1. Introduction
As the twentieth century draws to a close, a dramatic demographic change is sweeping Asia. The rates of this change vary from one country to another, but they all point in the same direction - the rapid ageing of Asian societies. Life expectancy is rising due to the lowering of mortality rates, while the birth rate is declining. These twin factors have resulted in an increase in both the percentage of elderly persons in the population and their numbers.
The coming decades will continue to witness this trend. Asia, which had 43 per cent of the world's population 65 years and above in 1950, is projected to have 57 per cent of this population in 2025 (469 million persons). Of this number, two-thirds are expected to be in China and India, the world's two most populous countries. By 2025, Japan, Hong Kong and Singapore are likely to have more than one-fourth of their population over the age of 65 years. In a number of other Asian countries, too, the percentage will be more than 12 per cent (Rowland, 1994). Among persons 65 years and above, the `old old' (75 years and older) will increase in number, resulting in a greater demand for care and support services.
2. The structure of care
The main care providers for the ageing are informal care givers such as family, friends and neighbours and formal institutions such as the State, private sector agencies and NGOs, including trusts, charities, endowments, cooperatives and mutual-help societies.
The predominance of some types of caregivers over others is not to be construed as stages through which a country passes in a sequential manner. Different forms of care have been found to coexist in varying amounts from one country to another and from one time period to another depending on:
3. The family as care givers
Virtually until World War II, care in old age was viewed as the primary responsibility of the family. Neglect in caring for parents or other elderly family members received strong social disapproval. Individuals and their societies were strongly against public care which was provided only as a last resort. Private charity and religious endowments funded voluntary organisations which provided care for those who had no family to support them. In cases of destitution, local authorities or provincial governments were to some extent the providers of care. However, the number of persons needing such care outside the family was small. The type of care provided was custodial in nature (usually old age homes). The State's involvement in the dispensation of care was not favourably viewed, particularly if this occurred on a regular basis, because it was feared this would contribute to the erosion of family responsibility towards the elderly.
After World War II, the impact of the accelerated pace of industrialisation, urbanisation, migration, modernisation and technological change on the family became more visible. The redefinition of the role of women in society, changes in the lifestyles and values of the young, and the decline in the influence of parents in matters relating to marriage and family formation have affected the traditional structure and composition of the family. The availability of care givers in the family has fallen because families have fewer children. On the other hand, due to longer life expectancy, the period for which care of the elderly is required has increased, with consequent increases in demands for care giving time and expenses.
Some changes in living arrangements of the elderly have become evident. The percentage of three-generation households has begun to decline. Married sons often choose to live separately even when they are in the same city, town or village.
Independent living by the elderly, especially when they have the economic capacity, is now rising in the cities. In Japan, for instance, some studies have reported that though most of the elderly continue to live with an adult child, the percentage has declined in recent decades. Support and care of ageing parents, however, continues to be a strong value (Mason, 1992).
A study in Hong Kong showed a declining trend in the numbers of the elderly living with their married children. In 1991, just over 10 per cent of households were classified as three-generation households (Chow,1994). The most common living arrangement of the elderly, however, continued to be co-residence with children.
A study of the living arrangements of the elderly in Korea, carried out in 1984 indicated that 50.8 per cent lived with a married son (38.4 per cent with the eldest son and 12.4 per cent with other sons) indicating a variation from the traditional pattern of all elderly living with their eldest married son. Twenty three per cent lived with their unmarried children and 2.4 per cent with their daughters. Thus, about 76 per cent lived with their offspring. The survey also showed that 22.6 per cent lived independently (Choe, 1994). Some subsequent surveys have shown that although most Korean elderly persons still desire co-residence with the whole family, there is a decline in this percentage, indicating a change in attitudes in favour of independent living arrangements as long as this is affordable and feasible.
A survey in China conducted in 1983 showed that 80 per cent of the elderly lived with their sons and grandsons and 10 per cent lived with their spouses. Only 4 per cent lived alone. Very few elderly people, however, lived with non-lineal relatives. Another survey in 1989 pointed in the same direction (United Nations, 1989a).
Surveys in Indonesia (1990), the Philippines (1988), and Thailand (1986 and 1990), also reported that two-thirds to three-fourths of elderly persons were living with one of their children and only 4 to 6 per cent were living alone, indicating that familial care continues to be pervasive (Knodel and Debavalya, 1992). Non co-resident children and other kin provide financial and other kinds of assistance to elderly family members, indicating that care responsibility has not been shed.
Country studies on the ageing in Korea, Sri Lanka, China and Malaysia sponsored by ESCAP showed that financial support to the elderly is provided mostly by their children. Physical care givers of elderly males are usually their spouse and children, children-in-laws and grandchildren. Other relatives, friends and neighbours also provide help. In the case of elderly females, the same circle provides care, except that the spouse ranks low in the order of care givers because men are often older than their wives and the provision of care is not a male role. Most care providers are women (United Nations, 1989a, 1989b, 1989c, 1989d).
Extended families in which uncles, aunts or other kin and their children co-reside are becoming increasingly uncommon. Single very old persons or old couples without children thus face a shortage of available family care givers. However, since the familial system of care is still strong, elderly persons with no children often find a place in the households of close relations as the survey in Thailand has shown (Knodel, Chayovan and Siriboon, 1992). Data on destitution of the elderly in Asian countries and unsatisfactory care in their existing living arrangements are unfortunately not available. The number of such persons could increase in the future, although abandonment on a large scale is unlikely.
The elderly are not only care receivers. When not sick or bedridden, they perform useful roles. If both the son and his wife work outside the home, co-residence with parents is viewed as an advantage, even a need, so that young children can be with the grandparents, thereby adding emotional strength to inter-generation family relationships and reciprocal care arrangements.
A 1991 survey of health and living conditions of the aged in Wuhan City and the surrounding rural areas of China, for instance, found that the Chinese elderly were engaged "actively in exchanges of social support with their families and kin. The elderly not only receive but also provide a substantial amount of help to others" (Liang, Gu and Krause, 1992). A Korean study observed that "support also flows from the elderly to their children in the form of goods, labour and services" (Kim and Choe, 1992). Some other studies, too, have reported that the elderly in Asian societies continue to make "significant though often unheralded contributions in economic, family and societal terms" (Andrews and Hennink, 1992). Thus, in the earlier phase of old age, there is a two-way flow of services and support. However, as physical ability declines with age, the elderly become a net receiver. Sometimes by choice, parents as well as the son's family like to live separately, but prefer to seek residence near each other, thus providing independence, privacy and proximity. In Thailand, for instance, particularly in rural areas, elderly parents and children may live in separate but adjacent dwelling units, providing close interaction, support and care, reflecting a functional familial support system (Knodel, Chayovan and Siriboon, 1992).
Thus, the familial system of care still predominates in Asia, including support from children who are not co-resident. It is the deepest reservoir of support for the elderly. To some extent, this is reinforced by economic necessity. Greater financial independence and higher incomes contribute to declines in co-residence, but emotional and material support continues. When independent living is no longer feasible, the elderly live with one of their children.
4. The state as the provider of care
After World War II, support for the welfare state began to grow among a wide cross section of people -- politicians, intellectuals, liberal thinkers and social activists. Countries which hitherto had been under colonial rule raised new hopes among people for greater well-being and social justice and assigned an important role to the State in providing social security and social services. Growing vulnerability of the elderly has strengthened the demand for the State to provide care, not as a substitute for informal systems, but in order to complement them. Negative attitudes towards dependence on the State changed to demands for allocation of State funds and acceptance of the rights of the elderly to State-sponsored care. Some entitlements for the elderly were defined by statute; others were laid down by administrative orders. To an extent, this also reflected growing cognisance of a political reality -- the need to respond to the aspirations of an increasing percentage of the elderly in the electorate. State response in providing care for the elderly has taken various forms such as:
5. Private sector in the provision of care
Most countries, particularly the more developed ones, now have an expanding market sector offering care services to the elderly in their own homes, in non-institutional settings, in institutions or in hospices for the terminally ill. These cater to those sections of society who can afford to meet the costs. Clients of private institutional care offered by the market are often children who are settled abroad or who, for various reasons such as infirmity or sickness which requires constant attention, cannot provide care at home. Sometimes, the elderly themselves who have savings of their own or are financially secure because of a pension, investment income or insurance, enter into such arrangements. Nursing care services at home, day care and home help services are available in the private sector for payment. These services often supplement the care that a family provides and are not necessarily a substitute for it. In fact, support services, whether by the State, the market or NGOs, help to enhance the capacity of the family to provide care.
The pricing of private care is usually done on the basis of costs, reasonable return on investments, elasticity of demand, competition, and what the market will bear. Cut-backs in government budgets which result in a reduction or elimination of services, unsatisfactory quality of public sector care, and the rising ability of people to pay due to their higher incomes and savings, or coverage by health insurance, indirectly stimulate the growth of private sector care. In some cases, the State withdraws from direct delivery of services and utilises private sector facilities for providing benefits, providing reimbursement based on the actual number of clients served. In such cases, the private sector providers of care function as intermediaries of the State, indicating a collaborative arrangement between private sector professionals and the State.
The types and standards of services offered by the market vary greatly and are based on an assessment of gaps in current services and the demand. Market segmentation takes place in response to capacity to pay. In some of the developing countries there is often no licensing or inspection mechanism to ensure minimum standards, leaving it to market forces to weed out the poor service providers, but not before they have caused pain.
The private sector's role in the operation of pension plans, long-term savings instruments, annuities and insurance is expanding, particularly in the more developed countries. With greater economic prosperity and liberalisation of the economy, such schemes are likely to continue to expand.
6. Non-governmental organisations as providers of care
Voluntary organisations have now emerged as an important provider of care services to the elderly, substituting to a large extent the care services provided in the past by religious orders, private charity and community organisations. Non-governmental organisations complement the efforts of the State by providing financial and human resources and a range of services. While universal income security in the form of a minimum pension can only be provided by the State, voluntary organisations provide services in other areas of need such as designing of services. NGOs are more flexible in their operations and also have a strong philosophical commitment to providing care. However, the geographic distribution of non-governmental organisations is uneven.
Voluntary organisations have been playing a strong advocacy role. They function as watchdogs monitoring the quality of government-run or private sector services, they identify gaps in services, negotiate with government regarding desirable change, and mobilise public opinion and support for political leaders who advocate larger allocations and more benefits. In some countries, where voluntary organisations are strong, the State recognises them as intermediaries and assigns direct delivery of services to them, giving grants for the purpose. With basic financial support from government, it thus becomes possible to organise services on a sustained basis while fulfilling certain minimum standards. However, cumbersome bureacratic procedures for release of grants can be limiting factors. Voluntary organisations belong to the not-for-profit sector and have a more flexible pricing policy for the services they provide. Pricing in this sector is determined not by considerations of cost alone or reasonable returns on investment. Programme goals and patterns of service utilisation are also taken into account and the deficit is met by raising funds. By providing an alternative to the State and the private sector, NGOs can moderate the prices charged by the private sector and cater to the needs of persons of modest means.
The development and strength of the voluntary sector varies considerably between and within countries. The voluntary sector is much stronger in the developed countries where State participation is also greater. It performs valuable complementary functions and roles. In developing countries, however, both the State and the voluntary sector leave large areas of need unmet. NGO efforts in the field of ageing in these countries is relatively new, as demographic ageing is a more recent phenomenon.
7. Other providers of care
In some countries, cooperatives, mutual help societies and communities organise services for the elderly on an actual cost or on a subsidised basis. Community financing of health care has been in existence in some countries, but the coverage is limited (Abel-Smith and Dua, 1987). The quality of the service is usually good, but the scale of operation is limited. Informal care arrangements provided by friends, colleagues at the workplace, neighbours and community groups are emotionally satisfying and an important source of assistance. These can, however, be fitful. Information on the nature and extent of the operation of these arrangements in rural and urban areas, and their strength, is not available, though it is likely that in most cases relatives are more likely to provide more sustained help than friends and neighbours who could be counted upon instead to provide companionship, temporary help, and limited involvement in personal or domestic care. Local authorities, too, provide various types of care services, but the range of their programmes and the scale of their operations are limited by availability of funds and perception of their priorities.
8. Care programmes and services
8.1 Income Security
One of the greatest forms of insecurity in old people arises from loss of income due to retirement with insufficient or no pension, insufficient or no savings, and reduced capacity to earn in old age arising from the nature of the employment market. Pension is one of the most sought after income security measures by old people as it reduces considerably their dependence on children and fear of destitution, while providing economic security within the parameters of the family. It also provides relief to the family in meeting some of the expenses for the elderly.
Income security measures vary considerably in the countries of Asia in the matter of eligibility, coverage and entitlements. In some countries (China, India and Malaysia, for instance) non-contributory pensions are available to old persons irrespective of their employment history, if they do not have adequate means of survival, and no children who can support them in old age. In Hong Kong, the old age allowance is given on a non-means tested basis to all persons who have reached the age of 70, the assumption being that it will encourage families to take care of their aged members and provide some financial relief. Old people between 65 and 70 years also get an old age allowance if they are poor (Chow, 1994). Korea, too, gives an old age allowance to the elderly. In 1992, 8.4 per cent of the aged population received the allowance (Choe, 1994). Australia has a flat rate of public pension subject to a means test (McCallum, 1989). In some of the other developed countries, too, pensions based on an age and means test are given as a welfare measure with resources from the general revenue.
Non-contributory pensions or old age allowances have been conceived as a welfare measure and are not intended to meet the full cost of living but rather to contribute towards meeting living costs. In India, the payment of non-contributory old age pensions does not have legislative support and cannot be claimed as a matter of right. The coverage, therefore, often shows fluctuations depending on budgetary resources (Bose, 1988). In Hong Kong and Korea, however, statutory backing provides a stable coverage.
Pension benefits initially covered government employees but gradually expanded to cover workers in organised sectors of private industry and others. In several countries, pension schemes are run by the State, employers and private bodies. While some schemes are mandatory, others are optional. For pension schemes not operated by the State, the market forces decide the contributions and benefits; however, financial norms and safeguards are laid down by the State to protect the interests of members. Several options are available in terms of benefits and contributions. The majority of workers in the developing countries are, however, in the informal or small-scale sector and are not covered by pensions or other retirement benefits. They have no other alternative but to continue to earn as long as they are physically able to do so. Due to poor incomes, lack of foresight, absence of suitable savings instruments, lack of information or absence of state promotion, they do not have enough savings to meet their needs in old age.
For the self-employed such as professionals in the services sector, businessmen and entrepreneurs, financial institutions such as banks, insurance companies and mutual funds now have programmes whereby money saved regularly for a specified period as per a prescribed schedule entitles them to a monthly payment on reaching a specified age or a lump sum payment. Such schemes are open for subscription to others as well. The schemes are financed from the savings of the members. In several countries, the State gives income tax rebates to the contributors and, at times, some relief in taxes to the body operating the scheme. Such savings, however, are threatened by the erosion in purchasing power due to inflationary pressures.
Provident fund schemes for employees in some countries are mandatory, requiring contributions from employers as well as workers. The government provides income tax rebates for the contribution and for the interest which accrues. Such provident fund schemes are a measure of compulsory saving which makes a sizable amount available to the worker at the time of retirement. They are statutory and compulsorily must cover establishments employing more than a specified number of persons. The balance in the account of the employee is paid at the time of retirement. This includes the interest that has accrued over the years. Developed countries of the region have pension schemes in addition to a basic national pension scheme set up by the State. These are operated by employers and financial institutions. They offer a range of choices. Japan, for instance, has eight public pension schemes (Ogawa, 1987). Several countries have a variety of personal savings and annuity plans, but these are utilised only by those in the organised sector of employment.
Income maintenance at a reasonable level also comes from economic activities in which the elderly engage themselves after retirement. Some non-governmental organisations are engaged in developing income generating programmes for retired workers, advising them on opportunities for part-time or full-time salaried or self-employment, and providing technical advice and support services. The extent of interest shown by the State in providing income opportunities to the elderly through enabling programmes and services varies from country to country. Some of the developed countries support retraining and career guidance facilities, and even offer some concessions to industry for the employment of older workers. In the developing countries of Asia, however, surplus labour is a problem, and even the young have difficulties in getting employment. There is, in consequence, limited participation by the State in promoting employment of the elderly.
8.2 Health care
Old age is not synonymous with disease, and age 60 does not necessarily herald the beginning of deterioration in health status. Most people, even after age 60, can lead years of productive and active life and be reasonably healthy. One of the major concerns facing families, nonetheless, relates to health care -- not only is health care for the elderly expensive, it is also time consuming and physically demanding for family care givers. Access to affordable health services and medical care -- diagnostic, restorative, therapeutic and rehabilitative -- therefore assumes significance in old age. In most Asian countries, State-run or State-supported general public health care services at primary, secondary and tertiary levels cover the elderly. Geriatric care, though late to arrive on the scene, is now getting attention. Geriatrics is emerging as a specialisation in the curriculum of medical colleges. Research is being conducted to study the body's response to drugs in old age and methods of treatment. Nutrition of the elderly is also emerging as an area of specialisation. Geriatric wards are now being set up in hospitals. Several hospitals now have separate counters for the elderly in out-patient services. Separate days have been earmarked for out-patient care in addition to the general outpatient facilities available to the elderly. Among other measures are the setting up of infirmaries and hospices, and organisation of health check-up camps and outreach mobile services, particularly by non-governmental organisations. Public health care services in the developing countries of Asia are usually overcrowded, unevenly distributed and over-strained due to shortages of funds for equipment, medicine and personnel, poor maintenance of existing facilities and inadequate space. The impersonal manner in which the services are delivered, as well as inefficient management, affect the quality of services. There is often a long waiting list for hospital beds and queues of patients who have to wait for long periods before they can see the doctor. These hospital-related factors discourage patients from going for treatment at early stages of disease. There are some patient-related factors as well which affect the extent of the utilisation of public health services by the elderly. Among these are the cost of transportation to the hospital for check-up and treatment, the long distance which those living in rural areas must travel, the unsatisfactory quality of services, unavailability of persons who can escort a sick elderly person, treatment costs and problems of compliance with hospital procedures and follow-up measures needed for treatment and recuperation. Medical care needs thus remain unmet or grossly undermet for large numbers of the elderly, particularly women.
Health insurance enables the use of medical treatment entitlements. Some countries have several types of health insurance coverage, either as a part of State social security programmes or private insurance policies (both for individuals and for groups). Health insurance policies usually cover hospital stay and treatment charges; additionally, they may cover illness-related post hospital follow-up treatment. Health insurance does not usually cover preventive health, personal care, aids and equipment, or ancillary support services at home, which are essential in the case of the very old. Health insurance policies prescribe a financial ceiling or permissible maximum number of days of hospitalisation. They thus set limits to long-term management of illness and disability. Health insurance coverage of the elderly sponsored by the State is not available in developing countries.
Private health insurance coverage is purchased by the more affluent members of society. Alternative schemes like group health insurance, which can be viable even on low premia, are also available in some countries. Because of the increase in the number of elderly and the growth in the number of elderly who can afford to pay for services, health and nursing care facilities are now expanding in the private sector. This usually takes the form of hospitals, nursing homes and private clinics.
A pressing need in families is training for care givers so they can provide nursing care to old family members. This training is particularly important for women who continue to be the primary care givers for the bedridden, the convalescing and the infirm.
NGOs are now becoming active as the providers of health care for the elderly. Health care at highly subsidized rates is an important area of NGO activity. For instance, in the Philippines, integrated geriatric care, which includes health care, is being extended by a consortium of NGOs (Domingo, 1994). Trusts, charities and health cooperatives provide non-profit services to the elderly, but their coverage and range of services is limited.
Most countries now have programmes intended to increase health consciousness among people. These programmes emphasise the value of steps taken early in life such as balanced diets, physical exercise, stress reduction, regular medical check-ups, relaxation and leisure activities. In India, yogic exercises and meditation are increasingly being advocated, both before and after retirement. Professional bodies, voluntary health organisations and the mass media are playing an increasingly important role in this regard. Some health education programmes are specifically directed to old people and are intended to strengthen their coping mechanisms.
8.3 Continuing education
The information needs of the elderly in a fast-changing contemporary society have received little attention. In recent years some non-formal programmes aimed at educating people on different issues connected with old age have been transmitted through print and electronic media. Some emphasised the role of family members in the care of the elderly and the reciprocal nature of relationships between generations. A few programmes target the elderly themselves. In the developed countries of the region, pre-retirement counselling and advice on how to lead an active life and make creative use of leisure time are being offered.
In some countries, open universities have developed continuing education programmes for the elderly. These are not intended for career development; rather they are meant to enable the elderly to creatively use their leisure, develop new hobbies or interests, appreciate their socio-cultural heritage, learn to cope with different situations which occur in old age, and develop a better understanding of this stage of the life cycle.
8.4 Housing
The housing situation of the elderly is influenced to a large extent by the housing situation of the general population which is unsatisfactory for the poorer segments of society. In most countries, house ownership is still limited to the more affluent sections of the population, as public housing schemes with loan facilities cover only small numbers. Some countries do provide protection against eviction or arbitrary increases in rents, but insecurity about their ability to pay rents and fears about being forced to move lurks in the minds of the elderly who depend on neighbourhood social networks and nearby services.
Several countries now assign priority or earmark units in public housing for those who have retired or are nearing retirement. Hong Kong, for instance, gives priority to old persons in its public housing programme. To encourage family living, households applying for public housing can have their waiting period reduced if they have elderly members living with them, (Chow, 1994). To encourage children to live with or near their parents, the Housing and Development Board of Singapore has schemes to facilitate this. Unrelated elderly persons, too, can form a household unit and rent an apartment in public housing estates (Cheung, 1994).
For the higher income market segment, architects are now giving attention to designs which are `elderly friendly' and take into consideration factors of accessibility, security, safety from accidents, free movement inside the dwelling unit and mobility outside. New apartment complexes try to provide blocks of flats with arrangements for common meals, laundry, recreation and leisure, and easy access to shopping, medical care, libraries, cultural centres and other community facilities. Parks try to incorporate features which will enable the elderly to spend time more comfortably.
Most of the housing units in which the low income aged currently live are old and need some investment to arrest their deterioration as well as add to amenities and facilities needed by old people. There are hardly any programmes enabling the elderly to upgrade the quality of their housing through credit and, in the case of the poor, through some element of subsidy. Current loan schemes for purchase of housing, extensions to existing housing or major repairs leave out the old as they are no longer employed. This is a gap which needs to be filled. Some NGOs have taken interest in making available low interest loans and subsidies for repairs or small extensions, but the scale of operations is very limited.
8.5 Welfare services
Welfare services were among the earliest programmes for the care of the elderly. The predominant welfare response in the past was to provide care in old age homes to those without any family support or means and who could no longer be on their own. Experience with old age homes has shown that while they provide physical care, emotional needs are unmet and the impersonal environment of institutions make the old feel emotionally starved. For instance, a government study of voluntary and private sector residential homes for the elderly in Singapore found institutional care to be unsatisfactory (Teo, 1992). The studies on ageing sponsored by ESCAP in Korea, Malaysia, China and Sri Lanka indicated that the elderly rate residential care arrangements poorly. However, though not a preferred form of care, residential institutional care becomes unavoidable when the old require constant nursing care and attention, and therapeutic services of a kind which are difficult to provide at home. For the affluent, institutions are increasingly appearing in the private sector which provide stay facilities on a short- or long-term basis. These provide a range of services, and not just passive care, so that institutions are lively and interesting places to live.
Current welfare services emphasise out-reach services in the community which are available to the elderly either in their own homes or in the homes of family members. These services are designed to strengthen the capabilities of the elderly, and they are more acceptable to elderly. They are also more cost-effective and they help family to cope with the physical, financial, psycho-social and other demands involved in caring for the elderly. Most of the services currently offered are day care centres, social and recreational centres, and multi-service senior citizens centres. Voluntary organisations help to organise games, excursions and recreational activities which are non-tiring. They arrange friendly escorts for sight seeing, and visits to places of religious interest and to relations and friends. Respite services are also provided to relieve families for short periods who have one or more infirm old member to care for. Among domiciliary services provided are friendly home visits by social workers to give company, help in cooking, personal care, laundry and home management, home meal services, home nursing, supplies of disability related aids and appliances, substitute family care, telephone assurance services, and help in maintaining links with friends, neighbours and relatives.
Welfare services are of considerable help to families in coping with their care responsibilities. The organisation of welfare services show a plurality of arrangements that the State, NGOs and the private sector provide. There is some kind of client segmentation. Private sector agencies cater to clients who have the capacity to pay and desire a better standard of personal care.
9. Future patterns of care
In the future, patterns of care for the elderly will depend on the changing social scenario and the extent to which problems occur in the informal systems of care. Perceptions of the role of the State vis a vis others who provide for the elderly, economic prosperity, income levels, public pressures, and the strength of non-governmental organisations and private initiatives will all determine the respective roles of care providers. Also the boundaries between family, the State, private agencies, non-government organisations and other providers of care will continue to be debated. Each will have a core area of operation as well as areas of competition, complementarity and collaboration. With greater economic prosperity, the market for a wider range of choices will develop.
The family will continue to be the most significant and the most desired care provider in those Asian societies where family ties are still very strong. However, the family will need capable and affordable support services to enable them to cope with their care responsibilities. These should not be just crisis oriented, but rather provide sustained support. Strong linkages and interweaving of informal and formal care arrangements will strengthen informal care rather than weaken it.
The role the State should play in the care of the elderly, and the forms it should take will be increasingly debated in each country. The issue will move up the political agenda because of the electoral implications of different options. With the concept of the welfare state losing its previous appeal and disenchantment with performance of the public sector, there will be mounting pressures for cuts in public spending and reduction of State participation in several areas. A renewed fascination with efficiency of the market will lead to a redefinition of the role of the State. The public sector will still be called upon to perform certain key functions for the care of the elderly. Its role in financing some areas of welfare, providing core services, regulating services and promoting the growth of care will continue.
In more and more countries, the State may respond with income security programmes, particularly for the lower income groups, including a minimum flat rate of old age pension based on need rather than means or contributions. The State may also promote and increasingly mandate that industry provide pensions, provident funds and other retirement benefits for its workers. It could also stimulate tax policies through the growth of privately sponsored pension schemes, long-term savings schemes and annuities, and lay down the norms and minimum requirements so that the interests of the members are protected. Another area where greater State participation is visualised is in health care through operation or promotion of health insurance schemes, hospital and nursing care facilities, and provision of services to the chronically-ill so that economically-disadvantaged groups can benefit. Making available affordable health care will be a key concern. The State may increasingly promote policies which make this feasible with the private providers of care in some countries entering into some form of arrangement with the State for delivery of services at an affordable price. State participation is also visualised in a manner which enables the expansion of affordable housing, shelter and welfare services.
Private sector participation in care services is likely to increase in the area of pension funds, long-term savings instruments, health insurance, and various forms of health care, residential care, welfare and other services. This will occur not necessarily because of withdrawal by the State or freezing of its expansion, but because of the rise in demand for better services and an increase in capacity to pay, due to greater economic prosperity. Health and nursing care are likely to see the maximum private sector growth, but here again their expansion will take place along with the State's own services. Though there will be no dividing line to limit the growth of the private sector, its expansion and rate of growth will be governed by the growing demand for better health care from those with a higher purchasing power. There will be greater market segmentation. In some segments of care, the private sector may come to be recognised as an intermediary by the State to provide services on a reimbursement basis as per prescribed norms.
Some regulatory or licensing mechanisms will be necessary for private sector services, as markets rarely function in perfect competition to provide efficient services at affordable prices; nor are consumers always knowledgeable enough about the services offered to facilitate rational choice. Industry will need to take a fresh look at the care responsibilities that older workers (particularly women workers), have towards dependent parents, and how best to support this. Industry participation can take the form of allowing flexible work hours during periods when care giving is needed, subsidising care expenses, providing counselling, and helping financially in meeting health insurance and health care costs.
NGOs will likely continue to play an important role in organising affordable care services, often with grants-in-aid from government. In the area of welfare services, NGOs would have an important role in reinforcing the capacity of the family to provide care, both complementing and supplementing State efforts in this direction. An NGO may even become an important provider of support services in certain areas, though perhaps more comfortably in a somewhat subsidiary role. However, local situations and inherent organisational strength would indicate how pervasive a role an NGO could play. Non-profit charities, trusts and endowments will fill an important gap and in several countries may become a third sector of care providers. The NGO sector, though greatly favoured by the State and promoted and assisted as an alternative to the State and the private sector in several spheres of care activity, may increasingly be perceived by the private sector as a serious competitor to its `for profit' services. The extent to which cooperatives, mutual help societies and community institutions can be promoted to organise supportive care services will need careful consideration. The coming decades will thus witness an increasing plurality in care arrangements in different countries with greater client segmentation and offers of choice. The share of different care providers will be determined increasingly by realities rather than by dogma. The family will continue to be desired as the key care provider. The functioning of other care providers in a manner which strengthens the capacity of families to cope with its care responsibilities towards elderly members will be a key concern of policy makers.
The World Bank has come up with a recipe for the best way to provide income security in old age through co-existing public and privately managed systems (World Bank, 1994). This will need to be examined by each country in the light of its current care arrangements, strength of financial institutions, state of the economy, and political assessments of ability to deliver the goods.
Abel-Smith, Brian and Ajay Dua. (1987). " The potential of community financing of the health sector in developing countries". In Health Care Financing, Asian Development Bank, Manila.
Andrews, Gary R. and Monique M Hennink. (1992). "The circumstances and contributions of older persons in three Asian countries: preliminary results of a cross national study". Asia-Pacific Population Journal, Vol. 7, No. 3, pp. 127 - 146.
Bose, A. B. (1988). "Policies and programmes for the aging in India". In A.B. Bose and K.D. Gangrade, eds. The Aging in India, Abhinav Publications, New Delhi.
Cheung, Paul P.L. (1994). "Planning for the elderly in Singapore". In The Ageing of Asian Populations, United Nations, New York.
Choe, Ehn H. (1994). "Programmes and policies for the aged in the Republic of Korea". In The Ageing of Asian Populations, United Nations, New York.
Chow, Nelson W.S.(1994). "Ageing in Hongkong". In The Ageing of Asian Populations, United Nations, New York.
Domingo, Lita J. (1994). "Governmental and non-governmental response to the issue of ageing in the Philippines". In The Ageing of Asian Populations, United Nations, New York.
Domingo, Lita J. and John B. Casterline, (1992). "Living arrangements of the Filipino elderly", Asia-Pacific Population Journal, Vol.7, No.3, pp.63 - 88.
Hui, Y. F. (1987). "Nature and adequacy of formal and informal support programmes to deal with the problem of the aged". In Population Ageing: Review of Emerging Issues, United Nations, ESCAP, Bangkok.
Kim, Ik Ki and Ehn H. Choe (1992). "Support exchange patterns of the elderly in the Republic of Korea", Asia-Pacific Population, Vol. 7, No.3, pp. 89 - 104.
Knodel, John and Nibhon Debavalya. (1992). "Social and economic support systems for the elderly in Asia: an introduction. Asia-Pacific Population Journal, Vol.7, No.3, pp. 5 - 12.
Knodel John, Napaporn Chayovan and Siriwan Siriboon.(1992). "The familial support system of Thai elderly : an overview". Asia-Pacific Population Journal, Vol.7, No.3, pp 105 - 126.
Liang, Jersey, Shengzu Gu and Neal Krause. (1992). "Social support among the aged in Wuhan, China". Asia-Pacific Population Journal, Vol.7, No.3, pp.33 - 62.
Mason, Karen O. (1992). "Family change and support of the elderly in Asia: what do we know?" Asia-Pacific Population Journal, Vol.7 No.3, pp. 13 - 32.
McCallum, John. (1989). "Legislation and the elderly in Asia and the Pacific". In Studies on the Integration of the Ageing in Development : Legislation, Social Security and Social Services, United Nations, (ESCAP), New York.
Ogawa, Naohiro. (1987). "Implications of the aging population for socio-economic development and national plans and policies -- lessons from the Japanese experience". In Population Aging : Review of Emerging Issues, United Nations, ESCAP, Bangkok.
Rowland, D.T. (1994). "Population policies and ageing in Asia: a cohort perspective". In The Ageing of Asian Populations, United Nations, New York.
Selvaratnam, S. (1989). "The Situation of the elderly in Asia and the Pacific: a regional profile". In Studies on the Integration of the Ageing in Development Legislation, Social Security and Social Services, United Nations, ESCAP, Bangkok.
Teo, Peggy. (1992). "Is institutionalisation the answer for the elderly? the case of Singapore". Asia-Pacific Population Journal, Vol.7, No.1, pp. 65-78.
United Nations. (1989a). Population Aging in China, ESCAP, Bangkok.
" " (1989b). Population Aging in Korea, ESCAP, Bangkok.
" " (1989c). Population Aging in Malaysia, ESCAP, Bangkok.
" " (1989d). Population Aging in Sri Lanka, ESCAP, Bangkok.
World Bank, (1994). Averting the Old Age Crisis, Oxford University Press, New York.