The decline in fertility levels, reinforced by continued increase in the levels of life expectancy, is producing fundamental changes in the age structure of the population of most societies. The most notable increases are occurring in the proportion and number of elderly persons, including a growing number of very old persons. In the more developed countries of the region, approximately one person in every six is at least 60 years old, and this proportion will be close to one person in every four by the year 2025.
The situation in developing countries that have experienced very rapid declines in their levels of fertility deserves particular attention. In most societies, women, because they live longer than men, constitute the majority of the elderly population and, in many countries, women and the elderly poor are especially vulnerable. The steady increase of older age groups in national populations, both in absolute numbers and in relation to the working-age population, has significant implications for a large number of countries, particularly with regard to the future viability of existing formal and informal modalities for assistance to elderly people. The economic and social impact of this phenomenon is both an opportunity and a challenge to all societies, because on the one hand, elderly people constitute a valuable and important component of a society's human resources. On the other hand, the provision of assistance to the elderly people with long-term support needs is becoming a great challenge to an increasing number of countries.
The Asia-Pacific region, contains approximately 62 per cent of the world's total population and in the near future, will have the highest proportion of the world's elderly as well. For this reason, countries in the region are required to enhance their awareness of the multi-faceted problems faced by the elderly, and formulate as early as possible, the policies and programmes necessary to provide for the increasing numbers of elderly people. In response to this urgent need of the region, ESCAP, with the financial support of the United Nations Population Fund, and in cooperation with a number of experts from the countries of the region, conducted two policy-oriented regional studies on ageing. These studies focused on emerging issues of the ageing population and local-level policy development to deal with the consequences of population ageing. The findings of these two studies have been documented in publications under the Asian Population Studies Series, APSS Numbers 80, 95-98, 109 and 131 (A-F). This present volume consisting of this introductory chapter which provides a summary of the whole publication and eight chapters which draw heavily on and synthesize the major findings of these two earlier studies. It is hoped that this book will take the planners, policy makers and the researchers of the region a long way in addressing the issues of population ageing.
In Chapter one, The Greying of Asia: Demographic Dimensions, which considers the demographic dimensions of population ageing, the author, Mercedes Concepcion, provides data for many of the countries in the Asia and Pacific region.
These data not only describe the elderly currently living in Asia and Oceania but also those who will live past sixty in the coming five and one-half decades. Through a series of easy-to-understand tables and figures, which are based on statistical data compiled by various United Nations agencies, the author provides readers with detailed information about the elderly. This information, which is broken down by subregion, and in many cases by country, includes information not only on numbers and percentages of the elderly within the population, but also on the numbers and percentages of the elderly who are at quite different stages of the ageing process (over 60, over 70 and over 80).
The author also presents comparisons between the largely dependent percentage of the population which is under 15, and the not-necessarily-dependent population which is over 60. These and other statistical indicators presented by the author, which increase the reader's understanding of what the elderly were like in the past, what they are like today and what they may be like in future, include: sex ratios for the elderly; life expectancy at age 60; location of residence (urban vs rural); marital status and the size of the population which could provide support for the elderly (income, medical treatment and personal care).
Having provided data on the past, current and future elderly, Concepcion then uses statistical data to discuss the social implications of population ageing. In this section Concepcion examines the extent to which the elderly are living with family and have someone to care for them should they need it; the conditions of elderly women whose chances of becoming widows increase rapidly as they pass beyond age 60; the declining absolute numbers of people in families; the declining availability of family members to care for the elderly; the employment prospects of the elderly; the meager resources with which most elderly people support themselves (savings, investments and pension funds); and the declining numbers of family members who can provide financial support for elders who require it.
In her summary, Concepcion reminds readers that as a significant segment of the population lives to greater ages than was the case with previous generations, and as fertility declines, family relations are changing. Concepcion also makes four important points. First, she emphasizes that as a result of the ageing of populations, the size of non-working-age populations relative to the size of working-age populations is expected to grow over the next half century; second, that population ageing implies a greater number of women in the population over age 60 and that the proportion of women among the elderly will increase with age; third, that the "old old" will constitute an increasing proportion of the elderly over the next 55 years; and, fourth, that population ageing and more rapid population growth in the developed regions will lead to more and more of the world's elderly concentrated in developing countries. As a result of these factors, Concepcion calls on families, governments and private organizations to ensure that the elderly can be as useful and as productive as possible.
In Chapter 2, The Situation of Ageing: The Chip and the Old Block, Usha Nayar, attempts to analyse the situation of the aged in times of rapidly changing technology. In this chapter, Nayar discusses the major issues and concerns in the life of the aged, the implications of these for the future and the impact that much higher percentages of elderly people will have on society, and, indirectly on social planners and planning. Nayar also considers these issues in the context and framework of the Life Span Perspective.
Under the heading, Societal changes and its impact on the status of the ageing, Nayar states that respect for the aged is a deeply embedded cultural value in Asian societies which possibly derives its strength from ancient Indian religious and secular texts and that expectations of the role of the elderly is derived from the Ashrama theory which divides life into four distinct stages or phases.
During the first stage, which is known as Brahmcharya, and lasts approximately 25 years, the individual is concerned with learning skills. During the next stage, Grihasthashram, which lasts from approximately age 26 to age 50, individuals are occupied with the duties of a householder -- raising and maintaining a family. During the third stage of life, Vanaprastha, which lasts from ages 51 to 75 years, the individual gradually withdraws from society, but without reducing responsibilities. During the last stage of life,Sanyasa, the individual totally withdraws and renounces all attachments in the pursuit of spiritual freedom.
Nayar also states that the ancient traditions have exhorted the individual to look after the infirm and the elderly, as well as the disadvantaged.
Although Asian societies have traditions which hold the elderly in reverence, Nayar states industrialization, urbanization and new technology have brought about radical changes which have weakened the family support system in Asian societies.
Under the heading Health and nutrition status, Nayar states that although the proportion of the elderly in the population has grown in the last four or five decades, there has been very little concomitant increase in the availability of health services and other forms of medical assistance or increased awareness on the part of the elderly that they must maintain their health and eat a nutritious diet.
Nayar is particularly concerned that the disabilities accompanying ageing, which give rise to profound anxiety and a sense of apathy and helplessness, have not been recognised as problems, and have scarcely received any attention.
Regarding educational attainment and literacy among the aged, Nayar states that the gender differences in literacy in the aged are striking. In China, for example, in 1990, only 11 per cent of women over 60 could read and write, compared with half of all men in the same age group.
Under the heading Housing and shelter for the aged, Nayar states that with some exceptions, few countries in Asia and the Pacific have done much to provide housing for the elderly or to ensure that other facilities are designed with the needs of the elderly in mind.
Nayar also expresses concern that over a lifetime of work, few elderly people, especially women, have earned enough to support themselves in their old age, nor do they have adequate opportunities to continue earning an income.
Along with examining leisure and recreation opportunities among the aged, Nayar decries the living conditions of the poor elderly who live with physical hazards such as slippery floors and stairs without railings and have no privacy in the facilities provided for them.
Regarding social perceptions of the elderly, Nayar decries the negative stereotypes of the elderly which depict them as physically and mentally weak, sickly, dependent and in need of care. She also decries the children's literature which portrays old women as witches and the fact that the elderly themselves hold negative views of ageing.
Under Self-perception of the aged, Nayar summarizes some of the studies which have been done on the values held by the elderly and under Integration of the aged in the family, Nayar describes how in pre-industrial societies, the elderly had a much higher status because they usually controlled the family's resources and were involved in productive activities. She also describes other factors which are straining relations within families such as: the replacement of the traditional joint family by the nuclear family; migration of younger family members in search of work; the rising cost of living; the erosion of human values, and the increasing emphasis on individuality. On a more positive note, Nayar cites studies of families which still hold their elderly members in high esteem.
Under the heading, The community, the state, the workplace and ageing, Nayar describes some of the programmes governments have instituted in both developing and developed countries of Asia and the Pacific and states that payments from state-supported pension and forced savings schemes are often not adequate to support people in their old age. Many elderly, especially women, are not covered because they were not employed in the organized sector. Nayar also expresses concern that in developing countries provisions for the elderly might not be made because they impinge on other welfare programmes, but she concludes that because the elderly are an important resource, their needs should be considered in all welfare programmes and that the corporate sector should also provide more meaningful support for the aged.
In concluding her chapter, Nayar identifies a number of emerging issues pertaining to ageing and social change. These include the unprecedented rapid growth of the elderly population in the Asian region; the need for health care which will help the elderly live disability-free lives; support for the elderly who are left behind in rural areas when younger family members move into cities to find work; the disproportionate number of women in the elderly population, many of whom have no source of income; the difficulties today's smaller families have in caring for elderly family members who can no longer look after themselves; the decline in income-earning opportunities for the elderly, who largely lack the education and skills needed for today's jobs; the increasing isolation of the elderly and the fact that little concern is paid to the rights of the elderly nor to the contributions they have made over their lives.
Nayar also reminds readers that Asian societies are in a good position to improve conditions for the elderly because respect for the elderly is already a deeply embedded value; that since families are still actively supporting their elderly members, it should be feasible for Asia to evolve a pattern of supporting the elderly that combines the best of the West, while drawing from the centuries-old wellsprings of eastern values.
Chapter 3, Productive Ageing, by Tan Poo Chang, is concerned with changing the widely held negative perception of the elderly as dependent and no longer able to contribute to society. In discussing productive ageing, Tan calls on society and elderly persons themselves to recognize the wealth of experience and talents which older people have and to tap their under-utilized resources. Tan states this is important not only on a national level, but also within families and the community, to ensure that the elderly have a place in this rapidly changing society.
After discussing the magnitude of population ageing in Asia and the challenges this will create, especially for more populous countries, Tan emphasizes that Asian countries, especially those with fairly high fertility rates, need to plan early for population ageing. Tan also states that with current economic and social progress, now is a good time to set aside some resources to meet the challenges of population ageing.
Under the heading, Perspectives on productive ageing, Tan defines productive ageing as involvement in both social and economic activities as one grows older and states that the range of activities, including economic ones, need not narrow with age as is presently the case.
To achieve productive ageing, Tan states that each and every person must lay the foundation for old age when they are most able and that productive ageing concerns not only older persons but all groups in society since the quality of life of the elderly affects their families and society at large.
Although advances in medical science make it possible for people to lead a healthy, active and creative life right up to very old age, Tan states this will not be possible unless everyone, young and old alike, push governments to place ageing issues high on the national agenda.
Under Issues of policy concern, Tan stresses that older persons are usually viewed as a burden for the family and the State, and rarely as a valuable resource.
To counteract these negative attitudes which are held by the elderly themselves as well as the whole population, Tan advocates such things as school programmes and public education campaigns aimed at both society at large and the elderly specifically.
To help people prepare for new or continuing roles, Tan advocates continuing education, orientation and counselling. According to Tan, some of the productive roles elderly people could play include helping with household work and child care, inculcating moral and religious values, teaching local history and traditions, resolving intra-family tensions and engaging in various social and economic activities. The elderly can also be effective agents of change by fighting social evils, in seeking a better quality of life for the disadvantaged and in caring for the environment.
Tan strongly advocates raising the present retirement age, which is 55 years in many countries in Asia because he believes this regulation implies that a person is unable to contribute fully after this age. Tan also believes that retiring people so early is a waste of resources, considering the investments in their education and training, and that people who retire at 55 may not have earned enough to provide for their old age.
To help the elderly remain productive, Tan advocates their access to continuing education and training and he emphasizes the importance of combating illiteracy which is much more prevalent among older age groups, especially older women.
Tan also advocates pre-retirement education for older workers which would provide information on the financial aspects of retirement and health, leisure and family life. In addition, Tan believes the elderly need advice on nutrition, a comprehensive counselling service to deal with various psychological problems and stresses, and an information system covering services and facilities required by older persons.
Regarding labour force participation rates, Tan shows that while more elderly work than is the case in the West because of the higher numbers of people working in agriculture and the informal sector, labour force participation of the elderly is expected to fall as the region becomes more developed and urbanized.
Tan also states that labour force statistics do not accurately reflect the actual work done by the older population and they underestimate the actual economic contribution of the elderly. Nor do statistics indicate that much of the work done by older people is part-time and does not provide much income.
Regarding health care, Tan states that because older persons, especially older women, are disproportionately represented among the poor, this has important implications for their nutritional status, access to adequate medical care and their physical well-being.
Tan also states that older women face more health problems, perhaps because they were not encouraged to exercise when young and had little time to do so when they grew up.
Tan believes that the rising cost of health care and the fact that many older persons are unable to support themselves or be supported by family are issues of critical concern which governments must address. Retirement schemes such as provident funds, pensions or insurance payments rarely provide adequate financial security for more than a small percentage of the elderly, and because of massive rural-to-urban migration and changes in family structure, many families find it difficult to care for the elderly. Tan states that elderly women are in an even worse financial position than elderly men because, due to their lower education levels and labour force participation, women are even less likely to have savings or receive benefits in their old age. Women also have less access to property and assets than men.
To improve conditions for the elderly, Tan advocates that all persons in the population become fully aware of ageing issues and concerns so that they make sure the needs of the elderly are considered in development planning. Younger persons must maintain a healthy lifestyle and make provisions for their old age income through various security schemes. Along with public awareness campaigns on ageing issues, Tan advocates programmes for the elderly themselves which focus on three main areas: health maintenance, skills development and income support.
To create an environment that is friendly towards older persons, Tan advocates housing, transportation and services which will enable the elderly to function independently with a high quality of life. He also calls for a central coordinating body to ensure that issues and concerns of the elderly are systematically considered in national policies and programmes and systematic research is undertaken to determine the problems faced by the present cohort of older persons.
To prevent social isolation, Tan advocates the establishment of centres where the elderly can interact with other members of society and make themselves useful, and that the elderly play a prominent role establishing and running such centres.
Tan suggests older persons could also organize gatherings and leisure activities such as travel for themselves, as well as family members and the community. All persons, especially the elderly themselves, should recognize the valuable human resources of the elderly, and government and NGOs should facilitate their active participation in the economy and society.
Not only does Tan believe retirement rules should be relaxed but both government and private agencies should provide lighter work and part-time or flexible work hours for older workers. Older persons should also be given expert advice, credit and assistance to start their own or joint businesses and formal and informal job training programmes. The large percentage of the elderly, particularly women, who have little or no education should have opportunities to increase their knowledge and skills. Training of care providers and other related manpower should also be given a high priority in many national agendas.
Regarding legislation which would support families in caring for the elderly and reduce the government's burden, Tan advocates such things as tax rebates and special housing benefits, and the holding of Family Day and Elderly Day.
Regarding research, Tan states that much more research must take place and that researchers must recognize that the elderly are not a homogeneous group.
In Chapter 4, Caring for the ageing: programmes and services, A.B. Bose provides a broad review of the range of caregivers who currently provide assistance to the elderly. These include informal caregivers such as family, friends and neighbours and formal caregivers such as the State, private sector agencies and NGOs, including trusts, charities, endowments, cooperatives and mutual-help societies. Bose also describes the principle types of assistance provided to the elderly (income security, health care, continuing education, housing and welfare services). He concludes his chapter by making predictions about future patterns of care for the elderly.
In presenting his information, Bose describes the situation in both the developing and developed countries of Asia and he also highlights innovations in programmes and services designed to care for the elderly as well as areas where improvement is needed.
Under the heading, The family as caregivers, Bose enumerates some of the reasons why families, which prior to World War II would never have sought outside care for elderly family members, are now doing so. These include the smaller size of families, an increase in the period for which the elderly require care, the declining influence of parents, and the younger generations' preference for the nuclear family.
However, although it is no longer universal for the elderly to live with family, Bose sites a number of Asian surveys which show that from two-thirds to three-quarters of the elderly still do live with their family, and even when they do not, either because of their own choice or geographical separation, younger members of the family still provide various forms of support.
According to Bose, the choice of caregivers for the elderly depends on such factors as: the magnitude of the problem of providing care and the extent to which informal systems are satisfactory; public perception of the role of the State in providing assistance and services; public debates about whether State assistance will encourage dependency and discourage self-help and private initiatives; the political influence of the elderly and their ability to influence government; the strength of the economy, its stage of development and the resources available for social security and welfare programmes for the elderly, and the availability of NGO and private care agencies.
Bose points out that, although the elderly are care receivers, they also perform useful roles. In households where both parents work outside the home, grandparents provide childcare, affection and guidance for their grandchildren and thus co-residence with the older generation is viewed as an advantage. As a result, at least in the earlier years of old age, there is a two-way flow of services and support.
Under the heading The State as the provider of care, Bose describes the various forms of assistance governments have begun to provide for the elderly, both out of concern for their welfare and because an increasing proportion of the electorate are elderly.
State responses in providing care for the elderly include: framing a national policy on ageing; providing social security benefits; requiring industry to provide retirement benefits; provision of health, housing and welfare services to the elderly, and charging the elderly lower fees for public utilities.
Regarding the private sector as a provider of care for the elderly, Bose notes that in most countries, particularly the developed ones, the private sector's role in operating pension plans, long-term savings and other schemes is expanding with economic prosperity as is the private sector's role in providing care. Private sector care for the elderly ranges from home care, and care in non-institutional settings to institutional care. These cater to those who can afford to pay and clients are often adult children who are working abroad or who cannot provide sick and disabled parents with the level of care required.
Regarding the quality of care provided by private agencies, Bose notes that in developing countries there is often no licensing or inspection mechanism to ensure minimum standards.
Bose also notes that the role of NGOs in providing care for the elderly is growing because they are more flexible in their operations and also have a strong philosophical commitment to providing care. Because NGOs are strong advocates for the elderly, they function as watchdogs in monitoring the quality of government and private sector care. They also identify gaps in services and mobilize public opinion. In countries where NGOs are strong, the government provides them with grants to deliver services to the elderly. Bose notes, however, that geographic distribution of NGOs is uneven.
Other providers of care enumerated by Bose include cooperatives and self-help societies and informal arrangements of friends and neighbours, but the scale of these appears to be small compared with other forms.
Regarding income security, Bose notes that income security measures vary considerably in Asian countries, but over all, few elderly people have an adequate source of income. This is because few elderly people held pensionable jobs during their working years and if countries provide non-contributory pensions or old age allowances, these are not intended to meet the full cost of living. For the more affluent self-employed such as professionals and entrepreneurs, banks, insurance companies and others provide saving schemes and in some countries governments allow contributors to avoid paying tax. Some countries also require citizens to contribute to provident funds (forced savings), but the value of such savings whether private or government, is likely to be significantly eroded by inflation.
Bose also notes that a few governments have recognized the employment needs of the elderly and provide retraining, career guidance and even incentives to employers who hire the elderly. However, in less developed countries, which have a labour surplus, the State is not encouraging the elderly to work.
Under the heading Health care, Bose states that in developed countries programmes now help the elderly maintain their health and physical abilities and care for them when they are ill, but in developing countries, public health services are usually overcrowded and lack funds for equipment, medicine and personnel. Also distances from clinics and hospitals and long cues discourage the elderly from seeking medical care. Bose also notes that although some countries have medical insurance schemes, these usually do not cover preventive health care, personal care, aids or home nursing and they set limits on the care provided for long-term illness and disability.
Bose also discusses the growth in care facilities for the elderly who can afford to pay for services and notes the pressing need for training for family caregivers, and health promotion programmes which educate younger people about preparing for a healthy old age.
Under Continuing education, Bose notes the growth in non-formal programmes designed to educate the people about ageing issues, pre-retirement counselling and educational programmes aimed at educating the elderly themselves.
Regarding the housing needs of the elderly, Bose states that some countries now provide housing for the elderly, protection against eviction or high rent increases and assistance in making house repairs. For the affluent, architects have begun designing buildings and interiors which are "elderly friendly".
Under the heading Welfare Services, Bose states that historically charitable institutions have provided care for the elderly who have no other assistance. However, he notes that studies of voluntary and private sector homes for the elderly have found that the elderly rate these facilities poorly.
Bose also notes that current welfare services emphasise out-reach services for the elderly, either in their own homes or in the homes of family members. These programmes, which are designed to strengthen the capabilities of the elderly, are also more cost-effective and help family to cope with the physical, financial, psycho-social and other demands involved in caring for the elderly.
Regarding future patterns of care, Bose predicts that with the concept of the welfare state losing its appeal and disenchantment with performance of the public sector, there will be mounting pressures for cuts in public spending. At the same time, 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 on means or contributions. The State may also promote, and increasingly require, that industry provide pensions, provident funds and other retirement benefits for workers. Bose suggest the state could also provide tax incentives to stimulate the growth of privately-sponsored pension schemes, long-term savings schemes and annuities, and lay down norms and minimum requirements to protect investors.
Bose also advocates greater State support for health care through health insurance schemes, hospital and nursing care facilities, and provision of services to the chronically-ill so that economically-disadvantaged groups can benefit.
Bose believes private sector participation in care services is likely to increase in the areas of pension funds, long-term savings instruments, health insurance, and various forms of health care, residential care, welfare and other services. This will occur because of rising demand for better services and increasing capacity to pay, due to greater economic prosperity. Health and nursing care are likely to see the maximum private sector growth, but here again expansion will take place along with the State's own services.
Bose states that industry also needs to consider how best to support the care responsibilities that workers (especially women workers) have towards dependent parents. Flexible work hours, subsidies for care expenses, counselling, and financial help in meeting health insurance and health care costs are some of the types of assistance Bose suggests industry could provide.
In Chapter 5, Ageing issues and the national agenda, Nelson Chow begins by expressing concern that because population ageing is happening much faster in Asia than has occurred in the West, Asian countries have much less time to prepare for this dramatic change. Not only will this pose difficulties for the establishment of measures such as pension schemes, which usually need many years to mature and take effect, but it also means that the ageing problems which Asian countries have to tackle, as well as the solutions needed, may not be the same as those found in Western industrially-advanced countries.
Chow states that the first problem posed by population ageing is usually the increasing demand for social services, especially health care. Also, with population ageing, the working population is likely to decline, and consumption patterns will change from a concentration on goods and services consumed by the young, to goods and services needed by the elderly.
In developing national policies and programmes on population ageing, Chow exhorts governments to be sensitive to the social and economic features of population ageing in Asia, which he believes are very different from the West. These include the fact that the majority of the region's elderly grew up, and in many cases still live, in rural areas and consequently have a much weaker support network than that enjoyed by their ancestors. Also, because of the wider age gap between husbands and wives in Asia and women's tendency to live longer, Asian countries will have an even higher percentage of elderly widows living alone than is the case in western countries. In addition, the elderly in Asia, especially elderly women, have had little or no education, which means that few elderly men and women are qualified for today's jobs. As a consequence, Chow states, a substantial proportion of the elderly in most Asian countries are likely to be lonely and living in poverty.
Chow also states that policies concerning the aged must take in to account the high level of respect paid to the elderly, the fact that families are expected to support their elderly members and that it is generally believed that families provide the best care for the elderly. Thus, in formulating policies concerning the elderly, Chow believes governments should attempt to preserve the family's traditional role as caregivers for the elderly but provide the support services and programmes families need for this role.
According to Chow, most countries and territories in the region have formulated policies to promote the welfare of the elderly, and without exception, these policies emphasise that responsibility for caring for the aged rests with families, and the government's role is only to assist.
Under the heading Social Security, Chow states that compared to the western industrialised countries, social security in the Asian region is still rather underdeveloped. Retirement pensions are only available for a small number of people, and although provident funds are rather inefficient, Chow states these are the most congruent with Asian values which emphasise individual and family responsibilities.
Chow favours state assistance programmes for the elderly and the creation of employment opportunities for older persons to prevent their early and unnecessary financial dependence on their families.
Regarding health care, Chow cites a WHO expert's recommendation that emphasis should be placed upon prevention, health promotion and health maintenance. Chow also favours community-based programmes which emphasise the participation of the elderly themselves in managing programmes.
Chow states that in Asia, as long as most children still perceive it as their duty to care for their elderly parents, and the elderly prefer to live in the community, more effort should be made to develop community-based programmes suited to the needs of this region.
To enhance the welfare of the elderly, Chow states they must be empowered to protect their own rights and interests. As the first generation to have grown up in a modern industrial society, the elderly find it difficult to adjust to the changes which have rendered their experience less valuable and lowered their status. To empower the elderly, Chows recommends assisting them to overcome their loss of status and prepare for new roles and challenges. Chows also states that attention must be paid to correcting the subordinate position of elderly women by ensuring that they have equal access to community resources and that society recognises their important contributions as caregivers. Lastly, elderly people in Asia must understand that they themselves are in the best position to protect their own interests and they must come together to fight for their rights.
To bring ageing issues higher up on the national agenda, Chow believes a more comprehensive approach is necessary and he supports The Vienna International Plan of Action on the Ageing which states, as one of its principles, that "The ageing should be active participants in the formulation and implementation of policies, including those especially affecting them". Chow also states that to enhance the involvement of the elderly, they must be involved in different kinds of community activities and at different levels. Once the elderly have learned to make their voices heard and form organised groups, Chow believes they will be in a better position to participate in government decision-making processes. Chow states that governments must adopt a proactive attitude towards population ageing and regard the welfare of their senior citizens as important as that of other members of society. Only then will the needs of the elderly be met.
In Chapter 6, Women in an ageing society, Keiko Higuchi is concerned with the problems faced by elderly women, who in most countries significantly outnumber elderly men because women live longer than men. Using data from her own country, Japan, Higuchi demonstrates that women, because of their lower status, are prone to serious economic, social, family, and above all, health problems.
In describing the family relations of elderly women in Japan, Higuchi notes that of women over 65 years of age, 15.4 per cent live alone (one out of every 6.5 women). In contrast, 5.4 per cent of men of the same age group live alone, or one out of 18.5 persons.
Because women face a greater possibility of being the last surviving member of their household in nuclear families, they have difficulty obtaining care when they become weak and consequently are more likely to spend their final years in care-providing facilities. Thus, 70 per cent of presently-institutionalized elderly people are women.
Higuchi states that the greatest health problems of the elderly are the development of dementia and disabilities which make them bedridden, and because women outnumber men in the older age groups, 60 per cent of the elderly with dementia, and 57.6 per cent of those who are bedridden, are women. Thus, Higuchi advocates more research be conducted into diseases which affect elderly women such as rheumatism and osteoporosis.
Under the heading Elderly Women's Sexuality, Higuchi expresses concern that the sexual needs of elderly women are not recognized and that their dignity may not be respected if they require assistance in bathing and excreting.
In considering the morale of elderly women, Higuchi explains that women born in the 1920s and 1930s, who grew up in an era when Japanese women were trained to serve and sacrifice themselves for men, are very different from women born in later years. Higuchi believes it is the self-sacrificing attitude of Japanese women over 75 which makes their rate of suicide second only to Hungary. In order to prevent suicides of older women, Higuchi advocates training females from early childhood to develop their mental independence and prepare themselves to live alone.
In discussing the economic status of elderly women, Higuchi states that the greatest issue is the poverty of elderly women. Because few of today's elderly women ever held jobs, they never had a chance to participate in a pension scheme. Although some women have contributed to the national pension scheme as wives of working men, the benefits they will receive are much lower than those paid by employee pension schemes. Higuchi also states that women who could participate in the national pension scheme sometimes do not because divorce or failure of their husband's business means they cannot afford to make payments. Women also forget to make their payments.
Considering the housing situation, Higuchi states that when their husbands die, elderly women are often forced to sell the family home to provide their children with their share of the inheritance, and/or to pay the inheritance tax. If elderly women manage to keep their homes, they often have difficulty maintaining them. Elderly men, on the other hand, are more likely to go on living in their homes.
Regarding employment opportunities for elderly women, Higuchi, states that there are few opportunities for either sex compared with younger workers and that earnings of elderly men and women are not equal. With little chance for employment, women have less chance of accumulating assets. Although the wives of farmers and self-employed workers often contribute to asset formation, their contributions are not recognized when their husbands die and they do not receive a fair share of family assets.
In the second major section of her chapter, which considers women's role as caretakers of the elderly, Higuchi notes that the burden of caring for the elderly is largely borne by women. In caring for their elderly parents, women are not only prevented from earning an income which will help support them in their own old age, their health may also be damaged by the fatigue of caretaking. Although some men are now helping to look after wives who require care, the family member most likely to provide care is the wife of a son. In some cases wives are unable to move with their husbands because of obligations to care for elderly in-laws.
To reduce the unequal burden falling on women, Higuchi recommends that care for the elderly be shared equally between male and female members and also that families seek outside help when necessary.
Higuchi also advocates "elderly care leave", but cautions that unless this is provided to both sexes, responsibility for elderly care will continue to be placed on women's shoulders and reduce women's opportunity to earn money for their own old age.
Higuchi decries the low status and low wages accorded to those who provide care for the elderly (the majority of whom are women). In Japanese hospitals, 97 per cent of nurses are women, 100 per cent of assistants are women and 98 per cent of workers in homes for the elderly are women.
To improve conditions for women care workers, Higuchi advocates that they be consulted in the planning of welfare services and that more women run for public office in order to influence policy decisions.
Under the heading Gender roles and the ageing society, Higuchi recommends not only helping women to overcome their dependence on men, but also helping men to develop the skills needed to look after themselves and provide care to other family members. If men and women are enabled to break free of traditional gender roles not only will the individuals concerned benefit, but so will society since the elderly will be able to do more for themselves and rely less on special services provided from outside.
Chapter 7, by Paul Cheung, Non-governmental response to ageing issues, begins by reminding readers that the voluntary sector has a long history in caring for the old. Although the State, and lately the private sector, have become more active in the provision of social services for the elderly, NGOs still predominate. Also Cheung states that as the demand for services for the elderly has increased, a new group of NGOs, managed by welfare professionals, has emerged.
Cheung describes NGO work with the elderly in four sections: first, the divergent activities of NGOs are identified and described; second, the relationships of NGOs with the State and the private sector are discussed; third, the strengths, gaps and weaknesses of voluntary services are examined, and; fourth, future scenarios for NGOs are described.
In the first section, Cheung states that providing homes for the elderly is the most common and traditional service performed by NGOs, and that in recent years NGOs have started to provide nursing care for people who require long-term medical care or who are terminally ill. In providing these more demanding forms of care, Cheung states that NGOs lack both the expertise and the financial resources.
NGOs also run day care centres, social visit programmes, counselling services and other befriending schemes for the elderly. While historically such activities were organised by churches, temples, clans, ethnic or work-based associations, more recently, professionally-run day care programmes have sprung up in some Asian countries.
In addition, NGOs offer rehabilitative and day nursing services for the elderly who are recuperating from illnesses or corrective surgery at home. However, in the developing regions of Asia, these are still in short supply, especially in the rural areas.
Some NGOs provide financial assistance to the aged poor as well as free meals or clothes because assistance provided by the State is generally inadequate. However, most NGOs see direct financial assistance as the responsibility of the State.
Other services provided by NGOs include suicide prevention programmes, care for the terminally ill, community-watch for those elderly living alone, and special medical counselling for those with degenerative ailments. But because these services are expensive and require professional expertise, they are usually small in scale or experimental in nature.
Although research concerning the needs of the elderly, public education about population ageing and training for those working with elderly and for the elderly themselves is needed, Cheung states these are still in the developmental stage.
While a few NGOs in Asia are actively lobbying for policy change on behalf of the elderly, in most developing countries, the welfare of the elderly receives very low priority in resource allocation because care for the elderly is considered a family responsibility. In affluent countries, governments are concerned that welfare-oriented policies will lead to budget deficits as has happened in the West.
Despite these concerns, Cheung states governments are recognising that the welfare needs of the elderly have grown beyond the resources of the family and are financing more assistance for the elderly in partnership with NGOs. This approach allows governments to demonstrate their involvement, while keeping costs down. It has also been argued that NGOs provide higher quality services than government.
The development of specialised rehabilitative and other services by NGOs, however, is slow, because, while most governments are keen to assist NGOs in providing residential care, they show great reluctance in supporting newer types of services.
Although the State and the private sector are involved in care for the elderly in Asia, Cheung states that NGOs, the State and the private sector are not three distinct choices for services. The State relies on the NGOs to provide services which effectively removes the State as a service provider and the private sector has yet to mature because their services are expensive and still socially unacceptable. In the end, services offered by NGOs are often the only choice available, and where these are not available, the elderly must rely on family and neighbours.
Regarding the strengths and weaknesses of NGO services, Cheung states that while NGO staff are usually motivated in their work, their working conditions and wages are generally poor. Raising salaries is not possible because funding is always limited. Also, NGO staff are often inadequately trained for working with elderly. Medical and social work schools have only just started teaching about geriatrics, and opportunities for continuing education for those already working with the elderly are few.
Regarding fund raising, Cheung states that raising funds for the disabled is generally easier, perhaps due to the perception that the elderly do not really need any assistance, and if they do, the family should provide it. NGOs thus need to educate the community that without financial contributions, service levels and standards will decline.
To provide a comprehensive range of care to the elderly, Cheung recommends networking between hospitals and community service agencies, so that continuity of after-care services can be provided.
Cheung also comments on the need for NGOs to provide services to the elderly living in rural areas who constitute the majority of the elderly in most countries, and whose needs are largely unmet.
Regarding the future, Cheung suggests that NGOs will be affected by three factors. First is the increasing affluence of the elderly which means they will be more discerning about the services they receive and this could stimulate private sector competition for NGOs. Also, as the educational level of the elderly rises, NGOs will have to revise their programmes and services to keep up with the changing tastes and lifestyles of the elderly. Second, with family size decreasing in future, members migrating to find work and women seeking employment outside the home, Cheung believes NGOs will have a greater role to play in caring for the elderly, especially if the elderly are frail or bed-ridden. Third, if NGOs provide more services in future to the elderly, the State is likely to impose stricter service standards.
In conclusion, Cheung states that the role of NGOs in providing services to the elderly in Asia can be expected to grow rapidly in the future as family support declines and government financing for NGOs increases, and that programmes and services offered by NGOs are likely to become more diversified and specialised.
In Chapter 8, Over to the next century: continuities and discontinuities, Graeme Hugo focuses attention on the future of ageing in Asia. The first section of the chapter charts the major changes which are likely to occur in the elderly population up to the year 2050. This provides background for a discussion of the social, economic, political and welfare issues which are likely to emerge over this period. The chapter then addresses implications which arise from these issues, including economic development and social change in the countries of the region as well as the well-being of the elderly population and their families. Policy implications are considered in the final part of the chapter.
Under the heading Asia's changing elderly population, Hugo notes that although the aged population of Asia in 2050 will be almost five times larger than that in 1995, there are huge differences between Asian nations not only in their contemporary ageing situation, but also in the projected trajectory of change over the next half century. The lowest rate of growth, for example, is anticipated to occur in Japan where the aged population will increase by 88 per cent between 1995 and 2050. At the other extreme, Pakistan's elderly population is anticipated to increase by more than 8 times over the same period.
Hugo also shows that the so-called 'old-old' will grow at a faster rate than the elderly population as a whole and because the "young-old" and the "old-old" can differ sharply in their labour force participation rates, health care utilisation, and needs for family and other support, it is important for policy makers to accurately estimate the numbers of each group. In 1995, 58.8 per cent of all older Asians were aged over 75, but by 2050, 68.5 per cent will be among the old-old.
Under the heading, Changing characteristics of Asia's aged population, Hugo stresses that the elderly of the future will not have the same needs as the elderly of today because each generation of older people has a distinctive composition as a result of the circumstances that prevailed when the cohort or generation was passing through crucial life stages. For example, the people who reached school-age during the post-war expansion of education have much higher levels of education than people born earlier and thus may be better equipped to deal with the problems of old age.
In discussing the predominance of women among the elderly, which is even greater in older age groups, and will increase in future, Hugo demonstrates that this too varies across Asia.
According to Hugo the spatial distribution of the elderly will also change in future. While the majority of elderly now live with or near their children, this will change as young working-age populations move from rural to urban areas and urban people return to rural areas on retirement.
Increasing formalisation of urban economies may mean that the elderly who are less educated and physically strong, will not be able to compete for work as they could in the past when the informal sector was dominant. If elderly people have to continue working to support themselves, this change may lead to a decline in their well-being.
Lack of housing in urban areas may also make it difficult for elderly people to live with their children, and women's increasing participation in the workforce may interfere with looking after the elderly.
Future generations of the elderly, who will have higher levels of education, are more likely to have pensions to support themselves, but also may be restricted from working in old age by compulsory retirement rules.
With the elderly of the future living to older ages, the incidence of illness among the elderly will likely increase and with it the pressure on the health systems of Asian countries. The incidence of mental illness and dementia are also likely to increase.
Under the heading, Changing levels of dependency and inter-generational relationships, Hugo points out that ageing does not mean the total burden of dependence will necessarily increase. The massive declines in fertility across Asia have seen the youth dependency ratio fall from a peak of 72.8 in 1965 to 51.1 in 1995.
Hugo states that in future, the traditional family structure may not be so strong and it would be a great mistake for policy makers to assume that the major economic and social changes transforming Asian countries will leave traditional family structures and functions untouched.
In the section Changing concerns and issues, Hugo reminds readers that while Asia has been the world's fastest growing economic region over the last decade, and this growth is likely to continue into the next century, poverty will continue to be a significant barrier to policy development and programme implementation in caring for the aged.
In considering the impact of economic and social development on the future well-being of the elderly, Hugo describes three schools of thought. The first suggests that the status of the elderly declines as economic development proceeds. This occurs as a result of trapping the elderly in traditional and less well-paid jobs, separating them from families, depriving them of meaningful roles and in general lowering their status in relation to younger groups.
A second school believes that as informal and family-based systems are weakened by social and economic change, they are gradually replaced by those provided by the State.
The third model rejects the notion that there is a massive withdrawal of family support from the elderly as modernisation and urbanisation proceeds. This model suggests that the decline in family support with development has been exaggerated and that in most more-developed countries, family support for the aged has been maintained. If the elderly do not live with their children and grandchildren, this is by choice. In considering the three models, Hugo suggests that different models may apply in different Asian countries over the next few decades due to differences in the cultural context, as well as the pace and nature of economic development.
In future, Hugo states, government and agencies other than the family will need to be involved in the care of the elderly if their well-being is to be maintained. Some of the elements involved in achieving this include: providing support where no family support is available; and providing support which backs up and encourages family and community-based support systems.
Hugo states that for many countries in Asia, it will not be feasible to mount social security systems such as those operating in many European countries because few Asian governments have the resources for this. In Asia, the challenge lies in finding new and innovative ways to foster traditional family and community-based support structures which themselves are undergoing change.
Hugo also states it is important to recognise that the aged can and do have a productive and significant role to play in the development of the family, the community and the nation's resources, although negative stereotypes of the elderly mean such roles are often overlooked.
Regarding new roles for the elderly, Hugo suggests they take over community maintenance activities which were formerly conducted by younger adults. Also 'the young-old' could take up some of the community-based care activities focused on the 'old-old' and undertake preservation and transmission of the traditional culture. However Hugo warns that the elderly must not be seen as a source of unpaid labour.
Regarding the changing roles of institutions, Hugo states that although the proportion of workers covered by conventional social security schemes will increase in Asian countries over the next few decades, innovative approaches are needed to bring coverage to the large numbers of informal sector and agricultural workers.
At present, health systems in many countries emphasize improving child survival, but in future they will need to provide appropriate services to deal with the increasing incidence of chronic illnesses of the aged.
Initiatives will also be needed to increase the proportion of the total population who are economically active through increasing female labour force participation, abolishing compulsory retirement ages, and encouraging part- or full-time work among the 'young-old'.
As in Western countries, aged care policy needs to shift from seeing the elderly as totally dependent toward policies which facilitate the elderly to stay independent as long as possible and which foster mutual self-help. Not only are such policies less costly, but they are also more acceptable to the elderly themselves.
Hugo states that while there are many examples of successful community-based programmes for the aged, these will need to be modified to suit different cultures. He also advocates more research into the local context of ageing in the least developed countries (LDCs) of the Asia-Pacific region.
Hugo advocates that non-governmental organisations, which have been crucial in delivering aged care in the more developed countries, play a major role in Asia because NGOs are often more able to operate effectively at the crucial community level than are government organisations.
In his conclusion, Hugo emphasizes that the initiation of effective aged care policies demands lead time, since many depend on initiatives which must be taken by individuals themselves before they grow old. Also programmes and policies are more likely to be efficient and effective if they are developed before the real 'crunch' of ageing comes in the early decades of the next century. In addition, Hugo believes that the well-being of the elderly in Asia will only be assured if there is a tripartite commitment and involvement by the government, the family and the local community and, most important, by the elderly themselves.