, in a nationally subsidized programme of the Ministry of Labor. Most cities with a population over 100,000 now have these centres. Other programmes Tax deduction An income tax deduction programme for persons supporting parents aged 70 and over was started in 1972 and a similar deduction programme for local income tax was started in 1973. Tax deduction programmes are intended to stimulate and promote traditional family support and care of ageing parents in their own homes, especially those who are frail and impaired. Telephone reassurance service This is a popular service in Japan although it is not supported by the national government. In most cases, the service is provided by volunteers, even when it is run by local governments. Services for improvements, additions to, or remodelling of, elderly people’s houses This kind of service has been growing rapidly in the 1990s although, again, it is not supported by the national government. Some local governments provide a grant for the improvement of homes of impaired older persons when this seems necessary to avoid institutionalization. Meal services A daily meal service is provided by only a very small number of local governments or voluntary organizations in Japan. Almost all of these programmes are currently at an experimental stage. Sheltered housing Sheltered housing for elderly people, popular in many Western countries, is not yet very well developed in Japan. The fundamental reason is that the national government still places greater emphasis on investment for infrastructure such as road construction, harbours and other basic public works. Compared to public infrastructure development, public housing, including that for older people, receives only minor attention from the Ministry of Construction.

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References Aoi, K. (1976) ‘Characteristics of the Japanese family’ (Nihonno Kazokuno Tokuchoh), The Community, vol. 46, Tokyo: Chiiki Shakai Kenkyusho. Cowgill, D. (1972) ‘The role and status of the aged in Thailand’, in D.Cowgill and L.Homes (eds) Aging and Modernization, New York: Appleton-Century-Crofts. Health and Welfare Statistics Association (Kohsei Tohkei Kyohkai) (1998a) Trends of Nation’s Social Welfare Services (Kokumin-no Fukushino Dohkoh), Tokyo: Health and Welfare Statistics Association, vol. 45, no. 12. ——(1998b) Trends of Nation’s Social Welfare Services (Kokumin no Fukushino Dohkoh), Tokyo: Health and Welfare Statistics Association, vol. 45, no. 9. General Management and Coordination Agency of the National Government (GMCA), Section on Policy for the Elderly (1987) International Comparative Survey on the Life and Opinion of the Elderly—1986 (Rohjinno Seikatsuto Ishikini Kansuru Kokusaihikaku-chohsa 1986), Tokyo: General Management and Coordination Agency. ——(GMCA) Statistics Bureau (Tohkei Kyoku) (1995) Japanese National Census, Tokyo: GMCA. ——(GMCA), Department of Statistics (1989, 1995) Annual Report of Labor Force Survey (Rohdohryoku Chohsa Nenpoh), Tokyo: GMCA. ——(GMCA) Section on Policy for the Elderly (1994) International Comparative Survey on the Life and Opinions of Older Persons (Kohrei-shakai Taisaku-shitsu), Tokyo: GMCA. ——(GMCA) Section on Policy for the Elderly (1996) International Comparative Survey on the Life and Opinions of Older Persons (Kohrei-shakai Taisaku-shitsu), Tokyo: GMCA. Japan Aging Research Center (1998) Yearbook of Basic Facts and Figures on Aging Society: 1998/1999 (Kohrei Shakai Kiso-shiryoh Nenkan, 1998/1999), Tokyo: Chuoh-Hohki Pub. Co. Ministry of Health and Welfare (1996) National Fundamental Survey on The Life of People (Kokumin Seikatsu Kiso Chohsa), Tokyo: Ministry of Health and Welfare. ——(1997) National Fundamental Survey on The Life of People (Kokumin Seikatsu Kiso Chohsa), Tokyo: Ministry of Health and Welfare. Miura, F. (1998) White Paper on the Problems of the Elderly Illustrated (Zusetsu Kohreisha Hakusho), Tokyo: National Council of Social Welfare. National Institute of Population and Social Security Research (1997) Population Projection for Japan, Tokyo: Ministry of Health and Welfare. Oouchi, H., Arisawa, H., Wakimura, G., Minobe, R. and Naito, M. (1971) Japanese Economy Illustrated (Nihon Keizai Zusetsu), 5th edition, Tokyo: Iwanami Publishing Co. Plath, D. (1972) ‘Japan: The after years’, in D.Cowgill and L.Holmes (eds) Aging and Modernization, New York: Appleton-Century-Crofts. Prime Minister’s Secretariat, Public Relations Office (Koh-hoh-shitsu) (1993) National Opinion Survey on Image of Late Life, Tokyo: Prime Minister’s Secretariat. Shanas, E., Townsend. P., Wedderburn. D., Friis. H., Mihoj. P. and Stehouwer. J. (1968) Old People in Three Industrial Societies, New York: Atherton Press. Watanabe, N. (1996) ‘Private pension plans in Japan’, in Z.Bodie, O.S.Mitchel and J.A.Turner (eds) Securing Employer-based Pensions: an International Perspective, The Pension Research Council, Baltimore, MD: University of Pennsylvania Press, pp.121–42. Watanabe, N. (1999) ‘Japan’, in D.Callund and M.Nightingale (eds) International Benefits Yearbook 1999, London: Sweet and Maxwell.

7

Development of long-term care for elderly people in Japan Hisanori Ishikawa and Daisaku Maeda

Pre-war long-term care (LTC) services for older people: a brief overview Before the Meiji Restoration (–1868) Social efforts for the welfare of elderly people in Japan have a long history and can be traced back to charitable work by Buddhist temples. These provided mainly outdoor relief to poor older persons without families to support and care for them. However, some Buddhist temples built almshouses for the care of frail or impaired poor older persons, orphans, the poor disabled and so forth, although the number of such almshouses was very few at that time. In ancient times, Buddhism was in effect the national religion in Japan. It might therefore be said that, in that period, the state was providing relief to poor elderly persons, although the quality and quantity were quite limited in relation to the needs at that time. In feudal times, however, societal efforts for relief almost disappeared because of incessant wars between feudal lords throughout Japan. The Age of Civil Wars came to an end when Japan was once again unified by the Tokugawa regime, approximately four hundred years ago. The Tokugawa regime promoted, among other things, mutual assistance between relatives as well as neighbours. It also gave protection and encouragement to Confucianism, Buddhism and Shintoism (the Japanese folk cult with a basic philosophy of ancestor worship) in order to maintain social order. Filial piety, respect for elderly people and ancestor worship became the basic moral laws of Japanese society. In the Tokugawa era’s climate of peace and prosperity, many Buddhist temples engaged in charity as one of their most important activities. Older persons were the main recipients as the Tokugawa regime placed a special emphasis on the virtue of respect for elderly people. The strict social policy of the Tokugawa regime placed special emphasis on mutual assistance among relatives and neighbours and on moral education, on filial piety and respect for elderly people, so the number of older persons who slipped through the safety net of mutual assistance was very limited. It is believed

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that almshouses were therefore not numerous throughout the Tokugawa era, although there are no official records. Relief was the responsibility of neither the central regime nor of the local feudal lords in the Tokugawa era. Relief was essentially charity to be performed by Buddhist temples or charitable individual persons. From the Meiji Restoration to the end of the Second World War (1868– 1945) In 1874, the new Meiji government issued the famous administrative order Jutsukyu-kisoku (the Relief Order of 1874), which stipulated that frail elderly persons of 70 or more who had no relatives to support them could be given public relief. Other targets of public relief were orphans and severely impaired persons. However, the amount of money given as relief was very small, sufficient only to maintain a bare existence and the order did not cover any indoor relief. The term ‘indoor relief, however, was not completely equivalent to ‘(institutional) long-term care’, as in many cases institutional care was also provided to able-bodied older persons who lacked adequate housing. Indoor relief to poor children, older persons and the disabled had to be provided by private charitable organizations or individuals, although some local governments did establish their own alms-houses. Generally speaking, what the government did was only to give these almshouses a partial grant which covered only a very small proportion of actual expenses. This strict Relief Order remained in effect for more than sixty years until 1932, when a new Public Relief Law (Kyugo-hoh) enacted in 1929 was put into practice. While a number of almshouses admitted all kinds of persons in need of indoor relief even under the strict Jutsukyu-kisoku Relief Order of 1874, the establishment of public assistance institutions that were dedicated solely to older persons, that is, homes for the aged, was very late. The first home for the aged was established in 1895 in Tokyo by a voluntary organization and the second in Kobe in 1899, also by a voluntary organization. The tempo of establishment of such public assistance institutions gradually accelerated alongside national economic growth and an increasingly deepened societal conscience for social justice. The number of homes for the aged in April 1933, the second year of enforcement of the new Public Relief Law (Kyugohoh) of 1932, was eighty-five. The number of old persons living in them throughout Japan was 3,476 (including 766 who were younger than 65) (NAHA 1933). The new Public Relief Law (Kyugo-hoh) stipulated that the national government should take responsibility for relief of the poor. Eligibility for relief was eased a little in comparison with the previous order (Jutsukyu-kisoku), although it was still very limited in terms of modern social welfare philosophy. This law lowered the age limit for relief from 70 to 65 and indoor relief was approved as a legitimate form of providing assistance. The number of homes for the aged increased to 131 and the number of older persons institutionalized in 1940

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increased to 4,582 (including 287 who were younger than 65) (NAHA 1940), one year before Japan’s entry into the Second World War. Thus, the number of institutionalized older persons increased by approximately 60 per cent in the seven years between 1933 and 1940. However, the number of relief institutions still fell seriously short of actual needs. Many older beggars could be seen wandering throughout Japan, while a huge amount of money was ungrudgingly spent for the expansion of military forces. Japan’s entrance into the Second World War in 1941 had a devastating effect on the lives of Japanese people, especially impacting on older persons without children on whom to depend, on orphans and disabled people. Because of the lack of food, clothing and, above all, money allocated to the services for these persons, the death rate among the institutionalized, especially that of older persons, was extremely high. Such miserable conditions continued until the end of the Second World War in 1945. It appears that the number of the homes for the aged at the end of March 1944, about one and a half years before the end of World War II, was 127 throughout Japan, and the number of the older persons institutionalized was 3,158 (Ueda 1976). During the four years 1940–44, the number of homes for the aged therefore actually decreased from 131 to 127 whilst the number of institutionalized older persons decreased significantly from 4,582 to 3,158. The social dislocation after Japan’s wartime defeat means that dependable figures on the number of homes for the aged and institutionalized older persons are only available from 1949. Then there were 189 homes for the aged although there are no data on the number of institutionalized older persons (Ueda 1976). From military state to welfare state (1945–1963)—changing national goals after the Second World War The development of social policy for older persons in general Emergence of a modern public assistance system Japan’s defeat in the Second World War caused a thorough eradication of prewar ultra-nationalism and militarism, and peace, democracy, human rights and social welfare became national goals. One year after the end of the Second World War, Kyugo-hoh (the old Public Relief Law) was abolished, and a completely new public assistance law (Seikatsu Hogo-hoh—literally the ‘Livelihood Protection Law’) was enacted in accordance with the modern social welfare philosophy, although it did not recognize the legal right of people to ask for the provision of public assistance. Five years later, in 1950, the old Livelihood Protection Law was abolished, and the new Livelihood Protection Law was enacted. This is the present Japanese public assistance law, which recognizes the legal right of people to ask for assistance and the

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right of appeal of administrative and legal appeal when the applicant thinks that the decision of the local welfare office is not adequate in view of his/her needs. This law significantly improved the living conditions of poor older persons. An effect was that older beggars, so commonly seen everywhere in prewar days, almost disappeared. The significance of the modern public assistance system was far greater at the time it was enacted half a century ago than can now be imagined. Fifty years ago, Japan’s public pension system merely covered government officials and the employees of very limited industrial firms and there was not a universal public health insurance system at that time. Therefore, without the Livelihood Protection Laws of 1946 and 1950 in the field of medical assistance, low-income Japanese persons would have suffered much more severely from the societal confusion after the war. Expansion of the coverage of the public pension system Another important step in the construction of Japan’s welfare state was the establishment of a public retirement pension system with universal coverage to secure minimum income after retirement for all senior citizens. The first step in this direction, although very limited in its scope, was taken in 1941, before the end of the Second World War, in the form of a law for the establishment of public retirement pension insurance for persons employed in mining, manufacturing, and other important firms. Three years later, in 1944, this law was revised to expand its coverage. In 1954, almost a decade after the end of the Second World War, the 1944 law was revised to cover almost all employees working for private enterprises, including those with only a very small number of employees. In contrast to the public retirement pension system for employed persons, that for self-employed persons was established much later although there was an insignificant optional programme for local governments which was enacted before the end of the war, as will be discussed below. Development of homes for elderly people under the public assistance system In accordance with the efforts by the national government, from the year 1950, the number of homes for the aged (one of the public assistance institutions at the time) started to accelerate (Table 7.1). During the ten years between 1951 and 1961, the number of homes for the aged more than tripled (from 172 to 619), and the number of institutionalized older persons more than quadrupled. However, the proportion of older persons institutionalized remained small, at only about 0.7 per cent of the population aged 65 and over. At the time, Japan had actually no care services for older persons living in the community. In most countries in Western Europe and

Development of long-term care for elderly people in Japan Table 7.1

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Japan: development of homes for the aged (when they were public assistance institutions) 1949–1963

North America, the proportion of institutionalized older persons was already estimated to be approximately 5 per cent. Social change and its impact on the lives of elderly people after the mid-1950s Japan underwent rapid economic development and urbanization from the mid-1950s. The impact of this change was so profound that it is sometimes referred to as ‘the second industrial revolution’. This exerted a very strong influence on social security and health and social welfare services in general. Therefore, the chapter briefly discusses the major features as a backdrop to the development of ageing policy and homes for the aged in Japan. First, the changing employment structure and location are important. In 1950, the proportion of the population engaged in primary industries was approximately 48 per cent, which fell to approximately 10 per cent in 1985 (Department of Statistics 1950, 1985). Rapid industrialization and urbanization greatly affected the lives of Japanese older persons through a number of changes in the social and economic structure of Japan. These included the impact of demographic change discussed in Chapter 6—the growth of the old-old aged 80-plus and the increased demand this places on various forms of care services. This can reduce the ability for families to provide care as, in many cases, children themselves are already old.

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Other factors include the migration of younger persons from rural to urban areas, associated with increase in geographical mobility and the dispersion of industrial areas. This last effect has meant that more young people have had to move away from their home areas to obtain employment, leaving older parents living alone at home. Another conspicuous change is the growing number of working women and many married, middle-aged women, once the most dependable caretakers of dependent older parents, are now working outside their homes. Full-time working women seldom quit their jobs to take care of ageing parents, although those with part-time and/or unskilled jobs frequently do. A further feature is the rapid decrease in the number of children in Japan since 1950, so people with fewer children are now gradually entering the aged population. These demographic and social changes are associated with a general ‘awakening of the Sense of Selfhood’, perhaps the cultural influence of Western industrialized countries, and the associated changes in living arrangements of older people mentioned in Chapter 6, in which an increasing number of both older and younger generations prefer to live separately from each other, for personal independence and freedom. Developments after the 1960s Development of social policy for older persons in general Universal coverage of public retirement pension insurance and public health insurance PUBLIC PENSION INSURANCE

The rapid and profound social changes discussed above drew attention to the need for both a universal public retirement pension insurance system and a public health insurance system. As noted earlier, when Japan’s rapid economic development started in the middle of the 1950s, the public retirement pension insurance system only covered employed persons of limited firms although its coverage was greatly expanded to cover workers employed by firms that had five or more employees. However, self-employed persons were not covered by the revision of 1954 and the need for this was pointed out early on by many progressive leaders of society. Therefore, the national government started preparations for a new public retirement pension programme for self-employed persons soon after 1954. Universal public retirement pension insurance coverage was achieved by the National Retirement Pension Insurance Law for Self-employed Persons (Kokumin Nenkin-hoh), enacted in 1959 and put into practice in 1961. PUBLIC HEALTH INSURANCE PROGRAMME

Prior to the 1960s, the public health insurance system only covered employees. Although Japan had public health insurance programmes for self-employed

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persons since 1938, they were not compulsory. Therefore, each local government was left to decide whether it took up this programme or not and, subsequently, quite a large number of local governments did not put it into practice. Universal coverage of public health insurance was achieved by the National Health Insurance Law for Self-employed Persons (Kokumin Kenkoh Hoken-hoh), enacted in 1958 and fully put into practice in 1961. Development of public services for older persons after 1960 Around the year 1960, Japan managed to succeed in meeting the basic needs of her citizens and the basic legislative and administrative framework needed for protecting and promoting basic human rights was completed: the Livelihood Protection Law (1950), Child Welfare Law (1947), the Law for the Welfare of Handicapped Persons (1949), universal coverage of public health insurance (1961), and universal coverage of public retirement pension insurance (1961). Consequently, Japan began to pay more attention to the social and qualitative aspects of citizens’ lives and started to develop various public services including the needs of elderly people for health, social, cultural, and recreational services. However, the efforts of the national government in the development of public services for older persons in the 1960s and 1970s were designed to catch up with those of the other industrialized countries of Western Europe and North America. With the exception of a number of unique actions, Japan followed the paths of other industrialized countries for the promotion of well-being of older people. Some programmes were mentioned in Chapter 6 and will not be repeated in detail. ENACTMENT OF WELFARE FOR THE ELDERLY LAW (ROHJIN FUKUSHI HOH)

In 1963, the national government enacted the Welfare for the Elderly Law (WE Law), which had two characteristics. First, it is a basic law that stipulates several principles to which all the other laws as well as governmental and voluntary actions related to the life of elderly people should conform. Second, it is a law which regulates welfare services for older persons, including institutional services, community care services, recreational services and the like. Its enactment was an epoch-making event in the history of the development of LTC in Japan and it will be discussed in more detail below. SURVEY OF BEDRIDDEN OLDER PERSONS BY THE NATIONAL COUNCIL OF SOCIAL WELFARE

In 1968, the National Council of Social Welfare, conducted a nationwide survey of bedridden older persons with the cooperation of Minsei-iin,

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special volunteers selected by local governments and appointed by the Minister of Health and Welfare, who are expected to cooperate with public welfare services. The interim report of the survey published early the following year revealed that there were at least 190,000 bedridden older persons living in the community throughout Japan and that approximately 8,000 were cared for not by family members but by friends or neighbours. The findings of this survey impacted on governments at all levels and compelled them to pay more attention to the problems of seriously impaired persons living in the community without adequate care. Evidence of the strong influence of this nationwide survey was that the Ministry of Health and Welfare increased significantly the amount of the national subsidy for home-help services in its budget for the next fiscal year, 1969. TAX DEDUCTION PROGRAMMES

As discussed in Chapter 6, this programme for persons supporting aging parents aged 70 and over was started in 1972, and a similar deduction programme for local income tax was started in the following year, 1973. The purpose was to stimulate and promote traditional family support and the care of ageing parents, especially those who were frail and impaired, in their own homes. FREE MEDICAL CARE FOR ELDERLY PEOPLE

From January 1973, the national government introduced a free medical care service for people aged 70 and over, with an age limit of 65 and over for permanently bedridden people. This service was needed because, at the time, the proportion of co-payment in the public health insurance for the selfemployed was 30 per cent for the insured and 50 per cent for their dependents. The increasingly high costs of medical care rendered the burden of co-payment very heavy for many older patients. The need for free medical care for the elderly was increasingly recognized among persons working in the field. To meet this need, a number of prefectural and local governments started pioneering this service around the end of the 1960s and the national government decided in 1972 to start the programme from January 1973. This service contributed greatly to the promotion of well-being of older persons. Due to a lack of adequate LTC services, however, this programme caused the so-called ‘social hospitalization’ of older people. This describes the phenomenon that a number of older persons remain hospitalized for a long period without a legitimate medical reason for being in hospital. With free medical care, older patients were able to stay in hospitals free of charge for a long time, although a regulation requiring older patients to bear a small copayment was introduced later to prevent the misuse of precious hospital

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resources. The name of this programme later changed to ‘National Programme for the Alleviation of Older Person’s Medical Care Co-Payment . Development of long-term care services for elderly people after the 1960s Start of the national subsidy programme for Homes for the Aged with Moderate Fees (Keihi Rohjin Hohmu) As noted earlier, the number of homes for the aged increased significantly after 1951. However, these homes at the time were public assistance institutions and only admitted older persons who were receiving public assistance and could not receive the care they needed from family members. Needless to say, some frail or impaired older persons were not so poor as to need public assistance, but were in need of care because they had no spouse or children to depend on, although the numbers of such older persons were not then so large. This was mainly due to significantly stronger mutual aid among relatives—indeed, at that time, it was not unusual for a nephew or a niece to take care of an ageing uncle or aunt in his/her home—as well as the then shorter average life-expectancy of older persons. To cope with this demand, a number of prefectural governments as well as voluntary organizations started Keihi Rohjin Hohmu (Homes for the Aged with Moderate Fees). However, due to lack of national government assistance for their establishment and running, the number of such homes did not increase very much, although the needs were becoming greater and more explicit due to the rapid social change outlined earlier. Therefore, to meet this need, in 1961, two years before the enactment of the WE Law, the national government started the national subsidy programme for the establishment and running of Homes for the Aged with Moderate Fees. Two years after the enactment of the WE Law, in 1965, the number of such homes was only thirty-six. Thereafter, however, it began to increase significantly and, in 1975, it reached ninety-nine, an almost threefold increase within ten years (Table 7.2). Development of Home-help Services The national subsidy programme for Home-help Services started in 1962 but pioneering efforts had started long before this. The first local programme was implemented in 1955 by the municipal government of Ueda City in Nagano prefecture followed by the Nagano prefectural government in 1956. A number of prefectural and local governments followed Nagano prefecture and, in 1961, six years after the start of the pioneering programme in Ueda City, the number of prefectural and local home-help programmes reached eighteen, sufficient to draw the attention of the national government to the need for this service. In April 1962, a year prior to the enactment of the Welfare for the Elderly

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Law, the national subsidy programme for Home-help Services was started. The purpose of the national programme was very similar to the original programmes started by the Nagano prefectural government (to provide domiciliary service to frail or impaired older persons living alone or as an aged couple in the community receiving public assistance). However, thereafter, the pace of development of home-help services was very slow until recently (before the start of the Gold Plan). This was mainly because of the limited scope—only public assistance recipients were provided with this service, although its coverage was later broadened to low-income older persons without adequate family care in their homes—and the very low wage of home helpers under the national government’s subsidy. Development of nursing homes for elderly people The 1963 Welfare for the Elderly (WE) Law did not create any new service except for nursing homes. However, several years before the enactment of the WE Law, a special national subsidy programme paid special additional allowances for the care of severely impaired older persons in Ordinary Homes for the Aged (which before the enactment of the WE Law were public assistance institutions). As a result, there were already many homes for the aged that had a special ward for the care of severely impaired older persons. Indeed, a number of voluntary organizations had plans to establish homes for the aged that had only special wards for severely impaired older persons. This law brought a very important change to the administration of institutions for elderly people, including newly established nursing homes, by separating them from the public assistance system. Until then, except for a small number of Homes for the Aged with Moderate Fees (Keihi Rohjin Table 7.2 Japan: development of long-term care institutions, 1960–1996

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Hohmu), homes for the aged had been administered under the public assistance law. Therefore, only poor older persons were admitted. The WE Law of 1963 stipulated that homes for the aged (Yohgo Rohjin Hohmu) and nursing homes (Tokubetsu Yohgo Rohjin Hohmu) were Institutions for the Welfare of the Elderly (Rohjin Fukushi Shisetsu). As a result, not only public assistance recipients but middle-income older persons became eligible to enter homes for the aged although there was still an upper limit on income. In the case of nursing homes, no economic conditions for eligibility were stipulated. The only requirement for admission to nursing homes was that the physical or mental impairment of an applicant was more serious than the level set by the Ministry of Health and Welfare and that he or she was considered to lack adequate care at homes. The number of nursing homes increased very rapidly, while the increase of the number of Ordinary Homes for the Aged slowed down (Table 7.2). Before the end of the 1970s, the number of nursing homes exceeded that of Ordinary Homes for the Aged and reached one thousand. The reasons for the slow down in the growth of the latter were the improvements in the supply of housing as well as the implementation of home-help services. The influence of the novel Kohkotsu-no Hito (literally ‘A man in ecstasy’), by Ms Sawako Ariyoshi In 1972, Kohkotsu-no Hito was published, written by a famous female novelist who was also noted as an influential critic on environmental and other social issues. The title A man in ecstasy’ was a euphemism for ‘a seriously demented man’. The novel described frankly and vividly the life of a seriously demented older man and the physical and psychological burdens on his daughter-in-law who cared for him almost single-handedly in her home. The novel became a bestseller and its impact was so strong that the phrase kohkotsu-no hito became widely used as a phrase for ‘a demented person’, recognized today by all adult Japanese. The novel exerted strong influence on the understanding of the problems of senile dementia, and the progress of both institutional and community care services for these patients and their caregivers was significantly accelerated by this novel. Initiation of Type B Homes for the Aged with Moderate Fees In 1972, the Ministry of Health and Welfare started a new type of Homes for the Aged with Moderate Fees which up until then had served three meals a day. The new type of homes do not serve meals except when a resident cannot cook because of illness. These homes are very similar to sheltered housing for elderly people in Western Europe and North America and are therefore, strictly speaking, not long-term care institutions. Because of the lack of domiciliary and care services in these homes, demand for them was not as large as for other LTC institutions, hence their smaller number even today (Table 7.2).

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Start of the national subsidy programme for short-term stay service (‘respite care’) In 1978, the Ministry of Health and Welfare started the national subsidy programme for short-term stay service for frail or impaired older persons. In principle, the length of stay provided was seven days. Initially, this service was provided only in the case of a family caregivers’ illness and other causes that prevented family caregivers from providing necessary care. In 1985, the programme was subsequently expanded to allow family caregivers to take a rest, although the fees in such cases were much higher than for emergency occasions. In 1989, the programme again revised its fees and reduced them for respite care to the same level as for emergency breaks, since when this service has grown rapidly. The Japanese name ‘short-term stay’ and not ‘respite care service’ stems from its initial purpose but today it can be translated as the more familiar ‘respite care service’. The national subsidy programme for day-care service In 1979, a year after the start of the national subsidy programme for shortterm stay service, the national government initiated the national subsidy programme for day-care services for elderly people. Prior to this national subsidy programme, a number of prefectural and local governments, including the Tokyo metropolitan government, had already put it into practice. Following this programme, three basic LTC services for frail and impaired older persons living in the community were at last achieved in Japan. The only important service left to be taken up by the national government was a visiting nurse service, the initiation of which had to wait until 1991, more than ten years later. Developments after 1980 Policy statement on the ‘Society of Longevity’ The proportion of elderly people in Japan exceeded 9 per cent in 1980. Since then although the level of ageing was still low compared to many industrialized countries, its impact became increasingly clear, not only to those directly engaged in work for elderly people, but also to leaders in various areas of Japanese society. In addition, many people also became aware that Japan was to become one of the most aged countries in the world within forty years. In 1985, the national government established a special sub-cabinet to deal with policies to be adopted for the coming ‘Society of Longevity’. In the following year, a policy statement on the national longterm programme to cope with the ‘Society of Longevity’ was adopted by the cabinet, who also decided that the progress of this programme should be regularly evaluated.

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Enactment of the Fundamental Law on Policies for Ageing Society In November 1995, approximately ten years after the promulgation of the policy statement outlined above, the Fundamental Law on Policies for Ageing Society was enacted by the national diet. The purpose of this law is to establish a more solid and powerful basis for national policies and programmes for ageing society than the 1986 policy statement. This had been an administrative guideline set by the national government, although it actually had made a much stronger impact than expected. In accordance with the 1995 law, the national cabinet in July 1996 adopted the policy statement on ageing society that was to replace the former one on the Society of Longevity. Development of social policy for elderly people in general since 1980 Enactment of Health Care for the Elderly Law (Rohjin Hoken-hoh) In 1982, the Health Care for the Elderly Law (Rohjin Hoken-hoh) was enacted by the National Diet, and put into practice early in 1983. This law had a twofold purpose. First, it aimed to strengthen and enlarge health and medical services for elderly people as stipulated in a chapter on health and medical services added to the WE Law in 1972. Second, it aimed to relieve the National Health Insurance System for Self-employed Persons (Kokumin Kenkoh Hoken Seido) from serious financial deficits which had resulted from a lack of coordination regarding payment of medical services for elderly people in the overall public health insurance system. Renovation of the public retirement pension insurance system Japan’s public pension insurance system was completely renovated in 1985, and put into practice in April 1986. The main purpose of the renovation was to restructure public retirement pension insurance programmes so that they can function well even at the peak of Japan’s ageing, which will be around the year 2020. All public retirement pension insurance programmes were integrated into a single comprehensive system, the National Pension Insurance System (Kokumin Nenkin Seido), although the fundamental structures of preceding programmes were maintained as before the renovation. One of the most important revisions was that the level of retirement benefits was considerably lowered, although serious consideration was given to the interests of those who had already retired. National sheltered housing programme In 1987, Japan’s national government decided to start the national sheltered housing programme for the elderly, entitled the ‘Silver Housing Project’. Prior to this programme, the national government’s policy on housing for

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elderly people placed major emphasis on the provision of public housing, with limited consideration of structure and facilities for the weakened physical and mental capability of the older residents. In addition, the needs for temporary care services in the event of short-term illness or emergency had also been ignored. A national registration system of trained careworkers A national registration system of trained careworkers was put into practice in 1988 and the first national examination was held in early 1989. The aim was to improve the quality of careworkers and thereby secure better services for frail and impaired persons living in the community and also in various types of institutions. The development of LTC National subsidy programme for the establishment of geriatric health care facilities In 1988, the national government started a national subsidy programme for the establishment of geriatric health care facilities (rohjin hoken shisetsu). These institutions are to provide long-term institutional care for elderly people suffering from chronic diseases who need intensive care but who do not need hospitalization. Prior to this programme, because of the lack of public homecare and institutional services and because of lenient public health insurance regulations regarding long-term hospitalization, many such persons had been hospitalized for lengthy periods. This represented a waste of financial and manpower resources. Another purpose of these institutions is to improve the services to such patients by caring for them in more appropriate facilities than nursing homes (tokubetsu yohgo rohjin hohmu—literally, ‘special nursing homes’). In Japan, nursing homes are not health care institutions, but social welfare institutions, so the health and medical care provided in them is limited. The new geriatric health care facilities should fill the gap between hospitals and nursing homes although the most important aim of this programme is to accelerate the development of LTC institutions as a whole by utilizing the public health insurance fund. Previously, nursing homes were established and run with money from general revenues. As it is almost always difficult to expand such revenues, the development of nursing home services in Japan has not been able to keep pace with the rapidly expanding needs for the long-term institutional care of elderly people. Researchers specializing in LTC have suggested that, in industrialized societies, the number of beds for long-term institutional care should be at least 4 per cent of the population aged 65 and over, even when home care and domiciliary services are well developed. This means that, at the peak of population ageing (around the year 2020), Japan will have to

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have approximately 1,200,000 such beds. However, when this programme started, there were only about 150,000 nursing-home beds throughout Japan. It seems, therefore, that without the establishment of this new type of LTC institution utilizing public health insurance programmes funds, this goal would be almost impossible. The mechanism to finance the establishment and operation of geriatric health care facilities (rohjin hoken shisetsu) is to be transferred to the new public LTC insurance system from the year 2000. The establishment of this new type of LTC institution, geriatric health care facilities (rohjin hoken shisetsu), brought about a small, but an important change in Japan’s public elderly care service policy. Because the geriatric health care facility is not a social welfare institution but a health care institution, it can be utilized just as hospitals and clinics. Unlike nursing homes (tokubetsu yohgo rohjin hohmu), geriatric health care facilities can be used by any older persons regardless of income or the availability of family care. The fees for these institutions are the same for any users, regardless of their own income or family’s income. By comparison, fees for nursing homes vary according to users’ own income as well as their family’s income, because they are social welfare institutions. In addition, when older persons are able to receive decent care from their family in their own homes, local welfare offices do not place them in nursing homes. However, for geriatric health care facilities, there are no such limitations. Older persons can use them just as hospitals or clinics, even when they can receive good nursing care at home from their family. Although not generally recognized, the establishment of this institution appears to be the starting point of recent change in Japan’s elderly care service policy with regard to the legal responsibility of the family. Other recent trends A ten-year plan for the promotion of health and welfare services for elderly people At the beginning of 1990, the Ten Year Plan for the Promotion of Health and Welfare Services for the Elderly (commonly called the ‘Gold Plan’) was promulgated by the national government. According to this plan, the pace of development of various public services for older people was to be greatly accelerated (Table 7.3). The details of the plan are discussed below under the Revised Gold Plan, since the 1990 plan was significantly revised in 1994. The Gold Plan was promulgated because of the increasingly evident gap between the pace of Japan’s ageing and that of the development of various social policies for older persons. To cope with the predicted gap between the supply and demand, the national government planned to introduce a new ‘consumption tax’. To persuade the public of the necessity for the new tax,

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Table 7.2 Japan: development of long-term care institutions, 1960–1996

the government made a long-term plan to cope with the coming ageing society and published it alongside the necessary huge sums which could only be raised with a new tax system. Restructuring of the administration of health and welfare services for elderly people The year 1990 witnessed yet another significant development: a fundamental restructuring of the public health and welfare services for elderly people, implemented through the revision of the Welfare for the Elderly Law, Health Care for the Elderly Law and several related laws. The restructuring can be summarized under the two following headings: Decentralization The revision of the Welfare for the Elderly Law transferred the authority to decide on admission of an older person into a home for the aged or a nursing home from the prefectural government to the local government. The local government has thus come to assume all responsibilities for public health and welfare services for older persons, from long-term institutional care to preventive, promotive and recreational services. Better coordination among the various care services has been achieved with both improved quality of life and higher efficiency. Long-term planning A key point with regard to the revision of the two basic laws on health and welfare services for elderly people was that all local governments were required to make a long-term plan for the development of health and welfare services for older persons, including institutional care services, community care services, preventive, promotive and recreational services. All local governments had completed these long-term plans before the end of the 1993 fiscal year.

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Revision of the Gold Plan The most conspicuous feature since 1990 with regard to social security and health and social services for older persons is the growing concern of people about the need for kaigo hoshoh (‘care security’) in the coming highly ageing society. ‘Care security’ means a social service system by which all the needs for care of older persons, both institutional care and home care, are met publicly, regardless of income. In March 1994, the ‘Advisory Group on the Welfare Vision in the Coming Highly Aging Society’ presented its report to the Ministry of Health and Welfare. This report proposed, among other things, the construction of a comprehensive public care service system. It also noted that the goals set in the 1990 Gold Plan were not satisfactory in light of the predicted future growth of the care needs of older persons. In September 1994, the National Advisory Council to the Minister on Social Security published the second report on the ‘Future Image of the Social Security System’. Among other things, this report stressed the pressing need for the establishment of a comprehensive public care service system as an integral part of the social security system and proposed establishing a public LTC insurance programme as soon as possible. In response to growing concern about the establishment of a public care service system, the government took two important actions. One was the revision of the goals of the 1990 ten-year Gold Plan, now called the Revised (‘New’) Gold Plan. The other was the creation within the Ministry of Health and Welfare of a special task force for the development of a comprehensive public care service. The Revised Gold Plan was made public in December 1994, with goals to be reached before the end of the fiscal year 1999 (Table 7.3): •

•

• •

•

Increase in the number of home helpers from 31,404 (1989) to 170,000 (earlier goal: 100,000) which will give a ratio of home helpers to population aged 65 and over of 1:127.6. For comparison, in Sweden this ratio is roughly 1:50. Japan’s goal includes part-time workers and its level will be still far below the levels of many other modern societies. Day-care centres to increase from 1,080 (1989) to 17,000 (earlier goal: 10,000.), giving Japan one such centre for every 1,300 older persons aged 65 and over. A typical medium-sized city of 100,000 population will have approximately thirteen centres. Beds for short-term stay service (respite care service) to increase from 4,274 (1989) to 60,000 (earlier goal: 50,000). Development of home nursing services will be accelerated, with a revised goal of 5,000 Home Nursing Stations throughout Japan. This goal was newly added in the Revised Gold Plan; in 1989, the number of such centres was negligible. Beds for long-term institutional care (nursing homes plus geriatric health care facilities) to increase from 189,830 (1989) to 570,000. When this

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goal is attained in 1999, the proportion of institutionalized older persons among those aged 65 and over will be 2.6 per cent. This figure is far less in comparison to many countries in Europe and North America, where estimates put the average institutionalized elderly population at around 5 per cent. However, the average length of stay of older persons in hospital in Japan is much longer than in other advanced countries. Thus, the gap between needs and available resources in 1999 will be narrower than pure numerical comparison indicate. Substantial increases in numbers of qualified workers through the strengthening of various training programmes. Qualified care workers to increase by 200,000, trained nurses by 100,000, and trained PTs and OTs by 15,000. This goal was not included in the original Gold Plan.

In addition to these numerical goals, the Revised Gold Plan aims to promote or develop the following services as quickly as possible • • • • • • • • • • • • • •

Round-the-clock visiting personal care services by home helpers Improvement of nursing-home facilities, to have more private rooms Strengthening of the family doctor system Individual care planning for older persons needing community care service Development of meals-on-wheels service Improvement of personal care service in LTC hospitals for older patients Modernization of nursing homes through the provision of grants for mechanization Expansion of community-based rehabilitation services Improvement and development of services for demented older persons, especially the expansion of group-home service Expansion of educational facilities and in-service-training for care workers and social workers employed in the welfare of older persons Development of technical aid service systems, including the strengthening of research and development systems Use of voluntary and private (for-profit) services to diversify service resources and for flexibility of the service delivery system Expansion of specially-designed public housing for older persons Improvement of physical environments for older persons and handicapped people so that they may live pleasant lives safely in the community.

The present Japanese long-term care services for older persons The following section provides a concise outline of Japan’s contemporary LTC service programmes for elderly people, although there is some unavoidable repetition from previous sections.

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Institutions There are several types of LTC institutions and, due to the serious shortage of beds in them, a special type of hospital or ward provides LTC for elderly people. Nursing homes for elderly people Nursing homes for the elderly (Tokubetsu Yogo Rojin Hohmu—‘Special Nursing Home for the Elderly) fall under the category of welfare institutions. Potential residents apply to the welfare bureau of the local government, which assesses applicants’ physical and mental condition and the capability of the family to provide necessary care. It decides whether or not the application should be accepted. However, because of the serious shortage of nursing homes, especially in the large metropolitan areas such as Tokyo, Yokohama, Nagoya and Osaka, even successful applicants have to wait for a long time before actual admission. In principle, the running costs of these institutions are borne equally by the state and city governments. When the placement for admission is by the township or village, running costs are borne jointly by the state (1/2), prefectural government (1/4) and local government (1/4). The construction costs for nursing homes for the elderly are shared by the state (1/2), prefectural government (1/4) and the establisher (1/4). The client as well as the relative who is legally responsible for their support and care are charged in accordance with WE Law. The administrative definition of the responsible relative is, however, very lenient and the charge is actually imposed only on the spouse or child who is living in the same household when the decision of placement is taken by the local government. The amount of the charge is decided according to income; savings are not taken into consideration, although interest from savings is counted. The calculation of the charge is very complicated. The average charge in 1996 was approximately 45,000 yen (US$400) per month, but it may safely be said that the charges imposed on the responsible relative are significantly less than the amount they have to pay when supporting the client at home. In October 1996, there were 3,458 nursing homes and approximately 236,000 nursing-home beds throughout Japan. As noted earlier, under the new ten-year Gold Plan, the number of nursing-home beds is planned to increase to 290,000 before the end of the fiscal year 1999. Geriatric health care facilities Geriatric health care facilities are LTC institutions designed as halfway houses between hospitals and the community. The running costs of the these facilities are borne jointly by the Public Sickness Insurance Scheme (1/2), the state (1/3), the prefectural government (1/12) and the local government (1/

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12). In order to promote the construction of health care facilities, the national government has programmes for special grants, low-interest loans and special tax deductions. The client of a health care facility is required to pay residential costs which differ among the facilities. The average amount is approximately 60,000 yen (US$550) a month, which, with the exception of those receiving public assistance, is equal for all clients regardless of income or savings. As a geriatric health care facility is categorized under medical care institutions, no charge is imposed on relatives, even if they are well off. Therefore, for those who have income above a certain level or who have a wealthy relative, a geriatric health care facility is more economical than a nursing home. In March 1998, there were, throughout Japan, 1,991 geriatric health care facilities caring for approximately 174,000 older persons. Under the new tenyear Gold Plan, the number of beds in health care facilities is to be increased to 280,000 before the end of the fiscal year 1999. As discussed earlier, because of the shortage of LTC beds, quite a number of seriously impaired older persons are hospitalized for long periods without real need, although the exact number of such older persons is unknown. The only information available is the number of hospitals with such wards and beds in so-called geriatric hospitals (Rojin Byoin) and there were, in May 1997, 1,574 geriatric hospitals with approximately 173,000 beds. Homes for the aged Homes for the aged are for frail or slightly impaired older persons who are functionally independent in ADL (activities of daily living) but in need of a meal service and limited domiciliary service. There are two types of homes for the aged. The first, Yogo Rojin Hohmu (literally, ‘Nursing Home for the Elderly’), has its origin in public assistance institutions for the aged. This type of home for the aged will be referred to as an ‘Ordinary Home for the Aged’. The other type, is the Keihi Rohjin Hohmu (literally, ‘Home for the Aged with Moderate Fees’). In one type of Keihi Rojin Hohmu (Type B), meal services are not provided. Type B, Keihi Rohjin Hohmu, and the most recently added type, Care House in Japanese, are actually sheltered housing, but not strictly LTC institutions. To enter an Ordinary Home for the Elderly, applications are made to the Welfare Bureau of the local government whilst, for a place in a Home for the Aged with Moderate Fees, applications are made directly to the home. The most important difference between the two is that an Ordinary Home for the Aged can be used by older persons who have no income or only a small income. Residents who have income have to pay a fee decided in accordance with the income of their family with whom they lived when the decision on placement was made by the local welfare office. Today, the buildings and facilities of Ordinary Homes for the Aged have been improved greatly. There is still, however, a significant gap in facilities of

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these two types of homes for the aged, though there is not an essential difference in their services. In October, 1996, there were 947 Ordinary Homes for the Aged including forty-seven homes for the aged blind. The total number of older persons institutionalized in Ordinary Homes for the Aged was approximately 64,400 including 2,754 persons in homes for the aged blind. There are generally some vacant beds in this type of home for the aged due to the development of home-help services and the improvement in the supply of public housing for elderly people. In October 1996, the number of Homes for the Aged with Moderate Fees was 740 (comprising Type A: 252, Type B: 38, Care House: 450). The total number of older persons living in these homes was approximately 30,300 (Type A: 14,200; Type B: 1,500; Care House: 14,600). In contrast to the Ordinary Homes for the Aged, most Homes of the Aged with Moderate Fees have a long waiting list, probably because of the difference in admission procedures, a discrepancy in facilities, and the traditional stigma placed on Ordinary Homes for the Aged which have their origin in public assistance institutions for the aged. In addition to these publicly-supported homes for the aged, there are a number of Yuryo Rohjin Hohmu (literally, ‘Home for the Aged with Fees’). Most of these homes provide so-called ‘lifelong care’. Therefore, even if residents become severely impaired, the home provides requisite nursing care as long as the residents wish. They are established and run without any public grant or subsidy, the only public support being a low-interest loan programme. Therefore their charges are very expensive and only those who in the upperincome group can afford a place. In October 1996 there were 275 such homes throughout Japan accommodating approximately 20,700 older persons. Day and home-delivery services Home-help service In the fiscal year 1998 there were approximately 167,900 home helpers throughout Japan. As noted earlier, the national government places particular emphasis on the rapid development of this service and, before the end of the fiscal year 1999, the number of home helpers will be increased to 170,000. Those who have little or no income can use this service without any charge. Generally speaking, however, in large metropolitan areas, the shortage of home helpers is very acute, while in some rural areas supply tends to exceed demand because of the conservative attitude of people toward using welfare services as well as a greater supply of home helpers. Visiting nurse service This service is now developing very rapidly and in April 1997 there were 2,637 visiting nurse stations throughout Japan. Under the Revised Gold

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Plan, the number of stations will increase to 5,000 before the end of the fiscal year 1999. The charge for this service is only 250 yen (approximately US$2.20) per visit. Day service for frail and impaired older persons This service is also developing very rapidly and in October 1996 there were approximately 4,800 day service centers throughout Japan. The number of the centres will be increased to 17,000 before the end of fiscal year 1999. Day service centres are obliged to provide transport for their users and some centres also provide home-delivery services such as visiting bathing, mealson-wheels and laundry services. There is a small charge to users of these centres, roughly equivalent to the cost of the materials they consume. Short-term stay service (respite care) Short-term stay services are mainly provided in nursing homes for elderly people. There is also a limited number of institutions providing only shortterm stay services. At the end of April 1996, there were are approximately 38,600 beds for short-term stay service throughout Japan and the Revised Gold Plan will see this increase to approximately 60,000 beds by the end of the 1999 fiscal year. Home care support centres Home care support centres are intended to give advice to family caregivers and information on home care, and to refer cases to appropriate social agencies. Some centres have a showroom for home care supplies and equipment. National standards require that each centre should have at least one social worker and one trained nurse. All centres receive telephone calls 24-hours a day. At the end of the 1996 fiscal year, there were 3,347 such centres throughout Japan and this is planned to increase to 10,000 before the end of the fiscal year 1999. Provision of technical aids for home care This programme, subsidized by the national government, is operated by all local governments. The programme covers most of the important technical aids for home care (for example, specially-equipped beds, mattress, airpads for the prevention of bed-sores, toilet chairs, automated urinals, fire alarms, automated fire-extinguishers, emergency alarm systems, special transmitters and receivers for wandering demented older persons, wheelchairs, special telephone equipment). At present, sixteen kinds of equipment are provided by this programme, free of charge for low-income persons. Those with income over a certain level pay a charge decided according to their income.

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Meal service In Japan, a daily meal service is provided by only a very small number of local governments or voluntary organizations and almost all of these programmes are still at an experimental stage. The reason this service has not developed in Japan is that almost always such frail and/or impaired older persons who need a daily meal service live with their children or have been institutionalized. This is due to the underdevelopment of home help and other essential community care services, so that frail and/or impaired older persons who need a daily meal service cannot live independently in the community. The future Japan has a wide variety of programmes and services for the welfare of older persons, but most important services have yet to be fully developed. In the field of long-term care services—both community care services and institutional care services—the shortage of services is very serious. The national government proposed the ten-year Gold Plan in 1990, revised in 1994, in an attempt to address these shortcomings. However, population ageing will continue at an accelerated pace this new century, and many needs of older persons, especially for long-term care, will grow very rapidly. To meet the expanding needs for long-term care and to secure decent levels of services for every senior citizen, Japan will have to start another tenyear Gold Plan before the year 2000. The budget needed for it will be much greater than that for the present Gold Plan. Securing the necessary revenue for the second plan is one of the most important challenges for the national government. The answer from the national government is the establishment of a public LTC insurance programme. In June 1996, the Ministry of Health and Welfare finished the first draft and presented it to the National Advisory Council on the Health and Welfare Services for the Elderly. After prolonged negotiations with related government advisory councils, political parties and representatives of local governments, the Ministry of Health and Welfare finalized its draft in November 1996, and presented it to the National Diet, who finally approved it in December 1997. According to the approved Act, the Long-term Care Insurance System will be started in the year 2000 (Ministry of Health 1998). It will cover both community care and institutional care services for older and middle-aged persons aged 40 and over (see Chapter 5). In the case of middle-aged persons between 40 and 64, however, the insurance will only cover care services for people suffering from such age-related illnesses as stroke or senile dementia. Contributions to the programme will be collected from persons aged 40 and over. This means that retired older persons will also be obliged to contribute.

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The Act calls for the contributions of retired older persons to be deducted from public pension payments. The contributions of middle-aged persons are to be collected alongside contributions to public sickness insurance programmes. The new LTC insurance is to be financed from insurance contributions (1/2) and general revenue (1/2). To cope with the predicted increases in general revenue caused by this system and related expenditures in the coming highly ageing society, the national government raised the rate of consumption tax from 3 to 5 per cent from April 1997. While the draft Act was undergoing consultations with the related government advisory councils and public bodies, and later during the deliberations at the National Diet, a number of opinions, both pro and con, were expressed in the media. It seems, however, that the great majority of Japanese citizens favour the introduction of the public long-term care insurance. The new programme is expected to greatly enhance Japan’s health and welfare services for older persons. Possible impacts of the new public LTC insurance The public LTC insurance is anticipated to have a revolutionary impact on Japan’s traditional value system which so far has placed primary responsibility for care of ageing parents onto children, however difficult it may be. Even today, ordinary Japanese middle-aged people usually think that children should take care of their ageing parents in every way. Therefore, a sizeable number of middle-aged professional women, such as veteran school teachers, quit their jobs to take care of their own or their husband’s ageing parents. In the future, however, ordinary Japanese people will change their attitude and delegate the primary responsibility to the public LTC insurance programme. In the insurance system, the insured can demand that the insurer provides the contracted benefits as a right, whether or not the insured have children. Obligations of children for the care of ageing parents will become much lighter than at present. The expected role of children, especially that of daughters-in-law, will be to provide auxiliary care voluntarily, when the services provided by the insurance do not seem sufficient for maintaining a decent standard of living for ageing parents. It appears that the public LTC insurance provides a finishing touch to the democratization and modernization of Japan that started half a century ago. References Department of Statistics (Tohkeikyoku), General Management and Coordinating Agency (Sohmuchoh) (1950) National Census, Tokyo: Japanese Government. ——(1985) National Census, Tokyo: Japanese Government. Ministry of Health and Welfare (1998) Outline of Long-term Care Insurance in Japan, Office for

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Long-term Care Insurance, Health and Welfare Bureau for the Elderly, Tokyo: Ministry of Health and Welfare of Japan. NAHA—National Asssociation of Homes of the Aged (Zenkoku Yohrohjigyoh Kyohkai) (1933) The First National Survey on Institutional Care Services for the Aged (Dai-ikkai Zenkoku Yohrohjigyoh Chohsa), in Y.Ogasawara (ed.) Basic Historical Literatures for the Study of the Problems of the Aged (Rohjin Mondai Kenkyu Kihon Bunkenshuh), vol. IV, Ohzorasha Publishing Company, Tokyo, Japan, 1990. ——(1940) The Third National Survey on Institutional Care Services for the Aged (Daisankai Zenkoku Yohrohjigyoh Chohsa), in Y.Ogasawara (ed.) Basic Historical Literatures for the Study of the Problems of the Aged (Rohjin Mondai Kenkyu Kihon Bunkenshuh), vol. IV, Ohzorasha Publishing Company, Tokyo, Japan, 1990. Ueda, C. (1976) Welfare of the elderly and institutional care (Rohjin Fukushi to Shisetsu Hogo), in: K.Yoshida (ed.), Development of Social Welfare Services after the end of the Second World War (Sengo Shakaifukushi no Tenkai), Tokyo: Domesu Publishing Co.

8

Ageing in Hong Kong Nelson W.S.Chow

Population ageing in Hong Kong Hong Kong, a British Colony for more than 150 years, was returned to the People’s Republic of China to become a Special Administrative Region (SAR) on 1 July 1997. As over 98 per cent of the population in Hong Kong are ethnic Chinese, the place has been dominated by the Chinese or Confucian culture, though Western practices have also been prevalent, especially among the young and the educated. Hong Kong is no doubt a typical example of where the East meets the West. This encounter of different cultures is most apparent among the older people as most have come from an agrarian social and economic background and are now the first generation to grow old in a highly industrialized city (Chow 1983). It is therefore not surprising to find that the majority of the older people in Hong Kong are unprepared for the kind of retirement life they are experiencing now. According to Chinese tradition, a person is considered old when he or she reaches the age of 60. The planning of both welfare and housing services for older people in Hong Kong uses the age of 60 as the cut-off point, but 65 has been employed for the planning of medical and health services. In March 1996, when the last By-census was conducted in Hong Kong, 14.1 per cent of the total population, or 890,000 out of 6,311,000 were found to be aged 60 and over, and 10.1 per cent of the total, or about 630,000 persons, were aged 65 or over (Census and Statistics Department 1996) (Table 8.1). It is projected that by the year 2016, 13.3 per cent of the population would be aged 65 and over, with the actual number exceeding one million. A note of caution has, however, to be made about projections of population ageing in Hong Kong as, since January 1995, it has been accepting 150 persons per day from the Mainland, or 55,000 persons a year, to settle as permanent residents in the territory. About half of these new arrivals are children born to Hong Kong permanent residents and, as the majority are young in age, they will delay the process of population ageing. In fact, migration, both in and out of Hong Kong, has always made population projection a difficult task in Hong Kong, as the number is not entirely under the control of the government, whether before or after 1997 (Barlett and Phillips 1995). Indeed, under one scenario that emerged in early 1999, Hong Kong’s Basic

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Table 8.1 Hong Kong: selected demographic characteristics of older population

Sources: Hong Kong By-census Report 1996; Hong Kong Population Projection 1997–2016. Note: *estimated.

Law (which is in effect the SAR’s constitution) appeared to give the right of abode of up to 1.6 million people from the Mainland who have a Hong Kong resident as parent. However, whether such substantial inflows will occur is the subject of much debate. Although the ageing process in Hong Kong may be somewhat delayed by a greater number of young immigrants coming in, life-expectancy presently standing at 77 years for males and 82 for females will keep rising and is already among the longest in the world. Furthermore, the proportion of ‘oldold’ in the older population will continue to increase. In 1996, those aged 75 and over accounted for 36.3 per cent of the older population, with 63.7 per cent aged between 65 and 75. In other words, though the population in Hong Kong may not age as fast as projected, older people in the upper brackets who tend to require more care will in no way decrease in number. Another fact demanding consideration is that the sex ratio is more imbalanced towards the female in the upper age brackets; as older women are usually financially more vulnerable than older men, their need for economic support is also concomitantly greater. Household composition and economic status In terms of household composition, 22.0 per cent of older people in Hong Kong in March 1996 either lived alone or as an older couple. Nearly half of the older people, 44.1 per cent, lived with their children, married or not married. Another 16.7 per cent lived in households with three generations and only 9.8 per cent were in households with two or more nuclear families. Nearly all studies on the living arrangements of older people in Hong Kong found that the trend was for more and more children to move away from their parents and start their own families when they can afford it (Chi and

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Chow 1997). On the other hand, although most older people would still prefer to live with one of their children, especially the eldest son, even after the son has married, they would not find it too objectionable if they have to live by themselves. In fact, studies in Hong Kong (and elsewhere in the region, as illustrated in other chapters) have found that an increasing number of older people would choose to live away from their children in order to avoid conflicts, even when the children have no objection to their living with them. The above changing trend has, however, to be put in the context that housing units are generally very small in Hong Kong due to the lack of space, and it is almost impossible for more than two generations to live in the same household. On the other hand, as property prices are extremely high in Hong Kong, the fact that some children continue to stay with their parents, even after their marriage, does not necessarily imply that this is their choice. Rather, it may reflect their financial inability to start a new home of their own. Economically, older people in Hong Kong are probably among the poorest in the population. The plight of some older people is caused by the fact that, except for those working in government service or fortunate enough to be covered by private retirement protection schemes, the majority of workers retiring now have either to depend on their own savings or the support of other family members (Chow 1998). In fact, legislation regarding the introduction of a retirement protection scheme for all employees, a Mandatory Provident Fund system, was not enacted in Hong Kong until the year of its return to China and is scheduled to be implemented only in the year 2000 (Secretary for Education and Manpower 1995). Since an employee joining a provident fund scheme would not normally have enough to cover the needs of old age until after having contributed for at least 20 to 30 years, the burden of financially supporting older people will continue to fall on the family system or governmental assistance for many years to come. One should note that the relatively inferior economic position of the older people has also produced an adverse effect in eroding the traditionally prestigious social status held by them. Although older persons in Hong Kong are still often ‘likened unto a treasure at home’, recent studies indicate that their social image has dropped so low that it is indirectly contributing not only to an increasing number of older people committing suicide, but also to the emerging problem of elderly abuse (Chi et al. 1997). The social and economic status of older persons in Hong Kong is obviously changing rapidly. For a society and culture that have for centuries held dear the value of filial piety, the eroding status of the older people has naturally been viewed with misgiving. While much can be said about the importance of preserving filial piety, circumstances in Hong Kong have changed so much that a new strategy to approach the ageing problem would probably bring about a better support system for them.

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Impacts of population ageing Population ageing was not recognized as an area to which the government should pay attention until the 1970s. Before that, the stand of the government was that the responsibility for elderly care must fall on the natural family unit. The first sign that made the government aware of the ageing problem was the increasing presence of older people. Although the number itself does not necessarily cause concern, when more and more older people were turning to the government for help and support, it became obvious that the problems associated with population ageing could no longer be ignored. As noted, a retirement protection system was absent in Hong Kong until the MPF was planned recently, and older people who are deprived of the means of a basic living, for whatever reason, can apply for financial assistance from the government (MacPherson 1993). From the very beginning of the introduction of the Public Assistance Scheme in 1971 (renamed the Comprehensive Social Security Scheme, CSSA, in 1993), the majority of those who are thus supported have been older people. At the end of 1997, it was reported that about 111,000 older persons, or 15 per cent of those aged 65 and over, were beneficiaries of the scheme, costing the government an annual expenditure of HK$4 billion (US$1=HK$7.8). The impact of population ageing is also felt as a result of the weakening caring roles of the family. Contrary to popular belief, the size of the average family in Hong Kong has never been large since only rich families can afford big houses spacious enough for several generations to live together. For ordinary people, the traditional practice has been for the elderly parents to live with one of their children, mostly the eldest son. However, as mentioned before, the recent trend is for the adult children, especially when they get married, to move away from their parents to start their own families. Despite the decreasing number of children living with their elderly parents, it has to be kept in mind that the concept of filial piety, although declining in importance as a value, still obliges children to provide their elderly parents with care and support, whether or not they are living together (Chow 1994). Hence, although co-residence might make the performance of the caring roles easier, separate residence does not necessarily imply a total exemption from the care and support roles for the children. In fact, what one should be more concerned about is the drastic drop in the fertility rate since the 1970s; it means there are simply fewer children around to provide the older people with care and support. With a Total Fertility Rate of about 1.1 to 1.2, Hong Kong has almost the lowest fertility in the world. With the weakening family functions to provide care, other sources of support for older people, coming either from the community or the government, have become necessary and, in some cases, essential. It should be noted, however, that the majority of older persons in Hong Kong remain healthy and are capable of self-care; some local studies have found that fewer

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than 10 per cent of them required regular help from others (Chi and Lee 1989). However, there is some evidence that health status is not necessarily as good as the lengthy expectation of life might suggest (Leung 1999). Rather than being a burden on their families, most of older persons in Hong Kong are, in fact, making valuable contributions towards other family members by doing the household chores for them. Recent studies have also found that older people formed the most important pool of volunteers and they usually performed their duties seriously (Chow and Chi 1999). To summarize, population ageing in Hong Kong has resulted in a greater need for the allocation of public resources for the care and support of older people. The failure of the government to introduce any compulsory retirement protection system in the past has led to a higher percentage of the older people nowadays finding themselves in poverty and requiring public financial support. The eroded functions of the family system to provide care, as well as the weakening value of filial piety, are other factors that have given rise to a greater demand for formal support services from the public sector. However, notwithstanding the increasing need for governmental support, it would be a mistake to imagine that the care of older persons is no longer a responsibility of the family system. The family system has, in fact, continued to perform its traditional role; only the form and the extent of care provided for the older people are no longer the same as before. Policies regarding the care of older people In caring for older people, both the family and the community have long been perceived to be of primary importance in Hong Kong. Their importance lies in the fact that within these two institutions older people are most ready to establish their social relationships. Moreover, since social relationships are perceived to have fundamental significance in the Chinese culture, older people often feel more comfortable in receiving help from the family and the community when they are in need. Hence, it is not surprising to find that the policies developed in Hong Kong on the care of older people have put both the family and the community in the forefront as the most important care agents. The principle that has guided the care of older people in Hong Kong since the early 1970s is the ‘care in the community’ approach. This approach was first proposed in a report, published in 1973, of a governmental Working Party. It was stated to mean ‘that services should be aimed at enabling the elderly to remain as long as possible as members of the community at large, either living by themselves or with members of their family, rather than at providing the elderly with care in residential institutions outside the community to which they are accustomed’ (Working Party on the Future Needs of the Elderly 1973, p. 15). This ‘care in the community’ approach proposed in 1973 has since continually been reaffirmed in subsequent policy

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papers issued by the government on the care of elderly people. In the most recent report on care for older persons published in 1994, the care in the community approach was slightly changed to ‘ageing in place’, to mean that ‘appropriate support should be provided for older persons and their families to allow old people to grow old in their home environment with minimal disruption’ (Working Party on Care for the Elderly 1994, p.48). Whether it is ‘care in the community’ or ‘ageing in place’, the question that needs to be asked is: to what extent is the approach successful in enabling older people to live a satisfactory life? Is the approach most fitted to the situation of Hong Kong society where, as mentioned above, the population is ageing fast and the structure of the family is changing rapidly? Conceptually, few objections can be raised against the ‘care in the community’ approach, especially when the family system is still shouldering most of the burden in taking care of the older people requiring attention (Chow 1999). However, evidence increasingly shows that the assumptions made by the Working Party in 1973 are not necessarily correct. First, a policy on the development of social services for older people published in 1977 clearly stated that the ‘care in the community’ approach could only succeed when the community was a caring one. Recent research has found that the roles and functions of older people, both within the family and in the community, have been so much weakened that the traditional value of respecting the old is now called into question (Chow 1997). In other words, one can no longer assume that the family or the community will show older people the same respect or feel the same sense of obligation for their care as before. Second, the ‘care’ that can be provided in and by the community has only been assumed but never clearly defined. Some take it to refer to the services provided in the community in support of older people, while others have in mind the assistance offered by relatives, friends and neighbours. The past development of services for older people has indicated that services are usually in short supply and they can only meet the needs of those in desperate need. The assistance offered by relatives, friends and neighbours is also known to be limited (Ngan 1990). In short, the unclear definition of care means that the older people living in the community have often to do without the support they require, whether from the family, relatives, neighbours, or services provided by public welfare organizations. Third, the ‘community’ is also an ill-defined term. While it refers, in most cases, to the communities where older people live, a geographical location does not necessarily entitle one to the membership of a set of social networks from which the older people could obtain help and assistance. What one can conclude from the above discussion is that while the ‘care in the community’ approach has been laudable, it is far from being an effective policy in safeguarding the interests of older people. The major shortcoming of the approach is that it has assumed too much, especially

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regarding the obligations of the Chinese in taking care of their older members. The changes that Hong Kong society has undergone, especially in terms of the continuous and substantial migration both into and out of Hong Kong, indicate that the community can no longer be assumed to be effective in performing its caring functions. The care that can be provided by the family, relatives and neighbours, even where it still exists, is also dwindling both in scale and scope. Indeed, the ‘community’, taken here to mean a set of social relationships offering help and mutual-support, has also been known to be diminishing. In other words, if the ‘care in the community’ approach is to actually perform what it intends to achieve, that is, to enable older people to live in the community for as long as possible, then a rethinking of the policy objectives is a must and the only way to stop it from being empty words. In his first Policy Address after becoming the Chief Executive of the government of the Hong Kong SAR, delivered in October 1997, Mr Tung Chee-Hwa announced that his ‘Administration will work to improve conditions for the elderly’ (Tung 1997, Paragraph 114). While recognizing that ‘Caring for the elderly is the responsibility of every family’, the Chief Executive proposed that the objectives of caring for the older people should be to give them ‘a sense of security, a sense of belonging and a feeling of health and worthiness’ (Tung 1997, Paragraph 114.). He went on to outline his Administration’s strategies to achieve these objectives, namely: establishing the Mandatory Provident Fund Scheme; increasing the allowance under the Comprehensive Social Security Assistance Scheme for older recipients; setting up Carer’s Support and Resource Centres and improving other community support services to encourage families to take care of their older members; introducing a ‘Senior Citizens Residence Scheme’ to enable older people who wish to live on their own to remain in the community; increasing subsidized residential care places through purchasing quality places in the private sector; establishing more health centres and psychogeriatric teams for older people; introducing an Elderly Volunteer Programme to encourage participation in community activities; and enlarging the functions of integrated teams to provide social networking and outreaching services to the vulnerable single older persons. It may be too early yet to assess the effectiveness of the expanded programmes of the Chief Executive in achieving the purposes of giving the older people ‘a sense of security, a sense of belonging, and a feeling of health and worthiness.’ What one can be sure about is that the new SAR government has not deviated much from the previous practices of the British Colonial Administration, that is, the policy is still to encourage the older people to live in the community as far as possible. The Chief Executive has stated unequivocally that ‘It is only right that we reciprocate the love of our parents and take care of them when they are old’ (Tung 1997, Paragraph 117). What the Chief Executive wants to impress the public about is that

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while the government is increasing its provisions for older people, it should never be seen as taking over the caring functions traditionally performed by the family or the ‘community’. The role that the government would play is still to complement, or at most supplement, the above institutions. Formal structure of care for older persons Before discussing the issues arising from the policies adopted in Hong Kong regarding the care of older people, it is necessary first to provide some details about the formal structure that has been set up to provide the necessary support. Subsequent to adopting the ‘care in community’ approach in 1973 as the direction for the development of services for older people, the government issued in 1977 a consultative paper on how such services should be developed to solicit the views of the public. The proposals were later formally adopted in a White Paper on social welfare published in 1979 (Hong Kong Government 1979). So far as the making of the relevant policies is concerned, it fell within the responsibility of the Secretary for Health and Welfare, although other bodies, such as the Housing Authority and the Hospital Authority, would also have a role to play in meeting the needs of older people. The provision of health and welfare services for older people can roughly be divided into two types: residential care and community support services (Table 8.2). Residential care services range from those that offer only minimal personal care to others fully integrated with the general hospital service. It should be noted, at this juncture, that residential services for older people in Hong Kong are heavily subsidized by the government, with the recipients paying only a nominal fee, and they are also provided at a very high standard. Their relatively high costs imply that they are usually insufficient in quantify to meet the demand, compelling those who could not wait any longer to seek admission into private nursing homes that are often not only inferior in standard but also charging exorbitant fees. The major shortcoming of the subvented residential care services for older people is therefore a matter of insufficient supply. The result is that, as shown in the findings of a study on the needs of older people for residential care and community support services, the limited pool of quality services subsidized by the government are not necessarily serving those with the least means and the greatest need (Deloitte & Touche Consulting Group 1997). The growth of private sector homes for older persons is discussed in Chapter 4. Compared to the residential care services, community support services are generally more sufficient in supply and range widely from general day centre services, such as meals and laundry, to the more sophisticated geriatric outreach support. Studies have shown that although older people living in the community can usually obtain some kind of assistance from the community support services provided by the public welfare and health

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Table 8.2

Residential and long-term care services for older persons in Hong Kong, July 1999

Source: various, including Hong kong Council of Social Service and Social Welfare Department. Note: *Shared housing for single elderly people.

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organizations, families still form the most important source of help (Ngan and Wong 1993). Support to carers is thus important to ensure that they would not cease to play their caring roles but continue their contributions. As mentioned above, the Chief Executive has announced in his first Policy Address in October 1997 the setting up of two carer’s support and resource centres to assist families that have older members to take care of. As the trend is for more and more adult children, married or otherwise, to live away from their elderly parents, two major changes tend to occur in the housing conditions of older persons. First, as children would usually move to the new towns to start their own homes, a much higher proportion of older people would be left to live in the old urban areas (Yeh 1999). Second, the trend would also result in more older people living alone or just by themselves within the household (Working Group on Housing for the Elderly 1994). In fact, the above two phenomena have already been happening for some years. As the general policy of the government is to encourage older people, as far as possible, to remain in the community and to live with their family members, the housing policy for older people has also been devised accordingly. Hence, applicants for public housing units will have their waiting time shortened by three years if they are prepared to live with an older member. Furthermore, successful applicants for public housing can also choose to have two separate units in the same block in the new towns, with one occupied by themselves and the other by their older family members, for ease of care for one another. Besides the efforts to encourage children to live with their elderly parents, the government also recognized the urgent housing needs of some who, for one reason or another, would have to live alone or with only other older persons. The Chief Executive promised to speed up the construction of public housing units for senior citizens. The last formal service for older people that must be mentioned here is the income maintenance programme. It has already been noted that the Comprehensive Social Security Assistance Scheme (CSSA) will continue, during the next two decades or so, as the mainstay of financial support for the older people who have insufficient incomes to maintain a living. While the government must ensure, on the one hand, that revenues are available for it to shoulder this responsibility, it has to safeguard, on the other, the living standard of the older recipients from erosion and from falling, as a result, too far below that of the general population. Apart from public assistance, the other financial support that older people have been receiving from the government is an old-age allowance. Although the amount is more or less nominal, fixed at HK$705 (US$90) per month for those aged 70 and over and less for those between 65 and 69, this costs the government an annual outlay of more than HK$3 billion, as eligible people number nearly half a million. Since the allowance has now been regarded by the public as a

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token of appreciation for the past contributions of the older people towards society, the government has no choice but to continue paying the benefit. To summarize, the formal structure that has evolved in Hong Kong to care for older people is no doubt a comprehensive one, with services provided at a high standard to meet their varying needs. The major shortcomings of the provisions lie in their insufficient supply, as the majority of the services are heavily subsidized by the government. Further expansion of the services will therefore depend not so much on a reform of the formal structure but an enlargement of the sources of finance. Issues surrounding the care of older people There are three main issues affecting the care of older people in Hong Kong in the future, namely: informal versus formal care; public versus private finance; and the impact of the changing role and status of older people in Hong Kong. Informal care versus formal care Informal care provided for older people has largely been understood in Hong Kong as care provided by family members. It has been mentioned that a ‘care in the community’ approach has been adopted in Hong Kong for the development of services for older people. At the time when the approach was first adopted, the concept of the ‘community’ was probably used to imply a much larger scope than the care provided by the family system. However, when the approach was put into implementation, what the majority of the older people living in the community have found was that, when they required help, they could only obtain it from their family members. In other words, just like what have happened in other places in the world, community care in Hong Kong often includes no more than family care, and in most cases, care provided by the female members of the family (Walker and Maltby 1997). Hence, although the Chief Executive has stressed that the care of older people is a responsibility of the family, it has to be recognized, as found by some local studies, that the family system in Hong Kong is probably the only institution on which older people can still rely for help and support (Ngan and Kwan 1995). Furthermore, the family system in Hong Kong is obviously unable to perform the same care functions for older people as before and must, in cases such as care for disabled elderly persons, be replaced by other institutions. Some have therefore argued that the time has come for the government to re-examine its care policies towards older persons and, instead of emphasizing the important role of the family system, it must now take a more proactive approach in establishing a more extensive and comprehensive network of formal services for the older people requiring support and care. There are also suggestions that, since Hong Kong residents, in accordance

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with the stipulations of the Basic Law, now have a right to enjoy social welfare, same as the right of the children to receive education, older people should be entitled to get the services they need. There is no question that more services should be provided to meet the needs of older people. However, it should be recognized that the increasing need of older people for formal services may not have arisen from the failure of the family system to provide the necessary care, but also as a result of longer life-expectancy and hence an increase in the demand for care that only formal services can realistically meet. It should also be noted that, notwithstanding the weakening care functions of the family system, all local studies have shown that the majority of older people requiring help and support are receiving them mostly from their family members. Indeed, there is hardly any evidence to show that the family system can ever give up its care functions to the government and be replaced by formal services. The family system must therefore remain as an important source of help and support for older persons, although more formal provisions are called for (International Labour Organization Regional Office for Asia and the Pacific 1997). To conclude, instead of arguing about the relative importance of formal and informal care in supporting older people, it appears definitely more fruitful to understand the strengths and limitations of each. While accepting the important place of the family system in providing care for older people, it would be necessary to identify, at the same time, the tasks that can best be performed by formal services. The future system for supporting older people in Hong Kong will probably be a mixture of formal and informal care, with each complementing and supplementing the other. There is no place for a policy that goes to an extreme and stresses only one source of help and support. From the point of view of older persons themselves, a good policy should also be one that combines the different sources of help and support for them. Public versus private finance To date, most of the social services provided for older people in Hong Kong are financed by public revenue. In the financial year 1997–98, the expenditure on medical and social welfare services, including social security, for older people amounted to HK$14.5 billion (US$1.9 billion), or about 7 per cent of the total government expenditure. Despite the commitment that the Chief Executive has pledged to provide older people with better and more adequate services, the government has not concealed the fact that it has almost stretched its financial resources to their limits. In other words, further expansion and improvement of the services for older people must rely on a more diversified finance system. When the Working Party on Care for the Elderly produced its report in 1994, it suggested the introduction of services on a self-financing basis, with

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the government assisting only in the capital and part of the initial operating costs. A recent consultant’s report on the finance of medical and health services has also recommended the setting up of cost-sharing services, in the form of either insurance or savings schemes. As a substantial portion of the medical and health services, especially those involving long-term care, are consumed by older people, any change in the finance method will alter the supply of and demand for the services, as well as the ability of the older people to pay for them (Ranade 1998). Similar to the question of formal versus informal care, the answer to the finance of the services for older people lies not in a choice between either government support or private funding. It is evident that with the increasing number of older people requiring help and support, it would be unlikely to be possible for the government to provide all the necessary funding; additional costs must come from other sources, either through increasing service users’ payments or through other collective means. Diversification of the income sources seems to be the step that the government must take; what is important is to ensure that the measures to be introduced are affordable for older people and are not denying any older person the necessary services. The changing role and status of older people As Hong Kong is a Chinese society, the care of older people has been closely related to the role and status occupied by them, both within the family and in society. Though the traditional value of filial piety has not disappeared entirely, studies have shown that older people are nowadays seldom regarded as the head of the household and their experiences are often not valued (Chow 1997). While there still exists a great deal of respect for the old, even older people themselves have accepted that they can no longer command the same degree of support from their children as in the past. So far as the recent expansion of formal services for older people is concerned, it is obvious that it came more from a commitment of the government to provide more adequate care for the older people than an emphasis on their traditionally prestigious roles and status. One may even argue that the traditional value of filial piety is no longer relevant to the formulation of a policy for supporting the old. The disappearance of the traditional role and status of the older people implies, however, that they are now free to devise a new image for themselves. This in itself is not necessarily bad as some of the traditional practices, like the expectation that they must have children living with them in order to be happy, are not conducive to a fruitful and productive old age. As noted in Chapter 1, the process of constructing a new image and hence new roles and status for older people is not going to be easy. However, it has now gradually been accepted by most people in Hong Kong that, just as the other age groups, older people should have their own rights and

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responsibilities as members of society (Kam 1995). Hence, as long as older persons are prepared to give their best to other members within the family and in society, they will also be treated equally and have their fair share in the use of community and societal resources. The conclusion that can be drawn is that the roles and status of older people in Hong Kong have definitely changed a great deal in recent years. There is no doubt that the status of older people has declined, to such an extent that their presence is no longer taken seriously. It may be difficult to accept that the traditional values and practices are disappearing so fast. However, rather than re-emphasizing the importance of traditional values and practices, it appears more fruitful to inject into them new meanings and hence project for older people a new image of their own. It appears that it would be more acceptable, in devising a new care policy for older people, to stress their rights and responsibilities as members of society. This should then form the basis of their entitlements to care and protection and upon this, the value of filial piety can be revitalized without its oppressive implications. Conclusion The impact of population ageing in Hong Kong is probably not very different from that in many other countries of the region undergoing the same processes of industrialization and urbanization. It is interesting that, from the time when government provisions for older people were not even in the pipeline, a ‘community care’ approach had already been adopted for the development of services, recognizing perhaps the societal feeling that the family has the primary responsibility for taking care of their older members. This has resulted, over the last twenty years or so, in a perennial shortage of formal services, as families have perpetually proven themselves willing but not able to fulfil alone the responsibility they are supposed to perform. The question as to why the family system, or the community at large, in Hong Kong is unable to provide the necessary care for older people is one that will never have a satisfactory answer. While one may argue that the modern family system simply cannot live up to the expectation of performing its traditional care roles, one has also to recognize the fact that the needs of older persons today for care are not the same as before. The problem that has presented itself, in so far as the care of older people is concerned, is that, while the family system is finding it increasingly difficult to support its older members, the government is also indecisive regarding the position it should take. The failure of the government to introduce any compulsory retirement protection scheme, although this has been debated for more than thirty years, is the most glaring example of the indecision of the government about its role in meeting the needs of the older people. Although the attitude of the government towards the care of older people has not always been reactive, one cannot be sure either of how much responsibility the government is prepared to take.

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The picture that one may obtain about the care of older persons in Hong Kong is hence a confusing one. While this is regarded as a responsibility for both the family system and the government with each playing a role, no one knows how the bits and pieces can actually fit together to form a complete whole. Gaps and loopholes are therefore not uncommon in the supportive system for older people but remedies are not always available, as no one is sure from whence the solution should come. The future development of a care policy for older people in Hong Kong must therefore begin with a clearer definition of the respective roles of the various systems, including the family and the government, in supporting older people. Only then can a policy be found that combines the various sources of help and support in providing the best form of care for older people. References Barlett, H.P. and Phillips, D.R. (1995) ‘Aging trends—Hong Kong’, Journal of Cross-Cultural Gerontology 10, 3:257–65. Census and Statistics Department (1996) 1996 Population By-census—Summary Results, Hong Kong: Government Printer. Chi, I and Chow, N. (1997) ‘Housing and family care for the elderly in Hong Kong’, Aging International, Winter/Spring: 65–77. Chi, I, Yip, P.S.F. and Yu, G.K.K. (1997) Elderly Suicides in Hong Kong, Hong Kong: Befrienders International. Chi, I. and Lee, J.J. (1989) Hong Kong Elderly Health Survey, Hong Kong: Department of Social Work and Social Administration, The University of Hong Kong. Chow, N. (1983) ‘The Chinese family and the support of the elderly in Hong Kong’, The Gerontologist 23, 6:584–8. ——(1994) ‘Care of the elderly—whose responsibility?’, Hong Kong Journal of Gerontology, 8, 1:12–8. ——(1997) The Policy Implications of the Changing Role and Status of the Elderly in Hong Kong, Hong Kong: Department of Social Work and Social Administration, The University of Hong Kong. ——(1998) ‘Social welfare and the challenges in a new era’, in S.L.Wong and T. Maruya (eds) Hong Kong Economy and Society, Hong Kong: Centre of Asian Studies, The University of Hong Kong. ——(1999) ‘Housing and environmental needs of elderly people in Hong Kong’, in D.R.Phillips and A.G.O.Yeh (eds) Environment and Ageing, Hong Kong: Centre of Urban Planning and Environmental Management, University of Hong Kong. Chow, N. and Chi, I. (1999) An Evaluation Study on the Social Networking Project for the Elderly, Hong Kong: Department of Social Work and Social Administration, The University of Hong Kong. Deloitte & Touche Consulting Group (1997) Study of the Needs of Elderly People for Residential Care and Community Support Services, a Consultancy Report, Hong Kong: Deloitte & Touche Consulting Group. Hong Kong Government (1979) Social Welfare into the 1980s, a White Paper, Hong Kong: Government Printer.

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International Labour Organization Regional Office for Asia and the Pacific (1997) Ageing in Asia: The Growing Need for Social Protection, Bangkok: ILO Regional Office for Asia and the Pacific. Kam, P.K. (1995) ‘Right of senior citizens and polities’, Hong Kong Journal of Gerontology 9, 2:38–45. Leung, E.M.F. (1999) ‘Housing and environmental issues for elderly people—a health and functional perspective’, in D.R.Phillips and A.G.O.Yeh (eds) Environment and Ageing, Hong Kong: Centre of Urban Planning and Environmental Management, University of Hong Kong. MacPherson, S. (1993) ‘Social security in China’, Social Policy and Administration 27, 1:50–7. Ngan, R. (1990) The Informal Caring Networks Among Chinese Families in Hong Kong, unpublished PhD thesis, The University of Hong Kong, Hong Kong. Ngan, R. and Kwan, A. (1995) ‘Community Care for the Chinese Elderly in Hong Kong’, Hong Kong Journal of Gerontology 9, 2:46–54. Ngan, R. and Wong, W. (1993) ‘The caring paradox: family care for Chinese elderly’, Asia Pacific Journal of Social Work 3, 2:50–66. Ranade, W. (ed.) (1998) Markets and Health Care: A Comparative Analysis, Harlow, Essex: Addison Wesley Longman. Secretary for Education and Manpower (1995) Report of the Consultancy on the Mandatory Provident Fund System, Hong Kong: Government Printer. Tung, C. (1997) Building Hong Kong for a New Era, Address by the Chief Executive at the Provisional Legislative Council Meeting on 8 October 1997, Hong Kong: Printing Department, Hong Kong SAR Government. Walker, A. and Maltby, T. (1997) Ageing Europe, Buckingham: Open University Press. Working Group on Housing for the Elderly (1994) The Report of the Working Group on Housing for the Elderly, Hong Kong: Hong Kong Housing Authority. Working Party on Care for the Elderly (1994) Report of the Working Party on Care for the Elderly, Hong Kong: Government Printer. Working Party on the Future Needs of the Elderly (1973) Services for the Elderly, Hong Kong: Government Printer. Yeh, A.G.O. (1999) ‘The changing spatial distribution of elderly population and its planning implications’, in D.R.Phillips and A.G.O.Yeh (eds) Environment and Ageing, Hong Kong: Centre of Urban Planning and Environmental Management, University of Hong Kong.

9

Singapore’s ageing population Social challenges and responses S.Vasoo, Tee-Liang Ngiam and Paul Cheung

Introduction One of the most challenging social phenomena of the future is population ageing in Singapore, one of the fastest ageing countries in the Asia-Pacific region. In Singapore, where the average life expectancy at birth is about 77 years, the elderly population is considered to comprise those who are 60 years and above (Department of Statistics 1997). The population-ageing trend has been conspicuous. In 1970, there were about 116,100 persons aged 60 and above. The number increased by over 50 per cent to 170,400 in 1980. By the turn of the century, the number will rise to about 329,900, some 11 per cent of the population. It has been estimated that 25 per cent of Singaporeans will be above 60 years by 2030 (Cheung and Vasoo 1989; Shantakumar 1994). Recently, the official retirement age has been raised from the previous 55 years old to 60 years and 62 years; it is intended to further increase this to 67 years in the near future (Shantakumar 1999).1 The annual growth rate of the ageing population for the next thirty years will be around 3 per cent and the elderly population will grow between 11 per cent and 26 per cent from 1990 to 2030 (Shantakumar 1994; ESCAP 1996). Such a sharp increase will have crucial implications for social policies and support services for older persons. More importantly, as in a number of other countries in the region (see Chapter 2), the number of ‘old-old’ persons 75 years and above will see a steep increase (Phillips and Bartlett 1995; Yap and Tan 1998) and this group is at high risk for care and attention. More family resources will have to be drawn to attend to their social and physical requirements and some families will face stress and difficulties in providing care for sick and disabled older persons. Senior citizens’ organizations and community groups will be able to play a more effective role if they can now actively begin examining the potential future needs and problems facing senior citizens and organizing programmes that attract participation of senior citizens living in various neighbourhoods. They will have to review their objectives, organizational structures and management capabilities so that their programmes are able to reach out efficiently and effectively to as many senior citizens as possible.

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The accelerated ageing has been identified as a major challenge that will confront Singapore in the future. This trend, shared by other newly industrializing countries, is anticipated to result in a broad-based transformation of the society, requiring adjustments and adaptations at all levels. It will significantly alter the dependency ratio between the young and the elderly. Social issues in ageing in Singapore In older housing estates, the ageing process has become yet more transparent. There are increasing numbers of older senior citizens living in these estates and it is urgent for community groups and organizations to begin to plan the establishment of more community-based programmes such as day care, meals programmes, home-help service and domiciliary nursing care and crisis response services. In taking a proactive approach to initiate a network of services in older housing estates, Singapore hopes to be able to provide support for families with vulnerable older members and prevent disruptions to the social and economic lives of families. One major concern facing older persons is the maintenance of good health and it is therefore important to promote healthy living to avoid the misery of poor health in old age. The prolongation of life as a result of improved medical technology can otherwise raise various moral and philosophical issues about sustenance of life and dying. Older persons and their families will increasingly have to be better prepared to deal with this life reality and dilemma. For older persons to reduce the risk of disabling conditions, it is important to enhance their physical and mental capacities and strengthen their support networks. Preparation for retirement is also an important issue, in which the community can take steps to help and encourage older persons. The more positive efforts the elderly take in maintaining healthy lifestyles, the less dependent they are likely to be and need care and attention. In this again the community can take action to motivate more older persons to be involved in local self-help groups. Through these self-help groups and mutual support groups, elderly people with different needs and problems could be assisted. The strong can help the less strong. In 1997, it was estimated that 48.1 per cent or almost one out of every two persons between the age of 55 and 59 years was economically inactive, and among those between 60 years and 64 years, the percentage was even higher at 67.6 per cent (Department of Statistics 1997). The labour-force participation rate of these two age groups is indeed low and there is an urgency to encourage more older workers to be retained in the workforce. Employers therefore have to be encouraged to appreciate that retirees and potential retirees have a wealth of accumulated experience which could be tapped by their companies. Singapore recognizes that it is sad to see such a pool of talent wasted. Indeed, as the number of people in the retirement age group is on the increase and likely to affect even more people in the future, it is timely for both the public and private sectors to devote more resources

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and programmes to the retraining and placement of retirees. However, at present, there is a lack of specialized services to cater for the specific job placement needs of retirees. There are a number of significant social adjustments that retirees have to make and they have to be tackled in the light of the resources and support available to them by their families, peers and the community. There is also generally a reduction of personal income faced by retirees and they need to plan how to use limited funds most effectively. Many retirees therefore need to have access to reliable advice on investments and savings, to avoid risky investments and ventures. More reliable investment advice should be made available through trade unions and bona fide companies. Lee (1998) has reviewed the changing incidence of poverty among older people and social security policy and responses in Singapore. In the years ahead, Singapore, a modern city-state, can expect a continuing acceleration of social and technological change. As a result, retirees will inevitably be confronted with complex problems that require them to become more conscious of the need to engage with the challenges of technological demands of the modern environment. Indeed, in future, retirees might well have to become computer literate in order to operate certain modern transactions. Retraining policies are therefore expected to be promoted in line with the higher retirement age and re-employment opportunities (Shantakumar 1999). In addition, a key aspect of retired life is how to use more leisure time. All retirees have to find meaningful ways of spending their leisure time and, indeed, many retirees face leisure problems and have difficulties in coping with the increased time available, and need to view leisure activities as opportunities for self-development. They tend to believe that only work provides them with meaning. The retirees require organizations that can help them to engage in various social and economic activities that enhance or sustain their social well-being. The work of a retirees club should be strengthened by providing more comprehensive programmes to deal with social and recreational needs, employment, retirement planning, volunteer service and personal guidance. Some impacts of an ageing population Two social implications have received particular emphasis. First, concern has been expressed as to whether the ageing of the population will increase the dependency ratio on the state for welfare and financial assistance. A related question is whether the traditional caring institutions will remain intact given the rapid social changes that Singapore is experiencing. Second, concern has also been expressed over the social and economic implications of population ageing and its potential impact on the economy’s future development. Recent data suggest that there are about ten people of working age per older person today but that this will fall to only 3.5 persons

Singapore’s ageing population Table 9.1

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Actual and projected working-age persons per older person and index of ageing of the population in Singapore, 1980–2030

Source: Inter-Ministerial Committee on Health Care for the Elderly (1999). Notes: 1 Working age persons per elderly person=residents aged 15–64 years divided by residents aged 65 years and above. 2 Index of ageing=residents aged 65 years and above divided by residents aged under 15 years.

economically active per elderly person. An index of ageing, at 30.9 in 1997, will more than treble to 103.9 by 2030 (Table 9.1). Increasing awareness of issues surrounding older persons in Singapore was generated as early as the 1970s. Several studies were conducted at that time and, in the 1990s, the number of studies has increased significantly. Even by 1985, there were at least ten known studies, one of which was ‘Social Policy and the Elderly’ (1981) conducted by the then Singapore Council of Social Service (1981). In addition, the appointment of five highlevel committees since 1982 to review the various issues and problems arising from population ageing reflected this concern.2 There was also an awareness that the rapidity of the ageing process and its consequences are related to, if not an outcome of, the policies implemented in the past. The five committees, chaired by cabinet ministers and comprising representatives from various sectors, were given the task of reviewing the policy options and recommending policy changes. The work of these committees, as well as other initiatives, marked Singapore’s continuing efforts to plan for an ageing society. The Report of the Committee on Problems of the Aged (1984), commonly known as the Howe Report, opened the door to greater public attention and debate on the issues facing older persons. The national efforts to approach population ageing may be discussed broadly under policy responses and delivery of programmes. Three factors deserve special mention at the outset. First, population ageing and its implications have been placed high on the political agenda. The ruling political party, The People’s Action Party (PAP) has explicitly identified population ageing as an important issue in its agenda for national discussion and action. Second, Singapore is spatially relatively small and an extensive network of government and non-government organizations are already in place. Therefore, it is possible to exploit what is already in existence in the creation of a support infrastructure for older persons. Third, the growing

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affluence of Singapore makes it possible for government and society to deploy resources to the programmes and services for older persons, leading to a rapid expansion of the formal support network. Policy responses In the 1970s, the concern for the welfare of immigrant older persons led to the establishment of a number of services catering to their special needs. Such services were formulated by the then Ministry of Social Affairs in conjunction with the then Singapore Council of Social Service. Although this attracted some attention, planning efforts were essentially sectoral and services were treated as an extension of the existing social welfare schemes. In the 1980s, concern broadened as the implications of population ageing were made known. The fact that the problems of older persons will not disappear along with the passage of the group of immigrant, destitute aged led to serious reviews of the issue. In June 1982, the appointment of a highlevel thirteen-member committee marked the beginning of the government’s efforts to understand the wider implications of population ageing and to implement appropriate policy measures. The Committee on the Problems of the Aged was chaired by the then Minister for Health, Mr Howe Yoon Cheong. In its deliberations, the Committee took the problems of older persons beyond the realm of humanitarian and social welfare concerns and noted the long-term impact and ramifications of population ageing. As a result, the Committee stressed the potential contributions of the elderly to the society and the importance of incorporating them in socioeconomic development, while concurrently acknowledging and meeting their special needs. To assist in its deliberations, the Committee commissioned the National Survey on Senior Citizens in 1983,3 providing updated information from an earlier study conducted in 1976.4 The Howe Report was finalized and released in March 1984. Several of its policy recommendations were controversial, such as raising the eligible age for provident fund withdrawal and legislation on filial piety and, indeed, led to much public outcry and discussion. However, the bulk of the Howe Report’s recommendations were accepted, among which the major ones included change in provident fund contribution rates for older persons to generate employment for older workers, legislation on minimum standards for aged homes, increased elderly dependants’ relief under the Income Tax Act and measures to foster family and intergenerational cohesion. To implement the Howe Report’s recommendations, several committees were established with members drawn from relevant ministries, statutory boards, the education sector and non-government agencies. A Co-ordination Committee was set up in August 1985 under the Ministry of Community Development (formerly the Ministry of Social Affairs) to implement the Howe Report, as well as to evaluate and oversee the implementation of its

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recommendations. In January 1986, the Committee to Co-ordinate the Development of Programmes and Activities was formed in the Ministry of Community Development to promote, direct and supervize the implementation of the Howe Report’s recommendations with respect to health and recreational needs, social services and institutional care by government and non-government agencies. A Committee on Public Awareness on Ageing was also established to spearhead a public education and awareness programme in the Ministries of Community Development and Communication and Information to project a more wholesome image of senior citizens (a programme was launched in November 1987). That year also saw the establishment of a tripartite Task Force on the Employment of the Elderly in the Ministry of Labour. The task force comprised employers, government and union representatives to study the need to provide counselling and retraining of older workers. Recognizing that population ageing is also a demographic issue, the government established in 1984 an Inter-Ministerial Population Committee (IMPC) to undertake a comprehensive review of Singapore’s population trends and to make recommendations on policy measures to arrest the declining fertility rate and to bring about the desired population size and composition. Chaired by the Permanent Secretary of the Ministry of Health and reporting to the First Deputy Prime Minister, the members of the IMPC comprised of Permanent Secretaries of relevant government ministries. Following the IMPC’s recommendations, Singapore’s population policy was revised in 1987. The Committee, assisted by the Population Planning Unit, monitored Singapore population’s trends. In June 1988, the National Advisory Council on the Aged, headed by the Minister for Home Affairs, was formed to undertake a comprehensive review of the status of ageing in Singapore. Its term of reference included the review of programmes and services available to older persons, to examine the premises, assumptions and policy recommendations contained in the 1984 Report on the Problems of the Aged, to suggest ways to enable older persons to work beyond age 55 and, finally, to examine how families could be helped to look after their elderly dependants. The National Advisory Council appointed four committees to look into the specific issues of concern: committees on community-based programmes for the aged, attitudes towards the aged, residential care programmes for the aged and employment for the aged. The composition of the members of the Advisory Council and the committees included experts from government ministries, statutory boards and voluntary organizations concerned with the provision and planning of services for the elderly. In September 1988, reports of the four committees were reviewed by the Advisory Council and subsequently submitted for government consideration. One key recommendation proposed was the establishment of a National Council on Ageing with the character and authority of a statutory board to plan and coordinate policies and programmes for older persons. Other proposals

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included raising the retirement age from 55 to 60, adjusting the senioritybased wage system so that more older people would be employed, expanding and strengthening public education programmes on older persons and ageing so that appropriate attitudes towards older persons could be inculcated, making land available for voluntary organizations to set up homes for older persons, lengthening the term leases for homes, studying the feasibility of providing health and medical services for frail older persons living in their own homes and increasing the dependency tax rebate for families who look after older persons. To meet further challenges of population ageing, the 1990s saw the development of two milestone policies implemented to deal with anticipated problems related to the social and health care of older persons. Very significant legislation, the Maintenance of Parents Act, was introduced in 1994 after much deliberation by community groups and the Parliamentary Select Committee. There was public endorsement for the policy to impose a legal obligation on children to maintain their parents. Such a social policy, almost unique in Asia, deals with prevention and problems of neglect of elderly parents. In most urban societies, it appears likely that family breakdowns will increase and these have consequences on care and support for the elderly. Another enlightened policy covering medical care of terminally ill persons was put in place. More specifically, under the Advanced Medical Directive Act, persons who have been medically certified to be brain dead can now under their earlier directives be taken off medical life support. Such a progressive and futuristic policy will perhaps reduce unnecessary suffering to both terminally ill older persons and their families. A national policy on ageing in Singapore has taken shape after a number of successive policy reviews. Two characteristics in the policy formulation process should be noted. First, the various committees have had the benefit of representation from various sectors, providing diverse inputs and making implementable decisions. Historically, cross-sectoral representation has worked well in the local context and it is the standard feature in Singapore’s government problem-solving approach. Second, the committees were given much publicity raising awareness of the issues especially when controversial recommendations were made. The enhanced discussion on policy changes by the public sees an increasing emphasis on the social care of older persons in Singapore. Public inputs thus become an important consideration in the committees’ deliberations. In anticipation of the serious social and economic challenges which will be posed by an acute ageing population in the next two decades, the government and policy-makers established the Inter-Ministerial Committee (IMC) on Ageing Population in October 1998. The IMC comprises ministers, members of parliament, senior civil servants and representatives of non-governmental organizations dealing with older persons. The IMC’s tasks were to identify the challenges of a rapidly ageing population, recommend policy directions

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and suggest coordinated national efforts to tackle the various issues confronting Singapore’s increasing elderly population. The IMC canvasses views and recommendations from a wide range of sources including community groups and those who have direct contacts with older persons. In this connection, the IMC set up workgroups to report in late 1999, on employment and employability, housing and land-use policies, financial security, social integration of the elderly, healthcare and cohesion and conflict in an ageing society (Ministry of Community Development 1999). Such a coverage of areas enables the I MC to propose comprehensive recommendations which will hopefully prepare Singapore to successfully and gracefully handle some of the challenges of its senior citizens in the future. Programmes and services The programme plans and services for older persons are coordinated through three principal organizations: the Ministry of Community Development, the Ministry of Health and the National Council of Social Service. The two ministries, in addition to providing some direct services, provide overall guidance in planning for welfare and health services respectively. The National Council of Social Service plays a coordinating role among nongovernment welfare organizations and helps in representing their views to the government. Some sixty-seven voluntary and religious organizations affiliated to the Singapore National Council of Social Service (1997) were providing services to older persons in 1997. In addition, other ministries or statutory bodies may also be responsible for certain schemes concerning older persons, such as the Housing and Development Board (HDB) which has been providing special housing for older persons. The services offered by government and NGOs are quite comprehensive and fall under the categories of formal and informal care. Formal services for older persons in Singapore include community-based services, residential and health care. Informal services are those given by the families or friends of older persons. Presently, community-based services available in Singapore cover such aspects as the home nursing services, befriending service, senior citizens’ or retirees’ club activities, day care centres, and a free or cheap meal service. While existing community-based services should be developed further, other forms of services for older persons such as telephone contact service, home-help service, neighbourhood mobilization scheme, health centres and support for family caregivers should also be explored and possibly introduced to provide a wider coverage of community-based services. Residential care in Singapore includes aged homes, nursing homes, community homes and commercial homes. Support services for older persons are particularly important in view of their rising number in the community, smaller size of the family and more women entering the labour-force. In addition, the number of single older persons (8,905) who live in one-person

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households (Shantakumar 1994) is expected to increase in the near future and they can be vulnerable in times of need and sickness. In Singapore, with only 2 per cent of elderly people living in institutions, the family’s role in ensuring the well-being of older persons is of paramount importance. In a rapidly changing society, the family is also subjected to numerous competing demands that might affect its capability in the provision of care. Family structure and care In terms of household structure, the National Survey of Senior Citizens (1996) showed that about 8.3 per cent of non-institutionalized older persons lived alone or with their spouse; the remainder lived in households with immediate relatives or others. The 1996 rinding also confirmed an earlier survey that the elderly tended to live with immediate family members and the survey also showed that older people enjoyed reasonably good public-flat accommodation. It was observed that 93.3 per cent of the older people were staying in satisfactory living conditions in terms of sleeping arrangements, accessibility to facilities and cleanliness. It was also found that home ownership was high and 79.1 per cent of older persons were living in households with a monthly income exceeding $1,000. In terms of preferred living arrangements, there was a distinct and overwhelming preference among older persons to live with their children, in particular, their married children. The choice of co-residence appears to be culturally influenced: Chinese and Indian respondents preferred to live with their married sons while Malays preferred their married daughters. The surveys also found an overwhelming reluctance among older persons to stay in old folks’ homes, as might be expected. The findings from a number of studies have shown that most of the older persons with immediate relatives would have few problems in obtaining support in times of need (Chen and Cheung 1988; Cheung 1988c; Ministry of Health et al. 1996). Older persons were also often found to be engaged in meaningful interactions with the children with whom they lived and maintained frequent contacts with children who were living apart. The respondents were also confident that they could rely on their family for help when they were ill or when they had other problems. So far, no evidence has been found to suggest that the family, as an institution, is shirking its responsibilities. However, several familial changes could restrict the effectiveness of the family as the primary source in the future. First, the increasing involvement of married women in the labour-force could reduce the availability of caregivers within the family. In 1997, the labour-force participation rate among married women was about 78 per cent. This has increased since 1987 and with the shrinking of family size, there is also likely to be fewer persons to share out the responsibility of care. There is also concern that the younger generation may not be as filial towards their ageing parents. The decline in family size, coupled with increasing external

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commitments and value changes of the family members could erode the coping capability of the family in the care for aged sick relatives. These changes suggest that formal support system may have an important role to play in the future. Therefore, to encourage the family to care for its elderly members to the fullest extent possible, the government has introduced measures which include the intergenerational co-residence scheme, income tax relief, moral education programme and community-based services. In the intergenerational co-residence scheme, married children and their parents are allowed to apply for adjoining HDB flats and their applications are given priority. For a person who is caring for an elderly dependant, $4,500 income tax relief is given, provided that the relative is not earning more than $1,500 a year. Moreover, children can claim tax relief of up to $6,000 a year for the equivalent sum of money they have contributed to their parents’ Central Provident Fund (CPF) account. In addition to the family support and community-based services, financial support services are also available. The Public Assistance Scheme under the Ministry of Community Development provides monthly allowances ranging from $200 for single-person households to $570 for four-person households and above. Some 1,960 persons aged 60 and above receive direct financial assistance (Department of Statistics 1997). In addition, voluntary organizations also render assistance in cash and kind to the financially distressed. Churches, temples, charitable foundations and various community service groups also provide ad hoc aid such as Hong Bao (‘money in red packets’) and food for needy older persons during the festive seasons. However, the various financial schemes lack coordination to ensure efficient and effective distribution of financial resources. Old-age financial security for Singaporeans is provided principally through the CPF scheme, whereby both employees and employers make monthly contributions. In 1999, the contribution was 20 per cent each by employees and employers. The scheme is run by a statutory board and guaranteed by the government. Contributors can also draw on the fund for approved purposes, such as the purchase of property, payment of medical expenses and other investment ventures. The principal sum plus interest can be withdrawn at age 55, except for a minimum sum of $40,000 which can only be withdrawn after the age of 60. This is to provide an added protection for financial well-being in old age and to protect against any squandering of savings. Part of the CPF is channelled into a Medisave account, which can only be drawn for medical expenses, with the cap for this account set at $20,000. To help reduce the burden of care on the family, services such as home visiting, day care and respite care are being offered. The government has also launched various initiatives to promote as much community involvement in provision of these services as possible. Two objectives are emphasized. First, to keep older persons fit and healthy, and capable of full participation in the mainstream of community life. Second, the elderly sick persons are to be provided supportive services which will enable them to live with their families for as long as possible.

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Are these measures likely to be effective in fostering greater family support? They reflect to a large extent the cultural emphasis on the importance of the family and are therefore consistent with general sentiments. However, these are essentially passive measures designed to maintain rather than to foster families ties. The moral education programme is therefore special as it takes a proactive role to inculcate specific filial attitudes, although whether such intervention can help to stem the influence of Westernization remains to be seen. However, education of this nature may help prepare the young to accept the challenge of caring for their aged parents. Community participation and involvement A major planning principle put forward by the various committees dealing with issues related to the problem ageing in Singapore is the recognition of the potential contribution of older persons to society and to their own welfare. This principle came through clearly in the main reports and has been endorsed fully because older persons of the future will be resourceful. If Singapore were to have a quarter of its population aged 60 and over, it is clear that this vast reservoir of human resources must be tapped if its economic prosperity is to be maintained. Harnessing the contributions of older persons is, however, easier said than done. Age-old prejudices often cast older persons in a poor light and emphasis is mainly placed on their problems rather than their potential contributions. The developmental emphasis of the government’s approach is therefore encouraging. Recognizing that contribution is possible only through participation, much prominent attention is given to three aspects of participation, covering health maintenance, community activities and gainful employment. Health is often the critical factor in a person’s adjustment in old age. While old age is not necessarily a time of ill health and disability, a variety of chronic illnesses do occur more frequently among older persons than among the younger population. In Singapore, the large majority of older persons enjoy reasonable good health and lead independent lives, but older persons are also disproportionately large consumers of medical care. It is observed that about 7 per cent of older persons in the population are reported to have been hospitalized, which accounts for a significant proportion of hospital admissions. In 1997, the projected admission of older persons based on a rate per 1000 resident population was 101.2 for those aged between 55 and 59 years old and 136.1 for those between 60 and 64 years old. The need for hospital care for older persons is likely to be more acute in the years ahead, as the population ages yet more. To reduce the level of morbidity among older persons, the role of primary health care has been emphasized and three aspects (health education, health screening and self-help groups) have been promoted actively. Participation in community activities may be taken as an indication of the integration of older persons into society, beyond the confines of the family.

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Greater involvement in the community, especially in age-integrated activities, signifies a respectable status accorded to older persons. Conversely, social isolation of older persons may reflect a poor image of elderly people in the eyes of the younger generation. Community participation of older persons can be grouped into two types: age-segregated and age-integrated. The rapid proliferation of Senior Citizens’ Clubs, encouraged by the government, is one example of the former and these clubs offer recreational programmes, health screening, keep-fit activities and opportunities for community services by older persons. There are over 240 such clubs with a total membership of more than 60,000 persons, run at community centres by the People’s Association. Among the few non-government run clubs, the Singapore Action Group of Elders (SAGE) is the largest and such age-segregated clubs meet certain needs of older persons. They provide a contact point for meeting and making friends and a forum for exchange of opinions and experiences. However, they do, perhaps unfortunately, also segregate older persons from other age groups. The establishment of a network of Senior Citizens’ Clubs may heighten the awareness of older persons as a distinct social group that can become articulate and resourceful, but, so far, these clubs are not linked to form a larger organizational base. The new Singapore chapter of the Retired and Senior Volunteer Programme (RSVP) could conceivably provide the linkage to these clubs, effectively organizing them into a potentially potent self-interest group. On the other hand, to what extent are older persons in Singapore involved in age-integrated activities? This is difficult to assess, as empirical evidence is scarce. In a study on the support systems of older persons, sponsored by the United Nations University,5 it was found that the most common avenue of participation is through religious activities. Apart from these, the study found that the higher the educational attainment, the greater the involvement in formal organizations. By and large, however, such involvement was not extensive, suggesting very strongly that avenues have to be developed for older persons to become more involved in age-integrated activities. Reasons for non-involvement included being too busy with household chores, lack of interest and lack of opportunities. It should be stressed that the potential for older persons to participate in community services has yet to be realized. More highly educated older persons possess varied experience and talents that could be tapped by the community for specific projects. At present, older persons are involved in ad hoc community activities and more could be encouraged to join in community services such as child-care, home nursing, crime prevention, befriending, teaching and home-help. The Volunteer Action and Development Centre of the National Council of Social Service and the Lions Befrienders Club are exploring various avenues for the involvement of elderly volunteers. It has been the emphasis of the government that older persons should be encouraged to work for as long as possible in order to maintain mental alertness and financial independence. In addition, Singapore has

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experienced labour shortages and older persons constitute an important source of labour supply. However, as noted earlier, there has been a gradual decline in their labour-force participation rates in the past five years. Challenges of an increasing population of retirees Re-employment of retirees In view of the future shortage of manpower and slow growth of Singapore’s population, the question of retirement from work is receiving growing attention and there will be increasing demands from trade unions and older workers to extend the retirement age beyond 62 years. However, despite the persuasions from both trade unions and government that the retirement age should be extended, the response from employers, particularly in the private sector, has been lukewarm and slow. Many employers are apparently concerned with the unsuitable nature of work, the high cost and possible lower productivity of employing elderly workers. If this situation continues into the next decade, there will be a need to take a more concerted action to popularize the extension of the retirement age. The National Wage Council (NWC) has noted that wages in Singapore are largely based on seniority. Consequently, the wage costs for employing an older worker are generally greater than for a new entrant, even if they are employed in the same job. As an inducement to encourage employers to retain elderly workers, the government has reduced the rate of provident fund contributions for elderly workers. To further facilitate the expansion of employment opportunities, the NWC advocated fundamental adjustments in the wage system. This takes into account considerations such as tying the salary to the worth of a job, shortening salary scales, reducing costly fringe benefits tied to seniority, and rewarding staff through one-off bonuses rather than through basic wage increments. To increase employment opportunities, the NWC has urged employers to allow greater options such as part-time work, flexi-time work, working at home or working on alternate days. The Ministry of Manpower’s Employment Service Department could set up a special section to assist older workers in job placements. The NWC has recognized that one obstacle in continued employment for older workers can be inadequate or outdated skills. It urged the Skills Development Fund, a statutory body financing skills training, to develop special schemes for older workers and to provide special subsidies to employers in retraining their elderly workers. It may be foreseen that, in the future, various local training institutes will develop training programmes for elderly workers. Will these measures taken together halt the decline in the older persons labour-force participation rate? The answer to this question is contingent on a number of factors. First, it is clearly essential that various measures to encourage employment of elderly workers are fully implemented. While the

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government can take steps to encourage the employment of elderly workers, employers themselves must also see the advantage of hiring them and reluctance on the part of the employers will not help to generate work opportunities. Second, the attitudes of older workers may be changing, such that leisure is increasingly valued over continued employment. If this is the case, then Singapore may follow the example of many developed countries in which the participation rates of elderly workers has dropped steadily regardless of employment opportunities. It is also important to note that the retention of retirees may affect job openings for the young and the potential problems of re-employing older persons and the resulting frustrations of younger persons deserve serious consideration. Health care provision Increasing demand for health care is probably inevitable due to advances in medical technology, longer life-expectancy, population ageing, increasing affluence and education and hence expectations of the people. In 1957, for example, life-expectancy at birth was only 63 years, whereas in the late 1990s it was 77.1 years (Shantakumar 1994; Department of Statistics 1997). Indeed, improvements in life-expectancy among older persons, particularly among older males, have been much greater than among the general population. In recent years, the issue of rising costs of health care in Singapore has been a subject of considerable public debate. This has been generated in part by the government’s move to restructure and corporatize public hospitals and the general concern among consumers of the increasing costs in health care. The total expenditure on health care in Singapore is about 2.8 per cent of the GDP (Ministry of Health 1997/8) and the level of health care expenditure is still low compared to many Western countries. Over the ten years from 1988, government recurrent expenditure on health care increased by two-fold from $506 million in 1988 to $1240 million in 1997 (Ministry of Health 1997/98). In the future, health care expenditure is predicted to increase steeply, especially with an ageing population and, as Singaporeans become more affluent and better educated, the demand for better health care services will expand. The important issue is that the increasing expectation for health care must be balanced with affordability (Toh and Low 1992, 205–24). More concerted efforts by the government are anticipated to implement various cost containment measures. These include curtailing the increasing demand for health care, promotion of primary health care, regulating the supply of health services, reduction of subsidies for those who can afford care, the establishment of community hospitals, cost controls on high-tech medicine and the efficient use of health care professionals. Summaries of projected demands for health and long-term care over the next three decades may be seen in the report on health care needs of older people (InterMinisterial Committee on Health Care for the Elderly 1999).

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What most people really want is good health and not good health care. As the major provider of health services to the population, the government could also lead in setting realistic standards of health care by regulating the amount of cost that the public is willing to pay and can afford to share. This could help in dampening or slowing down the demand for better health care and services so that it would not be incompatible with the country’s economic growth. Moreover, the government could also help to contain the increasing cost of health care by improving productivity in the public health services and encouraging competition among health care providers in both the public and private sectors. On the other hand, the provision of efficient preventive health care and frontline preventive services through the primary health care services will play an increasingly important part in keeping the population healthy and curtailing the demand for health care. Comprehensive immunisation programmes have helped to prevent many serious infectious diseases and, likewise, early detection and treatment of serious conditions might reduce the need for costly hospitalization. To help with this, the government could continue to ensure that the primary health care services are easily available to the population. Careful consideration has to be taken to ensure that there are sufficient subsidized classes of hospital beds (in Singapore, B2 and C class) for those in low income groups or the group will find health care less accessible and might lead to delays in seeking treatment, which can further add to costs. On health financing, the PAP government’s policy is that the Medisave Scheme (which aims to build an individual’s financial resources) should be used so that people who fall sick have the means to pay for their health care, especially in old age. As this depends on an individual’s personal savings, incentives have already been provided for people to stay well and use their Medisave account wisely. Service responses at the grassroots level Senior citizens’ organizations can arguably play a more effective role at the grassroots level if they begin to examine the needs and problems facing older persons and organize programmes which attract the participation of older persons living in various neighbourhoods. In addition, they must review their objectives, organizational structures and management capabilities so that their programmes reach out efficiently and effectively to as many older persons as possible. In order that senior citizens’ organizations can continue to be efficient and effective, those who are currently involved in the management of these organizations should focus their attention on pertinent areas. Reviewing objectives The present objectives of senior citizens’ organizations are primarily confined to the promotion of recreational activities. It is therefore necessary

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to re-examine these objectives to see if they are relevant in the context of the future changes in the needs of older persons living in the various localities concerned. In view of the changing expectations and profiles of older persons, it will be realistic to broaden the objectives of senior citizens’ organizations. In doing so, the organizations must be prepared to undergo growth and change. In reviewing the objectives of senior citizens’ organizations, the following questions might be addressed: are the organizations’ objectives meeting the changing needs of older persons living in the locality? What other relevant programmes or activities do they wish to promote in the next five years? Only when leaders and those involved in the management of senior citizens’ organizations begin to seriously consider answers to the above questions can they discover ways to strengthen and/or improve the programmes of the organizations. It is also important to consider other objectives in addition to the promotion of recreational activities. Other objectives could include promotion of health care, community service, personal social services, handicraft activities, mutual benefit schemes, cooperatives and home care, and a number of others. Knowing the profiles of senior citizens In planning and developing specific programmes for older persons, it is crucial to know the profiles of the older population living in the various constituencies. However, it appears that only very few of those in the management or leadership of senior citizens’ organizations have a good appreciation of the socioeconomic profiles of older persons in their areas. Such information can enable the people managing senior citizens’ organizations to shape and develop programmes appropriate and relevant to the locality. Enlarging the leadership base The leadership base of most senior citizens’ organizsations is rather narrow and the burden of leadership generally rests on a few committed volunteers. They can become overloaded by the various responsibilities and, in the end, may become burnt-out. Symptoms of burn-out leadership are indicated in various ways, such as low satisfaction from achievements, lack of drive in discharging the mission of the organization, estrangement and finally backsliding of organizational performance. In order to avert the burning out of the few committed leaders of some organizations, a change in leadership style and management may be necessary. Coopting more people into the various task forces to carry out ongoing programmes can help and these task forces will pave the way for a more equitable distribution of responsibilities, which would otherwise be undertaken by the committed few. Indeed, a number of task forces, when formed, will enlarge the leadership base and

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increase the participation of interested older persons as well as younger adults. Strengthening management Similarly, for senior citizens’ organizations to remain effective, those who manage them must periodically carry out exercises to identify difficulties and challenges. It is only through such exercises that they will be able to single-out specific areas which affect their organizations and make decisions to address them. Functions such as mapping out new programmes, setting directions for the organizations for a period of time and dealing with interpersonal issues must form an essential responsibility of key leaders in the organizations. Social programmes for older persons One of the most important issues that arises as a result of an ageing population is the provision of programmes for older persons. Traditionally, and to a large extent still today, older persons have been informally cared for by their immediate family or kin members. However, with the actual or potential breakdown of the extended family system discussed earlier, the capacity to look after older persons may well be affected. The decline of extended families and the tendency to form nuclear families inevitably leads to shrinkage in family size, which with the other social and economic changes noted above reduces the capacity to support older persons. Neighbours and friends have been identified as an important source of informal care to older persons. However, this source of caregivers seems to be diminishing as people are resettled in the new urban centres. Not only have older persons been separated from long-standing and familiar neighbours, but they also have the task of making new friends in their new environment. In response to the inability of some families to provide intensive care for disabled elderly members, various community-based services are gradually developing to help them remain independent in the community. These include various types of community-based services such as the home nursing service, befriending service, senior citizens’ and retirees’ clubs, financial assistance, and day care centres. However, with the exception of the home nursing service, most other community-based programmes have yet to be fully developed. Like the senior citizens’ organizations, the befrienders’ service was formerly run by the government but is now run by a voluntary service organization. There are as yet only a few day care centres and it is not convenient for older persons who live far away from these centres to utilize their services. In view of the general policy that older persons should remain as long as possible in the community, more day care centres should be set up in a number of urban centres. This is necessary to make the service more accessible to older persons who are less mobile.

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While existing services should be developed further, other forms of programmes for older persons should also be explored and possibly introduced to broaden the base of services. Several new programmes such as a meal delivery service, telephone contacts and support for family caregivers could be developed at the grassroots level. Meal delivery, for example, could be undertaken by homes for the elderly which have the infrastructure to provide and deliver meals to feeble or solitary older persons who live in neighbouring housing estates. A telephone contact service could also be set up to get in touch with older persons who are living very much on their own, to ensure their well-being. As family members are expected to play an important role in providing care to sick and disabled older persons, it would be useful to initiate a self-help group of family caregivers for older persons. This self-help group could be a source of encouragement in giving support and advice to families who are faced for the first time with the responsibility of having to care for sick and disabled older relatives. In addition to the community-based services, formal services for older persons are also provided by various homes for older persons. The government, voluntary and commercial homes serve a total of more than 5,200 older persons which is a small proportion of the older population but one that is likely to increase as more elderly infirm people require nursing care. With the future increase in the number of private and commercial homes, it will become increasingly necessary for the government to monitor their standards and quality, to safeguard the interests of residents and families. For more voluntary initiatives to develop, the government will also have to be rather more generous in the provision of matching grants. Conclusions The future demands for services for older persons in Singapore are likely to become increasingly acute. It is therefore timely for voluntary organizations and the government to review and monitor more closely future trends in service demand and provision. A more imaginative spectrum of services is also envisaged. In working together, Singapore will be better prepared to deal more effectively with its ageing challenges in the years ahead. More efforts and resources should be directed at the development of community care and support programmes for mobile older persons needing some care and attention. Such a service strategy has not yet been fully explored. In addition, more neighbourhood support services will be needed to strengthen the family’s capacity to look after older persons for as long as possible. If this is achieved, the social and economic burdens of care for older persons could be reduced. The government should review its funding to increase voluntary and community efforts to implement community care and multi-service centres in all housing estates and neighbourhoods of Singapore.

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Notes 1 2

3

4 5

More demographic details of Singapore’s population may be found in Shantakumar (1994) and Cheung (1988a and 1988b). These committees, which were formed to look into issues related to ageing, included: The Committee on the Problems of the Aged (1984), Advisory Council on the Aged (1988), National Advisory Council on the Family and The Aged, (1989), Inter-Ministerial Committee on Health Care for the Elderly, (1997) and the Inter-Ministerial Committee on Ageing Population, (1998). The National Survey on Senior Citizens was conducted jointly by the then Ministry of Social Affairs and the Ministry of Health for the Committee on the Problems of the Aged. The Survey was based on 5,538 persons aged 55 years and above and who were living in private households (Ministry of Social Affairs, Singapore, 1983). The Elderly in Singapore: report of a survey sponsored by the Ministry of Health in 1976 (Chen, P., 1982, Ministry of Health). ‘Research Project on the Transition of the Support Systems for the Aged in Singapore: Emerging Patterns and Policy Options’, National University of Singapore, research sponsored by United Nations University, Japan, 1987.

References Chen, A.-J. and Cheung, P. (1988) The Elderly in Singapore, Phase III ASEAN Population Project, Socio-economic Consequences of the Ageing of the Population, Singapore Country Report. Cheung, P. (1988a) Household and Population Projections, 1990 to 2030, Singapore: Ministry of Health, Population Planning Unit. ——(1988b) Population Trends: The Ageing of Singapore, Singapore: Ministry of Health, Population Planning Unit. ——(1988c) The Transition of the Social Support Systems for the Aged in Singapore: Emerging Patterns and Policy Options, Singapore: report presented at the Second International Workshop on the Social Support Systems in Transition. Cheung, P. and Vasoo, S. (1989) ‘Country study on the elderly: Singapore’, paper commissioned by the Economic and Social Commission for Asia and the Pacific. Department of Statistics (1997) Yearbook of Statistics, Singapore. Economic and Social Commission for Asia and Pacific (ESCAP) (1996) Population Ageing in Asia and the Pacific, New York: United Nations. Inter-Ministerial Committee on Health Care for the Elderly (1999) Report of the InterMinisterial Committee on Health Care for the Elderly, Singapore. Lee, K.M.W. (1998) ‘Income protection and the elderly: an examination of social security policy in Singapore’, Journal of Cross-Cultural Gerontology 13, 4:291–307. Ministry of Community Development (1999) Report of the Inter-Ministerial Committee on the Ageing Population, Singapore. Ministry of Health (1997/8) Annual Report, Singapore. ——(1984) Report of the Committee on the Problems of the Aged, Singapore. Ministry of Health et al. (1996) The National Survey of Senior Citizens in Singapore 1995, Ministry of Health, Ministry of Community Development, Ministry of Labour, Department of Statistics and the National Council of Social Services. Singapore: Singapore Stamford Press.

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Ministry of Social Affairs (1983) Report on the National Survey on Senior Citizens, Singapore. National Council of Social Service (1997) Annual Report, Singapore. Phillips, D.R. and Bartlett, H. (1995) ‘Ageing trends—Singapore’, Journal of CrossCultural Gerontology 10, 4:349–56. Shantakumar, G. (1994) The Aged Population of Singapore, Singapore: Singapore National Printers. ——(1999) ‘Ageing in the city-state context: perspectives from Singapore’, Ageing International, Summer, 46–60. Singapore Council of Social Service (1981) Social Policy and the Elderly in Singapore, report by the Study Group on the Elderly. Toh, M.H. and Low, L. (1992) ‘Health policies in the 1980s’, in L.Low and M.H. Toh (eds) Public Policies in Singapore, Singapore: Times Academic Press. Yap, M.T. and Tan, P. (1998) ‘The age of the aged’, in A.Mahizhnan and T.Y.Lee, (eds) Singapore: Re-engineering Success, Oxford University Press, Singapore, pp. 82–91.

10 Population ageing in China Du Peng and Guo Zhi-gang

Introduction Since the 1970s, the implementation of family planning policy and associated rapid fertility decline in China has received considerable attention, both within the country and internationally. As one of the main results of fertility decline over a very short period and with the fertility rate now at a relatively low level today, a new challenge is emerging in China, the ageing of its population. As an echo of the rapid fertility decline of last two decades, it is projected that there will be an accelerating period of population ageing in the near future. Population ageing trends in China China is the most populous country in the world. According to statistics from the State Statistical Bureau, the population of China (excluding Taiwan, Hong Kong and Macau) was estimated to be 1236.26 million in 1997, 21 per cent of the world’s total. China also has the largest population of people aged 60 and over, comprising one-fifth of the world’s total of older people. The elderly population of China numbered 96.97 million in the 1990 Census and increased to 121 million in 1998, accounting for 8.6 per cent and 9.8 per cent respectively of the national population. It is projected that the elderly population aged 60 and over will reach 126 million by 2000, about 10 per cent of the national population. If calculated on the basis of those aged 65 and over, China’s elderly population stood at 81 million in 1998, or 6.5 per cent of the national population and is anticipated to be nearly 86 million by 2000, about 6.8 per cent of the total. The founding of the People’s Republic of China in 1949 marked the start of a demographic revolution characterized by rapid mortality decline with an accelerated prolongation of life-expectancy, from around 40 years in 1949 to 70 years (72 years for females) in 1995. It is also noted for its sharp fertility reduction since China launched a rigorous family planning programme in the early 1970s, from a total fertility rate of 5.8 in the 1960s to the present low level of 1.6. The combined forces of mortality and fertility decline have brought about a rapid ageing of the population in China (Harper 1994).

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The total fertility rate declined from 1.85 in 1995 to 1.6 in 1996 and is likely to remain at about that level up to 2050. Male life-expectancy at birth is likely to improve from 67.36 years in 1995 to 76.2 years by 2050 and the female life-expectancy at birth will also increase from 71.89 years in 1995 to 81.7 years by 2050. Therefore, the number of the elderly people aged 60 and over will increase to about 126 million by 2000 (about 10 per cent of the total population), 336 million by 2030 and reach more than 420 million by 2050. This trend is unchangeable because all those who will be elderly in the middle of the next century have already been born and the change in the number of elderly people will only be affected by changes in the mortality rate (Du 1994). The rapid demographic transition in China, and particularly the rapid decline of fertility from its previously high levels, has resulted in an accelerated ageing process in China’s population (Kwong and Cai 1992). At present, as noted, the proportion of older persons aged 60 and over at about 9.8 per cent (6.5 per cent for 65 and over) is projected to increase to 22 per cent by 2030 when those who were born during the two baby boom periods (in the 1950s and 1960s) reach their advanced years. The proportion of population aged 65 and over will increase to 15 per cent. So, on sheer numerical grounds, the issue of ageing is of great importance for China and its socioeconomic development. Particular concern is expressed about the increase of the dependency ratio and its social welfare implications. Regional differences in population ageing Although China does not yet rank among countries with a high elderly population pattern, it cannot be said that population ageing has not taken place. Indeed, China has an uniquely large elderly population. In addition, China covers a vast territory and regional differences are evident in socioeconomic development, in age structures of population and also in the levels of population ageing between rural and urban areas, among provinces, autonomous regions and municipalities (Chow 1999). As well as having considerable geographical differences in development, largely favouring the major cities and the eastern seaboard, there are significant regional differences in fertility and mortality levels (see, for example, Banister and Harbaugh 1994). The urban-rural distribution of older people is also uneven and, as a result of this and of variations in income security, urban and rural older people enjoy very different living conditions, welfare, medical and health care, and pension systems. Urban-rural differences According to data from the 1990s fourth national census, of the 97 million old people aged 60 and over nationally, 18 million (18.9 per cent) live in

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cities, 6 million (6.2 per cent) in towns and 72.85 million (74.9 per cent) in counties. In other words, a quarter of the elderly population live in urban areas while three-quarters are in rural areas, roughly consistent with the level of urbanization of the population. In terms of the total population, those who live in cities, towns and counties account for 18.7 per cent, 7.5 per cent and 73.8 per cent, respectively. In 1982, of the 76.64 million people aged 60 and over in China, 14.0 per cent lived in cities, 5.2 per cent in towns and 80.8 per cent in counties. It is sometimes thought that the proportion of elderly people in cities is higher than that in counties but, according to census data from 1982 and the 1990s, rural areas have a higher proportion of population aged 60 and over compared with urban areas. In 1982, people aged 60 and over accounted for 7.4 per cent in cities, 6.4 per cent in towns and 7.8 per cent in counties, whereas people aged 65 and over accounted for 4.67 per cent, 4.22 per cent and 5.01 per cent. In 1990, the proportion of people aged 60 and over increased to 8.6 per cent in cities, 7.2 per cent in towns and 8.7 per cent in counties. However, the 1981 ‘one-per-thousand’ population fertility sampling survey data show that the ageing process took place earlier in urban than in rural areas, but the rural areas had higher proportions of elderly than the urban areas, at least in the period between the two censuses. This can be explained by the migration of the working age population from rural areas to cities and towns and particularly to towns located near to rural areas. Inter-provincial differences Table 10.1 illustrates the differences in elderly percentages among all the provinces, autonomous regions and municipalities, derived from the 1995 ‘one-per-cent’ sample survey data. It indicates that, in 1995, Shanghai had the highest percentage of older people in China. People aged 60 and over formed 16.7 per cent of its population and those aged 65 and over accounted for 11.4 per cent. By contrast, Qinghai province had the lowest level, with the proportion of the elderly (60 and over) being only 6.3 per cent and the 65 and over group, 3.6 per cent. This illustrates the large differences among regions in China. With regard to the proportion of population aged 0–14 years, the highest and lowest figures in 1995 were to be seen in Tibet (35.4 per cent) and Shanghai (17.1 per cent). In terms of levels of ageing, China can be divided into three types of region. The eastern coastal region is characterized by a high population density and high level of ageing. The second regional type is in the middle areas of the country, with a middle-level of ageing. The third type is to be seen in the northern, western and southern remote provinces where many people of minority nationalities live. In general, these areas have less developed economies and are more sparsely populated. They have retained relatively high fertility levels over the past dozen years or so, resulting in a

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Table 10.1 China: percentages of elderly populations by province, 1995

Source: calculated from the Tabulation of the 1 per cent National Sample Survey in 1995, pp. 2–10, The National Sample Survey Office (eds) Statistical Press of China, Beijing, 1997.

young age structure and a low level of demographic ageing. By contrast, the three municipalities (Shanghai, Beijing and Tianjin), have total fertility rates of about only 1.3–1.4, already amongst the lowest fertility levels in the world. Indeed, Shanghai’s rate of natural increase has been negative over five consecutive years, so it is projected that the ageing of the population there will remain among the highest levels nationally. It appears that there is still a decade or so before China as a whole faces a serious ageing challenge. However, large cities and eastern coast provinces with very low fertility and mortality rates already have an older population type. As a result, the pressure of population ageing in these areas will increase quickly and a number of problems associated with low fertility are emerging.

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Policies and programmes for older persons Traditionally, Chinese elderly people have received old-age support from their families since there were no social insurance and social security systems available for them. Shortly after the founding of New China in 1949, ‘Regulations on Labor Insurance of the People’s Republic of China’ were issued in 1951 and ‘Temporary Regulations on Retirement of the Staff and Workers by the State Council’ in 1958, which provided social security for income, medical care and social welfare for the majority of urban employees and workers. While farmers were allotted plots of land, social insurance in a real sense was not established in rural areas and the families and collectives provided support for the rural elderly population prior to the economic reforms of 1979. The state or the collectives have provided the ‘Five Guarantees’ to the childless and infirm old persons: food, clothing, medical care, housing and burial expenses. Many older people have been institutionalized in the nursing homes across the country. However, to date, and especially since the ‘responsibility system’ in agriculture, the coverage of social security in China remains relatively low, particularly in rural areas (Bartlett and Phillips 1997; Joseph and Phillips 1999). According to the 1994 Population Sampling Survey, which had a sample population of 1.29 million, including 124,114 old persons age 60 and over, many Chinese elderly depend principally on their children or relatives for economic support; one-third in urban areas and nearly half in rural areas. Income from older people’s own labour ranked the second (about one-fifth in urban and less than one-tenth in rural areas are self-dependent), and less than one-quarter of urban elderly people were dependent on pensions, social insurance and relief. Data and information from various sources, although collected and analysed on different bases, unanimously display a continuing close relationship between older persons and their families in present-day China. In particular, Lee and Xiao (1998), from national data, note substantial evidence of strong support for needs-based transfers from children to their elderly parents. They expect China’s further transformation to a market economy will stimulate intergenerational transfers among family members, thereby sustaining family support for older members. However, family size in China has been shrinking and the sharp declines in fertility will reduce the pool of adult children who might be involved in intergenerational support transactions. The average size of household in China, which stood at 4.33 persons per household in 1953 and 4.77 in 1964, had declined from 4.41 in 1982 to 3.97 in 1990 and 3.7 in 1995, and nuclear families made up 57.81 per cent. Single-person households and one-couple households in 1990 comprised 6.32 per cent and 6.48 per cent respectively. By 1990, single-old-person households and old-couple households had increased to 8.1 and 16.9 per cent respectively among the households with

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old persons, with two-generation and three-generation households occupying 24 and 50.4 per cent respectively. The already very large elderly population is expanding at an annual rate of 3 per cent. This combined with the low coverage of social security and the fact that the vast majority of elderly people in China remain dependent on family support, has meant that reform in old-age support and medical care security has been a major concern since the 1980s. The Ministry of Civil Affairs of China issued and carried out a nationwide ‘Basic Scheme for Rural Social Security for Old-Age Support at County Level’ in 1992, which stipulated that raising funds for old-age support should follow the principle of relying mainly on individual payment while, by policy, making collective compensation subsidiary to the state’s support. At present, there are still a few people in rural areas enjoying the advantages of this social insurance. However, reform has deepened in recent years in old-age support security and medical care for urban staff and workers. This has led to a national unifying of the security support system for older persons—originally managed by a number of different departments—with the issuing of the ‘Resolution on Establishing a Unified Old-age Insurance System for the Staff and Workers of Enterprises’ by the State Council in 1997. More than 400 cities across the country have established a lowest living cost security system by which local governments will meet the deficiency of those whose incomes are lower than the set standards for the lowest living expenses. In some provinces and cities, the lowest living cost security system is also implemented for rural residents. Nevertheless, family support is still mainly relied on by most Chinese older persons, whilst family support and social security for old age are integrated and protected by the Law for Protection of the Rights of the Elderly of the People’s Republic of China, implemented since 1 October, 1996. Currently, a number of experiments and improvements are being made in reforming the old-age support system in China, in the context of a market economy. In early 2000, the Minister of Labour and Social Security noted that, due to the poor operation of some enterprises, it was difficult to collect all fees for social insurance. A new tax to finance social security (pensions and unemployment) is therefore under consideration. The changing family life of elderly people in China As the largest developing country in the world, and because of the lack of formal social security and social services, the vast majority of Chinese elderly people have to depend on their family members in their later life. Therefore, the pattern of living arrangements and their changes have great impacts on the quality of life of older people. As an important step in tackling the emerging ageing issues, a new law on the Protection of the Rights and Interests of the Elderly came into force as of 1 October, 1996.

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Article 10 of the law stipulates that elderly people shall be provided for mainly by their families, and their family members shall take care of and look after them. Article 12 stipulates that the supporters shall pay medical expenses for elderly members suffering from illnesses and provide them with nursing care. To perform these duties, living arrangements of older persons become a key factor, affecting the care they may receive from their family members in daily life. In China, the social security system exists mainly in urban areas, but these cover only a quarter of the total population. For the majority of elderly people, especially those living in rural areas, children are still the best investment for old-age security (Lin 1994). Indeed, even in large cities today, many elderly people still believe that a son is their most reliable security for later life (Du 1998). In 1994, among all older persons aged 60 and over in China, 57.1 per cent depended predominantly on financial support from their children and other relatives and, in rural areas, this proportion reached 64.2 per cent. Research findings also reveal that elderly people who depend mainly on their children’s support usually live together with their children (Du and Wu 1998). Changing family size and living arrangements Using data from the 1982 and 1990 censuses, the general patterns of the living arrangements of the total population, change of family size and age distribution of household headship have been analysed (Ma 1984; Tian 1988; Zeng 1991; Wu and Du 1991; Yang 1992; Lin 1994; Guo 1995). These studies collectively provided a good picture of the changes in family structure and their impact on society. Overall, it is clear that, with the decline of Chinese fertility and mortality and the ageing of the population, changes are taking place in the structure of family types and in the size of family. The nuclear family is gradually taking the place of the extended family as the main family form. The proportion of two-generation families is steadily increasing. Small families with only one couple or a single person are increasingly typifying those for older people. The average size of Chinese family households is tending to reduce, and nuclear families are becoming the mainstay in Chinese family household types, accounting for 67 per cent (over two-thirds) of the total of families in 1995. Lineal families with three or more generations are the next most important family type, accounting for 17 per cent of the total of families. The distribution of family household types by the number of persons shows that the size of Chinese family households has shifted from the main form of four- and five-person households in 1982 to threeand four-person households. These two types of household account for half of the total of family households, so it is clear that household size is shifting downwards. The falling birth-rate reduces the number of

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children in each family who are able to shoulder the responsibility of supporting aged parents, and nowadays the young in each family have a heavier burden of old-age care. Under such conditions, the state and social security system should try to take on more economic responsibilities for the family whilst the family should be mainly responsible for attending to the moral and emotional needs of their older members. As the population ages, families without children or with only one child are also increasing in proportion and more and more old people will have no children or only one child to provide for them. However, in the 1990s, in terms of average size of family households with older people, these were generally two- or three-generation families, living with children. The 1990 average size of family households including elderly people aged 60 and above was 4.11 persons, higher than the average national size of 3.96 persons. Among them, older people living in twoperson families comprised 21.5 per cent and five-person families accounted for 17.9 per cent and six- or more-person families, 25.6 per cent. This reflects to some extent the universality of families with one couple and with three or more generations. The marital status of the old people has some impact on their family size. There are 50 per cent unmarried and 42 per cent divorced old people living a single life. The old people bereft of spouses generally live together with their children; only 17 per cent of them live separately; 83 per cent of them live in 2- and more-person families; whilst 73 per cent of them live in 3- and more-person families. It is clear that unmarried and divorced single old people are mor0e in need of care and help from society. Household size differs geographically, however, and family household size of those with older people shows that, in 1990, the average household size was 3.73 persons in cities, 3.75 in towns and 4.20 in counties. In the countryside, families with three and more generations were more frequent and birth-rates remain higher. Therefore, the family size of older people is larger in the countryside than in the cities. The proportion of older persons living in the families with four and more persons was 52.2 per cent in cities, 50.6 pre cent in towns and 58.6 per cent in counties. Likewise, the proportion of older people living in families of five and more persons is also greater in the countryside than in cities and towns. The life of the elderly population, their marital and family status are increasingly becoming a focus of attention in Chinese society. The family is the principal base of providing for older persons, and the marital and family status of old people has a direct bearing on their quality of life in their later years. In terms of marital status, in 1990, elderly people with spouses were in the majority; their proportion had markedly increased since 1982. The proportion of older people in other marital categories is on the decrease. For example, the proportion of those widowed declined by the biggest margin. These changes in marital status can have a positive influence on the life of older people. It is significant that although the proportion of single, widowed

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and divorced older people has decreased somewhat, the number of older persons in these categories increased because of the steady growth of the total elderly population. Unmarried and divorced older people are mostly males and the proportion of males in the unmarried aged population is still growing. Most unmarried old people in the countryside are males. In terms of the family status of older persons, apart from a few unmarried older people and families comprising one aged couple, the majority of older people are still living with their children in two, three or more generation families. With the advancement of age, the proportion of older people living in families of three and more generations continues to grow. There are some urban-rural differences, as more rural older people live with their children than their urban counterparts, which reflects the great difference in economic level and social situations between the two types of area. In terms of sex differences, more old females than males live with their children which has much to do with the income and social status of older people. One-child families In China, family support for elderly people has been considered the main alternative, therefore people, particularly in rural areas, want to have more children—especially sons—to take care of them when they become old. The traditional thinking based on thousands of years of feudal society still affects the rural masses for whom ‘the more children, the greater happiness’. However, the promotion of one couple, one child since the 1970s raises the question of who will support the parents when they become old (Wu and Du 1994; Phillips 1995). The questions raised by having only one child are more acute in cities than in the countryside because, up until now, most peasant women have been permitted two or even three children. However, in the urban areas, particularly the metropolitan cities, women predominately have only one child. In Shanghai, for example, the proportion of families with only one child is as high as 70 per cent and in Beijing, in 1990, 56 per cent. If the city itself, excluding the suburbs, is considered, the rates are much higher. Single children have sometimes been labelled ‘Little emperors’ and some people are concerned that China will bring up a generation of spoilt children. They fear a generation of selfish individuals, unable to cooperate and unwilling to take care of their old parents and relatives. Others suggest that the Chinese family is in a stage of transition from traditional to modern, and children are still seen as important as heirs to continue the family line, or as security for the future, so parents are becoming more child-centred than before. In the cities, as the number of ‘only child’ families increase, many people raise the problem of the future ‘4–2-1’ pattern of family support; this is to say, the ‘only child’ generation may have to look after two sets of grandparents (four people) and their two parents whilst, as lifespan

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increases, many might have to take care of several great-grandparents, even though they live in separate residences. Although family support is very important, given decreasing fertility and the nuclearization of family, depending solely on family support is definitely not enough, and often taking care of elderly members may impose too heavy a burden on children and family members even if they want to do their best. The reform of social security and social service systems is one of the priorities in China today and the guidelines have suggested that support of elderly people should be shared jointly by state, community and family. The most crucial challenge in population ageing will arise early in the twenty-first century, when the baby boom generation reach old age, and the ‘baby bust’ generation will have a hard task supporting them unless preparations are worked out beforehand. Families are providing not only income security to older members but also daily life and emotional care which cannot easily be substituted. However, the world is changing, because of industrialization, migration and the modernization of lifestyles; many in the children’s generation are unwilling to support their older members. The lack of social security and social services mean that the Chinese elderly have to seek support from their family, and it is a preoccupation for them to have children, especially a son, to respect them and ensure the family support they need. Otherwise, they risk there being no family member to take care of them in later life; much evidence of this can be seen in the 1992 Beijing Multidimensional Longitudinal Survey of Ageing. In the Beijing Multidimensional Longitudinal Survey, most elderly respondents (63.8 per cent) agreed that it was important to have a son to protect one’s old age whilst only 21.4 per cent disagreed (Myers and Du 1996). Almost half agreed that young people today have less respect for the elderly, in the process of rapid industrialization, modernization and urbanization in China. Perceptions of the young generation are changing dramatically. Young couples are much more educated, many prefer smaller nuclear families and not to live with parents to avoid family conflicts. They want to send children to kindergartens to receive better pre-school education instead of leaving them at home with their grandparents, because the grandparents will often spoil them. In addition, most of the young generation think the experiences of elderly people are irrelevant today; while the old generation still adheres to stereotypes of the generations prior to them. This is manifested in the answers of many elderly respondents stating that having a son is to protect one’s old age; children should give money to older parents to show concern and respect, and children should respect the views of their parents and ask for their opinions first in family affairs and act in accordance with them. As a result, the generation gap tends to enlarge. By 1994, even more elderly people believed that having a son was to protect one’s old age (the proportion agreeing with this opinion increased from 63.8

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to 73.6 per cent, a 10 percentage point change). It seems that as older people age, they become more and more convinced that only their sons will provide security in later life. Filial piety has been regarded as one of the traditional virtues in China for thousands of years. At its core it should provide for and respect the elderly, and it has played a key role in reinforcing family support. However, by modern standards, some aspects of traditional filial piety may be abandoned. For example, among the twenty-four classical examples of filial piety in history, some require absolute obedience to parents, which is often deemed unsuitable in modern society. In 1991, a famous Chinese magazine, Family, conducted a survey among its readers, the majority of whom stated they wanted to practise filial piety which indicates that filial piety is still a dominating ethical principle in China today, even if not always practical. The government is promoting filial piety as one of the ways to solve the issue of family support to the elderly, although in the past the state was held as a major component. Nevertheless, in the course of society transformation from a planned to a market economy, many changes are eroding the practice of filial piety. First, the awareness of providing for elderly people is fading. More and more children are tending to live separately from their parents; they are independent economically and it is common to witness obvious differences of living standards between children and their parents, so many elderly regard themselves as a burden on their children. Second, there is a traditional Chinese belief that the premise of filial piety is that ‘do not go far when parents are alive’. However, about 100 million young people are among the ‘floating population’ in cities and developing areas, leaving their old parents at home. This trend makes it difficult to practise daily care for parents. Third, the numbers of the very old elderly are increasing rapidly, many of whom are living in an ‘empty nest’ family with no child, so older persons cannot depend on the support and care of their children any longer. Fourth, the status of elderly people is becoming lower and their economic power is weaking, so the younger generation is gradually playing a dominant role in the family. Older persons often find themselves in passive and obedient roles. All of these changes indicate that it is not sufficient to promote only filial piety and family support for older people. In addition, relevant national policies, social security systems and various community services must be developed as soon as possible. Ethnic differences in ageing The population of China consists of fifty-six nationalities. The size of their populations varies and the number and proportion of elderly people in each nationality also vary greatly. According to the 1990 fourth national population census, the population of minority nationalities was 91.2 million;

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people of Han nationality accounted for 91.96 per cent of China’s total population and minority nationalities accounted for 8.04 per cent. The Zhuang nationality is the largest of the national minorities, with more than 15.41 million. The smallest national minority has only about two thousand people. The distribution of nationalities in China is uneven and shows a clear geographical picture. The Han nationality people live mostly in the east and central parts of China, while people of national minorities live mainly in western, southern and remote regions. As a result of differences in fertility and mortality levels and in socioeconomic development, the age structure of the population varies with nationalities. The proportion of elderly people among the various nationalities varies considerably. In 1982, the proportion of Han people aged 60 and over was 7.69 per cent, slightly higher than the national average (7.64 per cent). Elderly people of all the other fifty-five national minorities account for 6.88 per cent of the total population of all minority nationalities, a lower proportion than in the Han group. Among the minorities, the Russian nationality had the largest proportion (11.48 per cent) of elderly, whilst the Elunchun nationality had the smallest (2.49 per cent). However, both these nationalities have a very small population. The proportion of older persons ranges from 5 to 8 per cent among the other national minorities. It is thus clear that the size and proportion of China’s elderly population are determined principally by changes in the population of the Han nationality. According to the 1990 census, the proportion of elderly population aged 60 and over increased to 8.57 per cent whilst that of the Han nationality was 8.67 per cent, higher than the national average. Older people in all fifty-five national minorities represented only 6.94 per cent of their total. Compared with the 1982 census, the elderly proportion of both Han nationality and minority nationalities are increasing, but the Han’s rate of ageing is much faster than that of the minority nationalities. Large differences occur among minority nationalities themselves. There were nineteen nationalities with populations of more than one million in 1990 and, among them, ten nationalities’ elderly proportion increased during the period 1982–90 whilst nine decreased. Therefore, not every nationality in China is ageing. The nationalities whose elderly proportion decreased were mainly those of small sized populations so although their elderly proportion decreased, the influence on that of all fifty-five minority nationalities was limited, and the elderly proportion of all fifty-five minority nationalities is still, on average, increasing. As would be expected, the nationalities whose elderly proportion is decreasing are mainly those with fast growing populations. For example, the Manchu nationality, with a population of 9.82 million in 1990, saw its population increase by 128 per cent between 1982 and 1990. The period 1983–7 saw the fastest growth of minority nationalities in history, with an annual average growth rate of 50 per thousand. This was

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caused mainly by the nationality identification policy carried out between 1982 and 1987, when about 10 million Han population changed their nationality to minority ones. Its influence on population growth can be found easily in Manchu, Tujia and some other nationalities. That the majority of national minorities have a lower proportion of elderly compared with that of the Han nationality or the national average can be explained by higher fertility levels and a younger age structure among the national minorities. The government of the PRC has given priority to the development of minority populations, and different population policy has been implemented among the national minorities, even when strict family planning policy has been practised among people of the Han nationality in order to control the overall national population. During the earlier periods, family planning policy was not implemented in regions where the people of national minorities reside, while more recently, family planning has been encouraged in accordance with the conditions of each national minority. However, the regions where people of national minorities live are still less developed economically and the population transition is still at an early stage, with relatively high birthrates and death-rates starting to drop. For example, in Ningxia, Qinghai and Xinjiang, the proportions of children in 1990 were above 30 per cent and the proportions of people aged 60 and over around 6 per cent, the lowest proportion of elderly population in the country. The nationality differences in socioeconomic development, family planning practice and patterns of population reproduction will not disappear quickly. Therefore, the younger age structure of national minority populations compared to that of the Han nationality will continue for a prolonged time. Future training and resource needs As the absolute number and the proportion of the older population become larger and larger, their support will have to be provided by the combined efforts of individuals, families, community and society. Therefore, many of the functions of elderly support exerted soley by family will be more socialized and provided by the market. However, the corresponding social and market mechanism has not yet been cultivated and formulated, and policy, organization and personnel still do not meet the needs. Training for administrators, managers, service providers and researchers in this field is one of the major tasks. In recent years, there have been activities such as short courses on ageing (or on social gerontology), international study tours on ageing to Malta, Hong Kong, Thailand, Japan and the United States, and broadcasts, television programmes, books and materials on ageing issues have been produced. All of these efforts aim to train more specialized personnel. However, compared with the needs of society, these training activities are definitely insufficient and the government and NGOs still have a long way to go.

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For example, at a tertiary education level, the People’s University of China began a course in social gerontology in 1994, but it is still the only one to date in China to train undergraduates. This indicates that although China has paid great attention to family planning and population control, the college education system has not changed in preparation for an ageing society. In many Western countries, gerontology or social gerontology courses are very common in university campuses. China should establish the field of gerontology in higher education (currently not available), in order to promote education and training on ageing. At the same time, multilevel training activities are also very important in China, especially for government officers working on commissions on ageing affairs at various levels and areas. Conclusions and overview of future issues In the process of population ageing in China, the average household size is getting ever smaller. The key factors affecting family household size are fertility decline and changes in people’s perceptions. This trend has been affecting the foundation of traditional family support for older persons. It is inevitable that family support in China, particularly in rural area, will be needed for a considerable time to come, and most older persons can only be provided for mainly by their family. The functions of family support include providing for (income security), taking care of (physical care) and comforting older members, and some of these functions performed by the family will be very hard to replace. However, it is getting difficult for families to satisfy the needs of their elderly members in all three respects without the government’s policy and community services. On the other hand, most of the younger generation still consider that taking care of their elderly is their responsibility. Therefore, family support can be maintained for a long time, especially in the rural areas, as long as suitable policies are carried out. Currently, almost all elderly people have many children and, on average, four children are still alive, which means all children can share the responsibility of care. Therefore, elderly persons currently have sole caregivers and primary caregivers as well. However, as the nuclear family increases, so the family support system is being shocked, and the present rapid drop in fertility and the norm of small families are presenting one of the greatest challenges to the future of the family support system. The key problems of support for older persons in China’s ageing society are low incomes and low efficiency and many caregivers are in financial difficulties. To solve the low-income problem of the caregivers as well as of the older people is a top priority today. Research and policy-making on China’s elderly support issues are related to a number of major issues: (1) the needs of older persons in economic terms, daily care and mental health, which are ordinary issues for the

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elderly; (2) the influence of rapid population ageing, which is not confined only to elderly people but also relates to the other sections of the population; (3) impacts due to changes during the transition from a planned ecomony to a market economy; (4) influences of sociocultural changes with regard to elderly people, families and intergenerational relations. According to the theme of the International Year of Older Persons ‘Towards a Society for All Ages’, older persons should share the benifits of development instead of losing out and and being impaired. China is just entering its stage as an old population type country and faces a rapid ageing process and yet heavier degrees of ageing. Therefore, China needs to establish a social support system along with promoting, rejuvenateing and facilitating the support function of family. As for the future issues related to population ageing, the following are likely to be given top priority in China’s research agenda: • • • • • • • • • • • •

Changing family structure and its influence on family support for older persons. What is the role of government in solving ageing issues and what should be the national policy? The situation and support of rural elderly people. How can the social service system be improved and financed? Ageing of the labour-force and its influence on socioeconomic development. How can best use be made of cultural traditions in dealing with ageing issues? Is the status of elderly people reducing or changing? How to improve the social security and medical security system? How can active healthy ageing be achieved? What can be done to meet the special needs of older persons? Ageing industries: markets and policy. How can the legal system be improved to protect the rights and benefits of older persons.

References Banister, J. and Harbaugh, C.W. (1994) China’s family planning program: inputs and outcomes. CIR Staff Paper No 73, Washington, DC: Center for International Research, US Bureau of the Census. Bartlett, H.P. and Phillips, D.R. (1997) ‘Ageing and aged care in the People’s Republic of China: national issues and local perspectives’, Health and Place 3, 3:149–59. Chow, N.W.S. (1999) ’Aging in China’, Journal of Sociology & Social Welfare 26, 1: 25–49. Du Peng (1998) ‘Change of living arrangements of Beijing elderly’, China Population Science 2:36–40. ——(1994) The Process of Population Ageing in China, Beijing: People’s University Press.

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Du Peng and Wu Chao (1998) ‘Analysis on the economic resources of Chinese Elderly’, Population Research 4:41–7. Guo Zhi-gang and Chen Gong (1998) ‘Monetary flows between children and their old parents’, Population Research 1. Guo Zhi-gang (1995) Contemporary Population Development and Family Household Changes in China, Beijing: People’s University Press. Harper, S. (1994) ‘China’s population: prospects and policies’, in D.Dwyer (ed.) China: the Next Decade, London: Longman. Joseph, A.E. and Phillips, D.R. (1999) ‘Ageing in rural China: impacts of increasing diversity of family and community resources’, Journal of Cross-Cultural Gerontology 14:153–68. Kwong, P. and Cai, Guoxuan (1992) ‘Ageing in China: trends, problems and strategies’, in D.R.Phillips (ed.) Ageing in East and South-east Asia, London: Edward Arnold. Lee, Yean-Ju and Xiao, Zhenyu (1998) ‘Children’s support for elderly parents in urban and rural China: results from a national survey’, Journal of Cross-Cultural Gerontology 13, 1:39–62. Lin Jiang (1994) ‘Parity and security: a simulation study of old-age support in rural China’, Population and Development Review 20, 2:423–48. Ma Xia (1984) ‘Change of family size and family structure’, in State Statistical Bureau (ed.) Census of One Billion Population, Beijing. Myers, G.C. and Peng Du (1996) ‘Living arrangements among Chinese older persons’, paper presented at the 1996 Annual Conference of American Association of Gerontology, Washington, DC. Phillips, D.R. (1995) ‘A nation of pensioners’, China Now, no. 152:8–9 Tian Xue-Yuan (1988) ‘Report on China’s 1987 aged population over 60 years: sampling survey data’, Population Science of China, Special Issue, 1, January. Wu Canping and Du Peng (1991) The Ageing of Population in China, Malta: INIA (UN International Institute on Ageing). ——(1994) ‘The demographic aspects of population ageing in China: social and economic implications’, in The Demographic Aspects of Population Ageing and Its Implications for Socioeconomic Development, Policies and Plans, Malta: INIA and CICRED. Yang Haiou (1992) ‘Population dynamics and kinship of the Chinese rural elderly: a microsimulation study’, Journal of Cross-Cultural Gerontology 7, 2:135–150. Zeng Yi (1991) Family Dynamics in China, Madison: The University of Wisconsin Press.

11 Ageing and aged care in Taiwan Helen P.Bartlett and Shwu-chong Wu

Introduction Taiwan is the second most densely populated major area in the world, with a total population of 21.7 million in 1998. Its economic transformation in the 1970s has been described as a miracle, transforming Taiwan’s society from a primarily rural and agricultural base to one that is increasingly urban and industrial. The expansion of employment opportunities created unprecedented development in the economy, prompting upheavals in the traditional social structure. The process of modernization resulted in a challenge to traditional social values, at the heart of which was respect to older people. A dramatic increase in the number and proportion of older people in the population has moved Taiwan into an ‘aged phase’. Changes in family structure, increased labour-force participation of women, declining birth and death rates, have all reduced the available resources for taking care of older people at home. Expectations of depending on children for support in old age have also reportedly declined in Taiwan (Thornton et al. 1994). These changes present considerable challenges to meeting the needs of Taiwan’s ageing society as it enters the twenty-first century. Legislation to provide services for older people was introduced in Taiwan in 1980 through the Welfare Law for the Aged, and in recent years the implications of Taiwan’s ageing population have been increasingly recognized in policy and planning. Reflecting the increasing prominence of caring for an ageing population on the policy agenda, the Welfare Law for the Aged was amended in 1997. This delineated the types of services provided under the social welfare system more clearly and introduced penalties for unlicensed nursing homes. In addition, the implementation of National Health Insurance in 1995 has increased the accessibility of medical services to the older population. The objective of this chapter is to examine the demographic and health trends of Taiwan’s older population; outline both informal and formal care provision; and against this background, identify the key issues for policy and practice which are challenging Taiwan as it moves into the twenty-first century.

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Demographic profile In common with many other newly industrialized societies, Taiwan has undergone rapid demographic and socioeconomic changes. Fertility rates have decreased significantly from 5.9 children per woman in 1949 to 1.77 in 1997 (Ministry of the Interior 1997). As a consequence, the ratio of adult children to older parents will fall sharply in the future. Mortality rates have also declined, with life-expectancy at birth between the years 1951 to 1998 increasing from 53.4 years to 72.0 years for males, and from 56.3 years to 77.9 years for females. Leung et al. (1999) note that there has been a gradual decrease in the sex difference associated with life-expectancy, although women still live longer than men. The fertility and mortality changes have resulted in an older age structure, with 8.1 per cent aged over 65 in December 1997. By the year 2000, this is expected to rise to 8.5 per cent (Table 11.1). A further increase to 21.7 per cent is predicted by the year 2036. Of particular significance within the population of people aged 65 and above is the steadily growing proportion of those aged 80 and over which has risen from 9.2 per cent in 1960 to 13.7 per cent in 1994. It is projected that by 2010, this group will represent over one-fifth (20.96 per cent) of the older population and by 2036 it is expected that almost one-quarter (23.8 per cent) of the 65+ group will be aged 80 or over. A further demographic trend to note is that around 22 per cent of the older population is comprised of people from mainland China, a consequence of the migration of some one million Nationalist military and civilian supporters in 1949 and for several years after. As the majority of these migrants were male, this has been reflected in sex ratios during the 1990s. In 1990, there were 14 per cent more males than females and this Table 11.1 The growth of the elderly population in Taiwan: 1905–2036

Adapted from: Wu and Chang (1997).

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increased to 20.74 per cent in 1994. By 2000, the figure is estimated to fall to 11 per cent, before returning to a ratio weighted in favour of the female population (Leung et al. 1999). The Mainlanders have a distinct history, with different attitudes and patterns of family formation. Many of the males are single and childless (Hermalin et al. 1992). In this discussion of demographic trends, it is therefore important to recognize that two distinct and contrasting groups exist among the older population, the Taiwanese and Mainlanders. Compared with the younger cohorts in the population, a much higher proportion of those aged 65 and over have received no formal education. While the figure has improved from 87.96 per cent in 1956, in 1994 there were still over one-third of older adults who had received no formal education. However, the level of education is expected to improve considerably in the future. Health status The growth in Taiwan’s older population has been accompanied by an increase in certain chronic conditions and functional disabilities. In a survey of 3,055 non-institutionalized people aged 65 and over (Wu and Chang 1997), rheumatoid arthritis, hypertension and cataracts were the three most prevalent diseases amongst elderly people (Table 11.2); over three-quarters had suffered from one or more chronic disease and almost a half had two or more chronic diseases. Leung et al. (1999) note that cancer mortality continues to increase and that diabetes mellitus has emerged as another chronic disease, especially in older women. In addition, injury-related mortality in older people doubled between 1974 and 1994. Nevertheless, mortality from strokes in older people has halved in the past 20 years and hypertensive disease mortality had declined to a lesser degree. Improvements in lifestyles, increased accessibility to health care and health promotion programmes targeting these diseases are all likely to have played a part in improving these mortality figures (Leung et al. 1999). The measurement of functional disability has been used to estimate the need of a representative sample of 2,892 non-institutionalized elderly people for home or community-based long-term care (Wu et al. 1996). Disability in one activity of daily living (ADL) was experienced by 6.7 per cent, and 14.8 per cent were disabled in either one ADL or one instrumental activity of daily living (IADL). These figures increased significantly with age and differences between males and females were also found. For example, approximately one-third (33.1 per cent) of males and 46.8 per cent of females aged 80 years or over had one ADL or IADL (Table 11.3). Between 6–14 per cent of non-institutionalized elderly were found to have physical disabilities by Wu et al. (1996). A national survey of older people in 1991 estimated that 60 per cent were not in good health, although they could manage their daily routine and 3 per cent were unable to look after

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Table 11.2 Self-reported chronic conditions among non-institutionalized elderly people in Taiwan

Source: Wu and Chang (1997).

Table 11.3 Prevalence of functional disability among non-institionalized older people in Taiwan (%)

Source: Notes:

Wu et al. (1996). *ADL items: eating, transferring, dressing, toileting, bathing. **IADL items: shopping, laundry, preparing food, light housework, travelling, using telephone, finance management, taking medication.

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themselves (Directorate General of Budget, Accounting and Statistics 1991). The number of people in need of personal care assistance totalled approximately 90,000 in 1992, but Wu and Chang (1997) predicted that this would increase to 200,000 by 2010, and 500,000 in 2036. Health surveys have found consistently poor health behaviours among the older age group. The work of Wu and Chang (1997) confirms that there is still considerable scope for health improvement. For example, over onequarter (26.5 per cent) of older people smoke very often or frequently. Males are much more likely to smoke than females, some 43.1 per cent compared with 4.9 per cent. Around 5.3 per cent, the majority male, state that they consume a lot of alcohol. No exercise is reported to be taken by 38.1 per cent. Previous studies revealed that 33 per cent had a high salt diet and 27 per cent eat high cholesterol foods (Department of Health 1994). In the White Paper published by the Department of Health in 1994, health promotion strategies for older people are defined and include prevention of accidents and injuries, oral hygiene, vision promotion and health examination. The National Health Promotion Plan addresses the prevention and control of diseases in the older population, specifically major risk factors such as blood pressure, blood sugar and cholesterol. Key health promotion initiatives for older people during 1997 included: the publication of guidelines on the prevention, control and treatment of diabetes, osteoporosis and hypertension; educational activities and screening for hypertension, blood sugar and blood lipids for those aged over 40; teaching and patient education; health promotion centres for diabetes; the development of screening programmes for hypertension in voluntary organizations and churches; and occupational programmes in the prevention and control of hypertension (Department of Health 1998). A new preventive strategy commenced in 1999 is the administration of influenza vaccine to high-risk groups of older people, including those living in nursing homes, hospitals and those with certain chronic diseases. Informal care and financial support Family care Informal care-giving by family members has been the traditional form of long-term care in Taiwan and other Asian countries influenced by Confucianism. The mutual obligation that characterizes filial piety (Li 1997) has provided a firm basis for the provision of continuing care for frail elderly parents. Indeed, some 65.7 per cent of older people in Taiwan live with their adult children (Ministry of the Interior 1990) and studies have found that the majority of older people prefer to live with or nearby their children. In a survey of public attitudes towards long-term care, 56 per cent suggested that families take care of their dependent elderly in their own home; 32 per cent

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suggested community care; and only 10 per cent suggested institutional care. Respondents in the oldest group selected institutional care (Wu and Chu 1996). The main reasons identified by a Taipei survey for older people not living with their children were: childlessness; children living overseas; or accommodation too small (Chan 1992). Space constraints are also noted to contribute to declining co-residence, especially in urban areas (Li 1994). The increasing burden on caregivers has been well documented in recent years (Hu 1995; Wu and Lin 1999). Only around 3 per cent of older Taiwanese are estimated to be institutionalized, with over 80 per cent of those with disabilities being cared for by their own family without any formal support. In a national survey of older disabled people (Wu and Lin 1999), the daughter-in-law was found to be the primary caregiver in over one-third of cases (34.1 per cent), followed by the spouse (30.4 per cent). Sons and daughters were the primary caregivers in only 14.1 per cent and 13.8 per cent of cases respectively. Unsurprisingly, the majority (71.7 per cent) of primary caregivers were female, married (85.2 per cent), and had received no formal education (32.1 per cent) or elementary education only (34.1 per cent). In 91.7 per cent of cases, caregivers typically lived with the older person and some 44 per cent had been caregivers for over five years. Almost three-quarters (72.7 per cent) of caregivers were under the age of 65 and many (38 per cent) therefore also had child care responsibilities. Almost one-third (32.8 per cent) of primary caregivers were also in full-time work and suffered work conflicts (18 per cent) as a consequence. Almost onequarter (24 per cent) indicated that they had left their jobs to meet the demands of care-giving. Various forms of assistance were needed by caregivers, including accident prevention (70 per cent), respite care (42 per cent), social support, counselling and leisure activities. The impact of caring on the health of carers is of particular concern. Some 29 per cent of caregivers rated their health as ‘poor’, and a further 48.3 per cent considered their health to be ‘fair’. Despite the intention of the amended Welfare Law for the Aged (1997) to introduce a caregiver’s allowance, this has not yet been implemented. Very little has been discussed about the impact of the traditional family model on older people themselves or women, and the orthodox view that older people are better off in the East than the West is not necessarily supported by recent research. Despite attitude surveys showing a preference for living with children as an ideal state, various challenges to the Asian pattern of living as a cultural preference have been made (Hu 1995). An examination of elder suicide trends raises many questions about the quality of life experienced by older people living in the model Asian threegeneration family. For example, Taiwan has the highest elder suicide rates recorded in any Eastern or Western country. The number of suicides per 100,000 people aged 65 and over is 47.3 in Taiwan, slightly higher than Japan at 45.7 and over three times greater than the UK figure of 15.1. The

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rate is considerably greater in males (56.1) than females (38.1). Interestingly, this trend is not apparent until after the age of 65, the young (25–44) suicide rate being one of the lowest in the world. Possible explanations may be found in the family care-giving context; specifically the strains experienced in relationships with daughters-in-law (Lee et al. 1993). Hu (1995) has argued that as sons and daughters are not really the primary caregivers, family burden has not featured strongly in the policy debate and ‘the problem…is completely sealed into the private family business and thereby makes it more the object of generational and gender bargaining inside the individual family’. The breakdown of care-giving in Chinese society is complex and the decision to institutionalize, when it happens in any society, is not easy. It involves breaking and rebuilding harmony and in Taiwanese society the consequences are only just beginning to be understood (Kao and Stuifbergen 1999). Despite the traditional values, acceptance of institutional care is gradually increasing in Taiwan. In a study by Wu et al. (1994), 20 per cent of a sample of older people expressed a willingness to reside in a nursing home if ill or in need of long-term care. Furthermore, nursing home entry in Taiwan has been found to be influenced by the strength of intergenerational reciprocity (Wu et al. 1997). In a comparative study of institutionalized and noninstitutionalized disabled older people in Taipei, those who had provided instrumental assistance to their families before they were disabled were less likely to be admitted to a nursing home. Economic support Over half (52.3 per cent) of the population aged 65 and over in Taiwan are financially dependent on their children (Directorate-General of Budget, Accounting and Statistics 1999). This is unsurprising given that the provision of old-age pensions is not universal throughout Taiwan, being organized by each county and city government. A national pension system was due to be implemented in 2000, but plans for this have been postponed due to the economic consequences for Taiwan of its disastrous earthquake in 1999. People insured under the labour insurance scheme receive old-age benefit, paid in a lump sum on retirement at age 60 and government employees are entitled to receive a retirement pension at age 65. The number of claimants has increased markedly under both schemes over the past decades, in line with ageing trends (Chan 1992). An important development for older people has been the introduction of National Health Insurance in 1995 which provides complete medical services in case of sickness, accident and injury (Department of Health 1998). Prior to this, according to the Taipei Study on Gerontology, only around 15 per cent of older people were covered by any form of government or private health scheme (Chan 1992). The types of health care reimbursed

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for older people include: ambulatory care, inpatient care, Chinese medicine, dental care, rehabilitation, disease prevention and health promotion, and home care. People aged 70 and over, as well as those with moderate to severe disabilities, do not have to pay a premium. However, co-payment of between 5–30 per cent is required for in-patient care depending on the type of care and length of stay. Co-payment is also required for ambulatory care and is calculated on a fee per visit. However, co-payments are also waived for people on low income, veterans and their dependants and aboriginal residents. Long-term care Services for older people in Taiwan are organized separately under both the health and welfare systems. Four categories of services are provided under the social welfare system: skilled nursing facilities, intermediate care facilities, residential homes, and community and home care agencies. However, under the health care system, three types of services are offered: skilled nursing homes, adult day care centres, and home health care agencies. Overview of service provision In 1996, there were around 20,000 beds in Taiwan providing long-term care, the majority being located in Veteran Affairs hospitals or general hospitals (Wu and Chiang 1995). Approximately half were categorized as extended hospital beds. Only 15 per cent belonged to certified nursing homes, while the remainder were in non-certified facilities. This limited supply has resulted in a large proportion of hospital beds being occupied by long-term care patients. A survey in 1991 found that of 15 per cent of hospital discharges aged 65 and over had stayed in hospital for more than thirty days (Department of Heath 1991) and in Taipei, 15 per cent of acute beds were found to be inappropriately occupied by older people (Yen et al. 1996). Residential care homes are provided on a small scale for homeless aged people by county authorities and some voluntary and private welfare agencies. The demand for nursing-home care has increased as the residents in these facilities have aged and their dependency levels increased. Nursing homes have therefore been established under the welfare system as special units within residential homes and also as free-standing facilities. Most homes under the welfare system are public or non-profit-making. The health care system has also been encouraged to develop long-term care facilities. An experimental project for nursing homes commenced in 1991. The first legally registered home provided under the health system was established in 1995. The early homes include: the Cardinal Tien Hospital of Taipei, the Wei-Kung Hospital of Miaoli County, and the

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independent nursing home called Chiang-Chin Nursing Foundation. Incentives for medical care institutions were introduced to encourage them to set up nursing homes, and between 1995 and 1997, twenty-five nursing homes affiliated to medical institutions were approved. In July 1999, under the health care system, there was a total of 101 nursing homes with 4,308 beds, and under the social welfare system in May 1999 there were 123 old people’s homes providing 7,615 beds. However, many facilities are not yet authorized by the Department of Social Welfare or the Department of Health; in 1996 some 31 per cent of institutionalized older Taiwanese lived in unauthorized facilities. According to survey data provided by the Federation of Welfare Society for Aging in Taiwan, in May 1999 there were 710 uncertified homes with 22,022 beds. Many of these homes are in the process of becoming registered because of the penalties recently introduced under the Welfare Law for the Aged. Unfortunately, many uncertified homes are often associated with poor quality. Despite recent developments, nursing-home provision in Taiwan is limited (Wu and Chiang 1995). However, as families still prefer to keep their older members out of institutions, the nursing home is becoming an alternative to hospital. A major reason for the slow development of longterm care facilities outside hospitals is that the cost of such care has not been covered by National Health Insurance (NHI). The NHI was designed primarily for acute medical services. However, the importance of the private sector in developing long-term care in Taiwan is recognized, and incentives to facilitate their participation are being actively developed. From 1996, the cost of medical and nursing care services in nursing homes can be reimbursed under the National Health Insurance Program. Day care centres that follow a health model are a fairly recent phenomenon in Taiwan and are mainly attached to hospitals. There are currently twelve providing around 300 places. A few care centres provided by the welfare system have been developed since 1988 supported by the Taipei City government. Centres provide health checks, meals and entertainment. Five additional day care centres are currently being planned in Taipei. In 1997, a total of 256,132 visits were paid to day care centres. Recreation centres are more widespread and are run by organizations such as the Evergreen Academy and Community Longevity. In 1997, nearly 188,398 people enrolled in classes provided by 302 Evergreen Academies. Recently, government facilities are being made available to the private sector to provide day care and recreation centres. Little attention has yet been paid to developing housing programmes for retired older people and consequently there is a shortage of independent living accommodation for older people wishing to live separately from their family, or for those without family. A few large complexes of senior citizens’ apartments have been developed in Taipei City and County, Kaohsiung

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County and Tainan City. Only older people in good health and able to handle daily chores qualify for residency. Health care support to older people at home is a fairly recent phenomenon, initiated in 1989 with the home health care experiment. Home care services are provided by either free-standing or hospital-based centres. Because home health care in the form of visiting nurses and physicians is now paid for by National Health Insurance, this resource has increased considerably in the past few years. In March 1999 there were 214 home health agencies provided under the social welfare system. Home social care has been slower to develop and is available only for older people with low incomes, around 1 per cent of the older population. However, the City government in Taipei offers all disabled older people 16 hours of home social care per month, although continued funding of this facility in the future is uncertain. Long-term care policy Strengthening long-term care has become a priority policy issue for the government. The value of various forms of long-term care has been recognized and is being taken into account in the development of a comprehensive long-term care system. The importance of community and home-based care is also being increasingly emphasized. Both the Department of Health (1998) and Ministry of the Interior have taken responsibility for planning a long-term care system to meet the needs of Taiwan’s older people. Their strategy addresses a range of long-term care issues, including: 1

2

3 4

Planning for a long-term care system: two three-year plans involving development of institutional services, protection of older people living alone, standards for nursing homes and a review of existing regulations. Long-Term Care Service Network and Care Models: including home care, nursing homes, day care centres, public hospital long-term care, discharge planning, care for respirator-dependent patients, more beds for chronic patients. Development of long-term care workforce: to address the training of nurses and long-term care workers. Quality assurance of long-term care: including assessment, standards, supervision of nursing homes; guidelines on operational models for nursing homes.

Considerable progress has been made with various aspects of the long-term care plans. Based on the Nurse’s Law of 1991, a set of standards for nursing care institutions was announced in 1993 and amended in 1996. These made provisions for the standards, registration and monitoring of nursing care

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institutions. Guidelines have been produced on both the operation of nursing homes, and their design and construction. In addition, as the dependency levels of the older population increase, training and education of long-term care workers is required. This will be vital for nursing-home staff, where around half of the residents are cognitively impaired (Wu et al. 1998). The need to assure the quality of long-term care is recognized, but processes are still under development and the emphasis is currently on structural aspects of care, rather than process and quality of life. If standards and quality of care are to be effectively monitored in the long term across different types of long-stay settings, comparable nationwide indicators will be necessary. The development of a Minimum Data Set could provide a mechanism for assessing ADLs across settings and provide the kind of information that will be helpful for evaluating progress and outcomes at a national level. Future issues for policy and practice There are several important policy concerns to be addressed if the future needs of the older population in Taiwan are to be met. As traditional forms of care for older people come under pressure, careful consideration needs to be given to the most suitable models of long-term care for the future. The extent to which it is appropriate to reinforce the role of the family in providing long-term care will need to be carefully considered. Martin (1988) identifies some of the problems associated with using the West as a model in developing policies for the older population in Asian countries, and the need to balance the public safety net with encouraging family care and involvement. The question of age versus need is also raised by Martin as an important one for countries such as Taiwan to consider in the development of their programmes. There will be many other issues to address, including the coordination of formal and informal, public and private, and health and social sectors of care. If the private sector continues to develop, as it has in other parts of Asia such as Hong Kong (Bartlett and Phillips 1995), then the development of quality standards and education and training for care staff will need urgent attention to safeguard the interests of older people. These are key issues for the UK which has an established mixed economy model of long-term care and in 2000 is set to introduce national required standards and a new regulatory framework (Bartlett and Burnip 1998). In 1995, Wu and Chiang (1995) identified the major policy issues as: lack of long-term care resources; inappropriate use of hospital beds by long-term care patients; management of long-term care by two different bureaucratic systems; and lack of financial planning for the provision of long-term care services. More recently, the need to develop home and community care resources has been highlighted, in addition to questions of access to care, cost and quality evaluation. Financing long-term care, particularly the

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implementation of long-term care insurance, is a major policy issue for Taiwan. To inform the development of an effective long-term care system, the Institute of Health Policy and Management at the National Taiwan University is embarking on a five-year programme of research. This will (1) assess the patterns of long stay and discharge in acute care across different types of hospital, (2) assess the quality of care in different long-term care settings, and (3) assess the cost of care in different long-term care settings. References Bartlett, H. and Phillips, D.R. (1995) ‘Regulating residential aged care homes in Hong Kong: issues for the Asia-Pacific Region’, Asian Journal of Public Administration 17, 2:131–247. Bartlett, H. and Burnip, S. (1998) ‘Quality of care in nursing homes for older people: providers’ perspectives and priorities’, NT Research 3, 4:257–68. Chan, H.S. (1992) ‘Ageing in Taiwan’, in D.R.Phillips (ed.) Ageing in East and South-east Asia, London: Edward Arnold. Department of Health (1991) A Report on the Morbidity Survey in Public and Private Hospital Clinics: Taiwan Area, R.O.C.Taipei: Department of Health, Executive Yuan. ——(1994) Toward the Goal of Health for All—a Health White Paper, Taipei: The Executive Yuan, ROC. ——(1998) Public Health in Taiwan ROC, Taipei: The Executive Yuan, ROC. Directorate General of Budget Accounting and Statistics (1999) Monthly Bulletin of Statistics of the Republic of China, Taipei: Executive Yuan, ROC. Hermalin, A.I., Ofstedal, M.B. and Chang, M.C. (1992) Types of Supports for the Aged and Their Providers in Taiwan, Population Studies Center, University of Michigan. Hu, Y.H. (1995) ‘Elderly suicide risk in family contexts: a critique of the Asian family care model’, Journal of Cross-Cultural Gerontology 10:199–217. Kao, H.F. and Stuifbergen, A.K. (1999) ‘Family experiences related to the decision to institutionalise an elderly member in Taiwan: an exploratory study’, Social Science & Medicine 49:1115–23. Lee, M.L., Lin, H.S. and Chang, M.C. (1993) Living Arrangement of the Elderly in Taiwan: Qualitative Experience, Population Studies Center, University of Michigan. Leung, K.K., Tang, L.Y., Chie, W.C., Lue, B.H. and Lee, L.T. (1999) ‘Mortality trends of elderly people in Taiwan from 174 to 1994’, Age and Ageing 28: 199–203. Li, C. (1997) ‘Shifting perspectives: filial morality revisited’, Philosophy East and West 47, 211–32. Li, R.M. (1994) ‘Aging trends—Taiwan’, Journal of Cross-Cultural Gerontology 9: 389–402. Martin, L. (1988) ‘The aging of Asia’, Journal of Gerontology: Social Sciences 43, 4: S99–113. Ministry of the Interior (1990) Report on the Living Conditions of the Elderly in Taiwan Area, Taipei, ROC. ——(1997) Taiwan-Fukien Demographic Fact Book, Taipei, ROC. Thornton, A., Yang, L.S. and Fricke, T. (1994) ‘Weakening the linkage between the ancestors, the living and future generations’, in A.Thornton and H.S.Lin (eds) Social Change and the Family in Taiwan, Chicago: University of Chicago Press. Wu, S.C. and Chiang, T.L. (1995) ‘Long-term care in Taiwan: issues and directions’, Chinese Journal of Public Health (Taipei) 14, 3:246–55.

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Wu, S.C and Chu C.M. (1996) ‘Public attitudes toward long-term care arrangement for the elderly in Taiwan’, Australian Journal on Ageing 15, 2:62–8. Wu, S.C., Hsu, H.C., Chuang, Y.C. and Chang, M.C. (1996) ‘Application of functional assessment in estimating long-term care need among non-institutionalized elderly adults in Taiwan’, Chinese Journal of Public Health (Taipei) 15, 6:533–45. Wu, S.C., Li, C.Y. and Chang, A.L. (1997) ‘The influence of intergenerational exchange on nursing home admission in Taiwan’, Journal of Cross-Cultural Gerontology 12:163–74. Wu, S.C. and Chang, M.C. (1997) Health Care for the Elderly in Taiwan: A Fact Book, 1993– 1994, Taiwan Ageing Studies Series, no. 6, National Taiwan University and Taiwan Provincial Institute of Family Planning. Wu, S.C., Ke, D. and Su, T.L. (1998) ‘The prevalence of cognitive impairment among nursing home residents in Taipei, Taiwan’, Neuroepidemiology 17:147–53. Wu, S.C. and Lin, H.S. (1999) ‘A national profile of family caregivers of the disabled elderly people in Taiwan’, Chinese Journal of Public Health (Taipei) 18, 1: 44–53. Yen, W.K., Wu, S.C., Shu, C.C. and Chen, P.H. (1996) ‘Non-acute long-stay patients among general hospitals in Taipei City: prevalence, long-term care need, and longterm care attitudes’, Nursing Research 4, 2:151–60.

12 Ageing in Korea Issues and policies Sung-Jae Choi

Introducti on Modernization, the transformation of a total society from a relatively rural way of life toward a predominantly urban way of life (Cowgill and Holmes 1972; Cowgill 1974), has seen rapid acceleration in Korea for the past forty years. This process of modernization seems not only to diminish the status of older Koreans, but ultimately lead to the occurrence of the problem of ageing in Korea; an issue that has emerged as a social problem principally since the beginning of the 1970s. Modernization has changed Korean society into an ageing society, in which elderly people will have reached 7 per cent of the total population by 2000 (National Statistical Office 1997). This percentage is expected to increase unprecedentedly in the first quarter of the twenty-first century (ESCAP 1996). With an increasing elderly population, a cluster of issues associated with ageing is widely recognized as an emerging social problem. These are largely caused by societal factors associated with modernization and thus require societal intervention to solve them. Since the causal factors of the problem of ageing are societal rather than individual and/or familial, the main leverage in solving it lies with the state. From the basic position of seeing issues associated with ageing as social phenomena that require societal intervention, this chapter will review demographic transition and social policies designed to respond to the increasingly perceived problem of ageing. It will then examine issues related to the social policies and, finally, suggest gerontological research foci in Korean society. Demographic transition and future scenarios Changes in the fertility and mortality of a specific society are associated with the process of transition from an agrarian state to an industrialized and urbanized state (Kim 1996, 1999a, 199b), and then modernization brings about demographic transition which is facilitated by the reduction of both fertility and mortality. Since the early 1960s, when the Korean government

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Table 12.1 Korea: actual and estimated life-expectancy at birth, selected years

Source: National Statistical Office, 1997.

launched a 5-year economic development plan and adopted a family planning programme as a national policy, fertility and mortality in Korea have continually declined. With the decline of fertility and mortality, Koreans’ life-expectancy at birth has substantially increased and, consequently, the sheer number and proportion of the elderly has greatly increased for the past forty years. As shown in Table 12.1, life-expectancy at birth for men and women increased from 52.5 years and 53.7 years in 1960 to 69.6 and 77.4 years in 1995. They are expected to reach 74.5 and 81.7 years respectively in 2020. Along with the lengthening of life-expectancy, the proportion of people aged 65 and over has also greatly increased from 2.9 per cent in 1960 to 6 per cent in 1995 (Table 12.2). It is estimated to reach 7 per cent in 2000, 13.2 per cent in 2020, and 19.3 per cent in 2030. It is also estimated that it would take only twenty-two years for the proportion of elderly population aged 65 and over to increase from 7 per cent to 14 per cent in Korea, a process which took eighty-five years in Sweden, and twenty-five years in Japan (ESCAP 1996). This rate of population ageing in Korea is very high in comparison to many other countries. The changing demographic structure of populations was the common point of departure which saw the emergence of the phenomenon of ageing as a social issue or social problem (Maddox and Wiley 1976). However, since ageing is a multi-faceted and multi-causal phenomenon, the demographic transitions involved not only mean an increase in sheer numbers and proportion of the population, but also have physical, psychological, social, cultural, economical and political implications (Jones 1995). Awareness of ageing as an issue A social problem may be defined as a social phenomenon, of which causal factors are societal rather than individual and/or familial, and that negatively affects a large number of people and is judged undesirable in the light of social values by some influential individuals or a number of people in general. As such, it requires societal intervention to solve it. The problems

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Table 12.2 Korea: actual and estimated numbers and proportion of elderly population, selected years

Source: National Statistical Office, 1997.

associated with ageing in Korea are largely caused by societal factors and negatively affects a large number of elderly Koreans. The problems are judged undesirable in the light of Korean social values of humanitarianism, filial piety, and sense of community (Choi 1989). In Korea, issues of ageing began to be recognized as a social problem at the turn of the 1970s and have been perceived as increasingly serious since then. These issues of ageing are now well recognized as a serious social problem among both scholars and the general public. The subjective element involved in understanding or defining social problems (particularly, judging its seriousness) varies greatly according to differing perspectives on human conditions. The fact that strategies of national development have been overwhelmingly oriented toward economic development for the past forty years is well known. Fortunately or unfortunately, Korean government bureaucrats who have held the most significant positions in policy-making, have also held the viewpoint of ‘economic growth, then distribution’. To these government bureaucrats, the issue of ageing seems to be neither significant nor serious. However important and/or serious a particular social problem may be considered to be, if those in key positions of the government do not pay attention to them, the issues might remain neglected. There has been a wide gap in the perception of the problem of ageing between the bureaucrats holding the perspective of ‘economic growth, then distribution’ and those holding the perspective of ‘distribution matching economic growth’. Because of their persistent holding of economic growth oriented strategies, they have

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been reluctant to pay attention to the distribution of the fruits of economic growth, including the solution of social problems associated with rapid economic development. Though the awareness of the issue of ageing as an emerging social problem may depend on the subjective judgement of the government policymakers to a great extent, the objective judgement based on scientific studies that the problem of ageing is serious, cannot be denied. The major aspects of the problem of ageing in Korean society can be said to be: (1) economic dependency, (2) difficulties in health care, (3) role loss and difficulties in leisure activities, and (4) social-psychological conflicts and feelings of alienation. These problems are becoming serious and worsening because of a lack of appropriate societal measures designed to address these issues. Social welfare programmes for elderly Koreans Problems associated with ageing are usually dealt with through the social welfare programmes of any given society. Social welfare provisions for elderly Koreans can be grouped into four main categories according to the nature of the provision: income maintenance, health care, housing, and social services. These four major groups of programmes will be briefly examined hereafter. Income maintenance programmes Currently there are five categories of income maintenance programmes for older Koreans: public pensions, public assistance, the elder honour programme, and income-generating programmes. A summary of income maintenance programmes according to their coverage and beneficiaries is presented in Table 12.3. Public pensions There are four public pension programmes, all designed as contributory social insurance schemes as shown in Table 12.3. GEP, MSP and PSTP, which are for people employed in particular occupations, cover only 6.2 per cent of total employees and provide pensions to only 4.3 per cent of people aged 65 and over. The National Pension (NP) is the main old age pension programme covering most of the employees and the self-employed. While pensions for people with special occupations (GEP, MSP and PSTP) were instituted in the early 1960s, the NP for people in general was created by the National Pension Act in 1986 and came into force in 1988. The NP covered only the employees and employers of work places which have five or more full-time workers, and those employed in agriculture and fisheries until March of 1999, but currently covers all those who are not

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Table 12.3 Korea: beneficiaries of cash-payments under income maintenance programmes

Sources: aGovernment Employees Pension Management Corporation (1998). b Ministry of National Defense (1995). c Private School Teachers Pension Corporation (1998). d National Pension Management Corporation (1999). e Ministry of Health and Welfare (1998). f Ministry of Health and Welfare (1999). Notes: *There are 160,000 recipients of the NP but they are not recipients of the normal old-age pension (which is given to those who have been insured for 20 years and more) but recipients of a special pension given to those who have been insured for 5–19 years, and recipients of invalidity and survivor’s pension. **Since 244,000 of 660,000 recipients of the E RP are also the recipients of the NBLG, this number was subtracted from the total. ***For the same reason mentioned above (**) 244,000 recipients of NBLG was also subtracted from the total.

insured under GEP, MSP and PSTP. Since the NP programme only began in 1988, most of the current persons aged 60 and over cannot be beneficiaries of normal old age pension, which require twenty years’ of contributions. The NP covers old-age, invalidity and survivor’s pensions but its main function is that of the old-age pension. To be eligible for an old-age pension, one should have been insured for ten years or more and be 60 years old. There are some special categories in the old-age pension which also warrant eligibility (such as reduced old-age pension, incumbent old-age pension, and advanced old-age pension). The NP programme is financed by the contribution from the employee’s wages and the employer’s liability for general workers; by only the contribution from the self-employed for the self-employed; and by the contribution from the employee’s income and a flat rate of government assistance for workers in agriculture and fisheries. As of 1999, about 16

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million or 76.2 per cent of Korean workers were compulsorily covered by the NP programme (Table 12.3), and only 160,000 or 3.4 per cent of elderly Koreans aged 60 and over are recipients of the old-age pension. Public assistance programmes National Basic Life Guarantee programme (NBLG): This is a public assistance programme to guarantee a minimum level of life for all Koreans. This programme was first established by the Livelihood Protection Act in 1961 and re-codified by the ‘National Basic Life Guarantee Law’ programme in 1999. To be eligible for the NBLG programme an elderly person must be below the poverty line, have no one legally responsible for supporting him or her and, if the elderly person has someone legally responsible, that person must be unable to work. The NBLG stipulates five categories of benefits for elderly people: livelihood assistance, medical assistance, housing assistance, self-reliance assistance, and funeral assistance. In 1998, elderly recipients of the NBLG benefits totalled 244,000 (Table 12.3). The central government contributes 80 per cent of the programme costs, with the remaining 20 per cent shared by local government. Elder-Respect Pension (ERP): The ERP was designed to solve the problems that arose when the NP programme was instituted without any interim provision for those who have already reached the pensionable age of 60 and thus cannot benefit from the NP programme. Eligible persons are limited to those who cannot be covered by any kind of public pension, who are 65 years old and over, and who’s income is below 60 per cent of the mean income of individual member of the elderly household and below 140 per cent of the elderly household’s assets appraised. In 1999, 660,000 elderly Koreans received benefits from the ERP (Table 12.3). Elder Honor programme The Elder Honor programme (EHP) provides elderly people with discounts on public transport (operated by the government) and on admission to public facilities such as parks and museums, and also provides elderly people with some amount of cash for transportation allowance. Income-generating programmes There are three kinds of income-generating programmes that provide elderly people with an opportunity to earn income by making good use of their free time. The Older People Employment Service (OPES) and the Elderly Job Bank links those with jobs to offer with elderly job-seekers. The Elderly Workshop (EWS) helps set up workshops where elderly people can work together and receive remuneration for their work.

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Health care programmes Another essential aspect of the constitutional right to a decent living standard was substantiated by the institutionalization of medical insurance and medical assistance programmes in the latter 1970s. There are three kinds of health care programmes for elderly people: medical insurance, medical assistance, and health examinations. Medical insurance programme The first medical insurance programme was created as a form of social insurance scheme in 1976. Until 1999 there were two medical insurance programmes for Koreans including elderly people. One is National Medical Insurance (NMP) covering civil servants, private school teachers, and workers in agriculture and fisheries. The other is Workplace Medical Insurance (WMI), covering all those who are not covered by the NMP. The two programmes are to be integrated into one programme called ‘National Health Insurance’ from 2000. The M I pays for diagnosis, inpatient and outpatient treatment, operations, nursing, medication, and transport for treatment. The payment level varies with the medical care system and the kind of treatment. The MI pays 50–70 per cent of the fees for outpatient care and 80 per cent for inpatient care, while the patients themselves have to pay 20 per cent or more of the total medical fees. The MI scheme is financed by equal contributions from both employee and employer for those in workplaces, by equal contributions from both the insuree and the government for farmers and fishermen until 2005, and by the sole contribution of the insuree for selfemployed people and employers in workplaces with fewer than five workers. As of 1998, the MI covered 95 per cent of the Korean population. Medical Assistance programme The Medical Assistance programme (MA) had been a benefit category under the National Basic Life Guarantee (NBLG) programme until a separate programme was established by the enactment of the Medical Assistance Act of 1977. It covers not only NBLG recipients but also veterans, human cultural treasures, and disaster-stricken people. The MA scheme pays for the same categories of benefits as the MI scheme, but its payment level varies with the status of recipient and the medical care system (primary and secondary). Deductible amounts are imposed on those who are under self-reliance protection. When they are unable to make payments, the state makes loans without interest with a reimbursement period of one to three years. This programme is financed by the contributions of central and local governments and the medical fees are paid by recipients. As of 1994, 5 per cent of all Koreans and 14.9 per cent of all those aged 65 and over were covered by this programme.

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Elderly Health Examination programme The Elderly Health Examination (EHE) programme was established by the Elderly Welfare Law of 1981 for the detection and prevention of diseases. The state’s provision is not compulsory but subject to budget constraints. Hence, so far, provision has been limited to low-income elderly people. Nursing home programme Nursing home services are available for those who need long-term care. Nursing homes are classified into five categories according to the system of feecharges and the kinds of services offered: (1) free general nursing, (2) low-feecharging general nursing home, (3) full-fee-charging general nursing home, (4) free skilled nursing home, (5) full-fee-charging skilled nursing home. As of 1998 there were 89 homes—60 free, 13 low-fee, 4 full-fee, and 12 free skilled homes. The Elderly Welfare Law Amendment of 1994 allowed profit-making as well as non-profit organizations to run full-fee-charging nursing homes. Nursing-home fees are not now reimbursed by medical insurance. Housing service programmes Despite the fact that the demand for housing designed for the elderly is increasing in Korean society (Choi 1997; Korea Institute of Health and Social Affairs 1998), there is no explicit housing policy for older Koreans, neither for those living with their children nor for those living separately from their children. In addition, there is neither a housing supply programme nor a financing programme for the elderly. There are several reasons for this serious underdevelopment of adequate housing programmes. Up to the present time, national housing shortages have been so serious that there has been little opportunity to consider a housing policy aimed especially at older people. Since the social welfare policy for elderly people has focused on institutional care, the government has not paid attention to the housing problems of elderly people living in homes (Koh 1999). The provision of the Elderly Welfare Law stipulating that the state or local government should facilitate the construction of houses appropriate for elderly people is ambiguous in terms of the government’s responsibilities, and consequently housing programmes in accordance with this provision have rarely been created. The spirit of ‘family responsibility’ for taking care of the elderly in a co-residential arrangement, which is still relatively well preserved, is also hindering the development of a housing policy specifically for the elderly. Because housing prices are unprecedentedly high, few older Koreans can afford to buy or rent, though housing for elderly people would be supplied. An Elder’s House programme has been instituted since 1996 for the provision of group homes, which accommodate 3–5 elderly people who are

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recipients of public assistance (NBLG). By 1999, 317 elder’s houses were in operation. With regard to the institutional accommodation programme, there are two categories as defined in the Elderly Welfare Law: one is housing facilities and the other health care facilities. The amendment of the Elderly Welfare Law in 1997 instituted more detailed types of housing facilities and health care facilities. However, it seems that this amendment is not likely to facilitate the development of the institutional type of elderly housing for the middle-class and upper-class elderly who can afford to pay for their housing, because it did not stipulate financing for institutional housing. Social service programmes As the trend of modernization advances, the needs of elderly Koreans have not only been elevated to higher levels but have also diversified to include, for example, personal help needs, and social-psychological developmental needs, among others. As family structure and functions have substantially changed, the family’s need to strengthen its caring function has been increased and diversified. In spite of these changing needs, the number of social service programmes directed to meet the needs of the elderly population and their families are comparatively few in number. The Elderly Welfare Center programme, for establishing multi-purpose senior centres, provides a range of services concerning health improvement, adult education, recreation, counselling, information and guidance, among other things. In 1999, there were thirty-nine such elderly welfare centres. The Elderly/Senior Club House established by voluntary donations from local people is the most generalized elderly welfare facility in both urban and rural areas. By 1999, there were almost 36,000 club houses with members comprising nearing one-third of those aged 60 and over (Koh 1999). Organized programmes are seldom offered in the club houses, with most of the activities being casual. Elderly schools that are operated by voluntary organizations are the second most generalized welfare facilities provided for elderly Koreans. Currently the number of schools is 453 with 51,000 elderly persons attending. Government financial assistance to elderly club houses and elderly schools is meager and nominal. There are several community care services: home help, day care, and short-stay care services. The home-help service programmes are currently provided on a free-of-charge basis exclusively for the poor elderly people mainly receiving the benefits of the public assistance (NBLG). As of 1998 about 58,000 volunteer home helpers were working under the supervision of 221 voluntary organizations. The government provides the voluntary organizations with financial assistance for recruiting, training and maintaining volunteers. The major problem in home-help services is that older persons cannot receive proper services when needed because volunteers cannot usually respond immediately when the need arises.

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Day care services for the elderly are provided at thirty centres, and shortstay care services, which accommodate older persons for a limited short period (usually 2 to 15 full days, but sometimes up 45 days), are also provided at fifteen locations. Fees can be charged to users of both services according their income status. Problems and issues of social welfare programmes The chapter now examines some issues and problems of current social welfare programmes for older people in Korea. Problems will be first examined in terms of the issues of perspectives on social policy and then with respect to four basic dimensions of policy: coverage of programmes, benefit categories and kind of programmes, delivery systems and finance. Issues of values and perspectives on social policy One of the most serious challenges to formulating and implementing social policy is that the government holds an arguably erroneous perspective on the problem of ageing which acts as a barrier to policy development (Kim 1999b). Since issues of ageing are conceived as one of the serious social problems in contemporary society (and, accordingly, the main causes of the problem of ageing are more related to societal factors than to personal or familial factors), the efforts directed towards finding a solution should be initiated by society or the state (Horton et al. 1991). However, the Korean government’s policy on solving the problem of ageing has been generally based on the premise that ageing is a personal or family problem rather than a social problem and thus is solvable through family efforts. Unless the Korean government abandons such an erroneous perspective, it will take a long time before fundamental measures will or can be instituted. Policy-makers’ negative and limited conceptions of the effects of social welfare services have functioned as a barrier in furthering social policy for elderly Koreans. In Korea for nearly forty years, policy-makers have thought economic development to be the most important and effective means of national development and they have perceived social welfare services to be not productive but rather consumable in nature. Since the institution of social welfare in society takes care of economic and social-psychological problems of individuals and families, it certainly indirectly contributes to promoting workers’ productivity by helping with their individual or familial problems, including the problems of elderly parents. It should also be considered that social welfare can contribute to social-psychological as well as materialistic productivity in society, thus contributing to social integration. In relation to the government’s negative perception of the effect of social welfare policy, ‘productive welfare’, the government’s new guiding principle in formulating social welfare policy, proclaimed in August of 1999, may prove to

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be controversial. It seems that the concept of productive welfare was coined from the critical point of view of a disincentive to work being created by excessive welfare provisions and their consequently heavy financial burden on the state, a familiar debate in many Western welfare states. The concept of productive welfare may involve some positive aspects in that welfare benefits should be provided so that the receivers may be self-supportive, participating in remunerative works. However, legitimate concerns arise in terms of the negative meaning and perception that welfare or state-sponsored charity may hold in this society, particularly for older people. In the history of Korean social welfare, none of the government’s social welfare benefits have ever reached a level sufficient to guarantee a minimum standard of living. It is therefore quite illogical to argue that social welfare benefits have jeopardized welfare recipients’ work incentive and then made them live through welfare dependency. It is well recognized that the proportion of national budget for social welfare has always been relatively too small compared to those of other countries with similar size economies. In many cases, the concept of ‘productive’ in productive welfare may denote direct productivity in only an economic sense, disregarding indirect effects of social welfare on economic and social-psychological productivity. Since older persons have often come out of the labour market mainly because of the mandatory retirement system and have many difficulties in finding re-employment, the principle of productive welfare cannot be applicable to them. The concept of productive welfare may actually discourage provision of welfare services for the aged. If we could apply the principle of productive welfare, in what ways and how much would welfare provision for the elderly be productive? The traditional value of filial piety, which emphasizes family responsibility for the economic support of elderly people and the provision of care services by the family members living with them, is also hampering the development of a social welfare policy for older Koreans. Filial piety, according to its original meaning, can be dealt with at both the familial level and the societal level. One of the most important reasons for filial piety is to repay one’s parents for their love and care (Choi 1982). The role of filial piety at the familial level is to provide economic support and direct care services to parents in order to repay them for their love and care. Filial piety at the societal level is the state’s welfare provision to the elderly in order to repay their contributions to society. Filial piety has traditionally emphasized the familial level but not the societal level. To conduct filial piety at the societal level would arguably be to emphasize the duty of society to compensate elderly people for their contributions to the development of that society. Cultural traditions anchored in the value of filial piety in its present state may function as major forces resisting the negative social changes associated with the alienation of the elderly and the decline of family care for them (Sung 1991). Efforts to preserve and develop the value of filial piety could be justified in the sense that it can help retard the pace of family disorganization

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and the subsequent disruption caused to society. However, the tradition of filial piety can never be justified as a grounds for making the family assume sole responsibility for taking care of elderly people. One of the assumptions on which the value of filial piety is based is that human beings are ‘historical’ beings. Each of us have thousands of ancestors who lived in the past, and, likewise, we will have thousands of descendants in the future. So we are all historical beings, linking the past and future. We are born not as independent creatures, but as offspring of human relations closely linked together. Along with ancestor worship, which is one of the important way of performing filial piety, this assumption of viewing human beings as historical beings seems to have made Koreans feel the value of filial piety in a sense as a kind of religion. However, though Koreans may still appear to adhere to the demands of filial piety in a formal sense, there is a view which suggests that this value is becoming increasingly difficult to live up to in the face of modern realities, as in many other Asian societies today. Unless we look anew at the benefits in modernizing Korean society and develop ways of transferring such values to modern life, the value of filial piety may meet strong resistance in the near future. An emphasis on family responsibility for supporting elderly people is deterring policy development for elderly Koreans. In supporting or taking care of the elderly, the emphasis is on family responsibility because it is an age-old principle that has been supported by the traditional value of filial piety in Korea. In a modern welfare state, the emphasis on family responsibility can make the state’s responsibility minimal, and thus deter the development of the state’s welfare provisions. As discussed earlier, it is held that the causes of the problems of ageing in modern society are much more related to societal than other factors, particularly in the economic aspects of the problem. In this regard, income maintenance and health care for elderly Koreans should at least be assumed as a responsibility of the state. This does not mean that the state should assume all the responsibility for the support of elderly people, but it does mean that the state should take the initiative in preparing institutional programmes for economic and medical security for elderly people. The responsibility for taking care of frail or sick elderly people needs to be shared between the family and the state with the main role of the state being that of strengthening the care function of the family with social services. Recently, increasing controversy has surrounded the for-profit services for elderly people provided by profit-making organizations or individuals in the market, which in Korea is called the ‘silver industry’. The amendment of the Elderly Welfare Law of 1994 that allows profit-making organizations and individuals to run proprietary homes for the aged, nursing homes and elderly welfare housing, is making the controversy yet hotter. Despite the fact that problems of elderly Koreans are becoming diversified and their needs are also elevating to higher levels, social welfare services provided by both the public and

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the private sectors are still concentrated on the elderly poor and those in institutional care free of charge. The problems and needs of middle-class elderly Koreans are being neglected. A consensus is emerging that the responsibility to secure a national minimum level of living standard for all Koreans lies with the government and that citizens’ problems and needs beyond the national minimum level should be met by individuals or families in the marketplace. The level of services provided free of charge by the government should be improved to the level of a national minimum. However, this will not come to pass in the near future as long as policy-makers’ erroneous perspectives on social welfare are maintained. If the participation of profit-making organizations’ in the provision of for-profit services such as nursing homes, homes for the aged, and retirement communities is promoted without a great improvement of services free of charge, the gap between free services provided by the government and for-profit services provided by profitmaking organizations or individuals will be all the wider, negatively affecting social integration. However, it can be argued that the fear of expected negative effects of for-profit services can be no longer be used as an excuse to delay the provision of such services for elderly Koreans. Issues and problems associated with the dimensions of social welfare programmes Coverage of programmes The Korean government’s measures for social welfare in general have been almost exclusively focused on poor or low-income groups and based on the residual perspective of the social welfare system. Despite the stipulation of guaranteeing a minimum standard of living in the former law on public assistance, little of this has, in fact, been substantiated by real change. The new law on public assistance (the ‘National Basic Life Guarantee Law’), recreated from the former law (Livelihood Protection Law) in 1999, explicitly stipulates the guarantee of a minimum standard of living for all Koreans whose income is below the poverty line. Although a minimum standard of living in term of income maintenance is to be guaranteed with the new legislation, social services providing nonmonetary services are still focused on the low-income group. As noted earlier, the persistence of the government bureaucrats’ viewpoint favouring ‘economic growth, then distribution’, has limited the expansion of coverage of social welfare programmes, particularly in terms of social service programmes beyond those for the low-income elderly. However, the problems and issues of ageing have many facets and are not limited solely to the elderly poor. Modernization as a gigantic social change affects all elderly people to some degree at least, regardless of their socioeconomic status. Problems of health care, social-psychological conflicts and alienation, role

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loss and difficulties in leisure activities are common to many elderly Koreans. Therefore, policy concerns currently focused on the elderly poor should be directed more towards older persons in general. Benefits categories of programmes and the nature of programmes Some important benefits in health care and social service programmes are missing. As costs for long-term care are not paid from current medical insurances and there is no public long-term care insurance, many elderly Koreans receiving long-term care services and their family caregivers are subject to great economic burdens because of heavy medical care expenses. A visiting nurse service is one of the essential community care services, but has not yet been instituted as a public service. In addition, several housing services, supplying rental housing and housing designed for the convenience of older persons, need to be offered. Housing policy in Korea does not adopt the perspective of social policy which is much concerned in the results of distribution. A housing policy for elderly Koreans needs to be formulated so that older people are not heavily burdened with purchasing or renting housing. Policy that is heavily institutional-care oriented has hindered the development of more varied social services for older people in general, who reside at home. Institutional care programmes have not been well developed and there still remains much room for the development of institutional care itself. However, at the same time, the negative effects that may result from the emphasis on institutional care should be addressed as well. The welfare state was introduced to buttress the family as the basic unit of welfare provision, and thus welfare services should have been provided to strengthen the functions of the family. In most welfare states, welfare benefits tend to be provided to individuals after a breakdown in family functions rather than to support the family before breakdown. Such a policy has resulted in an increase in the institutionalized population and in ineffective and inefficient care services. In this regard, current community care programmes are very limited and involve only three kinds: home-help services, adult day care services, and short-stay care services. As noted above, it is problematic that home-help services are provided by volunteers. In addition, whilst the number of government-subsidized adult day care and short-stay care service centres is not enough for the normatively estimated need, those that exist are not well utilized. This is for a number of reasons, including the restriction of provision to the elderly poor, the effects of a face-saving culture reluctant to use services provided outside the family, the persistence of filial piety values that emphasize family care and, in addition, the low quality of services. Programme delivery systems The current public delivery system of social welfare services for the elderly is retarding policy development. The current delivery system for social welfare

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in general, including the delivery system for older persons, is that policies made by the Ministry of Health and Welfare are implemented through the general administrative agencies of central and local governments under the control of the Ministry of Government Administration and Home Affairs (MGAHA). Therefore, the delivery system of social welfare services is fused with the general administrative system. With the present public delivery system, it is very hard for policy planning and service delivery to be professional and to utilize people with specialized expertise and knowledge of social welfare. To improve this delivery system the government suggested a health and welfare office as an alternative, which would be, to some extent, independent from the MGAHA while staying under the control of the ministry. This type of delivery system may be a good alternative in the sense that its services could be more effective, efficient and responsive to clients’ needs, particularly to those of older clients. Social services and health services will be coordinated or consolidated, though the independence of the delivery system may not be fully secured. At present, it is uncertain whether or not the new delivery system will be finally implemented. It should be pointed out that the quality of services provided to older persons in public as well as voluntary sectors are generally low because of personnel shortages and a lack of training and professional knowledge and skills in social welfare in general and in gerontology in particular. Most of the voluntary social services agencies and institutions are operated with subsidies mainly from the government and with very limited assistance from their foundations established as juridical persons. Because the subsidy takes up almost all of the budget of voluntary organizations they are under the effective supervision of the public social service delivery system and consequently it is very difficult for them to avoid budget constraints and government supervision. As a result, it could be said that the planning and development of service programmes by most voluntary organizations in many respects lack sufficient autonomy from government control. Korean society has relatively well maintained social support networks operating on an informal basis in caring for family members compared to those in many other Asian as well as Western societies. It is desirable that these informal social support networks (which are informal service delivery systems that older people will usually use first), be maintained as long as possible. However, Korean society’s heavy and frequent reliance upon these networks seems to have deterred the development of formal social services. Indeed, the existence of this method of social support has been an excuse for the government not to have initiated formal social welfare programmes. However, it will be difficult to expect continued reliance on social support networks in the future because of the rapid modernization process that has taken place over the past forty years in Korea. Securing qualified personnel is one of the most important aspects of developing service delivery systems for older persons. Social service

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agencies and institutions lack staff trained in gerontological knowledge and services skills. Gerontological education is not systematically offered at colleges or at any special training institutes. Considering increasing future demand for gerontological care workers in institutional care and community care, it is desirable to develop appropriate educational programmes and a licence system for gerontological care workers in the near future. The financing of programmes and services Government budgets for elderly welfare have been very small compared to both Korea’s GDP and the national budget for social welfare. It must be recognized, of course, that a welfare state can never be achieved without substantial financial expenditure. The budget for social welfare has increased in Korea, but it remained at less than 5 per cent of the national budget and less than 1 per cent of GDP until 1998. Although the elderly welfare budget has also steadily increased, it was still less than 5 per cent of the social welfare budget in 1998. The experience of advanced welfare states shows that a major factor determining the size of social welfare costs on the supply side is national economic prosperity, while the major factors on the demand side are the proportion of the elderly population and the nuclearization of the family (Wilensky 1975; Konuma et al. 1984). The greatest proportion of the increase in social welfare costs is almost invariably that for the welfare of older people. However, the government’s budget for elderly welfare, as well as for social welfare in general, has not only been relatively small when compared to GDP and the national budget but also in comparison with developing countries, even taking national defence expenditure into consideration. As noted, most voluntary social services organizations are heavily subsidized by the government, but the subsidy is insufficient to provide quality services to older persons. Hence, these organizations need to secure substantial amount of funds from the general public to improve services and develop services responding to the emerging needs of older persons that could be implemented under their own planning. However, although the Community Fund-Raising Law of 1999 may enhance fund-raising activities at the individual and collective organizational level, it may take a long time to generate substantial funds from the general public, for a variety of reasons. There is a lack of fund-raising techniques and skills, an immaturity of community fund-raising organizational structure, the general public’s low motivation in relation to voluntary donations, and lower rates of tax deduction on donation, among others. For such reasons, voluntary social service organizations may have to continue to rely heavily on government subsidies for a relatively long time. As one way to finance and develop various services to respond to the needs of the middle- and upper-class elderly, it would be desirable for the

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government to encourage the economic market or the elderly market to participate in the provision of for-profit services such as nursing homes, homes for the aged, retirement communities, etc. Gerontological research foci in Korea Academic studies in gerontology had been comparatively few prior to the foundation of the Korean Geriatrics Society in 1968. It could be said that the founding of the academic association signalled the start of a disciplinary study of gerontology in Korea. The number of gerontological studies remained small throughout the 1970s but it nevertheless seems certain that the founding of the Korean Geriatrics Society gave an impetus to gerontological studies in a wider sense. Societal concerns for ageing as an issue can be said to have triggered scientific study into various aspects of the ageing process and their effects on elderly individuals, their families and society (Choi 1998). As ageing began to emerge as a serious social problem in the 1980s, increasingly more academic sub-disciplines of gerontology paid attention to many of the other facets. The Korea Gerontological Society, mainly comprising people engaged in social and behavioural sciences, social policy and planning, and health science, was established in 1978. It held its first annual meeting in 1980 and the Korean Society for Gerontology, of which members were mainly from the field of biomedical sciences, nursing, nutritional science and food engineering, was formed in 1989. Since the 1980s the number of gerontological studies have dramatically increased and diversified. A major step in the development of gerontology in Korea came in 1993 when the three main associations joined together to form the Federation of Korean Gerontological Societies. Since then multidisciplinary studies have greatly increased. Gerontological research topics became much more varied in the 1990s and, in particular, issues and problems of welfare policy for the elderly expedited various research topics. The major research foci in Korea are: quality of life (biological, social and psychological aspects, housing, life satisfaction); development of dementia screening scales; development of an ageing index in biological ageing; factors in healthy life; the role of the state, the community and the family in caring for older people; retirement housing and the elderly market; ageing and productivity; social insurance for old-age pensions, health care and long-term care; family care vs. formal care; co-habitation and life satisfaction; quality of community care services; filial piety and elderly welfare policy; social support networks for older persons and divorce in old age. Conclusion In Korea, ageing has increasingly been conceptualized as a problem (perhaps unlike many other countries in the region). It emerged as a social problem

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around the beginning of the 1970s, and has become such an issue in Korean society that it has emerged as a new concern never before experienced. However, the problem is becoming more serious due to government bureaucrats’ erroneous perspective on the problem, their inattention and belated responses. Korean society does not have as many older persons as many more developed countries do, so it is not possible to say as yet that this phenomenon is posing great problems to this society. However, in the light of the experience of more developed nations, Korean society, with an ageing population and with many issues related to income maintenance, housing, health and social care becoming increasingly important, needs to recognize the challenges as serious. Indeed, unless Korean society takes action against problems associated with ageing, it could follow the same path of many developed nations and meet with similar dilemmas. If it retains only reactive and haphazard policies to deal with ageing and its associated problems, issues will stay essentially unresolved. As a rapid rise of the aged population is expected and the reality of an ageing society dawns from year 2000 onwards, Korea must think about the most serious and the most important issues and problems and devise solutions. However, positively, the issues surrounding ageing that challenge contemporary Korean society could act as an accelerator to the development of a viable welfare state, if the government is able to overcome its arguably outmoded perceptions. These have up to now acted as a safeguard for economic development but have been barriers to the development of social welfare. The Korean government, benefiting from the experience of other advanced countries, could now take positive steps in developing social welfare policies for elderly people; this will be one of the most significant components for the future building of the Korean welfare state. The variance and ambiguity of the definition of a welfare state makes the creation of a workable mode for a Korean welfare state more difficult. The welfare state itself was in part the West’s answer to the challenge of communism as an alternative social order (Mishira 1993). However, it is argued here that the welfare state which Korean society strives to build should not be based on the model or variants of the ‘Confucian Welfare State’ or ‘household economy state’. This is characterized by conservative corporatism without worker participation, solidarity without equality, and laissez-faire market economics without liberatarianism (Jones 1993). Perhaps, however, Korea should view carefully the changes and rolling back of welfarism in many Western countries whilst deciding its way forward. The Korean welfare state should be built, of course, by complementarily sharing the responsibilities of economic support of, and caring for, older persons between the state, the community and the family. It should focus on efforts to develop both the values of a modern sense of filial piety acceptable in the new century and citizens’ collective responsibility towards people in

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general. The social policies of the Korean welfare state should be based on the findings of a range of gerontological studies so that they may be more responsive to the needs of older people and their families and develop more preventive strategies instead of the ultimately more expensive responsive measures. References Choi, J.S. (1982) A Study on Korean Family, Seoul: Ilji-Sa. Choi, S.J. (1989) ‘The thought of filial piety and welfare of the aged’, Korean Journal of Social Welfare 13:1–25. ——(1997) ‘Middle-aged Koreans’ expected needs and preferences for housing in their old age’, paper presented at the 50th Annual Meeting of the Gerontological Society of America in Cincinnati, USA, Nov. 4–18, 1997. ——(1998) ‘The role of gerontological associations in Korea’, Australasian Journal on Ageing 17, 3:128–31. Cowgill, D.O. (1974) ‘Aging and modernization: a revision of the theory’, in J.F. Gubrium (ed.) Late Life: Communities and Environmental Policy, Springfield: Charles C.Thomas. Cowgill, D.O. and Holmes, L.D. (1972) Aging and Modernization, New York: AppletonCentury-Crofts. ESCAP (1996) Population Ageing in Asia and the Pacific, Bangkok: Economic and Social Commission for Asia and Pacific. New York: United Nations. Horton, P.B., Leslie, G.R. and Larson, R. (1991) The Sociology of Social Problems, New York: Appleton-Century-Crofts. Jones, C. (1993) ‘The Pacific challenge: Confuscian welfare state’, in C.Jones (ed.) New Perspectives on the Welfare State in Europe, London: Routledge. Jones, C.F. (1995) ‘Aging in industrial societies, east and west: a Western comparative perspective’, Korea Journal of Population and Development 25, 1:101–22. Kim, I.K. (1996) ‘Demographic transition and population aging in Korea’, Korea Journal of Population and Aging 25, 1:27–40. ——(1999a) ‘Population ageing and its socioeconomic implications in Korea’, in Cho, K.H., Hong, S.H and Kim, K.W. (eds) Ageing in Korea Today and Tomorrow, Seoul: Federation of Korean Gerontological Societies. ——(1999b) ‘Population aging in Korea: social problems and solutions’, Journal of Sociology and Social Welfare 26, 1:107–23. Koh, Y.K. (1999) ‘Social services for older persons in Korea’, in K.H.Cho, S.H. Hong and K.W.Kim (eds) Ageing in Korea Today and Tomorrow, Seoul: Federation of Korean Gerontological Societies. Konuma, M., Jinusi, S.S. and Hosaka, D.S. (1984) Introduction to Social Security, Tokyo: Kawasima Publishing Company. Korea Institute for Health and Social Affairs (1998) Elderly Koreans’ Life and Their Welfare Needs, Seoul: Korea Institute for Health and Social Affairs. Maddox, G.L. and Wiley, J. (1976) ‘Scope, conceptions and methods in the study of aging’, in H.Binstock and E.Shanas (eds) Handbook of Aging and the Social Sciences, New York: D.Van Nostrand. Mishira, R. (1993) ‘Social policy in the postmodern world: the Welfare State in Europe by

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comparison with North America’, in C.Jones (ed.) New Perspectives on the Welfare State in Europe, London: Routledge. National Statistical Office. (1997) Population Estimate (1960–2030), Seoul: National Statistical Office. Sung, K.T. (1991) ‘Family-centered informal support networks of Korean elderly: the resistance of cultural traditions’, Journal of Cross-Cultural Gerontology 6:431–47. Wilensky, H. (1975) The Welfare State and Equality, Berkeley: University of California Press.

13 Ageing in Thailand An overview of formal and informal support John Knodel, Napaporn Chayovan, Siriwan Graisurapong and Chutima Suraratdecha

Introduction Concern about population ageing and the need for policies and programmes specifically targeted towards the older age groups is a relatively recent development in Thailand. Recognition of the rapid growth in the numbers of elderly and the inevitable shift towards an older age structure is beginning to increase the saliency of issues related to the health and social and economic welfare of older age groups to governmental officials and agencies. Researchers have been quick to pick up the challenge posed by the need for suitable data on these issues and considerable data collection efforts have been undertaken in Thailand during the last decade and a half. These include national and quasi-national surveys of the elderly as well as qualitative research using ethnographic methods, case studies, and focus groups (Chayovan, et al. 1988; National Statistical Office 1994; Andrews, undated; Chayovan and Knodel 1997; Pramualratana 1990; Caffrey 1992a and b; Knodel, et al. 1995; Knodel and Saengtienchai 1996, 2000). The present review draws on this research as well as a variety of other material related to policies and programmes affecting the elderly. Generally we use the term elderly to refer to persons aged 60 and older in accordance with the practice followed in most research and as incorporated in most official policies and programmes in Thailand. Demographic and socioeconomic setting In Thailand, as elsewhere in East and Southeast Asia, rapid and substantial demographic, social and economic change has characterized the lifetime of the current generation of elderly. These changes shape and condition their relations with their children, relatives and communities. As such they are important for understanding the past, present, and future situation of the Thai elderly. Table 13.1 presents past trends and future projections of key demographic indicators related to population ageing in Thailand for the period 1970 to

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Table 13.1 Demographic trends and projections: Thailand 1970–2030

Data Sources: United Nations, 1997 and 1998. Notes: All projections are based on medium-variant assumptions. Growth rates, total fertility rates, and life-expectancies represent averaged values from the two adjacent 5-year time periods (e.g. for 1960, the value is the average of 1955–60 and 1960– 65) except for 2030, in which case the value is interpolated between the mid-points of the 2025–30 and 2030–40 periods. Dependency ratios are defined as follows: Old-age dependency ratio=population age 60 and over/population age 15–59 Total dependency ratio=(population age 0–14+population age 60 and over)/population age 15–59.

2030 as estimated by the United Nations (1997 and 1998). Thailand’s total population grew by almost 70 per cent between 1970 and 2000, increasing from 36 million to just over 60 million and making it the eighteenth most populous country. At the same time, the population growth declined substantially from 3 per cent around 1970 to under 1 per cent currently. Future population growth is expected to slow even further, declining to less than half a per cent per year by 2020. The decline in the growth rate is attributable to a rapid and significant fertility decline. The total fertility rate fell from 5.6 around 1970 to below 2 by the later 1990s. Thus total fertility is currently below the replacement level (which is 2.2 at present mortality levels). Fertility is anticipated to remain low for the next few decades, although evidence on family size preferences suggests it is unlikely to continue to fall far below replacement (Knodel et al. 1996; Bongaarts 1998). The fertility decline is also the primary demographic force driving population ageing in Thailand. The fact that the decline was concentrated within such a relatively short period has important ramifications both for the extent and pace of change in the age structure. The median age of the

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population has steadily risen since the start of fertility decline and by 2010 is expected to have almost doubled since 1970. Moreover, the share of the population that is aged 60 or older has increased and will continue to do so at an accelerated rate in the coming decades. The pace of population ageing in Thailand and other countries with similar rapid fertility declines will by far outpace that experienced historically by Western countries (Jones 1993). The projections indicate that the population aged over age 60 will increase its share of the total from 10 to 20 per cent in a matter of only two decades. Major mortality improvements have also occurred in Thailand over recent decades. Life-expectancy at birth increased by ten years between 1970 and 1990 alone. Future improvements will be somewhat dampened by the AIDS epidemic. However, Thailand’s recent success in combating the epidemic means that only a slowing and not a reversal of the trend is foreseen (Surasiengsunk et al. 1998). Moreover, since levels at young ages are already quite low, unlike the past much of the future mortality improvement will be concentrated at the older ages. These improvements in mortality translate into increased survival rates for the older ages and thus contribute to the growing numbers of elderly persons. Combined with the past high fertility rates, the result is an unprecedented rapid growth of the numbers of Thai elders. During just the three decades between 1970 and 2000, the population aged 60 and older more than tripled and it is anticipated to almost triple again by 2030. Moreover, not only is the elderly’s overall share of the population increasing, but the elderly population itself is beginning to age as evidenced by increases in the percentage of the elderly population who are aged 70 or older. The changes in age structure that are taking place translate into changes in dependency ratios defined in terms of age groups. The old-age dependency ratio relates the population aged 60 and older to that of ages 15– 59 while the total dependency ratio relates both persons below age 15 plus those above age 60 to those in the working ages. The faster growth of the population above 60 relative to population in the working ages results in increases in the old-age dependency ratio. Only a small increase is evident by 2000 but by 2030 there will be less than two working age persons for every person age 60 and over. Changes in the total dependency ratio follow a different path. Because of recent fertility trends, the total dependency ratio has fallen substantially during recent decades. It is anticipated to remain low in the coming decades although some increase will occur. Rapid social and economic changes that have potentially profound and complex implications for the circumstances under which the future older persons will live, have accompanied the demographic change. Until the onset of the economic crisis that swept over much of the region since mid1997, Thailand experienced a prolonged period of rapid economic growth averaging 5 per cent annual increases in the gross national product during the quarter century between 1970 and 1995 (World Bank 1997).

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Nevertheless, Thailand has remained in the mid-range of developing economies in Asia in terms of the average GNP per capita. Although the majority of Thais still live in rural areas and are engaged in agriculture, between 1970 and 1990, the agricultural share of the labour-force dropped from 80 to 64 per cent and the proportion of the population in municipalities increased from 13 to 20 per cent (World Bank 1997). Formal education has also expanded. Especially striking are increases evident in the percentage of young persons who are continuing to secondary school which recently has been made mandatory. Although economic growth has abruptly come to a halt with the recent economic crisis, and even turned negative in 1997 and 1998, it is still too soon to know just how extensive or prolonged the impact will be. Even if recent predictions of renewed positive growth in 1999 prove too optimistic, it is unlikely that major reversals will occur in trends that are shaping the social context of older persons. Older people themselves have changed in important ways as a result of the demographic, social and economic change that has taken place. Older persons are living longer, a fact that contributes to the ageing of the elderly population. According to the Surveys of Population Change conducted by the National Statistical Office, between 1974 and 1976 and 1995 and 1996, life-expectancy at age 60 increased from 18.9 to 23.9 for women and 16.1 to 20.3 for men. The rapid expansion of education when the older people of the last few decades were in their childhood and youth has resulted in pronounced compositional changes in the percentage of those who we literate in recent decades. Gender differences in schooling in the past have also left their mark on today’s older people. Thus in 1970, close to half of men and over 90 per cent of women aged 60 and over were unable to read or write. By 2000, only slightly more than a tenth of elderly men and a quarter of elderly women will be illiterate (Christenson and Hermalin 1991). Moreover, the average educational level of the elderly population will continue to improve over the coming decades as the better educated cohorts succeed those less educated ones as time passes. Formal policies and organized programmes General government policies Governmental concern about older persons can be judged from policy statements from several sources: published formal statements presented to the parliament at the time a new government assumes office outline the policies they wish to pursue; national five-year plans for social and economic development are routinely formulated by the National Economic and Social Development Board (NESDB) to serve as guidelines for development activities; and a long-term plan for the elderly was formulated and

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subsequently revised by special committees formed for this purpose. Moreover, several laws as well as articles in the new constitution adopted in 1997 refer to the elderly. The general policy statements presented to the parliament by recent governments have all contained some references to the elderly. However, these statements typically group older people with other segments of the population such as children, indigent and disabled people, all of whom are seen as having special welfare needs. Among the five governments to take office during the period 1991 to 1997, several references were made to the need for ensuring health care to the elderly, including free medical insurance at government facilities. Other references have been made to establishing legislation to protect older persons from exploitation, looking after their livelihood, developing their potential, and promoting their support and care. The concern with health aspects of the elderly (and other groups) is related to the development of the free medical care programme for elderly people described below. Elderly issues do not appear to be of high priority in most of Thailand’s Five-Year Plans that guide national development (Chongvatana, et al. 1998). As with statements to parliament, they are usually included together with the broader set of disadvantaged groups mentioned above. The current eighth Five-Year Plan (1997–2001), however, includes a section dealing with ‘isolated indigent elderly’. The plan mentions providing social welfare benefits to elderly people, including an increased living allowance to indigent elderly, universal free health services for the elderly, and discounted fares for transportation, both in urban and rural areas. Other goals mentioned are to encourage and assist families to understand and care for elderly members; to encourage private hospitals, NGOs, religious institutions and communities to share in caring for the aged; and to apply legislative measures to regulate private enterprises involved with providing services to older persons (NESDB, undated). The first Long-Term Plan for the Elderly in Thailand (1986–2001) was developed by a special committee in compliance with recommendations of the 1982 World Assembly on Aging in Vienna sponsored by the United Nations. The plan outlined policies and strategies in five aspects: health, education, income and employment, social and cultural issues, and social welfare (Sub-Committee of Research and Long-Term Planning for the Elderly, undated). It emphasizes efforts to enable older people to be selfreliant and for the family to provide care and support. In 1992, at the request of the National Senior Citizen Council of Thailand for the government to be more explicit regarding policies on welfare, the longterm plan was revised (Working Group on Policies and Main Strategies for Support of Elderly 1992). The policies advocated include providing welfare, educating older persons on matters of relevance to them, supporting appropriate work, encouraging the community, religious

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institutions and the private sector to assist the elderly, training personnel, and collecting basic data on elderly issues. The elderly are explicitly mentioned in the 1997 Constitution of Thailand. Article 54 states that ‘persons who are 60 years old and over and who have insufficient income to maintain their living are entitled to receive assistance from the state’. Article 80 further states that ‘The state must provide welfare for elderly, the poor, the handicapped or disabled, and destitute persons so they can have a good quality of life and be self reliant’. A draft of an organic law specifying the type of welfare and benefits to which elderly people are entitled is being submitted to parliament. Moreover, existing legislation in the civil and commercial law specifies the reciprocal responsibilities of parents and children. One article specifically stipulates that children have a duty to support parents (section 2, article 1563). The criminal law also specifies penalties for persons who abuse the elderly (article 398) and for persons who desert elderly people (as well as children and ill persons) who cannot help themselves, leaving them prone to dangerous risk. Health policy and programmes Not only does the likelihood of chronic conditions increase greatly with old age but injuries and their complications can have serious consequences requiring medical attention and hospitalization. In recognition of the special health care needs of the elderly, the Ministry of Public Health (MOPH) officially established the Institute of Geriatric Medicine in 1994. The government has initiated a programme of free medical care for persons aged 60 and over. In addition, some Thai elderly are also covered by other government schemes, in particular voluntary government health insurance (through the Health Card Scheme) and the Civil Servant Medical Benefits Scheme. Thus, some elderly people have multiple health insurance coverage from the government since they may qualify for more than one scheme. Free medical care programme Starting in 1989, MOPH initiated a free medical care programme for disadvantaged elderly people that has been subsequently extended to cover all elderly persons. Under this programme, all government hospitals and health centres provide free services nationwide to persons 60 years and older with an ‘elderly card’. The programme operates through a ‘gatekeeper’ and referral system. The first contact in the rural area is the sub-district (tambol) health centre while in urban areas initial contact should be through local community health facilities. Complicated cases will be referred to higherlevel facilities such as district, provincial or general hospitals. The programme has been operating on a non-means tested basis and thus all

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Thai elderly are potentially covered by this form of government health insurance. Given the scale of the programme, it has been a major payer of health costs for older people. During the years 1995–97, this programme accounted for about 5 per cent of the MOPH total budget (personal communication from the Institute of Geriatric Medicine). The programme is currently being modified and will be integrated with the Medical Welfare Card programme. Under this modified programme, it is unclear if means testing will eventually be applied. Health card scheme The government-subsidized prepaid voluntary health insurance scheme, known as the Health Card Scheme, started as a pilot project in 1983 and was subsequently extended to all provinces. The current cost of a card is 500 baht a year.1 The target groups are farmers in rural areas, workers in small firms (with less than ten workers), seasonal workers, and self-employed persons. As of 1997, about 2 million health cards were issued. A card costs 500 baht per household and covers up to five-members including the elderly. The government has been subsidizing this project, initially spending 500 baht for each card sold. This amount was doubled starting fiscal year 1998. The benefits to those covered by a health card are similar to those of the free elderly medical care programme. It is also based on a referral system from lower- to higher-level facilities. Civil servant medical benefits scheme Health benefits have been included as one of the fringe benefits offered by the Thai government to all government and state enterprise employees. The health benefits also extend to employees’ spouses, parents, and up to three children. This benefit scheme has been in existence for many decades. Under the scheme, outpatient bills from public outlets are refunded to the patient. The costs of inpatient care may be directly paid to the hospitals or reimbursed to the patient depending on circumstances. Retirees, active employees and their dependents can freely seek inpatient care at public or private facilities with some ceiling applied to private outlets on the reimbursement. Both as a result of the economic crisis that started in 1997 and the rapid increase of expenditure from 4.3 billion baht in 1990 to 13.6 billion baht in 1996, the Ministry of Finance has instituted new regulations to contain costs by means of co-payment and reimbursement ceilings. Private health insurance Private health insurance does not play a major role in financing health care for Thai elderly people. Generally, private insurance is uncommon (Ron, et al. 1990). To the extent it exists, it is offered on a group or individual basis.

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Medical care coverage can be offered either as an attachment to a life insurance policy or as an independent insurance policy. In either case, health services are normally provided at private facilities on a fee-for-service basis. The extent of coverage depends on the insurance company and amount of premium. Unfortunately, most insurance companies do not offer policies to people aged 60 years and older because of the high health risks of older persons and potentially large amount of expenditures that could be involved. Once an insured person reaches 60 years old, the insurance policy will be terminated (based on informal discussions with insurance companies by Chutima Suraratdecha). Pensions and retirement benefits There are two major government sponsored plans for retirement benefits in Thailand: one for civil servants and state enterprise employees and one to cover general workers under the Social Security Act (Phananiramai and Ingpornprasit 1994). The latter programme, however, only took effect at the end of 1998. Government employees constitute approximately 6–7 per cent of the Thai labour-force. The new social security scheme will increase the number of persons under a government retirement benefit system to 18 per cent of the labour-force. Retirement benefits for government employees Although work as a government employee in Thailand has been associated with low pay, it has also been considered to provide a high level of security because of the wide range of welfare benefits it provides, including retirement schemes. At present there are two systems of retirement benefits for government employees: the pension system and the pension fund scheme. The government pension system has been in existence for a long time. In this system, civil servants with continuous employment for twentyfive years may choose to receive either a lump sum payment or a monthly pension upon retirement. Those who work with the government for ten years or more but less than twenty-five years will receive only a lump sum payment. State enterprises’ employees generally receive a lump sum payment upon their retirement. The projection of the increase in the amount of pension the government must pay for future retirees has prompted the government to initiate the socalled ‘Pension Fund for Civil Servants’ scheme in 1996. Those employed prior to the initiation of this scheme had to choose between the new and the old system. New employees, however, must join the new pension fund scheme. The conditions to receive a pension or lump sum payment upon retirement are similar in both systems. However, retirees under the new system receive a lower monthly pension but also receive a lump sum of their

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contribution at retirement. Based on the August 1998 round of the labourforce survey, there were about 2.4 million government employees, accounting for about 7 per cent of the total labour-force. Old age benefits for private employees A public social security system was established in Thailand in 1990 for workers of private enterprises with ten or more employees. The initiation of coverage for old-age benefits, however, was delayed until year end 1998. Contributions to the pension fund are made by three sides: employees, employers, and the government. The exact contribution of each side and the benefits to be paid for old age are still under discussion but may not be equal and are not to exceed 3 per cent for any one party. The Social Security Office, however, has started to collect an amount equivalent to 1 per cent of the employee’s salary from the employees and employers. Pension benefits are not to be paid for at least another fifteen years. In order to collect old-age benefits, members must be 55 years old and have contributed at least fifteen years. The benefits will be based on the number of years of participation and the average monthly salary during the last five years. Members who have made the contribution for less than fifteen years and retire at the age of 55 will receive a lump sum equal to their contribution plus interest. As of 1997, about 6.1 million workers, or 18 per cent of the total labour-force, are insured by the public social security system. It is projected that this number will increase in the future as more and more businesses are enrolled in the programme. Welfare programmes The Department of Public Welfare (DPW) is the main government provider of social welfare for elderly Thais.2 Several types of services are have been offered including residential services, monthly allowances for indigent elderly, and service centres for the elderly. In addition, various ministries and agencies have cooperated in an attempt to foster elderly clubs. Residential services Thai government policy has generally tried to foster familial care of older persons and has not emphasized institutional care. Nevertheless the DPW has established a small number of government residences intended mainly for the poor, homeless and deserted elderly. The first such home for the aged was established in 1953. The number had increased to sixteen by 1997. The total number of residents is slightly more than 2,000, including a small number who are not welfare cases but who are able to pay for their housing and services on the premises. Several charity organizations, especially ones associated with ethnic Chinese, also operate homes for the aged. In addition,

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there are private for-profit nursing homes. Systematic data on the nongovernmental homes are unavailable. So far, private homes can be managed free of government regulations. As a primarily Buddhist country, some elderly people live in temples as monks and nuns. According to the 1990 census, about 3 per cent of men aged 60 live in temples, 98 per cent of whom are monks. Only about 0.2 per cent of elderly women lived in temples. Of these, it is likely that most are nuns although the percentage is unknown since nuns are not specifically identified as such in the census. Thus the census figures suggest that only a small number of homeless elderly stay in temples. A national unpublished study carried out in 1994–95 by the DPW in the thirty-two provinces that reported back there were 1,115 elderly people staying in 362 temples (personal communication from the DPW). As a result of this study, the department started a programme to promote the use of temples as residences and service centers for needy elderly. As of mid-1998, almost 200 temples located in two-thirds of the provinces have agreed to participate and activities had already started in some. Monthly allowance for the indigent elderly In 1993 the DPW started a programme to provide monthly subsistence allowances of 200 baht for the indigent elderly in rural areas. Older persons eligible for the monthly allowance are selected by local village welfare assistance centres, set up throughout the country through the DPW, and must be approved by the provincial welfare office. The initial budget covered 20,000 elderly in over 5,000 villages. This programme subsequently expanded to cover 318,000 rural elderly in almost all villages by 1997. The 1998 number is expected to remain at this level. The DPW also initiated a project in 1993 to solicit donations from the private sector to fund monthly subsistence allowance of 200 baht for the indigent urban elderly. However, only several hundred elderly people have received allowances though this programme and almost all are in Bangkok. Social services centres for the elderly The DPW operates centres designed to provide a variety of social services for elderly people. The first centre was opened in 1979; by 1998 there were thirteen centres spread throughout the country and found in every region. Health care, physical and occupational therapy, exercise, income-generating activities, education, religious activities, and social work services are provided at the centre itself. The centres also arrange home visits by mobile units to provide counselling, medical services and information to older persons in need. In addition, emergency shelter for short-term stays of up to fifteen days are available for elderly people in difficulties.

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Elderly clubs Elderly clubs or senior citizen associations in Thailand were formally promoted by the government during the 1980s, based on the idea that informal group gatherings among older persons has long been common in Thailand. The goal was to facilitate the formation of self-help organizations of elderly people that can provide as well as receive assistance or services (Siripanich et al. 1996). The government, through the Ministry of Public Health and the DPW, thus encouraged and supported the elderly to form clubs in every community. In 1995, 14 per cent of the elderly nationwide reported themselves a member of an elderly group (Chayovan and Knodel 1997). The number of elderly clubs grew rapidly in Thailand during the 1980s. Although some clubs were formed out of genuine local initiatives, most were the result of government prompting with the support of either the Ministry of Public Health or the DPW. Club offices tended to be located either at a government health outlet or a temple. A 1994 study found that there were about 3,487 senior citizen clubs all over Thailand (Siripanich et al. 1996). The clubs varied considerably in size and activities. In the absence of continuing follow-up and support by the governmental agencies involved, substantial numbers of clubs were either dissolved or became inactive. The main reasons for the failure of so many clubs included a lack of clear initial aims at the time of formation, inadequate sizes and inconvenient locations for members. In their effort to promote the importance of elderly clubs and strengthen networking among them, the DPW organized a series of annual national conferences of club representatives starting in 1983. One outcome was an agreement to set up an autonomous organization to coordinate activities of elderly clubs all over the country. The Senior Citizen Council of Thailand was officially registered as a legal entity in 1989 and is a recognized organization in voicing the rights and demands of elderly people. At present, there are about 300 senior citizen clubs registered as members of the Council. To qualify for membership, the club must have at least fifty members, be in existence for not less than a year, and have continuous activities. Since many of the clubs initiated by the government promotion effort had less than fifty members, did not have continuous or organized activities, the number of member clubs is far below the number that had been formed at the height of the campaign to promote elderly clubs. Other activities In addition to the above mentioned programmes, there are numerous smallscale efforts to support and assist older persons made by governmental and non-governmental organizations, sometimes in collaboration with each other. For example, the Ministry of Transportation has reduced fares on

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state railways. The DPW has an explicit policy to encourage partnerships in various programmes with the private sector. One example is the programme to provide funds for cataract operations for the poor elderly and the donation of eyeglasses (for elderly people and children) in rural areas. As of 1997, the programme had distributed almost 15,000 eyeglasses, frames or lenses to their target population. HelpAge International (HAI) has its Asia regional office in Thailand, through which they also run a Thailand country programme. They work through local NGOs, including religious organizations, with HAI serving a coordinating and fund-raising function. The activities sponsored by HAI include training seminars, promotion of income generation activities among elderly people, eye care and cataract operations, and an ’Adopt a Granny’ programme whereby several hundred needy elderly cases in several provinces receive financial assistance. The programme is currently being expanded and modified (personal communication from Sawang Kaewkantha, HAI). Informal sources of support Cultural and religious underpinnings The Thai population is a relatively homogeneous population in major cultural aspects. The vast majority are ethnic Thais and speak some form of the Thai language; about 95 per cent profess Buddhism, typically of the Theravada branch. Still, numerous minorities can be defined in terms of ethnicity, language or religion. Muslims constitute approximately 4 per cent of the population and make up the largest and most notable religious minority. According to the 1990 census, most Muslims (81 per cent) live in the southern region, about half of whom are Malay-speaking. The remaining Muslims are mainly in Bangkok and the central region (Knodel et al. 1999). As in other Southeast Asian countries, the primary responsibility for older persons in Thailand has traditionally been with the family. A strong sense of moral obligation that adult children should support and care for elderly parents is a pervasive aspect of Thai cultural values and provides a strong normative basis for the prevailing pattern of familial support. As noted above, this responsibility is reflected in both the laws of the land and in the formulation of social policy. Focus group research indicates that both elderly parents and their adult children share similar view regarding this sense of responsibility and that it is found in all regions, transcending economic status or rural-urban residence (Knodel, et al. 1995). Repaying parents is generally viewed by Thais as a continual obligation that starts when the children are old enough to provide meaningful help, and commonly begins long before parents reach old age. However, the care and support provided by children when their parents are too old to take care of

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themselves is viewed as the culmination of this process. Underlying the obligation to repay parents are the concepts of ‘katanyu katawethi’ and ‘bunkun’, both of which are firmly ingrained in Thai Buddhist culture but have no simple English equivalents (Rabibhadana 1984; Podhisita 1985). Both terms relate to the reciprocation of actions that incur a sense of gratitude and debt. Katanyu refers to a constant sense of awareness on the part of someone for benefits which another person has bestowed upon him. Katawethi refers to doing something in return for them. Bunkun characterizes the person who bestows favours which incur a sense of gratitude and debt on the beneficiary. The concept of katanyu katawethi usually refers specifically to parent-child relationships while bunkun extends to many realms of life. Both concepts, however, characterize the essence of the relationship between parents and children. Giving life to and raising a child provides parents with the epitome of bunkun and instills a sense of gratitude and debt in the child that is virtually impossible to repay completely. This bunkun which parents have in relation to their children directly leads to the sense of obligation that adult children have to provide support and care to their parents when they are in their elderly years. Although Thai Muslims do not describe filial piety in these same terms, they also have a strong sense of obligation to parents that is deeply rooted in their religion. Indeed, throughout much of East and Southeast Asia there are similar cultural prescriptions related to the obligation to repay parents, especially when they reach older ages and can no longer support and take full care of themselves (Asis et al. 1995). Living arrangements A central feature of family support in Thailand for elderly members is coresidence (or a functionally equivalent arrangement) with one or more adult children. Table 13.2 provides several indicators relevant to describing the living arrangements of the Thai elderly in relation to their children. The surveys included information on adopted and step-children as well as the respondent’s own biological children. Approximately 4 per cent of elderly people are without any biological, adopted or step-children. A common, if narrow, measure of such co-residence is the percentage of elderly people who co-reside with one or more of their children in the same household.3 Among older persons with at least one living child, there has been a modest decline in literal co-residence, from 80 per cent in 1986 to 74 per cent in 1995. The lower levels of co-residence found in the more recent data possibly signifies the start of a trend away from co-residence. However, differences in sampling techniques and survey methodology between the sources could also account for all or part of the differences. Table 13.2 also indicates that very few Thai elderly live alone and that this has not changed over the period covered. By contrast, the percentage of elderly people living

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Table 13.2 Selected indicators of living arrangements among persons 60+

Source: Notes:

Knodel and Chayovan 1997. All results are based on national representative surveys; 1986 results are from the Socio-economic Consequences of the Aging Population in Thailand survey (S ECAPT); 1994 results are from the National Statistical Office Survey of Elderly in Thailand; 1995 results are from the Survey of the Welfare of Elderly in Thailand (SWET). Children include own, adopted and step-children.

with only a spouse has increased. This might reflect an increased tendency for adult children to establish separate, but nearby, households, as long as elderly parents have each other to live with. The finding that living alone has not increased, however, suggests that once one of the parents dies, coresidence may be initiated. Measures of literal co-residence ignore situations in which elderly parents and children live in separate dwellings very nearby, an arrangement that can also meet many of the same needs of older persons as sharing a dwelling. Such situations are not unusual in Thailand, especially in rural settings (Cowgill 1972; Knodel and Saengtienchai 1996). A more encompassing estimate of the extent to which living arrangements facilitate daily interaction between elderly parents and their children can be obtained by combining information on co-residence with that on the frequency of contact elderly people have with non-co-resident children. As Table 13.2 indicates, 91 per cent of elderly parents in 1986 and 90 per cent in 1995 either coreside in the same household or have daily contact with at least one child. This means that over half of elderly parents (54% in 1986 and 60% in 1995) who do not co-reside in the same dwelling with a child nevertheless see a non-co-resident child every day. The fact that there is little change in this more comprehensive measure between the 1986 and 1995 surveys suggests that the apparent decline between the two surveys in literal co-residence in the same household does not reflect a trend away from a family system of support and care of older persons. Instead, a limited modification of living arrangements may be occurring that retains frequent interactions and essential exchanges between parents and children but provides greater privacy for both parties. In focus group discussions, some elderly participants indicated a preference for this type of arrangement, especially as long as they are in good health (Knodel, et al. 1995).

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Comparisons between the younger and older, rural and urban, and Buddhist and Muslim elderly people with respect to living arrangements are shown in Table 13.3 based on the 1995 survey.4 Since minor co-resident children are likely to be largely dependent on parents, we focus on adult children only.5 The vast majority of elderly people have at least one adult child. Among those who do, there is little difference between the younger and older elderly or between Buddhists and Muslims in the percentage of elderly who live with children. However, it is more common for those in urban than rural areas to share the same dwelling with an adult child. This is more than compensated for, however, by the higher percentage of rural elderly people who have daily contact with their children. Thus the combined measure of co-residence and/or daily contact is slightly higher for rural than urban elderly. These findings probably reflect differences in land availability and housing styles between urban and rural areas. Having separate dwelling units either within the same compound or nearby is undoubtedly more feasible in rural villages than in towns or cities where land and housing prices make such arrangements prohibitive for many. Also shown in Table 13.3 are the percentages of elderly persons who coreside with an ever-married son and with an ever-married daughter. Living with married children reflects the ‘mature’ stage of living arrangements which eventually evolve once dependent single children leave the household. Far more Thai elderly parents live with an ever-married daughter than an ever-married son. This tendency, however, it largely a rural phenomenon. Among urban elderly people, there is little difference in the proportion who live with an ever-married son or daughter. The ruralurban differences in this respect undoubtedly reflect the far greater influence of Chinese ethnicity (and the associated preference for residing with a married son) among urban Thais compared to their rural counterparts. At the same time, there is little difference between younger and older elderly or between Buddhists and Muslims in the tendency to live with a married daughter rather than a married son. Material and social support from non-co-resident children Non-co-resident children can be important sources of economic and social support to elderly parents through providing money or gifts of food and useful items, as well as through frequent visitation. Results in Table 13.4 indicate that the vast majority of Thai elderly (over 90 per cent) have at least one child living outside the household. According to the 1995 survey, among elderly people who have a non-co-resident child, almost 90 per cent received gifts of food or clothes during the previous year and about the same proportion received some money from their children. Moreover, almost 70 per cent received at least a 1,000 baht from children. Although younger and older elderly as well as rural and urban elderly people are similarly likely to

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Table 13.3 Living arrangements in relation to adult children, by place of residence and religion, Thailand 1995

Source: the 1995 Survey of the Welfare of Elderly in Thailand (SWET).

Table 13.4 Intergenerational support from non-co-resident children to elderly parents, by place of residence and religion, Thailand 1995

Source: the 1995 Survey of the Welfare of Elderly in Thailand (SWET).

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receive gifts or money, younger and urban elderly who receive money are more likely to receive at least 1,000 baht. In the case of the urban elderly this probably reflects higher incomes of their children and the higher costs of living in urban areas. Muslim elderly people are somewhat less likely than Buddhists to receive material support from children, although most Muslims still receive each of the kinds of support shown. Table 13.4 also shows the percentage of non-co-resident sons and daughters of elderly people who provide different types of social and economic support to their parents. Except for giving at least 1,000 baht, the majority of both sons and daughters provide each of the other types of support to parents, i.e. giving food or clothes, giving money, and visiting at least monthly. Nevertheless, daughters are slightly more likely than sons to provide each type of support. This gender difference generally holds true regardless of age or place of residence of the parents. It also holds true for Buddhists. For Muslims, however, gender differences are largely absent except that daughters are more likely to give food or clothes than are sons. The likelihood for a child to give different types of support seems largely unrelated to the age or place of residence of the elderly parent. The main exceptions are that children of the younger and urban elderly are considerably more likely than those of urban parents to give at least 1,000 baht. Religious differences are also modest or absent except that Muslim children, especially daughters, are less likely than Buddhists to provide any money. Nevertheless, Muslim children of both sexes are as likely as Buddhists to provide at least 1,000 baht to their parents in a year. Thus in terms of significant money support the two religious groups are very similar. Main sources of support In each of the national surveys of older persons in 1986, 1994 and 1995, approximately half of all people aged 60 and over report that children are their most important source of income. There is little evidence of any change in reliance on children for support.6 Table 13.5 shows detailed distribution of main sources of support based on the 1995 survey. There is little difference in the percentage relying on children as the main source of income between rural and urban elderly people or between Buddhists and Muslims. Virtually no elderly respondents in any category shown report relying on welfare as their main source of income. Although the overall pattern of main sources of income differs little by religion, some contrasts are associated with age and to a lesser extent with place of residence. Reliance on one’s own or spouse’s work is the most important main source of support for the younger elderly, ahead of even children, but for older people it is far less common than depending on children. Rural elderly people are more likely to be supporting themselves through their own work or their spouse’s work than are urban elderly. By

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Table 13.5 Main source of income of persons aged 60+, by place of residence and religion, Thailand 1995

Source: the 1995 Survey of the Welfare of Elderly in Thailand (SWET).

contrast, urban elderly people are more than twice as likely as their rural counterparts to rely mainly on pensions and savings. Assistance from relatives other than children as a main source of income is rare in Thailand, with only 6 per cent reporting this as the case. However, relatives are very important for the small minority of childless elderly people, almost half (47 per cent) of whom indicate that their main source of income are relatives (not shown in the table). It is also common for childless elderly people to reside with other relatives. Analysis of data from the 1995 survey shows that over 60 per cent live with at least one other adult relative other than a spouse (Knodel and Chayovan 1997). Discussion and conclusions The last decade or so has witnessed a significant expansion of government programmes in Thailand designed to provide health, welfare and retirement benefits to significant numbers of elderly persons. Particularly noteworthy is the establishment of free government medical care for the elderly, monthly welfare allowances for the indigent elderly, and the Old Age Benefits Plan established under the Social Security Act. At the same time, there are important limitations and qualifications to this expansion of government assistance. Economic pressure is leading to modifications to the free elderly medical care programme, the consequences of which are not yet clear; full-scale old-age benefits from social security will not start for another decade and a half and will cover only the minority of the labour-force who are employed in large firms in the formal sector; and the amount of the welfare allowance for the indigent elderly is very modest and unlikely to cover even subsistence needs. Despite the expansion of government assistance, budgetary considerations as well as traditional values continue to direct government policy towards an emphasis on the family as the primary institution for assistance and support. This stress on the family’s responsibility for elderly members is evident in the original and revised Long-Term Plan for the

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Elderly as well as the national Five-Year Plans, including the current eighth plan. It is also evident in the very modest scope of the programme to provide residential services for the homeless or deserted elderly. Nevertheless, older persons appear to be receiving increasing recognition as their numbers and share of the population expand. The current constitution, adopted in 1997, explicitly identifies ‘the elderly’ as one of the disadvantaged groups in society for which the state must provide. Since private health insurance remains unaffordable or unattainable for most elderly people, the government can be expected to remain the most important provider of health services for the population in older ages. The rapid projected growth of the Thai elderly population means that the number of people eligible for free government medical care and the amount of government spending on the programme can be expected to rise rapidly unless restrictive eligibility criteria are imposed. Regardless of the share that the state will pay for elderly health care, population ageing is likely to exert considerable strain on the use of health facilities and personnel. This is virtually inevitable given the rapid growth in the size of the population that underlies the population aging process and the fact that elderly people make disproportionate use of health services, especially hospitalization (Knodel, et al. 1992a). Moreover, the demand for health services is likely to be further exacerbated by the improving educational composition of the elderly age group, since better-educated elderly people are likely to demand more and better services. The impact of population ageing on public welfare funding is harder to predict as it depends on uncertain trends in the existing family system, the future course of economic trends affecting both the state and families, and the extent of political commitment for the state to take on a greater role in societal welfare measures. The Asian economic crisis that started in mid1997 has undoubtedly created greater need for assistance on the part of families but has also posed difficulties for government funding of programmes. For example, the DPW recently requested the increase of the monthly subsistence allowance to 300 baht, but the request was turned down ostensibly due to the current financial crisis. The current economic situation may also be partially behind the move from a policy of universal free government health services for elderly people to a means-based programme. The full impact of the crisis on the well-being of older persons through effects on public programmes and the family support system is unknown. Systematic research into this issue would be useful. The family and particularly adult children continue to be the backbone of the system of support and care provided to Thais once they reach older ages and are no longer able to depend fully on their own resources. This is equally true for the majority Buddhist and the minority Muslim populations. Despite the major social, economic and demographic changes that have occurred in Thailand over recent decades, the evidence points to

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little if any significant erosion of this familial system of care and support. Although literal co-residence appears to have declined modestly, the large majority of elderly Thais still co-reside with children, and many who do not, live near enough to an adult child to have daily contact. There has also been little apparent change over the last decade in the proportion of elderly Thais who depend on children as their main source of income. The relative stability in the aspects of the family support system noted above does not mean that the current family system of support will remain unmodified in the foreseeable future. Many forces have been cited that have potentially profound and complex implications for intergenerational relations and the familial support system. These include smaller family sizes, increased economic activity outside the home by women (the predominant caretakers), physical separation of parents and adult children associated with urbanization and increased migration, and ideational change (Mason 1991; Martin 1989, 1990; Caldwell 1982). While these forces may cause some erosion in family support, the values that underlie familial support appear to be deeply ingrained in Thai culture and thus may be resistant to radical alteration or rapid change. A recent analysis suggests that, even though fertility decline means that older persons of the future will have fewer living children, this alone will not lead to a major reduction in key aspects of support from them (Knodel, et al. 1992b). Arrangements may also evolve that leave both generations of elderly parents and adult children better off. For example, higher incomes could permit a shift from literal co-residence to living in separate but nearby dwellings, an arrangement that could continue to meet the needs of both generations but enhance their privacy as well. A common perception underlying some government policy statements regarding older persons in Thailand and perpetuated by the media and by some non-empirically-based social science commentaries is that socioeconomic change is leading to widespread desertion of the rural elderly as their children move away to urban areas and leave them behind (e.g. Chanswangpuwana 1997; Charasdamrong 1992; Phananiramai 1997). Although there certainly are some such cases and they deserve priority for welfare assistance, evidence suggests the phenomenon is far rarer than typically assumed. For example, one newspaper feature focused on cases of deserted elderly people in an impoverished community which, it claimed, exemplified the phenomenon (Charasdamrong 1992). A subsequent systematic study of that same community yielded a very different picture. There were indeed two cases who were truly deserted by their family and lived off begging or offerings from their neighbours. However, overall among the 102 elderly people in the community no one else appeared to be deserted. Even among the few cases who lived alone or as a solitary couple, most received assistance from their children or relatives (Knodel and Saengtienchai 1996). Many elderly persons in the village were, however,

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very impoverished and, although not deserted, in need of economic assistance together with their families. On a national scale, the desertion of older persons does not seem widespread. The small minority of people who are in institutional dwellings are almost all in temples as monks or nuns. Among the large majority who live in private dwellings and have children, a 1995 national survey of older persons found 90 per cent either live with or very nearby children. Moreover, among the remaining elderly parents, a large majority receive substantial financial assistance from a child. Even among childless elderly people, over 60 per cent live with an adult relative and most of the remainder with a spouse (Knodel and Chayovan 1997). The fact that abandonment of the Thai elderly by their children or kin is uncommon, however, does not mean that Thai elderly people do not face serious economic problems. Nor does it mean that they necessarily have access to the extra-familial services that are necessary for their well-being (Knodel, et al. 1997). It does mean, however, that programmes intended for assisting elderly Thais should in many cases consider aid to needy families with elderly members rather than focus only on the tiny minority who are truly deserted by their children and kin. The interaction between the state’s and family’s role in ensuring the wellbeing of older persons is complex. Changes in family support may themselves lead to changes in state services as well as vice versa. Given the pressures social change is exerting on family care and the sensitivity of state measures to the uncertain course of the economy, it will be important to continue to monitor the situation. A good start in conducting careful empirical research on the older population using both surveys and qualitative research approaches has already been made in Thailand and should continue. Acknowledgments The research on which this chapter is based was supported in part by a research grant from the US National Institute on Aging (NIA) ‘Rapid Demographic Change and the Welfare of the Elderly’ (No. R37AG07637). Notes 1

2 3

The Thai baht was worth approximately US$0.04 (25–26 baht=$l) during much of the last decade when many of the various programmes described in this chapter were initiated. Since mid-1997, the rate was ‘floated’ and as of early 2000 is worth slightly less than US$0.03 (37–38 baht=$l). Much of the information relating to the DPW come from their annual reports; some information was solicited through interviews. In a small proportion of cases, co-residing elderly live with a minor child. In the 1995 survey, for example, 3 per cent of households of respondents age 60 or over with a co-resident child had no child of at least 18 years old.

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John Knodel et al. For the purpose of this presentation, urban is defined as officially designated municipalities and Bangkok. Given that the sample is nationally representative, the number of Muslims on which the results are based is relatively modest, thus some caution is called for when considering the results relating to religious differentials. For example, the total unweighted number of Muslim elderly in the sample is 229 compared to 4,223 Buddhists. Adult children includes those who are age 18 or over or are ever-married. No age limit is imposed on results relating to non-co-resident children. The percentage citing children as their main source of support was 47 per cent in 1986, 54 per cent in 1994 and 49 per cent in 1995. Differences in the coding schemes detract somewhat from precise comparisons. For example, 7 per cent of elderly are coded as receiving no income in 1986 while only 1 per cent are coded as such in 1994 and no one is coded as such in 1995. If these persons are excluded from the 1986 figures, the percentage reporting children as the main source of support rises to 51 per cent. The 1995 survey included separate codes for persons who cited two sources equally as their main source. If those who only cite children are combined with those who cite children plus another source, the percentage for whom children are the main source rises to 53 per cent. Thus the three surveys seem to reflect very similar percentages of elderly for whom children are the key source of support.

References Andrews, G. (ed.) (undated) Ageing in South East Asia: A Five-Country Study. The Centre for Ageing Studies, The Flinders University of South Australia. Asis, M.M.B., Domingo, L., Knodel, J. and Mehta, K. (1995) ‘Living arrangements in four Asian countries: a comparative perspective’, Journal of Cross-Cultural Gerontology 10:145–62. Bongaarts, John (1998) ‘Fertility and reproductive preferences in post-transitional societies’, Working Papers, no. 114, New York: Population Council. Caffrey, R.A. (1992a) ‘Family care of the elderly in Northeast Thailand: changing patterns’, Journal of Cross-Cultural Gerontology 7:105–16. ——(1992b) ‘Caregiving to the elderly in Northeast Thailand: changing patterns’, Journal of Cross-Cultural Gerontology 7:117–34. Caldwell, J.C. (1982) The Theory of Fertility Decline. New York: Academic Press. Chanswangpuwana, M. (1997) ‘Greying society’, Bangkok Post, 1 Oct. 1997 (from web site). Charasdamrong, P. (1992) ‘The misery of those left behind’, Bangkok Post, 10 May 1992. Chayovan, N., Wongsith, M. and Saengtienchai, C. (1988) Socio-Economic Consequences of the Ageing of the Population in Thailand: Survey Findings, Bangkok: Institute of Population Studies, Chulalongkorn University. Chayovan, N. and Knodel, J. (1997) A Report on the Survey of the Welfare of the Elderly in Thailand, Bangkok: Institute of Population Studies, Chulalongkorn University. Chongvatana, Noppavan, Wongboonsin, Kau and Kowantanakul, Rungratana (1998) Morbidity Pattern and Medical Welfare Policy for the Thai Elderly. Research Report 264/41, Bangkok: Institute of Population Studies, Chulalongkorn University. Christenson, B.A. and Hermalin, A.I. (1991) ‘Comparative analysis of the changing educational composition of the elderly population in five Asian Countries: a

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preliminary report’, Comparative Study of the Elderly in Asia, Research Report No. 91–11, Population Studies Center, University of Michigan. Cowgill, Donald O. (1972) ‘The role and status of the aged in Thailand’, in D.O. Cowgill and L.D.Holmes (eds), Aging and Modernization, New York: Appleton-CenturyCrofts. Jones, G.W. (1993) ‘Consequences of rapid fertility decline for old age security in Asia’, in R.Leete and I.Alam (eds), Revolution in Asian Fertility: Dimensions, Causes and Implications, Oxford: Clarendon Press. Knodel, J. and Chayovan, N. (1997) ‘Family support and living arrangements of Thai elderly,’ Asia-Pacific Population Journal 12, 4:51–68. Knodel, J., Amornsirisomboon, P. and Khiewyoo, J. (1997) ‘Living arrangements, family support, and the welfare of the elderly: findings and implications of the 1994 survey of elderly in Thailand’, Comparative Study of the Elderly in Asia, Research Report No. 97–43, Population Studies Center, University of Michigan. Knodel, J., Chayovan N. and Siriboon, S. (1992a) ‘Population aging and the demand for hospital care in Thailand’, Asian Pacific Population Forum 6 (1):1–4, 21–24. ——(1992b) ‘The impact of fertility decline on familial support for the elderly: an illustration from Thailand’, Population and Development Review 18 (1):79–102. Knodel, J.Gray, R.S., Sriwatcharin, P. and Peracca, S. (1999) ‘Religion and reproduction: Muslims in Buddhist Thailand’, Population Studies (forthcoming). Knodel, J., Ruffolo, V.P.Ratanalangkorn, P., Wongboonsin, K. (1996) ‘Reproductive preferences in post-transition Thailand: implications for the future course of fertility’, Studies in Family Planning 27, 6:307–18. Knodel, J. and Saengtienchai, C. (1996) ‘Family care for rural elderly in the midst of rapid social change: the case of Thailand’, Social Change 26, 2:98–115. Knodel, J. and Saengtienchai, C. (2000) ‘Studying living arrangements of the elderly: lessons from a quasi qualitative case study approach in Thailand’, Journal of CrossCultural Gerontology (in press). Knodel, J., Saengtienchai, C. and Sittitrai, W. (1995) ‘The living arrangements of elderly in Thailand: views of the populace’, Journal of Cross-Cultural Gerontology 10:79–111. Martin, L. (1989) ‘Living arrangements of the elderly in Fiji, Korea, Malaysia, and the Philippines’, Demography 26:627–43. ——(1990) ‘Changing intergenerational family relations in East Asia’, The Annals 510 (July): 102–14. Mason, K. (1992) ‘Family change and support of the elderly in Asia: what do we know?’, Asia-Pacific Population Journal 7, 2:13–32. National Economic and Social Development Board (NESDB), Office of the Prime Minister (undated) The Eight National Economic and Social Development Plan (1997– 2001), Bangkok: Government of Thailand. National Statistical Office (1994) Population Aging in Thailand (1990) Population and Housing Census, Subject Report No. 2, Bangkok: National Statistical Office (in Thai). Phananiramai, M. (1997) ‘Population changes and economic development in Thailand: their implications on women’s status’, TDRI Quarterly Review 12, 3: 15–26. Phananiramai, M. and Ingpornprasit, N. (1994) Population and Sustainability of Social Security Plan: A Case Study of Pension Benefit, Working Paper No. 5, Thailand Development Research Institute Foundation. Podhisita, C. (1985) ‘Buddhism and the Thai World view,’ in A.Pongsapich, C. Podhisita, S.Chantornvong, N.Bandhumedha, W.Wibulswasdi Anderson, S.

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Smukarn, K.Phutharaporn and S.Komin (eds) Traditional and Changing Thai World View, Bangkok: Social Science Research Institute, Chulalongkorn University. Pramualratana, A. (1990) ‘Support systems of the old in a rural community in Thailand’. PhD Thesis, Australian National University, Canberra. Rabibhadana, A. (1984) ‘Kinship, marriage and the Thai social system,’ in A. Chamratrithirong (ed.) Perspective on the Thai Marriage, IPSR Publication No. 81. Bangkok: Institute for Population and Social Research, Mahidol University. Ron, A., Abel-Smith, B. and Tamburi, G. (1990) Health Insurance in Developing Countries, Geneva: International Labor Office. Siripanich, B., Tirapat, C., Singhakachin, M., Panichacheewa, P. and Pradabmuk, P. (1996) A Research Report on the Senior Citizen Clubs: A Study of the Appropriate Model, Bangkok: Vinyan Printing (in Thai). Sub-Committee of Research and Long-Term Planning for the Elderly (undated) Long-Term Plan for The Elderly in Thailand (1986–2001), Bangkok: Department of Medical Service, Ministry of Public Health (English version). Surasiengsunk, S., Krianandana, S., Wongboonsin, K., Garnett, G.P., Anderson, R. and van Griensven, G. (1998) ‘Minor demographic impact of the HIV epidemic in Thailand’, AIDS 1998, 12, 7:775–84. United Nations (1997) The Sex and Age Distribution of the World Populations: The 1996 Revision, New York: Department of Economic and Social Affairs, Population Division. ——(1998) World Population Prospects, the 1996 Revision, New York: Department of Economic and Social Affairs, Population Division. Working Group on Policies and Main Strategies for Support of Elderly (1992) The Essence of Long-Term Policies and Measures for Elderly 1992–2011 (in Thai). World Bank (1997) World Development Indicators, Washington, DC: World Bank.

14 Ageing in the Philippines An overview Josefina N.Natividad

Introduction The chapter reviews the current state of older people in the Philippines drawing from various sources: census data, demographic surveys, published reports of government agencies and academic research on ageing and related topics. The Philippines has not yet reached the stage of great concern over demographic ageing and its consequences but it is expected to face these in the near and not so near future. While the state of research on elderly issues is in its infancy at present, in 1996 the first survey on a nationally representative sample of elderly (60+) and near elderly people (50–59) has been conducted and should provide more concrete data as a basis for planning. Selected findings of this survey will be cited in the succeeding discussion along with findings from the Philippine component of the 1984 ASEAN survey on Socioeconomic Consequences of the Ageing of the Population (SECAP) (see Chapter 2, p, 59). The demographic setting The Philippines is an archipelago of 7,107 islands with a total land area of 300,000 square kilometres. There are three main island groups, Luzon, Visayas and Mindanao, with Luzon, the largest island, containing the country’s capital, Manila. At the 1995 census the country had a recorded population of 68 million. Table 14.1 presents an overview of the demographic profile of the country over a 25-year period. Table 14.1 shows that the Philippines has had a history of high population growth that has been declining albeit very slowly. Its current annual growth rate (2.3 per cent) is twice that of many of its neighbours such as Taiwan. Should this trend persist, the population is expected to double in size in thirty years. This despite the fact that since 1971 the Philippines has had a formal population policy under Republic Act 6535 aimed at fertility reduction (Commission on Population 1994). Such resistance to a decrease in the growth rate though fertility reduction has been partly traced to the strong lobby by the Roman Catholic Church against the use of artificial methods of contraception.

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Table 14.1 Selected demographic indicators for the Philippines

Notes:

l

Philippine Statistical Yearbook 1996, 1998. Concepcion 1991 cited in National Demographic Survey 1993. Rates for 1973, 1978 and 1983 surveys are five-year averages, for 1986 and 1993, three-year averages all centered on the year in respective parentheses. Each survey was conducted on a nationally representative sample of ever-married women 15–49 years old. 3 National Demographic Survey. 4 Republic of the Philippines Fertility Survey. 5 Contraceptive Prevalence Survey, 6 Totals exceed 100 per cent because of multiple response. 2

Other demographic indicators support the conclusion that growth has been mainly fertility-driven. For example, while the total fertility rate (TFR) has been declining (from about 6 in 1970 to about 4 twenty years later), the rate remains too high compared to other countries in the region, being twice replacement level. As a consequence of high growth, the population remains predominantly young with a 1995 median age of 20 years. Such youthful composition also is reflected in the dependency ratio, with a higher proportion of dependents being young (below 14 years). The trend in the

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dependency ratio over the years reflects the effect of moderate fertility decline as the number of young dependents shows consistent but moderate decrease from 1970 to 1995. There has been no substantial change in the proportion of elderly dependents over the years. It has been observed that the ‘the population problem during the decade 1960–1970 became the employment problem of the 1980s and 1990s’ (Commission on Population 1994). The youthful composition of the Philippine population has meant that there is a large stock of new entrants into the labour-force that must be absorbed each year. Unfortunately economic growth in the country has lagged behind that of many of its neighbours in the 1980s and early into the 1990s. There have been two major dips in the growth of the Gross National Product (GNP) in recent years, the first in 1984–5 (—7.5 per cent) following the assassination of Benigno Aquino which triggered political upheaval in the country that ultimately led to the ousting of the long-term dictatorial rule of Ferdinand Marcos. The second dip was in 1990–1, soon after a bloody coup attempted to unseat the then president Corazon Aquino, when growth was registered at 0.5 per cent, down from 4.5 per cent the previous year. Modest growth resumed at an average of about 4 per cent thereafter (1991–7). One positive note is that the Philippines was been spared much of the severity of the downtrend in economic growth in the region in the late 1990s, although like many others, its currency was devalued in late 1997. One sorry consequence of the relatively poor economic growth has been the outflow of human resource into the international labour market. From the 1970s to the present, the Philippines has been a major source country for overseas contract workers to other parts of the region and further afield to the Middle East, North America and elsewhere. However, workers’ remittances from abroad accounted for 3.7 per cent of Gross Domestic Product for the period 1996–7 or an average of $1.7 billion annually (National Statistical Coordination Board 1998). The majority of those working abroad leave behind their spouse and children. Anecdotal accounts allege that elderly parents are pressed into taking over parental surrogate roles especially if the migrant worker is a woman, but the extent to which this actually happens needs to be verified by research. Urbanization in the Philippines has also undergone substantial changes. From a predominantly rural population in the 1960s, the proportion living in urban areas has risen to 48.6 per cent in 1990. Of the elderly population, a slightly lower proportion (46.6 per cent) reside in urban areas. Interestingly, more female older persons (48 per cent) reside in urban areas than males (44 per cent). Another impetus to population growth, though at a less significant level, is the improvement in mortality. Over the past twentyfive years, significant increases in life-expectancy at birth have been recorded and, in general, life-expectancy at birth has increased by 10 years for both males and females. Life-expectancy for older people has also increased

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slightly, with more marked improvements for females who showed a 1-year increase in life-expectancy at 60 for every 10-year interval over the past twenty-five years. If the trend toward a slow decline in growth rates persists, as seems likely, the proportionate share of the elderly to total population is expected to increase gradually as well. From the World Bank estimates, this share is projected to reach 10 per cent from its current figure of 5 per cent by 2020. Nevertheless, the growth rate of the elderly population is likely to be higher than that of the total population in general (Table 14.1). Furthermore, while their proportionate share may not be rapidly increasing, their absolute numbers are. Therefore it cannot be presumed that the needs of older persons in the Philippines will not be of importance in the coming decades because their numbers are steadily on the rise. Apart from changes in numbers, many characteristics of older persons have also changed over the years. For example, literacy rates among older Filipinos have been steadily improving (Domingo and Feranil 1987). This reflects the many changes in the social and political climate of their youth which corresponded to the middle and later part of American colonial rule (1898–1942), whose education policy encouraged universal basic schooling (up to primary level). Indeed, Christenson and Hermalin (1991) noted that the literacy rates of both males and females have been increasing from the turn of the century and are projected to reach 90 per cent for those born in 1956–60. Unlike many other neighbouring regional countries such as Thailand, Singapore, Taiwan and South Korea, there is no overwhelming difference between males and females in literacy rates (Domingo 1992). However, in terms of economic activity, there is still a notable gender difference and more males than females are still economically active at 60+, a reflection of the generally higher labour-force participation of males at all ages (Domingo and Feranil 1987). The institutional setting for ageing in the Philippines Government policies and programmes for older persons Government awareness of older people as a distinct population sector with specific needs is of recent origin. The new 1986 Constitution, crafted after the twenty-year dictatorial rule of Ferdinand Marcos, contains a specific article on the family, one section of which reads ‘The family has the duty to care for its elderly members but the State may also do so through just programs for the elderly’. This statement implies that the state is not enjoined to play the primary role in the provision of care for older citizens. Nevertheless, specific legislation passed in 1991 and 1994, known respectively as the Senior Citizens Act and Senior Citizens Center Act set broad guidelines for granting special privileges and providing various

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support services for older people. These two laws are products of the consolidation of dozens of proposed bills in both Houses of Congress that sought to grant various privileges to elderly citizens. Furthermore, older persons are entitled to one sectoral representative in the Lower House of Congress. Under the Senior Citizens Act (1991), elderly persons aged 60 and above must first secure a national identification card to avail of the privileges granted under the law (Senior Citizens Act: RA 7432). In general, the government classifies the elderly as a group as part of the disadvantaged segment of society. As such, their specific needs are addressed under the jurisdiction of the Department of Social Welfare and Development (DSWD), specifically the Bureau of Disabled Persons Welfare. Elderly people are grouped with mendicants, drug and alcohol dependents and former political detainees under the category of ‘socially disabled’ (Somera 1995; Domingo et al. 1994). The department provides assistance for physical restoration for those who lack financial resources to purchase technical devices (such as wheelchairs, crutches, canes) and seek medical treatment, self-enhancement services through activities that create opportunities for socializing, creative expression and self-improvement and livelihood development services to develop economic self-reliance. It co-ordinates elderly volunteer programmes which tap the talents and expertise of older people. It also runs residential institutions for abandoned, neglected and destitute older persons as well as after-care and follow-up services for those who are discharged from these institutions into the care of kin (Fermin 1988, cited in Somera 1995). Following the devolution of government services to local government units in 1992, social welfare of older people has largely been passed to the Office of Senior Citizens’ Affairs (OSCA) under RA 7432, to implement the provisions of the law on senior citizens at local levels. The DSWD provides technical assistance and sets quality standards for the local OSCAs, while retaining its functions as mentioned above relative to destitute elderly people. Each municipality has its own OSCA, headed by a councillor, who is a locally elected official at the municipality/town level. (The highest official in the town is the mayor, followed by a vice-mayor and a set of councillors all elected at large for a three-year term.) Health-related programmes Discounts for purchase of drugs Health care concerns are of paramount importance among older persons because of the increased incidence of chronic degenerative diseases and disability with age. Many of the bills in Congress which sought to grant privileges to older persons, and which were incorporated in the Omnibus Senior Citizens Act, specifically addressed the concern for increased health care costs.

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Under the law, senior citizens are entitled to a 20 per cent discount on medicines for their own use. To take advantage of the discount, they or their representative must present at the drug store their Senior Citizen’s ID and their purchase slip booklet, which is issued by the local OSCA. For prescription drugs the doctor’s prescription should also be presented. As a general rule, medicines purchased under this scheme should not exceed a week’s supply although, for medicines for treating chronic conditions such as hypertension or diabetes, a maximum of one month’s supply may be purchased at any one time. Free medical care programme Under RA 7432, senior citizens are entitled to ‘free medical and dental services in government establishments anywhere in the country subject to the guidelines to be issued by the Department of Health (DOH), the Government Service Insurance System and the Social Security System’. Apart from free medical and dental care, senior citizens can avail themselves free of available medicines in all public health programmes, available diagnostic and therapeutic procedures, use of operating rooms, accommodation in charity wards and professional and counselling services. A Department Order issued by the DOH in May 1993 specifies that free services be provided to senior citizens in government hospitals under DOH control, subject to the competence and capability of the health facility concerned (Senior Citizens Act: RA 7432). However, many institutions are excluded in the Order. These include the numerous provincial, municipal and city hospitals whose operations were devolved to the local government units in 1992 and government hospitals that are not under DOH control. Examples include the Philippine General Hospital, the Department of National Defense hospitals and the specialty hospitals such as the National Kidney Institute, National Lung Center and Philippine Heart Center for Asia. In practice, this severely limits the actual number of medical establishments in which free medical and dental care may be obtained. Government-sponsored health insurance In 1972, the government founded Medicare, a compulsory health insurance scheme covering public and private sector employees and their dependents, which may include an elderly parent of 60 years and above with income below a specified minimum. In 1990, it was estimated that 38 per cent of the Philippine population was under Medicare coverage (Solon et al. 1992). Medicare was replaced under the National Health Insurance Act of 1995 which instituted a National Health Insurance Program that aims toward universal coverage. To be covered by the scheme requires a monthly contribution based on salaries for formal sector employees and on household earning and assets for the self-employed (National Health

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Insurance Act of 1995 (RA 7875)). Financing for indigents has not been explicitly stated in the law. At present, like Medicare, the new health insurance scheme covers only inpatient care. While outpatient care is provided by the law, it is not yet being implemented following provisions in the law that call for a gradual implementation of the full coverage and range of services. Currently, beneficiaries are entitled to 45 days’ of room and board allowance for inpatient care plus specified amounts for drugs and medicines, laboratory and x-ray services prorated by type of hospital (primary, secondary and tertiary) and case (ordinary, intensive and catastrophic). Professional fees are also included, again prorated by type of specialization (general practitioner, specialist, surgeon, anesthesiologist). Dependents are entitled to 45 days’ of inpatient care per year provided this is shared among all dependents. Retirees who have paid their health insurance premiums while employed continue to be covered by the health insurance system even after retirement. Under the old Medicare programme Medicare support values, the proportion of total hospitalization expenses paid for by Medicare, ranged from 31.5 to 48.9 per cent only (Solon et al. 1992). The bulk of hospitalization costs are therefore out-of-pocket expenses. Currently the ceiling for the amounts to be covered by the new health insurance scheme remains low, thus support values are not expected to show substantial gains. Out-patient expenses remain fully out-of-pocket costs for the majority of the population. Payment of a fee for service is the most common mode for financing health care, especially outpatient care. Private health insurance The entry of private health insurance schemes is a relatively recent phenomenon and the sector remains underdeveloped (Solon et al. 1992) although, as in many other countries in the region, it has the potential to grow. A number of Health Maintenance Organizations (HMOs) operate in the Philippines but they are mostly investor-based, favouring the segment of the market that can afford to pay premiums. HMOs tend to focus on group rather than individual accounts and avoid the high-risk elderly sector by imposing age requirements for membership. Pension and retirement benefits Two major government corporations administer pension and retirement programmes for those who were employed: the Government Service Insurance System (GSIS) for public sector employees and the Social Security System (SSS) for private sector employees. The GSIS and SSS programmes were established in 1936 and 1954 respectively, making them among the oldest social security programmes in Asia. They also offer some of the

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widest coverage and range of available benefits (Asher 1998). Both GSIS and SSS charters were revised in 1997 to make them more responsive to the needs of the times. Both schemes also require their members to pay monthly contributions, broken down into employee and employer shares. GSIS or SSS membership is compulsory for formal sector employees while the selfemployed can opt to pay the employer share of the monthly contribution to be fully covered. Members of the Armed Forces of the Philippines, the Philippine National Police, the Bureau of Jail Management and Penology and the Bureau of Fire Protection are not covered by the GSIS because they have their own pension and retirement scheme. Pension and retirement benefits for public sector employees A GSIS member is eligible for retirement benefits if he is at least 60 years old at the time of retirement, has rendered at least 15 years of service and is not receiving pension benefits from permanent total disability. At age 65, retirement is compulsory. Under the new law, a retiree has two options with respect to pension benefits. The retiree can opt for a five-year lump sum (basic monthly pension times 60) plus the basic monthly pension for life at the end of the guaranteed five-year period. Alternatively, retirees can opt to receive a cash payment equivalent to the basic monthly pension times 18 plus the basic monthly amount for life starting immediately upon retirement (Primer on the GSIS Act of 1997 (RA 8291)). The amount of the monthly pension depends on the average monthly compensation computed as the average of the monthly compensation for the last thirty-six months of service prior to retirement. There are both floor and ceiling values for the monthly pension, set at 1,200 pesos and 9,000 pesos, respectively (US$1 equals approximately 40 pesos). Upon the retiree/pensioner’s death, the primary dependents are entitled to receive the survivorship pension which is 50 per cent of the basic monthly pension and the dependent children’s pension which shall not exceed 50 per cent of the basic monthly pension. If the primary dependent is a spouse s/he receives the survivorship pension for life or until s/he remarries. Children are eligible for the monthly pension until they reach age 21. As of December 1997, there were 90,045 old-age pensioners reported by GSIS. Pension and retirement benefits for private sector employees An SSS member is eligible for retirement benefits if upon retirement he is 60 years old, unemployed and has paid at least 120 monthly contributions prior to the semester of retirement or is 65 years old whether employed or not, whether or not he has completed 120 monthly payments. Members who have completed 120 monthly contributions are eligible for the monthly pension; those who have not are paid a lump sum equivalent to the total contribution paid by the employee plus the employer’s share and interest.

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The monthly pension will be the highest of (1) the sum of 300 pesos plus 20 per cent of the average monthly salary credit plus 2 per cent of the average monthly salary credit for each credited year of service in excess of ten years or (2) 40 per cent of the average monthly credit or 1,200 pesos provided that the monthly pension is paid for not less than sixty months (Guidebook for SSS Members 1998). The ceiling for monthly salary credit is 12,000 pesos. The lowest monthly pension is 1,200 pesos. Unlike GSIS, SSS also pays an additional thirteenth month pension at the end of each year. The retiree may opt to get the first eighteen monthly pensions as a lump sum payment. A monthly pension then commences in the nineteenth month. The dependent children of the retiree are also eligible for a monthly pension until they reach age 21, the sum being equivalent to 10 per cent of the retiree’s monthly pension or 250 pesos for each dependent child, whichever is higher. A maximum of five minor children may receive the pension. Upon his death, the retiree’s primary beneficiary will receive 100 per cent of the monthly pension for life, or until remarriage if a spouse, plus a pension for each dependent minor child. Children who are disabled and thus incapable of self-support are eligible for a lifetime pension. As of December 1997 there were 283,412 retirement pensioners under SSS. Welfare programmes Homes for the elderly In accord with the constitutional provision that the family has the primary role for caring for its elderly members, welfare programmes providing institutional care for older persons are aimed mainly at the abandoned, destitute and disadvantaged. The Department of Social Welfare and Development (DSWD) runs two homes for the elderly that cater to those who have no kin to care for them and no other means of support. The most famous of such homes is Golden Acres in Quezon City which houses about 200 old people. Other homes for the elderly are operated by Catholic religious orders and civic organizations. The DSWD 1998 Masterlist of Licensed/Accredited Non-government Organizations lists nine such homes in various parts of the country. Other reports mention nineteen homes run by civic and Catholic religious organizations (Domingo and Feranil 1987; Somera 1995). These homes take in only the abandoned elderly people. Privately-run nursing homes for elderly people who are not abandoned by kin and who can pay for such services are not documented in government records although they may exist. The well-to-do elderly who need institutional care may also be entrusted in hospitals to be cared for as inpatients. That the government recognizes the need for such homes in the future, and not just for disadvantaged elderly people, is manifest in one provision of

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the Senior Citizens Act which grants a realty tax holiday for the first five years of operation of residential communities or retirement villages solely for senior citizens. The law also gives priority in the building and/or maintenance of provincial or municipal roads leading to such homes (Senior Citizens Act (RA 7432)). These privileges are granted provided the establishment is non-stock, non-profit in nature. Special privileges for older persons In addition to discounts on medicines, the Senior Citizens Act also provides for a 20 per cent discount in transportation fees, restaurants, recreation centres, hotels and similar lodging establishments, admission fees in theatres, cinema houses, concert halls and similar places of culture, leisure and amusement. Private establishments may claim the foregone income as a tax credit. Senior citizens whose annual taxable income is below 60,000 pesos per year are exempted from payment of individual income tax. Furthermore, the person with whom the elderly member lives and who takes care of him/her, whether kin or not, can also claim tax benefits by declaring the elderly person as his dependent. Associations, clubs and organizations for older people The passage of the Senior Citizens Act was partly a result of the strong lobby by senior citizens’ groups under an umbrella organization called the Federation of Senior Citizens Association of the Philippines (FSCAP). This organization likewise successfully lobbied for a sectoral representative of the elderly in Congress. The Report of the President for 1989 states that the number of senior citizens’ associations has increased from 1,780 in 1987 to 2,011 in 1988, with a corresponding substantial increase in membership. No doubt the numbers are much bigger at present. Generally, associations for the elderly promote social and recreational, health-related, spiritual and livelihood activities. The Senior Citizens Center Act (RA 7876) formally recognizes the role of senior citizens’ associations in the community. It provides that the senior citizens’ centres to be established in each municipality shall be ‘administered, managed and operated by the Federation of Senior Citizens Associations of the Philippines while the DSWD shall provide technical assistance/ supervision’ (Senior Citizens Center Act of the Philippines with Implementing Rules and Regulations). The local government unit will provide administrative support and supervision. Another organization, the Coalition of Services of the Elderly (COSE) was established in 1989 with a grant from HelpAge International and other international organizations, most of which are Catholic-based (for example, Caritas Netherlands, and the Austrian Catholic Women’s Movement). It

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aims to provide services to urban poor elderly persons. With the help of a religious order, it has built group homes for the elderly and seeks to build more. Senior citizens’ centres The senior citizens centres established by law (Senior Citizens Center Act or RA 7876) are newly created units to be established in each municipality. The centres are envisioned to become the hub of activities related to older persons, to be run by elderly people themselves. During the first two years of implementation of the law, the DSWD is tasked to establish model centres in every province which shall be used as demonstration centres for all programmes related to old people’s concerns. Municipalities are expected to set up their own local centres patterned after the model within five years of the implementation of the Senior Citizens Center Act. As previously mentioned, the centres will be administered by members of the Federation of Senior Citizens Association of the Philippines. The socio-cultural setting The Philippines stands out among its Asian neighbours as being the only predominantly Christian nation in the region. As a result of three hundred years of Spanish colonization, at least 80 per cent of the population are Roman Catholics. The rest are divided among a Muslim minority residing mainly in the southern islands, comprising the Mindanao group, which largely escaped colonization by Spain, and Protestant sects which are a legacy of about forty years of American rule. The Japanese also briefly occupied the country from 1942 to 1945 during the Second World War. The Philippines is a linguistically diverse nation with about five major languages and dozens of minor ones. The national language, Filipino, is based on Tagalog, the language in the capital city of Manila and its immediate environs. Other major languages are Visayan, Ilocano, Hiligaynon and Maranao. English is widely spoken and up until the early 1980s was the medium of instruction in schools. Its long history of being under colonial rule makes the Philippines relatively more Westernized than most other Asia-Pacific countries. However, one characteristic that Filipinos (across various linguistic groups) share with most of their Asian neighbours is the primacy of the family in social life. ‘Philippine social organization is characterized by a bilateral kinship system, separated into generations and with the nuclear family composed of parents and children as the core unit’ (Lopez 1991). The bilateral ties ensure a potentially large pool of kin that can be relied upon for social, economic and emotional support particularly for elderly people (Castillo 1977). The culture likewise reinforces values that support the

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kinship system as a social alliance system by which members enter into reciprocal ties. Such values include the maintenance of smooth interpersonal relations, observance of debts of gratitude (utang na loob), especially towards family and those from whom one receives favours, avoidance of behaviours that bring shame (hiya), individually as well as to the family in general (Lopez 1991). Utang na loob implies a debt (utang) that requires the recipient to ‘return a favor with interest’ (Hollnsteiner 1973, cited in Lopez 1991) and not expect full payment. While utang na loob may be incurred among non-kin, it is of a different magnitude when incurred within the family, particularly in the parent-child relationship. Children are expected to be grateful to parents not just for having been cared for but for having been given life itself (Hollnsteiner 1973). Failure to repay utang na loob is sanctioned by hiya, the feeling of shame and social discomfort that comes from knowing that one is in a socially unacceptable position (Lynch 1973). Parents generally do not incur utang na loob from their children. It is the children who, having been given life must show respect and obedience to parents and care for them in their old age (Nurge 1965, cited in Lopez 1991). A child who shows no utang na loob by reneging on his implied duty to support his parents incurs strong social sanctions that will attempt to evoke in him the sense of hiya. On the other hand, data from focus group discussions suggest that older persons do not expect to be cared for and supported financially by their children as a matter of right. Rather they would prefer to leave the decision to their children, some adding that it is humiliating to have to ask outright for support. Such should be offered voluntarily (Domingo and Casterline 1992), the gesture being part of the expectation for the repayment of utang na loob. Despite such misgivings about receiving support from children, data from the 1984 ASEAN Survey shows that money from children is a major source of income amongst older persons (Domingo, et al. 1990) (Table 14.2). However, as noted in Chapter 1, as in many other countries of the region, there are in the Philippines significant differentials between urban and rural elderly people, with urban elderly showing evidence of higher reliance on children for economic support and rural elderly people relying on earnings from agricultural production. However, such differentials may be confounded because rural elderly people who rely on the farm for income may include those whose children work the farm for their parents, thus indirectly making children still the source of income. It is also evident in the table that pensions form a minor source of economic support with only 6.8 per cent reporting it as a source of income. Predictably, the proportion receiving a pension is much higher among the urban elderly since the likelihood of having been employed in the formal sector for which pension benefits are available is higher in urban areas. The lower labour-force participation rate among females is evident in the

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Table 14.2 Sources of income of older Filipinos by gender and residence, 1984 ASEAN Survey

Source: Domingo and Feranil 1990. Note: *totals exceed 100% because of multiple responses.

relatively low proportions who report current employment as a source of income. The males in general are more economically active even at these advanced ages. Living arrangements In most Asian countries, patterns of living arrangements among the older population reveal in a most concrete way the extent of support extended to older people by their children and vice versa. This is through living together or co-residence. As in neighbouring Asian countries (Knodel and Chayovan 1997; Truong et al. 1997), co-residence with a child is the most prevalent living arrangement in the Philippines (Domingo and Casterline 1992; Natividad and Cruz 1997). Table 14.3, using unpublished data from the 1996 Philippine Elderly Survey (PES), reveals that living alone is an uncommon occurrence for older persons (only 5.5 per cent), as is living with a spouse only (7.9 per cent). A significant proportion of the elderly population co-resides with a child (69.2 per cent). When the definition of co-residence is expanded to include children who live adjacent to the older person’s residence, the proportion increases further to 76.8 per cent. Simple co-residence (living in the same house) is generally higher in urban (72 per cent) than in rural areas (67 per cent), because the cost of setting up a separate household is higher in urban areas. In general, the picture one forms of the situation of the majority of old people in the Philippines is one of integration into a family network of children and, in many cases, grandchildren, either co-residing in the same household or close enough to be in daily contact. While this picture of high co-residence appears to be close to the normative prescription for children to repay their utang na loob by caring for

Table 14.3 Measures of living arrangements for Filipino older people, 1996 Philippine Elderly Survey

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elderly parents, there is evidence that the situation has its share of tensions and is not always considered ideal. Asked what they would consider an ideal living arrangement for elderly couples and for the widowed, respondents to the 1996 Philippine Elderly Survey did not give living with a child as the most common answer. Their answers suggest that the preferred arrangement for elderly couples is to live by themselves, while, for the widowed, both living alone and living alone but adjacent to a child are preferred over living with a child (Natividad and Cruz 1997). Focus group data provide some insights and explanation for the seeming inconsistency between actual and ideal living arrangements. Asis and Domingo (1995) report that their FGD participants recount the strains that co-residence causes to both parent and child, especially a married one. Yet they claim that there are constraints that lead to co-residence which may come from the parent’s inability to support him or herself or from the child’s continuing dependence on the support provided by the elderly parent, including a house to stay in or someone to care for the grandchildren. Data from the 1996 PES shows that 92.5 per cent of those who had a grandchild regularly cared for one (defined as being responsible for the care of the child on a regular basis). Current attitudes of older people toward homes for the aged further suggest that there may be more openness to living arrangements other than co-residence. As seen in the 1996 PES, 74 per cent agreed that it was ‘a good idea to have homes for the aged here in the Philippines’ (1996 Philippine Elderly Survey Main Questionnaire). Indeed, 29.6 per cent said that, if there were such homes in their province, they would want to live in one when they were older (Natividad and Cruz 1997). Discussion and conclusions One interesting facet of the ageing issue in the Philippines is that recent government action to address the specific needs and concerns of older people in the Philippines has been largely brought about by the lobbying of older persons themselves through an umbrella organization of associations of the elderly in the country. Having a sectoral representative in Congress also guarantees that they have a voice in the law-making bodies of the land. Altogether, this presents at the macro level a picture of an organized sector that can effectively convey its concerns to policy-makers. However, a closer look at the gains they made with the passage of the Senior Citizens Act shows that these are modest. While government has correctly focused on expanding health care and social security coverage to the greater majority, the actual amounts that recipients may expect to receive from such programmes are too low realistically to remove much of the burden of supporting older people from the family and on to a formal system. As a developing economy, it is unlikely that within the next decade

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or so the Philippines can institute formal systems that will offer retirement, pension and health care benefits that will fully allow retired people to rely on their own accrued benefits and live independently of children and other kin. For the foreseeable future they will have to rely on utang na loob for social security. Furthermore, since most of the reforms are newly implemented, it will take a while before the real benefits of higher insurance coverage and the broadening of the coverage of social security to the self-employed (which includes those in the informal sector) will be felt. Certainly, today’s older people will not be covered by these reforms as they require entry into the system during working age. Fortunately, a sustained level of high fertility assures the elderly population, both at present and in the near future, of enough children to rely upon in the absence of government-sponsored social security programmes. What bears watching is the seeming receptivity to the idea of having homes for the aged as expressed in the 1996 PES. Amidst evidence of older persons being firmly located in a network of support that flows both ways between parent and child, such openness seems out of place and may indicate points of strain in the current situation under which elderly people live. This may be a preview of things to come when an elderly parent will not necessarily live with a child even if they are available. How this may be realized is an interesting and important question. Perhaps the fact that the Philippines has been and continues to be relatively more receptive to Western ideas than some other Asian countries as a result of its colonial past contributes to this openness to a living arrangement that until now has been associated only with elderly people who have no known kin. But to conclude that this curious finding indicates a fundamental change in attitude away from traditional reliance on co-residence is dangerous. Currently there are not enough long-term survey data to gauge trends in the situation of older persons in the Philippines. While the 1984 ASEAN Survey provided valuable insights, the sample was not nationally representative. The 1996 PES provides baseline data because it is based on a national sample. It should thus be replicated and only then can changes be inferred. Overall, as stated earlier, research on elderly people and ageing in the Philippines is at its infancy. Available data point to very interesting developments in this sector. Only systematic research can answer whence these interesting things are coming and where they are likely to lead. References Asher, M. (1998) ‘The future of retirement protection in Southeast Asia’, International Social Security Review 51, 1:3–30. Asis, M. and Domingo, L. (1995) ‘Living arrangements and the flow of support between generations in the Philippines’, Journal of Cross-cultural Gerontology 10, 1: 21–51.

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Casdllo, G. (1977) Beyond Manila: Philippine Rural Problems in Perspective. Ottawa, Canada: International Development Research Center. Christenson, B. and Hermalin, A. (1991) Comparative Analysis of the Changing Educational Composition of the Elderly Population In Five Asian Countries: a Preliminary Report, Research Report No. 91–11, Population Studies Center, University of Michigan. Commission on Population and Cooperating Agencies of the Philippine Population Program (1994) The Philippines: Country Report On Population, International Conference on Population and Development, Cairo, Egypt. Domingo, L. (1992) The Filipina Elderly in Development: Status And Prospects, Research Report No. 92–15, Population Studies Center, University of Michigan. Domingo, L. and Casterline, J.(1992) ‘Living arrangements of the Filipino elderly’, Asia Pacific Population Journal 7, 3:63–88. Domingo, L. and Feranil, I. (1987) The Filipino Elderly: A Review of Literature and Existing Data, Quezon City, Philippines: Demographic Research and Development Foundation, Inc. Domingo, L., Feranil, I. and associates. (1990) Socio-economic Consequences of the Aging Population: Insights from the Philippine Experience. Quezon City, Philippines: Demographic Research and Development Foundation, Inc. Domingo, L., Feranil, I. and Domingo, M.F. (1994) The Filipino Elderly, State of the Nation Reports No. 11, University of the Philippines Press and the Center for Integrative and Development Studies. Fermin, C. (1988) Status of Programs and Services for the Elderly, paper presented at the Seminar-workshop: Development Implications of Urbanization Ageing, Morbidity and Mortality, Makati, Philippines. Government Service Insurance System (1997) Primer On The GSIS Act Of 1997 (RA 8291). Hollnsteiner, M. (1973) ‘Reciprocity in the Lowland Philippines’, in Frank Lynch and Alfonso de Guzman (eds) Four Readings on Philippine Values, Quezon City: Ateneo de Manila University Press. Knodel J. and Chayovan, N. (1997) ‘Family support and living arrangements of Thai elderly’, Asia Pacific Population Journal 12, 4:51–68. Lopez, M.E. (1991) ‘The Filipino family as home for the aged’, Research Report 91–7, Population Studies Center, University of Michigan. Lynch, F. (1973) ‘Social acceptance reconsidered’, in F.Lynch and A.de Guzman (eds) Four Readings on Philippine Values, Quezon City: Ateneo de Manila University Press. National Statistical Coordination Board (1998) 1998 Philippine Statistical Yearbook, Manila: National Statistical Coordination Board. Natividad, J. and Cruz, G. (1997) ‘Patterns in living arrangements and familial support for the elderly in the Philippines’, Asia-Pacific Population Journal 12, 4: 17–34. Nurge, E. (1965) Life in a Leyte Village, Seattle: University of Washington Press. Solon, O. et al. (1992) ‘Health sector financing in the Philippines’, Health Finance Development Project Monograph No. 2, March. Somera, R. (1995) ‘Invisible kin: Filipino aging in a bureaucratic context’, Issues in Anthropology: Focus on Asia, Africa and Latin America, vol. 2, New Delhi: Reliance Publishing House. Truong Si Anh, Bui The Cuong, Goodkind, D. and Knodel, J. (1997) ‘Living arrangements, patrilineality and sources of support among elderly Vietnamese’, Asia-Pacific Population Journal 12, 4:69–88.

15 Ageing in Malaysia Issues and policies Tan Poo Chang and Ng Sor Tho

Introduction Malaysia’s population has grown rapidly, more than doubling over the past three decades, from about 8 million in 1960 to about 18.4 million in 1991 (Department of Statistics Malaysia 1995). The current population is projected to increase to about 22 million by the turn of the century, and around 29 million by 2020 (United Nations 1994). Population growth rate has remained high despite declining fertility because of its young age structure, and mortality has declined to a low level. Nevertheless, with the increase in life-expectancy and declining fertility, Malaysia like other countries in the world, is also ageing. Compared with other countries in Asia, Malaysia will only have an ageing population (defined as 10 per cent or more of the population being 60+ years) in the year 2020 or so. The proportion of those age 60 years and over was estimated to be about 5.8 per cent of the total population in 1991, but in absolute terms, it was 1.07 million persons. By the year 2020, it is estimated that the percentage will rise to 10.8 per cent or 3.2 million persons (United Nations 1994), which is three times the size of the group in 1991. Main issues and concerns In the past, very little attention was paid to ageing issues in Malaysia. The main argument was that older persons form only a small percentage of the total population. The current official retirement age is 55 years, and persons who extend employment beyond this age are often offered less benefits or remuneration. In 1995, older persons age 55 years and over made up 8.8 per cent of the total population. This converts to about 1.8 million persons. In the years to come, say in the year 2000, the older population is projected to increase to 9.3 per cent or 2.1 million, and by the year 2020, 15.5 per cent or 4.6 million (Figure 15.1). The official retirement age essentially means that a person is considered able to contribute up to this age. It clearly sends the message that one becomes less useful once one passes this ‘magical’ age. Rather than a fixed retirement

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Figure 15.1 Malaysia: distribution of population aged 55+ by age group and sex, 1995 and 2020.

age at a fairly young age, a flexible retirement age and a wage based on efficiency and performance would pave the way for a faster development of this country. Retracing history, it is found that in the early years the retirement age was fixed at 60 years with earlier retirement allowed at 55 years only when the service of a person was not needed (under the 1951 Pension Ordinance). The retirement age was reduced from age 60 to 55 years under the Suffian Salary Commission in 1967. Compulsory retirement at age 55 years was adopted by the Cabinet Committee set up in 1975. The life-expectancy in 1957 was 55.8 years for males and 58.2 years for females (Department of Statistics Malaysia 1977:1). In 1995, the life-expectancy was 69.4 years for male and 74.1 years for females (Department of Statistics Malaysia 1997). It is indeed ironic that while life-expectation at birth has improved by some 14– 16 years, retirement remains at age 55 years. While it was once possible to ‘work to death’, one is now faced with ‘much idle’ time after retirement. The situation looks even more serious if we take into account lifeexpectancy at age 55 years. In 1995, a man, on average, would still have some twenty years and a woman twenty-three years to live upon reaching the retirement age of 55 years. If one compares this period to one’s lifespan, this amounts to some 1/3 of the life span or 1/2 of the adult life. Should Malaysia continue to use the present age of retirement and ‘waste away’ such a large proportion of its human resources? With higher educational achievements, it would become even more critical for valuable human resources with so much experience and knowledge to be preserved and utilized in the pursuit of a developed status for the country in the year 2020.

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The increasing number and higher proportion of the elderly population raise both interests and concerns. Most countries have responded by raising the age of retirement and highlighting the concern that ageing would result in a greater burden for the country. The developed countries have initiated and emplaced largely welfare-orientated policies and programmes (see Tan 2000). There is now increasingly more and more concern whether such welfare-oriented policies and programmes can be sustained in the long run with the rising large numbers of older persons. Many countries in Asia, including Malaysia, would not be able to afford to pursue such welfare-oriented policies. It is therefore timely that Malaysia considers the alternatives available and initiates relevant policies and programmes so that its increasingly large older population will be able to continue to maintain a high quality of life. In this regard, it is therefore necessary to highlight some of the main issues for consideration. The younger population may feel that the retirement age of 55 years should be maintained because they want to be promoted and do not want their social mobility jeopardized by the older folks remaining. But, these persons in their thirties should be the very people who agitate for a rise in the age of retirement as they will be 55 years and over in the year 2020. They are also likely to be the ones burdened by rising medical and other costs of caring for older parents and relatives who may not have their own resources. Perhaps, instead of promotion being based just on age and experience, other criteria for providing opportunities for younger persons can be implemented in stages. One such criteria is the knowledge of up-to-date technology and proven practical skills, where younger persons are likely to have an advantage over older persons. Emphasis on productivity for promotion will encourage more people to pursue raising the age of retirement. While the majority of older persons presently have a home in which to live with their children and other relatives (Andrews et al. 1986; DaVanzo and Chan 1994; Department of Statistics Malaysia 1998; Tan et al. 1998), this trend may not continue in the future. There is already evidence of an increasing percentage of older persons living alone and signs of weakening family support as a result of rapid urbanization and massive rural-urban migration and changes in family structure (Tan and Ng 1998a; World Bank 1994). In 1995, the number of older persons staying in Old Persons’ Homes (OPHs) was 4,581 (Jaafar 1997), that is some 0.3 per cent of the population aged 55+. The OPHs include eight homes under the Department of Social Welfare, 78 homes under non-governmental Organizations (nine are receiving grants from the Department of Social Welfare), and another 108 homes under the Central Welfare Council. There are also smaller homes operated by the private sector and voluntary organizations (Jaafar 1997). With the low preference of older persons to live in Old Persons’ Homes (OPHs) (see Hamid et al. 1989), it would indeed become critical for programmes and facilities to be made available for older citizens to continue

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to participate fully in society and the community and to integrate well with other groups. Unlike older men, who may have wives to depend on for physical and emotional care, older women are quite likely to have to rely on children and other relatives (Tey 1995; Tan et al. 1998). Without the necessary forward planning, it would indeed be difficult to adhere to the UN principles of ensuring independence, participation, care, self-fulfilment and dignity for older persons in this country as we enter the next century. Affordability of health care will remain a point of serious concern as one grows older, although many will remain basically healthy and physically able for many years after retirement at the age of 55 years. Evidence from survey data indicates that only some 10 per cent of older persons perceive themselves to be in poor health, with women being more likely to face health problems than men (Tey 1995; Tan et al. 1998), and this has also been confirmed by smaller-scale studies. It is therefore necessary, with increasing life-expectancy, for awareness programmes on preventive health measures to be implemented from a young age so that more and more older persons avoid illnesses and disability and are able to continue to participate in many mainstream activities. As it is, many older persons retire into their own homes and avoid much interaction in social or outdoor sporting activities (Masitah and Nazileh 1988; Hamid et al. 1989; Tan et al. 1998). With proper programmes and activities, many older persons would be encouraged to contribute enormously to their own development and those of the community and the nation. Financial provisions for older persons come from pensions, insurance and savings, as well as from children. A pension is likely to benefit only a very small proportion of older persons, and men more than women since they are likely to work in the formal sector where there is such a provision. Savings and pensions normally cannot keep up with inflationary costs, especially those of health, which tend to be higher at older ages. Survey data found that a large majority of older persons do not have sufficient financial resources to be independent and need to rely on family and others for support, particularly children (Tey 1995; Tan et al. 1998). So far, children have contributed shared housing, food and other necessities or even direct transfers of money. However, such transfers may become less certain if the children themselves face financial constraints. It is therefore necessary to create a safety net where older persons may apply for funds to meet their basic needs. Perhaps it can be made compulsory for every individual to contribute to such a fund, since at birth, everyone has a father and mother and everyone grows older. Besides financial support, older persons also need physical and emotional care. With rapid urbanization and massive rural-urban migration and changes in family structure, many families may find it increasingly difficult to care for their own older persons and may not have the capacity to cope alone (see Tan 1993).

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With the decline in mortality, there is also increased feminization of the older population and this imbalance is more pronounced at older ages (Department of Statistics Malaysia 1998). The preponderance of female over male older persons is expected to continue into the future since females on average live some five years longer than males. This trend should raise increasing concern as women, for various reasons (such as low education and labour force participation, widowhood, inadequate social security benefits, savings, access to credit and other inheritance), as noted in Chapter 1, are likely to be very vulnerable at older ages, resulting in many of them being poor (World Bank 1994). Current policies and programmes National ageing policy In recognition of the changes in characteristics and expectations of older persons as well as to develop mutual reliance rather than dependency, a National Policy for the Elderly was formulated in 1995 to ensure integration and participation of older persons in the development process. The aim of the policy is to ‘create a society of older persons who are contented and possess a high sense of self-worth and dignity, by optimizing their selfpotential and ensuring that they enjoy every opportunity as well as care and protection as members of their family, society and nation’. The objectives of the Policy are: a b c

To enhance respect and self-worth of older persons in their family, society and nation; To improve the potential of older persons to continue to be active and productive in national development, and create opportunities to assist them to live independently; To encourage the creation and availability of specific facilities to ensure the care and protection of older persons to enhance their well-being. (Tan and Ng 1997:7–8)

A number of strategies and action plans have been drawn up to achieve these objectives. The Department of Social Welfare under the Ministry of National Unity and Social Development Malaysia has been identified as the agency responsible for the coordination and implementation of the action plans in various areas such as education, occupation, participation in community, recreation, transport, housing, support system, health, social security, media and research and development. Many of these suggestions and action plans still remain on paper, and tend to emphasize welfare rather than a proactive approach, where older citizens are not mere recipients but decide and coordinate most of the activities themselves.

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Other policies and programmes for older persons Various policies support the central role of the family in caring for older persons. Amongst them are a tax rebate (maximum of RM5,000, US$1,300) for medical care of older parents effective 1996. In fact, a form of tax relief has already been provided for the support of older persons since 1979 but the significance of such relief is not widely felt since it applied to all income tax payers. Under the New Remuneration Scheme, medical benefits for public sector employees also extend to include their parents. Currently, there are a few organizations carrying out programmes to create awareness on ageing issues and conduct various activities for the benefit of older persons. Besides the Department of Social Welfare, which caters for the poor and destitute older persons, the Ministry of National Unity and Social Development celebrates the National Day of the Elderly in October each year. The Ministry also organizes seminars and various functions to raise awareness on ageing issues. The Ministry of Health Malaysia has initiated a Health Care for the Elderly Programme in 1995. The programme comprises promotive, preventive, curative and rehabilitative activities and services conducted mainly through the health clinics in the country. Government efforts are supplemented by the private sector and nongovernmental organizations (NGOs). There are a number of privately run nursing homes and a number of NGOs have organized a variety of activities and day centers (Abdullah 1997). Older persons in Malaysia also enjoy certain privileges extended by both government and private sector companies. The Immigration Department, for example, operates a special counter for people above 55 years, the disabled and expectant mothers. A number of companies provide concession tickets of up to 50 per cent, such as Malaysian Airlines, Malayan Railway and some express bus companies. Certain voluntary and private clubs also provide some assistance to older persons but these tend to be rather ad hoc. However, the efforts and initiatives of the Gerontological Association of Malaysia (GEM) (established in 1991) and the National Council of Senior Citizens Organizations Malaysia (NACSCOM) (established in 1990) deserve special mention. For a number of years, GEM has collaborated with NACSCOM and the Ministry of National Unity and Social Development Malaysia and various other organizations in promoting and raising awareness of health and other related issues. NACSCOM is an umbrella body for eighteen affiliates with a membership of about 4,000 throughout the country. Among others, NACSCOM has promoted interactive activities amongst older citizens in terms of health, educational and community development. It also functions as the ‘main voice’ for older persons and hopes to diversify into more activities with a formal Plan of Action for 1998–2000.

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Paving the way forward It is therefore clear that much needs to be done to ensure that older citizens are assured of a high quality of life. While there are already some policies and programmes in place, there is unfortunately not much follow-up action or adequate provisions available. Such provisions can be initiated by many groups since everyone grows older each day and we all have older parents, relatives and friends. Essentially it should be of interest to those younger members to start these initiatives since they are the ones likely to carry most burden for their older parents and relatives if they do not have a support system to refer to. Starting such initiatives when they are young would ensure that they can reap the benefits when they themselves grow old as any new programme or activity would require some lead time to mature. There are a number of reasons for a support network system to be initiated and sustained. With increasing education, urbanization and industrialization, more and more women would be engaged in wage employment outside the home. This essentially means that the care traditionally provided by women would be reduced. Furthermore, as culturally many older persons do not want institutional care, and with changing family structure, many families would find it increasingly difficult to cope alone (Tan 1993). With older persons increasingly having practically little or no role nor authority over family matters in the changing family structure, many of the older persons may not automatically be provided with care and support and they may withdraw from society. This is in part a result of rising education as financial resources have now shifted from the hands of parents to the younger generation. Worse still, delayed age at first marriage and childbearing may also mean that some older persons still have to support young children in terms of education, health and nutrition (Tan 1997). With an increasing lifespan, it is quite likely that a family may have to cope with more than one generation of older persons and the needs of older persons are likely to be relegated to a low priority. A rising proportion of persons have remained unmarried, particularly amongst the urban educated (Tan and Ng 1995). The implications in relation to their care and support, particularly during old age or when ill, will become an important issue as, unlike those who are married, they do not have younger members to fall back on. A few may be fortunate enough to have the support of nephews and nieces. However, as it is, those in the younger generations are already facing problems coping with their own immediate parents and grandparents and perhaps even great-grandparents. As fertility continues to decline, the situation will become more serious. However, keeping fertility high is not the answer because it is merely postponing the finding of a solution to a later period and by then there will be an even larger group of older persons to contend with. The older population is not a homogeneous group. More and more older persons will possess higher education and it would indeed be a sheer waste

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Table 15.1 Malaysia: education level of persons aged 55–64, 1991 and 2020

Note: *Estimated using the population in the age group 25–34 in 1991 (Department of Statistics 1995).

of valuable human resources if they were left to ‘idle’ at a fairly young age (Tan and Ng 1998b). While the bulk of older citizens today have little or no education, some two-thirds of those in the year 2020 will have at least secondary education (Table 15.1). To illustrate, using a conservative estimate of the 1987 government development and operating expenditure on education (Ministry of Education 1990, Tables 5.1–5.3), the average expenditure per person for various levels of education is as follows: Tertiary Secondary Primary

RM74,500 per person RM13,000 per person RM6,000 per person

With about 1.8 million older persons in 2020 having various educational qualifications, an estimated investment expenditure of about RM517 million would be required for the total cohort, bearing in mind that this does not include private costs of food, uniform, books, travel and other related expenditures. Some 50 years ago, with little investment, a person began to work in his/ her early teens and worked for some 40 years. Now, with so much additional investments and an extended life-expectancy, a person starts work in his/her mid-twenties and works for some 30 years. This simple example illustrates the need for some serious thoughts as to reviewing the age of retirement and utilizing our trained human resources more effectively. The illustration shown above is only for those age 55–64 years, so the potential loss would be much greater. With medical advancement and higher life-expectancy, many more older persons would remain healthy and able to continue to participate and contribute to society, family and the country. Furthermore, like many countries in Asia, Malaysia cannot afford the economic burden of setting up an institutional framework to cater for the large numbers of older persons. While in the past, governmental, nongovernmental or voluntary support had set up various services, these had been insufficient to enlist participation from all groups in society.

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In view of the tremendous changes taking place, it is proposed that Malaysia adopt a number of strategies and activities which continually involve older citizens in the mainstream of society through a community approach. Through this approach, the talents of older persons can then be appropriately tapped in their own interests as well as those of their families and the society at large. It is in the interest of everyone, young and old, to subscribe to such a network since it would provide a support for emergencies or crises, which can happen to anyone and at a time when we are least likely to expect them. Framework for community centre Older persons can become the main resource in the provision of community support. This, however, would require the setting up of various programmes and reference centres. One such reference centre is a Community Centre which has been set up in Malaysia. A community centre can easily be set up and manned by the local residents themselves, drawing on existing social and cultural structures, and taking into account available economic resources. Some emphasis on coordination of the various programmes and activities should be given to older citizens as this would provide a means for older citizens to remain useful within familiar surroundings. The local people themselves identify the main activities and programmes to initiate, which could include various educational, recreational, health, cultural and other services, and a family crisis centre. Such a community centre would be an endeavour to provide older citizens with a sense of independence, participation, care, self-fulfilment and dignity since a small allowance is provided for older citizens coordinating the various activities. The centre, however, does not limit participation and the running of such services to older persons. Based on the experience of the two existing community centres (one in an urban and the other in a rural area), it is possible to enlist participation from all groups, young and old, in society. At times, it has been necessary to enlist the expertise of younger persons in the coordination of some of the activities, and it has been successful in encouraging participation of family-oriented activities. The potential of community centres in providing support in the care of family members and in utilizing the expertise of older citizens is indeed farreaching. The activities that have been initiated so far at the two existing centres only represent the beginning of the realm of possible activities required by the community. Such centres may initially require a small grant and may find it difficult to attract people at the onset, but with the many benefits, the people should rally over. With continuing support from government, non-government and private agencies and individuals through participation in the various activities, these community centres can easily become self-sustaining. Maintenance of these community centres can be

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covered by the small fee levied on each participant of some of the activities. The levy of a small fee will result in a greater appreciation of the value of the services. It is pertinent to highlight that the collection of these charges should be monitored closely by a registered body, which will audit and present the accounts each month for public consumption. The model of extending community support can easily be duplicated to other areas in the country as well as to other countries in the region and in the world. Some of the critical areas of concern for programmes and activities are as follows. Programmes and activities A number of areas of critical concern should receive due emphasis at the community level. Health awareness While life-expectancy has improved for all groups in society, mortality and morbidity levels remain significantly higher for some groups than for others. For example, mortality levels are much higher for the Indian and Bumiputera males than the other groups (Table 15.2). For example, according to figures in 1996, an Indian male at birth is expected to live 65 years compared to 72 years for a Chinese male and 77 years for a Chinese female. Cause of death figures show that significantly more are dying from heart and pulmonary disease, accidents, cerebrovascular diseases and cancer (Government of Malaysia 1996). There is a need therefore to promote preventive measures and a healthy lifestyle so that increasingly more persons will live a high-quality long life. Of serious concern is the high mortality rate of those persons in the prime of their life. For example, in 1996, an Indian male alive at age 40 years is not expected to live past 70 years, which is some 10 years earlier than a Chinese female alive at age 40. The higher mortality rates of the Indians are also reflected by the higher percentage who would die before reaching age 50 years. To illustrate, according to 1996 figures, 3.4 per cent of Chinese males are likely to die before reaching age 50 years compared with 4.2 per cent for the Malay male and 9.1 per cent for the Indian male. Comparatively, for a female alive at age 40, only 1.9 per cent of Chinese females, 2.9 per cent of Malay women, and 3.2 per cent of Indian women would not survive past 50 years. It is expected that the mortality rates could be much higher for those in the urban than the rural areas, where the stress and strain of everyday life are much higher. The community centre may organize talks and other forums to discuss health issues of concern. In addition, some issues of critical importance such as various aspects of care and support for the young and old during illness may be made available through a home-visit team or the provision of advice and other expertise as well as training in the provision of care. A regular

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Table 15.2 Life-expectancy at birth and at age 40 by ethnic group, Malasia, 1996

Source: Department of Statistics 1997:65–70.

activity providing basic blood tests and other health checks should also be conducted and the current urban centre has successfully carried out this activity monthly with the assistance of volunteer doctors and nurses and the support of pharmaceutical companies and a private hospital laboratory. This is important in raising awareness of conditions which are treatable or preventable, particularly for older citizens who may not have the funds to pay for medical care and who may find it difficult to understand and use the healthcare system. To promote preventive health measures, there should also be regular recreational and other sporting activities. A Crisis and Emergency Service would also be particularly useful to assist those suddenly facing such problems and with no one close to provide immediate support and assistance. At the community level, some counselling service should be made available for groups with such critical needs. Education and communication classes Among the present group of older citizens, there is a need to improve their level of literacy through education and communication classes coordinated preferably by other older citizens. This will promote awareness as well as greater interaction with other members of society. Knowing a common language of communication improves self-esteem and has many other added advantages. Experience shows that many of those who are illiterate wish very much to learn, but feel too embarrassed to attend classes; yet those who are encouraged to try, find much to enjoy when they do so. A community centre may organize such classes as well other specific training courses depending on the demand and expertise available. It should also provide some tuition and other skills training courses from time to time. Younger persons should become involved in promoting productive ageing for their older relatives and friends and take a lifespan perspective in ensuring that they make adequate provisions for themselves and the generations to come. Outreach community talks focusing on ageing issues

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would have far-reaching consequences as with greater understanding much can be done to improve the quality of life of older citizens, the carers and society at large. Environmental issues A community centre should emphasize care of the environment issues and amongst other activities run a recycling centre to create awareness and reduce waste and promote the reuse of various items. From the items received, which include glass bottles, plastic, aluminium cans, tins, clothing, paper and other useable household and personal items, an urban centre can be successful in promoting the reuse of materials, the reduction of waste, as well as the recycling of some items. It is also able to generate income from the sale of these items in weekly flea markets or jumble sales, at occasional auctions as well as from regular sales to recyclers. This activity has also helped to raise awareness on the importance of taking care of and keeping the environment clean. Training and awareness courses and campaigns administered on a regular basis have long-term consequences that would improve the quality of life of the current generation and the future generations to come. Social activities and other special foci A community centre can easily organize various other social activities aimed at special target groups and in caring for the disadvantaged groups in the community, the poor, the sick and other less-abled older and younger persons. It can contribute significantly in overcoming social ills, particularly if parents are too busy at work and there are not enough organized activities to occupy the youths. Organized activities would also be a way of bringing groups together and integrating across generations. Such activities would be on a regular basis and would include recreational activities, such as exercise, sporting, dancing and cultural gatherings. An annual activity organized for various communities will promote unity and result in a sharing of expertise and facilities. This may be in the form of a family day, new year or other cultural gathering of local importance. Income-generating and voluntary activities An attempt should be made for older persons to earn some pocket money so that they feel useful and remain independent and live with dignity. The experience in the existing centres indicates that older persons can provide important leadership as well as coordinate training and educational courses. They can also participate and contribute significantly in raising awareness of major local issues, including recreational, health and other cultural events.

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There is also a need to encourage older and younger citizens to volunteer and help those who are less fortunate, as well as participate in activities that affect their living environment. Volunteerism is still a long way off from being inculcated as a way of life for many Malaysians. The income generated from the many activities can be used to subsidize important services to the poor and disadvantaged groups and to the public at large, such as in the running of communication classes and health awareness programmes and, in the not too distant future, home-visit teams and counselling. While it is quite a tremendous task to create awareness and teach people to love the environment and the community around them, the final rewards are unlimited. A community centre provides the opportunity for older and younger persons to participate in various activities and services, which they themselves decide, design and run. It also recognizes that older persons can provide a valuable resource by coordinating some of these activities and in caring for disadvantaged groups in the community, the poor, the sick and other less-able older and younger persons. Conclusion Older persons do not yet form a large proportion of the total population in Malaysia, although in absolute terms they are fairly large. It is therefore a golden opportunity for this country to initiate policies and programmes that takes a developmental perspective involving all groups in society, young and old, in line with a caring society. Malaysia has extended community support in caring for the older persons and shares the experiences of a model which has far-reaching consequences in meeting the emotional, financial and physical care of older persons by tapping the very rich resource of the bulk of healthy older persons. The model also gives older persons a choice of continuing independence, participation, care, self-fulfilment and dignity as we progress into the twenty-first century. It is not too early for Malaysia to place such community programmes in position. Productive ageing needs the support of the whole community to succeed and will require some lead time to mature. While many people think they have some idea of the things they would like to do when they grow older, there may be insufficient programmes available to cater to the various needs. Older and younger persons can focus on initiating and providing a community support network, which is currently lacking in this country and many other regions in the world. Like purchasing insurance, subscribing to a community support network is necessary to ensure support in times of need. Each of us is special and we would be able to provide for one other and for a common good. In particular, as one grows older, besides physical and financial needs, there is also the emotional need of feeling useful and wanted.

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References Abdullah, M.Baginda (1997) ‘Services and facilities for the elderly in Malaysia’, in Advanced Research Center for Human Sciences, Waseda University, Aging People in Transition, Waseda University. Andrews, G., Esterman, A., Braunack-Mayer, A. and Rungie, C. (eds) (1986) Aging in the Western Pacific—A Four-Country Study, Western Pacific Reports and Studies No. 1, World Health Organization Regional Office for the Western Pacific, Manila: WHO. DaVanzo, J. and Chan, A. (1994) ‘Living arrangements of older Malaysians: who coresides with their adult children?’ Demography 31, 1:95–113. Department of Statistics Malaysia (1977) Social Statistics Bulletin Peninsular Malaysia, 1975, Kuala Lumpur. ——(1995) General Report of the Population Census, 1991, Volume 2, Kuala Lumpur. ——(1996) Vital Statistics Malaysia, 1996, Kuala Lumpur. ——(1997) Abridged Life Tables Malaysia, 1991–1996, Kuala Lumpur. ——(1998) Senior Citizens and Population Ageing in Malaysia, Kuala Lumpur. Government of Malaysia. (1996) Seventh Malaysia Plan 1996–2000, Kuala Lumpur. Hamid, A., Tan, P.C. and Tey, N.P. (1989) The Aging of Population in Malaysia, Asian Population Studies Series, No. 96, Bangkok: ESCAP. Jaafar, Abdul Wahid. (1997) ‘Social and family aspect: Malaysian experience’, in P. C.Tan and S.T.Ng (eds) Proceedings 1996 Celebrations National Day for the Elderly, NACSCOM: 234–40. Masitah, Mohd. Yatim and Nazileh Ramli (1988) Malaysia Country Report on SocioEconomic Consequences of The Ageing of Population Survey 1986, Malaysia: National Population and Family Development Board. Ministry of Education Malaysia. (1990) Educational Statistics of Malaysia 1987, Dewan Bahasa and Pustaka, Kementerian Pendidikan Malaysia, Kuala Lumpur. Tan, P.C. (1993) ‘Implications of changing family structures on old-age support in Asia’, in Asian Population Studies Series, 124:160–5, E SCAP (Economic and Social Commission for Asia and the Pacific), Bangkok, and Japanese Organization for International Cooperation in Family Planning Inc., Tokyo. New York: United Nations. ——(1997) ‘Caregiving in Asia: the need for community support’, paper presented at the Expert Group Meeting on Caregiving for Older Persons: Gender Dimensions, Division for Social Policy and Development and Division for the Advancement of Women, United Nations, Malta, 30 November-2 December. ——(2000) ‘Situation of older persons in the newly industrialised countries of East Asia’, Bulletin on Ageing, Department for Policy Coordination and Sustainable Development, New York: United Nations. Tan, P.C. and Ng, S.T. (1995) ‘Current and emerging family patterns in Malaysia’, paper presented at Population Information Workshop: Towards an Effective Development Planning, Malaysia: National Population and Family Development Board. ——(1997) Proceedings 1996 Celebrations National Day for the Elderly, NACSCOM, Kuala Lumpur. ——(1998a) ‘Situation of older persons in Malaysia’, Paper presented at Assisted Living Vision 2020—Aging with Dignity, Thomson Adsett & Australian Aged Care Exporters Network and NACSCOM, 22 February 1998, Kuala Lumpur. ——(1998b) ‘Ageing in Malaysia: Paving the Way Forward’, paper presented at APHM

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National Healthcare Conference, Association of Private Hospitals of Malaysia, 22–24 June, Kuala Lumpur. Tan, P.C., Ng, S.T., Tey, N.P. and Halimah Awang (1998) Evaluating Programme Needs of Older Persons in Malaysia, Faculty of Economics and Administration, University of Malaya, Kuala Lumpur. Tey, H.C. (1995) ‘Health care and socio-economic support of the elderly in Peninsular Malaysia’, MEc Dissertation, Faculty of Economics and Administration, University of Malaya, Kuala Lumpur. United Nations (1994) The Sex and Age Distribution of the World Populations, The 1994 Revision, New York: United Nations. World Bank (1994) Averting the Old Age Crisis, New York: Oxford University Press.

16 Lansia—elderly people in Indonesia at the turn of the century Graeme Hugo

Introduction Indonesia has a penchant for acronyms. It is a reflection of the increasing recognition of ageing as a significant issue in Indonesia that the period since the writing of the present chapter’s predecessor (Hugo 1992) has seen the term lansia (lanjut usia: advanced age) emerge into common usage for the population aged 60 years and over. With the onset of the krisman (krisis monetor: monetary crisis) in 1997, this increased attention has been dampened but there is no doubting an arousal of greater interest in the ageing issue among policy-makers, although it is more reflected in gestures such as the declaration of a special day for older persons than in fully funded projects for social and economic support. In 1995, 13.3 million Indonesians were aged 60 years or over giving it the seventh largest elderly population in the world. A study by Kinsella and Taeuber (1993) announced that Indonesia will have the world’s fastest growing elderly population over the 1990–2025 period when it will increase by 414 per cent. The increasing recognition of the significance of the elderly was accordingly acknowledged with its inclusion in the nation’s last two five-year development plans to a greater extent than it had been in the five earlier plans. Moreover, it is covered in some detail in the second twenty-five-year long-term plan. Nevertheless, the bulk of attention payed to the elderly is in the Ministry of Social Affairs and the budgetary allocations regarding it have been small. The context Indonesia is the world’s fourth most populous country and its 200 million people (1997) make up more than half of the total population living in the Southeast Asian region. It consists of an archipelago of more than 13,000 islands, although in 1995 60.4 per cent lived on the three islands of Java, Bali and Madura (Figure 16.1) which account for only 6.9 per cent of the national land area. This concentration is even more marked for the population aged 60 years with over 70 per cent of them living in ‘inner Indonesia’ in 1995

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Figure 16.1 Indonesia: number of persons aged 65 years or over, 1995. Source: Biro Pusat Statistik, Intercensal Survey of Indonesia, 1995.

(Figure 16.1). The enormous geographical diversity within and between the islands is more than matched by Indonesia’s social, economic, religious and ethnic complexity, with more than 300 distinct ethnolinguistic groups being identified, all of the world’s major religions being significantly represented and major regional variations in average levels of well-being in the population (Hugo et al. 1987; Hugo 1997a). During the 1970s, 1980s and 1990s Indonesia has experienced rapid and sweeping social and economic change. For most of this period economic growth has exceeded 5 per cent per annum, self-sufficiency in the staple food, rice, has been achieved, as has universal attendance at elementary school. Whereas fewer than 5 per cent of eligible women were practising modern contraceptive methods two decades ago in many parts of Indonesia, more than 50 per cent of such women are now doing so and the proliferation of transport and communication systems has greatly reduced the isolation of even the remotest villages (Hugo 1988). In mid-1997, Indonesia experienced the onset of a monetary crisis exacerbated by the effects of El Nino, forest fires and political instability. This saw the economy decline by 13.7 per cent in 1998 and only appears to be bottoming out in 1999 with a decline of 3.7 percent in economic growth being projected. While Indonesia remains a predominantly rural nation with 63 per cent of the national population living in communities so designated, urbanization is occurring at a very rapid pace with the growth of the urban population being 4.76 per cent per annum over the 1990–95 period compared with 0.16 per cent for the rural population. In spite of enormous changes in the last three decades, Indonesia remains squarely within the echelons of the ‘less developed’ nations. Per capita GNP breached US$1,000 for the first time in 1997 but it was cut by two-thirds

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during the economic crisis. There is a great deal of controversy about the proportion of the population living in poverty with estimates of it ranging between 14 and 39 per cent in 1998. Life-expectancy in 1996 was around 63 for males and 67 for females. The demography of ageing in Indonesia Table 16.1 compares the ageing situation in Indonesia with that of the other main original ASEAN countries. It is apparent that even by regional standards the level of ageing is low with, in 1995, only 4.3 per cent of the population being aged 65 or over. However, some qualifications have to be made to this observation. First, while analyses of percentage age distributions have an important role, it should not be forgotten that social and economic planning is concerned with people, and change in the actual numbers of people in particular age groups should thus be a significant consideration in that planning (Hugo 1985). Second, there is some evidence to suggest that 65 may not be too advanced an age to use as a cut-off point in defining the elderly in less developed countries (LDCs) (Hugo 1985), so that the data presented here may understate the two dimensions of ageing in society. The rapidity of recent growth of the elderly population in Indonesia, depicted in Table 16.2 must be stressed (Adlakha and Randolph 1994). The population aged over 65 has grown more than twice as fast over the 1971–95 period as the total population. However, even more rapid growth is in store for the next four decades. As Table 16.1 indicates, the aged population of Indonesia will almost treble in the last two decades of this century. Indeed, over this period Indonesia will have one of the fastest growing aged populations among the world’s nations (Hugo 1985). It should also be noted from Table 16.2 that the proportional representation of the aged has increased substantially in the last twenty-four years from 2.51 per cent aged 65 years and over, to 4.3 per cent in 1995. Moreover, Table 16.1 shows that Table 16.1 ASEAN countries: aged populations in 1995 and projection of percentage of population aged 65 and over

Sources: United Nations 1997 and 1998.

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Table 16.2 Indonesia: growth of the elderly population, 1971–1995

Sources: Biro Pusat Statistik; Indonesian Censuses of 1971, 1980 and 1990; Intercensal Survey of 1985 and 1995.

this pattern of increase will continue such that by the end of the century they will comprise nearly 5 per cent of the population and by 2020, 7.0 per cent. The demographic explanation for the increased tempo of ageing and the growth of the aged population in Indonesia is fairly clear. Declining levels of mortality have been important in two respects: •

•

As in many LDCs a decline in infant and child mortality, together with continued high fertility in the 1950s and 1960s, created a ‘bulge’ in the Indonesian age structure (Figure 16.2) similar to those characteristic of many more developed countries (MDCs) which experienced a postWorld War II ‘baby boom’. This bulge will, of course, lead to a substantial increase in the number of elderly Indonesians in the early years of the next century. There has been an overall improvement in mortality in recent years which has seen life-expectancy at birth increase from 37.5 in 1955–60 to 57 in the mid-1980s and to around 63 years in the late 1990s. This reflects an increase in the longevity of Indonesians which has contributed to the rapid growth in the number of elderly people.

The major factor influencing the ageing of the Indonesian population, however, is the unexpected and rapid decline in fertility which has seen the Total Fertility Rate decline from 5.61 in 1967–70 to 4.68 in 1980, 3.31 in 1990 and 2.78 in 1997 (Central Bureau of Statistics et al. 1998). This unprecedentedly rapid fertility decline will inevitably produce an accelerated process of ageing of the population, especially beyond the year 2000 when the increase in the proportion of old people will increase much faster than was the case in Western countries in the post-World War II period. As Jones

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Figure 16.2 Indonesia age/sex distribution 1971, 1990 and 1995 and projected distribution 2015.

(1988) stresses, in discussing ageing in all ASEAN countries, ‘What is to come is crucial, not what has already happened’. Some aspects of the demographic structure of the elderly population are important and the growth rate of the ‘old-old’ population over the last fifteen years has been faster than that of the aged population overall. Moreover, the

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Table 16.3 Indonesia: sex ratios among the elderly population, 1980–2050

Sources: Biro Pusat Statistik; Indonesian Censuses of 1980 and 1990; United Nations 1997.

representation of those over 75 years among the total population aged 60 years and over will increase over the next few decades such that one in five will be in the ‘old-old’ category by the year 2010. Hence, not only is there an overall ageing of population but there is an ageing within the aged population. Whilst this latter trend is not marked as in contemporary MDCs, it does have important implications in terms of demand for health and specialized age-care services. Table 16.3 shows the universally recognized pattern of sex ratios decreasing with age, although this pattern is not as strong as in MDCs. It is interesting to note that between 1980 and 1990 there was an increase in the sex ratio of the elderly and a pattern of relative stability is projected into the future. In both MDCs and LDCs, one of the major issues or areas of concern as the population ages is the changing ‘balance’ between various age groups. Much attention has been focused upon the ‘dependency ratio’—defined as the ratio of the population under 15 and 65 years and older to those between the ages of 15 and 64. It has been feared that over the next 20 to 30 years the economically active age groups (generally taken as those aged 15 to 64) will not be able to support the dependent age groups, especially the elderly. Ageing, however, does not mean the total burden of dependency will necessarily increase; in fact, Table 16.4 shows that the total dependency ratio has fallen sharply since 1971. However, it is also clear that there are different tendencies within the young and old components of the ‘dependent’ population. Table 16.5 shows that the rate of growth of the number of children aged under 15 years has been substantially slower than that of the older age groups. As a result, the child dependency ratio has declined even more substantially than the total dependency ratio. On the other hand, the aged dependency ratio has increased, although it is still very low by MDC standards. Projections in Table 16.4 show these patterns continuing for the next two decades with the aged-dependency burden in 2005 being almost double that in 1971 while that of the young will be almost half that of 1971. Moreover, it is likely that these tendencies will continue during the early part of the twenty-first century. Chen and Jones (1988) project the total dependency ratio will fall to 45 in the year 2020 and thereafter increase due

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Table 16.4 Indonesia: actual and projected dependency ratios, 1971–2015

Sources: Biro Pusat Statistik; Indonesian Censuses of 1971 and 1980; Intercensal Survey of 1985 and 1995; United Nations 1997.

Table 16.5 Indonesia: average annual population growth rates of the ‘dependent’ age groups, 1971–1995

Sources: Biro Pusat Statistik; Indonesian Censuses of 1971, 1980 and 1990; Intercensal Survey of 1985 and 1995.

to the rapid increase in the aged dependency ratio, finally returning to 1980 levels by around 2050. They identify 2045 as the critical year when there is the important crossover when the aged dependency ratio will be greater than the child dependency ratio. In MDCs, one of the major problems associated with the sex imbalance of older age has been that ‘associated with widowhood, one-parent families (female headed) or one-person (female) households, reduced income and increased poverty of older women and greater risks of ill health and institutionalization of women’ (Siegel and Hoover 1984). To this could be added the problems of loneliness of single older women which, although well documented in MDCs, are less referred to in the Third World literature. Yet in village-based fieldwork in West Java, the present writer (Hugo 1975, 1978) found that one of the most significant social problems in these rural communities was the loneliness, poverty and deprivation of older widows and never-married women who lived on their own and often had to rely upon the charity of the community to survive. Indeed, a greater proportion of older women in Indonesia were not married in 1995 than was the case among their Australian counterparts in 1996. Hence, we must guard

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against lower overall sex ratios among the aged in developing economies being interpreted as indicating a lower incidence of problems and need among ageing women. Many authors note that the situation of older females in many developing economies deserves special attention due to their dependent and lower status which has not well prepared them to deal with changing social structures (see Chapter 1). Indeed, in 1995, 38.7 per cent of Indonesian women aged over 60 years were married compared with 86.1 per cent of men in that age group. The spatial distribution of elderly people in Indonesia Whereas the changing spatial segregation of the elderly is a major area of geographical and social gerontological research in MDCs, it is an almost totally neglected area in LDCs like Indonesia. In general, however, there is a substantially lower degree of spatial concentration of elderly people in LDCs than MDCs. This is, of course, associated with the fact that the majority of elderly persons in LDCs live with or very near their children and grandchildren which inevitably produces a greater age mixing in communities and local areas than in MDCs. Table 16.6 shows that, as in most LDCs (Hugo 1985), the aged are less urbanized than the total population. The proportion of the urban population aged 65 years and over increased significantly over the 1971–95 period but not as much as the proportion of the rural population in that age group. Hence, while older persons are becoming more urbanized, this is not occurring as fast as it is for the total population. This is due to: • •

The selective outmigration from rural areas of the young working-age population which produces an ageing of the origin areas. A well-developed pattern of urban-to-rural return migration, often associated with retirement from the public or private sector (Hugo 1978). This applies particularly to government, police and army employees who are usually compulsorily retired at around the age of 45 when most are still physically able to work. For many the small pension they receive makes it necessary for them to have an additional source of income. In fact, this is recognized in the institution of the ‘pre-pension period’ whereby both civil and military employees of the Indonesian government are released from duty before the actual period of retirement begins expressly to enable them to find other employment.

Despite the rural bias in the distribution of aged people as compared with the total population, the urban aged population is increasing twice as fast as the rural aged. This raises some important planning issues. For example, it is apparent that, while there is little difference between male and female urbanization levels at other ages, levels are significantly higher for older

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Table 16.6 Indonesia: rural-urban distribution of older population, 1971–1995

Sources: Biro Pusat Statistik; Indonesian Censuses of 1971, 1980 and 1990; Intercensal Survey of 1985 and 1995.

women than men. In this context, Neysmith and Edward (1984) observed in reference to LDCs generally that, although data are limited, it seems that a considerable proportion of such women live in slums and squatter communities, where they are engaged as housekeepers or child minders. It appears that the urban areas attract and retain more older females than males and, unlike widowers, widows remain in or migrate towards urban areas. The latter pattern has been observed in the migration to and from Indonesia’s larger urban centres where, following the death of their husbands, many older women migrate from rural to urban areas to join their children and/or to take advantage of greater access to amenities and services. For the period 1971–95 the following consistent trends were evident in Indonesian census and intercensal survey data: • • •

Males and females in all age groups became more urbanized. Male/female differentials in urbanization increase consistently with age. For individual years the overall urban proportion decreases with age for males but not for females; in fact, there is an increase at the oldest ages for females.

The greater concentration of older people in Java-Bali than is the case with the total population has already been noted. However, it would appear that this divergence between the distribution of the older and total population is increasing. Whereas between 1988 and 1995 the proportion of the total population living in Inner Indonesia declined from 62.5 to 60.4 per cent the relevant proportions for Indonesians aged 60 years and over were 68 and 70.7 per cent. Another aspect of the spatial distribution of elderly people is evident in Figure 16.1, namely considerable variations between regions. Three provinces (Central, East and West Java) had more than 2 million residents aged 60 years and over in 1995. The underdeveloped provinces of Eastern Indonesia had the smallest numbers of elderly residents (e.g. Irian Jay a had

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Figure 16.3 Indonesia: age dependency ratios by province, 1995. Source: Calculated from Biro Pusat Statistik Indonesian Intercensal Survey of 1995.

32,130 and East Timor 28,953). Although there is a disproportionate concentration in Java, North Sumatra and South Sulawesi, each had more than half a million elderly residents. Some of the most interesting regional variations are depicted in Figure 16.3 which shows variations in the aged dependency ratio between Indonesia’s provinces. In 1995, this ratio varied between 1.31 (Irian Java) and 9.21 (Yogyakarta). The highest age dependency ratios are in provinces which either have experienced major declines in fertility (such as Bali, Yogyakarta, East and Central Java, North Sulawesi) and/or heavy out-migration (West Sumatra, Nusa Tenggara, Timor, South Sulawesi). By contrast, the regions of very high inmigration (Jakarta, Irian Java) and frontier or natural resource exploitation regions (East Kalimantan, Jambi, Riau) had very low aged dependency levels. Interestingly, major destinations of ‘transmigrants’ (persons moving under government auspices from Inner to Outer Indonesia), do not have especially low ratios, indicating that much of the inmigration is of extended families, including older people, whereas the movement to natural resource exploitation areas is very selective of young adults. The well-being of elderly people in Indonesia The well-being of older persons is influenced by a complex set of interacting factors—their income, living conditions and arrangements, social contacts and, above all, their physical and mental health. Ageing often renders individuals more vulnerable to poverty, physical disability and emotional problems such as loneliness. In the traditional context, the family provided the support necessary to cope with these difficulties. There are insufficient data currently available to determine definitely whether or not the well-

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being of older Indonesians has deteriorated over recent years. Indeed, there is a lack of information concerning their contemporary situation vis-à-vis other age groups, let alone how this has changed over time. The onset of the 1997 financial crisis undoubtedly fell more severely upon the elderly than other groups, with the inflation rate of 57.5 per cent in 1998 seeing soaring costs of food and basic needs. However, there are no studies available of the direct impacts of the crisis on older persons although there are scattered indications of a worsening of their situation, but how representative such reports are cannot be established. This section examines some dimensions of the well-being of older persons in Indonesia. Living arrangements As is the case in most LDCs, few Indonesian elderly people live alone (Wirakartakusumah 1994). In 1986, fewer than a tenth lived alone and 15 per cent lived only with their spouse. In Australia, by contrast, at the 1996 census, 25.6 per cent of people aged 65 and over lived alone while a further 42.9 per cent lived only with their spouse. There are some substantial differences between the living arrangements of males and females among elderly Indonesians. This is largely a function of the fact that most Indonesian women outsurvive their husbands due to their greater longevity and especially the fact that women tend to be younger than their husbands. Hence eight out of every ten Indonesian aged men live with their spouses compared with fewer than three out of ten aged women. Most remaining aged men lived with other family members while, of the remaining women, 57 per cent lived with other family members and 13.5 per cent lived alone (compared with only 1.9 per cent of men). There are also some interesting differences between urban and rural areas in the living arrangements of elderly people in Indonesia. Indonesia’s large urban centres face a major crisis with housing completions barely keeping up with population growth let alone making up the huge backlog of demand (Hugo et al. 1987). The housing crisis in these cities results in most people living in structures hardly big enough for a nuclear family and which they cannot even hope to change for a bigger one to accommodate an elderly parent. Consequently, housing costs militate against the urban elderly living independently and the incidence of the elderly living with their children tends to be greater than in rural areas. For example, the Indonesian census of 1990 included a question on the relationship of each person enumerated to the head of the household. Of course, in many multigenerational households tradition will have resulted in the oldest person being designated the head even though he or she was not the main breadwinner. Nevertheless, data from 1998 show that a high proportion of older Indonesians reported that they were living in a household in which a child, child-in-law, or relative other than a wife, husband or parent was the designated head. It is interesting to note that there is a higher

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incidence of old people reporting themselves as the parent of the head of the household in urban than rural areas. These findings would appear to contradict the conventional wisdom of family support for the aged being eroded more quickly in urban areas, but it is clearly a function of the differential availability and cost of housing in rural and urban areas. Andrews et al. (1986) suggest that co-residency may be explained better by necessity than by cultural orientation and parents in urban areas may have no choice but to live with their children or vice versa. By comparison, elderly rural inhabitants would not suffer necessarily because they did not live with their children and family support can be experienced just as fully by parents who live near, but not actually with, their children. The trend from rural to urban living may affect younger people selectively, with the phenomenon of aged parents remaining in villages while their children move to cities. Workforce participation Workforce participation rates among older persons in Indonesia are higher than in most MDCs and these appear to be increasing (Tables 16.7 and 16.8). There are significant differences between the 1980 and 1995 figures although this may be due to the difference in the census (1980) and intercensal survey (1995) data collection procedures. The latter was carried out by a more trained workforce so it probably was better able to detect workers than was the case for the 1980 census. Nevertheless, there do appear to be increasing levels of participation in the workforce among the older population. Table 16.7 further shows that a complex pattern is in evidence. For both males and females, there was a decline in participation between 1971 and 1980. However, since then, the rate for females increased and that of males increased between 1980 and 1990 but declined between 1990 and 1995. As would be expected, there is a decline in workforce participation with age among the older population but other data show over a third of Indonesian males aged 75 years and over were still in the workforce in 1980. Moreover, Chen and Jones (1988) show that, in Indonesia, there is a reduction in hours worked per day with advancing age, especially in urban areas. In Indonesia, the mandatory retirement age for civil servants and military personnel is 55 years and this is also adopted by many formal-sector private employees. There are variations such as 65 years for higher-level educators and 60 years for lower levels, but the fixed retirement ages are generally lower than in Western countries. However, for the vast majority of Indonesian workers, the concept of retirement and the dependency it implies has little applicability. For example, farm workers and those involved in the urban informal sector continue to work until disability prevents them from doing so, although there are usually changes in both type and intensity of work undertaken with increasing age.

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Table 16.7 Indonesia: labour-force participation among the elderly population, 1980 and 1995

Sources: Biro Pusat Statistik; Indonesian Census of 1980; and Intercensal Survey of 1995.

Table 16.8 Indonesia: labour-force participation rates by sex and age, 1971–1995

Sources: Torrey et al. 1987; Indonesian Census of 1990; and Intercensal Survey of 1995.

Family support The high workforce participation notwithstanding, there is still a high degree of reliance on the family for economic and social support among Indonesia’s elderly population. The ASEAN Ageing Survey, for example, found that 22 per cent of males and 47 per cent of females indicated that their major source of support was their children or grandchildren, while 50 and 70 per cent respectively relied upon them for at least some income. There is some concern that social, economic and demographic changes currently occurring in countries such as Indonesia are undermining the basis of this family support. One of the most striking transformations in Indonesia has been the fertility decline referred to earlier. Demographers suggest that this has been associated with significant changes in family structure and intergenerational relationships within families. It is widely recognized that, in pre-transitional (i.e. societies with high stable fertility), essentially rural societies, the economic benefits of children far outweigh their economic costs over the lifetime of the parents. The fundamental issue in the transition from high to low fertility becomes a change in the direction and magnitude of net intergenerational wealth transfers. The critical factor is the net balance of the two flows—from parents to children and the other from children to parents— over the period from when people become parents until they die. In

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traditional societies, the net flow of wealth is from children to parents, and fertility will not begin to decline until there is a reversal of the net flow of wealth. It has been argued that the primary cause of this reversal is social— that is, changes in the traditional system of family relationships. This involves a gradual change from an extended family in which one’s primary responsibilities and the relationships are towards one’s parents, to one which is economically and emotionally nucleated and in which relationships with one’s spouse and children assume much greater significance. In the West these changes in family structure were caused by a social revolution encompassing a number of developments, especially the introduction of compulsory mass schooling. In the Third World, it is generally argued that a major cause of the initiation of fertility decline is the importing of Western concepts of family relationships and obligations, with mass education and the mass media being major vehicles of that importation. From a demographic viewpoint, the most important ‘social exports’ from the West have probably been the predominance of the nuclear family with the strong husband-wife ties and concentration of concern and expenditure on one’s children rather than one’s parents. That such changes in family structure have occurred in Indonesia and have been a fundamental factor in the fertility decline is generally accepted (Jones 1988). The changing pattern of intergenerational linkages is usually considered by demographers in terms of its impact on fertility. However, the strengthening of the ties between economically active adults and their spouses and children, and the reduction in the importance of the upward ties to their parents has major implications for the welfare of older persons (Hugo 1997b). The net intergenerational transfer of not only wealth but caring and attention upwards in favour of older people in traditional society, has meant that older people in such societies could count on their children for security in old age. However, intrafamilial changes such as those discussed above and the reversal of net intergenerational wealth flows associated with it, would suggest that in such circumstances the older generation may no longer be able to count on the degree of support in their old age that has been the case previously. Two aspects of traditional families favoured aged people being given strong support: • •

First, the intrinsic normative structure which placed major significance upon caring for one’s parents. Second, having a large number of progeny meant that the burden of care of the elderly was shared among a large number of children and grandchildren.

The contemporary changes in family structure and fertility in ASEAN countries, potentially at least, threaten to weaken both of these buttresses of support for older persons.

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An important question which has not been adequately addressed in the literature is how far the traditionally strong tendency to care for the aged within the family is a function of the burden being shared among a large number of kin for very few old people, and how far it is a function of intrinsic respect and veneration of the elderly. The assumption has been that it is largely the latter and the former has been little investigated. With the decline in fertility in Indonesia and the increased longevity, the ratio of kin carers to old people is being drastically reduced and this may well be a factor in reducing the strength and effectiveness of informal support systems for the aged. Clearly, this implication of fertility decline needs further research. Moreover, to suggest that children will care for their aged parents is to assume that all older persons have children to care for them in old age. Yet it is recognized that subfecundity and childlessness are substantial in many Third World contexts. This is especially significant when it is recalled that women usually outsurvive their husbands. Clearly, large numbers of Indonesian elderly persons, especially women, do not have children to call upon to care for them in old age. Moreover, the greatly increased mobility of Indonesians (Hugo 1988) means that the probability of an older person with only one or two children, having at least one living nearby has been reduced. A further element is the increased participation of younger Indonesian women in the workforce outside the home, especially in urban areas. This may interfere with women being able to perform a traditional role of providing intensive continuous care for the frail elderly at home. The economic situation of older persons The economic situation of older people is generally very difficult to establish in any context and almost impossible in a ‘data-poor’ setting such as Indonesia. Nevertheless, there are some indications that older persons are less well off economically than the rest of the adult population due to inability to earn. Despite the intense controversy in Indonesia about the measurement of poverty and fixing the poverty line, the poverty data are not disaggregated by age. Elsewhere, a number of developments in the Indonesian economy which may have had detrimental effects upon the aged have been identified: •

•

The increased importance of the formal sector in the economy is resulting in an increasing exclusion of the aged from economic production processes. In the rural and urban informal sectors, in which the extended family is often the unit of production, there is no concept of a mandatory retirement age and elderly people are readily incorporated into such processes, although their specific roles in that process may change as their physical capabilities decline. Related to the above is the fact that older workers find it especially

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difficult to compete in the formal sector of the labour market because they are generally less well educated than the younger generations who reached school-going age during the post-war expansion of education. This resulted in much higher proportions proceeding to later high school and tertiary education than had been the case with the cohorts educated in the 1920s, 1930s and 1940s. The rapidly increasing cost of living in urban areas in Indonesia, associated with the immense pressure being placed upon housing, land, services, food, etc., is especially felt by the aged. This is because such a high proportion of them do not have the independent power to compensate for such increases through obtaining increases in wages.

To this list the effects of the crisis need to be added. One study (Irawan et al. 1999) indicates that the percentage living in poverty in Indonesia increased between 1996 and 1998 in urban areas from 9.7 to 28.8 per cent and in rural areas from 12.3 to 45.6 per cent. Undoubtedly the effect on older people has been greater than the rest of the population. The exposure of elderly people in Indonesia to the risk of being in poverty is reflected in the findings of a longitudinal survey of some thirty-five villages in Java over the 1969–93 period, which reported ‘Twenty-five years ago, poverty was a widespread problem in both rural and urban Java. At the present time, it may be true to say that poverty in rural Java is primarily found among the older people with no children and the single women supported by their families’ (Collier et al. 1993:1–1). Literacy and education Older persons in Indonesia have very low levels of formal education, having passed through their childhood and young adult years during the colonial occupation when educational opportunities for indigenous people were very limited. Hence the ASEAN Ageing Survey found that only 7 per cent of males aged 60 years and over and 2 per cent of females had any secondary or post-secondary education, while only 44 per cent of males and 14 percent of females were literate (Chen and Jones 1988). The levels of education and literacy decrease consistently with increased age and are substantially lower in rural than in urban areas. Clearly, as each successive cohort enters the older age groups, there will be an improvement in average literacy and education levels. Hence, between 1990 and 1995, the number of Indonesians aged 60 years and over who had no schooling decreased from 2.228 million to 2.111 million and the proportions from 41.6 to 34.3 per cent. However, the fact that the majority of elderly Indonesians (and in the case of women, the vast majority) are illiterate has important implications for service provision and dissemination of information. Kinsella (1988) has pointed out ‘the accomplishment of literacy affords persons in developing

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societies a smoother relationship with the socio-economic transition now engulfing many nations. Formal education attainment greatly enhances economic prospects and permits younger persons to prepare for the economics of old age.’ Health Very little is known about morbidity among Indonesia’s older population and it has not been established that the health of the elderly in LDCs is worse than that of their younger counterparts. It might be that the higher levels of mortality at younger ages in nations like Indonesia selects out those more prone to illness, so that the survivors may on average be healthier than those in MDCs. Indeed, a comparative study of Indonesia and Australia by Evans (1985) found the age-specific prevalence of handicap at 55 and over to be 4.3 times greater on average in Australia than it is in Indonesia. Prevalence of handicap increased exponentially with age in both countries, but approximately twice as fast in Indonesia, while the familiar cross-over between the sexes appeared to occur 7–15 years earlier in Indonesia. Looked at demographically, this suggests that the process of ageing advances more rapidly in Indonesia than in Australia but that the population of handicapped people in Indonesia is maintained at a lower level by higher group-specific mortality rates. The 1980 Indonesian census asked a question on health status. This showed a decline with age in the proportion of Indonesians reporting that they were in good health, falling from 85 per cent at ages 55–59, 75 per cent at 65–69 and 64 per cent at age 70 and over. The ASEAN Ageing Survey included several questions on health and disability (Chen and Jones 1988). For example, some 60 per cent of older persons reported that they had experienced a major illness or injury which affected their activities of daily living. Among married persons, 74 per cent aged 60–64, 65 per cent aged 65–69 and 47 per cent aged 70 and over reported themselves in good health. The percentages were slightly lower for unmarried persons. Overall, 58 per cent of older persons could not see well; 26 per cent could not hear well; some 21 per cent wore glasses and nearly two-thirds had difficulty chewing. However, the majority (86.5 per cent) were sufficiently mobile to get around the home without help. Social security Where pension schemes exist in LDCs they are generally limited and only available to persons who have worked in the formal sector for a particular period, and are based upon the level of contributions made while employed. Pensions are the main source of income for only a very small proportion of Indonesia’s elderly population (about 13 per cent of males and 4 per cent of

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females in 1985). Moreover, it is important to note that the bulk of pension recipients are urban dwellers since ‘social security legislation does not usually provide old-age pensions to agricultural workers’ (Heisel 1985). In addition, pensions are rarely sufficient to meet the full living costs of elderly persons (Jones 1988). The average number receiving social security in Indonesia is very low, even in comparison to other ASEAN countries. Jones (1988) reports that some 11.5 per cent of Indonesia’s workforce (about 6 million persons) were covered by pensions or old-age assurance provisions. These are almost all civil servants, army personnel and city-based industrial workers. Prior to the crisis there was a rapid expansion of the numbers of Indonesian workers in the formal and government sectors. This is apparent from pre-crisis data showing the expansion of the formal sector had given an increase in the number of workers covered by pension plans between 1986 and 1993 from around 3.5 to 4.2 million among government employees and from 2.6 to 5.8 million among private sector employees. These numbers are likely to have been depleted as a result of the crisis and structural reforms. Service provision for older persons With the changes in intrafamily relationships referred to earlier, the degree of family support previously provided may no longer be available, so that there will be a greater reliance on services provided externally. There is, however, little aged service infrastructure present in Indonesia. For example, there are very few specialized institutions for older people and the level of institutionalization of the aged is very low. Adi (1982) reported that the city of Jakarta (1985 population 7.9 million) then had only nine institutions for the aged, with a total of 420 resident elderly people. In Repelita IV, Indonesia’s fourth five-year plan (for the period 1984–1989), it was stated that there was a need to make provision for the approximately 630,000 very poor elderly persons who were lacking family support. Objectives were set to provide 30,000 institutional places, 500,000 persons with noninstitutional support and 100,000 social security coverage by 1989 (Adi 1982). Data were not available at the time of writing to establish whether or not these very ambitious targets were met but interviews with government officials suggest that the realization has fallen far below these modest targets. More recent statistics indicate the limited extent of government support provided to the older population. For example, Santoso (1995) notes that in Indonesia as a whole in 1992 there were only 1,555 homes for elderly people; 46 run by the federal government, 23 by provincial governments, 23 by subsidized NGOs and 63 by non-subsidized NGOs. In 1993/94, the government provided assistance for 26,911 abandoned elderly persons in institutions and 1,226 persons were assisted with home care. This indicates the small scale of government assistance to the elderly. It is clear that, in Indonesia, as in most Third World countries, there is almost total reliance upon the

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family and, to a lesser extent, the local community to care for older persons. As Chen and Jones (1988) point out, Indonesian policymakers, whether of necessity or from philosophical conviction, seek to maintain the existing systems of family care and concern for the elderly. As in many other countries in this book, the family is still seen as ultimately responsible for its older members and institutionalization is only a last resort. The aim is to obtain as much community participation as possible and this philosophy is reflected in the kinds of income maintenance, health care, recreational programmes and publicly-funded institutional care available to older Indonesians. Overall, governments provide only limited special services for particular groups of older persons and rely extensively on private and charitable groups to assist in providing for the needy. Social security programmes are typically limited to employed individuals with complementary special welfare programmes for impoverished and impaired people. The ASEAN Ageing Survey found that 24 per cent of their aged respondents belonged to old people’s organizations and some 20 per cent participate in educational programmes for the elderly (Chen and Jones 1988). When compared with many Western countries, these are very high rates of participation in such social organizations. Nevertheless, although there is not enough information to allow an evaluation of the adequacy of provision of services, it is clear that there is a lack of non-institutionalized services for older people in Indonesia. Chen and Jones (1988) identified a number of areas of service provision which need to be given urgent attention in Indonesia and most other ASEAN nations: • • • •

The needs of the most vulnerable elderly, namely those without families or living alone, need to be thoroughly assessed and provision made for them. There is a need for more services to assist the home-based elderly, such as day care centres, respite centres, home nursing services, ‘meals on wheels’ and befrienders. There needs of rural older persons must be established since the few services which exist already are mainly in urban areas. Attention should be given to ways of assisting and encouraging families who care for their elderly members within the traditional system.

In Indonesia, the rapid growth of population is placing great strain on the provision of all types of public services and utilities, made distinctly worse by the economic crisis of the last years of the 1990s discussed in Chapter 1. In such a situation, it is difficult to persuade city, regional and national governments to move into what are largely new areas of spending to provide specialized services for older people. However, the need for such services, especially those which mesh with, support and encourage family-based

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systems, is considerable. There is a also pressing need to provide older persons, especially those with handicaps or disability, with greater opportunities for community-based social activities. In this context, the conclusions of a WHO-sponsored four-country survey remain especially relevant. The study specifically stressed the need to explore the appropriateness and effectiveness of day-centre programmes, particularly in urban settings in countries where the growing numbers of ageing in the population and limitations on extended family activities mean that opportunities for social interaction among the elderly are necessarily restricted…it is important that urban planning policies, public housing and community development activities take proper account of the special needs of the growing minority of the elderly. Housing policies in the past, for instance, have too often not responded to the needs of the extended family and have resulted in diminished opportunities for family interaction and support. (Andrews et al. 1986) It is undoubtedly true that the provision of many services for older persons are facilitated by the greater accessibility and economies of scale afforded by the concentration of population in urban centres, rather than in scattered rural communities. As a result current levels of provision are greater in urban areas. However, it should be pointed out that, unlike the situation in most Western cities, the elderly population in large Indonesian cities is not spatially concentrated to a significant degree which means there is not as much scope as in Western cities for areal targeting of services to particular city districts. Conclusion This chapter has discussed a number of issues which constitute, or potentially constitute, areas of concern for the maintenance and enhancement of the well-being of older persons in Indonesia. It should be stressed that most of these problems are largely based on the beliefs that: • • •

Traditional support systems are changing in character and that the family’s direct role in the care and support of aged people will be reduced. The resources available to the Indonesian government are insufficient to compensate for this loss of support. The resources accumulated by the old people themselves during their working lifetimes are not sufficient to compensate for the loss of support.

None of these assertions can be substantiated definitely with empirical data. First, with respect to reduction in family support for the aged in ASEAN

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cities, Jones (1988) has pointed out that it can be argued that, even if the ASEAN member countries under discussion were to become as urbanized and industrialized as the West, this does not mean that the aged would be accorded the same roles as in Western societies. Indeed, the earnestly expressed belief or hope of many Asian countries is that what is good in their family traditions will be durable enough to withstand, in the face of forces of economic and social change, creeping Westernization. One aspect of this is widely perceived to be neglect of older people. However, there are strong indications that there are changes occurring in intergenerational relationships and that many policy-makers are aware of them. Heisel (1985) has reviewed the perceptions and policies on ageing of LDC governments articulated in documents submitted to the World Assembly on Aging and to the Fifth Population Inquiry of the United Nations. She concluded that the issues most widely felt and commented upon were related to values of the traditional family system, which are still very important, as are the fact that older people command respect and attention from the young members of the family, who have the responsibility for caring for their elders. However, economic and social changes, particularly migration, have produced a decline in the traditional system of assigning responsibility in the family and in its capacity to cope with some of the fundamental needs of its aged members. Many of these observations are even more relevant at the start of the twenty-first century. With respect to the second and third propositions, there is also a degree of uncertainty. Jones (1988) has noted that it is difficult to foretell the old-age security implications of ageing trends in Asian countries because many of the factors which will alter the traditional role of older persons in their family as ageing occurs will at the same time be altering their work patterns and independent sources of income in old age. To these he adds that the social and economic changes underlying sustained fertility decline and ageing also leading to fundamental changes in the structure of employment, including a shift towards non-agricultural jobs (in urban areas), requiring higher average levels of education. This has inescapable implications for patterns of retirement and income earning capacity for older persons, which will in turn influence their role and status within the family and the community. Hence, many Indonesians prepare for their old age as do the bulk of their Western counterparts, by accumulating assets (especially housing) during their working lives and contributing to pension or superannuation schemes. However, two points should be made in this regard, which are clearer now than in Hugo (1992): •

The generation making these preparations, by and large, is in the early or middle years of their career cycle. Most of the population currently aged or about to enter old-age groups are not so fortunate. They represent a ‘transitional generation’ whereby they may have suffered a

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decline in family support but not benefited from the social and economic development which occurred late in their working lives, or from increased coverage of pensions. Second, it is clear that the proportion of the population able to make such preparations for old age is still limited to those most able to benefit from the changes which are occurring, and by no means all of the current working-age population are able to make extrafamilial arrangements for their later years.

Clearly there is much room for speculation about the impact of the urban transition on the well-being of older persons in Indonesia. What does appear certain is that change is occurring in family structures, that the aged population is growing at an unprecedentedly rapid rate and that there is at least potential for a substantial determination of well-being over the remaining years of this category. Ageing represents a challenge to Indonesia’s planners but it is one which is by no means insurmountable. However, it will take a judicious blending of policies and programmes which combine aspects of traditional systems of care and support of elderly people with new initiatives which bolster and enhance those systems, if the well-being of Indonesia’s elderly population is to be improved. References Adi, R. (1982) The Aged in the Homes for the Aged in Jakarta: Status and Perceptions, Pusat Penelitian, Jakarta: Universitas Katolik Indonsia Atma Jaya. Adlakha, A. and Randolph, D.J. (1994) ‘Aging trends: Indonesia’, Journal of Cross-Cultural Gerontology, 9, 1:98–108. Andrews, G.R., Esterman, A.J., Braunak-Mayer, A.J. and Rungie, C.M. (1986) Aging in the Western Pacific, Manila: World Health Organisation Regional Office for the Western Pacific. Biro Pusat Statistik (1998) Laporan Sosial Indonesia 1997, Jakarta: Biro Pusat Statistik. BKKBN (1995) Pedoman Pengelolaan Bina Keluarga Lansia (BKL), Jakarta: BKKBN. Central Bureau of Statistics (CBS) [Indonesia] and State Ministry of Population/ National Family Planning Coordinating Board (NFPCB) and Ministry of Health (MOH) and Macro International Inc. (MI) (1998) Indonesia Demographic and Health Survey 1997, Calverton, Maryland: CBS and MI. Chen, A.J. and Jones, G.W. (1988) Ageing in ASEAN; Its Socio-Economic Consequences, Singapore: Institute of Southeast Asian Studies. Collier, W.L., Santoso, K., Soentoro, and Wibowo, R. (1993) New Approach to Rural Development in Java: Twenty Five Years of Village Studies in Java, Mimeo Jakarta: International Labour Organization. Evans, J. (1985) ‘The development of handicap with ageing in Australia and Indonesia’, in Proceedings of the 20th Annual Conference of the Australian Association of Gerontology, pp. 27–33.

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Heisel, M.A. (1985) ‘Population policies and ageing in developing countries: paper presented at the International Congress of Gerontology, New York. Hugo, G.J. (1975) ‘Population mobility in West Java, Indonesia’, unpublished PhD dissertation, Department of Demography, Australian National University, Canberra. ——(1978) Population Mobility in West Java, Yogyakarta: Gadjah Mada University Press. ——(1985) ‘Population ageing: some demographic issues in developing countries’, background paper prepared for the Program for Developing Country Participants, International Congress of Gerontology, New York, July 12–17. ——(1988) ‘Population movement, economic development and social change in Indonesia since 1971’, Tijdschrift voor Economische en Sociale Geografie 79, 4. ——(1992) ‘Ageing in Indonesia: a neglected area of policy concern’, in D.R. Phillips (ed.) Ageing in East and South-east Asia, London: Edward Arnold. ——(ed.) (1994) Future Directions in Aged Care in Indonesia, Proceedings of Joint Indonesia-Australia Seminar, July 1994, Hilton International Hotel, Jakarta, Adelaide: Department of Geography, University of Adelaide. ——(1997a) ‘Population change and development in Indonesia’, in R.F.Watters and T.G.McGee (eds) Asia-Pacific—New Geographies of the Pacific Rim, London: Hurst. ——(1997b) ‘Changing patterns of population mobility, in T.H.Hull and G.W. Jones (eds) Indonesia Assessment: Population and Human Resources, Canberra: Australian National University. Hugo, G.J., Hull, T.H., Hull, V.J. and Jones, G.W. (1987) The Demographic Dimension in Indonesian Development, Kuala Lumpur: Oxford University Press. Irawan, P.B., Hardinsyah, Firdausy, C.M.Hutagaol, P., Romdiati, H., Raharto, A., Wiranto, T. and Ismawan, B. (1999) ‘The Impact of Crisis on Poverty and its Implications for Development Strategies’, prepared for the ‘Pra-Widyakarya Nasional Pangan Dan Gizi VII’ (Pre-National Conference on Food and Nutrition VII), Indonesian Institute of Sciences, Jakarta, 10–12 May. Jones, G.W. (1988) ‘Urbanization trends in Southeast Asia: some issues for policy’, Journal of Southeast Asian Studies XIX 1:137–54. Kinsella, K.G. (1988) Aging in the Third World, International Population Reports P95/79, Washington, DC: US Bureau of Census. Kinsella, K.G. and Taeuber, C.M. (1993) An Ageing World II, International Population Reports P95/92–3, Washington DC: US Bureau of Census. Neysmith, S.M. and Edward, J. (1984) ‘Economic dependency in the 1980s: its impact on Third World elderly’, Ageing and Society 4, 1:21–44. Santoso, I. (1995) ‘Social Welfare for Elderly People: Condition and Alternatives in Repelita VI and PJPT II’, paper presented at Seminar on Age Care and the Family in Indonesia: Policies and Strategies Beyond 2000, Adelaide. Siegel, J.S. and Hoover, S.L. (1984) International Trends and Perspectives: Aging, US Department of Commerce, Washington, DC: Bureau of the Census, International Research Document No. 12. United Nations (1997) The Sex and Age Distribution of the World Populations: The 1996 Revision, New York: United Nations. ——(1998) World Population Prospects: The 1996 Revision, New York: United Nations. Wirakartakusumah, M.D. (1994) Local Level Policy Development on Consequences of Ageing: Indonesia Case, ESCAP Asian Population Studies Series No. 131-C, New York: United Nations.

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Ageing, Islam and care for older persons in Brunei Darussalam Mark Cleary and Hairuni Ali Maricar

Introduction The small, independent Islamic state of Brunei Darussalam is located on the island of Borneo between the Malaysian states of Sabah and Sarawak (Figure 17.1). Bordering the South China Sea to the north, this tiny state of only 5,765 square kilometres, is of interest to social planners and demographers for at least two reasons. First, the country is amongst the ten richest in the world by virtue of its oil and investment revenues: the onshore and offshore oil fields around Seria contribute massively to a per capita GNP which, in 1996, stood at $20,400. That wealth has created important economic and social benefits for the citizen population—no income taxes or national insurance charges, coupled with free healthcare and education, characterize the state (Cleary and Wong 1994; Leake 1990). A second fundamental feature of Brunei Darussalam is the importance of the Islamic faith. It is the state religion and Islamic codes of behaviour and social welfare—including care of the elderly—imbue all aspects of daily life. The importance of Islam is further reflected in the nature of the political system where the ideology of the Malay Muslim Monarchy is fundamental to the daily life of the state (Gunn 1998). As a consequence of both its wealth and its distinctive religious culture, the ways in which the elderly population is cared for in Brunei Darussalam have a wider interest than the tiny size of the country might imply and this contention underpins the structure of this chapter. First, it will trace the demographic background to the question of caring for the elderly; second, it will examine the place of Islam in concepts of caring for the elderly; and third, it will focus on how those culturally distinctive concepts of care are reflected in actual and projected provision of services for these groups. The demography of the state Between 1921 and 1991, the date of the last full census in Brunei Darussalam, the population grew from around 25,000 to 260,482, a more than ten-fold increase. As Table 17.1 indicates, average annual growth rates

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Figure 17.1 Brunei: districts, towns and health facilities.

Table 17.1 Population change in Brunei Darussalam 1911–1996

Source: Economic Planning Unit, Census of Population 1991; Brunei Darussalam Statistical Yearbook.

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over the last three decades have been over 3 per cent and, to judge by the results of the 1996 partial survey, show few signs of decreasing. These high growth rates can be attributed to both high rates of natural increase and to inward migration, for the state has traditionally relied on an expatriate labour-force from both the ASEAN (Association of South East Asian Nations) region and further afield. Whilst localization programmes, especially in the Brunei Shell workforce, and economic recession have at various times acted as a brake on the employment of expatriate labour, noncitizens remain an important element in the population. Much of this workforce is employed in the construction and service sector although both sectors have been hit by recent shifts in government expenditure in the country (Cleary and Francis 1999). Ethnically, Malays comprised just under 67 per cent of the population in 1991. The Chinese formed the next significant group at 15.6 per cent, whilst the category of ‘other indigenous groups’ (such as Iban, Melanau and Punan) comprised around 6 per cent. It is from these three groups that the resident elderly in the state are drawn: the expatriate population leave the state on the termination of their employment contracts. The population is concentrated in two areas: in and around the sprawling capital, Bandar Seri Begawan, where most of the government offices, commercial outlets and light industry are concentrated: and around the onshore and offshore oil and gas installations at the other end of the state, close to the towns of Seria and Kuala Belait. Brunei Malays comprise around 75 per cent of the population in the district around the capital; in the Kuala Belait area, there are high concentrations of Chinese. The other two districts of the state—Tutong and the Temburong—are sparsely populated. In the latter area, primary rainforest dominates and there remain essentially tribal communities living a traditional way of life. Elsewhere the forces of economic and social change have created largely urban, modern lifestyles although rural kampong life, archetypal to the traditions of Brunei Malay culture, still remains both in the Kampong Ayer (water village) in the capital and in the rural areas. The juxtaposition of modern amenities and facilities with a strong traditional culture remains one of the most striking features of the country. The high rates of population growth have given the country a predominantly youthful age profile although demographers now expect the country to be entering a demographic transition with a decline in crude birth-rates and more moderate rates of population growth. That transition, however, has come rather more slowly than was anticipated. The cultural mores of Islam, coupled with good health care and educational facilities, have continued to keep growth rates a little higher than planners had anticipated a decade or so ago. But the youthful profile of the population is emphasized in Table 17.2. The proportion of young adults increased from 29.4 per cent in 1960 to 39.7 per cent in 1991 before slipping slightly to 37.3

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Table 17.2 Brunei Darussalam age cohorts 1947–1996

Source: Economic Planning Unit, Census of Population 1991. Note: The data for 1996 are based on mid-year estimates.

per cent in the 1996 mid-year estimates. The elderly population, defined officially as those over 60 (and therefore entitled to pensions), fell from 5.6 per cent of the population in 1960 to 4.1 per cent in 1991 but has now begun to move inexorably upwards. In general, however, provision for the elderly population still takes place within the context of a youthful population structure. As Table 17.3 suggests, the proportional importance of the 15–24 age cohort is likely to remain virtually unchanged for at least the next decade. The proportion of the population aged 55 and over does not begin to grow significantly until 2011. There are also some significant ethnic differences with the 1991 census showing that the elderly cohort is largest amongst the Malays and Chinese, with much smaller proportions for the category ‘other indigenous groups’. These demographic realities are reflected in social and economic priorities and policies. It is the young population that is of most concern, with the problems of underemployment being viewed with particular interest. The drive for economic diversification and heavy resource inputs into education at all levels dominate the rhetoric and policy of government departments (Duraman and Hashim 1998). By contrast, the relatively small size of the elderly population, coupled with its current slow growth rate, largely relegates questions about the care of the elderly to a secondary place. Such perceptions, of course, will alter when longer-term projections are taken into account as Table 17.3 suggests. There are particular difficulties in estimating the total projected population for Brunei Darussalam because of the size of the expatriate population. Around 30 per cent of the current workforce was expatriate in the mid-1990s and their future numbers are likely to reflect fluctuations in the state of the hydrocarbon and construction sectors of the economy. If attention is focused solely on the permanent population (that is, citizens and permanent residents of the state) a rather different picture emerges. With or without the expatriate population, the country will move inexorably towards an increasingly elderly population by 2011. The population aged over 65 is projected to double between 1991 and 2011, increasing from 7,000 to 14,000. These will be Brunei citizens and permanent residents as foreign nationals are rarely issued with resident

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Table 17.3 Brunei Darussalam: population projections by age cohort

Source: Economic Planning Unit, Demographic Situation and Population Projections 1991–2011, pp. 59–61.

permits once they reach 55. This elderly cohort will become increasingly important: removing the expatriate population from the projections means that the proportion of the population aged 65 and over will rise from 6.6 per cent in 1991 to almost 13 per cent in 2011. Improvements in life-expectancy from around 42 for men and women in 1947 to 72 and 77 respectively in 1991 further underpin this evolution and has meant that the youngest age cohorts are planned to fall during the next two decades. These changes, noted Niew (1989), ‘would mean a gradual shift from the burden of child dependency to old age dependency which will bring with it certain social and economic implications’. Pension costs, medical and other welfare expenditure and patterns of consumer demand are all likely to be altered by these demographic changes. In the short term, then, it might be argued that a focus on the needs and aspirations of the young population is entirely appropriate and this is fully reflected in the pronouncements of government and in the balance of expenditure priorities. But there is now an increasing awareness that in the medium and long terms, those priorities must increasingly recognize the size of the elderly population in the country. Islam and care for older persons Islam is the state religion and Islamic precepts of behaviour and attitude imbue all aspects of life in Brunei Darussalam. The concept of Melayu Islam Beraja (the Malay Muslim Monarchy or MIB) is fundamental to the political stability of the state, to the absolute authority of the Sultan and to all social life in the country (Gunn 1998). MIB draws heavily on the Koran itself, on that body of traditions relating to the Prophet Muhammad known as the Hadith and on the attitudes and precepts of Bruneian culture (Abdul Aziz Umar 1992). What then do these bodies of writing and tradition indicate about caring for the elderly? In various chapters of the Koran, strong emphasis is laid on the need for children to respect and care for their parents in their old age: And that ye be kind to parents. Whether one or both of them attain old age in thy life, Say not to them a word of contempt, nor repel them, but address them in terms of honour. And out of kindness lower to them the

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wing of humility and say: My Lord! bestow on them Thy Mercy even as they Cherished me in childhood. (Sura VXII, Al-Isra, verse 23–4; Abdullah 1975, 700–701) And we have enjoined on man (to be good) to his parents; In travail upon travail did his mother bear him. And in years twain was his weaning: (Hear thy Command); show gratitude to me and thy parents. (Sura XXXI, Luqman, verse 14; Abdullah 1975, 1083) Such commands represent much more than mere rhetoric—they are central to the social and religious philosophy of Islam taught in home, school and mosque and they are further reinforced in the Hadith. In many of these Hadith the importance of one’s obligations towards the elderly are seen as a touchstone of religious observance. Thus on one’s financial obligations to parents, Almighty Allah says, They ask you (O Messenger) what they should spend…Say whatever of good you spend let it be for the parents. Elsewhere, children are reminded that ‘Allah postpones the punishment for one’s sins till the day of judgement if He so desires but he awards the punishment for disobeying parents to this life’. The success of a good Muslim, notes Akhlaq Husain (1994:27), ‘lies in our fair treatment of parents so that they remain happy with us and pray for our good and betterment’. Respect and care for parents in particular and the elderly in general is central to Islam. In a country such as Brunei, where Islam is the fundamental pivot, these commands take on much greater force than they might in more secular societies. Given the strength of these religious dictates on caring for older people, it is perhaps not suprising that the state has seen provision for them as being first and foremost a family responsibility. As noted above, from an Islamic perspective, the notion of a family ‘abandoning’ its elders, either financially or socially, is inconceivable. Islam is forceful in its condemnation of children who fail in this duty and whose parents are required to work into old age merely to support themselves. Many will continue living with their children and extended families into their old age, and for most Bruneians the idea of placing family members in special homes for the elderly would be regarded as inconceivable: both socially wrong and an abrogation of religious duty. If parental love for their children is in some ways undermined (perhaps by their children’s failure to care for them) this is regarded by Islam as degrading and dishonourable. Failure to care properly for one’s parents is to ultimately compromise the chances of a place in heaven. Added to these religious dictates are important cultural attitudes towards the elderly in Malay-Muslim societies generally. Certainly Brunei-Malay

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culture is traditionally highly respectful towards older persons and it is tantamount to social disgrace to allow one’s elderly relatives to live in penury. Respect for older people is regarded as a central component of the MIB philosophy which governs everyday life in the country (Abdul Aziz Umar 1992). In principle then, an important nexus of religious, cultural and social practices govern care of the elderly and operate well in advance of any concerted state intervention. To that extent, the role of the state is seen as supportive rather than primary. Of course there is a gap between theory and practice and, even in a wealthy country such as Brunei Darussalam, there are important problems and issues confronting older people. But perhaps there is a key psychological difference here in that elderly people are rarely conceived of as ‘problems’ for which ‘solutions’ must be found. Rather they are viewed as having important contributions to make throughout their lives. Inevitably though, changes in the family such as the erosion of the extended family, the increasing numbers of women in the workforce and the pressures of consumerism threaten to erode traditional attitudes and practices. Elements of state provision for the elderly are thus required. But the religious and cultural foundations of care remain strong and, furthermore, have been reinforced through the ideology of MIB which structures social and religious life. This dual role of family and state colours service provision in the country. The provision and uptake of services The Ministry of Welfare, Youth and Sports is the main government department responsible for the planning and delivery of policies for the elderly. However, as we noted above, ultimate responsibility for elderly people rests squarely with the family, whether nuclear or extended, and there is thus no formal legislation setting out a framework for care, nor is there unequivocal social welfare legislation regarding the range of community and domicilary help for families with elderly members. The absence of such clear legislation, perhaps strange to Western observers, is seen as entirely consistent with the Malay-Islamic culture of the country. Care and support for the elderly, whether they be Malay, Chinese or other indigenous groups, remains largely unformalized and pragmatic. That said, however, it should be emphasized that there are provisions for a variety of informal types of assistance to be given to families facing difficulties in caring for their elderly relatives. All citizens and permanent residents aged 60 and above, as well as individuals who were born and have lived in the country for a minimum of fifteen years have, since 1955, been entitled to a monthly pension in addition to any occupational entitlements they may have accrued. That pension is, of course, non-contributory, since there is no income tax or social security

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charge payable in Brunei Darussalam. The pension stood at B$100 per person until 1990 when it was raised to B$150. In July 1998 it was fixed at B$200. In addition, a range of other monthly allowances are payable if the elderly have dependents to care for: payments of B$90 are paid for dependents below 15 and B$150 for dependents over 15. As of July 1998 there is no upper limit to the monthly entitlements payable. Increasing numbers of elderly people are also in receipt of occupational pensions, as new contributory schemes to pay pensions increase in both the private and public sector. Pension stipends are paid through the Ministry of Welfare, Youth and Culture and channelled through the mukim (groups of villages) or kampong (village) headman who pays it directly to the elderly people of the village. This decentralized system of payment may well help to reinforce the sense of local, community solidarity in caring for the elderly. The payment of pensions is thus seen as a traditional aspect of village help rather than the function of a rather remote bureacracy. The same system also operates for the payment of stipends to the blind, disabled, and the mentally infirm. Despite recent increases, the stipend is not sufficient, by itself, to maintain an elderly person since the cost of living in Brunei Darussalam is one of the highest in the region. The maintenance of price controls on key commodities such as rice, together with a free health system, does help the elderly population, and the Pensions Department has been active in encouraging small handicraft production among recently retired people as a way of supplementing income. But pension payments are primarily viewed as a supplement, an aid to traditional systems of caring for the elderly within the family. Not suprisingly the size of the pensions budget has grown steadily since 1955. From a figure of around 2,000 pensions paid in 1955, the total has grown to around 8,000 in 1991 and just under 12,000 in 1998, about 85 per cent of those eligible. Most are concentrated in the populous Brunei-Muara and Belait districts. The current pensions budget is around B$20 million per year and has almost doubled since 1991. The Pensions Department can increase its budgeted allowance through direct application to the Treasury. The recent economic difficulties in the region have had their impact on the finances of the state and have led to tighter controls over the public budget, although there is a yet no suggestion of any cuts to the pension and other provisions for the elderly: recent policy has rather seen a sizeable increase in payments made. Alongside these mandatory provisions, other discretionary grants are available through two Ministries: Culture, Youth and Sports and the Ministry of Religious Affairs. The latter, in particular, has sizeable sums to disburse through its accumulated fund of religious tithes, the zakat and fitrah. The former is essentially a tax on wealth whilst the latter is a tax paid by all Muslims before the celebration of Hari Raya. These religious funds are directed towards five categories of people with the ‘fakir’ (poverty stricken) and ‘miskin’ (poor) receiving the majority of such monies. It is clear from the

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Ministry that elderly people form a majority of those receiving such hardship funds. It is difficult to get precise figures for the amounts of money disbursed. In general these religious funds constitute around 10 per cent of the annual pension budget and can thus make a significant contribution to the well-being of the elderly. The allocation of such funds needs to be situated within the context of a traditional culture of religious piety and reciprocity which remains strong within Brunei Darussalam, despite social changes associated with modernity. Thus it is the ketua kampong or village headman who plays a key role in identifying and alleviating hardship. Even in the densely populated capital, Bandar Seri Begawan, the headman system survives, and the ketua kampong is apponted because of the respect he can command in the locality. Thus the headman can directly approach the mukim head (penghulu mukim) or he can make direct representation to the district office. He is an important cog in the administrative machine which can secure access to a range of discretionary religious and welfare funds. As the person who pays the monthly pension he is thus in an important position to assess the conditions and needs of the elderly population in the kampong (Figure 17.2). Whilst there may seem to be few formal systems of domicilary help and support, less visible informal networks, based around tradition and religion are of fundamental importance. For the Chinese population, alternative networks exist though they are more difficult to articulate. Certainly charitable and clan help is important and the influential Chinese Chamber of Commerce plays an important charitable role within its community. One of the consequences of the emphasis on care within the family and kampong has been the absence of old people’s homes in Brunei Darussalam. They have been actively discouraged over the years, and in the last decade, the only officially recognized home, catering for a small number of elderly Chinese in Seria, has shrunk. It currently has around ten people in residence. There are no private homes for the elderly nor, it is imagined, would the authorities look favourably on applications to develop such institutions. Indeed, for both the authorities and the population as a whole, the notion of sequestering older persons away from family and community is regarded almost with bewilderment. For Bruneians, at least, such a policy would run counter to both their religious and cultural traditions. Probably the most frequent way in which the elderly come into contact with the welfare authorities is through the medical services. There are large modern hospital facilities, free to Bruneians, in the capital, Bandar Seri Begawan, and in Seria, Kuala Belait, Tutong and Bangar in the Temburong district. Local, primary health care clinics have also been established in both urban and rural districts of the country and, whilst their main role is dealing with children and expectant mothers, they also see elderly patients for emergency treatment. The difficulties of delivering primary health care in the remoter rural areas are tackled by a system of travelling dispensaries and

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Figure 17.2 Access to discretionary funds in Brunei.

by the Flying Medical Service which provides health care in the remote interior on a monthly schedule of visits to fourteen rural centres (Figure 17.1). All medical care, consultations and hospitalization are free of charge. In the absence of any systematized scheme of domicilary visits to the elderly, it is largely through hospital doctors that access to welfare and psychogeriatric care is obtained. Such a system, which works reasonably well in the capital, is much less effective in remoter rural areas. It is clear that the hospital and welfare authorities will come into contact with elderly people only when medical needs require a visit to the main hospitals. As a result, a system of crisis management rather than preventive care has evolved. Doctors can thus refer their elderly patients (and their relatives) to a range of counselling and social services which are organized through the main hospital (the Raja Isteri Pengiran Anak Saleha Hospital or RIPAS) in the capital. A medical social work department was established in 1983 to provide amongst other things, counselling for the elderly and their families on social and medical issues. It is able to advise on a range of issues from adapting homes and equipment to the requirements of elderly people to the appropriate administrative departments to deal with particular requests. Thus it can help to secure monies from the various discretionary funds available in the state. Such procedures can however be slow and cumbersome and the department admits that its role is primarily one of ‘first aid’ for elderly people. Preventative activity and advice has continued to take second place. Recent estimates suggest that between 10 per cent and 15 per cent of the elderly population each year comes into contact with the

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hospital administration and can therefore, potentially, be counselled. The ability to deal with the psychiatric problems of the elderly are currently very limited. In part this reflects a different cultural attitude towards mental illness in which such issues are addressed within the community, rather than through special institutional provision. Conclusion Brunei Darussalam remains a country in which the dominant demographic questions are the size of the young population and the balance between indigenous and expatriate workers. The question of an ageing population remains very much secondary. But, as the demographic data make clear, the size and proportional importance of that elderly population is rising inexorably and, by the year 2010, it will have emerged as a very significant social, economic and medical issue. The provisions for the elderly in the country are certainly more generous and extensive than in many neighbouring countries in the region, but what makes the case of Brunei Darussalam especially interesting is the extent to which that provision is seen to flow directly from the Malay-Islamic way of life. Arising out of these traditions, planners have made a conscious decision to place responsibility for the elderly squarely with the family and village, not with the state. Whilst the state indirectly contributes to the welfare of the elderly through its wider social programmes (free healthcare, no income tax or national insurance contributions, free education), most of its provision has been geared towards providing a safety net for those elderly people facing particular problems. Care within the family and community then, is seen not as something to be imposed by government, but rather as something arising naturally out of the traditions of life in the state. The view that there might be clear alternatives to care within the family (through, for example, state or private old people’s homes) is seen as anathema. Whilst the cynic might argue that such a philosophy conveniently reduces demands on the public budget, a consideration of Islamic precepts on caring for the elderly suggests rather more deep-seated roots for these traditions of caring for the elderly within the family. These traditions of care for the elderly, backed up, it should be noted, by universal pension provision, do carry with them certain risks. Most of the social legislation in Brunei Darussalam has been framed within the context of rising GDP and wealth as hydrocarbon and investment revenues have grown. Standards of living are generally high and employment opportunities in the public and private sector are good. Any changes in this situation might well create rather a different economic and social climate and lead to family pressures which might threaten traditional notions of care for the elderly. This, coupled with the rising numbers of elderly people in the state over the next decade, may have important implications for the culture, context and

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provision of services for the elderly in Brunei Darussalam into the new millenium. References Abdul Aziz Umar (1992) Melayu Islam beraja Sebagai Falsafah Negara Brunei Darussalam’, in Sumbangsih UBD—Essays on Brunei Darussalam, Universiti Brunei Darussalam, pp. 1–21. Akhlaq Husain (1994) Muslim Parents, Calcutta: Adam Publishers. Cleary, M.C. and Francis, S. (1999) ‘Brunei Darussalam: the outside world intrudes?’, Southeast Asian Affairs 1999, Singapore: Institute of Southeast Asian Affairs. Cleary, M.C. and Wong, S.Y. (1994) Oil, Economic Development and Diversification in Brunei Darussalam, Basingstoke: Macmillan. Duraman,Ismail and Hashim, Abdul Amin Hj (1998) ‘Brunei Darussalam: Developing within its own paradigm’, Southeast Asian Affairs 1998, Singapore: Institute of Southeast Asian Affairs. Economic Planning Unit (1991) Census of Population (1991), Economic Planning Unit, Brunei Darussalam. ——(1996) Census of Population (1996), Partial Report, Economic Planning Unit, Brunei Darussalam. Gunn, G. (1998) Language, Power and Ideology in Brunei Darussalam, Boulder: Westview Press. Leake, D. (1990) Brunei: The Modern Southeast Asian Sultanate, Selangor: Forum Press. Medical Social Work Unit, RIPAS (1998), interview material, August-September. Niew Shong Tong (1989) Demographic Trends in Negara Brunei Darussalam, Brunei: Universiti Brunei Darussalam.

18 Older people in Vietnam amidst transformations in social welfare policy Bui The Cuong, Truong Si Anh, Daniel Goodkind, John Knodel and Jed Friedman

Introduction Older persons in Vietnam have witnessed major upheavals and substantial social change over recent decades. They have survived famines, decades of warfare, and pronounced socioeconomic and political change. By the 1960s, Vietnam had begun to promote a planned economy in the northern region through which the state tried to supplant the family as the organizer of agricultural and industrial production. The state also assumed primary responsibility for the welfare of its citizens, including older persons. However, due to inefficiencies in that system, the Vietnamese government has attempted to disengage from its former obligations through a series of market reforms instituted since the 1980s. Among these reforms, the state now emphasizes that families, as well as other institutions in the private sector and civil society, should contribute significantly to the care of older persons, as well as to social welfare more generally. It is against this backdrop of social policy transformation that our paper explores the current situation of older persons in Vietnam and assesses prospects for future change.1 We begin by examining Vietnam’s overall population structure and its implications for future aging patterns. We then summarize briefly the history of policies towards older persons and the evolution of current programmes relevant to both familial and non-familial sources of support and care. Formal government programmes discussed include pensions, social welfare and health care. Non-governmental sources of support considered include continued labour-force participation and assistance from the family. Our discussion of the latter, which constitutes the backbone of support for most Vietnamese elderly, focuses on living arrangements and assistance from adult children. Throughout the paper, we identify major social differences in support for older people, the clearest of which involve the gender-based nature of family support and the prevalence of public support across sub-regions and rural/urban areas. We utilize a variety of sources and analytical approaches. Much of our quantitative data come from two regionally representative surveys of older

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persons that were designed and implemented by the authors in 1996 and 1997.2 One survey covered the Red River Delta (Vietnam’s northern region, centered around Hanoi) and the other a corresponding southern region around Ho Chi Minh City, including the six surrounding provinces.3 These survey findings are bolstered by original analysis of nationally representative data from Vietnam’s 1994 Inter-censal Demographic Survey (GSO 1995). The changing demographic context is explored through population projections. In addition to these quantitative sources, we review prior literature and recent policy documents. The demographic context Population ageing is caused mainly by declines in fertility, although improved mortality at older ages is another contributing factor. In addition to the socioeconomic factors that have contributed to falling fertility throughout the world, Vietnam is one of several countries in Asia pursuing a strong population policy intended to lower fertility in the interest of national development (Goodkind 1995). The total fertility rate (TFR) has fallen from about six births per women in the 1960s (UN 1998a) to well under three births during the mid-1990s (NCPFP 1999). The speed of this fertility decline is unusual given that Vietnam remains a rather poor and agricultural society (GNP/capita as of 1998 was about $310—UN 1998b; World Bank 1998) and likely reflects the added impact of a strong population policy to the forces of socioeconomic development. Indeed, the speed of the decline exceeded official goals that aimed to reduce the TFR to below 3.0 by the year 2000. Fertility may fall below the replacement level of about two births per woman in the near future. Figure 18.1, which shows Vietnam’s population pyramid as of the year 2000, illustrates the effectiveness of its fertility policy.4 Ordinarily, growing populations with steady changes in fertility and mortality produce a pyramid the sides of which slope upwards fairly evenly. In Vietnam, however, the equally sized cohorts of persons at ages 15–19, 10–14, and 5–9 suggests the slowdown in childbearing over the past two decades, while the shrinkage of the population base of 0–4 year olds indicates an even sharper recent decline.5 These trends portend a future shrinkage in the proportions of young persons within the population. Vietnam’s population pyramid also reveals another unique structural feature with implications for trends in the speed of population ageing. There is a relative shortage of persons at ages 45–64, a cohort born between 1935 and 1954. This cohort was depleted for two reasons. First, a famine in the Red River Delta area in Vietnam’s northern region around 1945 likely caused a temporary decline in fertility and a corresponding sharp rise in mortality among infants and young children.6 Second, these cohorts were at primary ages for military service during Vietnam’s protracted war of

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Figure 18.1 Population pyramid for Vietnam in the year 2000.

Figure 18.2 Increase in numbers of Vietnamese 60+ (thousands), proportion 60+ in the population, and proportion 75+to 60+; every five years, 1990–2050. Source: Produced from International Data Base of the U S Census Bureau at www.census.gov.

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reunification (1954–75), when mortality was significantly elevated (Hirschman et al. 1995). The ‘notch’ of those currently 45–64 is even more pronounced due to a baby boom beginning around 1955, which increased the numbers of those born just after these cohorts. The present shortage of persons approaching their elderly years will postpone the pace of population ageing for at least another decade. That slowdown is shown in Figure 18.2. The additional numbers of persons at ages 60+ will actually fall over the next decade, contributing to stagnating proportions of those 60+ between 2000 and 2010 from 7.5 to 7.4 per cent. Ironically, for the same reason, this era will be characterized by ageing within the elderly population itself. Reduced numbers of new elderly will cause the proportion of those 75+ among the 60+ to rise above 29 per cent in 2010, a figure higher than any other Asian country, and one that Vietnam itself will not see again until 2040. The relative deficit of males within the notch of those currently 45–64 will also cause the ratio of female to male elderly to peak at 1.50 by 2010 (not shown), an unusually high level. Thus, although overall population ageing in Vietnam will slow over the next decade, as they allocate resources in the future, policy-makers should be aware of these impending trends among older persons themselves. Following 2020, once the current notch of near elderly have all entered their senior years, the pace of population aging will increase dramatically. The share of those at ages 60 and above will more than double from 10.8 to 24.8 per cent of the population. Of course, such rapid ageing will be due in large measure to falling fertility (and secondarily to improved old-age survivorship), which will contribute to ageing in other countries as well. Nevertheless, Vietnam’s ageing following 2020 will be even more rapid than elsewhere as the current shortage of near elderly is replaced by the nondepleted cohorts behind them. In regard to family policy, the ageing of Vietnam’s population depicted in Figures 18.1 and 18.2 raises important questions. Will the welfare of the future elderly people be jeopardized by the reduction in the numbers of child caregivers available to support them? Will other forms of public or private support emerge to compensate for that reduction? The next several sections will show how Vietnam’s current policy reforms are likely to render answers to these questions distinctive within Asia. Evolving policies towards older persons in Vietnam The systems of social institutions responsible for the welfare of older persons in Vietnam have changed over time. Table 18.1 identifies three such systems, the first of which describes in a very general way the era prior to the 1950s. For many generations, families, clans and villages bore the primary responsibility. A cultural heritage characterized by ancestor worship, patrilineal descent, and patrilocal co-residence led to near universal marriage

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Table 18.1 Systemic models of social welfare for older persons in Vietnam

and an incentive for parents to bear children, especially sons. Patrilocal living arrangements predominate to the present day, as we will show later. Clan groupings also sometimes provided supplemental care and support. Indeed, the limited number of Vietnamese surnames meant that most people were related by name to numerous cousins, both near and distant within the bloodline. In addition, most Vietnamese villages had regulations towards older persons as well as associations of elder persons, many of which had

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great clout in local village affairs (Dinh Khac Thuan 1997; Phan Dai Doan and N guy en Duong Binh 1998). Their members usually consisted of male elderly only; female elderly were better represented in organizations associated with the village pagoda, around which religious and social functions were centred. Substantial changes in this basic system did not occur until the mid-1950s, when a new socialist Vietnamese state emerged following World War II. The constitution of the new state, which incorporated parts of similar founding documents from France, the United States, China, and the former Soviet Union, stressed that all persons, including older persons, were entitled to social security (1946; Section B, Article 14—for a chronological summary of these and other relevant documents, see Appendix 18.1). However, this was only a general goal rather than a specific blueprint for future changes, given the limited financial and political resources available to the nascent state and the continuing struggle for Vietnamese independence from colonial French rule. To help further that struggle, Ho Chi Minh, the founder of the new state, called for the contribution of all social groups, including the elderly. Local associations of elders, along with many other groups, were soon coordinated under the Viet Minh, an umbrella organization (later renamed the Fatherland Front which was responsible, until 1995, for elderly issues among other affairs). Shortly after defeating their French colonial rulers in 1954, Vietnam was partitioned into northern and southern regions, and only the northern region came under the socialist central planning of the Communist Party. Beginning in the late 1950s, the government in the northern region began to set up a new system of social security (Figure 18.1, second section). The basic concept was that the state, in cooperation with state-affiliated organizations such as local work cooperatives and mass organizations, would provide for the social welfare needs of all citizens, including the elderly. For those elderly retiring from the state sector, which came to predominate in urban areas, the pension system was the major pillar of public support. For rural elderly, who constituted the bulk of all elderly, the state encouraged local cooperatives to allocate a minimum allocation of rice from its own stockpile, with extra rice to be provided for those who worked. For the poorest cooperatives that were unable to do so, the government provided subsidies. Medical care, another basic need, was to be provided free of charge (1959; Constitution, Article 32). The government also set up special programmes for families who had made patriotic sacrifices, as well for the most vulnerable citizens, such as lone and very poor elderly (1966; Circular 202/CP-TT). Following reunification with the south in 1975, an attempt was made to establish a socialist system there as well, although efforts were not very successful, particularly in the areas around Ho Chi Minh City and the Mekong Delta. Moreover, the subsidy system that had sustained social

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welfare in the northern region began to unravel. Such subsidies required an economic surplus in the state and/or cooperative sector, yet a lack of economic incentives led citizens to concentrate their work activities outside those sectors on cottage industries or small plots of private land. As subsidies shrank, people had to pay an ever-larger share of their own bills. Hints of the sweeping policy reforms to come included an Article in the 1980 Constitution requiring that children should be responsible for elderly parents (1980; Article 64), a likely indication of the growing insufficiency of funds for payments to older persons. Another directive (1983; 134-CT) requested that local governments and mass organizations conduct ongoing programmes to care for older persons. Meanwhile, older persons, at least in the north, were helping themselves. The activities of local elder associations had been curtailed during the war of reunification, but began to bloom again in the late 1970s. These associations often set up independent funds from member contributions, and provided resources for common activities, visits to ill members, and funeral arrangements. In 1986, Vietnam officially began a series of market reform policies known as Doi Moi. In order to maintain social welfare goals in the face of the collapse of the collective system and reduction of central subsidies, it instituted a more broad-based approach, as illustrated in the third section of Figure 18.1. The state continues to assume the key role in coordinating and providing for social welfare, but its financial role is now more limited, targeted towards its most vulnerable members who are destitute, disabled, or without immediate family to provide support. To ensure social welfare now that subsidies for most citizens have ended, the state now emphasizes the critical role of local governments, as well as the family, the private sector and civil society more generally. Nevertheless, the state continues its financial commitment to government workers and veterans and is attempting to extend coverage of state support in certain areas, such as the old age and health insurance systems. Responsibilities for older persons within the central government are shared across several organizations, the most important of which is the Ministry of Labor, Invalids, and Social Affairs (MOLISA), several programmes of which we describe in the next section. Among notable recent developments was the 1995 establishment of the Vietnam Elderly Association (VEA) by the Prime Minister, which for the first time granted older persons their own organization ‘with a unified structure and full legal status’ (Pham Khue 1998; Pham Thang and Duong Due Hoang 1998; Nguyen Kim Lien 1998). The VEA provides its members with a direct link to the central government and ‘motivates aged people and their descendents to comply with State laws and policies’ (Pham Khue 1998). Local chapters have expanded quickly since most villages in the north and north central regions already had organizations of elders of one kind or another. As of 1998, over 86 per cent of Vietnam’s more than ten thousand

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communes (i.e. clusters of villages or urban blocks forming the lowest level of administration) had established local VEA chapters (Pham Khue 1998). Cells of the VEA are currently expanding to intermediate (district and provincial) administrative levels. This might signal a bid on the part of the VEA to achieve union status. This status would place it on par with the Women’s Union, the Youth Union, and the Peasants Union, all of which have had such status since the 1950s. Regional patterns of individuals within the VEA and other elderly organizations are, however, sharply skewed. Among individuals in our regional surveys, 97 per cent of Red River Delta elderly at the end of 1996 reported belonging at some point to an elderly association, compared to only 48 per cent of southern area elderly in early 1997. This discrepancy likely reflects the lesser communal orientation of the southern citizenry in general (Rambo 1971) as well as, perhaps, an aversion to joining present government organizations in particular. Nevertheless, the VEA is well represented among communes in the southern region. We do not have statistics for sub-regions, but since VEA representation was 86 per cent among all communes, at least 70 per cent of southern communes presumably had them (assuming 100 per cent of northern communes had them). Thus, although VEA chapters are well represented among communes in the southern region, the popular base of support for individual VEA chapters may be rather thin. Institutional programmes There are three basic components of the government’s current social welfare system in Vietnam: pensions, social welfare and health care. Each are discussed in turn. The pension system The present pension system is the outgrowth of a scheme originally established in 1961, modified on numerous occasions during the 1980s to adjust to the changing economic policies, and significantly reformed in the mid-1990s. Currently official statistics indicate there are approximately 1.2 million people who receive pensions including some who are under age 60 (Nguyen Kim Lien 1998; Be Quynh Nga and Bui The Cuong 1999). A significant additional number of elderly receive disability payments. Table 18.2 lists the frequency and average monthly amount of various sources of public support to older persons. These figures are based on the two regional surveys of the Red River Delta and the southern region centered around Ho Chi Minh City, described in the introduction. Monthly retirement pensions constitute the most prevalent source of state support to older persons.7 Prior to 1995, such pensions were only available to workers

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Table 18.2 Percentage of Vietnamese elderly people currently receiving the following sources of monthly public support and average amount of payment per recipient

Sources: 1996 Survey of Elderly in the Red River Delta (Institute of Sociology); 1997 Survey of Elderly in Ho Chi Minh City and Environs (HCMC Institute of Economic Research). Notes: State pensions and state disabilities are mutually exclusive. Official family benefits are special benefits for disabled veterans, mother heroes, and early revolutionary service. Lump sum and irregular distributions, queried in the south only, are not listed here. *As of 1997, VND12,800=US$1.

retiring from the state sector. The frequency of pension receipts reflects to a large extent the proportions of those retiring from the state sector, which in turn reflects an urban bias as well as the two-decade gap in the promotion of state central planning between northern and southern regions (Goodkind et al. 1999). Thus, pensions are more common in the Red River Delta and in urban areas more generally. Nearly two-thirds of Hanoi elderly and almost half of other urban elderly in the Red River Delta receive monthly pensions. Among rural elderly in the north and all elderly in the south, fewer than 10 per cent receive them. Many older southern workers who joined the state

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sector after 1975 simply did not have enough time to accumulate the twenty years of experience necessary to qualify for a pension. For those that retire before qualifying for a pension, a lump sum payment is often provided.8 In addition to constituting the most prevalent source of monthly support for older persons, state pensions are the largest source of support as well. Pension sizes average about VND217,000 in the northern region and VND 309,000 in the southern region.9 Given exchange rates at the time of the surveys, these payments amounted to approximately US$22 per month, not trivial given that the GDP per capita at the time of the survey was under $300. The pension system heretofore has been funded ostensibly through a payas-you-go system based on payroll deduction, yet it has been largely reliant on government subsidies. Since 1993 (Decree 43/CP), as part of Doi Moi, the government expanded coverage to include private enterprises with more than ten employees. The reason was to make the system more equitable by covering a larger proportion of elderly citizens. Such a move was further necessary because the ageing of the state sector worker population had rendered a pay-as-you-go system limited to the state sector increasingly untenable (Goodkind et al. 1999). Yet, the system continues to run at a deficit due in part to the reluctance of most private sector enterprises to participate. The most recent data available for 1997 indicates a pension shortfall of about 0.3 per cent of national GDP, approximately one-fifth of total pension outlays (Be Quynh Nga and Bui The Cuong 1999). This shortfall has to be paid through borrowings or other government funds. Elders who had become disabled while working in the state sector are eligible for monthly disability payments, which substitute for the pension benefits disabled workers would have received otherwise. State disability payments are roughly half that of state pensions. Based on the two regional surveys, only about 1 per cent of all elderly reported receiving these payments. Social welfare The second most commonly received category of public support, after pensions, are ‘official family benefits’ which are given to those having made patriotic sacrifices for the cause of Vietnamese statehood. Such persons include disabled veterans, parents losing children during military combat, and those performing special revolutionary services. As Table 18.2 shows, a full 14 per cent of northern respondents received one of these benefits, compared with fewer than 8 per cent of the southern survey participants. These statistics give a rough indication of the proportion of families making sacrifices for the cause of reunification. The mean amount of these supports is less than half that of state pensions. Other sources of state support are received only rarely according to the surveys. For instance, despite the legislative attention targeting the poor and lone elderly referred to earlier, Table 18.2 shows that only 0.4 per cent of

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elderly respondents reported social welfare benefits other than family benefits. Overall, then, Table 18.2 shows a significant commitment on the part of the government to provide for state workers, a group that does not constitute the poorest or most disaffected members of Vietnamese society. The World Bank (1995) came to similar conclusions in an earlier study. Of funds spent on public transfers, over three-quarters were devoted to pensions and disabilities. Moreover, based on the 1992–3 Vietnam Living Standard Survey, the World Bank found that the top quintile of income earners received 39 per cent of all pension and disability payments compared to 7 per cent for the lowest quintile (note these results are not limited to the elderly). Vietnam’s urban population, which constitutes about a quarter of the population, also received a disproportionate share of pensions and disabilities. Thus, as of the early to mid-1990s, the state social transfer system in Vietnam was not effectively targeted to the poorest segments of the population, although it is possible that policy changes since then are more so. There have, however, been some programmes directed towards older persons in rural areas, where poverty has been concentrated for many decades (World Bank 1995). During the 1960s and 1970s, village welfare systems, sometimes subsidized by central or regional governments, seem to have sustained the needy, with social benefits provided to older persons for food and daily living, medical care, and support for funeral grants. Following the early stage of Doi Moi, a new Land Code in 1993 guided the parcelling out of lands formerly held by cooperatives. Elderly persons were typically granted 50–80 per cent of the land that was allocated to a non-elderly adult. It is important to realize that such allocations represented a kind of welfare benefit, as these lands could be farmed by elders, their families, or other tenants. A study by MOLISA determined that the land allocated to the average elderly person produced 8–13 kg of rice per month, an amount considered to be just below the poverty line (Pham Kien Cuong 1997). Average rural pensioners in the north, in contrast, received the equivalent of about 45 kg of rice. In addition, over the years, following the collapse of the cooperative system, many rural villages in the Red River Delta experimented with local pension funds. Such plans were largely abandoned in the early 1990s, but are now being reconsidered. For instance, a pilot project in Ha Tay province by the Vietnam Farmer’s Association has had modest success in supplementing local incomes for older persons, providing about 3–15 kg of rice per month from its pension scheme (Le Van Nhan 1997). It remains to be seen whether such a system can be sustainable and/or whether such a model programme can be repeated successfully elsewhere in the country, but a temporary regulation addressing such social welfare among rural workers will be enacted by the government in the summer of 1999. In addition to the rural elderly, since 1966 those elderly living alone (or with a spouse), and without other family members or other means to support themselves, have been identified as persons requiring special assistance (1966, Circular 202/CP-TT). The amount to be received in 1994

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by the lone elderly was set at 24,000 Dong (12 kg rice at 1994 prices) for those residing in their own home and 84,000 Dong for those residing in state social welfare centres (1994, Decision 167-TTg). A study by Dam Huu Dac (1999) suggested that, among those denned as lone elderly, only 25 per cent have no children or relatives; the rest have children (44 per cent) or grandchildren (14 per cent) that are too poor or live too far away to take care of them, or for other reasons do not want to care for them (17 per cent). Among an estimated 131,000 lone elderly in the nation as of the late 1990s, 42 per cent were receiving permanent benefits from the central government, including 2.6 per cent who were supported in state social welfare centres. Health care As mentioned earlier, health care, to the extent that it was available, was ostensibly free in the 1960s and 1970s, although user fees began during the 1980s. In 1992, the government set up a new health care scheme which was further revised in 1998 (1992, Decree 299/HDBT and 1998, Decree 58/ 1998/DN-CP). Under the more recent decree, two kinds of health insurance options (compulsory or voluntary) were made available to all citizens. Those required to participate include state workers, those working for enterprises with ten or more employees, and all those receiving state benefits. Contributions to health insurance are 3 per cent of total salary (1 per cent from the employee and 2 per cent from the employer) and 3 per cent from those receiving monthly benefits. Among voluntary contributors, over 90 per cent were students. Others joining voluntarily may contribute as much as they wish (as in the case of a life insurance policy), but clearly only a small minority appear to want to join so far. Between 1993 and 1997, the amount of contributions to the health insurance scheme increased by 480 per cent, while the number of those covered rose more slowly, from 3.8 million in 1993 to over 9.5 million in 1997, a 250 per cent increase. However, as of 1997, only about 13 per cent of Vietnam’s total population of 76 million was covered under the health insurance scheme, 7.6 per cent of whom were required to, the other 5 per cent or so of whom volunteered. Coverage rates for the elderly were much higher, roughly about one out of three, due to their greater tendency to receive state benefits in general, as well as their higher propensity of retiring from the state sector in particular (at least in the northern region). Those participating within these schemes receive a health card entitling them to 80 per cent coverage for medical fees, with clients responsible for the remaining 20 per cent (Decree 58/1998/ND-CP). The scheme offers 100 per cent coverage to pensioners, veterans, the disabled, those having made patriotic sacrifices, and the lone or destitute elderly. A 1989 Code on People’s Health Protection held that the elderly should receive priority in public health provision (Article 41), although anecdotal evidence suggests that this Code is not honoured in practice.

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Non-formal sources of support Given the limited assistance provided by the state and affiliated organizations, most elders still depend on their own work and/or their immediate families, especially adult children, as their primary sources of support and care. Table 18.3 provides an overview of the relative importance of different sources of financial support based on our two regional surveys of Vietnamese elderly. State support (of at least one kind) is not infrequent in either the northern or southern regions (30.2 and 17.3 per cent, respectively), yet a considerably lower percentage report that state support constitutes a primary source of income (15.3 and 4.9 per cent). By contrast, a far larger share report that children are a main source of their income (42.4 and 66.0 per cent; even higher when considered as main sources of household income), and many elders themselves are engaged in working for income (41.1 and 35.2 per cent). Children are more likely to be primary contributors to elderly income in the southern region and in urban areas of both regions. Possible reasons for these differences are discussed below when we examine familial support in more detail. First, however, we take a closer look at work patterns of older persons. Work patterns among older persons Some elderly people continue to work in spite of relative financial comfort due to the derived satisfaction from their jobs. Others are compelled to work, even if in poor health, due to a lack of financial resources. Thus elderly labour-force participation rates convey a mixed message about Table 18.3 Reported sources of income for elderly persons by place of residence, Red River Delta 1996 and Ho Chi Minh City and environs, 1997 (percentages)

Sources: 1996 Survey of Elderly in Red River Delta (Institute of Sociology); 1997 Survey of Elderly in Ho Chi Minh City and Environs (HCMC Institute of Economic Research). Notes: * Includes lump sum payments in the southern but not the northern survey. **More than one source can be reported as a main source of income.

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elderly well-being in Vietnam. Nevertheless, income derived from an elder’s job, or job of a spouse, remains an important component of overall income available to the elder’s household. Labour-force participation rates based on the two regional surveys are shown in Table 18.4 for those elders who have always worked. 10 Participation rates are compared among three major economic sectors—the agricultural sector, the non-state, non-agricultural sector, and the state sector. Elderly people are assigned to each sector based on either their current or most recent main occupation (for those who are no longer working). Working clearly declines with age. Roughly half of all older persons between the ages of 60 and 69 still work full or part time but fewer than half as many aged 70 or over do. Likewise, among those who do work, full-time work declines sharply with age. The overall proportion of working elderly is similar to neighbouring agricultural countries such as Thailand and the Philippines but approximately 50 per cent higher than that found in more economically developed Asian countries such as Singapore and Taiwan (Hermalin, in preparation).

Table 18.4 Rates of labour-force participation of Vietnamese elderly people by age and occupational sector, Red River Delta 1996 and Ho Chi Minh City and environs, 1997 (% of elderly people still working among those who have ever worked*)

Sources: 1996 Survey of Elderly in the Red River Delta (Institute of Sociology); 1997 Survey of Elderly in Ho Chi Minh City and Environs (HCMC Institute of Economic Research). Note: *12.3 per cent (weighted) of elderly women in the south have never worked. Only one woman in the northern sample (0.02 per cent weighted) has never worked.

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Slightly higher proportions of elderly people work in the Red River Delta than in the southern region. This regional variation is largely due to differences in labour-force composition in the regions. There is a much higher representation of agricultural elderly in the Red River Delta than in the HCMC area (71 per cent versus 46 per cent). This increases the proportion of those elderly working, given that agricultural elderly generally work into later ages than those outside of agriculture do, although often on a part-time basis only. In fact, within agriculture, virtually no regional difference in the work rates is apparent. A regional difference is apparent for workers in the non-state, nonagricultural sector (largely made up of household enterprises such as food stalls, small retail trade stores, and repair shops). Northern elderly people in this sector are more likely to work than their southern counterparts, especially at later ages. This sector is less commonly mentioned by the elderly in the northern than in the southern sample (16 per cent versus 43 per cent) as their current or last main occupation. The lower incomes in the north (and the likely more limited economic resources of their children) may force those elderly without farms or state pensions to continue to work, while similar elderly people in the south may have greater financial resources and thus more freedom to leave the labour-force. The state sector encompasses all occupations eligible for pension receipt: government workers, military personnel, and workers in state-owned enterprises. Only a modest minority (approximately 12 per cent overall) of elderly people stated these occupations as their last main source of employment. The majority (60 per cent) of monthly pensioners have worked in another job for at least some time after starting to receive their benefits, presumably in a job outside the state sector. The most common reason given for doing so was an insufficient pension. Familial support As elsewhere in Asia, traditional responsibility for the support and care of the elderly in Vietnam has resided with the family, and particularly with adult children. In placing the current patterns of non-formal support of older persons in Vietnam in context, however, it is also important to recognize that there is significant variation in family structure within Asia. One key difference has to do with the nature of gender relations in the family and how they condition patterns of intergenerational support. As Karen Mason (1992) among others has noted, two major types of family systems prevail: the patrilineal/patriarchal systems, found in East Asia and the northern tier of South Asia, that stress the responsibility of sons (and their wives) for caring and supporting parents, and the more flexible bilateral systems found in Southeast Asia and the southern tier of South Asia, in which daughters play an equally or more important role than sons.

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Table 18.5 Measures of co-residence between persons aged 60+ and their adult children, Vietnam 1994

Source: 1994 Vietnam Inter-censal Demographic Survey.

Co-residence of elderly parents and adult children, with all the exchanges of services and material support that living in the same household involves, has been central to the traditional support system for the older population in Asian countries (Knodel and Debavalya 1992). Table 18.5 shows levels of co-residence in Vietnam based on the nationally representative 1994 Intercensal Demographic Survey (ICDS) conducted by the Government Statistical Office.11 In this and subsequent tables, we focus on co-residence with adult children, defined as all ever-married children and single children age 18 or over. Co-residence is substantial throughout Vietnam. Over threequarters of all elderly people live with an adult child and over half live with a married child. However, the stem family form, consisting of elderly parents and only one married child, clearly predominates as indicated by the very low percentage of elderly people who live with more than one married child. Some modest regional and urban-rural variation is apparent in levels of co-residence. The lowest percentages are found in the Red River Delta (which includes Hanoi) and in the North Central and Central Coast regions. Higher levels of co-residence characterize elderly in the Northern Uplands and Central Highlands (regions with substantial proportions of ethnic minorities) and in the southern regions of the Southeast (which includes Ho Chi Minh City) and the Mekong Delta. As in many other Asian countries, urban levels of co-residence exceed those in rural areas, likely reflecting differences in availability and prices of housing and property (Hashimoto et

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al. 1992). The same reason probably underlies the higher percentages of urban elderly people who co-reside with more than one married child. To examine the extent of patrilocality, Table 18.5 indicates the ratio of the percentage of elderly people who live with sons to the percentage who live with daughters in relation to both single and ever-married children. The higher the ratio is above unity, the greater the tendency to live with sons rather than daughters and thus the more that patrilocal considerations dominate living arrangements. Several clear findings are evident with respect to the gender of co-resident children. First, the importance of gender depends on the marital status of the adult child. Co-residence with adult single children is largely gender neutral with ratios approximately at unity in all regions and in both rural and urban areas. By contrast, co-residence with married children clearly favours sons, with ratios above unity in all regions and in both urban and rural areas. Second, patrilocal dominance with respect to married children varies substantially by region and type of place of residence. Patrilocality is high in the northern part of the country (with ratios above 5) and much lower in the southern half (with ratios below 3 in the Central Coast and Mekong Delta and below 2 in the Central Highlands and Southeast).12 This is particularly interesting given that the large majority of the population throughout the country share several basic cultural features (e.g. Kinh ethnicity and Vietnamese as their native language). It seems likely that the large regional variation in patrilocality in Vietnam relates to the country’s geographical location within Asia and historical patterns of migration and cultural mixing. Vietnam virtually straddles the macro-regional division with regards to the family systems referred to above. The Red River Delta in the north is the oldest seat of Vietnamese (Kinh) civilization, which due to its proximity to East Asia with its Confucianist influences, was characterized by a patrilineal family structure (Keyes 1995). During the long historical process of migration of ethnic Vietnamese (Kinh) from the Red River Delta to southern areas (due in part to population pressures and intermittent invasions by China) Kinh migrants arrived in areas characterized by the bilateral kinship system typical of Southeast Asia. Contacts and intermarriage among Kinh out-migrants with non-Kinh in southern regions likely gradually diluted patrilocal patterns. More recently, forces of socioeconomic change may also be loosening the adherence to traditional patrilineal values as suggested by the considerably weaker dominance of co-residence with sons in urban than in rural settings. The 1996 Survey of Elderly in Red River Delta and the 1997 Survey of Elderly in Ho Chi Minh City (HCMC) and Environs provide more detailed information on support provided by adult children (including step and adopted children) in two major regions of Vietnam that include the country’s most prominent urban centres. Table 18.6 shows not only the percentages of elderly who literally co-reside but also the combined percentage who live

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Table 18.6 Living and support arrangements of older persons in relation to adult children, Red River Delta 1996 and Ho Chi Minh City and environs, 1997

Sources: 1996 Survey of Elderly in Red River Delta (Institute of Sociology); 1997 Survey of Elderly in Ho Chi Minh City and Environs (HCMC Institute of Economic Research).

either in the same dwelling or very near to a child. The latter measure captures not only literal co-residence but also situations where elderly and children either live adjacent or near enough for daily contact to occur (a type of ‘quasico-residence’). Table 18.3 gives figures from the two surveys on the extent to which children are either a main contributor to older people’s own income or to the household income. Financial and other material aid can also be measured from reports of receipt of food or minor items necessary for daily living and the provision of money or major durable goods from non-coresident children.13 In Table 18.6, results regarding living arrangements are restricted to those elderly persons who have at least one adult child, and results regarding support from non-co-resident children are restricted to those who have at least one child living outside the household. As Table 18.6 shows, the vast majority of elderly in both samples have at least one living child and very large proportions also have a child living outside the household. Although not covering the entire country, the results are remarkably consistent with corresponding regional measures from the ICDS (see Table 18.5).14 Overall co-residence levels are quite high albeit elderly people in the southern sample are somewhat more likely to co-reside than those in the northern sample and urban elderly co-reside more than those in rural areas. Regional variations diminish if the combined measure of co-residence and ‘quasi-co-residence’ is considered. Table 18.6 also shows that only a small share of elderly people live alone. Moreover, among this group almost half live next door to or very nearby a child in both samples (results not shown). Overall, the two regional surveys make clear that very high percentages of

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elders in both sample areas are in situations that permit closely intertwined lives of the two generations. Most Vietnamese elders also report that they receive food, clothing or items of daily living from non-co-resident children, although in this case the provision of such items was more commonly reported among the northern than the southern sample. By contrast, much higher proportions of elders in the HCMC City area than in the Red River Delta report receiving money or major durable items from a non-co-resident child. Compared to the regional differences in provision of financial and material support, differences between the rural and urban elderly are generally more modest. There are several possible explanations for the pronounced regional difference in exchanges of money or expensive durable goods. The cash economy, especially in the rural north, has been less developed than in the south and cash incomes, to the extent they exist, are low (Rambo 1971). This would result in adult children being less able to provide such support. In addition, as Table 18.2 indicated, a larger share of northern than southern respondents reported receipt of monthly state benefit payments (as pensions or disability insurance), reducing the need for monetary support from children. Cultural differences between the two regions with respect to the appropriateness of giving and using cash may also be involved. One additional point about family support worth noting is that compared to co-residence with married children, support from non-co-resident children follows less pronounced gender patterns. Although we do not present results here, previous analysis of the two regional surveys makes this clear (Knodel et al. 1998). Daughters are slightly more likely to provide food or other items of daily living, especially in the southern sample. Also in the HCMC area daughters are more likely to see parents often. In the Red River Delta, sons are somewhat more likely than daughters to provide money or major durables and to see parents often. This is consistent with the stronger patrilocality observed in terms of co-residence with married children. Discussion and conclusions A major transformation in governmental policies and measures regarding social welfare for the elderly has been taking place over recent decades in Vietnam. Following the end of French colonial rule in the north and reunification later in the south, governmental policy stressed the primary role of the state, especially at the central level, in providing welfare for all its citizens both young and old. This included free health care, various forms of social security, and special measures for groups deemed either particularly meritorious or vulnerable (such as the deserted elderly). During the period starting in the early 1980s, and particularly in the wake of market reforms known as Doi Moi, numerous shifts have been occurring in welfare policy with the effect of diffusing responsibility to a broader array of institutions

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including the family, the local community, and civil society. While there is some continuity in benefits before and after Doi Moi, this policy transformation represents a retreat from the more comprehensive state benefits to which older persons were entitled, at least in principal, under the earlier broader welfare policies. One common feature of the Vietnam context both before and after Doi Moi has been the lack of any comprehensive framework for making and implementing policies and programmes that relate directly or indirectly to older persons. There is still no national policy or strategy on ageing. The age dimension is usually absent in official documents compared to other social dimensions such as income, gender, children, and ethnic minority status. Official statistical data at government and ministerial levels rarely distinguish the elderly as a group. Given that many of the social welfare policy changes over the last decade have reduced benefits for older persons, it is interesting to note the opinions expressed about Doi Moi in the two 1996 and 1997 regional surveys of Vietnamese elders. Very few held predominantly negative views. In both the Red River Delta and the HCMC area, the majority of respondents thought the impact was mainly positive for society (70 and 53 per cent respectively) and almost all the rest thought the impact was mixed. However, when asked specifically about the impact on older persons, fewer thought the impact was mostly positive (46 and 33 per cent respectively) although again almost all the rest said the impact was mixed rather than predominantly negative. While it is impossible to know how much changing welfare policies influenced these opinions, whatever their negative impact on elderly wellbeing has been, it has apparently not been sufficient to overwhelm elders’ perceptions of the other positive impacts resulting from economic restructuring, for society as a whole or for their age group in particular. Currently, the great bulk of government payments to older persons in Vietnam is directed to state retirees and those having made sacrifices for the nation. Other sources of state welfare are minimal and the current system of social transfers is regressive. The recent proliferation of legislation towards older persons, and the poorest elderly in particular, may indicate more a recognition of a growing problem than an effective solution to it, and formidable obstacles remain. Official government policy is that social and health insurance should be centralized. Yet, in practice, the state has had to shift more of the burden for social welfare to local institutions, the growing private sector, and the institution traditionally bearing the greatest responsibility—the family. The recent survey findings reviewed above make clear that both work and family are critical to the well-being of Vietnamese elders and are far more pervasive and important sources of financial and material support for elders than is state assistance. Many older persons contribute to their own support through continuing to work into their sixties and even seventies.

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Extensive familial support centred on adult children is prevalent throughout the country. Most elderly reside with children and many who do not nevertheless live very near a child. Large majorities of elderly people report children as a main source of household income and many also report receipt of financial and other material support from non-co-resident children. Systematic and representative empirical studies of Vietnam’s elderly population are a very new phenomenon, and thus comparisons with the past can not be documented. Nevertheless, the high levels of co-residence and support from adult children suggest that so far there has been little erosion of the traditional pattern of familial support. Some evidence that this is unlikely to change greatly in the near future is provided by the nationally representative sample of ever-married women interviewed in the 1994 ICDS. Fully 86 per cent said they wanted to live with a child when they were old and almost all the rest said they wanted to live near one. Moreover, more than three-quarters (76 per cent) said they expected either financial or material support from their children. Still, a hint that change will eventually occur is provided by the fact that the percentage of those who expect such support is lower among the better educated and urban respondents. Thus as educational levels rise in the future, and more Vietnamese move to cities, reliance on children may be viewed as less appropriate by increasing numbers of Vietnamese. Whether more will be expected of the state, however, is not clear. If living standards increase together with education, self-reliance may be the major substitute for family support. It seems likely that ageing issues will receive heightened attention from the Vietnamese government in the coming years for several reasons. The first is the government’s increasing realization, due in part to formal projections of its future population, that ageing will become a problem. Moreover, it realizes that older persons are least able to cope with the changing social conditions unleashed by Doi Moi. Second, ageing issues are emphasized by international donor agencies and, due to social liberalization, are discussed more frequently within the government, the media, and among the public. Third, other factors, such as demographic imbalances involving those eligible for pensions within the pay-as-you-go system require that changes be made soon. These and other factors are propelling such concerns to the forefront of social policy consideration. At this point, the effectiveness of the post-Doi Moi strategy to mobilize support from all sectors—familial and non-familial, private and public, and within the public sector, across local and national levels—is still unproven. As in much of the rest of Asia, Vietnam will experience rapid growth in the number of older persons as well as substantial population ageing over the next several generations. The ongoing rapid decline in fertility ensures that the age structure transformation will also occur at a rapid pace. In the next decade or so, the ageing of Vietnam’s population will be comparatively slow, due to the current notch of near elderly in the current population pyramid.

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Although during this period older persons themselves will be increasingly composed of women and the oldest old, the temporary slowdown in ageing can provide some breathing space for the government to re-assess its approach to older citizens and better prepare for the inevitable rapid ageing that will immediately follow. Acknowledgments The research on which this chapter is based has been partially funded by a grant from the US National Institute on Aging (‘The Vietnamese Elderly in a Time of Change’, R03AG14886). Additional project support has been provided by the Fogarty International Center at the US National Institute of Health (D43 TW/HD00657). Notes 1

2

3 4 5

6 7 8

9 10

We use elderly to refer to the population age 60 and over. We note that the Vietnamese government treats women aged 56 and over and men aged 61 and over as eligible for particular old-age benefits and for this reason persons of these ages often correspond to the elderly age group as used in official documents (Nguyen Kim Lien 1998). These are the first regionally representative surveys specifically directed towards the elderly and address a wide variety of issues related to their socioeconomic welfare. Several earlier surveys were either more local or based on purposive samples (see e.g. Dang Thu 1994). For details about the surveys and their implementation, see Truong Si Anh et al. 1997. All results from these surveys are weighted to be regionally representative. However, when number of cases are shown, they are expressed in unweighted terms. The current age pyramid along with projections of Vietnam’s future population were obtained from the International Data Base maintained at the web-site of the US Bureau of the Census (www.census.gov). The population pyramid is based on projections made prior to recent findings of even lower fertility in Vietnam in the mid-1990s (NCPFP 1999). Thus, the actual contraction of the cohort aged 0–4 as of 2000 should be even more pronounced than that suggested by the pyramid in Figure 18.1. These assumptions are based upon the experiences of other countries undergoing famines, although no reliable demographic accounting of this tragedy in Vietnam has been produced. Discrepancies between these figures and others reported for the nation as a whole are due to accounting methods, sampling error, the time the statistics were compiled, and the inclusion of non-monthly payments. The amount of this payment is based on the retiree’s work experience and average wage over the preceding five years. The government has been increasingly encouraging state workers to retire early with a lump sum. For 1997, the most recent year with available statistics, 69,000 retiring workers were granted a lump sum payment and 34,000 workers retired with a monthly pension (MOLISA 1998). Southern state sector workers qualifying for pensions are more likely to retire from occupations conferring higher pensions or have a higher rank within each occupation. For details, see Goodkind et al. 1999. In the north virtually every elder respondent has worked for at least some period of time. For the southern region a noticeable minority of women (12 per cent of all

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12 13 14

Bui The Cuong et al. women in the south) has never worked. This difference is largely ascribed to two reasons that have historically distinguished the north from the south of Vietnam. Under state socialism, the government encouraged all adult citizens to work, and since the women in the north lived for a decidedly longer period of time under state socialism than women in the south, this encouragement may have resulted in higher labour-force participation rates. Also, in recent history the southern region has had higher income levels (Rambo 1971) and a more unequal distribution of wealth. Thus a select group of women in the south may have been able to choose never to work. The ICDS consisted of a listing of all household members for a probability sample of 13,093 households and a detailed questionnaire directed towards ever-married women of reproductive age within those households. The household listings included a total of 5,475 persons age 60 and over living in 4,085 households. The detailed questionnaire was administered to 10,489 women and included attitudinal questions on old-age support. Determination of co-residence is based on information about the relationship of household members to the household head. Based on this information, an unambiguous determination of co-residence status with a natural child can be made for 98 per cent of elderly members. We have assumed the remaining 2 per cent are non-co-resident. Both for this reason and because co-residence with adopted children cannot be determined, the estimates may slightly underestimate actual levels of co-residence. In the case of the Central Highlands, several of the ethnic minority groups are reputedly matrilineal. We restrict consideration of receipt of food or items for daily living and receipt of money and major durable goods to non-co-resident children given the difficulty of meaningfully measuring such exchanges within the same household. Both the ICDS and the regional survey show that in the Red River Delta 72 per cent of all elderly (including those without an adult child) live with an adult child. For HCMC and environs the regional survey indicates 81 per cent co-residence compared to 82 per cent based on the ICDS for the equivalent set of provinces (which straddle the Southeast and Mekong Delta).

References Be Quynh Nga and Bui The Cuong (1999) ‘National policies and programs on the elderly’ (Cac Chinh sack va Chuong trinh Quoc gia ve Nguoi Cao tuoi), Workshop on Social Research on Aging in Vietnam: Vision for The Future, Institute of Sociology, Hanoi, January 28–29, 1999. Dam Huu Dac (1999) ‘Situation of the elderly and directions of policy of caring for the elderly’ (Thuc trang ve Nguoi Cao tuoi va Dinh huong Xay dung Chinh sack Cham soc nguoi Cao tuoi), National Workshop on Policies for the Elderly, Parliament Committee on Social Problems, Hanoi, January 12–13, 1999 (In Vietnamese). Dang Thu (1994) Local Level Policy Development for Integrating the Elderly in the Development Process in Vietnam, Asian Population Studies Series, No. 131-F, New York: United Nations, Economic and Social Commission for Asia and the Pacific. Dinh Khac Tuan (1997) ‘The elderly living in Vietnamese villages before the August Revolution’ (Nguoi Cao tuoi trong Sink hoat Lang xa Viet Nam truoc Cach mang Thang Tarn), Age: Intel-generational Relationship, Vietnam Elderly Association. Hanoi: pp. 174–79. General Statistical Office (GSO) (1995) Inter-censal Demographic Survey 1994: Major Findings, Hanoi: Statistical Publishing House. Goodkind, D. (1995) ‘Vietnam’s One-or-Two Child Policy in Action’, Population and Development Review 21:85–111.

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Goodkind, D., Truong Si Anh, and Bui The Cuong (1999) ‘Reforming the old age security system in Vietnam,’ Southeast Asian Journal of Social Sciences 27, 2:139–62. Hashimoto, Akiko, Kendig, H. and Coppard, L.C. (1992) ‘Family support to the elderly in international perspective’, in H.L.Kendig, Akiko Hashimoto and L. C.Coppard (eds) Family Support for the Elderly: The International Experience, New York: Oxford University Press. Hermalin, A. (ed.) (in preparation) Aging in Asia: Facing the Crossroads (tentative title). Hirschman, C., Preston, S. and Vu Manh Loi (1995) ‘Vietnamese casualties during the American war: a new estimate’, Population and Development Review 21:783–812. Keyes, C. (1995) The Golden Peninsula, Honolulu: The University of Hawaii Press. Knodel, J. and Debavalya Nibhon (1992) ‘Social and economic support systems for the elderly in Asia: an introduction’, Asia-Pacific Population Journal 7, 3:5–13. Knodel, J., Friedman, J., Truong Si Anh and Bui The Cuong (1998) Intergenerational Exchanges in Vietnam: Family Size, Sex Composition, and the Location of Children, Research Report No. 98–430, Population Studies Center, University of Michigan. Le Van Nhan (1997) ‘Some activities of Vietnam Farmer Association toward to rural elderly’ (Mot so Hoat dong cua Hoi Nong dan Viet Nam Doi voi Nguoi Cao tuoi o Nong thon), Age: Intergenerational Relationship, Vietnam Elderly Association, Hanoi, pp. 565–70. Mason, K.O. (1992) ‘Family change and support of the elderly in Asia: what do we know?’, Asia-Pacific Population Journal 7, 3:13–32. Ministry of Labor, Invalids and Social Affairs (MOLISA) (1998) Statistical Yearbook of Labor, Invalids, and Social Affairs for 1997 (Nien giam Thong ke Lao dong Thuong binh va Xa hoi), Hanoi: Statistical Publishing House. National Committee for Population and Family Planning (NCPFP) (1999) Demographic and Health Survey 1997, Hanoi: Statistical Publishing House. Nguyen Kim Lien (1998) ‘Government policy on helping the elderly in Vietnam’, in HelpAge International, Mekong Basin Initiative on Aging, pp. 48–50. Pham Khue (1998) ‘The Third Age’, Vietnamese Studies 128:5–16. Pham Kien Cuong (1997) ‘What policies for the elderly in immediate and long-term perspectives’ (Truoc mat va Lau dai Can co Chinh sack Gi Doi voi Nguoi Cao tuoi o Nuoc ta), Age Intergenerational Relationship, Vietnam Elderly Association, Hanoi, pp. 434–41. Phan Dai Doan and Nguyen Duong Binh (1998) ‘Respect for aged people in Ancient Vietnam’, Vietnamese Studies 128:30–9. Pham Thang and Duong Due Hoang (1998) ‘Association of the elderly of Vietnam’, in HelpAge International, Mekong Basin Initiative on Aging, pp. 53–4. Rambo, A.T. (1971) A Comparison of Peasant Social Systems of Northern and Southern Vietnam: A Study of Ecological Adaptation, Social Succession, and Cultural Evolution, PhD Thesis, University of Hawaii. Truong Si Anh, Bui The Cuong, Goodkind, D. and Knodel, J. (1997) ‘Living Arrangements, Patrilineality and Sources of Support Among Elderly Vietnamese’, Asia-Pacific Population Journal 12, 4:69–88. United Nations (1998a) World Population Prospects, the 1996 Revision, New York: Department of Economic and Social Affairs, Population Division. ——(1998b) Expanding Choices for the Rural Poor (Human Development in Vietnam series), Hanoi: United Nations. World Bank (1995) Vietnam Poverty Assessment and Strategy, Report No. 13442-VN, Washington, DC: World Bank. ——(1998) Vietnam: Rising to the Challenge—An Economic Report, Report No. 18632-VN, Washington, DC: World Bank.

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Appendix. 18.1 A sample of significant legal and policy actions towards older people in Vietnam

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19 Ageing in Cambodia Tradition, change and challenges Elizabeth Uphoff Kato

Introduction In Cambodia before 1970, when the country was drawn into the Vietnam conflict through which the Khmer Rouge came to power, older people held a respected place in village society. Old age—which started in one’s fifties or sixties—was expected to be a time of relative leisure. Older people stayed active, but worked on less demanding tasks such as housekeeping, weaving mats, or tending vegetables, and took more time to visit neighbours. Families were large and lived together in the same village for generations. Obedience and respect to parents was reinforced through religion and custom, and parents could (except in the case of some unexpected catastrophe) count on their children to support and care for them in their old age. Much of older people’s life centred around Buddhism and the wat (Buddhist temple) and making merit for the next life. Further details may be found in Ebihara (1971), who provides one of the few anthropological accounts of village life in pre-war Cambodia. However, the traditional image of old age in Cambodia can no longer be taken for granted. The Khmer Rouge regime (1975–9) deliberately attacked the three institutions which defined the role and care of older people—family, community, and religion. The subsequent civil war and international embargo (1979–91) delayed reconstruction and trapped Cambodia in poverty. Now that Cambodia has opened up to the outside world, the situation of older people is being affected by a new market economy and a flood of foreign technology and culture. This chapter is based primarily on a study carried out by HelpAge International (HAI) and the Ministry of Social Affairs, Labour, and Veteran Affairs in 1997 (HelpAge International 1998; HelpAge International and Ministry of Social Affairs, Labour, and Veteran Affairs 1999). The study was for the purpose of generating information on the situation of older people in Cambodia that could be used as a starting point for developing policy and services. At present the Ministry has a small unit concerned with the situation of older people, but no programmes (Ministry of Social Affairs 1995). The study included a survey of 400 older people in four provinces

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(hereafter referred to as the ‘Rural Survey’), a survey of 200 older people in Phnom Penh (hereafter referred to as the ‘Phnom Penh Survey’), and qualitative studies in five villages (the ‘Village Studies’). In addition, relevant data from the National Institute of Statistics’ 1996 Demographic Survey were analysed by age (National Institute of Statistics 1996). For the purpose of the study, ‘older people’ were defined as 55 years of age and above, the age the government uses for retirement. The five village studies included a poor rice farming village, a rich rice farming village, a craft village, a village with many former refugees, and an urban squatter settlement in Phnom Penh. A complete report of the study is available from HAI and a summary of some aspects may be found in HelpAge International and Ministry of Social Affairs, Labour, and Veteran Affairs (1999). Demography and family structure Demography Cambodia’s demography has been deeply affected by the war and atrocities of the 1970s, and the subsequent isolation and underdevelopment of the 1980s. One consequence is that Cambodia is demographically a very young country, much younger than most other Asia-Pacific countries. In 1996, less than 5 per cent of the population was over 60 years old. By contrast, nearly half the population was under 15 (Huguet 1997; National Institute of Statistics 1996). However, since the age cohort currently responsible for supporting older people (ages 35 to 50, especially men) was severely reduced by the Khmer Rouge regime and the subsequent civil war, the current intergenerational support available for older people is less than would be expected given the small proportion of older people in the total population. Another consequence of Cambodia’s recent past is that the aged dependency ratio (aged 65 and over compared to those aged 15–64) will actually decline in the future (until 2010), as a result of the deaths in the 1970s and the baby boom in the 1980s (Figure 19.1). Therefore, unlike most other countries in the region, Cambodia will not face an ‘ageing crisis’ for many years. Indeed, the proportion of younger people who can potentially support older persons will increase for another ten years, unless affected by other factors such as AIDS. The percentage of people aged over 60 who are women (currently 58 per cent) will also increase slightly over the next twenty years as the war generation ages. The Cambodian Demographic Survey found that there were only 65.5 males per 100 females in the age group 40–44 (National Institute of Statistics 1996). Family structure Most older people in Cambodia live with their children, usually their daughters. Among ethnic Khmer, the youngest daughter is traditionally

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Figure 19.1 Cambodia: aged dependency ratio over time. Source: Huguet 1997.

responsible for caring for parents in their old age and may receive a larger share of inheritance in return. Few older persons live as a couple, and even fewer live alone. However over 10 per cent in the Rural Survey and 5 per cent in the Phnom Penh Survey lived with other relatives, suggesting that there is some flexibility in how a household is composed (Figure 19.2). The marital status of older men and women is very different. The majority of older men are married, but fewer than half of older women are. Only 12 per cent of all older men are widowers, but more than half of all older women are widows (National Institute of Statistics 1996). This difference is due to three factors: that women tend to live longer than men, the high number of male casualties due to war, and customs which encourage men to remarry (frequently to women much younger than themselves) while discouraging women from remarrying. This means that many women must face the difficulties of old age without a companion, whereas men rarely do. After poverty and health, the most frequently reported problem during the Village Studies was the difficulty in managing everything alone after a husband died. Despite the war, 94 per cent of respondents in the Rural Survey and 97.5 per cent in the Phnom Penh Survey have at least one natural child alive. Adoption is an important custom, providing homes for poor or orphaned children and assuring care and support in old age for childless men and women. Thirteen per cent of older people in the Rural Survey and 10.5 per cent in the Phnom Penh Survey have adopted children, usually from among

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Figure 19.2 Cambodia: older persons’ living arrangements. Source: HAI 1998.

relatives rather than from unrelated families. However, 3 per cent of older people in the Rural Survey and 2.5 per cent of older people in the Phnom Penh Survey have no children at all, whether natural or adopted. According to data from the Demographic Survey, men generally begin to hand the position of head of the household over to their children after the age of 55. However, more than 50 per cent of men aged 75 and over said they were the head of the household. By contrast, women appear to hand over responsibility as head of household to their children as early as age 40. By the age of 75, only 15 per cent of women reported themselves as head of the household (National Institute of Statistics 1996). Survival strategies Older people in Cambodia continue to work and remain productive until very late in life, both generating income and doing numerous unpaid activities for the household. The pervasiveness of poverty makes work a necessity rather than a choice. There is no national social security system and adequate pension plans are extremely rare. Most of the older people interviewed during the Village Studies—and virtually all of the poor older people—said that making a living was the single biggest problem they faced. During the Village Studies, it became apparent that older people in Cambodia use five strategies (usually in combination) to support themselves:

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their own work, savings, support from children, mutual assistance from neighbours, and assistance from the community. Older people generally rely on their own work for as long as they are physically able, then gradually supplement their own earnings with other strategies as they become more frail. Older people who are well-off supplement their own work with savings and support from their children. Older people who are poor rely on support from their children and mutual assistance from neighbours. Completely destitute older people, who have no strength to work and no relatives, depend on the charity of other people in the community. Income generation Fifty-five per cent of older people in the Rural Survey and 36 per cent of older people in the Phnom Penh Survey said they worked to generate income (money or food to eat). The main income-generating activities of older people in the Rural Survey are farming, gardening, and petty trade. By contrast, the main income-generating activities of older people in the Phnom Penh Survey are petty trade, wage labour, small business, and a professional/ technical occupations. Although the percentage of older people working for income and the number of hours worked per day decreased with age, 45 per cent of those over 65 in the Rural Survey are still working to earn income, and 19 per cent are still working more than seven hours. By contrast, only 16 per cent of the Phnom Penh Survey over the age of 65 are working at all (Figure 19.3). Older women are less likely to work to earn income, and worked fewer hours than men. Older women in the Phnom Penh Survey worked considerably fewer hours than either men in Phnom Penh or women in the Rural Survey. However, based on observations during the Village Studies, the number of older women who work may be underestimated since older women often do not consider activities such as preparing food for their children to sell as ‘work’. Almost all older people who said they generate income also said they both gave support to and received assistance from other family members. The main reason older people gave for not working was ‘poor health’, followed by sufficient help from children or other relatives. In the Phnom Penh Survey, poor health was slightly less important, while assistance from children and relatives and pensions were more important. A few respondents specifically cited lack of skills or credit as reasons for not working. Very few older people said that they were not working because they have sufficient personal savings or property. In addition to paid work, older people do a significant amount of unpaid work for the household, such as cleaning the house, taking care of grandchildren, cooking, collecting water and firewood, growing vegetables and herbs for home consumption, repairing things, and caring for

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Figure 19.3 Cambodia: percentage involved in income-generating activities by age. Source: HAI 1998.

live stock. Discussions with older men and women during the Village Studies indicate that gender roles remain fairly distinct in old age. Older men may help out, but older women have the primary responsibility for cleaning, cooking, and caring for grandchildren. By contrast, older men tend to have clearly defined tasks, such as caring for cows, repairs, or carrying wood and water, and then are free to do other things. Discussion groups described men’s tasks as ‘heavy’ and therefore more important than what older women did, although they generally agreed that older women worked longer hours than older men. Savings Very few older people can afford to stop working because they have enough savings. Most people are too poor and there are no institutions to assist in saving for retirement. Of older people who have stopped working, only 1 per cent of in the Rural Survey and 2 per cent in the Phnom Penh Survey said that they have stopped working because they have enough savings. However, even if they cannot save enough to stop working, many older people do manage to put aside savings in some form to supplement one of the other strategies. A fairly common method of saving in the countryside is to plant fruit trees in early old age, so that the fruit can be sold to help support them when they can no longer work. A few older people also hold back a piece of land or a cow after dividing inheritance to their children, in order to pay for medical expenses or their funeral.

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Figure 19.4 Cambodia: main source of support of older persons. Source: HAI 1998.

Support from children According to Cambodia tradition, children—in particular, daughters—are responsible for supporting their aged parents, and this remains the most widely used survival strategy for older people (Figure 19.4). In general, this strategy works very well, and most children do their best to take care of their parents. However, some older people do not have children, due to death or disappearance. An older person with no children of his or her own can adopt, but older people who do not have a basic level of possessions may have difficulty persuading relatives to give up a child—or to support the child once they have adopted him or her. The biggest cause of death and disappearance up until now has been the Khmer Rouge and the war. However, in the two poorest villages in the Village Studies—Tatok 2 (Battambang) and Phnom Kngap (Kampot)—many younger people have left to look for work in Thailand or other provinces and came back rarely or not at all, often leaving grandchildren behind for their parents to raise. In the near future, as the number of people who are sick and dying from AIDS increases, many older people will also lose children to AIDS. A second problem with relying on children is that if the children are poor, the amount of support they can give to their parents is limited. In all five villages studied, the older people who were rich were those who had some capital (usually from before 1975) and were able to increase the land

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and assets they received in 1979. When they divided the land and assets among their children, their children were well off enough to support them easily. For older people who have not been able to increase their assets, division of land has meant that their children have to support both their own families and their parents on even smaller pieces of land, causing standards of living to fall. Assistance from and to neighbours Older people who are well off can rely on their children and their savings for daily expenses and emergencies. However, for poor older people, neighbours are an important source of food, physical assistance, and (occasionally) interest-free loans in times of need. Most of the older people in the Rural Survey and the majority of the people in the Phnom Penh Survey said that they received assistance from their neighbours. Older people in Phnom Penh said they received less assistance than people in the Rural Survey, probably reflecting both weaker social relations and greater wealth in Phnom Penh. Again, assistance is generally reciprocal—older people must invest time in helping neighbours (watching children, giving massages, listening) in order to be sure of assistance in their turn. Community support For those older people who are truly destitute and who have no children to support them, it appears that neighbours or other villagers will usually provide enough food and care to keep them alive. One per cent of older people in both the Rural and Phnom Penh Surveys who were over the age of 65 said their neighbours were their main source of support. In two of the five villages studied (the village with many returnees and the squatter settlement) the research team met destitute older women with no family who were completely dependent on support from neighbours. A few other very poor older people received money from neighbours to go to the wat or for small luxuries such as betel nut. Development projects Despite the experience and skills that older people have, many development programmes do not include older people in their activities. One older man told the interviewer, ‘They only tell the young people—20, 30, 40—about projects, not the old people.’ Several of the credit organizations visited as part of the research said that they do not train or lend to anyone over 54 because they are ‘too old’. However, the credit organizations that do include older people said that they have not had problems related to a client’s age.

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Health and health care Illness and treatment Illness and the shortage of competent and affordable health care in Cambodia affect people of all ages. However, they have an especially serious impact on older people who are more likely to experience health problems and may be dependent on others. The results of the Rural and Phnom Penh Surveys suggest that older people in Phnom Penh may have slightly better health than older people in rural areas, in terms of fewer days of illness and fewer age-related physical disabilities (difficulty hearing, seeing, chewing, and walking). However, older people in the Phnom Penh Survey have far greater access to prostheses than older people in the Rural Survey, due to both greater poverty and lack of distribution in the rural areas. For example, 49 per cent of respondents with difficulty seeing in the Phnom Penh Survey have glasses, compared to 16 per cent for the Rural Survey. Forty-one per cent of respondents with difficulty chewing in the Phnom Penh Survey have dentures, compared to 11 per cent for the Rural Survey. When seriously ill, respondents said they were most likely to buy Western medicine without a prescription (Figure 19.5). This in itself poses a potential health risk, since expired and banned pharmaceuticals are not properly monitored in Cambodia and many of the people selling medicines have no training. The second most frequent choice of treatment was calling the ‘doctor’ (that is, a village health worker, medic, nurse, or any other person claiming medical knowledge who lives in the village, not a trained physician) to come to one’s house. The third most frequent choice was going to the hospital or clinic. Some older people also use traditional methods, but not the majority, and then usually as a cheaper alternative to Western medicines (traditional herbs) or as a last resort (healing ceremonies). Older people in the Phnom Penh Survey are much more likely than their rural counterparts to go to the hospital or clinic (49 per cent compared to 21 per cent), reflecting the higher incomes and greater availability of private and public clinics and hospitals in Phnom Penh. Chinese medicine is also used more often in Phnom Penh, reflecting the larger number of ethnic Chinese in Phnom Penh (HelpAge International 1997, 1998). Impact of illness In discussion groups and interviews, older people identified the first impact of their own illness as loss of time to work, and therefore loss of income. If they depend on children or other relatives, those relatives will lose time for working in order to care for them. Secondly, there is the expense of the treatment. Most of the older people interviewed during the Village Studies said that treatment for illness is their largest personal expense after food. In most cases where the older person is no longer working full-time, children

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Figure 19.5 Cambodia: choice of treatment when seriously ill (note: choices not cumulative). Source: HAI 1998.

(and sometimes nephews and nieces) paid for medical treatment. Some older people have plans for how to finance their illnesses—saving money from New Year’s gifts, selling vegetables or chickens, or (for richer people) setting aside a cow or a piece of land to sell when they became ill. However, if that is not enough, the main burden of finding enough money falls on their children. If not enough money can be found, the family must decide whether to sell cows or pawn land to pay for medical treatment. In some cases, older people said they have chosen to go without treatment rather than sell assets and risk their family’s livelihood. Although more research is needed, interviews during the Village Studies suggested that older women may find it harder to claim family resources for their own care because older females hold less formal authority within the family and because their work is not considered as valuable. Although both poor older men and women faced the same problem of whether to ask for treatment or whether to conserve their children’s money, it was only older women who said that their children were upset or quarrelled over the cost of paying for their illness. Health care and the community In all the five villages studied, older people took their traditional responsibility for visiting other older people very seriously. If another older

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person is ill, interviewees said they are obligated to visit and offer encouragement, advice, physical assistance, and occasionally food, because older people understand the problems of older people and have more time than younger people. If the person is very ill, older people who know Buddhist chants go to pray with the person. In the more stable villages in the Village Studies, this pattern of visiting included both men and women, and rich and poor. However, since this custom is based on reciprocity, older people who are not part of the social network (either because they are recently arrived or are very poor and have no leisure time) may not be visited. Social roles Feelings on becoming older During the Village Studies, the research team asked older people (individually and in groups) what their feelings were about becoming older. In general, the responses were negative rather than positive. The first feeling which almost all older people mentioned was frustration that they were physically no longer able to do what they wanted the way they could when they were younger. In particular, older people said they felt frustrated because when they were young they could do whatever they needed to in order to make a living, but now they don’t have the same strength or energy. Older people also said this is the major difference between the problems of older and younger people: younger people have the energy to solve problems, but older people often don’t. Another feeling, especially common among poor older people, was worry—worry about children and grandchildren, worry about having enough food to eat, worry about becoming sick and not having money to buy medicine, worry about dying and not having money for the funeral, worry about not having any inheritance to leave the children. These worries are even more intense if the older person is ill or frail. Some older people said that now they are becoming older, they try to work harder in order to save money for themselves and their children. Other older people said their main goal is to make merit for their next life. Many destitute older people said they have no hope any more and depended on fate. In general, men and women expressed the same feelings, although some of the discussion groups said that older women worry more about family and livelihoods than older men do. The role of religion and the wat Religion is still the focus of many people’s lives as they grow older. As one group of older men described it, ‘Young people make rice, old people make

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merit.’ During group discussions with older people in the five study villages, studying Dhamma (Buddhist teachings) and making merit were the most frequently cited goals for the future. The wat is still very much the centre of social life for most older people, especially on holy days and festivals. Besides the wat, the only meeting places for older people in the five villages studied were the houses of older men and women who held Dhamma study sessions. Despite the important place of religion and the wat in their lives, 21 per cent of older people in the Rural Survey said they never went to the wat on thngay sel (holy days), and only 47 per cent went four or more times a month. Older people in Phnom Penh went less often than older people in the Rural Survey, and women went less often than men. Group discussions in the five villages suggested this is because older women have greater responsibility for managing the household and grandchildren, and don’t have as much free time as older men. The three main reasons given for not going to the wat regularly were being too busy, poor health, and not having enough money. Lack of money for offerings is a significant barrier for poor older people. One of the ways that discussion groups in the five villages described the difference between rich and poor older people, is that rich older people can make merit whenever they want to, but poor older people must plan and save in advance. Some older people in the Phnom Penh Survey said they did not go to wat because they were not interested in religion. Community roles Older people held a number of important roles in the five villages studied. The most respected and influential role held by older men is that of acchar (teacher), or member of the wat committee. In the squatter settlement, which has no wat committee or formal acchars, certain older men with good character and knowledge of Buddhist teachings were treated as honorary acchars. The most respected older women were generally midwives and women who managed the preparation of food for ceremonies. Older men and women who knew traditional methods of healing, were particularly devout and knowledgeable about Buddhism, or who have good relations with everyone were also pointed out with respect. One role of older people, which was consistantly mentioned by both older and younger people, is that of moral teacher to younger people (Collins 1996; HelpAge International 1997). Virtually all older men and women interviewed in the five villages said they have a duty to educate children (their own and others) not to fight, to study hard, to twe ampeu la’a (do good actions), and to work hard. This is also the role of older people most frequently cited by younger people. Older people are often asked for

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advice and to settle disputes, but less so following the spread of education and new technology. The majority of older people in the Rural Survey also said that they helped to organize festivals and ceremonies in their village—preparing food, making decorations, and collecting money. A smaller number, but still more than half, of the Phnom Penh Survey said they helped. Men and women participate in organizing ceremonies almost equally in the Rural Survey. However, fewer women than men in the Phnom Penh Survey said they helped organize ceremonies (52 per cent compared to 78 per cent). Older people are also generally active in secular community activities. Ninety-eight per cent of the Rural Survey and 82 per cent of the Phnom Penh Survey said they gave assistance to community projects—money, labour, advice, urging relatives to get involved, or helping collect donations. Through the traditional institution of the wat committees (and the related building, school, and finance committees), older men often play a crucial role in the initiation and implementation of village projects. In three of the four rural villages studied, acchars and wat committees were the ones who came up with the ideas for building or repairing roads, bridges, wats, and schools; and then mobilized funds and labour from the community. Although older women are active in the implementation of projects (especially cooking for the volunteers), they are not allowed to be members of the committees because the committees work closely with monks. Older people played a much less important role in the Phnom Penh squatter settlement studied. This is partly because there are relatively few older people living there, partly because of the lack of a formal wat committee; and because the ‘modern’ institutions (local government, a squatter federation, and a credit NGO) which have taken responsibility for community affairs do not include older people. However, many of the older people living in the settlement still see themselves as having special responsibility for the community, for example persuading neighbours and family members to take part in a sanitation effort and taking up collections for funerals. Relations between older people and younger people Older people interviewed generally agreed that young people were less respectful than before, because of Pol Pot, the decline of monastery education, and the advent of foreign videos, but that very few young people were actually disrespectful. Younger people interviewed, from teenagers to middle-aged, all agreed that older people were important for society. When asked to give examples, the following points were commonly raised. Older people help with many things around the house and give advice and encouragement. Having an older person at home ‘makes children feel warm and secure’. Also, ceremonies and matchmaking could not be done without

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older people. Older people build things for future generations, such as wats and roads, and pass on both practical skills and moral guidance. Younger people’s images of older women, while affectionate, showed more respect for older men than for older women. This suggests that the socially accepted view of older people is still positive, but it is not a clear indicator of how people actually behave. For example, although younger people say that older people are important because they can pass on skills, interviews with older people and younger people made it clear that, with the exception of agricultural skills, few traditional skills are being passed from grandparents to grandchildren. Specialized skills such as weaving (mats, kramas, sarongs, and baskets), music, midwifery, and traditional medicine are seen as having no market and no future. Conclusion Despite the war and trauma of the past, Cambodian traditions of respecting older people, providing care, and using their special knowledge and skills have remained remarkably strong, especially in rural areas. Children (mainly daughters) and relatives are still the primary source of support for parents who are no longer able to work, and relationships with neighbours still form an informal network of support (although at a very low standard of living) for the most vulnerable. In turn, older people make an important contribution to the household in terms of income, childcare, housework, crafts and home gardening. Older people also play a crucial role in organizing and supervising religious events and village projects. Both old and young see older people as responsible for guiding the young people in the village to live moral and productive lives as members of the community. The real threats to the livelihood and dignity of older people in Cambodia are not from the past but from the present and future. The two most serious problems at present are poverty and lack of competent and affordable health care. In the near future, increasing rural stagnation, unequal geographic development, and the looming AIDS epidemic will have an impact. The social position of older people is also under threat. New patterns of education and entertainment are devaluing the skills and experience that older people have to offer. While older people (especially older men) hold unquestioned predominance in traditional community institutions such as wat committees, the new institutions (such as NGOs and government projects) for organizing development projects frequently ignore older people. This neglect undermines the traditional position of older people and excludes them from the development process, depriving them of respect and depriving Cambodia of the unique resources that older people possess. Attention to the situation, needs, and contributions of older people is

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essential both for the sake of older people and for the sake of the country. One of the most devastating consequences of Cambodia’s recent history has been the loss of culture, traditions, and awareness of what Cambodian society was like before the conflict. Older people have the experience and skills that can help restore what has been lost, but they cannot help if they are ignored in the rush for modernization and development. Acknowledgement This chapter draws heavily on a survey written by the Author for HelpAge International, Study on the Situation of Older People in Cambodia (1998). The Author and Editor gratefully acknowledge the permission of HelpAge International to use this material. References Collins, W.A. (1996) Dynamics of Dispute Resolution and Administration of Justice for Cambodian Villagers, Mimeograph; USAID, Phnom Penh. Ebihara, M. (1971) Svay, A Khmer Village in Cambodia, PhD Dissertation, New York: Columbia University. HelpAge International (1997) Traditional Medicine Survey Results, Phnom Penh: HAL HelpAge International (1998) Study on the Situation of Older People in Cambodia, Phnom Penh: HAL HelpAge International and Ministry of Social Affairs, Labour, and Veteran Affairs (1999) ‘The situation of older people in Cambodia’, in J.Randel, T.German, and D.Ewing (eds) The Ageing and Development Report: Poverty, Independence and the World’s Older People, HelpAge International, London: Earthscan. Huguet, J.W. (1997) The Population of Cambodia, 1980–1996, and projected to 2020, Phnom Penh: National Institute of Statistics. Ministry of Social Affairs, Labour, and Veteran Affairs (1995) Future Directions for Social Affairs within the Ministry of Social Affairs, Labor and Veteran Affairs for the Year 1995 and the Years 1996–2000, Phnom Penh. National Institute of Statistics (1995) Report on the Socio-economic Survey of Cambodia 1993/94, Ministry of Planning. Phnom Penh. ——(1996) Demographic Survey of Cambodia: General Report, Phnom Penh. White, J. (1995) Of Spirits and Services: Health and Healing Amongst the Hill Tribes of Ratanakiri Province, Phnom Penh: Health Unlimited.

Index Note: page references in italics refer to Figures; those in bold refer to Tables

accommodation see housing, long-term care active ageing 1 activities of daily living (ADLs) 96, 101, 152; in Taiwan 212, 213 adopted children 362–3 Ageing and Development Report, The 5, 13 age-related diseases 28, 44–5, 101 ageing in place approach, Hong Kong 163 ageing profiles 17–20 AIDS see HIV/AIDS antibiotics, ineffective prescription 30 APEC 2 Ariyoshi, Ms Sawako: Kohkotsu-no Hito 143 ASEAN 2, 301, 303, 319, 321 Socioecononiic Consequences of the Ageing of the Population programme (SECAP) 59 Asia-Pacific region, definition xiii–xiv, 2–3, 36–7 attention homes 85, 86 attitudes towards ageing, Cambodia 370 baby boom 39, 41, 94 Basic Pension program (Japan) 127, 128 bedridden older persons 139–40 Beijing Multidimensional Longitudinal Survey 203 birth-rate in Japan 116 Brunei Darussalam 2, 322–32; demography 322–6, 323; discretionary funds 329–30, 331; homes 330; hospitalization 330–1; Islam and care for older persons 326–8; life-expectancy 326; pension 328–9; provision and uptake of services 328–32; religious tithes 329–30

Buddhism 133, 370–1; temples as homes 252, 253; value systems 2, 20 bunkun 255 Burma (Myanmar) 8–9 Cambodia 2, 6, 360–73; adoption of children 362–3; age dependency ratio 361, 362; assistance from neighbours 367; care in the community 367, 369–70; community roles 371–2; demography 361; development projects 367; employment 364; family structure 361–3; feelings on becoming older 370; health care 368, 369; illness, impact of 368–7; income generation 364–5; living arrangements 362, 363; marital status 362; poverty 363; religion and the wat 370–1, 373; savings 365; social roles 370–3; support from children 366–7; young/old relations 372–3 care in the community 30; Cambodia 367, 369–70; Hong Kong 162–4, 165, 168, 171; Singapore 175, 179–80, 181, 184–6 care security (Japan) 149 care systems 19–20 formal, informal 165, 168–9, 346 Caribbean, migration, impact on population ageing 39 census analysis 52–4 Central Provident Fund (CPF) (Singapore) 105, 108, 183 child/parent relationship; Philippines 277–9; Thailand 254–5 China 6, 194–208; co-residency 122; dependence on children/relatives 198–9; economy 3; ethnic differences in ageing 204–6; family life 199–204;

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family size 198, 200–2; family status 201–2; fertility rate 46, 194–5; filial piety 203–4; household size 201; inter-provincial differences in population ageing 196–7, 197; kin availability 49; life-expectancy 194, 195; old-age mortality 46; one-child families 21, 46, 202–4, 207; population 22, 37, 194, 199; regional differences in population ageing 195– 7; research agenda 208; social security system 198, 200; training in gerontology 206–7; urban-rural differences in population ageing 195– 6; youth and elderly support ratios 47, 47 China Research Center on Aging 71 clubs: Japan 130; Philippines 276–7; Thailand 253 Coalition of Services of the Elderly (COSE) (Philippines) 276 community care see care in the community community roles in Cambodia 371–2 Confucian traditions 94, 133 Confucian value systems 2, 20 constraints on improving conditions 31–2 consumption tax 147 co-residence 160, 161; China 122; Japan 121–2, 121; Philippines 279–81; Singapore 183; Thailand 122–3, 255–7, 261–2; Vietnam 348–52, 349 cost-effective models of care 109, 110 costs of nursing care; Hong Kong 27 day care centres: Japan 154; Taiwan 218 dementia 28, 86 demographic ageing of population 15–18, 35–49 Demographic and Health Surveys 53 demography: Brunei Darussalam 322–6, 323; Cambodia 361; China 37, 194, 199; Hong Kong 158–60; Indonesia 299–301, 301–6, 301–2; Japan 35, 36, 115–19, 116, 116, 118, 118–19, 120; Korea 223–4, 225; Malaysia 284; Philippines 36, 267–70, 268; Singapore 84, 174; Taiwan 210, 211–

12; Thailand 243–6, 244; transition 38; Vietnam 335–7 see also population dependency ratio 94; Cambodia 361, 362; Indonesia 304–5, 305, 308; Philippines 45, 269; Thailand 245 development projects; Cambodia 367 disability, rates of 84, 96–7, 212–14 discretionary funds; Brunei Darussalam 329–30, 331 doctor-shopping 30 Doi Moi (Vietnam) 340, 343, 344, 352–4 drug purchase discounts 271–2 East Asian filial piety based model 5 Economic and Social Commission for Asia and the Pacific (ESCAP) 2, 24, 72 economic life of elderly people: Hong Kong 159–60; Japan 125–6 economic crisis 4, 5, 31, 299 economic support for the elderly: Taiwan 216–17; Thailand 259–60, 262 economy: Cambodia 360, 363–4; China 3; Hong Kong 3; Indonesia 300–1; Japan 3, 113; Korea 3; Singapore 3; Taiwan 3; Thailand 245–6; Vietnam see Doi Moi education: Indonesia 314–15, 317; Japan 130; Malaysia 291–2, 294–5; Thailand 246 Elder Honor programme (EHP) 228 elderly abuse 160 elderly support ratio 45–7 employment: Cambodia 364–5; Indonesia 310, 311, 319; Japan 124–5, 130–1; Singapore 175–6, 186–7; Vietnam 346–8, 353 empowerment 23 environment 13–14, 25; Malaysia 295 epidemiological transition 28, 44–5, 97 ESCAP 2, 59–64 ethnic differences in ageing 204–6 Expectation of Life at Birth (ELB) see lifeexpectancy expenditure per household 4 facilities for older persons 5–6 familial support 348–54, 366–7 family care see family support

Index family life in China 199–204 family size 21; China 198, 200–4; Hong Kong 161; Philippines 22 family structure: ‘4–2–1’ 21, 202; Cambodia 361–3; Taiwan 214–16 family support 13, 20–2; Cambodia 366–7; China 198–9; decrease in 47–9; Hong Kong 163, 164, 168–9; Indonesia 311–13; Korea 234; Singapore 180, 182–4; Taiwan 214–16; Thailand 257–9, 21–2, 263; Vietnam 340, 346, 348–52 females, elderly 29, 31, 305–6 fertility rates 21, 38, 39–42, 43; China 46, 194–5; decline 21–2, 41–2 Hong Kong 161; Indonesia 302, 311–12; Japan 117; Korea 223–4; Malaysia 42, 284, 290; Philippines 42, 267–9; Thailand 244–5; Vietnam 335 filial piety xvii, 20–1; China 203–4; Hong Kong 160, 161, 170; Japan 133; Korea 233–4; Philippines 20–1 Taiwan 214 financial support services 15–17; Malaysia 287; Singapore 94–5, 183 financing care 93–110, 364–5 gender differences see entries under health; life-expectancy geriatric outreach support 165 Gold Plan (Japan) 100, 142, 147–8, 148, 149; Revised 100, 147, 148, 149–50, 153–4 grandparents, care role of 28–9 Great Depression 113 gross domestic product (GDP) 4, 187 Health and Retirement Survey 56 health and social aspects of ageing (WHO study) 58–9 health care 29–31; Cambodia 369, 368–70; Indonesia 315; Japan 145, 151–2; legislation 145; Korea 229–30; Singapore 95–6, 187–8; Vietnam 345 health insurance 108; Japan 97–103, 138–9; Philippines 272–3; Singapore 103–7; Thailand 249–50, 261

377

Health Maintenance Organizations (HMOs) 273 health policy and programmes: Thailand 248, 260–1 health promotion 30 health status of elderly people 86, 87, 96–7; gender differences 27–9; Indonesia 315; Malaysia 293–4; Philippines 271–3; Taiwan 212–14, 213 HelpAge International 5 HIV/AIDS 28, 29, 245, 366, 373 hiya 20, 278 home care services: Japan 154; Taiwan 219 home-help service: Japan 141–2, 153 homes for the aged: Japan 136–7, 141, 152–3; Malaysia 286–7; Philippines 275–6, 282 Hong Kong: aged 60+ 158, 159; care in the community 162–4, 165, 168, 171; care policies 162–5; costs of nursing care 27; economy 3; economic status 159–60; elderly support ratio 45–6; formal structure of care 165–8; health status 86; household composition 159–60; housing 158, 167; impacts of ageing 161–2; income maintenance programme 167; informal vs formal care 89–90, 168–9; life-expectancy 159, 159; long-term care 5, 88; medical services 158; oldage allowance 167; population ageing 158–60; public vs private finance 169–70; residential care 165, 166 residency rights 159; retirement protection scheme 161; role and status of older people 170–1; speed of ageing 37; suicide 24, 160; total fertility rate 161; welfare schemes 158, 164–5 hospital, inappropriate use of 30–1 hospitalization: Brunei Darussalam 330–1; Japan 26; Singapore 184; Taiwan 217 household composition: China 201; Hong Kong 159–60 housing 26; Hong Kong 158, 167; Indonesia 309–10; Japan 121, 131; Korea 230–1, 234, 236; Singapore 181; Taiwan 218 Howe Report (Singapore) 177, 178–9

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human rights, Japan 139 images, older persons 22–3, 31 Inamino School for Senior Citizens (Japan) 130 income maintenance programme in Hong Kong 167 index of ageing 176–7, 177 Indonesia 2, 299–320 demography of ageing 301–6, 301–2; dependency ratio 304–5, 305, 308; economic situation of older persons 313–14; economy 300–1; education 314–15, 317; expenditure per household 4; family support 311–13; fertility 302, 311–12; health 315; housing 309–10; life-expectancy at birth 302; literacy 314–15; living arrangements 309–10; oldest old projections 37–8; population 299–301; poverty 31, 32 retirement age 310; service provision 316–18; sex ratios 304, 305; social security 315–16; spatial distribution 306–8; well-being of elderly people 308–9; workforce participation 310, 311 319 indoor relief 134 industrial development 3 industrialization 114 infant mortality 39, 43 information centres, Japan 130–1 institutional care: Korea 236; Taiwan 216 instrumental activity of daily living (IADL) 212 insurance-based fee-for-service systems 31 interim generation 96 Interministerial Committee on Ageing Population (Singapore) 22, 180–1 International Association of Gerontology 72 International Labour Organization (ILO) 72 International Year of Older Persons (1999) xvi–xvii, 71, 72, 207 iron rice bowl 18 Islam: Brunei Darussalam and care for older persons 326–8; value systems 2, 20 Italy, population over 60 35 Japan xv, 5, 113–31; benefits and

eligibility 101–3; birth-rate 116; characteristics of ageing in 114; coresidency 121–2, 121; definition of old age 115; demography 35, 36, 94–5, 115–19, 116, 116, 118, 118–19, 120; economy 3, 113; economic life of elderly people 125–6; educational and recreational services 130; employment for elderly people 124–5, 130–1; financing care in 94–5; Gold Plan 100, 142, 147–8, 148, 149; Revised Gold Plan 100, 147, 148, 149–50, 153–4; health insurance in 97–100; home-help service 141–2, 153; homes 136–7, 141, 152–3; hospitalization 26; housing 121, 131; impact of population ageing 119–20; industrialization 114; life and attitudes of the elderly study 62–3; life-expectancy at age 60 43, 44; lifeexpectancy at age 65 117; lifeexpectancy at birth 42, 118; living arrangements 120–3; long-term care services see Japan, long-term care; longterm insurance 100–3; meal services 131, 155; mortality rate 43; nursing homes 142–3, 151; pension schemes 127–9; population aged over 60 35, 36; population aged 65+ 116, 116, 119; projected population structure 118, 118–19; respite care 144, 154; retirement 123–5, 124; sex ratio 95; sheltered housing 131, 145–6; ‘Silver Industry’ 98, 99; ‘social hospitalization’ in 99; social security 129–30; social services 129–30; speed of ageing 36–7; tax deduction 131; total fertility rates 117; urbanization 114; Waseda University, changing society and quality of life study 63–4 Japan, long-term care 5, 130 133–56; 1868–1945 134–5; administration reform 148; after 1960s 138–44; after 1980 144–55; before Meiji Restoration 133–4; development of 146–7; pre-war 133–5; present long-term care services 150; since World War II 135–8 Kanreki 115 katanyu katawethi 255

Index Keihi Rohjin Hohmu 141 kin availability 47–9; China 49; Korea 48, 48 Korea (South, Republic of) 2, 11, 223–41; ageing as social problem 224–6; causes of death 44, 45; economy 3; Elder-Respect Pension (ERP) 228; Elderly Health Examination 230; elderly support ratio 45; family responsibility 234; fertility 223–4; filial piety 233–4; forprofit services 234–5; health care 229–30; housing 230–1, 234, 236; income-generating programmes 228; income maintenance programmes 226–8; institutional care 236; kin availability 48, 48; life-expectancy at birth 42, 224, 224; long-term care 236; medical assistance programme 229; medical insurance 229; National Health Insurance 229; nursing homes 230; population of elderly persons 224, 225; public assistance programmes 228; public pensions 226–8, 228; public service developments in 87–8; social service 231–2; social welfare budget 238–9; social welfare policy 232–9; social welfare programmes 226–32; speed of ageing 37; training in gerontology 237–8; voluntary organizations 237 Korean Gerontological Society 239 labour-force, age composition, Japan 119 see also employment language 277 Laos 2 life-expectancy 15, 18, 28, 29, 39, 42; Brunei Darussalam 326; China 194, 195; gender differences in 29; Hong Kong 159, 159; Indonesia 302; Japan 42, 43, 44, 117, 118; Malaysia 284, 285, 287, 291, 293, 294; Philippines 269–70; Singapore 42, 174; South Korea 42, 224, 224; Taiwan 211; Thailand 245 Lion Befrienders Club 185 literacy: Indonesia 314–15; Philippines 270 Livelihood Protection Law (1950) (Japan) 135–6

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living arrangements: Cambodia 362, 363; China 200–2; Hong Kong 159–60; Indonesia 309–10; Japan 120–3; Philippines 279–81; Thailand 255–7; Vietnam 344–5, 348–52 Living Standard Measurement Survey 53 long-term care 4–5, 82–91; in Asian populations 84–6; components 89; cost 27; demand for 85, 86; financing 90; formal vs informal care 89–90; Hong Kong 88; insurance in Japan 130, 155–6; insurance in Singapore 103, 105–6; Japan see Japan, long-term care; Korea 236; national policy 88–9; need for 83–4; numbers of elderly people 84; organization 88–91; provision 86–8, 90; quality 26, 90–1; regulation 90–1; Taiwan 217– 20; training 91 Long-term Care Insurance Scheme (Singapore) 103, 105–6 Long-term Care Insurance System Act (1997) (Japan) 130, 155 Macau Declaration and Plan of Action on Ageing (1998) 52 Malaysia 2, 7–8, 284–96; community centre 292–3; education 291–2, 294–5; environment 295; financial provisions 287; health 293–4; homes 286–7; life-expectancy 284, 285, 287, 291, 293, 294; national ageing policy 288; population 284; retirement age 284–6; rural-urban migration 287; social activities 295; special benefits 289; total fertility rate 42, 284, 290; voluntary activities 295–6 marital status: Cambodia 362 meal services: Japan 131, 155 medical care: Japan 140–1; Hong Kong 158; Korea 229; Philippines 272; Thailand 30, 248–9 medical insurance: Korea 229 Medicare 272–3 Medifund (Singapore) 106, 110 Medisave Scheme (Singapore) 104, 105, 106, 109–10, 183 Medishield (Singapore) 106, 110

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Index

mental health 28 migration, 22, 319 models of care 5 modernization xiv, 2–3 moral panic 16, 93, 94 morbidity 27, 28–9 mortality rates 38, 42–4; causes of variations in 27–8; childhood 39, 43; China 46; Japan 43; Singapore 43; Taiwan 43, 211 Myanmar see Burma national policies on ageing 6–13, 353 National Survey in Singapore (1995) 105 National Survey of Senior Citizens in Singapore (1995) 97 neighbourhood welfare centres (Japan) 130 non-governmental organizations 289 Novartis Foundation for Gerontology 72 nursing homes: costs 27; Japan 142–3, 151; Korea 230; Philippines 275–6; Taiwan 217–18 occupational structures 19–20 old-age security 15–20, 44–5 oldest old 37–8, 39 one-child families 21, 46, 202–4, 207 pension schemes: Brunei Darussalam 328–9; Japan 127–9, 136, 138, 145; Korea 226–8, 228; Philippines 273–5; Vietnam 341–3, 342, 344 People’s Republic of China see China Philippines 2, 9–10, 267–96; child/parent relationships 277–9; clubs 276–7; coresidence 279–81; demography 267–70, 268; dependency ratio 45, 269; family size 22; fertility 42, 267–9; filial piety 20–1; government policies and programmes 270–1; health insurance 272–3; health-related programmes 271–3; homes 275–6, 282; industrial development 3; language 277; life-expectancy 269–70; literacy 270; living arrangements 279–81; medical care 272; nursing homes 275–6; pension and retirement benefits public and private sector employees 273–5;

population over 60 36; self-image 22– 3; special privileges 276; urbanization 269–70 welfare programmes 275–7 policies for older persons xvii, 5–6, 6–12, 88–9, 108–9, 162–5, 220–1, 246–54, 337–40 politics of old age 13 population aged 65+ Asia-Pacific region 14, 15; aged 65+ to 75+ 14, 16; aged 75 14, 16; ageing 84 population ageing, by age and sex: 1950 40; 1990 40; 2030 41 population study/research: emerging issues of the ageing 59–62; household structure and 64–5; low-level policy development 63 positive discrimination 23 poverty 4, 32–3, 125, 126, 305, 329, 360; Cambodia 363; Indonesia 31, 32 primary health care systems 29–31 private care 85, 110, 169–70 productive welfare 232–3 public-private sector participation 25, 90, 110 quality of care 30, 85, 90–1, 219 quality of life (QoL) 14, 63–4, 239, 243 recreational services 130 religion 2–3; Brunei Darussalam 329–30; Cambodia 370–1, 373; Thailand 254–5 research on ageing 51–75, 79–81; census 52–4; cross-sectional and longitudinal surveys 54–6; international intergovernmental agency activities 71–2; interrelating research and policy 72–5; major country studies 65–8, 66–7; methodological and policy issues 68–71; multi-country studies 57–65, 60–1; qualitative data in case studies, focus groups, and in-depth interviews 57; types and primary uses 52–7; vital statistics 52–4 residency rights 159 residential care: costs 27; Hong Kong 165, 166; Singapore 181–2; Taiwan 217 residential homes: Brunei Darussalam 330; Thailand 251–2 respite care 26, 144, 154

Index Retired and Senior Volunteer Programme (RSVP) (Singapore) 185 retirement, preparation for 175–6 retirement age 19; Indonesia 310; Japan 114, 123, 124, 124; Malaysia 284–6; Singapore 174, 180 retirement benefits 19; Hong Kong 161; Japan 123–5, 124; Philippines 273–5 rural-urban migration 22, 287 savings 13, 365 self-images 22 senior citizens’ centres 277 Senior Citizens’ Clubs 185, 188–91 senior citizens’ rights groups 13 service development 4–13 services for older persons 5–6 sex ratio 39–41, 95; Indonesia 304, 305; Japan 95; Singapore 95; Taiwan 211–12 sheltered housing programme in Japan 131, 145–6 Shintoism 133 short-term stay service (respite care) 133, 154 Silver Housing Project 145–6 ‘Silver Industry’ 98, 99, 234 Silver Manpower Centers 131 Singapore 10–11; community-based programmes 175, 179–80, 181, 184–6; economy 3; employment 175– 6, 186–7; family support 180, 182–4; financial support services 94–5, 183; health care needs in 96–7; health care provision 95–6, 187–8; health insurance 103–7; hospitalization 184; housing 181; index of ageing 176–7, 177; intergenerational coresidence scheme 183; life-expectancy at birth 42, 174; mortality rate 43; policy responses 178–81; population trends 84, 174; preparation for retirement 175–6; programmes and services 181–2; residential care 181–2; retirement age 174, 180; Senior Citizens’ Clubs 185; senior citizens’ organizations 188–91; sex ratio 95; social impacts of ageing population 176–8; social issues 175–6; speed of ageing 37; wages 186

381

Singapore Action Group of Elders (SAGE) 185 social activities 130, 295 ‘social hospitalization’ 99, 140 ‘Social Policy and the Elderly’ study (Singapore) 177 social roles in Cambodia 370–3 social security system 35; China 198, 200; Indonesia 315–16; Japan 129–30; Thailand 251 social services: Japan 129–30; Korea 231–2; Thailand 252 social welfare policy: Korea 226–32, 232–9; Taiwan 210; Vietnam 337–41, 338, 343–5, 353 Society of Longevity (Japan) 144–5 speed of ageing 36–7, 38 status of older people 170–1 stereotypes 22 strategic social planning 28 successful ageing 1 suicide 21, 22, 23–4; Hong Kong 24, 160; Taiwan 215–16 support ratios 45–7 Sweden 37 Taiwan 210–21; day care centres 218; demography 210, 211–12; economic support for the elderly 216–17; economy 3; family care 214–16; filial piety 214; health status 212–14, 213; home care services 219; hospitalization 217; housing 218; institutional care 216; life-expectancy at birth 211; long-term care 217–20; mortality rate 43, 211 National Health Insurance 216–17, 218; nursing homes 217–18; residential care homes 217; sex ratio 211–12; social welfare 210 tax deduction 131, 140 technical aid provision 154 telephone reassurance service 131 Ten year Plan for Promotion of Health and Welfare Services for the Elderly see Gold Plan (Japan) Thailand 11, 243–63; child/parent relationship 254–5; civil servants’ medical benefits scheme 249; co-

382

Index

residence 122–3, 255–7, 261–2; demography 243–6, 244; deserted 262; economic growth 245–6; economic support 259–60, 262; educational level 246; elderly clubs 253; fertility rate 244–5; general government policies 246–8; Health Card Scheme 249; health policy and programmes 248, 260–1; life-expectancy at birth 245; living arrangements 255–7; medical care 30, 248–9; monthly subsistence allowance 252, 261; non-co-resident children support 257–9, 21–2, 263; old-age benefits 251; old-age dependency ratio 245; private health insurance 249–50, 261; residential services 251–2; retirement benefits for government employees 250–1; social services centres 252; welfare programmes 251–2 training of careworkers: China 206–7; Japan 146; Korea 237–8; long-term care 91 unemployment 4, 23 United Kingdom Royal Commission on Long-term Care (1999) 5 United Nations: ‘Development of a Research Agenda on Ageing for the Twenty-first Century 72 United Nations Commission on Human Settlement (HABITAT) 72 ‘Living Conditions of Older Persons in Urban Communities’ 72 United Nations Population Fund (UNFP) 59, 63, 64, 71 State of the World Population Report 1998: The New Generations 71 United Nations University social support systems in transition study 62 United Nations World Assembly on Ageing 51; Plan of Action 51, 68 United States: admission rates to nursing homes 83; cost of nursing-home care 83–4; nursing care 83 University of Michigan: rapid demographic change and welfare of the elderly study 64

urbanization: Japan 114; Philippines 269–70 urban-rural differences: China 195–6; Philippines 269, 278 urban-rural migration 19, 22 utang na loob 20 Vietnam 334–55; co-residence 348–52, 349; Doi Moi 340, 343, 344, 352–4; demography 335–7; health care 345; familial support 348–52; industrial development 3; legal obligations of children to provide care 340, 346; pension system 341–3, 342, 344; policies to older persons 337–45, 358– 9; population pyramid 335, 336; quasi-co-residence 350–1; rural elderly 344; social welfare 343–5; social policies 337–41, 338, 353; total fertility rate 335; work patterns 346–8 Vietnam Elderly Association 340–1 visiting nurse service 153–4 vital statistics, analysis of 52–4 voluntary activities: Korea 237; Malaysia 295–6 wages 186 Waseda University, changing society and quality of life study 63–4 welfare legislation in Japan 139, 141, 142–3 welfare programmes 19; Hong Kong 158, 164–5; Philippines 275–7; Thailand 251–2 World Bank Policy research report Averting the Old Age Crisis: Policies to Protect the Old and Promote Growth 109 World Fertility Survey 53 World Health Organization 2; extension of health and social aspects of ageing study 63; Programme on Ageing and Health 71 World Health Organization Regional Office for the Western Pacific (WHO/WPRO) Four-Country Study 58, 63 young/old relations, Cambodia 372–3 youth/elderly support ratios in China 47, 47