the well-being of the elderly in asia: a four-country
TRANSCRIPT
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The well-being of the elderly in Asia : a four-country comparativestudy / Albert I. Hermalin, editor.Ann Arbor : University of Michigan Press, c2002.
http://hdl.handle.net/2027/mdp.39015060636282
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The Well-Being of the Elderly in Asia
^e-.
A Four-Country Comparative Study
Albert I. Hermalin, Editor
Ann Arbor
THE UNIVERSITY OF MICHIGAN PRESS
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Copyright © by the University of Michigan 2002
All rights reserved
Published in the United States of America by
The University of Michigan Press
Manufactured in the United States of America
© Printed on acid-free paper
2005 2004 2003 2002 4321
No part of this publication may be reproduced,
stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, or otherwise,
without the written permission of the publisher.
A CIP catalog record for this book is available from
the British Library.
US CIP data applied for.
ISBN 0-472-11280-5
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Contents
List of Figures ix
List of Tables xi
Authors KJX
Preface xxi
1 Aging in Asia: Facing the Crossroads 1
Albert I. Hermalin andLora G Myers
The Source and Nature of the Challenges 3
Demographic Responses and Their Limitations 6
Non-Demographic Responses 12
Goals of the Volume 15
Tools and Perspectives 17
History of the Project, Data Collected, and Other Products 18
Impact 21
2 The Demographic, Socioeconomic, and Cultural Context
of the Four Study Countries 25
John Knodel, Mary Beth Ofstedal, and Albert I. Hermalin
Population Aging and Sociodemographic Change in
World Context 26
Demographic, Socioeconomic, and Cultural Context of the
Four Study Countries 35
Political and Cultural Setting 36
Demographic Change 44
Socioeconomic Change 49
Changing Characteristics of the Elderly 52
Demographic and Social Characteristics of the
Sample Elderly 54
Conclusions 59
3 Policies and Programs in Place and under Development 65
Mary Beth Ofstedal, Angelique Chan, Napaporn Chayovan,
Yi-Li Chuang, Aurora Perez, Kalyani Mehta, and Albert I. Hermalin
Social Security Retirement Programs 68
Health Care Programs 75
Other Programs and Policies Targeted to the Older Population 85
Conclusions 94
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vi Contents
4 Theoretical Perspectives, Measurement Issues, and
Related Research 101
Albert I. Hermalin
The Demography of Aging 101
Related Disciplines and Their Perspectives 104
The Conceptual Framework 107
Societal Changes and Their Impact on the Elderly 110
The Effect of Population Aging on Economic Development 114
Asian Interests in Research on Aging 119
Measuring and Understanding Living Arrangements 122
Identifying and Measuring Intergenerational Support
Dimensions 123
Measuring Work and Leisure 128
The Economic Status of the Elderly 129
Health Status and Health Care Utilization 130
Vulnerable Groups and Their Levels of Disadvantage 131
Cross-Cutting Issues, Transitions, and Policy
Recommendations 132
5 Patterns and Determinants of Living Arrangements 143
John Knodel and Mary Beth Ofstedal
Measurement Issues 144
Trends in Coresidence 147
General Patterns of Household Composition 149
Coresidence in Relation to Children's Gender and Marital Status 154
Determinants of Living Arrangements 162
Multivariate Results 170
Conclusions 179
6 Intergenerational Support and Transfers 185
Ann Biddlecom, Napaporn Chayovan, and Mary Beth Ofstedal
Measurement Issues 187
Background 190
Norms and Attitudes about Family Support 194
Availability of Children and Social Contact 196
Current Flows of Intergenerational Support 197
Conclusions 219
7 Work, Retirement, and Leisure 231
Albert I. Hermalin, Angelique Chan, Ann Biddlecom, and
Mary Beth Ofstedal
Trend and Levels of Labor Force Participation 237
Modeling the Retirement Process 247
Correlates of Labor Force Participation 251
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Contents vii
Attitudes and Preferences Related to Work and Retirement 265
Leisure Activities of the Elderly 275
Conclusions 283
8 Economic Well-Being: Insights from Multiple Measures
of Income and Assets 295
Albert I. Hermalin, Ming-Cheng Chang, and Carol Roan
Measurement Issues Related to Economic Well-Being 296
Levels of Income in Absolute and Relative Terms 301
Major Sources of Income 306
Factors Affecting Levels of Income 308
Household Income and Indirect Sources of Support 319
Subjective Measures of Economic Well-Being 324
Assets and Home Ownership 327
Changes in Economic Well-Being over Time 344
Conclusions 348
9 Physical and Mental Health of the Elderly 361
Zachary Zimmer, Josefina N. Natividad, Mary Beth Ofstedal,
and Hui-Sheng Lin
Methodological Issues 362
Health Risk Behaviors 366
Physical Health 371
Emotional and Cognitive Health 385
Self-Assessed Health 388
Conclusions 398
10 Patterns of Health Care Utilization 413
Mary Beth Ofstedal and Josefina N. Natividad
Health Insurance Coverage 417
Health-Seeking Behaviors 425
Use of Specific Medical Services 429
Unmet Need for Health Services 450
Conclusions 455
11 The Vulnerable and Their Potential Disadvantages 461
Albert I. Hermalin, Mary Beth Ofstedal, and Kalyani Mehta
Methods and Measurement Issues 462
Research Findings 469
Cross-Country Profiles of Relative Risks 486
Multivariate Results 492
Summary of Disadvantages Faced by the Sociodemographic
Groups 499
Policy and Programmatic Implications 503
Conclusions 508
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viii Contents
12 Capturing Change: Transitions at Older Ages and
Cohort Succession 519
Albert I. Hermalin
Cohort Succession and Its Implications for Population Aging 521
Transitions over the Later Life Course 532
Conclusions 539
13 Making the Choices: Policies and Research for the
Coming Years 543
Albert I. Hermalin
Major Findings and Their Implications 544
Anticipating the Future: Demographic, Social, and Economic
Trends and Their Interconnections 555
Policy Strategies in an Uncertain World 563
Developing a Research Agenda 574
Looking Backward and Looking Forward 577
Appendix A: Survey Design Information and Methodological Notes 583
Appendix B: Guide to Archived Data 590
Appendix C: Project-Related Publications 592
Index 599
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Figures
1.1. Factors Affecting the Weil-Being of the Older Population,
Policy Developments, and Their Interrelationships 7
4.1. Conceptual Framework of Factors Affecting Well-Being of
the Elderly and Others, and Policy Formation 108
7.1. Labor Force Participation Rates for the Philippines, Thailand,
Taiwan, and Singapore: 1970-1990 238
7.2. Percent of Older Males and Females in Labor Force, by Age
and Country: 1980s and 1995-1996 242
8.1. Interrelationships among Various Dimensions of Economic
Well-Being 300
8.2. Ratio of Mean Income in Sociodemographic Groups to
Overall Mean Income, by Country 312
8.3. Sufficiency of Income for the Cohort 60 and Older, 1989
and 1996 346
8.4. Distribution of Sufficiency of Income in 1996 by Level of
Sufficiency in 1989 347
10.1 Determinants of Health Services Utilization 415
11.1A. Philippines: Relative Risks of Economic Disadvantages
for Sociodemographic Groups 471
11. IB. Philippines: Relative Risks of Health Disadvantages
for Sociodemographic Groups 472
11.1C. Philippines: Relative Risks of Social Disadvantages for
Sociodemographic Groups 473
11.2 A. Thailand: Relative Risks of Economic Disadvantages for
Sociodemographic Groups 475
11.2B. Thailand: Relative Risks of Health Disadvantages for
Sociodemographic Groups 477
11.2C. Thailand: Relative Risks of Social Disadvantages for
Sociodemographic Groups 478
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x Figures
11.3 A. Taiwan: Relative Risks of Economic Disadvantages for
Sociodemographic Groups 480
11. 3B. Taiwan: Relative Risks of Health Disadvantages for
Sociodemographic Groups 481
11.3C. Taiwan: Relative Risks of Social Disadvantages for
Sociodemographic Groups 482
11.4A. Singapore: Relative Risks of Economic Disadvantages for
Sociodemographic Groups 483
11.4B. Singapore: Relative Risks of Health Disadvantages for
Sociodemographic Groups 484
11.4C. Singapore: Relative Risks of Social Disadvantages for
Sociodemographic Groups 485
11.5. Average Relative Risks Associated with Each Dimension of
Disadvantage, by Sociodemographic Group and Country 489
12.1. Proportion of Adult Males with at Least a Secondary
Education, by Birth Cohort and Country 525
12.2. Proportion of Adult Females with at Least a Secondary
Education, by Birth Cohort and Country 526
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Tables
2.1. Fertility, Mortality, and Percentage of Population 60
and Older in Selected Asian Countries, 1965 to 2030 27
2.2. Measures of Population Aging in the United States,
Europe, East Asia, and Southeast Asia, 1975, 1995, 2030 30
2.3. Dependency Ratios in the United States, Europe, and
Subregions of Asia, 1965, 1995, and 2030 34
2.4. Demographic Trends and Projections by Country:
1950-2030 46
2.5. Key Social and Economic Indicators, 1970-95 51
2.6. Demographic and Socioeconomic Indicators of the
Population Aged 60 and Over, by Gender, 1970-90 53
2.7. Basic Characteristics of Survey Respondents by Gender:
Philippines, Thailand, Taiwan, and Singapore 55
2.8. Basic Characteristics of Survey Respondents by Age:
Philippines, Thailand, Taiwan, and Singapore 57
2.9. Percent of Respondents with Various Types of Living Kin 59
3.1. Social Security Retirement Programs 70
3.2. Health Care Programs 78
4.1. Outline of Intergenerational Support System 127
5.1. Trends in Household Composition among Those Age 60
or Over 148
5.2. Percent of Elderly Living with Specific Types of
Household Members 151
5.3. Percent Distribution According to Household Composition 153
5.4. Percent Distribution by Number of Generations and
Generational Composition 154
5.5. Coresidence with Sons and Daughters Conditioned on
Availability 155
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xii Tables
5.6. Percent Coresident among Elderly Whose Children Are
All Married, by Sex Composition of Children 157
5.7. Percent Distribution of Elderly Parents According to
Location and Contact with Children, among Those with
Any Living Children 160
5.8. Mean Number of Living Children by Sex and Marital
Status of Children and Respondent's Place of Residence 161
5.9. Percent Living Alone (among unmarried) or with Spouse
Only (among married), by Selected Sociodemographic
Characteristics 165
5.10. Percent Living with Adult Children, Conditional on
Availability of Child, by Marital Status of Child and
Selected Sociodemographic Characteristics of Respondents 168
5.11. Odds-Ratios for the Effects of Sociodemographic and Health
Characteristics on Living Alone or with Spouse Only: Results
from Pooled Logistic Regression Models 172
5.12. Odds-Ratios for the Effects of Sociodemographic and Health
Characteristics on Living with Unmarried and Married
Children: Results from Pooled Logistic Regression Models 176
6.1. Percent Distribution of Weekly Visits between Parents and
Children among Elderly Adults with at Least One Non-
Coresident Child 198
6.2. Percent Distribution of Money and Material Transfers
Involving Older Adults 199
6.3. Percent of Older Persons Receiving Money and Material
Goods from Another Person, by Age, Gender, Marital Status,
Place of Residence, Education, and Living Arrangements 200
6.4. Percent Receiving Money and Material Goods from Another
Person, by Provider Type and Number 203
6.5. Percent of Older Persons Providing Money and Material
Goods to Another Person, by Age, Gender, Marital Status,
Place of Residence, Education, and Living Arrangements 206
6.6. Percent Providing Money and Material Goods to Another
Person, by Recipient Type and Number 208
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Tables xiii
6.7. Percent Distribution (of those with grandchildren)
Providing Child Care for Grandchildren 209
6.8. Amount of Money Transfers Older Persons Received and
Provided in the Year Prior to Survey Interview 211
6.9. Odds-Ratios for the Effects of Sociodemographic, Health,
and Family Structure Factors on Directional Flow of
Money Transfers 214
6.10. Odds-Ratios for the Effects of Sociodemographic, Health,
and Family Structure Factors on Directional Flow of
Material Transfers 218
7.1. Percentage Distribution of Type of Current or Past Employ
ment (if not currently working), by Gender, Age and Place
of Residence 234
7.2. Percent Currently in Labor Force, by Age and Gender 240
7.3. Current Economic Activity (in percent), by Gender, Age
and Place of Residence 244
7.4. Job Characteristics by Gender, Country, and Work
Status for Adults Age 60 Years and Older 248
7.5. Distributions (and mean values) of Independent Variables
by Gender, Retirement Status, and Country 254
7.6. Odds-Ratios from Logistic Regression Coefficients for
the Effects of Demographic, Socioeconomic, Health and
Family Characteristics on Retirement, among Males Who
Ever Worked 258
7.7. Odds-Ratios from Logistic Regression Coefficients for the
Effects of Demographic, Socioeconomic, Health and
Family Characteristics on Retirement, among Females
Who Ever Worked 260
7.8. Odds-Ratios from Pooled Logistic Regressions for the
Effects of Country and Demographic, Socioeconomic,
Health and Family Characteristics on Retirement, by
Urban-Rural and Gender 263
7.9. Predicted Probabilities of Retirement by Urban-Rural
Residence, Gender, Pension Status and Country 265
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xiv Tables
7.10. Main Reason for Stopping Work, among Persons Who
Ever Worked but Are Not Currently Working 266
7.11. Percent Distribution of Reasons Given for Retirement by
Those Not Working, Mid-1980s vs. Mid-1990s 269
7.12. Percent Distribution of Opinions about Stopping Work in
Old Age among Adults 64 Years and Older 272
7.13. Percentage of Adults Age 60 Years and Older Engaged in
Leisure Activities by Work Status, Gender, Age, and Self-
Reported Health Status 277
8.1. Mean, Median, and Percentage Distribution of Yearly
Income by Economic Unit: Philippines, Thailand,
Taiwan, and Singapore 302
8.2A. Mean and Median Income in Local Currency and $US
and National Income Measures: Philippines, Thailand,
Taiwan, and Singapore 305
8.2B. Income Indexes and Ratios: Philippines, Thailand,
Taiwan, and Singapore 305
8.3. Major Source of Income: Percentage Reporting Each
Source by Type of Economic Unit and Country 307
8.4. Ratio of Mean/Median Income in Sociodemographic
Groups to Overall Mean/Median Income, by Country 310
8.5. Percent of Respondents in Bottom Income Tier by
Sociodemographic Characteristics and Country 316
8.6. Odds-Ratios for the Effects of Sociodemographic
Characteristics on Being in the Bottom Tier of the
Income Distribution, by Country 317
8.7A. Percent Who Have Others Pay for All or Some of Their
Household Expenses (indirect support) by Type of
Economic Unit and Living Arrangement 321
8.7B. Ratios of Those in Lowest Income Tier Receiving Indirect
Support to All Economic Units in Same Living Arrangement 321
8.8A. Data on Income of Households and Financial Arrangements
of Elderly Units, by Country 323
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Tables xv
8.8B. Income and Structure of Household for Those Living with
Others 323
8.8C. Additional Details on Pooling Arrangements for Economic
Units Living with Others 325
8.9A. Distribution of Sufficiency of Income: Philippines,
Taiwan, and Singapore 327
8.9B. Percent Experiencing Some or Considerable Difficulty by
Living Arrangement, Receipt of Indirect Support and
Type of Economic Unit: Philippines, Taiwan, and Singapore 328
8.9C. Distribution of Satisfaction with Current Economic
Situation by Income Position, Type of Economic Unit and
Living Arrangement: Thailand and Taiwan 329
8.10. Percent of Elderly Units Owning Various Types of Assets,
by Country 331
8.11. Percentage Distribution of Home Ownership of Elderly
Residence by Sociodemographic Characteristic and Country 336
8.12. Median House Value for Respondents or Couples Who
Own Their Home by Sociodemographic Characteristic
and Country 342
8.13. Percentage Distribution of Major Sources of Income
in 1996 by Major Source in 1989 345
App. Unweighted Sample Size and Percent Missing Income, by
8A. Sociodemographic Characteristics Used in Table 8.5 355
App. Alternate Specifications of Factors Affecting Being in the
8B. Bottom Tier of the Income Distribution. Panel A: Odds-
Ratios for the Effects of Demographic, Socioeconomic
Characteristics and Health Status. Panel B: Odds-Ratios
for Reduced Models 357
9.1. Percent Currently Engaging in Health Risk Behaviors,
by Selected Sociodemographic Characteristics 368
9.2. Percent Reporting Selected Chronic Conditions, by Age
and Gender 373
9.3 A. Percent with One or More Life-threatening Condition, by
Selected Sociodemographic Characteristics (age standardized) 380
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xvi Tables
9.3B. Percent with One or More Debilitating Condition, by Selected
Sociodemographic Characteristics (age standardized) 381
9.4. Percent Reporting Difficulty Performing Selected Activities
of Daily Living (ADL), by Age and Gender 382
9.5. Percent Reporting Difficulty Performing One or More ADL,
by Selected Sociodemographic Characteristics
(age standardized) 385
9.6. Ratio of Mean Scores on Indicators of Depression and
Loneliness, by Selected Sociodemographic Characteristics 386
9.7. Ratio of Mean Cognition Scores, by Selected Sociodemo
graphic Characteristics (age standardized) 388
9.8. Self-Assessed Health Status, by Age and Gender 390
9.9. Percent Reporting Low Assessments of Health, by Selected
Sociodemographic Characteristics (age standardized) 392
9.10. Trends over Time in Self-Assessed Health 393
9.11. Odds-Ratios for the Effects of Sociodemographic, Social
Support, and Health Characteristics on Self-Assessed Health:
Results from Ordinal Logistic Regression Models 396
10.1. Percent for Whom Medical Care Costs in Past Year Were
Covered by Health Insurance or Provided at No Charge,
by Selected Sociodemographic Characteristics: Philippines 418
10.2. Percent Who Are Aware of and Have Used Public Health
Insurance Programs, by Selected Sociodemographic
Characteristics: Thailand 420
10.3. Percent Enrolled in Universal Health Insurance Program,
by Selected Sociodemographic Characteristics: Taiwan 422
10.4. Percent Distribution for Main Source of Coverage for
Health and Medical Care Expenses, by Selected Socio
demographic Characteristics: Singapore 424
10.5. Percent Distribution for Usual Method of Treatment
When 111, by Selected Sociodemographic Characteristics:
Thailand 426
10.6. Percent Distribution for Usual Place/Method of Treatment
When Iil, by Selected Sociodemographic Characteristics:
Singapore 428
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10.7. Percent Using Specified Preventive Services during
Past 6-12 Months, by Age and Gender 432
10.8. Percent Using Any Preventive Service during Prior 6-12
Months, by Selected Sociodemographic Characteristics 434
10.9. Percent Seeking Outpatient Treatment from Traditional
and Western Medical Providers during Prior Month
or Year, by Selected Sociodemographic Characteristics 436
10.10. Percent Hospitalized during Prior Year, by Selected
Sociodemographic Characteristics 440
10.11. Odds-Ratios for the Effects of Predisposing, Need
and Enabling Factors on Hospitalization: Results
from Country-specific Logistic Regression Models 442
10.12. Odds-Ratios for the Effects of Predisposing, Need
and Enabling Factors on Hospitalization: Results
from Pooled Logistic Regression Models 446
10.13. Percent with Unmet Need for Medical Care, by Selected
Sociodemographic Characteristics 451
10.14. Percent Reporting Specified Reasons for Unmet Need,
among Those Reporting Unmet Need 453
10.15. Odds-Ratios for the Effects of Predisposing,
Need and Enabling Factors on Unmet Need:
Results from Country-specific Logistic Regression Models 454
11.1A. Vulnerable Sociodemographic Groups and Their
Percentage of All Elderly, by Country 465
11. IB. Indicators of Economic, Health and Social Disadvantage
and Their Percentage of All Elderly, by Country 466
11.2. Profile of Economic Disadvantages 468
11.3. Average Relative Risks for Each Sociodemographic
Group, by Broad Dimension of Disadvantage and Country 487
11.4. Percent of Each Sociodemographic Group That Experiences
Disadvantages in Two or More Dimensions, by Country 493
11.5. OLS Regression Coefficients for the Effect of Socio
demographic Characteristics on Number of Economic
Disadvantages, by Country 495
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xviii Tables
11.6. OLS Regression Coefficients for the Effect of Socio-
demographic Characteristics on Number of Health
Disadvantages, by Country 497
11.7. OLS Regression Coefficients for the Effect of Socio-
demographic Characteristics on Number of Social
Disadvantages, by Country 498
11.8. OLS Regression Coefficients for the Effect of Socio-
demographic Characteristics on Number of Different
Dimensions Disadvantaged, by Country 500
11.9. Summary of Each Sociodeinographic Group's Significant
Disadvantages, by Broad Dimension and Country 502
11.10. Knowledge and Use of Select Specialized Programs for
the Elderly, by Country 506
App Definitions for Indicators of Economic, Health
11A. and Social Disadvantages 512
12.1. Projected Number of Children Ever Born among
Women 60+: Taiwan, 1985-2020 523
12.2. Projected Outcomes of the Likelihood of Completing
Senior High School in Randomly Selected Pairs of
Older and Younger Taiwanese Males, 1980-2000 527
12.3. Female Labor Force Participation Rates at Ages 45-49,
circa 1970, 1980, and 1990: Select Asian and
OECD Countries 529
12.4. Transitions in Living Arrangements over Three- to
Four-Year Periods for Those 55 Years and Older at
Baseline: Indonesia, Singapore, and Taiwan 534
12.5. Transitions in the Severity of Limitations between
1989 and 1996 536
12.6. Gross and Net Changes in Income Levels over Four-Year
Periods in Singapore and Taiwan 537
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Authors and Affiliations
Ann Biddlecom
Angelique Chan
Ming-Cheng Chang
Yi-Li Chuang
Napaporn Chayovan
Albert I. Hermalin
al berth @ umich.edu
John Knodel
Hui-Sheng Lin
harveyl @bhp.doh.gov.tw
Kalyani K. Mehta
Lora Myers
Josefina Natividad
Mary Beth Ofstedal
Aurora Perez
Carol Roan
roansche we @ charter.net
Zachary Zimmer
Research Investigator
Population Studies Center
University of Michigan
Assistant Professor of Sociology
National University of Singapore
Deputy Director-General
Bureau of Health Promotion, Department of Health
Taiwan, ROC
Section Chief
Center for Population and Health Survey Research
Bureau of Health Promotion, Department of Health
Taiwan, ROC
Associate Professor
College of Population Studies
Chulalongkorn University, Bangkok
Emeritus Professor of Sociology and Research Scientist
Population Studies Center
University of Michigan
Professor of Sociology and Research Scientist
Population Studies Center
University of Michigan
Director
Center for Population and Health Survey Research
Bureau of Health Promotion, Department of Health
Taiwan, ROC
Associate Professor of Social Work
Department of Social Work and Psychology
National University of Singapore
Administrative Associate
Population Studies Center
University of Michigan
Professor of Sociology
University of the Philippines
Research Investigator
Population Studies Center and Survey Research Center
University of Michigan
Professor (on leave),
Population Institute, University of the Philippines
Research Associate
Population Studies Center
University of Michigan (former affiliation)
Research Associate
Policy Research Division
Population Council
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Preface
The well known Chinese saying that the longest journey starts with a single step is
an elegant, motivational adage, but it fails to convey that the full panoply of rea
sons and preparations for that journey are often obscured in any retrospective
reckoning. So it is with this work. The many steps by the many actors covering
more than a decade of collaborative research and activity are numerous and com
plex but can be enumerated in a reasonably linear fashion. It is more daunting to
convey the original motivations for the journey and the groundwork that allowed
for the human and financial resources to be mobilized relatively rapidly.
A major impetus can be traced to my long involvement with the study of
fertility and family planning in Asia, especially Taiwan. By the late 1980s, I had
witnessed, over a period of 20 years, the rapid decline of fertility in much of East
Asia and several countries of Southeast Asia and the growing success of their
family planning programs. The speed of the decline exceeded the expectations
that I and many other observers held in the early 1970s and led to reflections
about whether the emerging low rates could be sustained into the future in societ
ies that relied so heavily on children for old age support. Reflections on that rather
specific relationship broadened quickly into wider concerns about the growing
older populations in these countries and their potential sources of support in soci
eties that were undergoing such rapid demographic, cultural, and socioeconomic
change. It soon became apparent that there was a unique opportunity to study both
these ongoing major transformations and their repercussions on several key soci
etal institutions. This insight was aided by the ethos of social and economic demo
graphic research at the Population Studies Center, set in motion by Ronald Freed-
man, that emphasized the study of demographic phenomena in the context of
broader family and social dynamics. My experience with several large fertility
and family surveys in Asia also demonstrated the feasibility of effectively using
this important mode of data collection and identified several organizations with
outstanding capabilities within the region.
The potential for mobilizing a strong collaborative team for a detailed ex
amination of population aging also grew out of the research culture of the Popula
tion Studies Center. Starting with Dr. Freedman's pioneering study in Taiwan in
the early 1960s, it has been Center practice to work closely with strong organiza
tions in developing countries over a long period, exchanging personnel and offer
ing opportunities for advanced training to outstanding young staff members. As a
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xxii Preface
result it was relatively easy to identify a number of close collaborators in the U.S.
and Asia, who had related interests in population aging and could devote time and
some organizational resources to the emerging venture. Though there have been
some inevitable changes in personnel over the 12-year period between the official
start of the project and the completion of this volume, the team, as described
below, has remained remarkably intact over the life of this study, attesting to the
strong collegiality and mutuality of interest that has guided this project from the
outset.
Major credit for outfitting the expedition as it started its journey in 1989
must go to the National Institute on Aging for granting me a Merit Award (R37
AG07637) which provided stable, flexible, and long-term funding over the period
1989-2001.1 am very grateful to Richard Suzman, currently Associate Director of
Behavioral and Social Research at the Institute, for encouraging me to undertake
this research and for his long-term support and interest in our activities. I also
appreciate the fine staff support at NIA over the years from Rose Li, Georgeanne
Patmios, and David Reiter. Though the NIA grant covered the direct expenditures
of the research, the training and core support grants to the Population Studies
Center from the National Institute on Aging and the National Institute of Child
Health and Human Development were also important resources. The training grants
provided the funds for our pre- and postdoctoral trainees, many of whom became
closely involved with the project, as detailed below. The core support grants con
tributed significantly to maintaining the outstanding administrative, computing,
library, and editing infrastructure at the Center, which is vital for the smooth con
duct of any large-scale project.
From the beginning, the project has aimed to understand the status of the
elderly within each country and then conduct comparative analyses that would
further elucidate the cultural and economic forces at work. A full discussion of our
approach is given in Chapter 1. To achieve our goals required a diverse set of
countries and collaborators who shared a long-term commitment to the research.
The countries we chose were the Philippines, Taiwan, Thailand and Singapore.
The three Southeast Asian countries had carried out important preliminary re
search on the status of the elderly as part of an ASEAN project, and Taiwan was
prepared to launch a large-scale survey on the same topic. The three U.S. investi
gators associated with the project at the outset, John Casterline (at Brown Univer
sity and later a visitor to the University of Michigan), John Knodel, and I, collec
tively had research experience and close ties with this group of countries. The key
organizations and personnel who initiated the project include the following:
• University of Philippines Population Institute - Dr. Lita Domingo
• The Taiwan Provincial Institute of Family Planning (now constituted as the
Center for Population and Health Survey Research) - Dr. Ming-cheng Chang,
Dr. Hui-sheng Lin, Yi-Li Chuang
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Preface xxiii
• Department of Population Studies (now the College of Population Studies),
Chulalongkorn University, Bangkok - Dr. Napaporn Chayovan, Dr. Werasit
Sit tit rai and Chanpen Saengtienchai
• Department of Statistics, Government of Singapore and National University
of Singapore - Dr. Paul P. L. Cheung and Dr. Kalyani Mehta, respectively
Though the organizations named above have remained the core collaborators over
the life of the project, there have been inevitable shifts in personnel over time as
well as some augmentation. A most sad event for all those engaged in the project
was the death of Dr. Lita Domingo in 1996 from complications due to kidney
disease. Lita brought great intelligence, energy, and warmth to all our delibera
tions and her death was a profound professional and personal loss. Colleagues at
the University of Philippines who worked closely with Lita on this project—Dr.
Josefina Natividad, Dr. Aurora Perez, and Prof. Grace Cruz—have been most
generous in their time and efforts in carrying on the work she so ably started.
In 1994, Dr. John Casterline left the project due to the press of other com
mitments but his efforts in helping shape the project in its earliest years have been
very influential. Similarly, Dr. Paul Cheung found that his duties as Chief Statisti
cian of Singapore were increasingly demanding and found it necessary to cut back
after 1998. Fortunately Dr. Kalyani Mehta and Dr. Angelique Chan, both at the
National University of Singapore, were able to take up many of the analyses and
related tasks for Singapore.
As noted, our affiliations were with the organizations named as well as
with the individuals identified. In each case, the organization played a strong role
in carrying out or facilitating a key survey or other data collection effort, and often
were the hosts for the annual workshops which rotated across venues. These
workshops were our major mechanism for planning each stage of the project, for
reporting on research completed or underway, and for discussing some of the
broader issues associated with population aging in Asia. Over time these workshops
were attended by representatives of other countries in Asia who were interested in
launching similar research (including China, Indonesia, South Korea, and Vietnam)
and by U.S. researchers who were interested in the development of the project or
who were invited to present recent developments of relevance to the project—
such as the launching of the Health and Retirement Survey in the United States. I
wish to thank the Directors of the organizations who assisted the project in one or
more of these ways and also by facilitating the archiving of data collected in the
course of this project (as described in Appendix B). In addition to those who
played a dual role as director and investigator, like Dr. M. C. Chang, Dr. P. L.
Cheung, and Dr. A. Perez, these include: Dr. Corazon Raymundo, Dr. Josefina
Cabigon, Dr. Vipan Ruffolo and Dr. Kua Wongboonsin. I also appreciate the joint
invitations from the Department of Sociology and the Center for Advanced Studies
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xxiv Preface
(CAS) of the National University of Singapore to spend time there in 1999 and
2000 to pursue research and writing relevant to this manuscript. Much of the
material in Chapter 7 first appeared as a CAS working paper and we appreciate
the permission to incorporate it here. Within each organization we also offer our
thanks to the many staff members who played a valuable role in conducting the
surveys within each country, and they are recognized to the extent known to us in
Appendix A, which provides the details of the surveys within each country.
At the Population Studies Center there are a large number of people who
played a special role in the project and the production of the volume. Special
thanks go to my co-investigator, John Knodel, who has been close to the project
from its planning stage onward. John took the leadership in organizing and help
ing carry out the innovative set of comparative focus group discussions in each
country, in helping design and write up the results of the large representative sample
survey conducted in Thailand, and he has contributed substantially to analyzing
the results of our efforts through numerous papers and his role in several chapters.
As noted at the outset, the project has been greatly enriched and aided by
the large number of pre- and postdoctoral trainees at the Center who expressed
interest in our research and chose to become affiliated with our work to some
degree. Among the predoctoral trainees these include Megan Beckett, Jennifer
Cornman, Xian Liu (as both a pre- and postdoc), Mary Beth Ofstedal, James Raymo,
Michael Schoenbaum, Shiau-ping Shih and Zachary Zimmer. It is a source of
great satisfaction to me as an advisor or mentor to these students, that five used
data from the project for their dissertation and all have been involved in one or
more papers stemming from the project. It is also rewarding to note that most of
them have continued research careers closely involved with population aging.
The long and special involvement of Mary Beth Ofstedal with this project
and volume merits special mention and appreciation. Mary Beth was the Center's
first predoctoral trainee in population aging per se. She arrived in 1987 just as
plans were getting underway to mount the first intensive survey of aging in Tai
wan. Her considerable skills in survey research were most valuable in helping
fashion the complex questionnaire, and in assisting with the first round of analy
sis. From 1991 to 1997 Mary Beth was a staff member at the National Center for
Health Statistics, specializing in the Longitudinal Survey of Aging while complet
ing her dissertation. In 1997 she returned to Michigan as an assistant research
scientist at the Population Studies Center and the Survey Research Center. Since
returning she has been closely involved with this project and in the preparation of
this volume, writing or co-authoring several chapters, reviewing others, and play
ing a very active role in all phases of planning and production. It is a source of
great satisfaction that Mary Beth and Zachary Zimmer as co-principal investiga
tors were awarded an R01 grant from the NIA in 2001 to continue aspects of this
project in Asia, with a special focus on health transitions, and that they will be
working with many of the same colleagues.
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There have been eight post-doctoral fellows associated with the project:
Emily Agree, Ann Biddlecom, Angelique Chan, Bruce Christensen, Ellen
Kramarow, Rose Li, Xian Liu, Lindy Williams. Each has contributed one or more
papers related to the project and has been actively involved with project develop
ments through workshops or related efforts. Their substantial contributions are
gratefully acknowledged. As with the predocs, many continue to work in this area
and several have become more closely involved with the project: Rose Li has
been a program officer at NIA and NICHD; Angelique Chan took up a post at the
National University of Singapore and has become a key collaborator of the project
there; and Ann Biddlecom, after several years with the Population Council, has
returned to the Population Studies Center as Research Investigator, devoting part
of her time to analyses from this project and contributing to this volume as author
and in a number of other helpful ways.
As noted at the outset, in addition to the direct financial support for project
activities, the success of the project and the preparation of this volume are also
due to a large extent to the excellent infrastructure at the Center. Lora Myers has
been the key administrator from the outset of the project, handling the numerous
reports and responsibilities associated with the grants, arranging the subcontracts
and facilitating the workshops with utmost skill and effectiveness. Her rapport
with all project collaborators contributed greatly to the esprit of the group and
beyond her many administrative duties she was able to contribute to our scientific
deliberations through her good judgement and ideas about aging issues. Ingrid
Naaman as secretary to the project from its outset has also been invaluable to its
smooth operation. She has effectively prepared the many proposals, reports, and
papers emanating from the project and cheerfully assisted in hosting workshops
and visitors. Her skill and patience were particularly manifest in the preparation
of this volume, as she processed a high proportion of the material and learned new
software to facilitate the conversion to camera ready copy.
Several others at the Center also played important roles in preparing this
volume. Fran Heitz was of great value in assisting with the analysis of several
chapters and in producing standard formats for the many analytic tables. N. E.
Barr, the Population Studies Center editor, played a key role at several stages.
First she served as copy editor for the volume, contributing substantially to the
clarity and readability of each chapter through her effective changes and sharp
eye for ambiguity. Secondly, she took the lead in producing camera ready copy by
establishing the protocols and actively processing each chapter to meet space and
appearance criteria. Another major contributor to the volume was our librarian
Yan Fu. Van's skill in hunting down often recondite Asian and other sources that
reported on important policy and program developments in the region, as well as
locating many other relevant references has greatly enriched the breadth of the
volume and expedited its completion. Pearl Johnson, who assisted Yan in the li
brary until 2001, was also most helpful on the numerous library matters arising.
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xxvi Preface
I very much appreciate the encouragement of Ellen McCarthy, our editor
at the University of Michigan Press, to undertake this volume and her advice at
each of the critical stages. Kathy Osborn assisted ably in applying the software
needed to convert the text toward a final format. Thanks are also due to Ronald
Freedman, Linda Martin, Robert Schoeni, Peerasit Kamnuansilpa, and S. C. Wu
for their helpful comments on specific points or earlier drafts of several chapters,
and to an anonymous reviewer for several useful suggestions.
The specific goals of the project and of this volume were described above
and are treated at greater length in Chapter 1, which also reviews the structure and
content of the succeeding chapters. It is worth noting here, however, the broader
philosophy that guided our work. Although this is technically an edited volume,
we have striven to achieve an integrated monograph. This was facilitated through
our joint work at several workshops, in which chapter outlines and early drafts
were reviewed and critiqued, and by my editorial efforts to achieve coherence
across chapters. Accordingly one will find many cross-references within the chap
ters as well as special chapters devoted to the underlying framework as well as to
a synthesis of the results. Although this volume is informed by more than 10 years
of research, the analyses presented were newly undertaken in order to build sys
tematically on previous work and to achieve appropriate uniformity in structure
and format. A conscious effort was made to make the volume as up to date and
broadly relevant as possible. To this end, policy issues and research references
through the end of 2001 and into early 2002 are reflected, and broader develop
ments on aging in Asia and elsewhere are introduced.
The project has benefited a great deal from having colleagues in each country
with considerable research experience and with close knowledge of the culture
and of ongoing developments with special relevance to population aging. Although
many are in influential governmental or university posts and/or have served on
important committees dealing with the topic, it must be stressed that the opinions
expressed in the volume are those of the individual authors and do not represent
official country positions. It is our hope, however, that the research and policy
implications raised throughout the volume will contribute to ongoing discussions
and to the development of effective policy, program, and research strategies.
The content and style of presentation undertaken have been chosen to serve
a number of potential audiences: specialists in Asia who wish to learn more about
population aging in the region, demographers with growing interest in population
aging as a specialized area of inquiry: and gerontologists who wish to pursue the
developments in East and Southeast Asia. We hope our efforts will prompt contin
ued attention to the rapid demographic and socioeconomic changes ongoing and
their implications for the welfare of the older population in the region. These
transformations are unique in the history of Asia and merit close scrutiny by the
social science community in the years ahead.
Albert I. Hermalin
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Chapter 1
AGING IN ASIA: FACING THE CROSSROADS
Albert I. Hermalin and Lor a G. Myers
In the broadest sense, this monograph is a study in social change and in
anticipating future social change. It examines the effects on the current
and future elderly of the rapid demographic transition that has occurred over
much of Asia, accompanied in many countries by equally dramatic social and
economic transformations. Policymakers in Asia have been aware of these
trends and their potentially deleterious consequences for a decade or more,
and have sought to fashion appropriate policies and programs that anticipate
and mitigate their effects. Accordingly, any study of the sociodemographic
trends and their impact must be examined in the light of policies put in place
and under development.
This convergence of demographic and socioeconomic changes in Asia
has led to concern for the vitality of several key institutions, the strength of
intergenerational relations, and the well-being of a large segment of the popu
lation. For example, one strand of literature and popular opinion holds that
these changes have weakened respect and support for elders, a viewpoint
buttressed by reports in the mass media of isolated older individuals aban
doned by their children and living in dire straits. A very different school of
thought, which draws on limited data, holds that longstanding family and
cultural arrangements in Asia will protect the elderly from the deleterious
effects of these changes. Meanwhile, policymakers must simultaneously strive
to maintain strong institutional arrangements and make realistic assessments
of sociodemographic trends in order to effectively meet evolving needs.
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2 The Well-Being of the Elderly in Asia
A second major theme that concerns both researchers and policy-mak
ers is the potential impact of population aging on economic development.
Will emerging older age structures adversely affect numbers of workers and
their productivity and, if so, what policy levers are available to mitigate these
effects? Will the costs of new pension and health programs associated with
population aging detract significantly from improvements in consumption and
savings levels? Governments are also concerned that the economic growth
they need to develop more services and support for the elderly, as well as to
maintain and expand other social programs, may not be forthcoming as a
result of population aging.
Our study is an empirical analysis of the effects of population aging to
date and an attempt to discern some of the future patterns and issues. How
well off are the current elderly and what factors affect their situation? To the
extent that Asian societies are accommodating the rapid cultural, demographic,
and socioeconomic changes, what forms do these adjustments take and how
robust might they be under future pressures? How have policymakers been
responding and what major challenges lie ahead? Current techniques of data
collection and analysis allow a more complete answer to the first question
and providing it will occupy much of this volume. At the same time by re
viewing current policies and programs in relation to our analytic findings, we
hope to shed some light on the other key issues as well.
The analyses in pursuit of these goals relies to a great extent on detailed
surveys and related studies carried out over a several-year period in four Asian
countries—the Philippines, Taiwan, Thailand, and Singapore. Though no small
group of countries can represent the diversity of Asia, these four focal countries
exhibit considerable variety in terms of cultural heritage, ethnicities, and
history, as well as in their levels of demographic and socioeconomic change.
Each chapter contains analyses that compare and contrast these countries,
with an eye to identifying commonalities and differences in their responses to
the underlying forces. Though the focus on four countries sacrifices some of
the generality to be gained from including a larger number, it facilitates these
comparative analyses that would not otherwise be possible. As such this work
should be seen as complementing other literature on the topic that includes
more countries, but usually in the form of a country-by-country review without
a common framework. (Phillips, 2000; Bengston et al., 2000; Phillips, 1992).
To contextualize our detailed analyses of the four countries, at various points
we relate our findings to wider trends in Asia and elsewhere.
In this introductory chapter we review the nature of the challenges
facing many Asian countries as a result of population aging and socioeco
nomic trends and the potential levers available, as well as their limitations.
We also provide a brief introduction to the surveys and material that form the
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Aging in Asia: Facing the Crossroads 3
core of our analyses, and a guide to the subsequent chapters that take up
specific themes stemming from our broad goals.
The Source and Nature of the Challenges
Population aging in its most direct manifestation refers to alterations in the
age structure of a population, which results in increasing proportions of the
population at older ages (conventionally demarcated at age 60 or 65), and
consequently, decreasing proportions at younger ages. It occurs first through
declines in fertility levels: as adults have fewer children, the number at younger
ages relative to those at older ages decreases. Once low levels of fertility are
reached, declines in death rates contribute further to an older age structure.
In the post-World War II period, East and Southeast Asia were the leaders
among developing regions in the speed and magnitude of their fertility de
cline. As described in greater detail in Chapter 2, fertility rates in a number of
countries in these regions declined from an average of 5 to 6 children per
woman in the 1960s to less than 2 children per woman by 1990. These changes
have led to a rapid increase in the proportion of the population 60 or older
and have set the stage for even faster growth of the older population in the
future.
The current older population is very much a "transitional" generation
in terms of their demographic history and on many other dimensions. (Phillips
[2000, p. 13] refers to the current older population as an "interim" generation
in a somewhat different sense.) They raised their families during periods of
much higher fertility and as infant and childhood mortality rates were falling.
As a result they have larger numbers of living children on average than previous
cohorts of elderly, and, given current fertility rates, have significantly more
living children than will future cohorts of elderly. In societies in which older
people rely to a large extent on children for economic, physical, and emotional
support, a sharp reduction in number of children raises concern about the
continued welfare of the elderly.
Chapter 2 also traces the noteworthy improvements in life expectancy
that occurred throughout East and Southeast Asia over the past 30 years. These
improvements in mortality serve to enhance both the numbers at older ages
and their average age, leading to a higher proportion at the oldest ages (those
above ages 75 and 80). The differential in life expectancy between men and
women means that women predominate at the older ages and particularly at
the oldest ages, while the changing levels of mortality will have an impact on
the proportions widowed at each age. These gender differences in the older
population intersect with differences in the labor force histories of men and
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4 The Well-Being of the Elderly in Asia
women, as well as with differences in patterns of authority and inheritance
arrangements, in affecting well-being, service demand, and policy needs.
Equally or more challenging to the welfare of the elderly, in the eyes of
many observers, are the rapid socioeconomic transformations that have oc
curred over much of Asia during the last 40 years. Many countries in the
region experienced major, sustained economic growth that led to substantial
increases in per capita income, shifts from a reliance on agricultural produc
tion to the manufacturing and service sectors, dramatic increases in the levels
of school attendance and educational attainment, and greater participation of
women in higher education and the labor force. (Chapter 2 also documents
the magnitude and nature of many of these changes.) While these develop
ments have brought considerable attention to the economic prowess of Asia,
leading to such sobriquets as the "four Tigers" and moving a number of coun
tries from the "developing" to the "newly industrialized" country category,
they have also put pressure on a number of traditional social and cultural
institutions.
One outcome of these socioeconomic changes was another demographic
transformation—a rapid urbanization in many countries of Asia, fueled by
high rates of rural to urban migration. To the extent that these migrants were
predominantly younger and better educated than their rural neighbors, these
movements led to aging population structures in rural areas, a phenomenon
sometimes referred to as "aging in place" (Morrison, 1990). These changes
conjure up images of isolated rural elderly residing in economically stagnant
agricultural areas. Countering this image however is the argument that older
people prefer, and are better off, remaining in their familiar rural surroundings
than following their children to the strange environs of the city. Consideration
must also be given to the likelihood that decisions of younger family members
to migrate to cities are not independent of the needs of older parents, and that
often one child may stay behind to assist, as illustrated by a community study
in Thailand (Knodel and Saengtienchai, 1996). The issue is far from resolved,
and accordingly our analyses pay close attention to urban-rural differences
on a number of dimensions of well-being.
An extensive literature has theorized, on the basis of experience in the
West, that industrialization is inevitably accompanied by a movement away
from extended family organization to a nuclear living arrangement and greater
independence among individuals in their social and economic lives (Goode,
1963). Although this thesis has been modified in several important respects
(see discussion in Chapter 4), the underlying association between moderniza
tion and changing forms of family organization remains influential. In the
context of East and Southeast Asia, the demographic forces making for smaller
numbers of children and increasing numbers of elderly, combined with the
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Aging in Asia: Facing the Crossroads 5
socioeconomic forces allowing children to gain more education and pursue
new jobs in new locations, raise the specter that many older people will lose
the physical, economic, and social support that was customary in earlier times.
At the same time, insofar as children remain attentive to the needs of their
parents, the improved economic conditions of the children can work to the
parents' benefit. Close analyses of the extent and nature of parental support
and their effects on economic well-being are needed to help resolve the issue.
A fundamental question for Asia is thus anticipating the kinds of changes
that will occur in terms of longstanding societal and familial norms that his
torically have provided much of the support required by older persons. In this
regard, it is important to note that much of the prior demographic and socio-
economic change occurred while these societies were quite different in their
family structures than the pre-industrial West. These changes have had sub
stantial impact on several dimensions of family life and other societal norms
while leaving other aspects relatively intact, as discussed further in Chapter
4. It remains to be seen how continued changes will affect the intergenerational
support system and other dynamics of family life, and how variable these
responses will be over time and across countries.
Policymakers have been aware of these trends and cross-currents for
some time, and have undertaken several measures to address them while pon
dering a broader and more extensive set of programs. The 1982 United Na
tions World Assembly on Aging (United Nations, 1982) was significant in
raising awareness of emerging trends in population aging. It is possible to
identify since then a sharp upswing, particularly in Asia, in the number of
conferences, books and reports, and new investigations by demographers and
other social and health scientists regarding various facets of this topic.
In addressing these issues, policymakers in Asia are facing several di
lemmas. Leaders are seeking approaches that will address the emerging needs
of their growing older populations while preserving their societal structures.
They also recognize the high costs and related problems associated with the
social welfare programs for the older populations in the West. In a broad sense,
policymakers in Asia are exploring whether economic "modernization" in
evitably means "Westernization," in terms of social programs, or whether they
can fashion programs at reasonable costs without undermining the traditional
family arrangements that already provide substantial support.
Several other features of the Asian landscape and the dynamics of
population aging there heighten the implicit challenges. The speed of
demographic transformations over much of East and Southeast Asia and the
recency of economic successes mean that many of the countries in the region
have experienced much faster growth in their older population than occurred
among the currently industrialized countries, and some are doing so while at
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6 The Well-Being of the Elderly in Asia
an earlier stage of economic development. For example, it has taken (or will
take) between 21 and 27 years for Thailand, Singapore, and China to increase
the proportion of their population 65 years and older from 7 to 14 percent,
while the same change took around 45 years in Spain and the United Kingdom
and 68 years in the United States (Kinsella and Gist, 1995). Another concern,
as noted, is that the very process of population aging can impede economic
development by reducing the size of the population in the economically
productive ages relative to those at the younger and older ends of the age
continuum. (See Chapters 2 and 4 for further discussion of these trends and
the relevant theory.) In addition this region, which over much of the past 30
years has been noteworthy for its economic successes and confidence in its
ability to address social and economic problems, experienced a serious
economic recession beginning in mid-1997. Although the recession has had
different effects in different countries, it did undermine the ability of several
countries to move ahead as scheduled with expanding existing social welfare
programs or initiating new programs, and it has engendered caution throughout
the region about the speed and magnitude with which new policies and
programs designed to meet various social goals, including the needs of the
older population, can be undertaken. (It should be noted that almost all our
data collection and analyses precede the economic crisis, though some post-
1997 data are used in the concluding chapters when examining transitions.)
Figure 1 illustrates the broad dynamics at work and the inherent chal
lenges. (A more detailed version of this figure guides the theoretical discus
sion in Chapter 4). Within each country long-standing societal and cultural
arrangements guide the familial support and exchange institutions, which in
turn largely determine the well-being of the elderly in terms of health, eco
nomics, and work. These traditional arrangements are under pressure from
the rapidly changing demographic and socioeconomic conditions, which also
affect the resources and the range of policies and programs that policymakers
can undertake in response. The bi-directional arrow between well-being of
the elderly (and the underlying family and related structures) and the policies
and programs suggests the dynamic interplay occurring over time. As policies
and programs affect levels of well-being, the adequacy of the response, along
with the political influence of the elderly and other forces, guide future pro
gram development.
Demographic Responses and Their Limitations
To the extent that population aging, in its narrowest sense, is a demographic
phenomenon, it is inevitable that consideration would be given to the possi
bility of demographic responses that would alleviate the situation. The most
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8 The Well-Being of the Elderly in Asia
common types of responses include efforts to raise birth rates, encourage
marriage, and influence immigration patterns.
Some countries have experimented with policies aimed at raising birth
rates to some degree as a way of slowing the aging of their populations.
Singapore, prompted in large part by concerns about population aging and its
consequences, formulated a new population policy in 1987 that promoted
fertility. Using the slogan "Have Three, and More If You Can Afford It,"
Singapore offered several fertility incentives, including tax rebates upon the
birth of a third child, subsidies for childcare center fees, priorities in housing
allocation, and a special leave program for female civil servants with young
children (Cheung, 1989).
Associated with the emphasis on demographic responses is the ten
dency to view population aging as a problem or crisis, whether or not the
proposed solutions point to higher fertility or other responses. This is illus
trated by titles such as Averting the Old Age Crisis (World Bank, 1994) or
Gray Dawn: How the Coming Age Wave Will Transform America and the
World (Peterson, 1997). As Hermalin (1995) and others have noted, this line
of thought has several drawbacks. An older age structure should be viewed as
a recent human triumph, reflecting on one hand couples' success in achieving
desired small numbers of children, and on the other as gains toward the uni
versal aspiration for longer and healthier lives. Moreover, the attempt to fash
ion a demographic solution to the perceived problem assumes that a society's
demographic behavior can be fine-tuned up or down—contrary to widespread
evidence on the outcome of efforts to adjust fertility rates through exhortation
or financial incentives (Uhlenberg, 1992; Hohn, 1987). It also overlooks the
potential social and economic dislocations caused by frequently shifting fer
tility rates, as societies, for example, cope first with the costs of expanding
schooling and training capacities after an upturn in fertility, and then cope
with the costs of excess capacity after a downturn.
Nonetheless, a number of countries in Europe and elsewhere have pro
grams of child allowances, and other financial and non-financial inducements,
to maintain or enhance fertility levels. Hohn (1987) presents an overview of
the plans in several European countries, along with estimates of their efficacy
and suggestions for future initiatives that are responsive to a wider array of
social and economic factors associated with parenthood. (For a historical com
parative analysis of family policies in industrialized countries see Gauthier,
1996.) New approaches can be expected from time to time. Singapore, for
example, introduced a new bonus plan for births starting in April 2001. Under
this plan the government will contribute a specified amount for second and
third births into a special Child Development Account for five years and will
also match parents' contributions into that account up to a stipulated limit.
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Aging in Asia: Facing the Crossroads 9
The family can spend the funds in the account for education and developmen
tal expenses like childcare and nursery fees (Ministry of Community Devel
opment and Sports, 2001). In addition, programs that expand the availability
of childcare have been adopted in Japan and other countries, both to encour
age childbearing as well as female labor force participation. It is not expected
that these plans will radically alter the levels of fertility and hence future age
structures, but rather that they will slow down the rapid rate of population
aging by modestly increasing the average number of births from the very low
levels now prevailing. In a number of countries in Asia and Europe, total
fertility rates per woman are in the neighborhood of 1.5 births, so that even a
20 percent increase would leave fertility levels below the population replace
ment level of 2.1 children.
A prime contributor to the low fertility rates in many countries has
been a decline in the proportion of young adults who marry, and the later ages
at marriage for those who do. This change is particularly notable in several
Asian countries where universal marriage was the norm until recently. For
example, in Taiwan 19 percent of women aged 35-39 were unmarried as of
1999, compared to 13 percent in 1990 and 7 percent in 1980. (Chapter 2
shows how the average age at marriage has advanced in the four countries
under study.) In Japan, the trends are similar but at a somewhat different level,
with 10 percent of women single at ages 35-39 in 1995, double the proportion
20 years earlier (Retherford et al., 2001). These trends reveal that greater
proportions of the population are delaying and possibly foregoing marriage,
and they have implications for the family arrangements and needs of these
cohorts as they age (Hermalin, 1993).
Lower marriage rates are a response to a number of ongoing demo
graphic, socioeconomic, and cultural factors. For example, increasing educa
tional and career opportunities for women open up alternatives to marriage
and also increase the difficulty of finding suitable partners. And the decline
of arranged marriages and the greater acceptance of premarital sex have helped
reduce some of the pressure to marry. (For Japan, see the discussion by
Retherford et al., 2001; Raymo, 1998.)
Though policies directed toward enhancing marriage rates appear less
common than those directed toward births within marriage, several instances
can be cited. Singapore, starting in 1984, has promoted interactions between
young men and women through various organized activities as well as initiat
ing a computerized match-making service for university graduates and oth
ers. And the initiatives in other countries that reduce the opportunity costs of
motherhood, such as enhanced maternity leave programs and subsidized
childcare, also serve to make the prospect of marriage and parenthood more
attractive.
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10 The Well-Being of the Elderly in Asia
Demographers and others studying marriage trends often employ the
analogy of the market, where the number of eligible brides and grooms at
each age, and at different levels of education and other characteristics, help
determine the numbers of each gender who marry at each age. One result, for
example, of Singapore's decreased fertility rates and rapid rise in the educa
tional level of women over the past several decades, is an insufficient number
of eligible women in the appropriate age range for men in their late 20s with
modest education. This has led many of these men to secure brides from other
countries, to the extent that the proportion of marriages between Singaporean
citizens and foreigners has increased to one quarter in recent years.
This influx of foreigners as a result of marriage raises the more general
question of immigration as a demographic response by countries undergoing
rapid population aging. Technically speaking, policies focusing on migration
are not demographic policies if they do not have as their goal a change in
population size or population age structure, although policies designed to re
cruit labor or reunite families may have direct demographic responses (H6hn,
1987). From this narrower demographic perspective, the United Nations (2001)
has calculated the rate of immigration needed under various assumptions for
countries with older age structures to achieve demographic goals in terms of
numbers or proportions of people in various age categories. Lesthaeghe (2000)
presents a detailed analysis of replacement migration for Europe in relation to
other demographic and social factors.
Most migration policy in recent years has been more narrowly focused
on recruiting workers to supplement the existing labor force and/or to fill
certain occupational niches. As such migration is a policy for addressing the
potentially deleterious economic consequences of population aging. An analy
sis by McDonald and Kippen (2001) reviews the labor supply prospects of 16
more developed countries in terms of the potential of immigration as well as
other steps. But migration policy is often a complex and contentious issue
within countries, intersecting with long-standing traditions, cultural values,
and the competing interests of various ethnic and socioeconomic classes.
International migration on the world scene has taken a number of
different forms over the last 500 years, and has varied considerably in intensity
and underlying dynamics over this period (Massey et al., 1998). The migration
patterns that emerged in the 1960s were quite different from those of the past
in the variety of receiving and sending countries, and in the shift of the supply
of migrants from Europe to the developing world. Much of the driving force
for migration over the last 40 years has been labor scarcity in countries with
capital-intensive industries and rapid economic development, the availability
of labor in densely settled countries in earlier stages of industrialization, and
the wage differentials across these countries. In the 1960s, the countries of
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Aging in Asia: Facing the Crossroads 11
Western Europe started to receive so-called "guest workers" from Southern
Europe and elsewhere; by the 1970s several Southern European countries
were importing migrant workers from the Middle East and North Africa, and
the oil-rich nations in the Gulf region also sought labor migrants from Asia as
well as the Middle East (Massey et al., 1998, Chapters 1 and 5).
By the late 1980s, Japan as well as several of the rapidly industrialized
countries in the region were receiving international migrants, mostly from
other countries in the region. Japan, as of 1990, had slightly more than a
million registered foreigners, mostly from Korea, but during the 1980-90 de
cade most of the increase among East Asians was due to migrants from China
(Massey et al., 1998, Table 6.1 and page 163). Okunishi (1995) estimates that
as of 1993 there were 950,000 foreign workers in Japan (including 300,000
illegal unskilled workers) but representing only about 1.5 percent of the total
labor force, and McDonald and Kippen (2001) do not expect that Japan can
absorb a large number of immigrants in the future. Atoh (2000), while noting
that the net inflow of foreigners increased somewhat in the latter part of the
1990s and that demand for foreign labor in some industries is likely to persist,
concurs that there is little likelihood of a major change in the level of immi
gration in Japan in the coming years.
The four focal countries of our study represent a spectrum of migra
tion policies and behaviors: Singapore and Taiwan receive a considerable
number of labor migrants; Thailand both receives migrants and sends its own
labor to other countries; while the Philippines is a country with a relatively
large outflow of their own workers. It is of interest that a substantial number
of migrants from Thailand and the Philippines work in Singapore and Tai
wan, enhancing the value of treating the four countries from a close compara
tive perspective.
Singapore has developed a pro-immigration policy, welcoming profes
sionals (those with stipulated levels of education, earnings, and experience)
to become permanent residents and at the same time admitting a large number
under a guest worker policy. As of 2000, these two groups constituted 26
percent of the country's population. Many of the workers in Singapore are
from the Philippines, predominantly women employed as domestic workers,
and Thailand also supplies a substantial number of laborers.
As of 2000, Taiwan had over 300,000 foreign workers, about double
the number in 1994, representing about 3 percent of the Taiwan labor force.
The Philippines and Thailand together supply approximately 80 percent of
the total. Although most foreign workers are employed in manufacturing and
other traditional industries, increasing attention has been focused on labor
shortages within Taiwan's large high-tech sector and the possible need to re
cruit more highly trained workers.
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12 The Well-Being of the Elderly in Asia
Thailand is both a sending and receiving nation with regard to immi
gration. As noted, substantial numbers of Thais are working in Singapore and
Taiwan, and in total the number of workers legally registered to work abroad
was 184,000 as of 1997, with the number of illegal emigres probably exceed
ing this number (Sobieszczyk, 2000). At the same time there are estimated to
be over one million foreign workers in Thailand—200,000 professional ex
patriates and over 900,000 unskilled farm and construction workers from the
poorer neighboring countries (Martin et al., 1995; Stern, 1998).
The Philippines is a major labor exporter—in fact, according to Martin
et al. (1995) it is second only to Mexico in this respect. Battistella (1995)
reports government estimates of 4.2 million workers abroad in the early 1990s,
including 2.4 million documented workers and 1.8 million undocumented,
but more conservative estimates place the number of documented workers at
1.6 million. The remittances from the overseas workers are significant inputs
into the families and communities as well as the economy as a whole, and
labor emigration policy has become an explicit factor in economic develop
ment planning.
Immigration policy impinges directly on the size of the labor force and
economic development, so it is likely to receive continuing attention from
governments. McDonald and Kippen (2001) project that sustaining current
immigration levels in Singapore would serve to maintain the size of their
labor force through 2050. Immigration also has a direct effect on age struc
ture, but in most cases this effect is likely to be secondary and only marginally
alter the overall trend toward an older population. Accordingly, nothing sug
gests that the rapid levels of population aging projected by the United Nations
and others for many countries of the world over the next 30 to 50 years will be
substantially changed. Singapore, for example, despite policies promoting
births and migration is still projected to have 30 percent of its population over
age 60 by 2030, if the estimated levels of future fertility, mortality, and migra
tion are borne out. (See Chapter 2 for more details on these and related data.)
Non-Demographic Responses
Because of the limited potential impact of demographic responses in slowing
population aging, policy attention is being devoted to programs that will protect
and enhance the well-being of the elderly and will mitigate the potentially
deleterious effects of population aging on economic development. Policies
addressed to the first issue involve programs that provide direct assistance to
the elderly in areas of perceived need as well as initiatives that will sustain
family arrangements for the support of older parents.
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Aging in Asia: Facing the Crossroads 13
Chapter 3 provides details on the large-scale social security and health
insurance programs in place and under development in the four study coun
tries. All four countries are currently reviewing and amending these programs
in the face of their changing demographic profiles and the observed shortfalls
in existing programs. Many of these programs initially served special groups
such as civil servants or employees of large firms; others, with more general
intent, have proved to be inadequate due to problems of enforcement or the
presence of provisions that have diminished their effectiveness for current
needs.
As described in Chapter 3, Taiwan launched a new national health in
surance program in 1995, referred to as Universal Health Insurance, replac
ing a number of partial systems tied to classes of employees, and is set to
launch a new national pension program in the near future. Thailand is phasing
in a new national pension program, delayed as to starting date and scope by
the economic crisis which affected that country strongly in 1997. Singapore
has altered provisions of its Central Provident Fund to enhance its effective
ness as a source of retirement income, and has added health insurance fea
tures for older ages. In the Philippines a new National Health Insurance pro
gram was introduced in 1995.
In addition to these broad pension and health care programs, many of
the countries in Asia, including the four study countries, are expanding the
range and availability of governmental services for the elderly. As described
in Chapter 3, these include provisions for long-term care, community ser
vices such as daycare, senior centers, and services within the home, programs
to enhance cultural and recreational activities, and attention to those with
special economic problems.
In fashioning new programs and amending existing ones, policymakers
are constrained not only by the costs involved, especially in periods of uncer
tain economic growth, but by the desire to insure that these programs do not
undermine existing social arrangements that provide a substantial share of
the economic, physical, and emotional support to the elderly. The aforemen
tioned community service enhancements, for example, are intended to help
older people remain with their families while they serve their perceived needs.
In addition explicit steps to sustain family support are underway in several
countries, ranging from laws requiring children to care for parents (as de
scribed for Singapore in Chapter 3) to incentive programs that promote shared
living arrangements or related support. How well such efforts to sustain exist
ing family arrangements succeed in the face of ongoing demographic and
socioeconomic trends and the advent of broader pension and health programs
is a critical question for the coming years and one meriting major research
attention.
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14 The Well-Being of the Elderly in Asia
The second major concern for policymakers concerns the effect of popu
lation aging on economic growth. The policy levers here center on steps that
will enhance labor force participation and productivity. These include poli
cies that will increase the labor force participation of women by upgrading
their skill levels through education and life-time learning programs. Also im
portant are policies that address retirement age issues and the structure of
pension program—insuring that they maximize savings and do not contain
incentives for early retirement (World Bank, 1994; Gruber and Wise, 1999).
Several features of recent demographic and socioeconomic history pose
a number of more specific challenges. Past trends in birth rates and life ex
pectancy mean the numbers of older people, especially those at advanced
ages, will rise sharply in the coming years. This will create additional de
mands for long-term care, geriatric facilities, personnel, and expertise in the
health infrastructure—all while maintaining existing capability in the areas
of infectious diseases and the needs of mothers and children. Past and con
tinuing improvements in life expectancy at older ages also mean that growing
numbers of elderly will encounter a series of major transitions over their later
years in terms of work, health, wealth, and living arrangements. Government
policies and programs can anticipate some of these and seek to enhance well-
being at each stage, but often difficult choices will be involved. In the realm
of work and retirement, for example, current statutory retirement ages among
civil servants and other covered employees are relatively young in much of
Asia, and governments may be tempted to move these back to reduce the
social welfare costs and maintain productivity. But in the short run, this may
run counter to the need to create more jobs for the rapid rise in the young
adult population, reflecting high past fertility and the changing skill require
ments of many jobs.
Dramatic increases in social and economic development over the last
quarter century in much of East and Southeast Asia also pose several dilem
mas. As a result of these changes, the younger generation is much more edu
cated, urban, and professional than their elders, attributes that can benefit
society even while they present potential problems. The sharp differences
across age groups is not only a potential source of intergenerational tension
and conflict, but it means that the future elderly will have sharply different
characteristics than the current elderly. They are likely to demand different,
more sophisticated, and costly services, as well as bring different resources to
providing for their own needs. And they are likely to have expectations that
are different from those of their parents. As a result, policymakers need to
fashion programs to assist the current elderly as appropriate, but avoid getting
locked into policies and approaches that might be rendered ill-suited in the
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Aging in Asia: Facing the Crossroads 15
coming years given the changing socioeconomic characteristics of the nature
elderly.
In some countries, policymakers will also be challenged to ensure
adequate implementation and enforcement of new or amended programs.
Countries with large sectors of the economy devoted to agricultural, small
businesses, and informal labor may find it difficult to set and enforce
contributions to social programs from owners, employers, and employees,
particularly where past standards have been lax. In such cases projected
revenues may not match actual benefits, jeopardizing the system and causing
financial strain for the country.
Both the changing conditions under which programs will operate and
the newness of the programs themselves suggest that monitoring program
effectiveness and making appropriate adjustments will be regularly required
in the coming years. As addressed further in Chapter 13, developing an effec
tive dialogue between policies and research will be important to anticipate
problems and develop guidelines for future actions.
Goals of the Volume
The strength and recency of the demographic and socioeconomic forces at
work make it difficult to distinguish short-term adjustments from possible
long-term transformations, and we make no claim to having a crystal ball. At
the same time, policymakers are looking to research to help guide future
actions. Sufficient data are now available to allow us to take stock of the
current trends and to draw out the key issues for future policy and research
consideration.
Accordingly, our first goal is to set forth a clear picture of the status of
the elderly in the four Asian countries we have studied intensively: the
Philippines, Thailand, Taiwan, and Singapore. More specifically, we will
examine the well-being of the elderly in terms of their physical, mental, and
emotional health; their economic sufficiency as reflected in income, assets,
and living conditions; and their patterns of work, retirement, and leisure. We
will describe both the current distributions and the recent changes on a number
of measures by comparing our results to earlier survey data. A careful
delineation of the actual conditions facing the elderly is important to counter
less informed opinion that tends to focus on two extremes: that ongoing changes
have had severe deleterious effects on the older population, or that pervasive
family support arrangements have successfully buffered the elderly from
adverse consequences.
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16 The Well-Being of the Elderly in Asia
A second goal is to understand the factors that influence the well-being
of the elderly in these four countries. As suggested by Figure 1, these factors
include not only the personal characteristics of the elderly but their living
arrangements and support systems, and the policies and programs in place in
the governmental and private sectors.
In carrying out these goals, each analytic chapter will focus on com
parative analyses across the four countries to assess the importance of cul
tural variation as well as other conditions on the differences in outcomes. In
so doing we will be able to determine the extent to which a single Asian
pattern is evident versus multiple context-specific patterns. The analyses will
include both detailed descriptive patterns and multivariate techniques designed
to identify the major forces at work. To better identify country-specific ten
dencies, the multivariate analyses will be carried out separately for each country
and across countries by pooling the data.
An important unknown in anticipating the future well-being of the
elderly and the programs needed is the degree to which current societal systems
may shift in the coming years. Accordingly, a third goal will be to assess the
strength of key societal elements that have supported the elderly in the past,
to discern the level of recent trends, and to anticipate future changes.
The detailed analyses in pursuit of these goals are presented in Chap
ters 5-11. Chapters 5 and 6 take up the third goal first, describing current
patterns of living arrangements and support levels, and contrasting these with
those observed some years earlier. As stated above, and depicted in Figure 1,
these basic institutional and familial arrangements are key determinants of
the well-being of older persons on several dimensions. In these chapters we
also analyze the characteristics of the elderly and their children that affect
these arrangements. Though cross-sectional surveys are limited in their abil
ity to trace change, knowledge of current interrelationships combined with
the ability to anticipate the social and demographic characteristics of future
elderly can provide useful insights on the patterns likely to emerge.
Chapter 7 initiates the analysis of the dimensions of well-being,
investigating both the level of labor force activity of older persons and some
of their leisure activities. For those still working we describe their main
occupation, whether they are subject to mandatory retirement practices, and
whether they have pension coverage. For retirees, we investigate the nature
of their previous work, their retirement process, and the reasons for retirement.
Chapter 8 focuses on the economic well-being of older individuals and
couples, employing multiple measures of income and relative income posi
tion, taking into account individual versus household measures and indirect
sources of support. Data on asset holdings are also employed to present a
fuller picture of overall economic levels.
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Aging in Asia: Facing the Crossroads 17
Chapters 9 and 10 turn to health-related measures of the older popula
tion. Chapter 9 examines the health status of the elderly, through their reports
of select chronic diseases, levels of difficulty in eating, dressing, and other
activities of daily living, measures of depression and cognition, and levels of
self-reported health. Several health behaviors are also reported. Chapter 10
focuses on the levels of health care utilization and perceived needs by exam
ining the proportions using various services, the costs involved, and the ex
tent to which those with stated problems were limited in obtaining care.
Chapter 11 reverses the analytic strategy by identifying the
sociodemographic groups often thought to be particularly vulnerable to the
emerging trends of population aging in these countries and examining the
degree to which they are relatively disadvantaged compared to other older
persons on a variety of well-being measures. Chapter 12 looks to the future
using cohort analysis to illustrate how the elderly in the coming years will
differ from the current elderly and the policy considerations that arise as a
result. It also looks at changes within cohorts, using transition rates to exam
ine shifts in economic status and living arrangements as older people age.
The final broad goal of the volume is to interpret the policy and pro
gram challenges that emerge from the trends and interrelationships observed
in our analyses. Chapter 3 describes in some detail the current policies within
each country. In a number of the chapters, the degree of involvement of the
current older population with various programs is described and the effect of
that involvement on their well-being is analyzed. Each analytic chapter touches
on the policy implications of the findings and the concluding chapter brings
together information on this topic—tracing the meaning of our results for
policy and program development. The goal is to identify those areas needing
more urgent attention and some of the policy levers that appear most promis
ing, as well as those areas in which governments may have more time to
develop policy. Chapter 13 also provides a summary of key findings and dis
cusses promising lines of future research and ways of strengthening ties be
tween policy and research.
Tools and Perspectives
Gerontology is a large and diffuse field with theoretical, substantive, and
methodological contributions from many disciplines. The analyses presented
here are from the perspective of the demography of aging, itself a wide-rang
ing and eclectic field, informed by the theory and methods of demography, by
the set of problems addressed, and by the methods and data it shares with
other fields (Martin and Preston, 1994). In the analytic chapters that follow,
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18 The Well-Being of the Elderly in Asia
this perspective is manifest in attention to the underlying quality of the data, a
focus on the constituent elements of complex constructs, and an attempt to
detect the influence of possible causal factors by controlling for other forces
through standardization or statistical multivariate techniques.
The breadth of gerontological interest precludes a single encompass
ing theoretical basis for these analyses. (Even individual disciplines with
gerontological concerns maintain a number of distinct theories and hypoth
eses.) Our strategy, therefore, as developed at some length in Chapter 4, is to
provide a broad heuristic framework (expanded from Figure 1) within which
a number of specific theories and hypotheses can be located, and which can
serve effectively as a guide to the specific analyses of well-being forming the
core of this work. In carrying out these analyses the goal is to provide the best
estimates possible of current well-being in each dimension, to identify the
factors associated with these levels, and to draw careful comparisons across
countries as to levels and dynamics wherever possible.
As to conventions, we use the word "elderly" as synonymous with "older
person" for stylistic variety. In some quarters, "elderly" has a connotation of
someone frail or dependent. As our research makes clear, the "elderly" in our
sense of the word are often independent and providing goods and services to
others. In presenting data for the four focal countries, we have decided to
sequence them as the Philippines, Thailand, Taiwan, and Singapore rather
than alphabetically. This order has the virtue of pairing the Philippines and
Thailand, which are the most rural of the four countries and at the lower end
of the per capita income scale, and Taiwan and Singapore, which are pre
dominantly Chinese and at the upper end of the income scale.
History of the Project, Data Collected, and Other Products
Although the analyses presented in the following chapters were newly under
taken for this volume, from another perspective this work attempts to distill
ten years of observation by a diverse team of researchers in the United States
and several Asian nations. The very broad research framework described above
has led us to employ a variety of data sources, including censuses, surveys,
and ethnographic and other qualitative data sources. The following is a brief
review of these sources, how they were obtained, and where future investiga
tors can find and use them.
Early Data
At the outset of the study in 1989, we took stock of existing data relevant to
the social and economic status of the elderly in the Philippines, Thailand,
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Aging in Asia: Facing the Crossroads 19
Taiwan, and Singapore. These included censuses, other official statistics, and
a set of surveys sponsored by the Association of Southeast Asian Nations
(ASEAN) in three of the countries (see Chen and Jones, 1989). In 1989 we
also initiated a new panel study in Taiwan, the Survey of Health and Living
Status of the Elderly in Taiwan (Taiwan Provincial Institute of Family Plan
ning, et al., 1989), which demonstrated the practical need for data on mea
sures of health, economic status, and social support.
The early sources proved valuable for a variety of analyses. Census
data were employed to analyze labor force trends and to compare current and
future cohorts on educational attainment and other traits (Raymo and Cornman,
1997; Hermalin and Christenson, 1992). Casterline, et al. (1991) used ASEAN
data and the 1989 survey in Taiwan to compare living arrangements of the
elderly in the four countries.
They also set the stage for a new round of surveys that would expand
the scope of coverage and enhance comparability across countries.
Data Collected 1990-1999
In 1990 the project began data collection efforts that continued through the
decade. In 1991-1992 a series of focus group sessions were held in each of
the four study countries with both elderly participants and adults with elderly
parents. The goal was to learn about current attitudes toward the elderly, their
role in the family as givers and receivers of support, and how these roles
might be changing over time. Specific topics included living arrangements,
support exchanges, social contacts, work and economic status, health status,
utilization of health programs, and role in the community. These efforts repre
sented a pioneering use of focus groups in comparative social science re
search and resulted in detailed analyses of cross-generational attitudes and
expectations concerning living and support arrangements for the elderly (see
the special issue of Journal of Cross Cultural Gerontology, Vol. 10:1-2,1995.)
During 1993-1996, new surveys of the elderly were conducted in the
Philippines, Thailand, Taiwan, and Singapore. Each of the surveys is nationally
representative, with more extensive subject matter and broader age coverage
than the ASEAN surveys and other early efforts. They incorporate lessons
from the successful 1989 Taiwan survey, from the focus groups, and from the
U.S. Health and Retirement Survey (HRS), which was launched in 1992. A
core questionnaire was adopted with modification by each country. Because
of multiple auspices and country-specific concerns, the exact timing and content
of these surveys vary across the countries. Issues of comparability are addressed
at many points in the chapters that follow. The surveys are listed below; for
additional detail, see Appendix A.
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20 The Well-Being of the Elderly in Asia
The surveys conducted in collaboration with the project and which
form the major data base for the analyses which follow are listed below. Some
of the surveys covered those aged 50 or 55 and older but only the interviews
with those 60 and older are analyzed here. Additional details about their de
sign and execution are presented in Appendix A:
1989 Survey of Health and Living Status of the Elderly in Taiwan
(AM.049)
1993 Follow-up Survey of the Health and Living Status of the Elderly in
Taiwan (#=3,155)
1995 National Survey of Senior Citizens in Singapore (#=4,750)
1995 Survey of the Welfare of the Elderly in Thailand (#=7,708)
1996 Survey of the Health and Living Status of the Middle Aged
(#=2,462) and Elderly (#=2,669) in Taiwan
1996 Philippine Survey of the Elderly (#=2,285)
Detailed analyses of these surveys form the core of this monograph. How
ever, we also make select use of more recent panel data collected in 1999
when Taiwan conducted another round of interviews with the elderly and
near-elderly, and Singapore reinterviewed those first studied in 1995.
Archived Data and Publications
As much as possible, the data and publications that form the background for
this monograph have been made available for general use. A focus group data
archive is based at the Population Studies Center, University of Michigan.
The full set of transcripts, both in original language and English translation is
available by request. In addition many of the data files from the surveys also
are available for further analyses. See Appendix B for additional information
about the content of and access to these data archives.
A comprehensive bibliography for the project is given in Appendix C.
"Research Reports on the Elderly in Asia" was established at the University
of Michigan Population Studies Center (PSC) in 1990 as a working paper
series for the project. As of mid-2001, the series includes more than 50 items
representing a range of topics and analytic approaches. Many of these Re
search Reports, as well as other papers originating from the project, have
appeared as articles in peer-reviewed journals. In addition, overseas colleagues
have also produced a large number of reports and publications for in-country
circulation. The appendix presents a list of the Research Reports and describes
a website for identifying the papers, dissertations, and other publications ema
nating from this project.
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Aging in Asia: Facing the Crossroads 21
Impact
Going beyond the products we can claim as our own, we believe that the
project has had an important impact on the field. Demographers have been
recruited to study the elderly in the four countries and the United States Our
colleagues abroad have presented their work to a wide range of public, scien
tific, and government assemblies, and several are now involved with influen
tial government committees on the topic of aging. In addition, a number of
investigators initiating research on population aging in other countries have
drawn on our questionnaires as starting points. These include Bangladesh,
the People's Republic of China, Sri Lanka, South Korea, Malaysia, South
Africa, Egypt, and the multi-country Pan-American Health Organization spon
sored SABE project. The PSC Research Reports numbered 1,49 and 50 pro
vide complete questionnaires for the Taiwan surveys in 1989 and 1996. These
items are among the most frequently requested in the series.
REFERENCES
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and Population Policies: The Case of Japan." Paper presented at Expert Group
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Battistella, Graziano. 1995. "Philippine Overseas Labour: From Export to Man
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Bengtson, Vern L., Kyong-Dong Kim, George C. Myers, and Ki-Soo Eun, eds.
2000. Aging in East and West: Families, States, and the Elderly. New York:
Springer Publishing Company.
Casterline, John B., Linda Williams, Albert I. Hermalin, Ming-Cheng Chang.
Napaporn Chayovan, Paul Cheung, Lita Domingo, John Knodel, and Mary
Beth Ofstedal. 1991. "Differences in the Living Arrangements of the Elderly
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Chen, Ai Ju, and Gavin Jones. 1989. Ageing in ASEAN: Its Socio-economic Con
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48.
Gauthier, Anne H. 1996. The State and the Family: A Comparative Analysis of
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22 The Well-Being of the Elderly in Asia
Gruber, Jonathan, and David A. Wise, eds. 1999. Social Security and Retirement
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Hermalin, Albert I. 1993. "Fertility and Family Planning among the Elderly in
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Hermalin, Albert I., and Bruce A. Christenson. 1992. "Census Based Approaches
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H6hn, Charlotte. 1987. "Population Policies in Advanced Societies: Pronatalist
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Kinsella, Kevin and Yvonne J. Gist. 1995. Older Workers, Retirement, and Pen
sions: A Comparative International Chartbook. IPC/95-2, Bureau of the Cen
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Knodel, John, and Chanpen Saengtienchai. 1996. "Family Care for Rural Elderly
in the Midst of Rapid Social Change: The Case of Thailand." Social Change
26(2):98-115.
Lesthaeghe, Ron. 2000. "Europe's Demographic Issues: Fertility, Household For
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ing on Policy Responses to Population Ageing and Population Decline, Popu
lation Division, Department of Economic and Social Affairs, United Nations
Secretariat, New York, 16-18 October.
Martin, Linda G, and Samuel H. Preston (eds.). 1994. Demography of Aging.
Washington, DC: National Academy Press.
Martin, Philip L., Andrew Mason, and Ching-lung Tsai. 1995. "Overview." ASEAN
Economic Bulletin 12( 1): 117-124.
Massey, Douglas S., Joaquin Arango, Graeme Hugo, Ali Kouaouci, Adela
Pellegrino, and J. Edward Taylor, eds. 1998. World in Motion: Understand
ing International Migration at the End of the Millennium. Oxford: Clarendon
Press.
McDonald, Peter and Rebecca Kippen. 2001. "Labor Supply Prospects in 16
Developed Countries, 2000-2050." Population and Development Review
27(l):l-32.
Ministry of Community Development and Sports. 2001. "Baby Bonus." Singapore:
Singapore Government. Retrieved March 22,2001 from the World Wide Web:
http://www.mcds.gov.sig/HTML/home/faq.html.
Morrison, Peter A. 1990. "Demographic Factors Reshaping Ties to Family and
Place." Research on Aging 12(4):399-408.
Okunishi, Yoshio. 1995. "Japan." ASEAN Economic Bulletin 12(2): 139-162.
Peterson, Peter C. 1999. Gray Dawn: How the Coming Age Wave Will Transform
America and the World. New York: Random House.
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Aging in Asia: Facing the Crossroads 23
Phillips, David R., ed. 1992. Ageing in East and South-East Asia. London: Edward
Arnold.
. 2000. Ageing in the Asia-Pacific Region: Issues, Policies and Future
Trends. London: Routledge.
Raymo, James M. 1998. "Later Marriages or Fewer? Changes in the Marital Be
havior of Japanese Women." Journal of Marriage and the Family 60:1023-
1034.
Raymo, James M., and Jennifer C. Comman. 1997. "Labor Force Status Transi
tions across the Life Course in Taiwan, Singapore, Thailand, and the Philip
pines: 1970-1990." Comparative Study of the Elderly in Asia Research Re-
/jorrNo. 97-44, Population Studies Center, University of Michigan.
Retherford, Robert D., Naohiro Ogawa and Rikiya Matsukura. 2001. "Late Mar
riage and Less Marriage in Japan," Population and Development Review
27(1):65-102.
Sobieszczyk, Teresa. 2000. "Pathways Abroad: Gender and International Migra
tion Institutions in Northern Thailand." Unpublished Dissertation, Cornell
University.
Stern, Aaron. 1998. "Thailand's Migration Situation and Its Relation with APEC
Members and Other Countries in Southeast Asia." Human Resources Devel
opment Working Group Paper No. 011 (January). Bangkok: Institute of Asian
Studies, Chulalongkorn University.
Taiwan Provincial Institute of Family Planning, Population Studies Center, Uni
versity of Michigan, Institute of Gerontology, University of Michigan. 1989.
"1989 Survey of Health and Living Status of the Elderly in Taiwan: Question
naire and Survey Design." Comparative Study of the Elderly in Four Asian
Countries Research Report No. 1, Population Studies Center, University of
Michigan, Ann Arbor.
Uhlenberg, Peter. 1992. "Population Aging and Social Policy." Annual Review of
Sociology 18:449-474.
United Nations. 1982. World Assembly on Aging, (Vienna, Austria). New York:
United Nations.
United Nations. 2001. Replacement Migration: Is It a Solution to Declining
and Ageing Populations? ST/ESA/SER.A/206. New York: United Nations.
World Bank. 1994. Averting the Old Age Crisis. New York: Oxford University
Press.
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Chapter 2
THE DEMOGRAPHIC, SOCIOECONOMIC, AND
CULTURAL CONTEXT OF THE FOUR
STUDY COUNTRIES
JohnKnodel, Mary Beth Ofstedal, and Albert I Hermalin
In Chapter 1 we singled out three factors that have increased the focus
on population aging throughout East and Southeast Asia: the rapid
demographic changes, particularly sharply lower fertility, that have led to a
rapid rise in the proportions at older ages; the concurrently rapid socioeco-
nomic changes that challenge many traditional family arrangements; and the
interest of policymakers in these regions in fashioning appropriate policies
and programs to address these changes.
In this chapter we provide an overview of the magnitude and nature of
the demographic and socioeconomic changes, reserving a discussion of the
policies and programs in place and under discussion for the next chapter.
Though our analytic focus throughout the volume is on a comparison of the
four study countries, it is useful to start by placing the demographic dynamics
in the larger context of changes ongoing in Asia and to contrast the Asian
profile with that of Europe and the United States. Subsequent sections of the
chapter will then provide a more detailed demographic profile of the four
study countries as well as their socioeconomic changes.
25
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26 The Well-Being of the Elderly in Asia
Population Aging and Sociodemographic Change in World Context
Table 2.1 provides trends in three key demographic parameters for the three
broad subregions of Asia and for select countries within each, including the
four study countries. As is well known, the age structure responds primarily
to fertility levels and secondarily, once low fertility levels are reached, to
mortality. Accordingly the table presents 30-year trends in fertility and mor
tality, and the past and projected proportions for those aged 60 or older.
The most dramatic declines in fertility have taken place in East Asia,
where over a span of 25 years the total fertility rate fell from an average of 5.5
children per women to just 1.9, with little variation among countries. All
countries in this subregion currently have fertility rates below the population
replacement level. Southeast Asia also shows a sharp fertility decline on
average between 1965-70 and 1990-95, but the region exhibits considerable
variability, with some countries below the replacement level and others
remaining at high fertility. South-Central Asia shows the least reduction overall,
but significant fertility declines in the last 10 to 15 years are apparent in each
of the countries.
Improvements in life expectancy across Asia are no less dramatic. Be
tween 1965-70 and 1990-95, life expectancy at birth rose in each subregion
by about 10 years or more. East Asia shows the lowest level of mortality in
1995, with life expectancy at about 70 years. Southeast Asia has a life expect
ancy of 64 years overall, but considerable variation exists among countries.
South-Central Asia's life expectancy is about 60 years.
The effects of these rapid changes in fertility and mortality are reflected
in the proportions 60 or older, with the countries or subregions showing the
largest and earliest declines generally experiencing the highest proportions at
the older ages. In 1995, more than one-tenth of the East-Asian population was
60 or older, with Japan exceeding one-fifth. By 2030, it is projected that al
most one-fourth of the entire subregion will be in the older age category, with
Japan exceeding one-third and many other countries not far behind. Taiwan is
somewhat lower in fertility and higher in expectation of life than the regional
average in the most recent period, and its proportion 60 or older is somewhat
higher as well, and projected to remain so.
In both Southeast and South-Central Asia the proportion of the popula
tion 60 or older was approaching 7 percent in 1995 and is projected to ap
proximately double that by 2030. Reflecting their diverse fertility and mortal
ity trajectories, the countries within these regions will differ considerably in
age structure. For example, by 2030 Singapore and Thailand are projected to
exceed 30 and 20 percent above age 60, respectively, in keeping with their
low fertility levels. The other countries in Southeast Asia have lower projec-
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28 The Well-Being of the Elderly in Asia
tions corresponding to their higher fertility rates. In the Philippines, which
has the highest fertility in the subregion, only about 13 percent of the popula
tion is expected to be over 60 in 2030—a proportion similar to that found in
the other higher fertility countries in the region. Sri Lanka, which had a fertil
ity rate close to replacement level in 1990-95, is the only country in South-
Central Asia for which the estimate of those age 60 or older in 2030 approaches
20 percent.
The United Nations classifies the countries of the world as more devel
oped, less developed, and least developed, with the latter category a sub-class
of less developed (United Nations, 1999). A strong association exists between
level of development and population aging. In 1995,18.4 percent of the popu
lation in the more developed countries was aged 60 or over, as compared to
7.3 percent in the less developed countries and 4.8 percent in the least devel
oped. The medium-variant projection for 2030 estimates percentages of 29.2,
14.6, and 7.0, respectively, displaying sharp increases for all but the least
developed countries. All the countries of Asia, with the exception of Japan,
are in the less developed category, as are all countries of Latin America and
the Caribbean, and Africa. Among these three geographic regions, Asia has
the highest proportion of those 60 or older and is projected to maintain this
lead into 2030, although the differences between it and Latin America are
quite small as shown in the table below.
Percent of Population Age 60 or Over
*Medium Variant Projection
Source: United Nations, 1999, Vol. II, Table A.I
AfricaAsiaLatin America and the Caribbean19954.98.27.42030*6.917.215.7
A more detailed demographic comparison of Asia and Latin America,
including a discussion of differences in the level of attention given to popula
tion aging, is given in Hermalin (1995). But given the generally greater famil
iarity with trends and issues in population aging in the United States and Eu
rope, the tables that follow focus on comparisons with the more developed
regions.
Table 2.2 compares the United States, Europe, East Asia, and South
eastern Asia on a number of measures of population aging. The measures
chosen are designed to look at the age distribution of the older population, the
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Demographic, Socioeconomic, and Cultural Context 29
growth rates at different advanced ages, and elements of population size. In
the first panel we see that the proportion of the population 60 or older is
higher in the older industrial countries of the United States and Europe than in
Asia. In Europe, which is somewhat higher on this measure than the United
States and is projected to remain so, the proportion over 60 in 1995, at 19
percent, is almost twice as high as East Asia (at 10 percent) and almost three
times as high as Southeast Asia. The second panel of Table 2.2 presents the
age distribution within the older population (age 65 or older). As shown here,
there is also a much higher concentration of the "oldest-old"—those above
age 80—in Europe and the United States, with one in five of the older popu
lation above 80 in the former and almost one in four in the latter, in contrast to
about one in seven in the two Asian subregions. But these differentials are
projected to diminish considerably over the next 30 years. By 2030, the pro
portion 60 and over will approach 30 percent in Europe and 26 percent in the
United States, compared to 24 percent in East Asia and 15 percent in South
east Asia. The proportions aged 75 or older which are currently over 5 percent
in the United States and Europe will advance to 9 and 10 percent, respec
tively, by 2030; in East Asia, the proportion will triple from 2.2 percent to 6.6
percent, and in Southeast Asia it will advance two and a half times from 1.3 to
3.2 percent.
The implied growth rates and resulting population sizes shown in the
lower part of the table are quite revealing. In each of the four areas^ the growth
rates among the older population will be fastest at the oldest ages, leading to
further increases in the mean age of the 60-plus population. The rates of growth
will be considerably higher in East and Southeast Asia than in Europe and the
United States. Between 1995 and 2030, the average annual growth rate for
the 60-plus population is projected to be around 3 percent for the two subregions
of Asia, compared to 2 percent for the United States and 1 percent for Europe—
rates similar to those experienced between 1975 and 1995. The population 80
and older will be growing at an average annual rate of about 4 percent over
the next 30 years for the Asian areas and only about 2 percent in United States
and Europe.
Though these rapid rates of growth for the older population in parts of
Asia and elsewhere are often talked about from the standpoint of the speed
with which these areas are aging (for example, the number of years it takes a
country to double its population over age 65 from 7 to 14 percent is quite
frequently shown), from a policy standpoint attention must also be given to
the numbers involved. Although future fertility levels will largely determine
the proportion of elderly within each country, the number of elderly at any
given point is essentially a function of past births and mortality levels. Because
of the past large birth cohorts, Asian countries must anticipate a sharp increase
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32 The Well-Being of the Elderly in Asia
in the number of elderly. Some of the magnitudes involved are shown in the
bottom panel of Table 2.2. In 1995 the number age 60 and over in Europe and
the United States combined, 182 million, was about equal to the number in
East and Southeast Asia combined, at 179 million. By 2030, East and Southeast
Asia are projected to have 518 million over age 60, 76 percent more than the
combined total of the United States and Europe.
The changes at 80 and over are in some ways even more dramatic. The
numbers in Europe and the United States combined are projected to nearly
double, from 30 million to 56 million, but the numbers in East Asia and South
east Asia will be four times as large, advancing from 16 million to 65 million.
As a consequence, the number of oldest-old in the two subregions combined
will be 15 percent greater than the combined total of the United States and
Europe by 2030. It is also worth noting that in 2000, about 46 percent of the
world's population aged 75 or older was estimated to reside in Asia; and in
1998, the number aged 80 and over in China, India, and Japan combined was
estimated to be more than 22 million.
In addition to the rapid growth of numbers at older ages, the gender
imbalance that occurs at the older ages due to the differential in life expect
ancy between men and women merits attention. As of 1995, slightly more
than half of all those 60 or older were women but this proportion rises to two
out of three for those 80 or older in East Asia and six out of ten in Southeast
Asia. Older women in many parts of Asia currently have lower education and
labor force experience than men, less income and access to assets, and dimin
ished authority within the family. Though these conditions are changing to
some extent, these disadvantages make many women dependent on family
members and on public programs, especially at advanced ages and under con
ditions of illness or disability. These needs often place pressures on family
members for caregiving and may tax insufficiently developed public programs.
The current gender composition at older ages is not expected to vary
greatly over the next 50 years according to United Nations projections, given
current estimates of future life expectancy for each sex. They reveal that by
2050 both East and Southeast Asia will have about 85 males per 100 females
aged 60 or older, but only 59 males per 100 females among those 80 and
older. The improvements in life expectancy that have occurred in the past and
are projected for the future do alter the rates of widowhood, so that the pro
portion of the older population who are widows will continue to decline. The
changes that have occurred over the last 20 years for the four study countries
are shown below (in Table 2.6).
These changing proportions and numbers related to older populations
have strong policy implications, particularly in the provision of health and
social services. In many countries in Asia (and elsewhere in the developing
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Demographic, Socioeconomic, and Cultural Context 33
world), the health infrastructure has been largely attuned to addressing infant
and child mortality and infectious diseases, and providing family planning
and other reproductive services. The number of new medical, public health,
and social service programs, personnel, and facilities required to address the
needs of the older population are likely to put substantial strain on many econo
mies. (See Chapters 3 and 10 for additional discussion.) By contrast, insofar
as the relevant European and American infrastructures have expanded to meet
the past growth in their older populations, they may be able to adjust more
easily to the more modest rates of growth at the oldest ages projected for the
near future.
The question of costs and services is part of the larger question of the
effect of population aging on economic growth and productivity raised ear
lier. The demographic metric most often invoked as an indicator of popula
tion age structure effects on the economy is the dependency ratio. This ratio
relates the age segments of the population with little economic productivity
(defined in Table 2.3 as under age 15 or over age 64) to the age segment most
economically active (15-65). Although like many single measures it has its
controversial and ambiguous aspects (Schulz et al., 1991, Chap 3; World Bank,
1994, p. 35; Johnston, 1999), the differences between Asia, Europe, and the
United States in this regard are worthy of notice.
Table 2.3 contrasts the United States, Europe, and the two subregions
of Asia on the overall dependency ratio and ratios for both the younger and
older age components in the 1960s, the 1990s, and as projected to 2025-2030.
In the United States, as of 1990-95, the total dependency ratio was 52 people
either under age 15 or over age 64 to every 100 people between the ages of
15-64, compared to 50 in Europe, 49 in East Asia, and 68 in Southeast Asia.
As expected because of declining fertility rates, the portion of the depen
dency ratio due to the older population has been increasing over the past 30
years and the portion due to the younger population has been decreasing in all
regions. The overall ratio is affected by the magnitude of each component and
the rate of change. For the past 30 years, the decline in the younger age popu
lation more than offset the rise in the older population in the United States and
Europe, causing the overall ratio to fall. But over the next 25-30 years it is
expected that the decline in the younger age population will be limited while
the older age group will continue to grow, producing ratios similar to 1960
levels. The story in East Asia is similar, with the steep decline in the overall
dependency ratio expected to level off. In Southeast Asia, however, the later
onset of the fertility decline means that the overall dependency ratio is ex
pected to continue to decline through 2025-2030, as the decrease at younger
ages more than compensates for the increase at the older ages. It is of interest
that in the next 25 to 30 years, all four regions are expected to be fairly similar
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Demographic, Socioeconomic, and Cultural Context 35
in their total dependency ratios (ranging from 46 in Southeast Asia to 59 in
the U.S.) but sharply different in their indexes of aging, which represent the
ratio of the aged dependency ratio to the young dependency ratio (see row 4).
The changes in the overall dependency ratio and its components in
each region are a reflection of the magnitude and speed of the demographic
transition experienced in terms of fertility and mortality rates. An important
line of economic research has combined these resultant changes in age struc
ture with life cycle variations in savings and consumption to trace aggregate
effects on economic growth and investments (Coale and Hoover, 1958; Ma
son, 1987; Bloom and Williamson, 1998). A number of these analyses view
the sharp declines in the dependency ratios in East Asia experienced between
the 1960s and the 1990s as a "demographic gift" which contributed signifi
cantly to the high savings and economic growth rates this region generally
enjoyed over this period (Mason et al., 2001; Bloom and Williamson, 1998).
From this standpoint, those countries in Southeast Asia (and in other develop
ing regions) that are projected to have overall declines of dependency ratios
in the coming years can expect a stimulus to their economic growth if appro
priate policies are in place. For the United States, Europe, and portions of
East Asia where the ratios are projected to level off or increase, their gener
ally higher per capita incomes should make it easier to adjust to the changes
in age composition. A more detailed discussion of these and other economic
models, which relate the effects of population aging to aspects of economic
growth, is presented in Chapter 4.
Demographic, Socioeconomic, and Cultural Context of the Four Study
Countries
We turn now to the social, cultural, economic, and demographic settings of
the four study countries as they bear on the circumstances of the elderly within
their populations. In all four countries the current elderly populations have
lived through rapid demographic, social, and economic changes. In important
respects these changes have operated in similar directions in each of the coun
tries. Yet, because they occurred at different paces, were conditioned by dif
ferent cultural settings and political conditions, and evolved from different
levels of Socioeconomic development, these changes have resulted in vari
able circumstances for the elderly populations in the four countries. The cur
rent demographic, socioeconomic, and cultural contexts are characterized by
a combination of common and contrasting features that shape the behavior of
the elderly and condition their relations with their children, relatives, and com
munities.
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36 The Well-Being of the Elderly in Asia
In addition to reviewing the broad settings, we describe some basic
socioeconomic and demographic characteristics of the elderly who constitute
our samples. We draw both on the four major surveys that provide the basis of
the analyses and on other more standard sources.
Political and Cultural Setting
The political and cultural context has played an important role in defining the
nature and magnitude of demographic, social, and economic changes in each
of these countries, and in shaping the family, social, and productive lives of
their populations. The four countries represented in this study have distinc
tive political histories and cultural underpinnings, yet they share a number of
significant cultural mores—such as the centrality of the family in social life
and in support for the elderly. In this section we provide a brief review of the
political history and cultural context for each country.
Philippines
The Philippines is an archipelago of 7,100 islands stretching almost a thou
sand miles. It is comprised of three major island groups, Luzon in the north,
Mindanao in the south, and Visayas in between, and it is separated from the
mainland Asian continent by the South China Sea to the west and the Philip
pine Sea to the east.
The Philippines was originally inhabited by Malay and Negrito groups.
Centuries of pre-colonial cultural and commercial contact with other coun
tries in Asia, including China and India, and almost four hundred years of
western colonization have produced a culture that is a blend of eastern and
western influences. In the 16th century the Philippines became a colony of
Spain, some 40 years after the historic circumnavigation of the globe by
Ferdinand Magellan and his documentation of the archipelago, which he named
after the Spanish King Philip II in 1521. Spain occupied the country for 333
years (1565-1898). After a brief period of independence following the Philip
pine revolution of 1898 the country was next colonized by the United States
from 1899 up to the start of World War II, when the Japanese invaded the
country and ruled from 1942 to 1945. The Philippines became an independent
nation in 1946 (Agoncillo, 1990).
The most tangible legacy of Spanish rule is Catholicism, which is pro
fessed by a large majority of the Filipino population. The Catholic religion
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Demographic, Socioeconomic, and Cultural Context 37
has had a pervasive influence on Philippine culture. For example, the Church
actively advocates against artificial contraception and the Philippines is one
of the few countries where divorce has not been legalized. Although Islam
was introduced to the country in the 14th century by Arab traders via the Malay
Peninsula to the south, the subsequent Spanish colonial settlements in the
northern and middle parts of the archipelago arrested its northward spread. To
this day Mindanao, which was never colonized by Spain, is the only Muslim
area in the Philippines.
The Philippine^ island geography and mountainous topography have
contributed to the development of dozens of distinct languages, all belonging
to the Austronesian family of languages. Of the many languages, five may be
considered major, and one, Tagalog, became the basis of the national lan
guage Filipino. English is also used widely throughout the archipelago, a legacy
of American rule.
A major characteristic that Filipinos share with their Asian neighbors
is the primacy of the family in social life. Kinship is of bilateral descent with
both maternal and paternal kin given equal importance in defining links be
tween generations. This system ensures a large pool of potential sources of
economic, emotional, and social support among kin (Castillo, 1977; Lopez,
1991; Medina, 1991). Other cultural values support the kinship system as a
social alliance system by which members enter into reciprocal ties. These
values include the maintenance of smooth interpersonal relations manifest in
the avoidance of open disagreement, the observance of debts of gratitude (utang
na loob) to those owed favors, and the avoidance of behaviors that bring shame
(hiyd) to one's self and to family (Lopez, 1991).
Utang na loob are debts generally repaid "with interest" rather than
discharged in kind (Hollnsteiner, 1973). This type of debt is most evident in
the parent-child relationship, whereby children are expected to be grateful to
parents for having given them life itself. This lays the groundwork for the
cultural expectation that children should care for elderly parents. Failure to
repay utang na loob is sanctioned by hiya, the feeling of shame and social
discomfort that comes from knowing that one is in a socially unacceptable
position (Lynch, 1973). Respect for all older persons is also a fundamental
value.
The culture does not proscribe specific differential treatments of chil
dren according to their gender, and makes no gender-based distinctions in
matters of property ownership and inheritance. All children inherit equally
from parents. Similarly, all are expected to repay debts of gratitude to their
parents by caring for them in their old age (Medina, 1991).
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38 The Well-Being of the Elderly in Asia
Thailand
Thailand is the only Southeast Asian country never to have been colonized by
a Western power. The government has been a constitutional monarchy since
1932 when the absolute monarchy was ended though a bloodless revolution.
Despite the democratic aims of the 1932 revolution, Thailand has since been
ruled under various degrees of military dictatorships with frequent coup d'etats
replacing one military clique with another (10 successful coups out of 19
attempts have occurred since 1932). Thailand experienced a brief period of
relative democracy from the early to mid-1970s, which ended in a violent
overthrow of the elected government and the installation of a short-lived ultra
right wing government by the military. During the 1980s, military influence
weakened, although again an elected government was overthrown by a coup
in 1991. Since 1992, when massive popular demonstrations against an
unelected military prime minister resulted in his resignation, parliamentary
democracy has become more firmly established.
The Thai population is relatively homogeneous in major cultural as
pects. The vast majority are ethnic Thais and speak some form of the Thai
language; about 95 percent profess Buddhism, typically of the Theravada
branch. Still, numerous minorities can be defined in terms of ethnicity, lan
guage, or religion. Muslims constitute approximately 4 percent of the popula
tion and make up the largest and most notable religious minority. Christians
and Hindus constitute less than one percent each. According to the 1990 cen
sus, most Muslims (81 percent) live in the southern region, and about half
speak Malay rather than Thai; the remaining Muslims reside mainly in Bangkok
and the central region (Knodel et al. 1999). The Malay-speaking Muslims are
ethnically and culturally quite distinct from the ethnic Thai majority and con
siderably less assimilated than Thai-speaking Muslims. According to the 1995
Survey of Elderly in Thailand, 3 percent of the respondents age 60 and over
indicated they were Muslims and about half of these indicated they spoke
Malay.
A particularly influential ethnic group is the Chinese and Thai-Chinese,
though it is difficult to estimate their numbers with any precision. Indeed,
because considerable assimilation including extensive intermarriage has taken
place, there is no agreed-upon definition of Chinese ethnicity in Thailand.
Various estimates suggest they constitute from 7 to 12 percent of the total
population (Kaplan, 1981). They tend to reside in the urban areas and to be
involved in commercial activities. According to the 1995 Survey of Elderly in
Thailand, about 4 percent of the population aged 60 and over identified
themselves as Chinese and another 9 percent as mixed Thai and Chinese.
Although some older Chinese still speak their native dialect, these cohorts are
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Demographic, Socioeconomic, and Cultural Context 39
dying out. Younger cohorts are all fluent in Thai and indeed many no longer
can speak Chinese. Other numerically smaller minorities include Indians and
Pakistanis, who are engaged largely in trade, Cambodians concentrated largely
along the border areas near Kampuchea, Vietnamese living largely in the
northeast, and a variety of hill tribes located mainly in the mountainous regions,
especially in the northwest.
Four regional dialects are spoken in Thailand: central, northeastern,
northern, and southern versions of the Thai language. The official language is
the central dialect, which is spoken throughout the central region, the lower
north and parts of the upper south. It is generally understood throughout the
country, although older people are more likely than younger persons to feel
uncomfortable conversing in it. The other regional dialects are only partially
mutually intelligible. The northeastern dialect is very similar to Laotian. Nu
merous small minorities speak their own distinctive (not mutually intelligible)
languages including versions of Cambodian and numerous tribal languages
such as Hmong and Karen. Because all residents must attend school taught in
the Thai language, younger generation members of non-Thai ethnic groups
understand Thai, but their elders often have only minimal mastery.
As in other southeast Asian countries, in Thailand the family tradition
ally assumes primary responsibility for the elderly. A moral obligation for
adult children to support and care for their elderly parents pervades Thai cul
tural values and provides a strong normative basis for the prevailing pattern
of familial support. As noted in Chapter 3, this responsibility is reflected in
both the laws of the land and in the formulation of social policy. Focus group
research indicates that both elderly parents and their adult children share similar
views regarding this sense of responsibility and that it is found in all regions,
transcending economic status or rural-urban residence (Knodel, Saengtienchai
and Sittitrai 1995).
Age relationships are an important part of Thai culture firmly embed
ded in the language. Forms of address typically incorporate acknowledgement
of who is more senior, and many terms identifying kinship distinguish who is
older and younger than the reference person. In general, respect for seniority
in age is an integral part of Thai culture and traditionally older persons are to
be treated with respect. These traditional values have likely changed in recent
decades, especially in practice, but systematic evidence to determine the ex
tent and nature of such change is still lacking.
Ethnic Thais tend to be matrilocal, preferring to live with a married
daughter than a married son (especially those in the northeast and upper north,
essentially the areas coterminous with the regional dialects) (Knodel,
Saengtienchai, and Sittitrai, 1995). At the same time Thais tend to be to rela
tively flexible in this matter, living with a son if no daughter is available
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40 The Well-Being of the Elderly in Asia
(Knodel, Chayovan and Siriboon, 1992). Inheritance is bilateral with chil
dren typically inheriting equally, except for children remaining with their
parents, who commonly gain the house and perhaps an extra share of the
land. Ethnic Chinese and those Thai-Chinese who still identify strongly with
their Chinese heritage, however, tend to be patrilocal.
Repaying parents is generally viewed by Thais as a continual obliga
tion that starts when the children are old enough to provide meaningful help—
long before parents reach old age. Accordingly, the care and support provided
by children when their parents are too old to take care of themselves is viewed
as the culmination of this process. Underlying the obligation to repay parents
are the concepts of katanyu katawethi and bunkun, both of which are firmly
ingrained in Thai Buddhist culture and have no simple English equivalents
(Rabibhadana, 1984; Podhisita, 1985). Both terms relate to reciprocation of
actions around a sense of gratitude and debt. Katanyu refers to a constant
sense of awareness on the part of someone for benefits that another person
has bestowed upon him. Katawethi refers to doing something in return for
them. Bunkun characterizes the person who bestows favors that incur a sense
of gratitude and debt on the beneficiary.
The concept of katanyu katawethi usually refers specifically to parent-
child relationships while bunkun extends to many realms of life. Both con
cepts, however, characterize the essence of the relationship between parents
and children. Giving life to and raising a child provides parents with the epitome
of bunkun and instills a sense of gratitude and debt in the child that is virtually
impossible to repay completely. This bunkun parents have in relation to chil
dren directly leads to the sense of obligation adult children have to provide
support and care to them when the parents are in their elderly years. Although
Thai Muslims do not describe filial piety in these same terms, they also have
a strong sense of obligation to parents that is deeply rooted in their religion.
Indeed throughout much of east and southeast Asia, there are similar cultural
prescriptions related to the obligation to repay parents especially when they
reach older ages and can no longer support and take full care of themselves
(Asisetal., 1995).
Taiwan
Taiwan is an island approximately 100 miles from the Chinese mainland that
comprises about 4.25 million square miles of land area. The island is mostly
mountainous with dense population concentrations in cities. The total popula
tion of Taiwan was 22 million in 1999, 5 million of whom lived in one of the
three major cities in Taiwan: Taipei, Kaoshiung, and Taichung.
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Demographic, Socioeconomic, and Cultural Context 41
For many thousands of years prior to 1500, Taiwan was inhabited ex
clusively by the Taiwan Aborigines, a population group that shares cultural
features with certain groups in Oceania and the Philippines (Fricke, Chang,
and Yang, 1994). Taiwan was annexed by China only in 1682. Major waves of
Chinese settlement from the 17th through the 19th centuries brought two main
Chinese dialect groups to the island: the dominant Hokkien speakers who
migrated in from neighboring Fujian province and tended to settle in the coastal
and valley regions, and the Hakka speakers who predominantly came from
Guangdong province and who, as a result of their later arrival, tended to clus
ter in upland and hilly areas. Customarily these two groups are referred to as
Taiwanese. By the 19"1 century the aborigines had been decimated, with sur
viving communities driven into remote mountainous areas. For the most part,
the Chinese settlers tried to recreate on the island the social and cultural forms
of their home communities on the mainland, and they considered themselves
part of China. By the end of the 19th century the Chinese population of Taiwan
numbered over 2.5 million, and in 1885 the island was elevated to provincial
status within China, with its capital in Taipei.
With China's loss in the Sino-Japanese War of 1894-95, the second
distinctive phase began. Taiwan was ceded to Japan, which ruled it as a colony
from 1895 to 1945. Japan introduced a number of kinds of modernization to
the island during its period of occupation, including expanded transportation
and communications, increased education, and broadened public health ef
forts. Yet, the occupation of Taiwan by Japan did little to change basic family
organization or to alter the basic structure of rural society (Barclay, 1954;
Cohen, 1976; Hermalin, 1976). Following World War II, the period of Chi
nese territorial unity lasted only five years, until 1949, at which point the
victory of Mao Zedong and his followers in the Chinese Civil War drove the
remnant Nationalist forces into exile in Taiwan, where they formed the Re
public of China, a rival regime that continues to exist.
The Taiwanese family system is based on the patrilineal Chinese kinship
system that was brought to Taiwan by the migrants from Southeastern China.
Under this system, inheritance is passed through the male line and the
availability of male heirs is vital to the continuance of the lineage. (Although
daughters often received a substantial dowry, they were not entitled to a share
of the inheritance until after post-World War II, and even then many women
voluntarily signed away their share (Lee, 1999). Whereas daughters typically
leave their natal families to join their husbands' families upon marriage, sons
were expected to remain in the family household, eventually assume
responsibility for the family farm or business, and provide care for their parents
in old age. The household ideal called for several married sons and their families
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42 The Well-Being of the Elderly in Asia
living together in the same household with the older parents (Cohen, 1976;
Wolf, 1968). For various reasons including economic considerations this ideal
was rarely achieved (Cohen, 1976; Wolf, 1968; Freedman, 1958), but it was
and still is quite common for older parents to live with one married son and
his family.
The intergenerational contract in Chinese society is governed by strong
norms of filial piety, which stress the primacy of children's relationships with
their parents (Cornman, 1999). Children are expected to be obedient and sub
servient to their parents, particularly their father, throughout their lives. Par
ents provide care for children with the expectation that their children will
support them in old age, making it a moral obligation. Given the gender dif
ferences in family membership under the patrilineal family system, parents
primarily expect old-age support from their sons, although women as daugh
ters-in-law are expected to show respect to and support their husbands' par
ents. Despite this strong patrilineal system, Chapter 6 reveals that daughters
also provide considerable assistance to older parents.
Over 90 percent of the Taiwan population are Buddhist, Confucian, or
Taoist, with about 5 percent Christian.
Singapore
Singapore is a city-state located at the southern tip of the Malaysian Penin
sula. The country is comprised of one main island, which is separated from
Peninsula Malaysia by the Straits of Johor, and roughly 60 smaller islands for
a total land area of about 250 square miles.
During the early stages of its history (around the end of the 14th cen
tury), Singapore was caught in the struggles between Thailand (then Siam)
and the Java-based Majapahit empire for control over the Malay Peninsula,
and eventually the island became part of the Malacca Sultanate. In 1819 the
British established a trading post in Singapore and in 1824 Singapore's status
as a British possession was formalized, an arrangement which continued
through 1959, except for a 3-year period during World War II when Singapore
was occupied by Japanese forces. An unsuccessful attempt by the Communist
part of Malaya to take over Singapore by force in 1948 led to a 12-year state
of emergency, but Singapore eventually attained self-government in 1959. In
1963 Singapore merged with Malaya, Sarawak, and North Borneo to form
Malaysia, but the merger was short-lived and Singapore was separated from
the rest of Malaysia in 1965. Since 1965 Singapore has thrived as a sovereign,
democratic, and independent nation.
Singapore's population is multicultural, descended primarily from im
migrants from the Malay Peninsula, China, the Indian sub-continent, and Sri
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Demographic, Socioeconomic, and Cultural Context 43
Lanka. The total population of approximately 3 million consists of 79% Chi
nese, 14% Malays, 6% Indians, and 1% Eurasians (General Household Sur
vey, 1995). Social policies and services for the population tend to be concep
tualized from a multicultural perspective, and sensitivity to the worldviews of
these various cultures is considered important. Cultural aspects that are of
particular relevance to this study are highlighted for each of the major ethnic
groups below.
The Chinese have a pragmatic, achievement-oriented world view em
phasizing the importance of contributing to family and society. Confucian
values and principles such as a strong work ethic and maintenance of hierar
chical relations between the individual, family, and state form the basis of
society. The present cohort of elderly Chinese in Singapore consists largely of
believers in Taoism, Buddhism, and Confucianism, with a small minority of
Christians. Many of them believe in ancestor worship, a system of beliefs and
rituals that ascribe high status to ancestors. Older family members are re
spected because they are perceived as "future ancestors." The elderly are ex
pected to behave with propriety and their descendents, especially the sons,
are expected to be filial. The Chinese subscribe to a patriarchal and patrilineal
family system, under which males in the household are the main providers
and decision makers. However, as a result of social changes the balance of
power between the genders is being re-negotiated.
The centrality of Islamic religion and family is a distinguishing cul
tural feature of the Malays. The bilateral, egalitarian family system differenti
ates this community from the patrilineal Chinese and Indian ethnic communi
ties. Malay elderly are respected for their religious knowledge and actions;
their status is increased, for example, if they have performed the haj (pilgrim
age) to Mecca. The Muslim doctrine advocates each devotee to remember
that after death he will have to face judgment before God, and therefore he
must conduct his life according to the principles of the religion. Older Malays
tend to avoid being burdensome to their children by striving to be as indepen
dent as possible, although a large proportion of elderly Malays live with mar
ried daughters and sons-in-law.
Although the Indian ethnic group is characterized by a high level of
heterogeneity across linguistic, religious, and regional boundaries, certain
cultural similarities such as dressing, food, and music bind its members. The
majority of Indians follow the Hindu religion, which emphasizes reincarna
tion and the law of karma (or principle of cause and effect). Within Hinduism,
the spiritual search for the upliftment of one's soul is emphasized. In daily
living, the family assumes great importance in the life of each person. Apart
from Hinduism, a considerable proportion of Indians are Muslims, followed
by Christians. Among Indians, some differences exist between those who
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44 The Well-Being of the Elderly in Asia
have their roots in North India and those whose ancestors came from South
India. North Indians tend to be more conservative and the dominance of the
male in the household is emphasized. The traditional norms seem to be chang
ing faster among South Indians, and women tend to be more liberal. Never
theless, the patriarchal system is still prevalent among most Indian house
holds, except for the Malayalee sub-community. The Indian community is
similar to the Malay community in the emphasis of religion in daily life. How
ever, it is more similar to the Chinese community in the linguistic divisions
that exist, unlike the Malay community which is united by a common lan
guage (although some variations exist such as Javanese and Boyanese Malay).
Demographic Change
Table 2.4 shows the past and future trends of key demographic indicators
related to population aging in the four countries. For all but Taiwan they are
based on the United Nations medium variant projections as presented in the
1998 revision (United Nations, 1999). Although projections of population
dynamics for 30-50 years in the future of necessity rely on strong assump
tions, they can still illustrate some of the major patterns likely to emerge.
As indicated by trends in the total fertility rate, all four countries have
experienced significant fertility decline. Indeed this is the primary demographic
force underlying the inevitable population aging that is underway. Thailand,
Taiwan, and Singapore were all experiencing total fertility rates slightly below
2 births per woman in 1995, and thus have already fallen below replacement
level fertility (which, at present mortality levels, corresponds to a total fertility
rate between 2.1 and 2.2). The Philippines, however, has not experienced a
similar degree of decline and in 1995 had a total fertility rate approximately
twice the level of the other three countries. Current fertility levels in Singapore,
Taiwan, and Thailand are very similar, and are projected to remain so for
some decades. Nevertheless, the timing of the declines in these three countries
have differed significantly over the past few decades, with Singapore reaching
low levels first and Thailand last.
The different paths toward low fertility have important ramifications
for the course of population aging, as is evident from the differences among
the four countries in the proportions of their populations aged 60 and older.
Most striking is the much slower and more moderate levels of aging that char
acterize the Philippines' population compared to the other countries. Even by
2020, the projections suggest the elderly will still constitute less than one in
ten Filipinos, whereas both Taiwan and Singapore will have exceeded this
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Demographic, Socioeconomic, and Cultural Context 45
level two decades earlier. The concentration of Thailand's fertility decline in
a more recent period means that population aging there will lag behind
Singapore and Taiwan by about a decade. Taiwan's age pyramid is influenced
by massive migration of military personnel in 1949 when the Nationalist sol
diers left the communist mainland for Taiwan. The migrants were predomi
nantly males in their 20s and 30s who married at low rates. This event has
contributed significantly to population aging in Taiwan and accounts for why
Taiwan currently has a higher percentage aged 60-plus than Singapore, even
though Singapore experienced a somewhat earlier decline in fertility. Never
theless, with the possible exception of the Philippines, the pace of population
aging to be experienced by the countries under study will be extremely rapid
compared to the historic experience of the West (Jones, 1993). If the projec
tions are correct, Singapore, Taiwan, and Thailand will see the share of their
60-plus population double, from 10 to 20 percent, within about two decades,
with this change taking place somewhat earlier in Singapore and Taiwan (2000-
2020) than in Thailand (2010-2030).
Major decreases in mortality levels have occurred in the study coun
tries over the last half of the 20th century. Life expectancy at birth has risen 20
years in all four, and both Singapore and Taiwan now have life expectancies
comparable to those in North America. Although mortality levels are not as
favorable in the Philippines and Thailand, life expectancy at birth in both is
somewhat above the regional average for Southeast Asia (see Table 2.1). Con
tinued mortality improvement is expected in the next few decades, although
at a more moderate pace, with much of it concentrated at the older ages since
levels at younger ages are already quite low.
The past and future improvements in mortality translate into increased
survival rates to older ages and thus an increasing number of elderly persons.
Combined with the high fertility rates of the past, the result is unprecedented
growth in the numbers of elders in each country. For example, during the
quarter century between 1970 and 1995, the size of the population age 60-
plus more than tripled in Taiwan (reflecting in part the aging of the special
cohorts of military migrants referred to above) and much more than doubled
in the other three countries. These rates of growth are far higher than those for
the overall population, accounting for the elderly's increasing share of the
population, and are anticipated to continue unabated for some time (see the
last three columns of Table 2.4). Thus, the number of persons 60 and older is
projected to more than double once again during the quarter century between
1995 and 2020 in all four countries, and perhaps more than triple in Singapore,
despite falling rates of overall population growth. In addition, the elderly popu
lation itself is beginning to age in each country and will continue to do so
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^mots.r-00CO*'NOm^NOr-r-
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r- vo CN in m invo"u **^^ CN t^^ m vo m r*-— r- CN — CN d r-r^ Tt CN Tt CN Ttinoo CN vo in m — r-— vo ^ Tt 06 Tt tsr- ^i ^ ^ Tt -- Ttoo — • CN ™ r*; m r^- £ $ £J 3 £J TJCNoo r- in ov r- o ts-^ Tt -H o o « vdCNOO O Tt NO O CN — '— • Tt ^ ^^ vo c> om o O r-; oo vo r^ts CN ts vo m vo r-r*^ s CO inO vo O CN O ooTt 00 2 Tt — Tt —oo Tt — • r- m oin Tt °° Tt C*S Tt OOp vq ^ CN O^ Tt O;m r^t n r-*uv *^8± -82
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|Ii!iillH^^ V^ PN C*i ir i "^ OM ^ r* ^ rs vb on^
oo ^l m m m vo™40N NO - Tt vo NO— O SS Tt C> C> TfOO J5v CN Tt CN T>^^ to — 0N m —^H Ov « i/S ^" CN Or- vo m vo m vo- pi ?2S3» ?r- Tt mr- CN m— NO & ON — OO OOr- ° •* mOO CO Tt CO ^3 NO^^ in '/^ oo CN r- ONr- tVj Tt mOO CO ^ CN — f; NO— • — r*-' r- i— o rir- — - m inm 06 ?J vi d m. ^^vo ^ m r-in in 1 ^ m oo oin Tt CN m oi m d
vo vo fi ooTt Tt r-; Tt CN 0vd o 3 m ve i Tt m
vo ^ m r-oin-aporeTotal fertility rateb
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# permens a-e rt0+ ( m e s_0;
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% of elderly a-e _+
Old-a-e dependemey ratio
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48 The Well-Being of the Elderly in Asia
through the early decades of the 21st century. Singapore, Taiwan, and Thai
land have already experienced some aging of their elderly populations be
tween 1970 and 1995, with the increase in the percent of elderly age 70-plus
being most marked in Singapore and least in Thailand. Although the elderly
population in the Philippines has aged little during the 20th century, it is pro
jected to begin aging quite rapidly beginning in 2020.
Two of the dependency ratios presented earlier for several regions are
also presented in Table 2.4 for the four countries under study. These are the
old-age dependency ratio, which relates the population aged 65-plus to the
working age population (15-64), and the overall dependency ratio, which re
lates the population under age 15 and aged 65-plus to the working age popu
lation. The changes in age structure that are taking place in the study coun
tries translate into changes in both dependency ratio measures. The faster
growth of the older population relative to population in the working ages
leads to increases in the old-age dependency ratio. Although the ratio was
fairly low in all four countries up to 1995, by the end of the projection period
in 2030 it has increased substantially in each, although to varying extents. On
one extreme is Singapore, where by 2030 the older population is anticipated
to be about 36 percent the size of the working-age population. On the other
extreme is the Philippines where the older population is anticipated to be only
11 percent the size of the working-age population.
Changes in the total dependency ratio do not necessarily follow those
for the old-age dependency ratio, because recent fertility trends have a large
impact on the number of persons under age 15. In all four countries the total
dependency ratio has fallen during the course of the recent fertility declines.
So far, lower fertility has more than compensated for the rapid growth of the
elderly. Thus, the overall dependency ratios in 1995 are substantially below
those of several decades earlier. However, in all but the Philippines, the fertil
ity declines appear to have plateaued and are projected to remain low and
relatively stable, which means that the anticipated continued growth of the
older population will cause the overall dependency ratios to rise in Singapore,
Taiwan, and Thailand. Within the timeframe shown, this will occur first in
Singapore and last in Thailand; only the Philippines, where fertility decline
lags, will fail to experience a rise in the ratio. Even given these increases, it is
worth noting that the overall dependency ratios projected for all four coun
tries will be lower than the ratios these countries experienced in 1950, prior to
the onset of their fertility decline. As discussed in Chapter 4, these past trends
and future projections have a number of important implications for under
standing past economic growth trends and possible future trajectories.
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Demographic, Socioeconomic, and Cultural Context 49
Socioeconomic Change
The demographic trends of the past decades that have precipitated unprec
edented increases in the elderly population have been accompanied by rapid
social and economic changes with potentially profound implications for the
circumstances under which the future elderly will live. Many of these changes
are anticipated to alter the patterns of familial support for the elderly that have
traditionally prevailed in much of the world, including the four countries un
der study. The forces most commonly cited as potentially undermining famil
ial support include the increased economic activity outside the home by women
(the predominant caregivers); the physical separation of parents and adult
children associated with urbanization and increased migration; and ideational
changes, especially Western-style individualism spread through mass media
and public education (Mason, 1992; Martin, 1989 and 1990; Caldwell, 1982).
At the same time, some believe that rising incomes will permit adaptations to
past arrangements that might leave both generations of elderly parents and
adult children better oile For example, higher incomes might allow a shift in
living arrangements from literal coresidence to separate but nearby dwell
ings, thus continuing to meet the same needs of both generations but enhanc
ing their privacy as well.
The economic crisis that began in mid-1997 and swept much of the
region notwithstanding, all of the study countries except the Philippines have
experienced rapid economic growth over the past few decades. As shown in
Table 2.5, the gross national product (GNP) grew by more than 5 percent per
year on average in Singapore and Thailand and more than 8 percent per year
in Taiwan during the quarter century between 1970 and 1995. Only in the
Philippines has growth been rather stagnant. By 1995, however, substantial
differences are evident among the four countries in the level of economic
progress achieved. The per capita GNP in that year (in U.S. dollars) varied
from just over $1,000 in the Philippines to almost $27,000 in Singapore. Al
though per capita GNP in Taiwan is only about half that of Singapore, both
countries have become newly industrialized and enjoy levels of income far
above those of either the Philippines or Thailand. To some extent the differ
ences in average income as measured by per capita GNP are moderated by
differences in purchasing power, as indicated by the purchasing power parity
indices. In both the Philippines and Thailand, relatively low costs of living
increase their purchasing power, while in Singapore the opposite holds. Nev
ertheless, substantial differences remain among the four countries even after
purchasing power is taken into account.
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50 The Well-Being of the Elderly in Asia
The countries also vary substantially in terms of the other social and
economic indicators provided in Table 2.5. In all, the percentage of the labor
force in agriculture decreased between 1970 and 1990, although in the city
state of Singapore agriculture was of negligible importance even at the earlier
date. As with indicators of per capita economic levels, the Philippines and
Thailand differ considerably from Singapore or Taiwan in agricultural labor,
with the former countries maintaining a significant portion of their labor force
in agriculture compared to a decline to low or no proportion in the latter
countries. The Philippines, Taiwan, and Thailand have experienced substantial
increases in the level of urbanization over the last few decades, reflecting net
rural-to-urban migration as well as rural-to-urban reclassification of some areas.
Nevertheless, the three countries vary substantially with respect to their present
levels of urbanization, which correspond roughly to the percentage engaged
in agriculture. Although definitional differences also affect such figures, it is
clear that at present Thailand is the most rural of the three with only a minority
of the population in cities and towns, the Philippines is more intermediate,
and Taiwan is already substantially urbanized.
Definitional differences create problems for comparing the four coun
tries with respect to women's participation in the labor force. Nevertheless, in
all but Thailand, where the participation rates are by far the highest, Table 2.5
shows a trend towards increased labor force participation among women. In
1970, about one-quarter of women in Singapore and one-third of those in the
Philippines and Taiwan were in the labor force; by 1995 the portion had risen
to about half in all three countries.
Although all four countries have seen rapid increases in education in
recent decades, they vary in terms of the secondary school enrollment ratio, a
measure that relates the number of secondary school students to the entire
population within the relevant age range. In 1995, the proportion of eligible
children enrolled in secondary education was 96 percent in Taiwan, more
than three-quarters in the Philippines and Singapore, and more than half in
Thailand. It should be noted that, in all four countries, primary school atten
dance is virtually universal and has been so for several decades.
With regard to the average age at which men and women enter their
first marriage, the trend in all four countries has been towards a rising age at
marriage, particularly for women. Increases in women's age at marriage have
been particularly pronounced in Singapore and Taiwan. In none of the coun
tries is early marriage prevalent; most women currently wait until the early or
mid-twenties and men often until the latter twenties to first marry.
Finally, Table 2.5 presents two indicators of health service availability,
namely the ratio of the total population to the number of practicing physicians
and to the number of hospital beds available. In all countries except the
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Table 2.5. Key Social and Economic Indicators, 1970-95
Annual percent growth
in GNP, 1970-95GNP per capita 1995 (US$)Purchasing power parity
1995 (US$)Percent of labor force hiagriculture19701990Percent living hi urban areas
1970
1995Percent of females (15 andover) active in labor force19701980
1995Gross enrollment ratio forsecondary school enrollment
(as % of eligible age group)
197019801995Mean age at marriage
Males19701990Females19701990Health indicatorsNumber of people per
physician
19801993Number of people per
hospital bed
19801993Philippines0.61,0502,850584533
543548C
4946647925.426.822.823.87,8488,273589780Thailand5.22,7407,540806413
207377
69d17295524.726.022.023.56,8034,416651765Taiwan8.412,3%14,700"371338b
58"3639
4554809628.829.822.826.51,516892446208Singapore5.726,73022,77030100
1002643
50465876e27.830.024.227.01,111714239275
Sources: World Bank, World Development Indicators 1997; World Bank, World Development Report,
various years; United Nations, World Urbanization Prospects: The 1996 Revision; International Labour
Office, Yearbook of Labour Statistics; United Nations, Demographic Yearbook, various years; Statistical
Yearbook of the Republic of China, various years; Central Intelligence Agency, World Fact Book, 1997;
Yearbook of Labor Statistics, Republic of China, various years; Taiwan-Fukien Demographic Fact Book,
various years; Taiwan Statistical Data Book, 1996.
1 Figure for 1996. b % living in localities of 100,000 or more. c Interpolated between 1978 and 1983.
d Adjusted from data on 13+ population. c 1997 (data from World Development Report, 2000-2001).
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52 The Well-Being of the Elderly in Asia
Philippines, the availability of physician services improved between 1980 and
1993, as evidenced by a decline in the ratio of people per physician. Availability
of physician services is highest in Singapore and Taiwan, and considerably
lower in Thailand and the Philippines. Availability of hospital beds shows a
similar pattern across countries, with availability in the latest period being
highest for Taiwan (ratio of 208) and Singapore, and lowest in Thailand and
the Philippines. Availability of hospital beds deteriorated somewhat in all
countries except Taiwan between 1980 and 1993.
Changing Characteristics of the Elderly
As a result of the demographic, social, and economic changes that have taken
place in the four countries, the elderly themselves have changed in important
ways. Table 2.6 illustrates some of these changes. The improvements in health,
which are reflected in increases in life expectancy at birth and increasing
proportions surviving to reach the elderly age span, have also meant that the
elderly themselves are living longer. Life expectancy at age 60 has increased
between 1970 and 1990 in all four countries for both men and women. Im
provements in old age mortality during this period are particularly pronounced
in Singapore and Taiwan. In Singapore, in just two decades, at least five years
have been added to the length of time a 60 year-old can be expected to sur
vive. These improvements in old age mortality are contributing to the aging
of the elderly themselves, as evidenced by the increases in the proportion of
the elderly aged 70 or above, as was shown in Table 2.4. Improving mortality
has also reduced the proportion of elderly who are widowed, although large
gender differences persist. The declines in widowhood have been greatest in
Taiwan and among women in Singapore. In Thailand and the Philippines,
where mortality improvements at old age have been more modest, so have the
reductions in widowhood.
The spread of mass education earlier in the century is evident in the
recent decreases in the proportions of elderly who are illiterate. In 1970, ap
proximately half of men aged 60 and over in all four of the countries were
unable to read or write. By 1990, illiteracy among elderly men had dropped to
about one fifth in all of the countries. In contrast, in 1970 more than 90 per
cent of women aged 60 and over were illiterate in all but the Philippines
(where 70 percent were illiterate). By 1990, illiteracy among elderly women
was also sharply lower in the Philippines and Thailand, but the declines were
more modest in Taiwan and Singapore where about two thirds remained illit
erate. Since literacy is generally acquired early in life and remains relatively
fixed, these reductions primarily reflect a process over time whereby older
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54 The Well-Being of the Elderly in Asia
and less literate elderly people die off and are replaced by younger, more
literate elderly. The gains in literacy shown in Table 2.6 reflect the expansion
of educational opportunities, and the gender differentials in opportunity, dur
ing the times that current cohorts of elderly were in their childhood and youth.
This expansion of educational opportunities has continued (as shown by the
secondary enrollment figures in Table 2.5) and will greatly affect the educa
tional level of future cohorts of elderly, as discussed by Christenson and
Hermalin, 1991, and in Chapter 12.
Labor force participation among the elderly has also changed in the
four countries. As noted by Raymo and Cornman (1999), Singapore and Tai
wan tend to resemble one another in terms of trends in labor force participa
tion, as do the Philippines and Thailand. In Singapore and Taiwan, modest
but clear-cut declines in economic activity among elderly men are evident
between 1970 and 1990. Given the non-agricultural nature of the economies
in Singapore and Taiwan, these declines may resemble the almost universal
trend toward earlier retirement observed throughout the West (Quinn and
Burkhauser, 1994). In the far more agriculturally oriented Philippines and
Thailand, the trends for men are less clear although some reduction between
1980 and 1990 is apparent. Among older women, economic activity rates are
substantially lower than for men in all four countries, and the trends over time
are mixed. (For more detail, see Chapter 7.)
Demographic and Social Characteristics of the Sample Elderly
Table 2.7 presents basic demographic characteristics of the population aged
60 and over based on four recent surveys of the older populations described in
Chapter 1. Overall the age structure of the samples are relatively similar. In
all samples the younger elderly predominate. Close to or just over 60 percent
of the elderly in each sample are in the 60-69 age range and only about a tenth
are 80 or older. Also women in each sample tend to be somewhat older than
men, reflecting their higher life expectancies at older ages.
All four countries have substantial differences in the marital status dis
tributions between men and women, reflecting the combined influence of
higher male than female mortality, the tendency for men to marry women
younger than themselves, and the greater likelihood for older men than women
to remarry following widowhood or divorce. The proportions of men cur
rently married differ only modestly across the four countries: approximately
three-fourths of men aged 60-plus in Philippines, Singapore, and Taiwan are
married, compared to over four-fifths in Thailand. Greater contrasts are evi
dent in the proportion of women who are currently married, which ranges
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56 The Well-Being of the Elderly in Asia
from a low of only slightly above 30 percent in Singapore to over half in
Taiwan. In each of the countries only a small percentage of older persons
never married. The highest proportion never married is found among men in
Taiwan, owing largely to the migration of the nationalist soldiers in the late
1940s, many of whom never married. This migration is also responsible for
an aberrant gender distribution in the Taiwanese elderly population, for which
males outnumber females. Few elderly are separated or divorced in any of the
four countries; the highest occurrence (5 percent) is found among women in
Thailand.
In all but the Philippines, substantial differences in the educational
distributions of older men and women are evident, reflecting historical differ
ences, which favored schooling for sons over schooling for daughters. The
proportion of the older population with no formal education is highest in
Singapore, where half of the men and over four-fifths of the women aged 60
and over have had no schooling. In Taiwan, the lack of formal schooling is
also very high for women, among whom three-fifths have had no education.
The Philippines stands out both because only relatively minor gender differ
ences characterize educational distributions and because only a modest mi
nority of older men or women received no schooling. Among those who re
ceived schooling, it has generally been limited to the primary level. In all
countries the proportion of older persons receiving secondary or higher edu
cation is modest, ranging from about 20 percent in the Philippines and Tai
wan to less than 10 percent in Thailand and Singapore, but substantially lower
for women than men everywhere but the Philippines. Indeed in all countries
but the Philippines, less than 10 percent of the current cohort of older women
received secondary or higher education.
The distribution of elderly with respect to urban and rural residence
largely mirrors that of the population as a whole. In Thailand, the most rural
of the four countries, over four-fifths of the elderly population are living in
rural areas. (It should be noted that the definition of urban in Thailand is
relatively restricted and to some extent the high rural proportions are an arti
fact of this definition.) In the Philippines, the majority of the elderly popula
tion also live in rural areas, while in Taiwan less than a third do so. (Singapore's
entire population is urban.) Despite these differences among the three coun
tries, the proportion of elderly living in capital cities is relatively similar. Thus
the main differences reflect the proportions living in provincial urban areas.
Table 2.8 indicates the distribution of elderly on the same characteristics
used in Table 2.7, but by age rather than gender. In all four countries substantial
differences in the marital status distributions are evident between the population
in their 60s and those who are 70 or older. Reflecting the increasing toll that
mortality takes on marriages, the proportions currently married are substantially
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58 The Well-Being of the Elderly in Asia
lower and the proportions widowed substantially higher for the oldest-old
(70-plus years) in all four countries. Only in Taiwan is slightly more than half
of the population age 70 and older still currently married.
We also find age-based differences in educational distribution. Reflect
ing the trend toward increasing education, those age 70 years or older are
more likely to have no formal education and less likely to have completed
secondary schooling than the elderly in their 60s in all four countries. Differ
ences are particularly large in Thailand, where rapid changes in the provision
of formal schooling corresponded to the time when the current elderly were
reaching school ages. Thus, more than half of those age 70 and above had no
education in Thailand, compared to less than 20 percent of those in their 60s.
Table 2.9 presents information on the availability of various types of
living kin relative to the elderly respondents in the survey. These kinds of data
are important because exchanges between elderly and kin of different
generations are of course constrained by the availability of such relatives.
Between half and two-thirds of respondents have a living spouse. Whether or
not an elderly person has a spouse has important implications for their well-
being, in terms of both potential care giving and care receiving. This in turn
affects the extent of dependency of the elderly upon other persons within the
household or within the kin network.
Only a minority of respondents have a living parent, which is not sur
prising given the sample composition (aged 60 and above). The proportion of
respondents from the survey in the Philippines that have a parent is distinctly
larger than in Taiwan or Thailand; information on Singapore is not available.
Over 95 percent of the elderly in all four countries have a living child
and about 90 percent have at least one son and one daughter. Given the age of
the respondents, most of their children are already adults (defined as ever-
married or age 18 or over) and therefore the percentages with an adult child,
adult son, or adult daughter, are only slightly lower than the percentages who
have any living child, son, or daughter. Because the children are usually adults,
most of them are also married, which means that the percentages of elderly
with a married child tend to be almost as high as the percentages with any
child. At the same time, in each of the three countries for which data are
available, two-fifths or more of the elderly still have a single adult child.
Given that most of the respondents' children are already married, most
of the respondents have grandchildren. In the three countries with available
data, approximately 90 percent have at least one grandchild. Reflecting the
fairly large families from which many elderly respondents came, many still
have a living sibling. In the Philippines almost all have a living sibling, while
in Taiwan and Thailand more than 80 percent do (data are not available for
Singapore). Additional details of family structure are presented in Chapter 5.
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Demographk, Sodoeconomic. and Cultural Context 59
Table 2.9. Percent of Respondents with \ arious Tvpes of Lrung Kin
Note: Adult children include any ever-married child of any age and any single child age 18 plus
- = not available.
Conclusions
PhilippinesSpouseParentChildSonDaughterA dult childAdult sonAdult daughterSingle child 18+Single son 1 8+Single daughter 18+Married childMarried sonMarried daughterGrandchildSibling54.113.696.189.991.794.988.189.839.127.532.892.682.284.992.597.7Thailand62.68395.688s989.4Taiwan67.47.795.890.887.195.5 94.388.789.247.831.928.893.282.783.892.383.289.484.439.530.418.091.181.080.489.882.8Singapore50.8-95.789.086.7__-———mm——-1
This chapter provides context for the analyses that follow by providing dcmo
graphic, socioeconomic and cultural detail about each of the four study coun
tries and their regions. The initial section compares the major demographic
trends and projections for East and Southeast Asia, as well as the four coun
tries, with Europe and the United States so that the pace of population aging
and its distinctive features may be placed in wider perspective. Over the next
30 years East Asia and some of the countries in Southeast Asia will converge
to the aging profiles developing in Europe and the United States.
The chapter also highlights some aspects of the cultural and political
setting of each country included in this study as well as of the major social
and economic changes that have occurred over the last 40 to 50 years. The
fact that all countries are situated in Southeast and East Asia narrows to somc
extent the range of cultural differences that characterize them, but considerable
variation still exists. All share a strong sense of filial piety stemming from a
socially instilled sense of reciprocity children feel toward their parents (Asis
et al., 1995). Yet differences exist in terms of the views of the appropriate
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60 The Well-Being of the Elderly in Asia
roles of sons and daughters in carrying out these morally grounded obligations
towards parents as explored in Chapters 5 and 6 (see also Ofstedal et al.,
1999). Such differences reflect broader cultural differences that have long
and deep historical roots and that correlate with major ethnic boundaries and
religious beliefs. Christianity prevails in the Philippines where the vast majority
profess Roman Catholicism. In contrast, 95 percent of the Thai population are
Buddhists. Singapore is unusual in being an explicit tripartite multi-cultural
society with religion and ethnicity closely intertwined: Buddhism predominates
among the majority ethnic Chinese, Islam among the ethnic Malays, and
Hinduism among the ethnic Indians. In Taiwan, over 90 percent of the
population are Buddhist, Confucian, or Taoist.
The circumstances for the elderly respondents at the time of the sur
veys were strongly influenced by the major demographic and socioeconomic
changes that occurred in all countries during their lifetimes, and particularly
over the preceding several decades. Fertility declined, the population aged,
economies grew, labor markets shifted, and educational opportunities in
creased. Although in all four countries under study these changes have been
rapid and profound, they have differed to some extent in terms of their pace
and origin. As a result, the circumstances for the elderly of the Philippines,
Thailand, Taiwan, and Singapore have common and dissimilar features. This
combination provides an intriguing context for the analyses that follow.
While this chapter has focused primarily on past changes and their
impact on the current cohorts of older persons in each country, it is important
to note that future cohorts of elderly will look much different. For example, as
was touched on here and will be elaborated in Chapter 12, the educational
distributions for the elderly will change precipitously, with the proportion of
elderly who have no education declining to a negligible level and the propor
tion having completed secondary or higher schooling increasing substantially.
In addition, recent declines in fertility mean that future cohorts of elderly will
have substantially fewer children than the current elderly. These as well as
other anticipated socioeconomic and demographic changes will influence the
social and economic roles of future elderly, their family lives, and the types of
policies and programs best suited to their needs.
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62 The Well-Being of the Elderly in Asia
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Medina, Bclen. 1991. The Filipino Family: A Text with Selected Readings. Diliman,
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Demographic, Socioeconomic, and Cultural Context 63
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Chapter 3
POLICIES AND PROGRAMS IN PLACE AND UNDER
DEVELOPMENT
Mary Beth Ofstedal, Angelique Chan, Napaporn Chayovan,
Yi-Li Chuang, Aurora Perez, Kalyani Mehta, and
Albert I. Hermalin
The purpose of this chapter is to provide an overview of public
programs designed to assist the older population in the four countries
that are the focus of this volume: the Philippines, Thailand, Taiwan, and
Singapore. Emphasis is placed on social security and health care programs,
though examples of other programs will be touched on as well.
There are several reasons for monitoring the development of policies
and programs in Asia and other developing regions. From the relatively nar
row perspective of this volume, knowing the nature of the policies and pro
grams in place is a valuable context for the specific analyses to be presented
on health, work and retirement, economic well-being, living arrangements,
and intergenerational support. In turn, the situation of the older population on
these dimensions is relevant input for further program development. Accord
ingly, to the extent possible, we will discuss both programs currently in place
as well as those under consideration.
From a broader perspective, attention to program development related
to population aging in these countries provides a rich opportunity to study an
important component of social change in the making. Policymakers in Asia
and elsewhere are very aware of the potential consequences of population
aging in terms of the pressures on traditional family arrangements for support
65
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66 The Well-Being of the Elderly in Asia
of the elderly, and of the high costs of many social welfare programs in more
industrialized countries. They are faced with several conflicting goals: they
want to provide for the needs of their older population and anticipate the
social and economic changes arising, but they wish to do so in a manner that
does not undermine the traditional family arrangements currently providing
substantial support and that is not so costly as to jeopardize future economic
development. In a sense they are testing whether "modernization" inevitably
means "Westernization" in terms of social welfare programs and their costs,
or whether they can develop novel arrangements that better suit their cul
tures, resources, and needs. Studying this process is not only of broad social
science interest; it is possible that the programs that evolve will have implica
tions and benefits for social welfare programs in more industrialized coun
tries. Several examples of intriguing features built into the programs of these
countries will be touched on below.
An important backdrop to current policy development is to keep in
mind that in most cases these countries are not starting from scratch. Although
family support arrangements are key elements of the social fabric, these coun
tries have had social welfare programs of various types and breadth for some
time, and the structure of these programs and their perceived effectiveness
often influence the programs under development. Many of the countries first
developed programs for civil servants, military personnel, and even employ
ees of state-owned enterprises. Over time new programs were developed for
other classes of workers, often in a piecemeal fashion, with various consoli
dations and amendments taking place as economies changed and programs
matured. Few sources have attempted to summarize these multi-layered pro
grams in a comparable manner, making it difficult to delineate them succinctly
and with a standard set of criteria. Accordingly the material to be presented
should be regarded as a brief and preliminary introduction to a complex topic.
It is of interest to note that, in addition to specific programs, broad
provisions or concerns about the older population have been included in a
number of these countries' five-year plans, constitutional provisions, or gen
eral legislation — despite the fact that rapid growth of this age segment is a
very recent phenomenon. Often these considerations are coupled with reaffir-
mations of the family's responsibility for care and support of the elderly. (For
additional discussion of national policies on aging for countries in East and
Southeast Asia see Phillips, 2000; and for a larger group of countries see
Randel et al., 1999.)
For example. Section 4, Article XV (15) of the 1987 Philippine
Constitution states: "the family has the duty to care for its elderly members,
but the State may also do so throughyw^/ programs of Social Security." And
Section 11, Article XIII (13) states: "The State shall adopt an integrated and
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Policies and Programs in Place 67
comprehensive approach to health development which shall endeavor to make
essential goods, health and other social services available to all the people at
affordable cost. There shall be priority for the needs of the underprivileged,
sick, elderly, disabled, women, and children."
In Thailand the elderly are explicitly mentioned in the 1997 Constitu
tion. Article 54 states that "persons who are 60 years old and over and who
have insufficient income to maintain their living are entitled to receive assis
tance from the State"; while Article 80 adds that "the State must provide wel
fare for the elderly, the poor, the handicapped or disabled, and destitute per
sons so they can have a good quality of life and be self-reliant."
Chayovan (private communication) points out that elderly issues per
se were not of high priority in most of Thailand's Five Year Plans that guide
national development, usually including the elderly within a broader set of
disadvantagcd, as suggested by the language above. But the current Five Year
Plan (1997-2001) does include a section on the "isolated indigent elderly," as
well as provisions for universal free health services for the elderly, discounted
fares, and for encouraging and assisting families to understand and care for
elderly members, among other measures. Thailand did draw up a "Long-Term
Plan for the Elderly in Thailand" (1986-2001), following the 1982 World As
sembly on Aging in Vienna, and revised it in 1992 to include some explicit
provisions regarding welfare policies.
Taiwan at an early date developed programs that subsidize organiza
tions providing services as well as direct assistance to the elderly. It passed
the Senior Citizen Welfare Law in 1980, which subsidizes programs that as
sist elderly leisure activities and provides health examinations. The program,
which covers those aged 70 or older, also provides or assists privately funded
shelters for elderly who have no means for independent living. In 1993, new
legislation provided monthly subsidies of US$120 to elderly in poverty (de
fined as those 65 or older with monthly income below US$180 and who have
no financial support from children).
Policies concerning the older population in Singapore must be viewed
in the context of a general philosophy that stresses individual responsibility,
followed by reliance on family and the community. The government promotes
the idea that respect for elders is an integral part of Asian culture and way of
life, and the Maintenance of Parents Act passed in 1995 requiring children to
support their parents by providing them with a monthly allowance has re
ceived considerable attention within Singapore and elsewhere. By the end of
1998, 424 cases were filed and 328 elderly were successful in getting orders
compelling their children to support them (Straits Times, 4th April 1999). At
the same time, since the 1980s the government has set up a number of inter-
ministerial committees to ascertain the social and economic consequences of
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68 The Well-Being of the Elderly in Asia
population aging for Singapore, and many policies and programs have been
instituted to cater to current and future needs of the elderly. Based on the
recommendations of one inter-ministerial committee established in October
1998, six working groups have been instituted with each assigned to deal
with a particular aspect of aging, ranging from financial security, to housing
and land use, to cohesion and conflict. (See Vasoo, Ngiam and Cheung, 2000,
for a review of policies.)
Social Security Retirement Programs
Differences in the history and structure of social welfare programs for in
come maintenance and health across countries, as well as different account
ing and reporting provisions, make it difficult to capture the key elements of
each country's programs in tabular form with comparable measures. Table
3.1 attempts to sketch the broad contours of the retirement provisions of the
social security programs. Many of these programs also encompass provisions
for sickness and injuries (to be discussed below), disability, unemployment,
death, and other risks, which may be noted but not discussed in much detail.
To supplement the information in Table 3.1, we provide a brief narrative about
each country below.
The Philippines*
The Philippines has one of the oldest social security programs in Asia, with
very wide coverage and a broad range of benefits. It is also beset with a num
ber of financial and administrative problems that must be addressed to assure
solvency and compliance. The social security aspect is two-tiered, with the
first tier providing mandatory basic coverage of the defined benefit type, and
the second tier providing voluntary supplementary coverage through private
occupational pension plans.
Coverage under the first tier comes from two sources. The Govern
ment Security Insurance System (GSIS), created in 1936 and administered by
the Department of Budget and Management, is a retirement benefit plan for
selected government employees. Benefits under GSIS cover the following
contingencies: retirement, separation, unemployment, disability, and death
(through both a compulsory and optional life insurance feature). Retirement
benefits are available to those who have 15 years of service and are at least 60
years of age. Compulsory age at retirement is 65 years. Those reaching age 65
with 35 years of service can obtain a pension of close to 80 percent of their
last salary, up to a special wage ceiling. Retirees can claim benefits under two
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Policies and Programs in Place 69
basic options, each of which combines a lump sum plus a lifetime annuity. In
1997, about 94,000 people were receiving pensions from GSIS.
The Philippines' broader Social Security System (SSS), created in 1954,
covers those in the private sector and is of the defined benefit type, with
contributions by the employee and employer, but with the government re
sponsible for the solvency of the funds and as the guarantor of the mandated
benefit levels. The SSS program also provides benefits for death, disability,
sickness, and maternity. According to Asher (1998), although the SSS reported
16.6 million members in 1995, two-thirds of these are believed to be non-
contributing members, i.e., workers who had not contributed during the prior
year but had contributed for at least one month in the past. The World Bank's
(1994) estimate that only 19 percent of the 1990 Philippine labor force con
tributed to the SSS in the prior year supports this claim. In the same report,
the World Bank estimates that only about 7 percent of those 60 or older in
1990 were pensioners. (Data from the 1996 survey, presented in Chapter 8,
indicate that only 9 percent of older Philippine couples or individuals rely on
pensions or retirement funds as their major source of income, supporting the
World Bank's findings of low coverage.)
Asher (1996) describes several problems facing the social security pro
grams in the Philippines. Major among these is lack of compliance, as it ap
pears that only 40 to 60 percent of the 500,000 employers in the SSS program
collect and remit the mandated contributions. Asher asserts:
The present social security arrangements in the Philippines
are unlikely to be sustainable, and steps would need to be
taken to adjust the benefit level (including rationalization
and drastic reduction in loans to members), improve com
pliance, enhance the administrative efficiency, enhance the
rate of return on portfolio, and undertake organizational and
institutional changes, including greater insulation of social
security arrangements from short-term political consider
ations. These would pose a formidable challenge to policy
makers, (p. 83)
Thailand2
Thailand has been developing its social security programs over many years,
with legislation dating back to the 1950s and a number of substantial changes
and additions since then. With regard to pension provisions, there are three
major mechanisms: a well-developed program for government employees and
officials; a program of employer-sponsored provident funds under government
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1t*- 4l
O CJiCJM05^ .S5s gQL,-^- CE|*7 U
UCO B gS O US CQType of Plan§|JiS
ooauto Q£Name of Basis o
Mandatory Pro-ra>,EB§;1J—^^t -§voXaO00i Defimd benefioeo.uB
EO2£. C/lGovernment Sesrtity
Insrtanrt System (G:uaIsio||2
llfIPvo o— o/^ON i^e2^§t5^m E-oo ^*Or-Defimd benefi—IPrivate sector
employes; me
employed"BSosial Secrtity Syste
(SSS)1£2O ^18v<) ^,EC 3v& Iflo o.° EJ3me. Defimd
bemfit2. Blended*311Government wi: r-— "•*Civil Servant Plani11— <Provident F.n<> *•e °ex uEmployes in
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72 The Well-Being of the Elderly in Asia
regulation; and, most recently, a government organized retirement program
for private sector employees. In addition there is a means tested social pension
program for the elderly poor which is described below under programs
providing economic assistance.
The original program for civil servants, initiated in 1951, was com
pletely financed by the government and provided a replacement rate of about
70 percent of last month's salary for those with at least 25 years senice at age
60. (Lump sum options were also available and government workers who
retired with 10 to 25 years of service received only a lump sum.) The rela
tively high proportion of the labor force in government service (approximately
7 percent) and the projected high cost for future retirees led to a revised pro
gram in 1997 that is a blend of a defined benefit and a defined contribution
plan. Under the new plan, employees contribute 3 percent of their monthly
salary with a matching contribution by government. In addition, the govern
ment makes a contribution of 2 percent to the fund (to compensate for the
lower pensions) and those in the new plan will receive both a defined benefit
pension based on years of service and a pension based on the defined contri
bution accumulations and earnings. Under the new plan, those who worked
in government senice for 35 years would receive 70 percent of average sal
ary over the last five years of service, 15 years of senice are required to
receive benefits, and lump sums only are available to those who have 15 to 25
years of service (Ramesh and Asher, 2000, Chapter 3; Asher, 1998).
In 1987, Thailand directed private firms meeting certain criteria to es
tablish provident funds for their employees. Under this program employees
can voluntarily agree to contribute 3 to 5 percent of their salary, and employ
ers must match or exceed the workers' contributions. In 1997, state-run enter
prises were ordered to develop similar programs (Ramesh and Asher, 2000,
Chapter 3). Although in theory this program covers a high proportion of the
non-civil servant work force, its optional nature has limited coverage. As of
1999, about one million employees in 4,000 firms were participating, repre
senting a small percentage of the labor force or registered firms.
The most recent and ambitious component of Thailand's social secu
rity program was undertaken with the passage of the Social Security Act of
1990. This act spelled out the intention to phase in a broad program of ben
efits to all private sector workers in enterprises of 20 or more employees
(reduced to 10 or more in 1993), including coverage for injuries, sickness,
disability, death, unemployment, family allowances and old-age pensions, with
the latter three benefits to be phased in at a later date and the others initiated
in 1991. As of 1997, these provisions covered about six million workers,
representing approximately 18 percent of the labor force but about 45 percent
of wage and salary workers (Ramesh and Asher, p. 60).
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Policies and Programs in Place 73
The initiation of old-age benefits was delayed until 1999 but has now
been instituted under the Social Security Office. Workers have to be at least
55 years of age with 15 years of covered service to collect pensions, so that
the first pensions will not be paid until 2014. The amount of benefit is 15
percent of average monthly salary over the five years immediately prior to
retirement plus 1 percent of salary for each additional year of service over 15.
This means that a retiree with 35 years of service would receive a pension
equivalent to 35 percent of average salary over the last five years of employment
(Ramesh and Asher, 2000, p. 61). Funding for the program is provided by
contributions from the employee (2%), employer (2%), and government (1%).
These contribution rates are lower than originally planned and reflect in part
the uncertainties arising from the economic crisis. A planned two-phase
expansion of the program—first to employers with five to nine employees
and then to firms with one to five employees—was accelerated in 2001, with
coverage expanded to businesses with only one employee scheduled to become
effective as of April 2002. This change would bring the number of covered
workers to 9.6 million (Bangkok Post, November 21, 2001).
Despite relatively frequent attention to social welfare issues for many
years, it would appear that an adequate pension program for most of Thailand's
workers is still somewhat in the future. Aside from Thailand's relatively large
civil service sector, and those employees in state-owned enterprises actively
involved in the provident funds authorized in 1997, the remainder of the la
bor force has relatively little coverage at present. This is certainly true of the
large number of employed in agriculture, the self-employed, and those in the
informal sector, who currently have no coverage, but it also applies to the
private workers in the formal sector. Only a relatively small number are par
ticipating in the provident funds set-up by employers under government regu
lation, and no retirees are scheduled to receive pension benefits under the
Social Security Act until 2014, with the projection of wages covered quite
low except for those with very long periods of service.
Survey results confirm that old-age retirement income is still highly
limited in Thailand, with only 2.3 percent of older couples or individuals
reporting pension or retirement funds as their major source of income in 1995.
Taiwan3
Taiwan, like a number of the other countries, has a well-developed old-age
retirement program for civil servants and is in the process of updating and
expanding its program for other workers.
Under the Civil Servant Retirement Regulations (CSRR), first imple
mented in 1943 and amended in 1992, employees can retire when they reach
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74 The Well-Being of the Elderly in Asia
age 60 or complete 25 years of service. The mandatory age of retirement is
65. The amount of the pension, based on a fairly complex formula involving
length of service and wage equivalent, provides those with less than 15 years
of service a lump sum, while those with more than 15 years have a choice of
lump sum, a monthly pension, or some combination. Before 1992 the maxi
mum monthly pension was 90 percent of the final wage-equivalent, but the
1992 amendment reduced that maximum to 70 percent. It also introduced an
inducement for early retirement at age 55. The amended version also calls for
employees to pay 35 percent of the premium, which is set at 8 percent of the
"wage equivalent." Before 1992, there was no co-payment from employees.
The nature of the calculation of the maximum pension means that workers
with long tenure may be near the maximum at relatively early ages (around
age 50) and have relatively little economic inducement to remain with the
government thereafter.
The influx of Mainlanders in 1949-50, their strong role in government
service, and the rather generous CSRR pension system stirred interest on the
part of other workers for retirement benefits. Shih (1997) reports that more
than one-third of labor disputes in the early 1980s concerned pensions and
workers' welfare. This led to the passage of the Labor Standards Law (LSL)
in 1984, which governs labor contracts and regulates retirement practices in
the private sector. It was built on the earlier Provincial Factory Workers Re
tirement Act (PFWRA, 1957-1984), which covered production workers in
factories owned by the Taiwan provincial government. The LSL covers manu
facturing and non-manufacturing workers in the private sector, but excludes
employees in the finance, banking, commerce, and service industries. Work
ers can retire after 25 years of service, or at age 55 with 15 years of service.
Pensions are awarded as a lump sum with a 45-month wage equivalent maxi
mum. The pension is funded by employers who are required to set aside a
fraction of their expenditures on salaries into the company's pension fund.
The government of Taiwan is in the process of starting a new national
annuity program, originally to be implemented at the end of 2000, but post
poned due to uncertainty as to the appropriate funding mechanism. Accord
ing to press reports as of November 2001, a number of different plans have
been developed with major differences in the means of financing and the
nature of the benefit structure, and no consensus has emerged as to how to
proceed (China Post, 2001).
Singapore
Singapore is the only country in this group that relies on a broad-based
compulsory retirement provident fund mechanism for income and related
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Policies and Programs in Place 75
benefits. The Central Provident Fund (CPF) covers about two-thirds of the
labor force, excluding foreign, part-time, and casual workers, and self-
employed workers who elect not to contribute. (The self-employed are covered
under Medisave, the health insurance portion of the program). CPF is financed
by mandatory wage-based contributions from employers and employees, which
are currently 12 percent and 20 percent, respectively. These high contributory
rates make the CPF an important factor in Singapore's high level of savings.
The contributions and earnings are exempt from taxes, providing members
with a generous tax shelter.
A distinguishing feature of Singapore's system is the wide range of
objectives and programs that have been incorporated under it. These include
home ownership financing, investment in specified outlets, payments for higher
education, home and life insurance, and special accounts for hospital and
medical expenses. The number of options for use of accumulated funds has,
somewhat ironically, weakened the CPF's ability to function as a source of
older age income. Many members and contributors arrived at age 55 (the
minimum age for withdrawing accumulations from the "ordinary" fund) with
insufficient funds to provide adequate monthly income. As a result, the gov
ernment mandated minimum amounts that must be kept in this fund, but ac
cording to As her (1996), many members are not likely to attain this goal. In
1995 the government set up a program to add funds from general revenues to
certain classes of older retirees to assist with their medical or other accounts,
despite the government's general philosophy of avoiding entitlements. As Asher
notes, this step shows that social insurance principles can be incorporated
into a provident fund system with moderate changes.
The surprisingly low reliance on the CPF for retirement income is con
firmed from the 1995 survey (reported on later), which shows that only 2.2
percent of older Singaporeans list pension or CPF funds as their major source
of income, and the proportion relying on children or other relatives is the
highest among the four countries compared. In April 2001, the government
announced a new supplementary voluntary defined contribution plan (Supple
mentary Retirement Scheme) to allow higher rates of retirement savings in
order to enhance the role of CPF as a source of retirement funds (Ministry of
Finance, 2001).
Health Care Programs
All of the countries have at least some public health programs for older persons,
although the coverage and benefits vary greatly. General features of these
programs are summarized in Table 3.2, and will be discussed in more detail
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76 The Well-Being of the Elderly in Asia
below. As with the retirement programs, many of the health programs are
restructured or integrated versions of programs in existence for some time.
An interesting feature of these programs is that, because many are aimed at
employees, older persons are often regarded as dependents on their children's
or grandchildren's policies. In addition, as will become apparent in the
discussion below, the programs can be complex with regard to what services
are included and excluded from coverage.
The Philippines
In 1995 the Philippine Congress passed the National Health Insurance Act to
establish a National Health Insurance Program (NHIP). This program, which
became operational in 1998, aims to provide health insurance coverage to the
entire Philippine population by the year 2010. NHIP replaces the Medicare
Program (which had been in place since 1972) and is being managed by Phil
ippines Health Insurance Corporation (referred to as PhilHealth). Under NHIP,
individuals and their employers contribute according to the employee's in
come to a Health Insurance Fund. This fund is then used to provide benefits
equivalent to a certain proportion of the cost of a member's hospital care and
selected outpatient procedures.
The NHIP currently covers employees in both the private sector (SSS
members) and the government (GSIS). In 1998, SSS members comprised about
72 percent of the NHIP's membership, or a total of 19.9 million persons,
more than half of whom reside in the National Capital Region (NCR). About
2.0 million (10 percent) of the SSS members covered by the NHIP were self-
employed, which includes the "extended self-employed," or the informal sec
tor of the business community such as mobile peddlers and sidewalk vendors.
Public sector employees comprised 22 percent of the total NHIP membership
in 1998. This group includes government employees, retirees, pensioners of
the national government including the Armed Forces of the Philippines (AFP)
and the Philippine National Police (PNP), local government units, and gov
ernment-owned and controlled corporations.
As mandated by the Social Security Act of 1997, the Overseas Workers
Welfare Administration (OWWA) takes charge of the membership of the Over
seas Filipino Workers (OFW). In 1998, some 375,860 OFWs were registered
members of the NHIP, representing about 5 percent of the overall member
ship. (This number represents only the OFWs in destination countries where
the Philippine government forged bilateral agreement for social security pro
visions of the Filipino workers.)
The contributions of members to the NHIP's Health Insurance Fund
vary according to income level, ranging from a monthly premium of 75 pesos
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Policies and Programs in Place 77
(equivalent to approximately US $1.50) for those earning less than 3,000 pe
sos per month to a maximum of 187.50 pesos for those earning 7,500 or more
pesos per month. For the employed sector, the premium is shared equally by
the employer and the employee, whereas for the self-employed sector, the
member pays 100 percent of the premium. For indigent members, premium
payments are subsidized by the local and national government.
The main focus of NHIP is on coverage for hospitalization. NHIP cov
ers in-patient care plus some selected procedures such as chemotherapy, ra
diotherapy, hemodialysis, and cataract surgery. The program does not cover
outpatient doctor visits, preventive care or dental care. Additional exclusions
in the benefit package include such things as nonprescription drugs and de
vices; out-patient psychotherapy and counseling for mental disorders; drug
and alcohol abuse; cosmetic surgery; home and rehabilitation services; opto-
metric services; and normal obstetrical delivery (except the first). A careful
scrutiny of the exclusions indicates a bias against the elderly in terms of ac
cess to home and rehabilitation services and optometric services, for which
they have the greater need.
In-patient services may be obtained in accredited hospitals and from
accredited health care professionals. Access to NHIP benefits requires at least
three monthly contributions within the six-month period immediately prior to
confinement for both private and government sector members, provided that
the 45-day room and board allowance for the member and another 45 days to
be shared by the dependents for the calendar year has not been used. The
costs of hospitalization chargeable against the NHIP is, for the most part,
lower for government than for private sector members to accommodate the
differential between hospitalization costs in government and private health
institutions.
In addition to the government program, several non-governmental or
ganizations are attempting to address the health needs of the elderly. The Inte
grated Geriatric Care (IGC) project, piloted in Davao province in southern
Philippines is a good example. It is a consortium of the Medical Mission
Group Hospital and Health Services Cooperative, the PILIPINA Legal Re
source Center and the Cooperative Rural Bank of Davao. The program pro
vides persons age 55 and over with a comprehensive package of services,
including health care, legal services, and financial management.
Thailandv
Thailand has been expanding health insurance coverage for its population
through a series of programs over the last 12 years, and has initiated a number
of programs with a special focus on the elderly. Estimates from the Ministry
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80 The Well-Being of the Elderly in Asia
of Public Health and Kamnuansilpa (2001) indicate that the proportion of the
population without health insurance declined from about 67 percent in 1991
to 29 percent in 2000.
In recognition of the special health care needs of the elderly, the Thai
Ministry of Public Health (MOPH) officially established an Institute of Geri
atric Medicine in 1994. The government has initiated a program of free medi
cal care for persons aged 60 and over. In addition, some Thai elderly have
coverage through government programs such as voluntary government health
insurance (through the Health Card Scheme), the Social Security Act, and the
Civil Servant Medical Benefits Scheme (CSMBS). Those elderly who qualify
may be covered by more than one program.
Starting in 1989, the MOPH initiated a free medical care program for
disadvantaged elderly that was subsequently extended to cover all elderly
(for a description of this program, see Knodel et al. 2000). Under this pro
gram, all government hospitals and health centers provide free services na
tionwide to those 60 years and older with an "elderly card."5 The program
operates through a "gatekeeper" and referral system. The first contact in the
rural area is at the sub-district (tambol) health center, while in urban areas
initial contact is made through local community health facilities. Complicated
cases are referred to higher level facilities such as district, provincial, or gen
eral hospitals. Through 1997 the elderly card program was non-means tested,
and thus all Thai elderly were potentially covered by this form of government
health insurance. In 1993, 3.5 million elderly persons were covered by this
scheme. Given the scale of the program, it has been a major payer for health
costs for the elderly, accounting for about 5 percent of the total MOPH budget
during 1995-97 (communication from the Institute of Geriatric Medicine).
The program is currently being modified; it will be integrated with the Medi
cal Welfare Card program and will be means tested.
The government has also established a subsidized prepaid voluntary
health insurance program known as the Health Card Scheme. It started as a
pilot project in 1983 and was subsequently extended to all provinces. The
target groups are farmers in rural areas, workers in small firms (with less than
10 workers), seasonal workers, and self-employed persons. As of 1997, about
2 million health cards were issued. A card costs 500 baht per household per
year and covers up to 5 members including the elderly. The government has
been subsidizing this project, initially spending 500 baht for each card sold
and doubling this amount in FY 1998. The benefits provided by the health
card are similar to those of the elderly card, and cases are handled using a
similar referral system from lower to higher level facilities.
Health care has been included as a fringe benefit offered by the Thai
government to all government and state enterprise employees for many decades.
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Policies and Programs in Place 81
The health care scheme, which is also extended to employees' spouses, parents,
and up to three children, reimburses for outpatient care and either pays directly
or reimburses for inpatient care. Retirees, active employees, and their
dependents can freely seek inpatient care at public or private facilities with
some reimbursement ceiling applied to private outlets.6 Both as a result of the
economic crisis that started in 1997 and the rapid increase in expenditures
(from 4.3 billion baht in 1990 to 13.6 billion baht in 1996), the Ministry of
Finance has instituted new regulations to contain costs by means of co-payment
and reimbursement ceilings.
The major program for providing health care to the population at large
is the Social Security Act, which took effect in 1991 and was described in the
previous section on retirement programs. This program provides coverage for
injuries, sickness, and disability to private sector workers in firms with 10 or
more employees. Workers can select a public or private hospital as their medical
provider, with the selected provider receiving a capitation rate for each work
ers. The program is financed by a contribution of 1.5 percent of wages (up to
a specified maximum) paid each by the employer, employee, and govern
ment. The Social Security Office, which administers the program, is also now
responsible for the Workmen's Compensation Fund, which began operating
in 1974, and covers job-related injuries and sickness.
Private health insurance does not play a major role in financing health
care for Thai elderly as it tends to be uncommon (Ron, Abel-Smith and Tamburi
1990). It can be obtained, however, for groups or individuals, either attached
to a life insurance policy or as a stand-alone insurance policy. In either case,
health services are normally provided at private facilities on a fee-for-service
basis. The extent of coverage depends on the insurance company and the
amount of the premium. Unfortunately, most insurance companies do not of
fer policies to people aged 60 years and older because of the high health risks
of older persons and potentially large amount of expenditures that could be
involved.
Taiwan
The Universal Health Insurance (UHI) program was implemented in Taiwan
in April 1995. UHI replaced previously existing health insurance programs,
such as the Laborers' Insurance, Government Employees' Insurance, and Farm
ers' Insurance programs, and expanded on their coverage to provide benefits
for the workers' dependents and others. UHI provides health insurance cover
age for the entire population with the exception of military officers and ser
vicemen (who are covered under a separate program), as well as incarcerated
and missing persons.
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82 The Well-Being of the Elderly in Asia
Funds for the UHI program come in roughly equal proportions from
the insured, employers, and the government. A monthly premium based on
salary is assessed and is shared between the employee (30-40 percent) and
the employer (60-70 percent). For certain categories of workers (e.g., private
school teachers, farmers, fisherman, members of occupational associations,
retired servicemen and their dependents) premiums are subsidized by the
government either in part or in full. Those not working are covered as dependents
of their employed family members, who must pay their premiums. Generally
parents pay for their dependent children and adult children pay for their elderly
or retired parents. Low-income individuals who have no family members to
share the costs of health care are covered free of charge by the government.
In addition to the premium, the insured is required to make a co-pay
ment for each office visit or hospital stay, ranging from NTS50 -150 (US$2-
6) for office visits, up to NT$420 (US$17) for emergency care. Co-pays for
hospital stays are charged as a percentage (10 percent) of the total medical
costs. The ceiling for co-payments is NT$15,000 (US$600) per person for
each inpatient service, and NT$39,000 (US$1,600) per person for an entire
calendar year.
The UHI program covers dental care as well as most inpatient, outpa
tient, in-home nursing care, and preventive care. However, the program re
quires co-payments for medications, and no coverage is provided for long-
term institutional care or medical aids or equipment, including such items as
eyeglasses, hearing aids, dentures, or ambulatory aids.
Since the UHI was initiated, utilization of both outpatient and inpa
tient care has increased dramatically in Taiwan (Cheng and Chiang, 1997)
with a concomitant increase in health care costs (Chiang, 1997). The increase
in utilization occurred across the board, but was especially pronounced for
those who were uninsured prior to the introduction of UHI. As a result of the
deficits experienced, the Bureau of National Health Insurance has made sev
eral changes in benefits and premiums and is contemplating others.
Singapore
Singapore has several government programs in place to take care of medical
needs in old age; currently these programs only cover medical care up to age
75. Recently, the government introduced a new program to provide lifetime
insurance coverage for long-term care services to elderly Singaporeans with
severe disabilities. The details of each of these programs are provided below.
In general, these programs do not pay the full cost of care and the insured has
to make a co-payment. This is in line with the government's health care
financing philosophy that emphasizes personal responsibility. As Health
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Policies and Programs in Place 83
Minister Yeo Cheow said in a 1999 speech: "The co-payment principle, coupled
with community support and government subsidies has to date kept acute
care services affordable to all Singaporeans."
Since 1984, every Singaporean with a Central Provident Fund account
has a Medisave account. Contributions to Medisave are shared equally be
tween the employer and employee, are tax exempt, and earn interest. At present,
between 6 and 8 percent of an individual's monthly contribution to the CPF
account is put into the Medisave account, which is used to pay for costs of
hospitalization and certain outpatient treatments of the individual or a family
member until the age of 75 years. Once an individual has withdrawn his/her
lump sum from the CPF account at the age of 55, he/she must maintain
S$ 17,000 in the Medisave account to meet health care needs during retire
ment. This amount is being increased incrementally to S$25,000 in the year
2003 (Inter-Ministerial Committee on an Ageing Population, 1999).
In June 1990 the Medishield and Medishield Plus Schemes were
introduced when the government realized that Medisave was insufficient to
cover most individual's medical costs. Medishield is a low-cost medical
insurance plan that covers hospitalization expenses, catastrophic illnesses,
and certain outpatient treatments such as kidney dialysis, chemotherapy, and
radiotherapy for cancer. The annual premium is deducted automatically from
the member's Medisave Account, unless he or she decides not to be insured.
Medishield Plus is similar, but both the premiums and benefits are higher.
Both of the plans are voluntary. As of January 2001, about 90 percent of
elderly Singaporeans between the ages of 61 and 69 were insured under the
Medishield Scheme. This is the result of a government plan instituted at the
end of 2000, which helps defray hospitalization costs for the years 2001 and
2002 if elderly signed up for Medishield or a Medisave-approved insurance
plan by December 31, 2000.
Medishield and Medishield Plus cover health expenses only until the
age of 75. For the most part, coverage is partial, with the patient paying some
percentage of the cost, and each type of treatment covered carries a claim
maximum. Before any claim can be made, the member has to pay a fixed
annual deductible (ranging from S$500 to S$4,000 depending on the type of
plan). Of the remaining claim amount, Medishield/Medishield Plus pays 80
percent while the member pays the balance from his Medisave account or out
of pocket. For outpatient treatment, Medishield pays 80 percent of the actual
expenditure up to the maximum amount. Medishield allows the member to
claim up to S$20,000 a year with a lifetime limit of S$80,000. Under
Medishield Plus Plan A, a member can claim up to S$70,000 a year, with a
lifetime limit of S$200,000. For Medishield Plus Plan B, the annual claim
limit is S$50,000, and the lifetime limit is S$l50,000.
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84 The Well-Being of the Elderly in Asia
In 1993, the government began a Modi fund program for needy
Singaporeans who don't have Medisave or Medishield accounts or for whom
the savings in these accounts are insufficient. It is not an entitlement and is
funded by State budgetary surpluses. Also, in January 1996 the Singapore
government began a four-year Top-Up Scheme. Every Singaporean bom on
or before April 1, 1934 was given a yearly addition to his or her Medisave
account, if a family member or the individual him/herself put a yearly co-
payment of S$50 into the Medisave account beginning in 1995. Depending
on age, the individual received a top-up of between S$100 and S$350.
Recently the government introduced a new insurance plan to provide
insurance coverage to elderly Singaporeans who require long-term care. The
program, Eldershield, is scheduled to begin in June 2002 and will provide
older Singaporeans with basic financial protection and help defray out-of-
pocket expenses in the event of severe disability.
Eldershield is a voluntary program that is funded primarily by premiums
paid by program members. Premiums are structured to be payable annually
starting at age 40 and continuing through age 65. The maximum age of entry
into the program is 70, and persons with pre-existing disabilities are not eligible
to join. Individuals joining after age 40 are required to pay larger premiums
over a shorter period of time; those joining at age 65 or later must pay the full
premium in a single lump-sum payment. Unlike the Medisave and Medishield
programs, which provide coverage only through age 75, Eldershield provides
lifetime coverage to its members.
In keeping with the government's philosophy of promoting family
support and community-based services for care of the elderly, Eldershield
payouts will be made in the form of cash benefits, and not tied to the
reimbursement of institutional care. This allows individuals requiring long-
term care and their families the flexibility to choose where the care will be
provided—at home or in a nursing home or other institutional setting. Payouts
are made when a person cannot perform three of the following activities of
daily living (ADL) unaided: walking, eating, getting out of bed, dressing,
bathing, or going to the toilet. Initially payouts will be set at SS300 per month,
up to a maximum of 60 months. Once the program is underway the government
will consider enhancing Eldershield to provide higher coverage and payouts.
Private insurance companies provide a number of health insurance plans
available in Singapore. Most of these plans include insurance for prevalent
diseases such as heart attack, cancer; and stroke; some also cover
hospitalization, surgery, intensive care, and permanent disability. However,
most elderly Singaporeans currently do not rely on health insurance to pay
their medical costs. As shown in Table 10.2 of Chapter 10, less than 3 percent
of the respondents indicated supplemental (private) medical insurance as their
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Policies and Programs in Place 85
main type of support for health and medical costs. Instead, almost half of
them relied on their children or other family members to pay the bills through
the Medisave accounts of these individuals.
Other Programs and Policies Targeted to the Older Population
The foregoing sections have focused on the broad retirement and health
programs in effect in each country that cover all or major segments of the
working population and provide specified benefits before retirement ages and/
or subsequent to retirement. In addition, each country has a number of policies
and programs designed for the elderly that address many of the special needs
that often arise for that segment of the population. For discussion purposes,
these programs may be considered under four broad categories:
• Programs Providing or Subsidizing Regular or Special Medical Services.
These include free or subsidized medical care or medicines, home nursing
services, and centers for rehabilitative or custodial day care.
• Programs Addressing Residential or Long-Term Care Needs. These
include special residential structures, as well as improvements to current
residences, and nursing homes.
• Programs to Enhance Daily Life Services to the Elderly. These include
day care facilities, senior citizen recreational centers, home visits for doing
chores and providing transportation, special educational and counseling
services, cultural events and various subsidies to make attendance more
affordable.
• Programs to Provide Economic Assistance. These include special tax
benefits and/or special payments to elderly with low incomes.
It should be recognized that a number of these categories overlap to a
certain extent. For example, programs that provide day care for elderly still
residing at home may be physically part of nursing homes or similar structures;
subsidies to the elderly for reduced transportation fares or costs of cultural
events contribute directly to enhanced daily life and also provide an economic
benefit.
Although some of these programs have been operating for years, they
represent an area of increasing public and legislative attention as countries
seek to adjust their policies to the rapidly growing older population and the
changing social and economic environment. In developing new programs and
adapting older ones, central governments have been using a range of strategies,
often involving local governmental authorities, voluntary organizations, and
the private sector, as well as creating new incentive programs for the public.
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86 The Well-Being of the Elderly in Asia
Although providing an exhaustive list is not possible, the following section
describes several programs and policies in each category that illustrate this
range of strategies. In addition, Chapter 11 presents data from the surveys
about the knowledge and utilization of several of these programs. In
conjunction with the Chapter 11 data, the information presented here will
help clarify effective future directions in the provision of senices.
Programs for Providing or Subsidizing Regular or Special Medical
Services
Some of the programs discussed in the Health Care Programs section are
mainstays in the provision of medical care to the elderly and will be touched
on briefly here along with more specialized programs to round out the picture.
In the Philippines, in addition to the benefits the elderly may accrue
directly or as dependents under the National Health Insurance Program, current
elderly (aged 60 or older) can avail themselves of several special programs.
Those earning less than 60,000 pesos a year can register and obtain a senior
citizen ID card which entitles them to a 20 percent discount on medicines
needed for their own use. In addition those registered are entitled to "free
medical and dental services in government establishments anywhere in the
country subject to guidelines issued by the Department of Health, the
Government Senice Insurance System and the Social Security System"
(regulation quoted in Natividad, 2000, p. 272). However, Natividad notes
that many institutions are excluded from this regulation because they
technically do not fall under Department of Health control.
In Thailand, as described in Health Care Programs section, the special
"elderly cards" and the family "health cards" provide a range of medical
benefits at government hospitals or health centers to a high proportion of the
elderly at little or no cost. A1998 survey by Kamnuansilpa et al. (2000) found
that 80 percent of the elderly people surveyed possessed the elderly card and
another 9 percent had other coverage. (The survey did not cover Bangkok.)
The authors also note that, although the Ministry of Public Health has a "home
health care" policy, under which public hospitals are to develop outreach teams
that visit people at home and sub-district health centers are also to engage in
home visits, less than a third of the surveyed elderly report such contact.
Older people may also receive physical and occupational therapy at one of
the Social Service Centers described further below.
The Universal Health Insurance program in Taiwan now provides the
elderly with basic in- and outpatient senices. In addition, home health services
for the elderly, initiated in 1989 in an experimental program, have been
expanding rapidly. As of March 1999, 214 of these freestanding or hospital-
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Policies and Programs in Place 87
based agencies were providing service (Bartlett and Wu, 2000, p. 219). This
growth has been greatly facilitated by the fact that home visits by nurses and
physicians are now paid for by the Universal Health Insurance System.
Basic medical services to the elderly in Singapore are primarily covered
through the various health care provisions of the Central Provident Fund, as
described above. In addition, the Home Nursing Foundation, a joint public-
private sector organization established in 1958, is a major provider of
community-based elderly health services. The Foundation provides home
nursing service as well as rehabilitation service at its health care centers.
Programs Addressing Residential or Long-Term Care Needs
Given the widespread expectation in most of Asia that older parents will reside
with their children and a demographic profile that until recently was
characterized by large families, a young age structure, and modest expectations
of life above 60, the development of special residential facilities for the elderly,
either for those in relatively good health or for those requiring extensive care,
has only recently gained broad significance. Nevertheless each of the four
countries has operated a few such facilities for some time and each is currently
responding to the growing demand. As with other programs, these efforts
often involve the public, private, and voluntary organization sectors within
each country.
In the Philippines the Department of Social Welfare and Development
manages three residential centers for the elderly, mainly for those abandoned
and destitute. Civic and religious organizations accredited by the Department
operate homes as well—Natividad (2000) cites reports of 19 such homes—
although these tend to be smaller in scale. The number of privately run nursing
homes is not known, as these are not identified in government documents.
Incentives incorporated into the Senior Citizens Act passed in 1991 include
real estate tax relief for the first five years of operation of residential
communities or retirement villages solely for older persons, and priority for
building the roads leading to such communities (Natividad, 2000, p. 276).
Although like the other countries Thailand fosters familial care for the
elderly, the Department of Public Welfare has established a small number of
government residences, mainly intended for the poor, homeless, and deserted
elderly. The first such home was established in 1953, and as of 1997,16 were
in operation, serving about 2,000 residents. Several charitable organizations,
in particular several associated with ethnic Chinese, also operate homes for
the aged. In addition, there are private for-profit nursing homes, although
systematic data on these homes are unavailable as they are managed free of
government regulations.
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88 The Well-Being of the Elderly in Asia
As Thailand is a primarily Buddhist country, some elderly live in temples
as monks and nuns. According to the 1990 census, about 3 percent of men
aged 60 and over live in temples, 98 percent of whom are monks, but only 0.2
percent of elderly women lived in temples. The census figures thus suggest
that only a small number of homeless elderly live in temples. A national
unpublished study conducted in 1994-95 by the Department of Public Welfare
in the 32 provinces reported that there were 1,115 homeless or destitute elderly
residing in 362 temples (personal communication from the Department of
Public Welfare). As a result of this study, the DPW started a program to promote
the use of temples as residences and service centers for needy elderly. As of
mid-1998, almost 200 temples located in two-thirds of the provinces had agreed
to participate and some have already initiated activities. (The above from
Knodel et al., 2000, pp. 251-252.)
The government in Taiwan has mounted recent efforts to develop an
adequate long-term care system for the elderly with chronic diseases and
disabilities that combines community-based services with various residential
facilities. Both the Department of Health and the Department of Social Welfare
are involved in this system. In 1991 the Department of Health began
encouraging hospitals to establish nursing homes on a pilot basis. By 1995
there were 9 such homes with 470 beds. In 1999, Bartlett and Wu (2000, p.
218) reported 101 nursing homes with 4,308 beds registered with the
Department of Health, and 123 homes for older people with 7,615 beds under
the Department of Social Welfare. In addition they cite a survey identifying
710 uncertified homes with more than 22,000 beds, many of which are in the
process of becoming registered under recent legislation designed to involve
the private sector in meeting the growing demand. This demand has been
stimulated by changes made in 1996 to the Universal Health Insurance Program
that allow the cost of medical and nursing care services in nursing homes to
be reimbursed. Prior to the expansion of nursing home facilities, a significant
portion of long-term care took place through extended stays in hospitals.
In addition to long-term housing for elderly with health needs, the
Ministry of Social Welfare provides some residential housing for poorer older
citizens at no or low cost, as do a few voluntary and private welfare agencies.
Housing arrangements for healthy older retirees who wish to live independently
are a recent phenomenon with a few large complexes of senior citizen
apartments developed in or near several major cities (Bartlett and Wu; 2000).
Singapore's program for residential facilities geared to the older
population includes a highly developed set of incentives to maintain the elderly
in the community and with or near their families, and a program of partnerships
with various organizations for maintaining special residential and nursing home
facilities.
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Policies and Programs in Place 89
The government provides several incentives such as tax relief and
priority housing arrangements for families that take care of an aged parent.
For example, a co-resident adult child could obtain tax relief of up to S$4,500
per parent in 1998. In addition, children who choose to live within 2 km of
elderly parents receive tax rebates and priority housing. A second program,
the Joint Selection (JS) scheme, allows married children and parents to submit
separate applications to purchase flats close to each other in the same housing
estate. Five percent of the flats offered for sale in these estates are set aside
for allocation to such applications. These applicants are also entitled to other
benefits such as a lower down payment and a larger mortgage. Similar benefits
are offered under the Multi-Tier Housing Scheme, which encourages married
couples to live in the same flat with their parents or grandparents for care and
support. A related program, the Conversion Scheme, was implemented in 1993
to help maintain established community and family ties. It enables lessees of
3-room or smaller flats to purchase an adjoining or smaller flat from the open
market for conversion into a larger flat to accommodate married children and
parents.
More recently, programs have been developed for Singapore's elderly
who choose to live alone or with a spouse. The government is building more
housing for elderly who choose not to live in an extended family setting and
also upgrading existing housing facilities for the elderly. For example, the
government started the Studio Apartment Scheme in November 1997 to cater
to the special needs of the elderly. The studio apartments, which provide
sufficient living space for one or two persons, come with pre-installed fittings
and special safety features for the elderly (e.g., pull cords and heat detectors
linked to an alarm system; support hand bars, non-slip flooring). In addition,
the studio apartments are located near neighborhood centers for easy access
to communal and commercial facilities, as well as the transportation network.
In addition to these incentive programs, provisions have been made to
house Singapore's elderly who are destitute or do not have families. These
include a mix of government and organization-sponsored facilities, as well as
volunteer and private nursing homes. Homes run by community service
organizations and religious organizations are often subsidized by the sponsoring
organizations, although residents are required to make a minimum payment,
and those who are able to contribute more are encouraged to do so.
Last, residential homes for the aged run by volunteer welfare
organizations have increased in the last decade to meet increasing demands.
At present, there are about 45 such homes (Directory of Social Services, 1997),
most of them affiliated with the National Council of Social Services (NCSS),
the umbrella body for all voluntary welfare organizations in Singapore. NCSS
provides partial funding for these establishments. In addition, there are nursing
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90 The Well-Being of the Elderly in Asia
homes that cater to the disabled and frail elderly, some of which offer temporary
respite stays so that family caregivers can have a break from their duties. Also
several private nursing homes run by individuals are available to ambulant,
semi-ambulant, and non-ambulant persons. The standard of care and facilities
available vary according to prices charged. Some homes have qualified nurses
on their staff, while others rely on non-nursing personnel.
Under a five-year master plan for elder care, the Ministry of Community
Development and Sports (MCDS) will revamp its funding scheme for Voluntary
Welfare Organizations (VWOs), fund a series of programs for the elderly, and
spend S$15 million on a five-year public education program. Under the new
funding scheme from April 1st 2001, MCDS will give its 50 percent share for
VWOs operational costs, even if the organizations have raised more than their
50 percent share. MCDS will also spend more than S$30 million over the
next five years on programs for healthy elderly. These include mutual-help
schemes in 142 Senior Citizens' Clubs, enhancing befriender services, and
supporting programs developed by senior citizens themselves. MCDS will
also spend approximately S$ 15 million to fund support services for frail elderly.
These support services involve setting up three centers whose twelve case
managers will plan the services and support needed for the individual elderly.
In addition, MCDS will be financing the development of six
neighborhood service centers to cater to elderly social service needs. The
type of information the centers will provide include teaching simple first aid
and information on where elderly can go to learn computer skills. MCDS also
plans to build three multi-service centers as one-stop facilities for the whole
family, providing day-care services for the very young and elderly. The overall
plan is to integrate health and social service needs of the elderly. "The objective
is to eventually put all community-based services under one roof so that centres
will become a one-stop service point for residents of all ages and for different
needs" (Abdullah Tarmugi, Minister for Community Development and Sports).
Programs to Enhance Daily Life Services
This category of services includes a variety of programs designed to assist the
older population with problems encountered because of limited mobility, other
types of limitations, or the lack of social contact and stimulating activities.
We include here discount policies designed to encourage participation in
recreational and cultural activities, although these are also programs with
economic benefits.
In the Philippines, registered seniors with ID cards are entitled to 20
percent discount on costs related to using transportation, hotels, restaurants,
and recreational facilities. They also receive a discount of 20 percent or more
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Policies and Programs in Place 91
on admission fees at theaters, cinemas, concert halls, and other places of
culture, leisure, and amusement.
The Senior Citizen Center Act passed in 1994 provided for the creation
of senior citizen centers in each municipality. These centers, envisioned as
the hub of activities oriented to older persons, are to be run by the elderly
themselves. In the first two years, the Department of Social Welfare and
Development was charged with establishing demonstration centers in each
province to serve as models for each municipality. It is of interest that the
passage of this Act was partly the result of strong lobbying efforts by senior
citizen groups under an umbrella organization called the Federation of Senior
Citizens Association of the Philippines (Natividad 2000, pp. 276-277).
In Thailand, the Department of Public Welfare operates centers designed
to provide a variety of social services for elderly. The first center was opened
in 1979; by 1998, 13 centers were operating throughout every region of the
country. Health care, exercise, counseling, training, and welfare services are
provided at the centers; home visits by mobile units are arranged through the
centers. In addition, emergency shelter is available for short-term stays of up
to 15 days for elderly in urgent need of temporary lodging and assistance
(Department of Public Welfare, 1997).
In Thailand, elderly clubs or senior citizen associations were first
promoted by the government during the 1980s based on the idea that informal
group gatherings among older persons is a tradition in Thailand. The goal was
to facilitate the formation of organizations that could provide as well as receive
assistance or services (Siripanich et al., 1996). Thus, with support from the
Ministry of Public Health and the Department of Public Welfare, the number
of elderly clubs grew rapidly in Thailand during the 1980s. Although some
clubs were formed from genuine local initiatives, most were the result of
government prompting and support. Club offices tended to be located either
at a government health outlet or a temple. A1994 study identified about 3,500
senior citizen clubs of various sizes and with various activities throughout
Thailand (Siripanich et al., 1996). In the absence of continuing follow-up and
support by the governmental agencies involved, substantial numbers of clubs
were either dissolved or became inactive. The main reasons for the failure of
so many clubs included a lack of clear initial aims at the time of formation,
inadequate sizes, and inconvenient locations.
In their effort to promote the importance of elderly clubs and strengthen
networking among them, Thailand's Department of Public Welfare organized
a series of annual national conferences of club representatives starting in 1983.
One outcome was an agreement to set up an autonomous organization to
coordinate activities of elderly clubs all over the country. The Senior Citizen
Council of Thailand, registered as a legal entity in 1989, is a strong voice for
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92 The Well-Being of the Elderly in Asia
the needs and rights of elderly. At present, about 300 senior citizen clubs are
registered as members of the Council. To qualify for membership, the club
must have at least 50 members and have existed for a year or more with
continuous activities. Because many of the clubs initiated by the government
promotion effort had fewer than 50 members or did not have continuous or
organized activities (i.e., had been established in name only), the number of
current member clubs is far below the number formed at the height of the
government's promotional campaign (Knodel et al. 2000, p. 253.)
In Taiwan, several types of centers and programs accommodate the
needs and interests of the elderly residing at home. Aside from in-home medical
and nursing care provided by the home care offices described above, there
were 893,000 person-visits in the year 2000 for assistance with household
chores, counseling and related services through the social welfare system and
988,000 person-visits in the year 2000 for "meals-on-wheels" service.
Day care centers have also been expanding in Taiwan. Under the
Ministry of Health there are approximately 20 day care centers that provide
nursing and other health services for those participating. In addition, for the
healthy elderly there are a growing number of day care facilities provided
through the social welfare system and they report 278,000 person-visits to
these facilities during the year 2000. Services provided at these centers include
cultural and recreational activities, health maintenance, afternoon rest periods,
and snacks. Rounding out the picture are a large number of senior citizen
centers and Evergreen Academies operated by local governments and other
auspices which provide a wide variety of leisure activities, free or discounted
tickets for various events, and a large number of courses, with fees subsidized
for low income elderly (Bartlett and Wu, 2000).
The Evergreen Academies were established in 1987 to provide the older
population with instruction and training in a wide variety of subjects and
crafts. Local governments are responsible for developing their own programs,
assessing the attitudes and needs of their elderly residents, selecting appropriate
locations for the academies, designing teaching plans, and purchasing
materials. The academies are open to persons 55 years of age and older, and
enrollment fees for low-income elderly or residents of publicly supported
old-age homes are subsidized. In 1997 there were 302 Evergreen Academies
in Taiwan, and some 188,000 people were enrolled in classes (Bartlett and
Wu 2000, p. 218).
Other cultural, artistic, social, and training activities are provided for
elderly Taiwanese over age 60. These are delivered through the 12 district
senior citizen centers in Taipei as well as through various other government,
community, and religious organizations in other areas. Discounted tickets and/
or complimentary passes are provided to older persons for transportation on
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Policies and Programs in Place 93
public buses, entrance to exhibitions, and other educational and recreational
activities.
As in the other countries, Singapore has several different structures—
both governmental and private—that address the daily needs of the older
population. For those requiring a program of day care, the Ministry of
Community Development operates six social day care centers that cater to
about 200 elderly. Some of the centers have special transportation for the
disabled. The Salvation Army operates a similar center. Charges are usually
levied for the services provided. The Ministry plans to open four or five new
day care centers in the coming years.
In addition, Singapore has 31 government-operated senior citizen's
centers that offer recreational activities, health screenings, and opportunities
for community services via the senior citizen clubs that meet there. Volunteer
programs have become more popular and have been encouraged by the
government as a means of promoting active, healthy life styles among the
elderly. Some non-governmental centers, like the Singapore Action Group of
Elders (SAGE), provide personal and telephone counseling, as well as a variety
of cultural and recreational activities. Finally, public transportation facilities
in Singapore encourage local travel among the elderly by providing discounts
and special equipment such as low steps and nonskid floors.
Programs Providing Economic Assistance
In addition to the array of services and programs outlined above, each of the
countries recognizes that the elderly population as a whole, as well as particular
subgroups, may require direct economic assistance.
In the Philippines this assistance takes the form of tax exemption for
registered elderly who earn less than 60,000 pesos per year, and tax abatements
for those who coreside with and claim such elderly persons as dependents
(Natividad 2000, p. 276). The elderly may also benefit economically from
income assistance projects that provide seed capital to families below a given
poverty threshold. Some community-based organizations such as the Coalition
of Services to the Elderly (COSE) have set up group homes for highly
vulnerable single elderly.
In Thailand, the Department of Public Welfare assists extremely poor
elderly men and women in rural areas with a minimum pension of 200 baht
($6 U.S.) monthly, under a program initiated in 1993 (Knodel et al., 2000, p.
252). Eligible older persons are identified by the Department's network of
Village Welfare Assistance Centers, and must be approved by the provincial
welfare office. Starting with 20,000 elderly in 1993, the program was expanded
to over 300,000 rural elderly in 1997. Though the amounts provided are too
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94 The Well-Being of the Elderly in Asia
low to meet minimum subsistence requirements, and the program may not
have reached all its target population, it is significant as a separately budgeted
poverty relief plan not tied to the Social Security Fund. In addition, several
non-governmental and religious organizations are working with the Help Age
International regional office on income generating and support projects for
the elderly.
Taiwan provides both direct and indirect assistance to low-income
elderly through a cost-of-living assistance program to needy elderly 65 years
or older (defined as monthly income of less than US$180 and no support
from children); and by paying the full Universal Health Insurance premiums
for older low-income insurees.
The Ministry of Community Development in Singapore has a social
assistance program available to the poor, sick, and disabled elderly based on
a means test. The criteria are quite stringent; only 1,789 elderly received
payments under this program in 1999 (Singapore Department of Statistics,
2000). Financial assistance may also be provided by Family Service Centers,
which are partially funded by the government. In addition, a variety of non
governmental organizations and ethnic and religious groups provide financial
aid and aid in kind to poor older persons, especially those living alone. Indirect
support is also provided through free or low-cost medical clinics and services
operated by these organizations, and the government has set up a Medifund
program to assist poor patients who cannot meet their hospitalization expenses.
Conclusions
This chapter provides an overview of policies and programs that address a
range of needs often faced by older people. These include the broader social
security plans that provide retirement income and the health insurance
programs that help defray the costs of medical services to working and retired
citizens. In addition, each country has a variety of other programs focused on
potential needs such as in-home medical and household services, day care,
residential and nursing facilities, leisure and recreational activities, and special
economic assistance.
The cultural tradition in these countries of relying on families for the
physical care, economic security, and emotional support of the elderly, as
well as the relative recentness of the demographic shift to older age structures,
did not inhibit the early establishment of these programs for the elderly. The
countries were influenced in their decisions by several factors: the influence
of policies developed by more industrialized countries, the far-sightedness of
policymakers in recognizing changing socioeconomic and demographic trends,
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Policies and Programs in Place 95
as well as recognition by governments that regardless of social norms, certain
individuals and groups fall outside the prescribed arrangements and require
special assistance.
It is also clear that both the major programs and the more specialized
ones are in a state of development in each country. In the Philippines and
Singapore, both of which have broad coverage on paper and long-established
programs, benefits are inadequate for many of those targeted for service. The
Philippines suffers from a lack of compliance by employers and the need for
greater administrative and political action to make the programs work properly.
In Singapore, the compulsory coverage and high contribution rates that should
provide adequate old-age support have been undermined by having the CPF
serve many other goals, from home ownership to investments to meeting the
costs of higher education. Government officials are working out ways to
reassert the primacy of retirement income within the program and strengthen
the provisions for covering medical services at older ages.
In Thailand and Taiwan, new pension programs are being developed to
broaden coverage from a narrow base of civil servants and select others (such
as military personnel or employees of large firms) to most of the labor force,
but they are still at a very early stage. The final details and date of
implementation for Taiwan are still not set and the social security program in
Thailand will not pay its first retirement benefits until 2014. It will be important
for these countries to set up these extensions and new programs in as efficient
and cost-effective a manner as possible if they are to achieve the twin goals of
good coverage with minimum strain on individual and government budgets.
In addition, because any program is likely to cover only those in the formal
sector, approaches to the informal sector (which can be quite large) also need
to be developed. A review by Asher (1998) of the retirement programs in
place and under development in Southeast Asia expresses several cautions
with regard to the adequacy of financing, the replacement rates (i.e., the portion
of wages covered in retirement), and for those relying on provident fund
approaches, the availability of appropriate higher-yielding investments and
the impact of the plans to increase overall savings and investments. These
concerns suggest that these programs will be receiving continued scrutiny in
an attempt to improve their effectiveness and efficiency.
In contrast to the retirement programs, the programs for providing health
coverage within each of the countries seem closer to achieving their aims.
Each country, through some combination of financing through public provision
of benefits, social insurance, or other insurance and savings plans, is extending
health care coverage to a broader share of its general and older populations.
But significant pockets of non-coverage remain in some countries, and the
portion of health care costs paid privately also remains high in a number
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96 The Well-Being of the Elderly in Asia
(Ramesh and Asher, 2000, Table 4.4). As with pension programs, the health
care system and methods of financing health care costs are likely to receive
continued scrutiny. Thailand, for example, concerned that its level of health
expenditures as a share of gross domestic product is above average for a country
of its income level, undertook a major health care reform project between
1996 and 1999 in cooperation with the European Union, and a National Health
System Reform Committee was established in July 2000.
Countries in Asia will also need to give attention to emerging needs as
the proportions at older ages increase, particularly those at the most advanced
ages (80 and over), as described in Chapter 2. This development will increase
demand for mechanisms to provide and finance long-term care for the elderly.
In this regard the steps taken by Singapore under its new Eldershield program
described above, and Japan's new mandatory long-term care program initiated
in April 2000, after several years of discussion and preparation (Campbell
and Ikegami, 2000), are likely to prove influential throughout the region. Also
of relevance in the case of Japan, is the intense political debate that occurred
in the course of crafting the legislation involving several interest groups and
local officials as well as national parties (Eto, 2001; Campbell and Ikegami,
2000).
Though many issues remain, it is noteworthy that each country currently
has most of the infrastructure needed for initiating new programs and
strengthening existing ones. Many of the specialized programs described above
are under the jurisdiction of well-established ministries, and in several cases,
under joint jurisdiction. In addition, each country has non-governmental and
ethnic and religious organizations involved in meeting the needs of the elderly,
and quite often these organizations have active partnerships with governmental
units in providing services. Also worth noting is that each country has
grassroots organizations of older people that are helping shape policies and
programs and, occasionally, manage the resulting facilities and services.
Although lobbying by age-based groups runs the risk of fomenting
intergenerational conflict, it also helps insure that the needs of the elderly will
not be overlooked in governmental deliberations. Governments will also face
pressure to adjust and enhance these programs from the ups and downs of
economic cycles and from competing social demands. The recent economic
crisis in Asia is likely to make all countries in the region more cautious about
the structure of potentially costly programs, and we can expect countries to
balance their desire for strengthening a number of social welfare programs
with avoiding steps that may hinder their economic growth.
The existence of a range of programs does not in itself speak to the
strength and adequacy of their provisions. Although some shortcomings noted
in the literature were mentioned, overall we have not touched on the degree to
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Policies and Programs in Place 97
which the various programs, particularly those that address more specialized
needs, reach their target populations and fulfill their intended service. To do
so requires careful evaluation of each program and many of these have not
been undertaken. Chapters 7 and 8 touch on the use of pensions in retirement
and as a source of income, and Chapter 10 discusses sources of financing
health care. In Chapter 11 we present data from the surveys on respondents'
awareness of some of the programs and services reviewed above. These results,
together with the overview presented in this chapter, will be used in the
concluding chapter to shape several policy recommendations.
ENDNOTES
1. The following account borrows heavily from Asher (1996).
2. Based in part on Asher (1996).
3. Follows the discussion by Shih (1997).
4. The following account draws heavily from Knodel et al. (2000).
5. The elderly card entitles the elderly to free medical services at public health
facilities for the following items: (a) drugs, operations, intravenous solution, blood
or blood component, parenteral nutrition, oxygen, (b) prosthesis and medical device
including repairing cost, (c) medical service, medical examination, diagnosis,
laboratory investigation and other expense for hospitalization, except special nurse,
or professional fee, (d) dental service including acrylic prosthesis, (e) public
accommodation and food.
6. The medical benefits covered by the Civil Servant Plan are: (a) drugs on
National Essential Drug List, blood and blood components, intravenous solutions,
oxygen and others for treatment of diseases, (b) prosthesis and medical devices
including cost of repair, (c) medical expenditure, cost of investigation, not including
special allowance for special nurses, (d) accommodation and food, and (e) annual
personal health examination.
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Siripanich, B., C. Tirapat, M. Singhakachin, P. Panichacheewa, and P. Pradabmuk.
1996. A Research Report on the Senior Citizen Clubs: A Case Study of the
Appropriate Model. Bangkok: Vinyan Printing (in Thai).
Straits Times (Singapore), 4th April 1999.
Vasoo, S., T.L. Ngiam and P. Cheung. 2000. "Singapore's Ageing Population:
Social Challenges and Responses." In David R. Phillips, ed., Ageing in the
Asia-Pacific Region: Issues, Policies and Future Trends. London: Routledge.
World Bank. 1994. Averting the Old Age Crisis. New York: Oxford University
Press.
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Chapter 4
THEORETICAL PERSPECTIVES, MEASUREMENT
ISSUES, AND RELATED RESEARCH
Albert I. Hermalin
This chapter establishes the groundwork for the analytic chapters that
follow by developing the theoretical framework that guides these
analyses, addressing several key measurement issues, and briefly reviewing
relevant prior research. Given the breadth of subject matters associated with
the study of aging and the number of disciplines involved, the first two sec
tions identify the disciplinary stance—the demography of aging—that guides
this volume and its relationship to other disciplines that also are actively in
volved with this topic.
The Demography of Aging
The study of aging, or gerontology, is a diffuse enterprise, with theoretical,
substantive, and methodological contributions from many disciplines. It is a
rapidly expanding field in many parts of the world, but also one with long
antecedents. The multi-disciplinary breadth is not surprising. From one
perspective, the field focuses on an age-defined segment of the human
101
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102 The Well-Being of the Elderly in Asia
population with all the related behavioral and social science issues associated
with human action and organization. These are treated with differential
emphases by researchers from anthropology, economics, history, political
science, and sociology. From another perspective, the study of aging is
concerned with the basic processes of aging and the special conditions that
occur toward the end of life, which highlight the involvement of the biological
sciences, medicine, public health, social work, and epidemiology. An
important recent development touched on below is the increasing amount of
research conducted across the disciplines in each broad grouping.
The growing interest in aging within most of these disciplines arises
from recent demographic trends in the developed and much of the develop
ing world, described in Chapters 1 and 2. According to United Nations pro
jections, every region of the world will experience an increasing older popu
lation age structure over the next 50 years, and in the less-developed regions
the increases will be particularly rapid in contrast to past trends (United
Nations, 2001). At the same time, attention to aging and older age as a dis
tinct stage of life can be found in very early writings, and even the percep
tion of old age as a "problem" in Western civilization appeared in early 20th
century literatures (if not before), according to Achenbaum (1996). He notes
that the term "geriatrics" was coined in 1914 and the term "gerontology,"
meaning the scientific study of aspects of growing older, in 1908.
We position our work within the demography of aging, an emerging
field that is itself eclectic—distinguished both by the traditions, theory, and
methods of demography and by the set of problems it has addressed and the
methods and data it shares with other social sciences. The field is more de
fined by the demographic training of its practitioners and the perspectives
that flow from that orientation than by any special problems, theories, or
techniques. Indeed, in their introduction to the influential National Acad
emy of Science volume, Demography of Aging, Martin and Preston (1994)
describe the field as "a rather capacious umbrella for a variety of studies
addressed to the causes and consequences of population aging," before at
tempting to identify several distinguishing features (p. 3).
Part of the vagueness concerning the definition and range of the de
mography of aging stems from ambiguity in the parent field of demography,
or population studies. In a classic formulation by Hauser and Duncan (1959),
the following definition was offered:
Demography is the study of the size, territorial distribution, and com
position of population, changes therein, and the components of such
changes, which may be identified as natality, mortality, territorial
movement (migration), and social mobility (change of status), (p. 2)
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Theoretical Perspectives, Measurement Issues 103
As the authors note, this definition casts a wide net for demographic
endeavors when one reflects that "composition" can go beyond measuring
variation in such basic characteristics as age, gender, or marital status to in
clude many other qualities such as education, occupation, and health status;
and that changes in composition arise from individuals moving from one sta
tus to another as well as through natality, mortality, and migration. This inher
ent breadth of the field brings demographers into contact with many other
disciplines that address some of the same statuses and changes, leading to
interdisciplinary exchanges of measures, methods, and frameworks.
The authors' distinction between "demographic analysis" and "popu
lation studies" helps further identify where the interdisciplinary exchanges
are most likely to occur. They define "demographic analysis" as the study of
the components of population variation and change, and reserve the term
"population studies" for investigations concerned with the relationships be
tween population factors and other variables—social, economic, political,
biological, etc. In short, "population studies" is as broad as the range of the
determinants and consequences of population trends. From this standpoint,
demography may be considered quite narrowly as "demographic analysis" or
more broadly as also encompassing "population studies" as well as "demo
graphic analysis." It is in the arena of "population studies" that demography
overlaps with many other fields, and where multiple frames of reference and
strategies come into play alongside the perspectives of demographic analysis
(Mauser and Duncan, 1959, pp. 2-3). As a result, "population studies" cannot
be thought of as a single theoretical discipline.
In recent years several additional reviews of demography have appeared
that reaffirm the complexity of the field and its multidimensionality, while
stressing the perspectives, concepts, and methods that maintain it as a distinct
discipline (Caldwell, 1996; Preston, 1993; Keyfitz, 1993; Stycos, 1987). These
dual aspects are clearly in evidence in the study of population aging. The
more formal aspects of demography are seen in the measurement of mortality
levels, trends, and differentials and through models, such as stable population
analysis, that relate age structure to levels of fertility and mortality, and in the
analysis of population movements that affect population size and composi
tion. The traditional tools and perspectives within demographic analysis—
such as the centrality of age, the life table as a device for understanding time-
varying risks, the concept of the cohort, the emphasis on decomposition, the
attention to quality of data, and expertise with complex forms of data collec
tion via registration systems, censuses, and population surveys—have con
tributed to elucidating many dimensions of population aging. Increasingly
however demographers are combining these tools and perspectives with those
of other disciplines to address aging from the standpoint of population studies
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104 The Well-Being of the Elderly in Asia
and a wider array of issues that include studies of health, work and retire
ment, living arrangements, and intergenerational exchanges.
Related Disciplines and Their Perspectives
As noted at the outset, the field of gerontology has a long history involving
many disciplines. For each discipline, several issues within the field of aging
are particularly consonant with their perspectives and/or methods.
For example, four editions of the Handbook of Aging and the Social
Sciences (Binstock and Shanas, 1976; 1985; Binstock and George, 1990; 1996),
among other compendia (e.g., Birren, 1996), have attempted to trace the
theoretical, substantive, and methodological connections within the social
science disciplines to various dimensions of research on aging. For sociologists,
examinations of age stratification, cohorts, the life course, family and social
support systems, and social change figure prominently in aging research (Riley
et al., 1972; Uhlenberg and Miner, 1996). Anthropologists have offered insights
into the effects of culture on the definition and experience of old age; the
number and nature of age grades; and the characteristics of age-set societies
in which age becomes a major axis of social organization (Fry, 1996; Foner
and Kertzer, 1978; Stewart, 1977). Historians have shared with anthropologists
the tasks of tracing the definitions of aging across space and time, as well as
investigating particular issues such as the impact of science and technology
on perceptions of aging, or variations in the development of private and public
measures to address the problem of the elderly over time (Achenbaum, 1985,
1996).
A number of theoretical and substantive issues in aging have engaged
economists. On the theoretical side, the relevance of rational choice models
and the role of expectations are under discussion (Myers, 1996), and the mo
tivations associated with intergenerational support patterns have been increas
ingly elaborated (Lillard and Willis, 1997). Economists have developed use
ful models for investigating the interrelationships between population growth
and structure and economic development (Lee, 1994a; Easterlin, 1991; Ma
son et al., 2001); they have been active in studying the economic status of the
elderly, patterns of labor force activity and retirement, and the implications of
different types of public and private retirement programs (Smeeding, 1990;
Quinn and Burkhauser, 1994; Gruber and Wise, 1999; Smith, 1995; World
Bank, 1994). Political scientists have investigated the political attitudes and
behaviors of older people, the politics associated with old-age policies, and
the interest groups focused on specific age strata or issues of generational
equity, among other topics (Binstock and Day, 1996; Quadagno, 1989).
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Theoretical Perspectives, Measurement Issues 105
Many of these concepts and issues have become common currency
within studies of aging, permeating all the fields involved. Thus they will
appear frequently under the rubric of "demography of aging" as well as the
other disciplines cited. Accordingly, several will be addressed at greater length
below and within specific chapters.
In addition to the social sciences, the study of aging has strong roots in
psychology, biology, and the health sciences. Handbooks on the psychology
of aging (Birren and Schaie, 1996) and the biology of aging (Schneider and
Rowe, 1996) have appeared in concert with those in social science, and sev
eral of the concepts and issues from these disciplines intersect a broad defini
tion of the demography of aging as well. For example, psychologists have
been prominent in developing scales of depression, cognition, and other im
portant mental states, and a number of these have been used in large-scale
population surveys to measure variations among the older population. In ad
dition, concerns with the life course, stages of development, and disassociat
ing effects of aging from cohort effects parallel similar issues in demographic
analysis and other social sciences.
The biology of aging is a broad field covering human and animal models
and molecular and cellular research, as well as analysis of the relation of
aging to specific systems (immune response, circulation, neurological, etc.).
Although many of these endeavors remain discipline specific, in recent years
demographers and biologists have contributed to an emerging interdisciplinary
field of "biodemography" that meshes perspectives from each discipline on a
number of methodological and substantive issues, especially those centering
on longevity. A National Academy of Science committee attempted to codify
some of the emerging interrelationships, and their results appear in Wachter
and Finch (1997). The topics addressed include establishing the trajectory of
mortality at advanced ages in humans as well as other species, evolutionary
theories of senescence and their applicability for demographic modeling,
assessment of intergenerational relations and the role of the elderly in different
societies, and the potential for population surveys to assist with genetic studies.
This latter topic has received additional emphasis in a newer National Academy
of Science committee report focusing on whether biological measures should
be included in social science research (Finch et al, 2001). Of particular
relevance is the description of an ongoing project to collect bioindicator data
from a subsample of the Taiwanese respondents to the surveys employed in
this monograph (Weinstein and Willis, 2001).
Researchers in the health sciences have a prominent role in studies of
the elderly given their strong interest in various aspects of physical, mental,
and emotional health, and the utilization of health services and their costs. In
the past, research studies on health and on income and retirement tended to
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106 The Well-Being of the Elderly in Asia
be discrete, limiting analyses of how health interacts with income, assets, and
retirement. This limitation, as pointed out in an influential committee report
(described in Juster and Suzman, 1995), served to stimulate development of
surveys of the elderly that included detailed demographic, socioeconomic,
and health sections, such as the Health and Retirement Study (see Juster and
Suzman, 1995, for an overview). Demographers, economists, and health sci
entists have had frequent contact in both the development and analytic stages
of these studies.
A major area of intersection for social scientists and public health
specialists is the study of relationships between social factors—such as socio-
economic status, social integration, and stress—and health status (George,
1996). Studies of the apparently strong influence of social support on health
outcomes have received considerable attention (Bruhn et al., 1987; Marmot
and Wilkinson, 1999), as have investigations into the relationship of
socioeconomic status to levels of mortality and morbidity (Preston and
Taubman, 1994).
Interdisciplinary contact is also fostered by the overlapping interests
of demographers and epidemiologists in the strategies and measures used for
assessing factors responsible for differential outcomes in morbidity and mor
tality. A particularly fruitful intersection has been in the application of life
table techniques to generate measures of active life expectancy that reflect
the years a cohort may expect to live without disability under given age-spe
cific prevalence levels of chronic disease (Manton and Soldo, 1992). The
advent of these measures provides insights as to whether increases in life
expectancy at the older ages are accompanied by improving or worsening
health (Manton et al., 1997; Manton and Gu, 2001; Crimmins et al., 1997;
Verbrugge, 1984; Freedman and Martin, 2001). Aconference in February 2001
was organized to further strengthen connections between demography and
epidemiology in aging research and other fields (Weinstein et al., 2001).
The breadth of topics of relevance to the demography of aging and
these other disciplines, and the multiple perspectives from which they may be
approached, rule out the possibility of using a single overarching conceptual
framework from which to analyze age-related dimensions and issues. For that
matter, even the individual disciplines have multiple theoretical perspectives
and alternate ways of classifying these. The Handbook of Theories of Aging
(Bengtson and Schaie, 1999) and earlier reviews (Birren and Bengtson, 1988)
describe many of the perspectives within each discipline, and Marshall (1996,
1999) discusses the nature of theory within the social sciences and the
challenges associated with codification. The strategy adopted here is to provide
a broad heuristic framework that can serve to organize and locate many of the
topics of interest and to tie in some of the specific related theories.
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Theoretical Perspectives, Measurement Issues 107
In the remainder of this chapter we set forth this broad framework and
several of the theoretical perspectives associated with the empirical analyses
to be presented in subsequent chapters, and review select dimensions of past
research on population aging in Asia.
The Conceptual Framework
The organizing framework for this volume, which expands on the model pre
sented in Chapter 1, is set forth in Figure 4.1. The framework attempts to
reflect both the major societal-level interrelationships and policy concerns
usually addressed via aggregate level or macro-analysis, and the large num
ber of meritorious individual or micro-level questions centering on the cir
cumstances of the elderly and the determinants of their well-being.
The well-being of the elderly, shown in the center, is viewed as con
sisting of three broad dimensions: economic well-being; physical, mental,
and emotional health; and activity levels, which incorporates work, retire
ment, and leisure activities. To the left of these dimensions are two sets of
determinants differentiated by their proximity to and influence on the elderly.
At the far left are the more remote, broad societal factors that set the bound
aries within which the more proximate policies, programs, and influences
operate (Intermediate Institutions and Influences). These exogenous social,
economic, demographic, and cultural factors influence personal characteris
tics of the elderly (e.g., level of education), their living arrangements and
support/exchange systems, and the formal arrangements through employers
or government programs that are available to them.
At the two extremes of age, humans cannot produce enough from their
labor to sustain their needed consumption, so that each society must develop
a set of mechanisms, including formal and informal elements, that define the
timing and content of support, the appropriate participants, and their mutual
obligations. In terms of Figure 4.1, living arrangements and other aspects of
the family exchange system, along with governmental and employer programs
that impact family transfers, are key components of the intergenerational
transfer system that societies depend upon to smooth out consumption needs
and productive abilities across the life cycle. In periods of relative stability
these components are maintained by a well-developed normative and value
structure. However, rapid demographic, social, or economic changes of the
sort experienced by many countries in Asia are likely to produce strains that
compromise these arrangements. Because the elements of the transfer system
have such wide-reaching social and economic consequences and are so closely
entwined with policy decisions, they are increasingly the subjects of research
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Theoretical Perspectives, Measurement Issues 109
in rapidly changing societies. As discussed below, certain elements have
received more attention than others, and an important goal of this volume is
to achieve a greater balance in analyzing the components of the system and
their consequences for the dimensions of well-being.
Figure 4.1 also attempts to represent several other important processes.
The development of new programs and policies that affect the elderly (far
right), as well as those in other age strata, is viewed as guided by perceived
needs and preferences. These have been added to draw attention to the logical
distinction between measuring the objective status of the elderly and infer
ring what this means for policies and programs. In some cases the connec
tions may be quite direct, as in developing policies or programs to fill the
needs of those with specific physical limitations or who lack any assistance.
But in others, the objective status measures must be complemented by assess
ments of needs and preferences to adequately inform policy development.
For example, do retirees prefer the availability of leisure activities or some
level of gainful employment? And how does one appraise the adequacy of
income levels or housing quality among the elderly? In this case, it must be
said that new policies or programs will be guided not only by the needs and
preferences of the elderly, but by the degree of economic and political influ
ence they possess, especially in relation to the needs and influence of "com
peting" age groups. Including other age groups in this figure also emphasizes
that the well-being of the elderly on various dimensions can influence the
well-being of other age strata and vice versa. Of course, the development of
new policies and programs is also a product of existing programs and institu
tions, and the broader socioeconomic and cultural dimensions that character
ize a society at any given time, as portrayed in the figure.
The process is clearly dynamic, as new policies and programs, along
with ongoing social change, affect the well-being of each age group and the
structures of the influential institutions. This feedback process is suggested
by the dotted lines in the diagram. As described in Chapter 3, the assessment
of current policies and programs and the development of new ones are an
active process in much of East and Southeast Asia given the recent demo
graphic and socioeconomic changes there. A number of the countries in the
region have introduced major new welfare programs, or are in the process of
reviewing new initiatives and modifying existing arrangements. These activi
ties impinge directly on the elderly and non-elderly alike, and—as shown in
Figure 4.1—have the potential to alter existing social and economic arrange
ments.
The framework in Figure 4.1 serves as a heuristic and organizational
device for identifying a number of specific theories and models of promi
nence in population aging research, and the topics that will be the focus of
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110 The Well-Being of the Elderly in Asia
this volume. In the following sections we review major components of this
framework and their relation to specific chapters.
Societal Changes and Their Impact on the Elderly
The plan of action adopted at the World Assembly on Aging held in Vienna in
1982 recognized two major concerns associated with population aging: the
humanitarian issues related to the specific needs of the elderly, and the devel
opmental issues related to the societal implications, in particular the effects
of population aging on production, consumption, savings, and the associated
socioeconomic conditions and policies (United Nations, 1983). Considerable
theory and research bearing on both these issues have developed over the
years.
One major axis of theory and research has been the effects of eco
nomic development on the status of the elderly and their well-being along
various dimensions. An influential theory by Cowgill (1974; Cowgill and
Holmes, 1972) was developed in conjunction with a review contrasting the
role of the elderly in primitive societies (Simmons, 1945) with their role in
several Western industrialized countries. He found that many of the factors
associated with "modernization"—industrialization, urbanization, modern
health technology, and increased education—tended to reduce the status of
the elderly by limiting their job opportunities, separating them from their fami
lies, and lowering their social status relative to the young. Subsequent tests
and reviews of this posited relationship have been more agnostic as to the
effects of development. Palmore and Manton (1974) used national level cor
relations to test Cowgill's thesis and found little direct support, and also drew
a distinction between the potential effects on the elderly of early levels of
development versus more advanced levels, suggesting the possibility of a U-
shaped relationship between elderly status and modernization. Treas and Logue
(1986) conclude that the relationship between economic development and
the welfare of the elderly may depend on many situational factors. For ex
ample, wage labor may make the young more independent, but increasing
land values may give the elderly considerable economic power.
The thesis that modernization impinges adversely on the older
population has also come under attack from historians and comparative social
analysts who show that the status of the elderly within societies has varied
considerably over time and across societies. They identify times and places
throughout history in which the elderly were not well off, despite various
levels of economic development or technological progress, as well as instances
in which the well-being of the elderly improved along with rapid socioeconomic
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Theoretical Perspectives, Measurement Issues 111
development (Achenbaum and Stearns, 1978; Achenbaum, 1982; Cooper,
1999).
A related line of thought points to deleterious ell eeels of industrializa
tion and urbanization on the elderly arising from their presumed effects on
family structure and relationships. For many years, social science research
found evidence of Western industrialization's negative influence in the reduc
tion of obligatory family responsibilities, the growth of nuclear living arrange
ments, and the decrease in arranged marriages, among other factors. But more
recent studies by social historians have established that many of the presumed
aspects of family life in the Western past did not accord with the historical
record. As summarized by Thornton and Lin (1994, p.4)
These historical studies showed that the social and economic changes
that had occurred in Western societies had not produced many of the
family changes that several generations of earlier scholars had written
about. In fact, the data showed that several key features of Western
family life previously believed to have been the result of important
social and economic changes were widespread in many Western soci
eties before the other changes occurred. So revolutionary was this new
historical research that many of the earlier conclusions have been la
beled as myths in the recent literature.
These revisions have led to more careful empirical studies of family
relationships and the role of the elderly across historical periods and societies.
Hareven (1982) and Quadagno (1982) illustrate this line of research for early
industrial periods in the West.
In a seminal work, Goode (1963) traced the relationship between in
dustrialization and what he termed "the conjugal family" across societies.
While recognizing the existence of nuclear families early in Western history
and the lack of a simple relationship between modernizing forces and family
structures world wide, he notes a broad shift across cultures from a familial
focus on cross-generational relationships to an emphasis on the husband-wife
relationship. This shift has been manifested by a greater choice of marriage
partners among young adults, greater emotional bonds between husbands and
wives, and more independent living among young couples, among other out
comes. Goode is careful to note, however, that because these changes do not
necessarily imply a weakening of other facets of family structure, they may
coexist with many traditional family arrangements. Goode's wide-ranging
research has been the source of a number of studies, some addressing the
broader thesis and others offering detailed analyses of specific regions or
societies.
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112 The Well-Being of the Elderly in Asia
McDonald (1992), for example, attacks the idea of worldwide conver
gence to the conjugal family form in the form set forth by Goode, but recog
nizes that social change can lead to reconstitution of family systems via "com
promise between ideology and economic structure" (p.23). Many analysts
seem in accord with what Freedman (1993) termed a more general conver
gence hypothesis, which recognizes movement from more to less dependence
on kinship-based institutions in developing societies as a result of socioeco-
nomic change, but with significant variation in the forms taken by this trans
formation across societies. Wilson and Dyson's (1992) analysis of India and
Caldwell and Caldwell's (1972) examination of agricultural peasant societies
are in accord with this formulation.
Other studies have explored family changes in East Asia over the past
several decades. Thornton and Lin (1994), using data on many aspects of
family structure gathered in Taiwan during the rapidly changing period fol
lowing World War II, examine in some detail which aspects of marriage and
family have changed and which have remained relatively intact. Mason et al.
(1998) examine the impact of industrialization on several dimension of fam
ily life in an analysis comparing several Asian countries to the United States.
Whyte and Parish (1984) examine urban life in China in the 1970s to trace the
nature of the changes arising from political and economic forces and their
similarity to changes elsewhere. Mason (1992) develops a model for tracing
how the effects of changes in industrialization, urbanization, and migration
on the family in Asia are likely to impact on the care of the elderly.
Whyte et al. (forthcoming) utilize contrasts between urban Taiwan and
the city of Baoding, PRC, to illustrate that the concepts of modernization and
development need to be carefully specified in order to trace potential effects
on the family. Although China is less economically advanced than Taiwan, on
a number of measures the older people and their children in Taiwan appear
more traditional in terms of family living arrangements and exchanges than
do their counterparts in Baoding. This comes about, in the view of the authors,
in part from the actions of the Chinese government in the 1950s and 1960s to
promote a "proletarian culture" distinct from Confucian, Western and, after
1960, Soviet cultural influences. At the same time, the rapid economic growth
in Taiwan was distinctive in the prominence of family controlled firms and
investments in the process, which maintained to a high degree family controlled
work settings as against non-familial enterprises, and served to maintain several
aspects of traditional family relationships (Whyte et al., forthcoming). These
contrasts highlight the importance of paying close attention to the "micro-
institutional" context within which individual and family behavior operates,
as well as the broad path of economic development. A related caution is
expressed by Thornton and Fricke (1987) with their attention to the importance
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Theoretical Perspectives, Measurement Issues 113
of the "familial mode of social organization," and the need for carefully
specifying the contexts was noted by Goode in his original formulation.
In terms of Figure 4.1, the foregoing theories and analyses examine the
potentially deleterious effects on the well-being of the older population from
modernizing forces either directly, or indirectly through their effect on family
organization, and the intergenerational support system. It is well to stress,
however, that careful empirically testing these hypotheses requires studies
over time in which societies of different types are traced to study the impact
of these forces, as recognized by Goode (1963) and Thornton (1991) among
others.
Nevertheless the theoretical underpinnings have considerable relevance
for current and future research on population aging in Asia. As previously
established, many countries in the region have undergone and are undergoing
rapid demographic, social, and economic changes that are transforming the
industrial base, the level of urbanization, and the educational level of younger
adults. Family size is shrinking, life expectation is increasing, more women
are entering the labor force, and new ideas and life styles are widely commu
nicated and rapidly adopted. Given these circumstances, a prime area for re
search is the impact of these changes on the well-being of the elderly in terms
of their health, their labor force participation and economic status, and their
family involvement. A second, related, major research objective is to ascer
tain the current state of key familial dynamics in terms of living arrange
ments, support and exchange arrangements, and levels of social contact, au
thority, and respect. The goals here are twofold: to trace how these impact on
the well-being of the elderly and to judge the extent to which these basic
societal systems are themselves changing. Although the latter cannot be ac
complished from a cross-sectional survey, it may be possible to glean on the
basis of knowledge of past family arrangements the degree to which various
elements may be changing in response to ongoing societal transformations,
and giving rise to new modes of accommodation. And of course well ex
ecuted current studies serve as benchmarks for monitoring future trends in
these basic systems.
In focusing on the broad question of the effects of population aging on
the welfare of the elderly we should not lose sight of the importance of
individual characteristics and lifetime experiences on well-being. As a result
of their common history, older people in any given age cohort have been
influenced by elements that distinguish them from older and younger groups,
ranging from the relative size of their cohort, to the social, economic, and
political forces predominant during their different life stages. However, older
people within any cohort have considerable variation in their experiences with
family support systems and non-familial institutions, which greatly influence
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114 The Well-Being of the Elderly in Asia
their well-being. Thus, the life course perspective (see Thornton and Lin,
1994; Elder, 1987) presents both an important framework for understanding
the current situation of the older population and a measurement challenge,
given the long and varied histories of older individuals (Hermalin, 1993).
Consideration of the life course also reminds us that well-being is a multi
dimensional concept and that advantages on certain facets can be associated
with disadvantages on others. For example, an analysis by Easterlin et al.
(1993) addresses the question of whether the large baby-boom cohort in the
United States (roughly those bor n between 1946 and 1964) are likely to be
worse off economically than earlier smaller cohorts. Using cohort analysis,
which compares the baby-boom cohort at various life cycle stages with earlier
cohorts, they conclude that the baby-boomers are not likely to end up at an
economic disadvantage. At the same time, the authors look at several family-
related characteristics of this cohort—marriage and divorce rates and number
of children—and conclude that on these aspects of well-being the baby-
boomers may be at a disadvantage in comparison with earlier cohorts.
In the analytic chapters that are to follow we incorporate aspects of the
life course perspective and the variation across individuals by paying close
attention to the way that the several dimensions of well-being vary by
sociodemographic characteristics that reflect family dynamics, residence,
educational attainment, and occupational history (as well as age and gender).
We realize that these are only broad surrogates for the myriad biological and
social influences each individual faces.
In sum, the research objectives set forth have several purposes. On one
hand, they provide snapshots—point-in-time analyses—of the well-being of
older populations living in societies going through considerable demographic,
social, and economic change. As such, they serve as detailed benchmarks for
future studies that will help establish the impact of such change on key insti
tutions and the welfare of the older population. More immediately, carefully
gauging levels of well-being on several dimensions and understanding how
these levels vary with key sociodemographic characteristics are important
inputs for policymakers who must make decisions on the kinds of programs
to develop to address the needs of the older population.
The Effect of Population Aging on Economic Development
Population aging has important implications for many facets of an economy,
including economic growth, labor force dimensions, saving rates, and income
inequality among other dimensions (Johnson and Lee, 1987; Kelley, 1988).
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Theoretical Perspectives, Measurement Issues 115
The connections involve a number of basic theoretical perspectives and have
been tested with a variety of models, data, and methods. Some relationships
appear well established, while others remain inconclusive, varying with the
data and analytic techniques employed. On some topics several key questions
are unresolved. We discuss and illustrate here only a few of the connections
between population aging and economic outcomes, focusing on those most
relevant to the situation in Asia and which intersect with important policy
issues. These include the relationships between aging and labor force rates,
economic growth, savings, and transfer systems.
The most direct effect of changes in fertility and mortality on eco
nomic parameters is through their effect on age structure and hence on the
proportion of the population that is of working age. As shown in Chapter 2,
the dependency ratio which measures the working age population to the non-
working older and younger segments is often used to capture this relation
ships. The analysis by Bloom and Williamson (1998) of 78 countries finds a
strong relationship between the growth rate of the economically active popu
lation (a related measure) and the economic growth rate between 1965 and
1990. They argue that East Asia's so-called economic miracle was fueled in
part by its demographic transition during this period in which the working
age population grew much faster than its dependent population, helping to
expand the per capita productive capacity of these countries. The authors
caution, however, that this relationship between demographic structure and
economic growth is not inevitable but dependent on having appropriate so
cial, economic, and political institutions in place that allow the potential af
forded by the demographic changes to be realized. (See also Bloom et al.,
2000, for related analysis and discussion). It is worth noting that these recent
analyses help resolve a long-standing debate about the effect of population
growth per se and economic growth, which has resulted in contradictory find
ings. By utilizing the components of population change and the resulting age
structure more explicitly in modeling and analysis, the manner in which de
mographic change interacts with economic change has been clarified. (See
Bloom and Williamson, 1998; Bloom et al, 2000; and A. Mason, 1987, for
further discussion of the issues.)
A related type of analysis of the potential economic impact of population
aging is provided by Easterlin (1991), who uses historical data for ten European
countries and the United States to trace the relationship between past population
growth rates and growth in per capita gross domestic product. Examining
these past trends and past and future dependency ratios (of the type discussed
in Chapter 2), Easterlin finds little empirical evidence that declining population
growth has slowed the rate of economic growth and concludes that projected
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116 The Well-Being of the Elderly in Asia
total dependency ratios are in line with past experience (given the trade-off
between fewer young dependents and more older dependents).
Beyond the general question of the relation of population change to
economic growth, there is particular interest on how demographic trends and
structure impinge on savings. A formulation by A. Mason et al. (2001, p. 116)
views per capita growth in income as a function of the growth rate of the
number of workers per capita (the economic support ratio) and the rate of
growth of output per worker. (More precisely, the formulation uses "equivalent
adults" and "effective workers" to take into account differences in consumption
and productivity with age.) The component representing workers per capita is
reflected in the dependency ratio as discussed above and in Chapter 2. The
component representing output per worker is affected by technological changes
and by physical and human capital per worker. The relation of demographic
change to technological change is ambiguous according to the authors but
under certain conditions population aging can lead to substantial increases in
capital per worker. Several recent analyses indicate that savings rates will
increase during the portion of the demographic transition when the ratio of
workers to population is increasing (or the dependency ratios are decreasing)
but the relationships are complex and not all the research points in the same
direction. In the main, a number of aggregate level studies of international
time series found a close relationship between demographic change and savings
(see reviews in Lee et al., 2000; Bloom and Williamson, 1998), while analyses
at the household level are not generally supportive (see for example the findings
for Taiwan and the related discussion in Deaton and Paxson, 2000b). In an
effort to reconcile these differences, Lee et al. (2000) undertook microdata-
based macro simulations of the relation of life cycle savings to the demographic
transition in Taiwan and found that "under the assumption of pure life cycle
savings, aggregate savings rates would decline modestly during the early stages
of the demographic transition, then rise quite substantially during a long middle
period, and then decline again as the population aged rapidly in the last stage
of the transition." (Lee et al., 2000, p. 195)
As described earlier, the need to smooth consumption over the life
cycle gives rise to various private and public mechanisms for achieving this
goal. In many developing societies, transfers from children to parents are a
major source for ensuring adequate consumption in later life. In many indus
trialized countries, pay-as-you-go social security systems, which represent
another form of transfers across generations, have become a dominant form
of retirement income. The importance of transfer systems of different types
within all societies and their potential implications on savings behavior, and
hence economic growth, have led to extensive modeling of the transfer sys
tems in operation within an economy and their relation to population change
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Theoretical Perspectives, Measurement Issues 117
and structure. Formulations by Lee in a series of papers (1994a, 1994b, 2000)
provide the basis of an accounting framework that uses age-specific rates of
consumption and income, and of the relevant benefits, taxes, or exchanges
that go into each transfer system, along with relevant demographic fertility
and mortality schedules. These schedules and the underlying demographic
and economic assumptions enable one to calculate the average age of receiv
ing versus giving for each type of transfer, the average amount of the transfer,
and the lifetime transfer wealth. (For a description of this accounting frame
work, see National Research Council [2001, Chapter 5]).
The consequences of population aging on levels of consumption arise
from both the slower rate of population growth and the changing age compo
sition associated with decreasing fertility and mortality. In the absence of any
other change, slower population growth perse enhances potential consump
tion because a smaller share of output is needed as investment to maintain a
fixed amount of capital per workers. But when the changing age structure is
taken into account, potential consumption may decrease because of the "in-
tergenerational transfer effect." This factor arises whenever net aggregate trans
fers take place between members of different age groups, as in the case of
support of older parents by young children, pay-as-you-go social security pro
grams, and other societal mechanisms for smoothing out the need for con
sumption across the life cycle, as noted above. In the models developed by
Lee, the intergenerational transfer effect is captured by the difference be
tween the average age of consumers in a society and the average age of pro
ducers. When this difference is negative (i.e., the average age of consumers is
less than that of producers) this signifies a net transfer from the older to the
younger population and a concomitant enhancement of overall societal con
sumption with population aging. A positive difference represents a net trans
fer from the younger to the older population and a reduction of overall soci
etal consumption with population aging.
Two important insights arise from this economic accounting framework.
Empirical measures of net transfers across different types of societies show
that they flow from the older to the younger generations in primitive societies
and some in early stages of development. In the more industrialized societies
such as the U.S., Japan, and England, however, net transfers flow from the
younger to the older generations (National Research Council, 2001, Figure
5.1). But these models also demonstrate that the flow of transfers may be in
opposite directions for different components of the overall transfer system. In
the United States, for example, there is a strong upward transfer across ages
arising from the public sector social security and health programs, at the same
time that there are strong downward net transfers arising from the family sector,
through bequests, gifts, child costs, and support for higher education.
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118 The Well-Being of the Elderly in Asia
Intergenerational transfers are closely related to the process of wealth
accumulation and thus have several important policy implications. In terms
of the relation of population growth to economic growth as formulated by A.
Mason, et al. (2001) as described above, the potential impact of population
aging on increases in capital per worker will depend to a great extent on how
the needs of the older population are met. Where transfer systems dominate,
the demographic transition to an older population will not necessarily
contribute to greater accumulation of capital or real wealth, and thus not
enhance the growth of income per capita. As stated by A. Mason et al. (2001,
p. 121-122):
From the perspective of meeting retirement needs, systems based on
transfers and systems based on the accumulation of real wealth are in
one sense identical. Either system produces a stream of income during
the retirement years. Likewise either flow represents wealth to that in
dividual—real wealth in one case, transfer wealth in the other. From
the perspective of the economy, however, real wealth and transfer wealth
are very different. Real wealth is productive and contributes to im
proved standards of living.... In contrast, transfer wealth contributes
nothing to economic growth. (Mason et al., 2001, pp. 121-122)
There are also a number of important research questions associated
with these economic insights. Will families reduce their support for older
parents or their own savings behavior after social security programs are insti
tuted, or will older parents increase their private transfers to children, realiz
ing the tax burdens they may be facing under a pay-as-you-go system? These
and related questions cannot be answered from the economic accounting
models alone; they require additional research on the behavioral and motiva
tional aspects of familial transfers.
The uncertainties associated with savings behavior and trends in the
national savings rate have led to some caution that a fully funded pension
program may not generate an increase of investments for development, and
does not address questions of equity (Johnston, 1999). These policy questions
are taken up in the concluding chapter. Some of the challenges involved in
carrying out research on intergenerational exchanges are developed below
where measurement and related issues pertaining to the analytic chapters are
discussed. We turn first to a short review of past research on aging in Asia that
touches on some of these aspects.
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Theoretical Perspectives, Measurement Issues 119
Asian Interests in Research on Aging
Questions about the interrelationships among economic growth, aging popu
lation structures, and the welfare of the elderly that have gained prominence
within industrialized countries have also caught the attention of many less
industrialized nations. Researchers and policymakers have interests in both
the humanitarian and developmental implications of population aging, par
ticularly in East and Southeast Asia where extended living arrangements and
support for older parents by their children are traditional social systems. Inso
far as forces associated with industrialization and modernization undermine
these social systems and otherwise adversely affect the welfare of the elderly,
they raise the need for social welfare programs to take their place. Policymakers
are also concerned that the adverse age structures associated with population
aging will limit their potential for continued economic development and thus
the resources required to pay for these programs, as well as other social and
economic goals on their planning agendas.
Asian policymakers and researchers have displayed prescient attention
to these implications of population aging. Although only two Asian societies,
Japan and Hong Kong, had more than 10 percent of their populations in the
60 or older age group as of 1990, there has been an outpouring of confer
ences, research projects, books, and papers about aging in Asia since the early
1980s. Overviews of these research efforts have been provided by Andrews
(1992), Hermalin (1997a), Martin and Kinsella (1994, who also report on
other developing regions) and Andrews and Hermalin (2000). These reviews
describe the nature of many of the salient studies in the region, discuss re
search issues, and provide references to the cross-national or multi-country
studies and a number of the single-country efforts. Many of the multi-country
studies have been sponsored by international agencies like the WHO Regional
Office for the Western Pacific (Andrews et al., 1986; Andrews and Henrick,
1992); the Association of Southeastern Asian Nations (ASEAN) (Chen and
Jones, 1989); and the United Nations Economic and Social Commission for
Asia and Pacific (ESCAP). The latter organization has been particularly ac
tive in promoting research and workshops on population aging throughout the
Asian and Pacific regions and a list of their publications on this topic can be
found in the Asia-Pacific Population Journal (1997, p. 6), as well as in
Andrews and Hermalin (2000).
Although it is difficult to summarize the wide variety of studies under
taken in the region, it is probably fair to say that they tended to concentrate on
measuring the welfare of the elderly on select dimensions, like health, while
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120 The Well-Being of the Elderly in Asia
assessing the state of the underlying familial system by measuring the living
arrangements of older persons and the nature of the support they are receiving
from children and other kin. In this sense these studies address the first of the
broad theoretical issues discussed above—the effect of social and economic
change on key family institutions that have traditionally served to support the
older population. This motivation is consonant with policymaker concerns
about population aging and the desire to discern at an early stage whether
rapid changes in key societal institutions were underway. The emphasis on
analyzing living arrangements is also consonant with the relative abundance
of data on household structures, routinely gathered on censuses and surveys.
Analyses of trends in coresidence and differentials in living arrangements by
characteristic provide partial indicators of changes underway and can serve
as harbingers of what might evolve over time. These research efforts were
valuable in establishing the high levels of coresidence among older parents
and their adult children that could be used as benchmarks for tracing changes
over time (Martin, 1989). And in fact, although these findings demonstrated
no imminent crisis in key familial arrangements supporting the elderly that
required reactive policy and program implementation (Hermalin, 1997), the
longer term trends now available for several countries indicate various de
grees of change in the level of coresidence, raising questions about key deter
minants and the future, as discussed in Chapter 5.
It should also be said that the value of the data provided by these ear
lier studies is compromised somewhat by conceptual and measurement prob
lems. We address some of the broader issues here and take up more specific
problems in discussing the analytic chapters below. In terms of Figure 4.1, a
focus on living and support arrangements places undue emphasis on interme
diate variables that affect the well-being of the elderly rather than the dimen
sions of well-being. Though some of the earlier studies did give special atten
tion to health, relatively little attention was paid to the income and wealth
levels of the elderly, their work and leisure activities and preferences, or their
level of their involvement with families and friends. Even within the realm of
health, analyses were often limited to measuring rates of chronic diseases and
degrees of disability rather than patterns of health behaviors or health care
utilization and its associated economic factors.
The focus on living arrangements and the receipt of support from chil
dren also tends to slight the other intermediate variables operating and im
plicitly assume that those not coresiding or receiving support will suffer vari
ous disadvantages. However, even at earlier stages of their history, significant
fractions of the older population in many of these countries lived indepen
dently, or did not rely on their children or other kin for major support.
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Theoretical Perspectives, Measurement Issues 121
Nevertheless, it remains true that living and support arrangements re
main important intermediate institutions and their differences over time and
across societies can be highly revealing. However, in pursuing these topics
many of the earlier studies had insufficient empirical breadth and limitations
in their measurement strategies. Perhaps most important, a formal structural
definition of living arrangement fails to provide vital information about the
content of the relationships and interactions. For example, older parents liv
ing with married children may be recipients of considerable financial and
emotional support, or they may be mainly aiding their children and grandchil
dren with child care, shopping, and meal preparation. Older parents who do
not reside with their children may maintain frequent contact but prefer inde
pendence, and have the economic means to achieve this (or receive support
from children to facilitate independent living). In the U.S., though support
and coresidence patterns differ, contact with children remains high (Bumpass,
1990; Eggebeen and Hogan, 1990; Crimmins and Ingegneri, 1990).).
At a more general level, despite the rapid socioeconomic and demo
graphic changes ongoing in many developing countries, it is unlikely in the
near term that existing social arrangements for the support of the elderly will
be precipitously abandoned and replaced by completely new structures. Rather
one can expect and can already discern a series of accommodations, as exist
ing forms adjust to new pressures and roles, and relationships become rede
fined accordingly. A number of family scholars have emphasized the impor
tance of identifying which (and to what degree) aspects of familial life change
in response to broader societal changes and which elements prove more en
during (Goode, 1963; Hareven, 1977; Thornton and Lin, 1994; McDonald,
1992). In many parts of Asia where key familial arrangements center on the
economic and moral authority of elders, it is likely that these accommoda
tions will take the form of subtle redefinition of relationships and that changes
in the forms of family structure will proceed more slowly.
These considerations suggest that current and future research should
devote greater attention to distinguishing the forms of living arrangements
from the actual functions they serve, and not try to infer the content from the
structure. One way to do this is to measure the functions and duties carried
out by those living together, or near one another. There are two challenges
here. One is to accurately measure the division of labor within the household
(or network) and obtain a reasonable accounting of the mini-household
allocations and contributions. For those living apart, more careful accounts of
levels of contact, patterns of exchange, and degrees of indirect support are
also required. The possibilities here are discussed further below and in Chapters
6 and 8. The second challenge is to gain a better understanding of the meaning
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122 The Well-Being of the Elderly in Asia
of these accommodations and shifts in relationships, and what these may
presage for broader normative changes. One way to approach the latter is
through focus group discussions and other qualitative data collection efforts
that provide opportunities to explore the meanings behind activities that are
difficult to capture in the usual survey instrument. As part of the research
project in the four countries studied here, 18 to 24 focus group sessions were
conducted in each country. Although data from these sessions are used only
limitedly in the chapters that follow, they inform a number of the perspectives.
(See Knodel, 1995 for a more detailed analysis of these data.) In related
research, Ngin and DaVanzo (1999) used focus groups and ethnographic
interviews to explore ideal living arrangements in Malaysia; Knodel and
Saengtienchai (1999) used a quasi-qualitative case study approach in Thailand
to study living arrangements of the elderly; and Hashimoto (1996) used a mix
of participant observation, focused interviews, and surveys in a U.S. and
Japanese community to study the cultural meaning of exchanges and support
in the two cultures.
The analytic chapters are organized in keeping with the framework
discussed here and presented in Figure 4.1. Chapters 5 and 6 examine the two
key intermediate structural arrangements, types of living arrangements and
levels of support and exchange, providing a snapshot of current patterns, evi
dence of recent change, and variation by sociodemographic characteristics.
Chapters 7 through 10 are devoted to establishing levels and differentials of
well-being among the elderly in the realms of work and leisure, income and
assets, health status, and health care utilization. Each of these chapters dis
cusses the overall level of well-being as revealed by specified measures, the
variation in levels by individual characteristics (and which characteristics seem
most salient as revealed by multivariate analysis), and the change over time in
selected indicators. Chapter 11 reverses this style of analysis to some extent,
addressing which sociodemographic groups in each country are disadvan-
taged on one or more aspects of well-being, and how disadvantaged they are
relative to other groups. In the sections below we address key conceptual and
measurement issues associated with each of these chapters so that the chap
ters themselves can focus on the empirical results.
Measuring and Understanding Living Arrangements
Living arrangements are often a form of intergenerational transfer and support,
as when older parents coreside with children or children provide living expenses
for separate quarters. These aspects have distinct measurement challenges, as
described below.
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Theoretical Perspectives, Measurement Issues 123
An important first step in understanding living arrangements and other
forms of support is to "map" the kin available to the elderly respondents—
that is, to identify the number of children and other relevant kin, their key
characteristics, and their location vis-a-vis the elderly respondent. The num
ber and location of kin help establish potential for coresidence and other forms
of support, and serve, so to speak, as the denominators for observed levels of
support. Chapter 5, for example, reveals that only 4 to 9 percent of the elderly
across the four countries are in a situation where they are not living with a
child, or without a child nearby, or not in at least weekly contact with a child.
A second important step is to refine the definitions of dwelling and
household used in many censuses and surveys. These instruments often de
fine household as a single dwelling, which excludes children living in mul
tiple-family compounds or in the same neighborhoods as their elderly par
ents, a common arrangement in much of the developing world. For example,
our survey in Taiwan revealed that while native Taiwanese over 60 tend to
coreside with only one child, about 1.5 other children live near them in the
same township or city. Moreover, while married sons are more likely to coreside
than married daughters, daughters are more likely to live nearby, so that over
all access to sons and daughters is more balanced than the coresidence data
alone imply (Hermalin, Ofstedal and Chi, 1992, Table 4). In Thailand, Knodel
and Chayovan (1997) find that a very high proportion of older persons who
do not coreside with their children live adjacent to them or see them daily.
Another measurement challenge can arise when survey data do not
distinguish between married and unmarried coresiding children, although this
often has implications for the direction of support, especially among rela
tively young coresiding children. Moreover, demographic trends in age at
marriage and childbearing can lead to increased levels of coresidence that
have no implication for levels of parental support.
Chapter 5 makes use of these more nuanced measures of living ar
rangements in describing current levels and the factors associated with differ
entials by sociodemographic group.
Identifying and Measuring Intergenerational Support Dimensions
Intergenerational support arrangements, along with other key aspects of the
social fabric, are culturally defined. As noted above, a considerable impetus
to the growth of aging research in East and Southeast Asia, as well as other
regions, stems from concerns that the rapid social changes occurring on many
fronts may place in jeopardy existing social welfare and familial arrangements
for the elderly.
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124 The Well-Being of the Elderly in Asia
Soldo and Hill (1993) review the theoretical orientations to intergen-
erational transfers from sociological, economic, and psychological perspec
tives, and Lillard and Willis (1997) provide a more detailed overview of the
economic hypotheses on the motivations for transfer. The theoretical under
pinnings for family transfer systems range from altruism, to shorter or longer
term exchange arrangements, to security considerations (Frankenberg et al.,
n.d.; Schoeni, 1997). As modeled by Becker (1974), an altruistic head of house
hold would allocate resources to members of the family in such a way that no
one could be made better off without making someone else worse off. Altruis
tic transfers to parents may be further encouraged by norms that stress filial
responsibility. Andreoni (1989) extended the altruism model to include "warm
glow" giving, indicating that providers may be motivated to do more than
recipients require or expect. Other models of motivations for intra-family trans
fers identify quid pro quo arrangements, where family members assist each
other in times of need and transfers serve as insurance against risk.
Exchange models include short- and long-term trade-offs among fam
ily members. Shorter term transfers would include older parents taking care
of grandchildren in exchange for financial or other tangible support from chil
dren. Longer term exchanges include adult children supporting their parents
in old age in return for the care and assistance they received while growing
up. Parents may attempt to insure this support by retaining control over land
or a family business. A related long-term exchange model focuses on support
for older parents as repayment for the parents' provision of expenses for edu
cation. As returns to education increase, so do the potential benefits to both
children and parents of extending the children's years of education.
Testing these various hypotheses has proven difficult because they re
quire detailed data on the amount and nature of various transfers across many
family members, often over a long period. Without such information it may
be difficult to distinguish which motivating force is the prime determinant of
an observed pattern of transfers. The collection of data about family transfers
has grown more sophisticated in recent years but formidable measurement
challenges remain, stemming from the inherent complexity and multidimen-
sionality of the intergenerational system. Further progress is important both
to facilitate testing of competing models and to gain an adequate description
of the overall system, allowing changes that occur in response to demographic,
socioeconomic, and cultural forces to be monitored. The discussion below
illustrates various facets of such a system and some of the characteristics
associated with each dimension.
As Table 4.1 suggests, an adequate description of an intergenerational
support system requires three broad elements: a "map" of the network in terms
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Theoretical Perspectives, Measurement Issues 125
of potential providers and recipients, their characteristics, and their locations
in relation to one another; a designation of the potential types of exchanges,
such as time or money; and a delineation of the content and qualities of all
exchange types (e.g., how much and how often). In studying the elderly,
intergenerational transfers are conceived as a series of exchanges between an
indexed elderly person or couple (i.e., the focal point of the investigation)
and his and/or her family network. The definition of network is not
straightforward, as the relationships likely to be salient may vary across
societies and over time within societies. In some societies for example, siblings
may be important sources of exchange, while in others they are not. "Mapping"
the number, location, and characteristics of kin, as described above, serves as
the denominator against which the frequency and nature of exchanges can be
judged. It is important to distinguish those elderly who do not receive certain
kinds of support (e.g., physical assistance) because they lack potential or nearby
caregivers from elderly who do not receive support despite the availability of
kin. In addition, the size and characteristics of the network are important for
testing competing theories about the motivations and dynamics of exchange,
such as the differences in support provided by sons versus daughters in certain
settings (see for example Lee et al., 1994).
Soldo and Hill (1993) distinguish the three major transfer "currencies"
as space, money, and time, displayed in Table 4.1 as the broad categories of
exchange. Space, of course, refers mainly to living arrangements discussed in
some detail above. In addition, in terms of exchange, it is important to ascer
tain the home owner (and if it's the child, whether the parent assisted in the
purchase or transferred title) and the purpose of coresidence (whether it's
mainly to provide assistance to the adult child or to the parent). These dimen
sions will help establish the direction and significance of the exchange.
A high proportion of the elderly in developing countries report receiving
support in the form of money or its equivalents in material goods. To understand
the nature and significance of exchanges involving money and material goods
requires attention to several dimensions. Because the magnitudes involved
are clearly salient, it is often helpful to know how regularly or frequently
transfers are made and in what amounts. The significance of material exchanges
can be gauged by the purpose of the transfer (to help meet basic living needs,
supplementary needs, or other purposes) and the degree of impact the transfer
has on both the recipient's needs and the provider's resources. Identifying
past transfers can be important in understanding current transfers, and for
testing theories of altruism versus reciprocity. Whether or not parents have
given children gifts or loans in the past for education, travel, business, or
other purposes can greatly affect the pattern of exchanges currently observed.
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126 The Well-Being of the Elderly in Asia
It is also important to be sensitive to the possibility that material support can
be provided indirectly, by paying the rent, taxes, or other costs for the recipient
rather than by a direct transfer of funds.
The third currency of exchange, time, also requires elaboration along
several dimensions. An important consideration is the purpose. Are the elderly
receiving help with physical functioning (often referred to as ADLs—Activities
of Daily Living) or with basic household activities (the so-called lADLs—
Instrumental Activities of Daily Living), or is the contact mainly for emotional
support, companionship, or participation in leisure activities? Here also the
magnitude of the exchange in terms of frequency and amount of the time
spent may be salient. Providers may also make indirect transfers of time by
purchasing third-party assistance for recipients, especially in societies where
household help is common. Other indirect transfers of time may arise in the
division of labor for major household tasks. For example, an elderly parent
may be a net provider of time to others through participation in household
cooking and childcare, or a net recipient because of limited involvement.
It is not surprising in the light of all this complexity that no standard
strategy has as yet evolved for capturing the essential elements of an
intergenerational support system. There are almost as many approaches as
there are questionnaires, as each team of researchers achieves a unique com
promise among the constraints and challenges. (For a review of varied ap
proaches, see Hermalin, 1997b, and the National Research Council, 2001,
Chapter 5.). This lack of uniformity limits the potential for comparative analy
ses.
One can conceive the end result of collecting all the transfer informa
tion implied by Table 4.1 as a large matrix defining the nature and magnitude
of various types of exchanges between a focal elderly person and the mem
bers of his or her network. These matrices would be the input for constructing
measures that capture the social and economic aspects of the elderly person's
support system, such as the size and structure of the network, the number of
supports received and provided, the sufficiency of support, who the major
providers of support are, and whether the support provided is shared across
members of the network or concentrated in a few providers.
Although the data collected in the four study countries were not suffi
cient to produce all the measures enumerated above, they provided enough
detail and comparability across surveys to tap a number of key dimensions.
Accordingly, Chapter 6 reports on the proportion and characteristics of the
elderly receiving each major type of support, the providers of these supports,
and the degree of diffusion of support for those elderly with multiple needs.
Other aspects of exchange, such as the support provided by the elderly and
the flows of direct and indirect support will also be covered in this chapter.
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Table 4.1. Outline of Intergenerational Support System
SPACE
Elderly Unit
Characteristics
of couple
or individual
MONEY
TIME
Dimensions of Intergenerational Transfers
Participants:
Direction:
Purpose:
Magnitude:
Timing:
Form:
Impact:
Kin Network
Relationships
Size
Location
Dyads Involved
Underlying Network
Characteristics of individual
members
Provider and Recipient of Each Exchange
Basic or Supplementary Support
Physical Care; Household Assistance;
Child Care; Companionship
Amount of Money or Value of Goods
Amount of Time Exchanged
Regularity and Frequency of Exchange
Chronological Time: Current or Past
Persistence of Exchange over Time
Direct vs. Indirect
Gift or Loan
Needs of Recipient
Resources of Provider
Effect on Recipient and Provider
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128 T/ie Well-Being of the Elderly in Asia
Measuring Work and Leisure
The nature and duration of the work that people perform over their lives is
related to their economic position and health status at older ages. Chapter 7
looks at the main occupations of the elderly in the four countries, the degree
to which they remain in the labor force, and the nature of withdrawal from the
labor force for those who are not working. The degree to which the elderly are
subject to mandatory retirement practices and their coverage by pension pro
grams are also addressed. Work is one component of the broader set of activi
ties older people may engage in, and to fill in the picture, Chapter 7 also
analyzes data collected on the nature of their leisure activities. (Time spent in
looking after others and household duties are covered primarily in Chapter 6.)
Conceptually, assessing the well-being of the elderly in terms of work
and leisure activity levels presents a different challenge than looking at eco
nomics or health, where absolute levels can be readily defined. In this case,
comparisons between the current and preferred statuses of the elderly will
help gauge their well-being. For instance, do those out of the labor force wish
they could work, or do those working wish they had less involvement? For
those not working, an assessment of their well-being on this dimension re
quires knowing what activities they take part in, how involved they are, and
how much companionship they experience, among other aspects.
In addition to characterizing elderly well-being, measures of the level
and nature of labor force participation at the older ages are crucial for coun
tries with aging populations because they figure in economic growth and pro
ductivity, the cost of social security programs, and the need for community-
based centers and programs geared to the elderly. As noted in Chapter 3, those
in the formal sectors of the Asian economy—employees of the government
and of large corporations—generally must officially retire at a relatively early
age, but the prevalence of family farms and businesses has allowed many
older individuals to sustain economic activity into advanced years. In addi
tion, several of the developing and newly industrialized countries in Asia have
followed a pattern observed in developed countries and raised mandatory
retirement ages to help reduce pressure on pension and social security pro
grams and sustain economic growth. Other forces, however, such as the en
hanced resources of the elderly's children and the changing potential for smaller
family enterprises, may encourage earlier withdrawals from the labor force.
The similarities and differences between the more industrialized countries
and the developing world with regard to both the formal and informal dynam
ics of retirement and leisure offer rich analytic potential. Chapter 7 sets forth
the basic patterns of work, retirement, and leisure in the four countries and
traces their implications for the policy challenges these countries are facing.
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Theoretical Perspectives, Measurement Issues 129
The Economic Status of the Elderly
The framework outlined in Figure 4.1 shows economic status as another di
mension of well-being that is key to policy development. The rapid social and
economic development experienced by many countries in East and Southeast
Asia might be expected, a priori, to increase the economic vulnerability of
many elderly. This expectation arises from the potential obsolescence of their
traditional skills with industrialization, the absence of wide-spread public- or
private-sector retirement programs, the generally rising price levels, and their
potential isolation as children migrate from rural areas to jobs and opportuni
ties elsewhere. Countering these negative influences is the potential for the
current elderly, through their education or businesses/land holdings, to pros
per in the course of their countries' economic development, and for them to
enjoy increased levels of support from their more affluent children. How these
opposing trends have played out for the current elderly is the major focus of
Chapter 8, where we investigate a variety of economic well-being measures
for different groups of elderly.
Although the measurement challenges for economic well-being may
be less complex conceptually and operationally than those for intergenerational
transfers, they are far from absent. Although income, current and past, is used
as a prime indicator of economic well-being in nearly all settings, eliciting
reliable estimates in a survey is problematic. Non-response tends to be high
and non-random. In less developed economies with large proportions of the
population in farming or small business, those so-engaged may have diffi
culty providing net income accurately, as might those with multiple sources
of income. Among the elderly these basic issues may be compounded by
memory problems, lower involvement in economic affairs, and the multiplic
ity and irregular flow of income sources. The asset and wealth positions of
older individuals, which constitute important components of their economic
status, are even more difficult to ascertain. In addition to the limitations noted
for income, older people may hold property jointly with children or others,
and current market values may not be known.
Extended living arrangements, which characterize much of the region
under study, further complicate assessing the economic status of an elderly
respondent or couple because one needs to distinguish the income of the elderly
from the income of the household, the direct and indirect flows that can take
place, and the relevant items of consumption and savings. Indeed, as Deaton
and Paxson (1990) note, the analysis of savings behavior prominent in more
industrialized countries, which centers on permanent income and life-cycle
models, may be less applicable to countries where extended households are
common, since the economic goals of such households may be protection of
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130 The Well-Being of the Elderly in Asia
living standards from short-term risks rather than transference of resources
between generations. To help address this problem, they devise a method of
estimating individual age-saving profiles from household data (Deaton and
Paxson, 2000a).
Chapter 8 addresses the level of economic well-being in each of the
four countries using a multiplicity of measures reflecting absolute, relative,
and attitudinal dimensions of income, assets, and wealth. Although the num
ber and nature of the measures are not identical across countries, there is
sufficient overlap to permit detailed comparisons on several dimensions.
Health Status and Health Care Utilization
A great deal of concern about the effects of population aging stems from the
rising disability levels of an increasing older population and the attendant
costs. Changes in life expectancy at older ages can be tracked quite directly
(although large-scale deficiencies in registration systems exist in many coun
tries), but tracking levels and trends in disability is more difficult.
A number of important debates in the biodemography of aging center
on patterns of mortality at very old ages as over-all life expectancies advance
(Wilmoth, 1997; Olshansky et al., 1990). A related strand focuses on the lev
els of disability associated with increasing longevity. Will increased life ex
pectancy be accompanied by more years of active life or by more years of
disability or restricted functioning? The compression of morbidity hypothesis
set forth by Fries (1980) argues for the former scenario, as does some recent
U.S. data that point to lower levels of disability at older ages in the past few
years (Manton and Gu, 2001). The issue, however, is far from resolved.
As Chapter 2 indicates, the four countries under study still have a rela
tively "young" older population, with approximately 60 percent between the
ages 60 and 70. But this population structure will yield rapid increases over
the coming years in the "oldest-old" (those over age 75 or 80) in these and
other developing and newly industrialized countries in Asia, which in turn
will greatly increase the numbers with chronic diseases and various types of
disability. Because the health systems in many developing and newly indus
trialized countries have been oriented more to fighting infectious diseases
and addressing the needs of mothers and children than caring for the elderly,
new resources will be needed to address these changes. Policymakers should
also keep in mind that once a country achieves low fertility, future mortality
levels become increasingly decisive in determining the overall proportion of
elderly as well as the age distribution within the older ages. Given the uncer
tainty of future levels of mortality at older ages in developing—as well as
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Theoretical Perspectives, Measurement Issues 131
industrialized—countries, policymakers must anticipate that the number and
proportion at the oldest ages may be even higher than now projected.
In addition, developing and newly industrialized countries need to learn
more about the health conditions and health care needs of their older popula
tions. Many have rather limited information on the prevalence of chronic con
ditions, the levels of physical and mental functioning, and the rates of health
care utilization among the elderly. These data are important components for
estimating future demand for services and costs, and hence the types of health
care programs and policies that should be developed.
Data on conditions and utilization come from the providers of health
services (hospital and doctors), epidemiological studies of special groups or
catchment areas, and population surveys on health conditions and behavior,
health care utilization and costs, and self-perceptions of health status (or self-
reported health). In some cases it has been possible to combine self-reports
with a small number of anthropometric tests and/or to incorporate elements
of existing cognitive tests (e.g., the mini-mental exam).
Sufficiently detailed questions on health and related dimensions in
population surveys greatly enhance the potential to examine differentials in
health and health practices by salient socioeconomic variables and to test
models about their interrelationships. Of the survey data available in the four
countries in this study, all but Singapore's included a considerable amount of
detail on health. For this reason, two chapters are devoted to the subject.
Chapter 9 focuses on the health status of the elderly, including levels of self-
reported health by characteristic, the prevalence of select chronic conditions,
the proportions experiencing difficulties with eating, dressing, and other
activities of daily living, measures of depression and cognitive scores, and
information on current and former smoking behavior. This information by
characteristic of the elderly for nationally representative samples provides a
backdrop for over-all assessments of the health of the current older population
and guidance for future needs and costs.
Chapter 10 looks more directly at levels of health care utilization and
perceived needs by examining the proportions that have used various ser
vices, the coverage associated with these services, and the levels of unmet
need. The variation in health insurance coverage across the countries, de
scribed in Chapter 3, makes the current levels of utilization important bench
marks for assessing future trends as new programs are introduced.
Vulnerable Groups and Their Levels of Disadvantage
A theme in the social change literature that is especially prominent in discus
sions of population aging is the adverse effect of transformations on groups
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132 The Well-Being of the Elderly in Asia
ill-equipped to adjust to the underlying changes. As Chapter 3 points out,
many of the broad social welfare programs and programs oriented toward the
elderly arose to mitigate the effect of family changes and industrial organiza
tion on the older age groups.
Chapter 11 uses the survey data from the four countries to identify the
sociodemographic groups among the elderly that may be particularly vulner
able to adverse outcomes. These include women, the least educated, those
residing in rural areas, and several others. Then assessments are made of each
group's relative risk of experiencing different types of adverse outcomes on
the well-being measures developed, in comparison to those not in these par
ticular groups. Chapter 11 also makes use of data from each country on the
extent to which older respondents are aware of and make use of various pro
grams directed toward the elderly. This knowledge, combined with the find
ings on the degree of disadvantage of the most vulnerable groups, can assist
policymakers in assessing how well current programs are functioning and
what changes might improve their effectiveness.
Cross-Cutting Issues, Transitions, and Policy Recommendations
Despite the amount of detail to be presented in the next seven chapters, sev
eral important questions remain to be discussed. One might be termed cross-
cutting issues—the analyses that involve interrelationships among the mea
sures of well-being or detailed testing of various hypotheses about factors
contributing to levels of well-being. For example, what is the relationship
between health status and economic status? Does poor health lead to poor
economic status or does low income produce poor health? Although the level
of association between these two outcomes at any given point may be mea
sured, establishing the causal connections is much more difficult. Other inter
relationships that are difficult to sort out in a cause-effect manner include:
• The relationship between coresidence and health. To what extent does
coresidence with children affect health or health status lead to coresidence?
• The relationship between health and retirement. To what degree does health
status prompt retirement and withdrawal from the labor force affect health?
• The relationship between assets and retirement. To what extent do asset
levels affect retirement or retirement affect the level of assets?
Although the forthcoming chapters analyze these interrelationships and dis
cuss some of the causal issues, it must be recognized that only limited progress
on these issues can be made from cross-sectional surveys. Unraveling the
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Theoretical Perspectives, Measurement Issues 133
cause-and-effect questions requires longitudinal data best obtained from panel
studies in which representative samples are reinterviewed over time. Panel
studies have the advantage of capturing many of the key transitions older
people make after they reach age 60 and, increasingly, survive to age 80 and
beyond. The very concept of aging is associated with certain key transitions
such as the movement from work to retirement, from independent living to
coresidence with children or other forms of assisted living, and from good
health to lower levels of functioning. In addition to sorting out the cause-and-
effect issues illustrated above, panel study data will help establish the timing
of these changes, their magnitude, and their differentials across
sociodemographic groups. Transition rates can be very useful to policymakers
in identifying what kinds of programs are most important to what groups at
what ages.
Of the four countries studied here, only Taiwan started with a panel
survey, with multiple interviews of the original 1989 sample as described in
Chapter 1 and Appendix A. However, a special effort was made in Singapore
in 1999 to follow up the 1995 sample, and this produced useful panel data for
a large subset of respondents. In the Philippines, follow-up efforts are under
way in two provinces for the 1996 respondents, both as a test for a larger
effort and to gather changes on a few key topics. Although the insights emerg
ing from these longitudinal data are incorporated here only to a limited ex
tent, several examples are included in the relevant substantive chapters and
Chapter 12 devotes a section to transitions.
The aforementioned transitions refer to changes that occur to a cohort
of older people as they age. It is also important from a research and policy
viewpoint to take into account the changes that occur as a result of new co
horts coming along who may have very different characteristics than their
predecessors. Particularly in the light of the rapid demographic and socioeco-
nomic changes that have taken place in East and Southeast Asia, it is critical
for policymakers to realize that future cohorts of elderly will be very different
from current cohorts in terms of their characteristics, preferences, and needs,
and that policy development must look beyond current perspectives. Although
future cohorts will have fewer children on average, they will be more urban
and much better educated than current cohorts, which is likely to translate
into different health needs, different preferences for living arrangements and
life styles, and different tastes for work and leisure. Chapter 12 demonstrates
these differences through a series of cohort analyses and discusses their im
plications for policy formation.
The final chapter, Chapter 13, also expands on the policy implications
of the substantive analyses presented, and discusses future research direc
tions that can help guide policy development in the years ahead.
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134 The Well-Being of the Elderly in Asia
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Chapter 5
PATTERNS AND DETERMINANTS OF LIVING
ARRANGEMENTS
John Knodel and Mary Beth Ofstedal
Living arrangements, and in particular coresidence with an adult child, lie
at the heart of the traditional system of familial support for elders in all
four of the countries encompassed by this study. For many elders, support and
care from adult children living within the same household or residential
compound is crucial for their psychological, physical, and economic well-
being. Thus it is not surprising that much of the recent sociodemographic
research on Asian elderly, including that featured in theme issues of several
journals, has focused on this topic (DaVanzo and Chan, 1994; Knodel, 1992,
1995, 1997; Logan, Bian and Bian, 1998; Martin, 1989). Previous studies,
however, were often hampered by the lack of data with sufficient detail to
analyze important aspects of living arrangements and their place within the
broader network of intergenerational exchanges. The recent rounds of surveys
undertaken in conjunction with our collaborative project in the Philippines,
Taiwan, and Thailand, and to a lesser extent in Singapore, go well beyond
most previous data collection efforts in providing detailed information,
permitting a fuller description of living arrangements of the older population
and a more comprehensive examination of their determinants and consequences.
In all of these countries there is a long tradition of extended family
households, and expectations concerning coresidence in old age remain high
143
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144 The Well-Being of the Elderly in Asia
among current cohorts of elderly and their adult children. Views of both elders
and their adult children, as expressed in focus groups in all four countries,
confirm living arrangements as a crucial part of family support (Asis et al.,
1995). Nevertheless, their significance for the well-being of elders should not
be exaggerated. As Figure 4.1 in the previous chapter reminds us, although
living arrangements may be a means to achieve various dimensions of well-
being for both generations, they are not an end in themselves. Focus group
data from all four countries underline the costs and benefits of coresidence,
from both the elderly parents' and the adult children's perspectives (Asis et
al., 1995). For instance, while both generations report that lack of privacy is a
disadvantage of coresidence, older family members who require personal
assistance and younger members who need help with child-care or finances
benefit greatly from coresidence. These costs and benefits are complex in that
they involve many dimensions, are embedded in normative expectations, and
tend to shift over the life course of both generations and perhaps over historical
time. Moreover, intergenerational exchanges of material support and services
between households, as well as social visits, are all aspects of the broader
interconnected familial support system that influence well-being. These latter
types of exchanges will be taken up in Chapter 6.
Government planners in all the countries under study are concerned
about the potential erosion of family support systems, including coresidence,
in response to the socioeconomic changes engulfing Asia and most of the
developing world. However, the extent to which living arrangements have
changed and will continue to change, the nature of that change, and its impli
cations for the well-being of the elderly and their families are all issues that
need to be addressed with empirical data. The present chapter casts a broad
net on the topic of living arrangements, covering such aspects as trends in
living arrangements over time, generational composition of households, and
differentials related to the marital status and gender of children. The chapter
concludes with a multivariate examination of the determinants of living ar
rangements.
Measurement Issues
Research on living arrangements looks at both household composition and
the relative location of kin not residing in the household. One particularly key
aspect concerns coresidence with children. For most purposes, the interest in
coresidence with children stems from its greater potential for meaningful and
frequent exchanges of services between elderly parents and their children.
Generally coresidence is defined as living in the same dwelling or household
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Patterns and Determinants of Living Arrangements 145
with the focal elderly person. For some purposes, however, this definition can
be considered as either too narrow or too broad. For example, if our goal is to
capture all cases where the daily lives of elderly parents and their children are
intimately intertwined as a result of living arrangements, the typical concept
of coresidence captures only part of this and thus can be considered too nar
row. For this reason, we introduce the concept of quasi-coresidence in some
analyses to allow for cases in which the focal elderly person either lives adja
cent to a child or near enough to have daily contact.
In addition, when the research interest in coresidence centers on the
ability of living arrangements to facilitate care of elderly, a definition of
coresidence that does not incorporate the ages of coresident children may be
too broad. In this context, the coresidence of adult children is likely to have
quite different implications than the coresidence of dependent minor chil
dren. For this reason, we define all unmarried children at least 18 years of age
and all married children, regardless of age, as adults. We assume that by age
18 most children are capable of making significant economic contributions to
the household and providing various types of physical and emotional assis
tance to their parents. No doubt some coresident children we define as adults
remain dependent on support from their parents. This is especially likely to be
the case for those who are still in school or not working, a situation that varies
among the four countries being studied. For example, among coresident chil
dren aged 18 to 21 in Thailand, 18 percent were still studying and 28 percent
had not worked in the previous year. In contrast, in Taiwan 53 percent were
still studying and 62 percent were not currently working. Nevertheless, for
convenience, we have imposed a uniform definition of an adult child in the
tables that follow.
One unusual aspect of the Taiwanese data set in relation to determin
ing coresidence should be noted. In the Taiwan survey, children who were
attending school away from home, serving in the military, or working tempo
rarily away from home were counted as members of their parent's household
although they were not physically present. Because most such children are
unmarried, this classification has virtually no effect on calculations of the
percent of elderly who live with a married child, but it does slightly increase
the calculated percent who live with an unmarried child. However, even in
the case of unmarried adult sons, for which the impact is largest, the propor
tion coresiding increases only by one percentage point, from 20 to 21 percent.
Tabulations in this and other chapters refer to elderly living in private
households and thus exclude the small minority who live in institutional set
tings. The reason for this is that, with the exception of the Taiwan survey, the
sampling universes were defined in this manner. For the sake of comparabil
ity, we exclude the 0.9 percent of Taiwanese respondents age 60 years and
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146 The Well-Being of the Elderly in Asia
over who were residing in institutions. We note that recent census figures
indicate that in the other countries, the fraction of elderly living in institu
tional settings is also very small (1.8 percent in Thailand, the vast majority of
whom were monks living in Buddhist temples; 1.5 percent in Singapore, and
0.2 percent in the Philippines). Despite their small numbers, however, elderly
in institutions obviously differ in their living arrangements from those in pri
vate households, and this exclusion should be kept in mind when interpreting
results.
Living arrangements at any particular point depend not only on the
costs and benefits of specific types but also on the availability of kin as poten
tial household members. Thus another issue related to the measurement of
living arrangements is whether or not tabulations should be conditioned on
the availability of children or other relatives. As Table 2.9 indicates, well over
90 percent of elders in each of the four countries have at least one living adult
child, a much smaller majority have a living spouse (ranging from one-half in
Singapore to two-thirds in Taiwan), and only a very small minority have a
living parent with whom they could live. In the analyses in the present chap
ter, we typically examine coresidence with adult children only among respon
dents who in fact have at least one living adult child. Other analyses are con
ditioned on the availability of more specific types of children—for instance,
sons, daughters, or married children. When analyses are conditioned on avail
ability of particular types of children or kin, this is noted both in the text and
table headings.
Finally, two important qualifications need to be kept in mind when
interpreting our findings. First, because living arrangements are dynamic,
changing over the life course of the elderly, they are only imperfectly cap
tured in cross-sectional surveys. Second, our measurements are directed at
the forms of living arrangements rather than their functions. As qualitative
research using both focus groups and quasi-case studies has revealed, similar
living arrangements can have quite different meanings for the well-being of
the elderly (e.g., Knodel, 1995; Knodel and Saengtienchai, 1999). For ex
ample, the same household composition can be associated with very different
support and care arrangements across families, as can wider configurations
that take account of children and other kin outside the immediate household.
Moreover, changes in forms and functions may only be loosely linked. Thus
to judge the implications of trends in living arrangements for the well-being
of elders requires evidence about possible changes in functions as well. Like
wise, even if the form of living arrangements remains relatively unchanged, it
should not be presumed that the nature of the relations among household
members have also remained static (Hermalin, 2000).
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Patterns and Determinants of Living Arrangements 147
Trends in Coresidence
Before examining results in detail from the most recent round of surveys, it is
useful to compare basic indicators of living arrangements with those from
previous surveys to determine current trends. In all four countries, results
from earlier surveys permit some over-time comparisons. As Table 5.1 shows,
despite the very substantial social and economic changes over the last several
decades described in Chapter 2, coresidence remains the predominant living
arrangement for older persons in each country, and only modest changes are
evident. As a result, the percentage of elders who live alone or who live with
a spouse remains small.
The clearest signs of declining coresidence with children are found for
Taiwan, although the particularly sharp reduction between 1985 and 1989
might partially be an artifact of differences in the surveys that are the sources
of the trend data. Taken at face value, however, it appears that coresidence
with a child declined by almost 15 percentage points during the two-decade
period for which data are presented.
Reductions in coresidence appear to be more modest or even absent in
the other countries. In the case of the Philippines, problems of comparability
between the sources raise some uncertainty as to the trend. The only prior
survey specifically directed at the older population was based on a subnational
sample in 1986 (as part of the ASEAN Population Program). If the results of
this earlier survey are compared with the 1996 survey, which also targets the
older population, there appears to be a modest decline in the percent living
with a child. However, the earlier ASEAN survey is probably unrepresenta
tive of the national situation. This is suggested by the fact that analysis of
households with persons aged 60 and over from the 1988 National Demo
graphic Survey, which covered a nationally representative general sample of
households, indicated a somewhat lower level of coresidence and one that is
similar to that found in the new 1996 survey. Moreover, analysis of the 1993
round of the National Demographic Survey indicates virtually the same level
of coresidence with children as the 1988 survey. Thus all surveys except the
sub-national ASEAN survey are consistent and point to no change in this
aspect of living arrangements. In Singapore, the 1995 survey indicates a slightly
lower percent of the elderly living with a child than was true in 1986. Never
theless, the level remains extremely high. Thailand shows a modest decline
from 77 to 71 percent of elderly coresiding with a child over a nine-year
interval, but the level even in 1995 is still very substantial.
Although not included in Table 5.1, it is possible for Thailand and
Taiwan to determine the percentage of elderly who see a child daily (including
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148 The Well-Being of the Elderly in Asia
Table 5.1. Trends in Household Composition among Those Age 60 or Over
Country and YearPhilippinesNat. DemographicSurvey19881993Elderly surveys1984 (subnational)1996ThailandElderly surveys198619941995TaiwanSurvey of Income andExpenditures197619801985Elderly surveys19891996SingaporeElderly surveys19881995Household Composition
(Percent Distribution)Lives
Alone43.325.54.33.64.3, .tLives w/
Spouse
Only109.137.96.711.611.9* N8.812.817.3^i • •>10.29.623.3Y—12.616.135.9Lives
with
Children6869.37470.476.272.870.983.781.678.370.769.08885.0Other
Composi
tion1818.32116.112.812.012.97.55.64.46.65.275.8Total
Percent100100100100100100100100100100100100100100
Figures for Taiwan refer to population age 65+; figures for other countries are for
population age 60+.
those who are coresident) for at least two time points. This figure captures
situations in which the elderly respondent may not live with a child but lives
close enough, often next door, to permit daily interaction. In Taiwan, the percent
who see a child daily declined from 82 to 79 percent between 1989 and 1996,
which is similar in magnitude to the decline in coresidence. However, in
Thailand this percentage declined only one percentage point, from 91 to 90
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Patterns and Determinants of Living Arrangements 149
percent, between the 1986 and 1995 surveys (Knodel and Chayovan, 1997).
Thus the apparent decline in coresidence does not necessarily reflect a trend
toward disengagement between elders and their adult children. It may instead
reflect only a limited modification of living arrangements. Possibly rising
standards of living during the intervening period allowed married adult children
to occupy separate dwelling units next to or near their elderly parents. Such
arrangements might provide greater privacy for both parties while retaining
close interaction consistent with a family system of support and care of elderly.
Focus group discussions in Thailand have revealed that some elderly prefer
this type of arrangement, especially if they are in good health (Knodel,
Saengtienchai, and Sittitrai, 1995). Survey data in the Philippines has also
revealed a preference for this arrangement, particularly among married elderly
(Natividad and Cruz, 1997).
Evidence from other parts of East Asia shows more pronounced de
clines in coresidence. For example, in Japan, the percentage of persons age
65 years and over living with any child fell from 77 to 52 percent between
1970 and 1997 (Hermalin, 1995; Japan Aging Research Center, 2000, Table
25). Even more dramatic is the decline that occurred in the Republic of Ko
rea, where the percent of older adults coresiding with a child fell about the
same magnitude but over a much shorter period (from 78 percent in 1984 to
54 percent in 1994) (Kim, 1999). The pace of these declines is quite remark
able when compared to the experience in the U.S. during the late 19th and
early 20th centuries. Between 1880 and 1940 the percent of elderly (age 65
years or over) living with children declined from 64 percent to 49 percent
(Ruggles, 1994). This decline is somewhat smaller in magnitude than that
experienced in Japan and Korea, and it occurred over a much longer period
and under very different social and economic circumstances. Interestingly,
the decline in the U.S. continued at an accelerated pace after 1940, with the
percent coresiding dropping to 30 percent in 1960 and further to 18 percent in
1980 (Ruggles, 1994). It is unclear at this point whether Asia will follow the
U.S. pattern or whether declines in coresidence in Asia will level of! or even
reverse.
General Patterns of Household Composition
Most studies of living arrangements of the older population focus on house
hold composition. Typically distinctions are made among household mem
bers that are likely to reflect their potential for being a source of either mate
rial or non-material assistance or, conversely, a dependent of the elderly. Table
5.2 indicates the prevalence of several types of members that are of interest
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150 The Well-Being of the Elderly in Asia
from this perspective. The figures presented are not mutually exclusive; that
is, respondents who coreside with one particular type of household member
may also live with the other types of members shown.
Given that a spouse can play an essential role in providing care for a
frail or ill older person, or conversely can require such care, the presence or
absence of a spouse is likely to have important implications for the well-being
of the referent individual. The proportion of elderly who live with a spouse
ranges from slightly under half in Singapore to almost two-thirds in Taiwan.
It is important to note that the marital status distribution for the 1995 Singapore
sample is rather different than for the population 60 and over enumerated in
the 1990 census (Shantakumar, 1994). Thus the low proportion married among
Singaporean elderly may reflect a sample bias due to the low response rate.
Besides spouses, the presence or absence of children is likely to have
important implications. As shown in Table 5.2, the proportion of elderly
coresiding with a child is unusually high in Singapore (85 percent) compared
to the other countries (69 to 71 percent). In part, the high proportion coresiding
with a child in Singapore may be related to the fact that Singapore is a city-
state with no rural sector while the others are countries with small town and
rural populations. When compared only to the levels of coresidence in the
capital cities of the other three countries, the level in Singapore no longer
appears unusual. Among elderly with at least one living child, the percent
who coreside with a child reaches 92 percent in Manila, 79 percent in Taipei,
and 86 percent in Bangkok, compared to 89 percent in Singapore (results not
shown). However, the factors contributing to high metropolitan levels of
coresidence may be different in Singapore than in the other three countries.
One possible contributor to the high coresidence levels in the capital
cities of the other countries is the migration of elderly parents from rural areas
to join adult children who migrated earlier. Since Singapore is a city-state
with no rural sector, this factor could not contribute to high coresidence there,
although rural areas in neighboring Malaysia might play a role comparable to
that of the rural sectors of the other three countries. Also we do not have
direct evidence that rural elderly migrate to join children in the cities to any
significant extent. Focus group discussions among rural elderly in the Philip
pines and Thailand revealed a strong attachment on the part of elders to their
own home and probably a strong preference to "age in place" rather than
leave to join children who migrated to cities (Domingo and Asis, 1995; Knodel,
Saengtienchai and Sittitrai, 1995). Another factor that likely contributes to
high coresidence levels in urban areas in all of the countries is the high cost of
housing in such areas. In rural areas, land is more plentiful and building mate
rials and labor are less costly, making it affordable for families to build and
maintain separate dwellings. However, in urban areas, space is scarce and the
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Patterns and Determinants of Living Arrangements 151
Table 52. Percent of Elderly Living with Specific Types of Household
Members
Percent living with:SpouseAny childAdult childMarried childMinor child (< 18)GrandchildSiblingParent/parent-in-lawNon-relativePhilippines52.070.467.450.19.258.32.50.94.3Thailand60.470.969.350.75.255.03.32.21.2Taiwan64.069.067.741.92.050.30.71.70.8Singapore48.285.0--40.8--36.41.72.06.5
Notes: Results refer to elderly in private households. Children include own, adopted
and stepchildren.
-- = not available.
cost of buying or renting a home can be exorbitant. In Singapore the govern
ment offers housing subsidies to young adults who coreside with their parents
and, particularly in light of Singapore's high cost of living, these subsidies are
likely to further contribute to the high rates of coresidence there. Finally, it is
possible that Singapore's high rate of coresidence is partly an artifact of the
sample. As noted earlier, the marital status distribution for the 1995 Singapore
survey sample is somewhat different than that enumerated in the 1990 census
for the population 60 and over, with the sample containing a higher propor
tion of unmarried individuals. Since unmarried elders are more likely to
coreside with children, the rate of coresidence observed in the survey may be
somewhat inflated.
Since most children of elderly are grown, the percentage living with an
adult child differs little from the percentage living with any child. The per
centage living with a married child, however, is substantially lower and varies
among the four countries. The lower proportions in Singapore and Taiwan
probably reflect the later ages of marriage that prevailed there in recent de
cades compared to the Philippines and Thailand (see Table 2.5). Some elderly
still have children who are minors and live with them. Elderly in the Philip
pines are most likely to have their minor-aged children living with them. This
undoubtedly reflects the higher fertility in the Philippines over the last few
decades compared to the other three countries. Far more common than living
with their minor-aged children is for elderly to live with grandchildren (not
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152 The Well-Being of the Elderly in Asia
all of whom are minors). In most cases, the grandchildren are the offspring of
coresident adult children.
Very few elderly live with either their parents or siblings. In the case of
parents, a major influence is 'low availability' in that only a small minority
still have a living parent. However, even among those respondents who have
a living parent, most do not live with the parent. This is not surprising in that
respondents are 'in competition' with their siblings for their parents' pres
ence. As discussed below, in all four countries, a stem family norm prevails
such that an elderly parent eventually lives with only one adult child. The low
presence of parents and siblings in the respondent's household reflects this
pattern. Coresidence with non-relatives is also rare. In Singapore where it is
most common, the non-relatives are mostly domestic helpers in the service of
the household. Indeed, the percent of elderly who coreside with a non-relative
in Manila and Bangkok (but not Taipei) is similar to that in Singapore, reflect
ing the association between the presence of domestic help and living in large
cities in some settings.
Table 5.3 presents a simple typology of living arrangements based on
household membership. The categories shown are mutually exclusive and
exhaustive. They are based on combining information about the presence or
absence of a spouse, a child or child-in-law, and anyone else. Prominence is
given to spouses and children (together with their spouses) since they are
likely to have the most general relevance for support and care of the referent
elderly household member. In total, eight combinations are possible (includ
ing living alone as one category). In each of the four countries, very few
elderly live alone and only modest proportions live with only a spouse. Most
households include at least one of the respondent's children. Several clear
differences are apparent among the countries, however. For example, Singapore
is unusual in that a high proportion of elderly live with children/children-in-
law only or in combination with a spouse (20 percent and 26 percent, respec
tively), but without grandchildren or others present. In addition, in Taiwan
one-fourth of all elderly either live alone or reside only with a spouse, a pro
portion that is far higher than in any of the other countries.
Table 5.4 provides a more detailed examination of the generational
depth of households by showing the percent of respondents residing in one,
two, and three or higher generation households, with further distinctions of
composition for households with two or more generations. The underlined
percents in Table 5.4 represent the total percent residing in a two or three-plus
generation household, and the figures listed underneath represent the percent
in each subgroup. Here again, several differences are apparent across the four
countries. Consistent with patterns in previous tables, one-generation house
holds are most common in Taiwan (27 percent) and least common in Singapore
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Patterns and Determinants of Living Arrangements 153
Table 5.3. Percent Distribution According to Household Composition
Household CompositionAloneSpouse onlyChildren/children-in-law onlyOthers onlySpouse & children/children-in-lawSpouse & othersChildren/children-in-law &othersSpouse, children/children-in-law& othersTotalPhilippines5.57.97.48.915.45.926.122.8100.0Thailand4.311.97.96.615.15.521.627.9100.0Taiwan9.716.15.72.016.02.218.729.6100.0Singapore3.35.920.04.726.31.023.715.1100.0
Notes: Results refer to elderly in private households. Children include own, adopted and
stepchildren. Children-in-law are grouped with children for this tabulation. The category
"others" includes grandchildren.
(13 percent). Two-generation households are considerably more common and
three-generation households less common in Singapore compared to the other
countries. The proportion of households with three generations is very similar
in the Philippines, Taiwan, and Thailand, constituting slightly less than half
of all households with elderly members. The extent to which elderly live with
a grandchild but no child, a configuration sometimes referred to as a "skip
generation" household, is specifically indicated under the two-generation
households. This situation typically arises when adult children migrate to take
jobs in urban environments and either send their own children back or leave
them behind to be cared for by the grandparents. While such households are
very rare in Singapore and Taiwan, they represent a discernible if still small
minority of cases in the Philippines and Thailand.
Table 5.4 also indicates the mean size of households of different gen
erational depths. Overall the average size of the households in which elders
live in these four countries is between four and five members and thus rather
moderate. Of course, mean household size increases with generational depth.
Thus the substantial minority of elders who live in three generational house
holds are together with far more members than those in one or two genera
tional households. Three-generation households in the Philippines are the larg
est on average, probably reflecting the persistence of higher fertility among
adult coresident children than in the other countries.
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154 The Well-Being of the Elderly in Asia
Table 5.4. Percent Distribution by Number of Generations and Generational
Composition
Number of Generations
Generational CompositionOne generationTwo generations- w/ parent- w/ child- w/ grandchildThree or more generations- 3 gen. w/ child & grandchild- 3 gen. w/ parent & child- other 3 gen. & 4+ gen.Mean household size- one generation- two generations- three generationsPhilippines17.236.80.224.512.146.045.40.10.55.092.184.057.01Thailand19.632.80.424.18.247.645.90.90.94.472.113.705.98Taiwan26.725,00.422.12.548.247.00.60.64M1.673.576.78Singapore13.35030.648.91.136.435.01.00.4£312.023.385.88
Note: For Singapore, grandchildren and great-grandchildren can not be distinguished
and thus are combined.
Coresidence in Relation to Children's Gender and Marital Status
The importance of children's gender, sometimes in connection with sibling
order, has received considerable attention in the literature on support of elderly
parents, particularly in connection with coresidence. As Karen Mason (1992)
stressed in a review article about family change and support of the elderly in
Asia, two major types of family systems prevail. Patrilineal systems are found
in East Asia and the northern tier of South Asia and stress the responsibility of
sons for caring and supporting parents. More flexible bilateral systems are
found in Southeast Asia and the southern tier of South Asia in which daughters
play an equally or more important role than sons. The countries included in
the present study, in addition to the ethnic groups within Singapore, fall on
both sides of this divide. With the exception of Singapore, the new surveys
provide detailed information on characteristics of both coresident and non-
coresident children. It is thus possible to examine in some depth the extent to
which coresidence is conditioned on gender (as well as other characteristics
of adult children). For Singapore, the more limited information available still
permits equivalent tabulations to be approximated. As the following analyses
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Patterns and Determinants of Living Arrangements 155
Table 5.5. Coresidence with Sons and Daughters Conditioned on Availability
Among elderly who havechild of specified type,% living with any:SonDaughterSingle adult sonSingle adult daughterMarried sonMarried daughterRatio of living with:Single adult son/singleadult daughterMarried son/marrieddaughterPhilip
pines51.647.270.260.824.328.61.15.85Thailand40.855.258.263.323.740.4.92.59Taiwan68.320.569.270.157.45.9.999.73SingaporeChinese77.146.646.534.734.68.21.344.22Malay | Indian67.5 66.963.2 48.041.7 36.435.4 32.727.2 28.027.8 12.51.18 1.11.98 2.24
Notes: Single adult children are age 18 and over. For Singapore, results referring to single and
married children are based on the 95% of cases for which a determination could be made (see text); in
addition they are conditional only on having a child of the particular sex and not on adult status or
marital status.
reveal, very striking differences are observed in terms of the gender of the
children with whom the elderly coreside. These differences, however, are also
clearly conditioned on the marital status of the child.
Table 5.5 shows the percentage of elderly living with children of dif
ferent genders and marital statuses. For all countries except Singapore the
results are conditioned on availability of having a child of the respective com
bination of these characteristics. For Singapore, because of data limitations,
they are only conditioned on having a child of the particular sex (regardless of
age and marital status).1 In addition, it was not possible to identify the spe
cific gender and marital status combination of coresident children in Singapore
for 5 percent of the cases, so these respondents are excluded from the analy
sis. Because there are pronounced differences among the three main ethnic
groups in Singapore with respect to gender preferences related to coresidence
with married children (Mehta, Osman and Lee, 1995), results are shown sepa
rately for these three groups rather than for the country as a whole.
Elderly parents in general are considerably more likely to live with a
son than a daughter in Taiwan as well as in Singapore among the Chinese and
Indians ethnic groups. In contrast, Filipino and Singaporean Malay elderly
parents are only slightly more likely to live with a son than a daughter, while
Thais are more likely to live with daughters than sons. The marital status of
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156 The Well-Being of the Elderly in Asia
the child, however, strongly affects the gender patterning of coresidence.2
The pronounced tendency to live with sons rather than daughters is largely
absent with respect to single adult children in Taiwan and very much moder
ated among Chinese and Indians in Singapore. Likewise the strong tendency
to live with daughters rather than sons in Thailand is almost absent with re
spect to single adult children. A very clear pattern of living with married sons
rather than married daughters is evident for Taiwan and Singaporean Chinese
and Indians. In contrast, Singaporean Malays show an almost equal tendency
to coreside with a married son or daughter. Filipino elderly are somewhat
more likely to coreside with a married daughter than son and Thai elderly
show a strong tendency to live with a married daughter rather than a married
son.
In order to highlight the extent of any tendency to live with children of
one gender over the other, the bottom panel of Table 5.5 presents the ratio of
the percentage of elderly who live with sons to the percentage who live with
daughters (conditioned on availability). A ratio of unity indicates equal ten
dencies of elderly to live with sons as with daughters; ratios above unity re
flect greater tendencies to live with sons, while those below unity show greater
tendencies to live with daughters. With respect to coresidence with single
children, the ratios are close to unity in all countries, indicating the absence of
preference for living with children of either sex prior to their marriage. In
contrast, pronounced differences in the ratios referring to coresidence with
married children are apparent among the countries and ethnic groups in
Singapore.
The strongest tendency towards patrilocality is evident for Taiwan where
elderly are almost ten times more likely to live with a married son than a
married daughter. Only six percent of Taiwanese elderly who have a married
daughter live with one. Likewise strong son preference is evident in Singapore
for the Chinese, for whom the ratio is four times unity, and for Indian elderly,
who are more than twice as likely to live with a married son than a married
daughter. The reverse situation characterizes Thailand, where elderly are
substantially less likely to live with a married son than a married daughter.
Both in the Philippines and among Malays in Singapore, elderly are also more
likely to live with married daughters than with married sons, although the
imbalance is much more muted than in Thailand.daughter. Only 6 percent of
Taiwanese elderly who have a married daughter live with one. Likewise strong
son preference is evident in Singapore for the Chinese, for whom the ratio is four
times unity, and for Indian elderly, who are more than twice as likely to live with
a married son than a married daughter. The reverse is true in Thailand, where
elderly are substantially less likely to live with a married son than a married
daughter. Both in the Philippines and among Malays in Singapore, elderly are also
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Patterns and Determinants of Living Arrangements 157
Table 5.6. Percent Coresident among Elderly Whose Children Are All
Married, by Sex Composition of Children
Sex Composition of
ChildrenAUUnstandardized
Standardized1Those with onlyMarried sons
Married daughtersPhilippines% | N53.0 550
57.2 55043.7 49
62.3 71Thailand% N65.6 2,116
63.8 2,11957.4 207
67.1 233Taiwan% N60.0 1,010
53.6 1,01056.6 157
32.4 133
"Standardized on the distribution of number of married children for all families with only
married children, all of whom are the same sex.
more likely to live with married daughters than with married sons, although the
imbalance is less pronounced than in Thailand.
Table 5.6 assesses the flexibility of elders in terms of the general preference
to reside with a child of a particular gender. Since preferences with respect to the
gender of a coresident child is largely limited to married children, as the previous
table revealed, to facilitate interpretation of results, we limit our analysis to elderly
whose children are all married. We then compare the percent coresident among
elderly whose married children are all sons or are all daughters with the percent
coresident among all elderly whose children are all married. The subgroup of
elderly whose children are all of the same gender is of interest because they
obviously have no choice with respect to the gender of a coresident child if they
wish to coreside with a married child. If gender preferences are flexible, the lack
of a child of the preferred gender should have little affect on the likelihood of
coresidence. In contrast, if the gender preferences are relatively inflexible, elderly
who do not have a child of the preferred gender will forego coresidence and thus
exhibit lower levels of coresidence than if they had a child of the preferred gender.
In making the comparison between the levels of coresidence among elderly
whose children are all of one gender and elderly in general whose children are all
married, it is useful to control for the number of children the elderly respondent
has. Since the fewer children a respondent has, the greater the chance that they are
all of the same gender, elderly whose children are all the same gender tend to have
fewer children on average than elderly in general. Given the likely positive
association between coresidence and having larger numbers of children, we present
the standardized percent coresident among all elderly, using as the standard the
distribution for number of children among elderly whose children are all of the
same gender. Although Table 5.6 shows both the unstandardized and standardized
percentages, the more appropriate comparison is between the standardized percents
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158 The Well-Being of the Elderly in Asia
coresident for all elderly and the percents coresident among those whose children
are all of the same gender. Note that given the expected positive association between
large numbers of children and coresidence, we would anticipate that the
standardized percentages are lower than non-standardized ones. This is true for
Taiwan and Thailand but not for the Philippines, which reflects that in the
Philippines sample the relationship between number of children and likelihood of
coresidence is somewhat irregular (Natividad and Cruz, 1997), which in turn
probably reflects fluctuations due to small sample size. Indeed, elderly whose
children are all married and of the same gender are a rather small subset of each
survey (as indicated by the unweighted number of cases shown in Table 5.6) and
thus some caution is necessary in interpreting the results.
The results for Thailand indicate considerable flexibility in whatever gender
preferences exist regarding coresidence. Elderly whose children are all married
daughters are more likely to coreside than elderly whose children are all married
sons, but even in the latter situation, the chance of coresidence is only slightly
lower than the standardized percentage for all elderly parents (whose children are
all married). In the Philippines there is some suggestion of a daughter preference
in relation to coresidence with married children. Among elderly Filipinos who
have only married sons, the percent coresiding is somewhat lower than the
standardized percent (44 percent versus 57 percent). Likewise, there is also an
apparent gender preference in Taiwan. In that country, which has a strong patrilocal
tradition, having only married daughters substantially reduces the chance of
coresidence compared to having all married sons. Nevertheless, in both countries
there is some flexibility as evident from the fact that more than two-fifths of Filipino
elderly who have only married sons and almost one-third of Taiwanese elderly
who only have married daughters still live with one of them.
It is not possible to conduct the same analysis for Singapore because
the survey does not provide information on the number of a respondent's chil
dren who have been married. However, a rough approximation of the degree
of flexibility can be obtained by examining coresidence with a married child
among respondents whose children are all of the same gender (regardless of
whether they are married or single). The results (not shown) indicate that
Chinese elderly are 1.4 times as likely to live with a married child when all
the children are sons than when all the children are daughters (42.3 versus
29.4 percent, respectively). This suggests somewhat greater flexibility than
among the Taiwanese elderly, but still indicates that having only daughters
results in a substantial reduction in the likelihood of coresiding with a mar
ried child for Singaporean Chinese elderly. Indian elderly are also substan
tially more likely to live with a married child if all children are sons than if all
are daughters, while for Malays the opposite is true. However, given the rela
tively small numbers of cases on which the Indian and Malay results must be
based, these findings can only be taken as suggestive.3
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Patterns and Determinants of Living Arrangements 159
Table 5.7 indicates a hierarchical classification combining living ar
rangements and contact with children in order to capture the extent to which
elders who do not live in the same household with one of their children may
still live in circumstances that permit close links in their daily lives. In both
the Philippines and Thailand, more than half of elderly parents who do not
coreside with a child are in a quasi-coresident situation as defined above, that
is they either live next door to a child or see a child daily. Moreover, substan
tial shares of elders who neither live in the same household or next door nor
see a child daily, still have fairly frequent contact, either on a weekly or monthly
basis. Only a tiny fraction of elderly parents do not see at least one child
monthly. In Taiwan, although the combined percentage of elderly parents who
do not live with or next to children or close enough to see one daily is higher
than elsewhere, weekly visits are quite common.
The embeddedness of Asian families is further demonstrated in Table
5.8, which shows the mean number of children living in the household and
nearby, according to the child's gender and marital status and the older re
spondents' place of residence (urban versus rural). The figures in the top panel
simply show the mean number of living children in total (top row) and mean
numbers of married and unmarried sons and daughters. Overall, the number
of living children ranges from about 4.5 in Taiwan and Singapore to just under
6 children in the Philippines. Thailand falls in between with 5.3 living chil
dren on average. A majority of the children in each country are married, but
the number of unmarried children is not negligible. In the Philippines, the
elderly have about 1.5 unmarried children on average, while the figures for
Thailand and Taiwan are approximately 1.2 and 0.8, respectively.
The second panel focuses on elderly residing in urban areas and the
third panel on those in rural areas; both panels further break down the num
bers of children according to whether they live in the household or nearby
(children living further away are not included in the second or third panels).
Perhaps the most striking finding from this table is the density of the family
network in terms of their proximity. In all countries and in both urban and
rural areas, the elderly have at least two children on average who either live in
the household or nearby. This figure reaches as high as three children in both
urban and rural Philippines, and over four children in Singapore.
There is interesting variation in the balance of children living in the
household and nearby across the countries and in rural versus urban areas. In
urban Thailand, the average number of children living in the household is
higher than the average number living nearby. In contrast, in urban areas in
each of the other countries, the number of children living nearby exceeds that
living in the household by some margin. This is particularly true for Singapore,
where the number of children living nearby is more than twice the number
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160 The Well-Being of the Elderly in Asia
Table 5.7. Percent Distribution of Elderly Parents According to Location and
Contact with Children, among Those with Any Living Children
Living with a child in samehouseholdLiving adjacent to a childSees a child dailySees a child at least weeklySees a child at least monthlySees a child, but less thanmonthlyDoes not see a childTotal percentPhilippines73.46.48.34.92.64.40.0100.0Thailand74.29.96.43.23.32.70.4100.0Taiwan72.73.64.79.94.53.80.8100.0Singapore88.8-1.65.72.20.51.2100.0
Notes: Tabulations include both minor and adult children. The classification in this table is
hierarchical in that inclusion in a higher category in the list removes the respondent eligibility for
lower categories.
- = not available.
living in the household. In rural Thailand, the pattern is quite distinct from
that in urban Thailand—the average number of children living nearby is larger
than the average number coresident. This is also consistent with the pattern
observed for rural Philippines and Taiwan.
Another finding of interest concerns the marital status distribution of
children in each location. In general, the number of unmarried children living
in the household exceeds the number of coresident married children on aver
age (except in rural Taiwan, where married sons account for the largest share
of coresident children. In contrast, however, living nearby appears to be ex
clusively an arrangement for married children. The average number of un
married children living nearby is very low in both urban and rural areas in all
countries.
In the first part of the chapter we have focused on a descriptive over
view of the living arrangements of the elderly and their structure with respect
to the marital status and gender composition of coresident children. Before
moving on to the analysis of living arrangement determinants, it is useful to
summarize the findings thus far.
First, we find that intergenerational coresidence is quite common, with
the percent living with one or more child ranging from 69 percent in Taiwan
to 85 percent in Singapore. Furthermore, close to half of elders in all the
countries except Singapore live in three generational households. However,
in none of the countries are elders likely to live with more than one married
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Table 5.8. Mean Number of Living Children by Sex and Marital Status of
Children and Respondents Place of Residence
Residence of Parent
Location of Children
Sex/Marital Status of ChildrenTotalMarried sonsUnmarried sonsMarried daughters
Unmarried daughtersUrbanChildren living in household
Married sonsUnmarried sonsMarried daughters
Unmarried daughtersChildren living nearby
Married sonsUnmarried sonsMarried daughters
Unmarried daughtersRuralChildren living in household
Married sonsUnmarried sonsMarried daughters
Unmarried daughtersChildren living nearby
Married sonsUnmarried sonsMarried daughters
Unmarried daughtersCountryPhilippines5.912.150.792.16
0.761.40
0.260.470.24
0.411.57
0.830.060.63
0.051.30
0.160.550.19
0.392.02
1.010.060.88
0.07Thailand5.332.040.582.07
0.641.57
0.300.430.25
0.590.63
0.290.020.28
0.041.01
0.160.260.31
0.281.69
0.750.040.84
0.07Taiwan4.401.720.481.86
0.321.09
0.490.340.04
0.221.32
0.570.040.67
0.040.96
0.550.270.02
0.121.27
0.470.030.73
0.04Singapore4.592.34"2.26"1.410.87"0.54"3.04
1.41'1.63"inap.
* Means are for all sons and all daughters, regardless of marital status, because the
Singapore survey data does not contain marital status information for children.
Notes: Means are based on the full elderly sample and thus include the small percentage
childless in each country. Means may not sum exactly to the overall category mean
because of missing data on children's sex, marital status and place of residence. Residing
"nearby" is defined as: same compound, barangay or city (Philippines); next door or same
village (Thailand); and next door, same neighborhood or same/neighboring
city/town/village (Taiwan); same city/country (Singapore).
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162 The Well-Being of the Elderly in Asia
child at a time reflecting the prevailing stem family structure common to all.
On the other hand, living with more than one unmarried child is more com
mon for those who have the option of doing so. Relatives other than direct
descents (children and grandchildren) and their spouses are only infrequently
found in households with elderly.
Second, the gender patterns of coresident children vary considerably.
These differences are mainly limited, however, to married children. None of
the surveys revealed pronounced gender preferences with respect to
coresidence with unmarried adult children. In a very general sense, the findings
for married children conform to characteristics of the two broad family systems
prevailing in Asia referred to above (Mason, 1992). Thais, Filipinos and ethnic
Malays are generally considered to have bilateral family systems, while Chinese
and Indians (especially from Northern India) are generally considered to have
pair ilinca I/patriarchal systems. Our results indicate Thai elderly and, to a lesser
extent, Filipino elderly are more likely to coreside with a married daughter
than with a married son while in Taiwan and among the Chinese and Indians
in Singapore, there is a pronounced tendency to coreside with married sons
over married daughters.
Finally, most elderly parents who do not live with children either live
nearby or have reasonably frequent contact with them. Thus there is little
evidence of wide-spread desertion of parents by adult children in any of the
four countries. Even the living arrangements of childless elders, with the ex
ception of Taiwan, typically include residing with a spouse or relatives and
thus appear to reflect a functioning family support system.
Determinants of Living Arrangements
The foregoing analyses have described the household composition of older
Asians in detail, with particular focus on coresidence with children and the
gender and marital status composition of coresident children. In this final
section of the chapter, we investigate the determinants of living arrangements
by examining how different types of living arrangements vary according to
characteristics of older adults and their families.
The conceptual model that guides this analysis posits that living ar
rangements are influenced by three sets of factors: 1) the availability of cer
tain types of kin with whom to coreside, 2) the preferences of the individuals
involved with regard to shared versus independent living arrangements, and
3) the needs and resources of these various individuals. This model has been
elaborated elsewhere both in our own work (Casterline et al., 1991; Hermalin,
Ofstedal and Chang, 1991; Ofstedal, 1995) and that of others (Burch and
Matthews, 1987; DaVanzo and Chan, 1994; Wolf and Soldo, 1988); here we
provide a brief synopsis of the major premises.
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Patterns and Determinants of Living Arrangements 163
In terms of availability, an older person's options for living arrange
ments are to a large extent a function of having kin, particularly children.
Those with larger numbers of children have more opportunities for coresiding
with one or more of them, and indeed previous research in Asia (Casterline et
al., 1991; Martin, 1989; Ofstedal, 1995) as well as the U.S. (Aquilino, 1990;
Wolf and Soldo, 1988) has shown number of living children to be a strong
determinant of coresidence with children. Beyond the mere existence of kin,
it may also be important to take into account their attributes, such as their
gender, age, marital status, and childrearing status.
In addition to availability, living arrangements are likely to be influ
enced by the preferences of those involved. These preferences may be shaped
to a large degree by cultural norms and expectations, which as noted previ
ously have traditionally promoted the value of intergenerational coresidence.
However, preferences are also influenced by exposure to new ideas and val
ues that occurs through the mass media, in classrooms and work places, and
in social exchanges with family members and friends.
Finally, to act on their preferences, families must have the physical and
economic resources to do so. Hence, a last part of the model relates to the
needs and resources of various family members in terms of economic, physi
cal, and social support. Elderly parents who need daily physical care (e.g., for
bathing, dressing, feeding, etc.) may require the presence of another family
member in the same household. With regard to economic support, coresidence
may benefit older parents as well as adult children who do not have the finan
cial resources to maintain separate residences.
As alluded to in the above discussion, an important feature of the con
ceptual model is that it views coresidence decisions as involving multiple
actors (Casterline et al., 1991; Ofstedal, 1995). Thus, it is important to take
into account not only the needs, resources and preferences of the elderly indi
vidual or couple, but also those of other family members to the extent pos
sible.
In keeping with this perspective, we expect different factors to be at
play when considering coresidence with unmarried versus married children.
To a large extent, this will reflect the varying availability of each type of child
over the life course. When parents are young, still employed, and in good
health, their children are also likely to be young and unmarried; however, as
parents age, retire, and become increasingly frail, their children are likely to
be predominantly married. In addition to availability, other factors may also
come into play. Coresidence with unmarried children, at least during the early
stages of old-age, may be in large part a response either to cultural or norma
tive patterns that promote parent-child coresidence until the time a child mar
ries, or to the needs of the unmarried children who lack the financial and/or
social resources to establish independent living quarters. In contrast coresidence
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164 The Well-Being of the Elderly in Asia
with married children, which generally occurs later in old-age, may be more a
response to the financial, health, and social needs of older parents. This is not
to say that coresidence with married children is primarily beneficial to elderly
parents as opposed to the younger generation; indeed, research presented in
other chapters in this volume (see especially Chapter 6) and elsewhere
(Hermalin, Roan and Perez, 1998) indicates that elderly parents are often
very engaged in the care of grandchildren and household maintenance, and
this is likely viewed as a major benefit to the younger couple, both members
of whom may be working full-time.
Whereas the previous analyses focused mainly on coresidence with
children, this analysis also examines those who live independently from their
families, either alone or with a spouse only. The analysis begins by examining
bivariate associations between key life course, socioeconomic and family char
acteristics that are indicative of needs/resources, preferences and availability
on one hand, and alternate types of living arrangements on the other. These
descriptive analyses are presented separately for each country. We then present
results from a series of multivariate logistic regression analyses to examine
the net effects of these characteristics on living arrangements controlling for
the other factors.
In the course of the multivariate analysis, we first estimated country-
specific models for each outcome to examine the extent to which covariates
differed across countries, and then a corresponding set of models in which the
data were pooled across countries and relevant country interactions were tested.
Tables presenting the pooled results are shown and discussed in the chapter.
Those presenting the country-specific models are not shown here but are avail
able from the chapter authors.
Descriptive Results
Table 5.9 presents the percent of respondents in each country who live alone
(among those who are unmarried) and who live with a spouse only (among
those who are married), by selected sociodemographic characteristics. We
focus first on patterns of living alone among the unmarried, and then note
similarities and differences in patterns of living with spouse only among the
married.
The overall percentage of unmarried elderly living alone (shown in the
top row of figures) ranges from a low of 6 percent in Singapore to a high of 26
percent in Taiwan, with roughly one-tenth living alone in both the Philippines
and Thailand. In all countries, unmarried men are more likely than unmarried
women to live alone, although the gender difference is not statistically sig
nificant for the Philippines and only marginally so for Thailand. In Taiwan
the difference is particularly marked, with men being about three times more
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166 The Well-Being of the Elderly in Asia
likely than women to live alone. As will be noted throughout the volume, the
gender pattern in Taiwan reflects the distinctive nature of older unmarried
men in Taiwan, many of whom are Mainlanders who never married and, as a
result, have limited if any family members with whom to live. In contrast, the
vast majority of unmarried older women in Taiwan are widows with children.
In the Philippines, those in the younger age group are less likely than
those 70 years of age or over to live alone, whereas in Taiwan the reverse is
true. There are no differences in the propensity to live alone by age in Thai
land and Singapore. Among unmarried respondents, those who are either di
vorced, separated or never-married (referred to as 'other unmarried') are con
siderably more likely than those who are widowed to live alone. This pattern
holds for all countries, but is especially pronounced in Taiwan and Singapore.
Living alone is more common in rural than urban areas in all three
countries containing rural areas. This is a finding that is observed consistently
throughout the remainder of the chapter: rural elderly are more likely to live
apart from their children and urban elderly are more likely to coreside with
children. This pattern reflects in part out-migration of children from rural
areas to seek employment, as well as selective migration of older parents to
join their children in urban areas. In addition, the high cost of housing in large
cities in all of the study countries places a serious constraint on the ability of
urban families to maintain separate dwellings (Lopez, 1991).
Finally, there are interesting differences across countries with respect
to the association between education and living alone. In both the Philippines
and Thailand the percent living alone declines with increasing education,
whereas in Taiwan and Singapore the percent living alone increases dramati
cally with increasing education. It may be that the greater economic resources
associated with higher education allow older Taiwanese and Singaporeans to
"buy" privacy, whereas in the Philippines and Thailand the more difficult
economic circumstances in these countries require older parents to share their
resources with other family members who are not as well-off. Furthermore, at
least in Taiwan, those with higher education are disproportionately Mainland
ers who have fewer children with whom to coreside and a stronger tendency
to prefer independent living arrangements (Cornman, 1999).
Turning now to patterns of living with a spouse only, the overall per
centages range from 11 percent in Singapore to 24 percent in Taiwan. The
propensity for living with a spouse only is higher than that for living alone in
all countries except Taiwan. In contrast to living alone, which was more com
mon for men than women, the percent living with a spouse only is higher
among women than men in all countries, though not statistically significant
for Singapore. Those in the oldest age group are more likely than their younger
counterparts to live with a spouse only; for Taiwan and Singapore this is also
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Patterns and Determinants of Living Arrangements 167
a departure from the pattern observed for living alone. The urban/rural pat
tern is consistent for both types of living arrangements. Rural elderly are more
likely than those in urban areas to live independently from their children and
other family members, regardless of whether this results in living alone or
living with a spouse only. Finally, the pattern by education mirrors that for
living alone in the Philippines, with the less educated being more likely to
live with a spouse only. In Taiwan, those with the highest level of education
have the highest propensity for living with a spouse only, and this finding is
also similar to that for living alone. In Thailand and Singapore there are no
significant differences by education.
In Table 5.10 we return to the most common alternative to independent
living and, indeed, the most prevalent type of living arrangement in each of
the four study countries, coresidence with children. Here we present the per
centage of all respondents (both married and unmarried combined) who
coreside with various types of children for each country, according to the
same sociodemographic characteristics as in the previous table. As noted pre
viously, for several factors we expect their associations with intergenerational
coresidence to differ depending on the marital status of the coresident child.
Accordingly, we examine separately coresidence with any adult children (first
column for each country), with unmarried adult children (middle column),
and with married children (last column). It should be noted that respondents
can be living with both types of children; in that case they will be represented
in all three columns in this table. For the Philippines, Thailand and Taiwan,
the percentages shown in the table are conditional on the availability of the
child in question. As noted previously, the Singapore survey collected infor
mation only on the number of living sons and daughters and not on their
characteristics; as a result, the Singapore sample is conditioned only on avail
ability of one or more children for each outcome (hence the sample size is the
same for each column).
As seen in the previous section, among older persons who have at least
one living adult child, the percent coresiding with a child ranges from just
under three-quarters in the Philippines, Thailand and Taiwan, to nearly nine-
tenths in Singapore. Conditional on availability, the propensity to live with an
unmarried child is higher than that for a married child in each country, with
the differential being especially pronounced in the Philippines. Among those
with one or more married children, slightly over half of older parents in Thai
land and Taiwan live with a married child, and less than half of those in the
Philippines and Singapore do so.
The age patterns observed likely reflect life course influences of children
and their parents. The propensity for living with any adult child is slightly
higher for the younger than the older age group, with the exception of Thailand,
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Patterns and Determinants of Living Arrangements 169
for which there is no difference by age. This pattern also generally holds for
coresidence with unmarried children, however, the reverse pattern is found
for coresidence with married children. In Thailand, Taiwan and Singapore,
those in the older age group are more likely than their younger aged
counterparts to live with a married child. Although we have conditioned the
samples on availability of at least one child of the specified type, these different
age patterns may be partly a function of availability in that older parents are
likely to have more married children and fewer unmarried children, whereas
younger parents may have more children who have not yet married. However,
it may also be a function of the different life stages of members of both
generations and of the needs and resources associated with these stages.
Individuals age 60-69 have fewer needs of their own and greater resources to
share than those age 70 or over—they are more likely to be in good health and
to be generating income from employment. In addition, their unmarried
children are younger and may not yet be established in careers of their own,
and a shared living arrangement with their parents may be beneficial if not a
necessary way to save on expenses. On the other hand, the higher propensity
for coresidence with married children in the older age group may reflect the
increased frailty of the older parents, their dependence on children for some
level of financial support, and the tendency to turn to married over unmarried
children to satisfy these needs. These considerations are also reflected in the
patterns by marital status. With the exception of Thailand, those who are
married (and also younger) are more likely than their unmarried counterparts
to coreside with unmarried children, whereas those who are widowed are more
likely to coreside with married children. The finding that divorced and separated
individuals tend to have the lowest propensities for coresidence may have
important implications for old-age living and support arrangements for future
cohorts, for whom divorce and separation are more common experiences.
With regard to urban/rural differentials, the patterns mirror those for
independent living observed in Table 5.9. Those in urban areas are more likely
than those in rural areas to coreside with any child, and this pattern generally
holds regardless of the marital status of the child. One exception is that there
is no urban/rural difference in the propensity to coreside with unmarried chil
dren in the Philippines. Also, in Taiwan the percent coresiding with married
children is only slightly higher in urban than rural areas and the difference is
not statistically significant.
Again, the findings for education reveal some expected and unexpected
associations. As noted earlier, our hypothesis is that education is negatively
associated with coresidence, particularly with married children. In this regard,
the findings suggest strong and consistent support in three of the countries:
Thailand, Taiwan and Singapore. With regard to coresidence with unmarried
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170 The Well-Being of the Elderly in Asia
children, the patterns are more varied. In Thailand we find the same negative
association as for married children; however, in Taiwan there is no association
between education and coresidence with unmarried children, and in Singapore
the association is reversed: those with higher education are more likely to
coreside with unmarried children. The Philippines shows a very different
association between education and intergenerational coresidence. The percent
coresiding with any child increases sharply with education, especially when
comparing those with primary education to those with no formal schooling.
The patterns for coresidence with unmarried and married children are more
muted and not statistically significant, but in the same general direction.
Multivariate Results
Because a number of the characteristics examined in the preceding tables are
highly correlated, it is difficult to attribute effects to individual factors based
on the bivariate analyses alone. There are several other factors not examined
in Tables 5.9-5.10 that we have hypothesized will influence living arrange
ments as well. To address these limitations we turn to a set of multivariate
logistic regression analyses in which we simultaneously estimate the effects
of a number of factors on different types of living arrangements. The living
arrangement outcomes examined here are all dichotomous and correspond
with those just presented using the same sample restrictions: a) living alone
versus with others, among unmarried respondents; b) living with spouse only
versus with others, among married respondents; c) living with unmarried chil
dren versus not living with unmarried children, among those with one or more
such children; and d) living with married children versus not living with mar
ried children, among those with one or more such children.
As noted previously, in the course of this analysis we first estimated
separate regression models for each country for each outcome of interest (re
sults not presented). While the country-specific models allow us to examine
the extent to which effects are similar or different across countries (e.g., whether
the effect of education on living arrangements differs across countries), it is
not possible to formally test whether the differences that are observed are
statistically significant. In addition, we are also interested in evaluating any
remaining differences across countries in the propensity for various living
arrangements, once other factors are controlled. In order to address both is
sues we pooled or combined the countries into a single data file and estimated
one model for each living arrangement outcome. Residual country effects are
then assessed by including country indicators for three of the four countries,
with Taiwan serving as the omitted group. For factors that exhibited different
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Patterns and Determinants of Living Arrangements 171
associations across countries in the country-specific models, we conducted
formal statistical tests for interaction effects. For example, the association
between education and living arrangements appeared to be quite distinct for
the Philippines in both the country-specific regressions, as well as the bivari-
ate results in Tables 5.9-5.10. To test whether the education difference is sta
tistically significant, we included interactions between the country indicator
for the Philippines and the dummy variables for each level of education. Only
those interactions that were found to be statistically significant were retained
in the final models and they are presented along with the main effects from
the pooled models in Tables 5.11-5.12.
As is the convention throughout this volume, results from the logistic
regression models are presented in the form of odds-ratios. Odds-ratios above
1.0 indicate that the group in question has a higher likelihood of experiencing
the outcome relative to the comparison (omitted) group, and odds-ratios be
low 1.0 indicate that the group in question has a lower likelihood of experi
encing the outcome. For continuous independent variables, the odds-ratio in
dicates the amount of increase or decrease in the log-odds of experiencing the
outcome that is associated with a one-point increase in the independent vari
able.
The first two models focus on the two independent living arrangements,
namely living alone and living with a spouse only. Results from these models
are shown in Table 5.11. The sociodemographic covariates are listed first in
the table, followed by the residual country effects and the country interactions.
The only country that exhibited significant interaction effects in relation to
these outcomes is the Philippines; interpretation of these results will be given
below.
Focusing first on the model predicting living alone among unmarried
respondents, the results suggest that women are less likely than men to live
alone, whereas divorced and separated individuals, rural residents, and those
who are currently employed are all more likely than their respective counter
parts to live alone. With regard to income there appears to be a curvilinear
effect, such that those with moderate levels of income are more likely than
those with low or high levels to live alone..t In addition, the likelihood of
living alone is negatively associated with both the availability of any children
and the number of living children. Specifically, the odds of living alone among
those with one or more living child are .4 times the odds for those with no
living children. In addition, there is approximately a 10 percent reduction in
the odds of living alone with every increase of one in the number of living
children. The effects of all of these covariates just described are generally
consistent across countries in that no significant country interactions were
observed.
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Table 5.11. Odds-Ratios for the Effects of Sociodemographic and Health
Characteristics on Living Alone or with Spouse Only: Results from Pooled
Logistic Regression Models
*p<.05 **p<.01 ***p<.001
Independent VariablesAge of respondent60-64
65-6970-74
75-79
80+Female (vs. male)Divor/separ/never marr (vs. widowed)Rural (vs. urban)EducationNo formal schooling
Any to completed primary
Any secondary and aboveRespondent/spouse's incomeLow income (-lowest quintile)
Moderate income
High income (-highest quintile)
Missing incomeWorking (vs. not working)Self-rated healthHigh/good
Moderate
Low/poor1+ ADL difficulty (vs. no difficulty)1+ living children (vs. none)
Number of living childrenCountry (vs. Taiwan)
Philippines
Thailand
SingaporeCountry interactionsPhilippines*age It 75
Philippines*primary education
Philippines Secondary education
Philippines*ADL difficulty
Philippines'low incomePseudo-R2Live Alone vs. Live w/Others
(unmarried respondents)0.98
0.95
1.201.120.53***1.98***1.74***0.97
1.140.61***0.53***
0.48***1.42**0.91
0.901.100.39***
0.90***0.96
0.34***
0.22***0.49***
0.65*
0.16***
0.29***.168Live w/Spouse Only
vs. Live w/Others
(married respondents)0.43***
0.68***
0.75*1.121.54***inap.2.04***1.08
1.49***0.62***0.92
0.71**1.050.941.050.810.24***
0.92***0.69
0.53***
0.45***0.55**
0.40***2.43***.067
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Patterns and Determinants of Living Arrangements 173
There were a number of factors, however, for which the effects were
significantly different for the Philippines than for the other countries. These
are shown in the "country interactions" entries toward the bottom of the table.
The first of these factors is age. Whereas age is not associated with living
alone net of other factors in Thailand, Taiwan or Singapore, age is a signifi
cant factor in the Philippines. Specifically, Filipinos under age 75 are less
likely than those age 75-79 to live alone. (This effect was consistent for each
of the detailed age groups [60-64,65-69, 70-74] in the Philippines, but due to
small sample sizes not all of the individual age interactions were significant.
As a result, the groups were collapsed in the country interaction.) Education
also exhibited a differential effect in the Philippines, reiterating the bivariate
associations observed in Table 5.9. Unlike their counterparts in the other coun
tries for whom education is not associated with living alone once other fac
tors are controlled, older Filipinos with primary, and especially secondary
level education are substantially less likely to live alone than their uneducated
peers. This finding is counter to the hypothesis that higher education is asso
ciated with a greater preference for independent living, as well as the eco
nomic resources to achieve it. Finally, health is also an important factor in the
Philippines. Specifically, those who have difficulty performing one or more
ADL (for definition, see Chapter 9 on Health Status) are less likely to live
alone than those not so impaired. No health effects were observed with re
spect to living alone for any of the other countries.
Turning lastly to the country effects, the significant odds-ratios for Thai
land and Singapore indicate that, other factors being equal, the likelihood of
living alone is lower in both of these countries than in Taiwan (the compari
son country). These results are consistent with those presented in Table 5.9,
which shows substantially lower percentages living alone in Thailand and
Singapore compared to Taiwan. Table 5.9 also shows a much lower percent
age living alone in the Philippines than in Taiwan. The lack of a residual
country effect for the Philippines in the multivariate model indicates that this
differential is fully explained by other variables in the model, most impor
tantly the interaction effects that are included.
The results for the second model predicting living with a spouse only
among married respondents show some interesting similarities and differences
with the patterns for living alone. Consistent with the previous model, those
residing in rural areas are more likely than those in urban areas to live with a
spouse only. In addition, low income individuals (in all countries except the
Philippines) and those with missing values on income are less likely to live
with a spouse only than those with moderate incomes. The propensity for
living with a spouse only is also reduced for those with any living children
and also as the number of living children increases.
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174 The Well-Being of the Elderly in Asia
Differences in associations emerge in relation to age, gender, and edu
cation. In the previous model, neither age nor education was associated with
living alone, except for older Filipinos. Age has a strong effect on living with
a spouse only, however, with those under age 75 less likely to live with a
spouse only than those age 75-79. This effect is consistent across all coun
tries. In addition, those with secondary education are more likely than those
with no formal schooling to live with a spouse only in all countries except for
the Philippines. Finally, whereas women were less likely than men to live
alone, women are significantly more likely to live with a spouse only.
With regard to country interactions, the Philippines again exhibits some
deviations as alluded to above. In contrast to the other countries, for which
education is positively associated with living with a spouse only, older Filipi
nos with primary and secondary education are less likely to live with a spouse
only compared to those with no education. In addition, whereas low income is
associated with a lower propensity for independent living in the other three
countries, in the Philippines those with low income are substantially more
likely to live with a spouse only than those with moderate incomes.
Finally, the country effects are similar to those observed in the previ
ous model. Other things being equal, older Thais and Singaporeans are less
likely than their Taiwanese counterparts to live with a spouse only. The lower
propensity for living with a spouse only for older Filipinos compared to Tai
wanese (as shown in Table 5.9) is to a large extent explained by the interac
tions in the model. Some residual country effect remains for the Philippines
(odds-ratio of .69) but it is not statistically significant.
Although a number of factors were found to be significantly associ
ated with independent living, the overall variance explained by the models is
fairly small. The model explains approximately 17 percent of the variance in
living alone and only 7 percent of the variance in living with a spouse only.
Table 5.12 presents logistic regression results for models predicting
coresidence with unmarried and married children, respectively. For three of
the countries, the samples are restricted to respondents who have at least one
child of the specified type; because this information is not available for
Singapore, the Singapore sample is conditioned only on availability of one or
more living children in both models. As with Table 5.11, results are presented
as odds-ratios.
Focusing first on the results for coresidence with unmarried children,
there is a strong inverse relationship with parent's age, such that the propen
sity for living with an unmarried child declines as parent's age increases.
Women are less likely than men to live with an unmarried child, as are those
who are widowed or otherwise unmarried compared to the currently married.
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Patterns and Determinants of Living Arrangements 175
An exception to the pattern for marital status is in Thailand, where widowed
individuals are more likely than married persons to coreside with an unmar
ried child (note interaction effect in lower panel of table). Other things being
equal, there is a sharp reduction in the likelihood of coresiding with unmar
ried children in rural versus urban areas.
Education and income exhibit strong effects on coresidence with
unmarried children, although the effects vary somewhat across countries. In
both Taiwan and Thailand, elderly with primary or higher education are less
likely than those with no formal schooling to coreside with an unmarried child.
This pattern is reversed in the Philippines and Singapore, however, as indicated
by the odds-ratios associated with the corresponding interaction effects shown
in the lower panel of the table. With regard to income, there is a strong positive
association in that the likelihood of coresidence increases with increasing
income. This pattern holds in all countries except Thailand, where the
association is partially reversed. Multiplication of the income odds-ratios with
the odds-ratios for their corresponding interaction variables indicates that low
income Thais are more likely to coreside with unmarried children than those
with either moderate or high incomes (odds ratios of 1.26 versus 1.01 and
1.00, respectively).
Neither work status nor health status are associated with coresidence
with unmarried children net of other factors. However, the likelihood of
coresidence increases significantly as the number of unmarried children in
creases.
As discussed above, education, income, and widowhood show varied
patterns of association among the countries. Older Filipinos and Singaporeans
who received some education and widowed and low income Thais all have a
higher than average propensity for living with unmarried children. On the
other hand, high income Thais have a lower than average propensity. Net of
these differences and of compositional differences on the covariates, how
ever, important country differences remain. Thais and particularly Singaporeans
are less likely to coreside with unmarried children than Taiwanese. Filipinos
also have a slightly reduced likelihood of coresidence compared to Taiwan
ese, although the difference is not statistically significant.
To some extent the residual country effect for Singapore is likely due
to our inability to adequately control for availability of unmarried children.
For all other countries, the sample is restricted to those with one or more
unmarried child, but for Singapore it is restricted to those with one or more
living child. As a result, the Singapore sample may contain a high proportion
of respondents who have no unmarried children and for whom coresiding
with an unmarried child is, thus, not an option.
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Table 5.12. Odds-Ratios for the Effects of Sociodemographic and Health
Characteristics on Living with Unmarried and Married
Children: Results from Pooled Logistic Regression Models
Independent VariablesAge of respondent60-6465-6970-7475-7980+Female (vs. male)Marital statusMarriedWidowedDivorced/separated/never marriedRural (vs. urban)EducationNo formal schoolingAny to completed primaryAny secondary and aboveRespondent/spouse's incomeLow income (~lowest quintile)Moderate incomeHigh income (-highest quintile)Missing incomeWorking (vs. not working)Self-rated healthHigh/goodModerateLow/poor1+ ADL difficulty (vs. nodifficulty)Live with
Unmarried Child1.88***1.35***1.25*—0.74**0.81***—0.70***0.55***0.69***-0.63***0.54***0.81**—1.36***1.44**1.071.05—1.021.01Live with
Married Child1.071.010.95—0.82*1.04-1.71***1.090.72***-1.041.061.65***—1.051.71***0.67***1.06—0.961.05
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Patterns and Determinants of Living Arrangements 177
Table 5.12. continued
Number of unmarried childreni*
Number of married children"Country (vs. Taiwan)
Philippines
ThailandSingaporeCountry interactionsPhilippines*primary education
Philippines*secondary education
Singapore*primary education
Singapore*secondary education
Thailand*widowedThailand*low incomeThailand*high income
Singapore*female
Taiwan*secondary educationPseudo-R21.23***0.75
0.61***0.19***1.91***
1.66*
1.85***
2.83***
1.99***1.55*0.74*.0971.07***0.68***
1.070.43***0.54***•1.29**
0.58***.060
aFor the Philippines, Thailand, and Taiwan, samples for each model are restricted to
respondents with 1+ child of the specified type. For Singapore, sample in both models is
conditioned only on having 1+ living children, since information on availability and
number of unmarried versus married children is unknown.
ror Singapore, variable represents total number of living children, since information
on number of unmarried versus married children is unknown.
* p < .05
p<.001
As noted previously, we expect coresidence with married versus
unmarried children to respond to a somewhat different set of considerations.
In particular, we hypothesize that coresidence with married children will be
more responsive to the financial, health and social needs of older parents than
is the case for coresidence with unmarried children. The results presented in
the far right column of Table 5.12 lend partial support to this hypothesis.
With regard to financial needs, the results show that elderly parents
with a low level of income are more likely to coreside with a married child
than those with moderate or high levels of income. This is in contrast to the
pattern for coresidence with unmarried children, for which there is a strong
positive association with income. In addition, elderly parents who are retired
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178 The Well-Being of the Elderly in Asia
(or not working) are more likely than those currently working to coreside
with a married child. Work status is unrelated to coresidence with unmarried
children. These results suggest that coresidence with married children may be
responsive to the financial constraints of elderly parents.
Another interesting difference in results for married versus unmarried
children pertains to the marital status of the elderly parent. Widowed elderly
have a substantially higher likelihood than their married counterparts of
coresiding with a married child. Other unmarried persons (primarily divorced)
are neither more nor less likely than married persons to live with a married
child. In contrast, married elderly are much more likely than either widowed
or otherwise unmarried elderly to coreside with an unmarried child. Other
things being equal, health status does not appear to be associated with
coresidence with either married or unmarried children.
Age, gender and education show little association with coresidence
with married children with a few exceptions. The oldest-old (age 80+) are
slightly less likely than those age 75-79 to coreside with a married child, other
things being equal, but there is no difference in propensity for those under age
80. The only country for which there is a gender difference is Singapore,
where women are more likely than men to coreside with a married child.
Finally, in both Singapore and Taiwan, education comes into play in that those
with secondary or higher levels of education are less likely than those with no
formal education to coreside with a married child. This is consistent with the
hypothesis that more educated individuals tend to prefer independent living
arrangements. The fact that this education effect is not obsened in Thailand
or the Philippines suggests that either such preferences do not operate there
or that elderly are less able to act on these preferences due to financial and
other constraints.
One factor that does show a similar association for coresidence with
unmarried and married children is place of residence. Rural elderly are sig
nificantly less likely than their urban counterparts to live with a child, regard
less of the child's marital status. Also, the likelihood of coresidence with a
married child increases with the number of married children, a finding paral
lel to that for unmarried children in the previous model.
Finally, with regard to country differences, the results mirror the de
scriptive findings in Table 5.10, suggesting that the underlying propensity for
coresidence with married children is quite similar in Thailand and Taiwan,
but that it is somewhat lower in both the Philippines and Singapore. Once
again, although a number of factors exhibit strong effects on coresidence with
children in both models, the amount of variance in living arrangements that is
explained is under 10 percent for each.
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Patterns and Determinants of Living Arrangements 179
Conclusions
The very substantial social and economic change during the last several de
cades in the countries under study does not yet appear to have led to or been
accompanied by major shifts in the predominant form of living arrangement
among elderly population members. Coresidence with adult children still pre
vails widely in the Philippines, Singapore, Taiwan and Thailand. The most
notable shift away from coresidence with children is evident in Taiwan where
living only with a spouse has risen to levels above those found in the other
three countries. But this transformation has been occurring at a rather slow
pace compared to the rapid economic and social development that has trans
formed Taiwan into one of the most advanced newly industrialized countries
in the region. In the case of Thailand, increases in arrangements in which
children live very nearby appears to have largely compensated for the modest
reduction in coresidence observed there. In the Philippines and Singapore
changes appear to be even less pronounced than in Taiwan or Thailand.
Despite the remarkable persistence in coresidence in these countries
suggested by available data, it is possible that more dramatic change could
characterize them in the coming decades. As noted earlier in the chapter, re
cent evidence indicates pronounced declines in coresidence in at least two
Asian countries, Japan and Korea. In addition, attitudinal data available for
Taiwan among young adults suggest further declines in coresidence there in
the future. For example, surveys of women aged 20-39 indicate that those
who expect to coreside with a married son during their old age declined from
56 percent in 1973 to 45 percent in 1986 (Weinstein et al., 1994). In both
instances, these percentages are distinctly lower than the percent of persons
aged 65 and over who were living with a married child (almost always a mar
ried son rather than daughter) at the time (Hermalin, 1995). Furthermore, fo
cus group discussions among the adult children of elderly parents in Thailand
elicited frequent views that in the future, when they themselves are elderly,
they would be less likely to receive the same care from their own children that
they give to their parents and that coresidence would be less common (Knodel,
Saengtienchai and Sittitrai, 1995).
The patterns of association observed in relation to several socioeco-
nomic and demographic factors also suggest the possibility of further declines
in coresidence in the coming years. For example, higher levels of education
and income tend to be positively associated with independent living arrange
ments and negatively associated with coresidence with children. (A key ex
ception is the positive association between income and coresidence with un
married children, perhaps reflecting a prolonged dependency of children in
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180 The Well-Being of the Elderly in Asia
families who have sufficient financial resources to accommodate such an ar
rangement.) In addition, the results show a consistently strong effect of num
ber of children on living arrangements, whereby those with larger numbers of
children are less likely to live independently and more likely to coreside with
unmarried or married children. As the standard of living rises in these coun
tries, and as future cohorts of elderly become increasingly educated and have
fewer children, we might expect to see continued increases in independent
living and declines in intergenerational coresidence. Thus, the modest changes
evident to date for the four countries in our project could possibly presage
more dramatic future changes in living arrangements.
The analysis of determinants of living arrangements revealed a num
ber of other key findings, as well. The following table lists the factors that are
statistically significant predictors of the various living arrangement outcomes
examined in the chapter. Both place of residence (urban versus rural) and
number of living children show pervasive effects across all outcomes exam
ined, highlighting the importance of availability of kin, as well as more mate
rial constraints relating to the high cost of living and relative shortage of land
and housing in urban compared to rural areas.
Significant Factors Affecting AlternateLiving AloneMale (+)Divorced (+)Rural (+)Income (+/-)Work status (+)# children (-)CountryLiving with
Spouse OnlyAge (+)Male (-)Rural (+)Education (+)Income (+)# children (-)CountryLiving ArrangementsLiving with
Unmarried ChildAge (-)Male (+)Married (+)Rural (-)Education (-)Income (+)# children (+)CountryLiving with
Married ChildWidowed (+)Rural (-)Income (-)Work status (-)# children (+)Country
Also of interest is that the dynamics of living alone and living with a
spouse only are not always the same. For example, among the unmarried,
living alone is much more prevalent for men and for those currently working,
and income shows a curvilinear effect, whereby those with moderate levels of
income show the highest propensity for living alone. In contrast, living with a
spouse only is much more common among women and those of higher
socioeconomic status, as reflected by education and income.
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Patterns and Determinants of Living Arrangements 181
The dynamics of coresidence with unmarried versus married children
are also somewhat different. Whereas coresidence with unmarried children
appears to be primarily responsive to the children's needs and life stage,
coresidence with married children appears to be more strongly influenced by
the physical, social and financial needs of the parents. This may in large part
be a function of the way in which the life courses of parents and their children
move in parallel, and the opportunities that are thus available at various stages.
When children enter adulthood and secure their first jobs or obtain advanced
education prior to marrying, their parents are likely to still be fairly young,
married, in good health, and possibly working. Likewise, when parents are
older, retired, experiencing declining health, and possibly widowed, their chil
dren are likely to have become married and possibly even raised families of
their own. Hence, the opportunities for living with married versus unmarried
children change over time and, at specific points in the life course, may be
somewhat constrained.
A key point that we have tried to emphasize in this chapter is that an
individual's living arrangement at any given point in time reflects the outcome
of a complex decision involving multiple family members, each of whom has
a unique set of needs and resources to be balanced. Furthermore, living
arrangements are fluid and are likely to change during later life, perhaps many
times, in response to the changing needs, resources and availability of family
members. The present analyses, which are based on cross-sectional data,
capture the situation at only a single point in time and in the lives of the
survey respondents. To date, little is known about the transitions in living
arrangements that occur during later life in these countries. Panel data that
follow individuals over time are just becoming available for several of the
study countries, and these data will be useful for describing transitions and
conducting more refined investigations of their determinants. An example of
the potential that longitudinal data offers for studying living arrangements is
provided in Chapter 12.
Finally, the relation between forms of living arrangements and functions
and how this relation may be changing over time is another critical issue to
consider. It is indeed these functions that directly determine the implications
of living arrangement structures for the well-being of the elderly. As suggested
in the framework presented in Figure 4.1, we view living arrangements as an
intervening factor that influences various dimensions of well-being, rather
than an indicator of well-being in and of itself. In keeping with this perspective,
subsequent chapters examine living arrangements as an independent variable
to determine what impact they have on specific dimensions of well-being and
whether this impact is the same or different across countries.
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182 The Well-Being of the Elderly in Asia
ENDNOTES
1. The 1995 Singapore survey includes the following information: total number
of sons, total number of daughters; the number of coresident sons; the number of
coresident daughters; whether or not the respondent lived with any single children;
and whether or not the respondent lived with any ever married children. Based on
this information, it is possible to determine for 92% of elderly parents whether or
not they are living with a single son, single daughter, married son, or married
daughter. The remaining 8% of elderly parents coreside with at least two children
of opposite gender and opposite marital statuses. Information on household
headship allowed us to sort out the gender and marital status for an additional 3%
of the cases. For the remaining 5% of cases, it was not possible to identify the
specific gender and marital status combination of coresident children, so these
respondents are excluded from all analyses of coresidence.
2. Here and in all other tables in this chapter references to married children
include both those who are currently and formerly married (i.e., widowed, divorced
or separated).
3. The results for the Chinese elderly are based on 299 elderly whose children
are all sons and 224 whose children are all daughters. However, among Malays
there are only 30 cases whose children are all sons and 35 cases in which all are
daughters and among Indians only 14 have only sons and the same number only
daughters. Given that we do not know if any of the children are married, we can
not condition the results on having at least one married child as we in effect do for
the other three countries. Thus it could be misleading to report more precise results
for the Malays and Indians.
4. A dummy variable representing missing income was included in the model
as a control. Most of the missing data on income is due to don't knows, although
some respondents refused to provide their income. The finding that those with
missing income were less likely to live alone or with a spouse only most likely
reflects the less complicated financial situation of elderly living alone or with
spouse only compared to living in multigenerational households.
5. The rinding that married women are more likely than married men to live
with a spouse only, other things being equal, is likely due to the age difference
between spouses. Women tend to be several years younger than their spouses, on
average. Therefore, a 65 year-old woman is likely to be married to a man in his
late sixties, whereas a 65 year-old man is likely to be married to a woman in her
early sixties. The former couple is further along in their family life-cycle than the
latter couple, and their children are more likely to be married and to have moved
away from home. Thus, holding age constant, a married woman is more likely
than a married man to be living apart from children and in a couple-only household
with her spouse.
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Patterns and Determinants of Living Arrangements 183
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Hermalin, Albert I., Carol Roan, and Aurora Perez. 1998. "The Emerging Role of
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184 The Well-Being of the Elderly in Asia
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Knodel, John, and Chanpen Saengtienchai. 1999. "Studying Living Arrangements
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Knodel, John, Chanpen Saengtienchai, and Werasit Sittitrai. 1995. "The Living
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Cross-Cultural Gerontology 10(l/2):79- 111.
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Natividad, Josefina N., and Grace T. Cruz. 1997. "Patterns in Living Arrange
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Ofstedal, Mary Beth. 1995. "Coresidence Choices of Elderly Parents and Their
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Weinstein, Maxine, Te-Hsiung Sun, Ming-Cheng Chang, and Ronald Freedman.
1994. "Co-Residence and Other Ties Linking Couples and Their Parents." In
Arland Thornton and Hui-Sheng Lin, eds., Social Change and the Family in
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Wolf, Douglas A., and Beth J. Soldo. 1988. "Household Composition Choices in
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Chapter 6
INTERGENERATIONAL SUPPORT AND TRANSFERS
Ann Biddlecom, Napaporn Chayovan,
and Mary Beth Ofstedal
Intergenerational support and transfers—which commonly take the forms
of coresidence, time, and money—are fundamental aspects of the social
fabric in society. Intergenerational support systems play a key mediating role
between broad societal-level changes, such as declining fertility rates and
rising GNP, and the individual welfare outcomes of the elderly, such as physi
cal health and economic status (see Figure 4.1 in Chapter 4). Moreover, fam
ily transfers have social and economic consequences that can directly im
pinge on the design and effectiveness of public support programs and policies
(Mason, Lee and Russo, 2001; National Research Council, 2001; Schoeni,
1997). Both family and public transfers are often intended to smooth the dif
fering consumption needs and productive contributions that occur across the
life course, and when changes occur in one source of support, there are likely
to be accommodations in the other source of support.
Family support and transfer systems are particularly critical to exam
ine in Asia because of the historically important role of family care for the
elderly, especially elderly parents, and the recent broad-level changes that are
sweeping the region (see Chapter 2). For example, survey data show that
transfers from family members remain central to the economic well-being of
most older persons in Asia. Income from family members, primarily adult
children, was the primary source of income for the majority of the elderly in
Fiji, Korea, Malaysia, and the Philippines in the mid-1980s (Andrews et al.,
185
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186 The Well-Being of the Elderly in Asia
1986: 72); Taiwan, Singapore, Thailand, and the Philippines in the mid-1990s
(see Chapter 8); major urban areas of Vietnam in 1996-1997 (Anh, Cuong,
Goodkind and Knodel, 1997); Cambodia in 1998 (Kato, 2000); and South
Korea in 1998 (Yoon and Cha, 1999). In Malaysia, the majority of elderly
receive money transfers from children, regardless of whether this is a primary
source of income or not (Lillard and Willis, 1997). Recent studies of urban
areas in China find that from one-third to one-half of Chinese elderly receive
financial assistance from family (Chen and Silverstein, 2000; Hermalin,
Ofstedal and Shih, forthcoming).
Intergenerational support systems are not static institutions in the face
of broad demographic, economic and social changes. Rather, these systems
of family support come under strain and are forced to adapt in both function
and form (Hermalin, 1998; Martin and Kinsella, 1994; Mason, 1992). In this
sense, Asia is at a crossroads. Strong norms of obligation for intergenerational
support, still very much in force, currently coexist with massive changes on
key demographic and socioeconomic dimensions such as lowered fertility,
longer life expectancies, increased female labor force participation, and a
switch from agriculture-based economies to manufacturing and service-based
economies. Given current and projected increases in the older population in
both proportionate and absolute terms, governments face questions about the
degree to which family support is or will continue to be sufficient for the
needs of the elderly (Holden, 1996; Lee and Mason, 2000; Martin, 1990;
Mason, Lee and Russo, 2001; Ogawa and Retherford, 1997; Phillips, 2000;
Silverman, 1995). Concern is also growing in a number of political and scien
tific quarters that the traditional system of familial support for the elderly
might be eroding as couples bear fewer children, as more adult children live
away from their parents, and as women enter the labor force in larger num
bers (Holden, 1996; Westley, Lee and Mason, 2000; Silverman, 1995).
It thus becomes crucial to understand intergenerational support because
of the key intermediate role that it plays in the well-being of the elderly and
the relevance it has for public policy, as countries seek to attend to the emerg
ing needs of the elderly without undermining the strong norms for family
support of the elderly. Family transfers are quite difficult to measure (Hermalin,
1999), but governments are increasingly pressed to monitor sources of pri
vate support as they respond to societal-level changes and public programs to
meet the needs of the elderly. As governments continue to develop and imple
ment policies and programs in Asia, there is a concomitant need to study how
private transfer patterns adapt to new public sources of support and what
implications these changes have for future state initiatives.
This chapter describes changes to the family support system in the
Philippines, Thailand, Taiwan, and Singapore; provides a detailed snapshot
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Intergenerational Support and Transfers 187
of current intergenerational support systems and covariates of transfer pat
terns; and draws on this evidence to speculate on likely changes in family
support in the 21st century. Much of the existing research on informal support
in old-age in Asia has focused exclusively on support received by the elderly
and overlooked support provided by the elderly to others. In the countries
examined here, we have the opportunity to document support in both direc
tions, yielding a full picture of the role of older persons in their support net
works. The chapter begins with an overview of measurement issues and re
sults from prior studies on intergenerational transfers in Asia. Descriptive
assessments of attitudes about support, kin availability, and support behavior
follow. We specifically examine what expectations exist for intergenerational
care and support, what kind of support each generation actually provides, and
who provides it (particularly with respect to gender). The chapter concludes
with multivariate models of support flows and a discussion of likely scenarios
for future intergenerational support in Asia.
Measurement Issues
The measurement of support is complex. Important dimensions of measure
ment are currencies, timing, participants, and magnitude (see Chapter 4;
Hermalin, 1999; National Research Council, 2001; and Soldo and Hill, 1993,
for reviews). The currencies, or forms of support, are space (living arrange
ments), time (social contact or visits, childcare or help with daily activities),
money (cash) and material goods (food, clothing and other goods). Quantify
ing the amount of any type of transfer can be difficult. Respondents may not
know the fair market value of property or material goods or recall accurately
financial transfers made over a period of time. Time transfers can be mea
sured in terms of the frequency of contact and/or duration, and by the nature
and intensity of services provided.
Because the currencies and forms of support are so varied, comparative
analyses of support across countries or even within the same country across
time are challenging. Even how one particular currency is measured can vary,
thus confounding comparisons in support across time or space. For example,
survey data on the reported level of material support received by older persons
in Taiwan showed a decrease from 1989 to 1996. However, the question about
material support—which is often transferred in the form of gifts on special
occasions as well as an ongoing form of support—changed between surveys
such that gifts for holidays or birthdays, included in the 1989 survey, were
explicitly excluded in the 1996 survey. The four country surveys used in the
analyses presented here contain information on whether respondents received
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188 The Well-Being of the Elderly in Asia
or provided money or material goods from/to others. However, the questions
about money and material goods differ between countries in both wording
and about whom the question concerns. For example, questions about money
transfers in the Philippines exclude "small gifts"; in Thailand the questions
are about transfers of "1,000 Baht or more"; there are no restrictions in the
Taiwan data; and in the Singapore survey the question about older people providing
money refers only to coresident children. Material goods in the four country
surveys refer to household necessities, food, clothing and the like, but again
the question wording and referent groups vary among the surveys. Specific
questions used in these surveys to measure transfer flows are described in
Notes for Tables (Table 6.2) at the end of this chapter.
Transfers also occur over time, usually forcing researchers to impose
arbitrary windows of time in which to collect information. Current transfers
could mean support given in the prior week, month, or year. Or researchers
may look at transfers over the entire life course to explore family support
issues such as whether parents invest in their children early in life in ex
change for support from their adult children later in life (Henretta et al. 1997).
Transfers can also be measured into the future, as is the case for bequests,
where a usually large transfer of money or assets such as a house or land is
made upon the death of the parent. The survey data used in this study contain
information about current transfers using varying time periods. In Singapore,
the time frame is 6 months prior to the interview for receipt of money and
material goods. In Thailand, the Philippines, and Taiwan, most questions re
fer to transfers made within the past year (prior to the interview). Survey
questions about more nuanced dimensions of transfers, such as the magni
tude of transfers or the identification of specific others in the exchange net
work, are even more varied across countries.
It is worth stressing the importance of defining time boundaries for the
measurement of money transfers. Parents may make relatively large money
investments in their children's future at certain points in the life course: money
to a son or daughter to buy a home, money for higher education, or money to
start a new business. These large investments are significant but can be missed
if questions about parent-child transfers focus only on current transfers. Tai
wan was one of the few countries that attempted to measure large lifetime
transfers of money between parents and children as well as current money
transfers. The Thailand and Philippines surveys included questions about past
transfers concerning the division of property (home, land, or other assets)
among children and other family members. For the sake of comparison across
all four countries, however, we restrict our analyses mainly to current money
transfers.
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Intergenerational Support and Transfers 189
Measurement of transfers can also be sensitive to who is doing the
reporting. In a comparison of Taiwanese parents' and children's reports of the
transfers children made to their parents, Roan, Hermalin and Ofstedal (1996)
found a relatively high degree of concordance in reports (upwards of 65 per
cent) for the following types of support: money, help with household chores,
and visits. When parents and children gave differing reports of transfers, the
pattern tended to be children reporting greater support than did parents. In
this chapter, intergenerational transfers are measured from the reports of the
older respondents. In all countries the surveys collected information about
exchanges between older persons and their children. Except in Singapore the
children were individually identified and a number of their characteristics
were gathered from the older respondents.
Though we use the term "intergenerational" to describe transfers in
this chapter—and certainly children are important participants in the support
systems of the elderly—the measures we use for transfers of money and ma
terial goods include exchanges with siblings (intragenerational exchanges),
other family members, and non-relatives, such as friends. The countries var
ied somewhat in how they defined the pool of potential providers and recipi
ents. In the Thailand survey questions about material goods are with respect
to children who do not live with the respondent; in other countries the ques
tion refers to all children, coresident or not. In Singapore, the question about
the provision of monetary support is with respect to coresident children only;
in the other three country surveys all children are included.
In examining time transfers, the focus is on children when measuring
the frequency of social contact and visits, and in looking at the degree to
which older persons with grandchildren assist with childcare. Older people
may also require time transfers to assist them with activities of daily living
(ADl.s). such as dressing or bathing, or with instrumental activities of daily
living (lADLs), such as shopping or meal preparation. Older people may also
provide assistance to others with household chores or personal assistance. On
these dimensions the potential pool of providers and recipients encompasses
a wider array of family members and others, including paid providers and
domestic helpers. However, comparable data from the four country surveys
are limited in this regard. Questions about help with ADLs and lADLs were
asked in different sequences, different tasks were listed, and different forms
of evaluation were used. For example, in Taiwan respondents are asked whether
they have difficulty doing any daily activities (e.g., eating or moving about
the house), and if they do, whether there is someone who helps them. In
contrast, interviewers in the Singapore survey determined through observation
and checking with respondents or family members the need for physical
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190 The Well-Being of the Elderly in Asia
assistance with ADLs. The difficulty in "standardizing" across countries the
measure of time transfers limits the scope of our analysis on this dimension of
support.
In general, data on intergenerational transfers identifies exchanges be
tween an elderly person or couple and any other person in a specified class,
and the analysis utilizes the dyads to measure the frequency and nature of the
exchanges in which older persons are engaged. When the data are sufficiently
detailed in terms of the characteristics of those with whom the exchanges
take place and the nature of these exchanges, as is the case with the data in the
Philippines, Taiwan, and Thailand, it is possible to develop more global net
work measures of exchange that take into account the interrelationships across
dyad transfers (Walker, Wasserman, and Wellman, 1993). A focus on the whole
family support network enriches our understanding of intergenerational sup
port by connecting the transfer activities of family members to each other and
enabling analysis of the tradeoffs and strategies that occur within families
(Hermalin, 1999). Indeed, recent anthropological studies suggest that mul
tiple exchanges are often used as part of a family investment strategy (Cicirelli,
1994; Peterson, 1990, 1993). For example, in the Philippines there is evi
dence that older, presumably more independent children contribute resources
to their parents for investment in younger siblings, such as financing their
education or small business ventures (Cicirelli, 1994; Peterson, 1990, 1993).
In the analyses presented here, we focus mainly on dyadic transfers, but re
sults from other research that examines transfer flows within broader kin net
works will be described.
Background
Prior research on intergenerational support and transfers in Asia has tended to
be country or setting specific, often with an emphasis on the relationship
between family support and family size or composition (Frankenberg, Beard
and Saputra, 1999; Knodel et al., 2000; Lee, Parish and Willis, 1994; Peterson,
1993; Rahman, 2000). As multiple data sets on aging have become available,
comparative research on transfers in Asia has pointed to the variability in
family support systems across countries, and the differential pathways the
systems may take in response to ongoing socioeconomic and demographic
change (Andrews et al., 1986; Chen and Jones, 1989; Hermalin, 1995; Martin
and Kinsella, 1994; Mason, 1992; Phillips, 2000). By its very nature,
comparative research also highlights cultural differences that can lead to
distinct family support systems, such as studies on gender differences in transfer
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Intergenerational Support and Transfers 191
behavior across countries, and particularly the importance in some countries
of having sons for support in old age (Ofstedal, Knodel and Chayovan, 1999).
A useful conceptual framework underlying the study of intergenerational
transfers is that support is determined by the needs of the elderly, the avail
ability of potential providers and the ability and willingness of the providers
to meet the perceived needs (see Chapter 4 and Chapter 5; Hennalin, Ofstedal
and Chang, 1996; Soldo and Hill, 1993). Needs are difficult to measure but
assessments of income sufficiency and physical and emotional health can
provide indicators. Chapter 11 on the vulnerable and disadvantaged elderly
addresses measurement issues that bear on the question of need. In the analy
ses below we utilize several measures that speak to needs as well as to the
size of the kin network.
One does not expect a one-to-one correspondence between needs and
the receipt of support. A study using an earlier wave of the Taiwan data found,
for example, that while the likelihood of receiving ADL assistance increased
as the level of functioning decreased (measured as an index of the number of
activities the respondent reported having difficulty doing), about 80 percent
of older adults who experienced difficulty with 3 or more ADLs said they
neither received nor needed assistance (Hermalin, Ofstedal and Chang, 1992).
Moreover, there was a substantial discrepancy between the proportion of older
adults who received help with ADLs (6 percent) and the proportion reporting
a high level of difficulty with ADLs (27 percent).
In short, although intergenerational transfers may be made in response
to actual or perceived need, there will be cases where the elderly have needs
that are not being met. In addition, transfers may be motivated by factors
other than need, such as individual preferences or culturally defined obliga
tions. Preferences may be expressed on a variety of dimensions, such as a
preference for privacy that might lead older adults to live separately from
their children. An older adult might also wish to honor the cultural obliga
tions of the younger generation to support the older generation, leading an
older adult to accept support from children despite the absence of a strong
need for that support.
A growing area of research on intergenerational transfers examines
motivations for transfers, the results of which can help shed light on how the
family support system will respond to public programs targeted to the welfare
of the elderly. Four economic models of private transfer behavior predominate
in the literature (see Chapter 4 for more details), altruism, warm glow,
exchange, and insurance (Lillard and Willis, 1997; Schoeni, 1997; Soldo and
Hill, 1993), and the evidence—primarily from the United States—does not
conclusively support one over another. The altruism model assumes that private
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192 The Well-Being of the Elderly in Asia
transfers are made to those in relative need. The warm glow model assumes
that the people who give money derive personal satisfaction from doing so
regardless of the level of need of the recipient. The exchange model, as its
name implies, assumes that people provide money (or time) in return for
something else. Lastly, the insurance model of private transfers posits that
such transfers are made when recipients experience a drop in financial
resources or are unable to finance a substantial investment (e.g., buying a
home). Testing among competing hypotheses is often difficult because of the
measurement challenges for distinguishing the effects of transfer motivations.
The analyses in this chapter are not structured to test the different hypotheses
about motivations for transfers, but the arguments about motivations are
important given their implications for how private transfers might respond to
public forms of support for the elderly.
The underlying question for many policymakers and social scientists
is how are family systems of support responding to rapid demographic and
economic change? Only longitudinal data can fully address this question. One
major strategy for monitoring transfer systems is to conduct detailed cross-
sectional studies over time to obtain trend data on which dimensions of fam
ily systems change and which remain relatively stable. Panel studies (i.e. fol
lowing the same people over time) are also needed because there are likely to
be several transitions in family support as individuals age through the life
course. Understanding when these individual transitions take place and their
nature is important for developing effective public policies that address the
well-being of the elderly. We present some figures below from a series of
surveys over time to describe changes in family support of the elderly and
research findings based on panel data that highlight support changes over the
individual life course.
Repeated cross-sectional suneys and censuses often allow examina
tion of one important form of intergenerational transfer—coresidence—be
cause it is relatively easy to measure household structure in a consistent man
ner. As Chapter 5 indicates, the majority of older adults studied here coreside
with at least one adult child, ranging from 69 percent in Taiwan to 85 percent
in Singapore, and any decline in coresidence has been modest. The largest
decline among the study countries occurred in Taiwan, where parent-child
coresidence decreased by about 15 percentage points over two decades. De
clines in extended family coresidence have been more extreme in South Ko
rea and Japan, however, where only about half of elderly adults live with their
children (Kono, 1998; Yoon and Cha, 1999).
Longitudinal data on money and other transfer currencies are harder to
find. With caveats about the comparability of data and measures, we can still
make a few observations about family transfer behavior in Asia. The most
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Intergenerational Support and Transfers 193
important point is that there is little evidence of a large decline in older adults'
participation in family exchanges, especially with receiving money support
from family and friends (see table below). Surveys of the aged carried out in
the Philippines, Thailand, Taiwan, Indonesia, and Singapore in the 1980s show
that a large proportion of elderly women and men received money (or material
support) from family at that time (Chen and Jones, 1989: Table 5.7; Knodel,
Chayovan and Siriboon, 1992). Approximately a decade later, the percentage
of older persons receiving money support from family continues to remain
high. In the Philippines in 1984, 60 percent of elderly women and 43 percent
of elderly men received such family support (though the survey was not
nationally representative). By 1996, more than 4 out of 5 elderly Filipinos
received financial transfers from their children or other family members and
friends (Natividad and Cruz, 1997: 29). A similar pattern occurred in Thailand.
Percentage of Adults Age 60 Years and Older Receiving Money
from Family or Friends
Country
(survey year)Philippines(1984)"(1996)Thailand(1986)"
(1995)Singapore
(1986)"
(1995)Taiwan(1989)
(1996)Indonesia(1986)aI.(1993)"Women608859
8997
96867783Percentage
Men43885787868460
6062Total~8858
889171
68cc55
Sources: Derived from Chen and Jones (1989, Table 5.7), Frankenberg, Lilian!
and Willis (2000), Knodel, Chayovan and Siriboon (1992, Table 7), and authors'
tabulations of 1989 Taiwan survey and 1995-1996 Taiwan, Philippines, Thailand
and Singapore surveys.
3 Measured as receiving money or material support from family or friends.
Measured as receiving money from non-coresident children.
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194 The Well-Being of the Elderly in Asia
While interpreting this change is difficult because of the different measures
and samples used in each survey, it seems clear that private money transfers
have not declined and that a very high proportion of elderly Filipinos and
Thais are financially supported to some degree by their families.
In Singapore in 1986, 97 percent of elderly women and 86 percent of
elderly men reported receiving money or material support from family or
friends, with the vast majority of support coming from children or
grandchildren (Chen and Jones, 1989: 59). Though the questions were asked
differently, a similarly high proportion of Singaporean elderly reported
receiving money support from family members in the 1995 survey (Chan,
1997). In Taiwan, money support from family has dipped just slightly over
time, from 71 percent in 1989 to 68 percent in 1996, with most of the decline
attributed to fewer elderly women receiving money from family. While there
appears to be a decline in family support in Indonesia between 1986 and 1993
(Chen and Jones, 1989; Frankenberg, Lillard and Willis, 2000), the
measurement differences qualify any firm interpretation and the majority of
elderly Indonesians still receive monetary support as of the early 1990s. The
ASEAN surveys in Thailand and Indonesia in the mid-1980s also found that
most elderly reported family members as their main source of money or material
support (Chen and Jones, 1989: 58), a finding that still holds for the elderly
one decade later (see Table 8.3 on the economic status of the elderly).
Norms and Attitudes about Family Support
The still relatively high levels of intergenerational support in Asia reflect the
strong norms of filial support characterizing all four Asian countries (Domingo
and Asis, 1995; Lopez, 1991; Mason, 1992; Thornton and Lin, 1994). In Tai
wan and Singapore, responsibility for parental support traditionally has been
placed on a married son (often the oldest), while in the Philippines and Thai
land roles are more gender-neutral. Studies of the Philippines and Thailand
show no consistent gender or birth-order preferences in intergenerational sup
port such as coresidence, school investments, and land and non-land (such as
a house or material goods) transfers (Ofstedal, Knodel and Chayovan, 1999;
Natividad and Cruz, 1997; Quisumbing, 1994).
Focus group data indicate that older persons actively participate in
family decisions in Taiwan and that the larger the family, the more likely this
is the case (Williams, Lin, and Mehta, 1994). In the Philippines, participation
is more directly tied to the role the older person plays in the family exchange
system. Older parents who provide support to their children are more likely to
control household decisions than those who do not provide support. The
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Intergenerational Support and Transfers 195
qualitative data also indicate that Filipino elderly who redistribute money they
receive from children are viewed as being "in charge" of the household
(Williams and Domingo, 1993).
Several questions on attitudes about intergenerational exchange were
included in the country surveys (with the exception of Thailand). In the Phil
ippines, more than four out of every five older adults agreed that parents
should help out their adult children financially, if they were capable of doing
so, and that they are obligated to take care of grandchildren. A similar ques
tion in Taiwan about helping out adult children by caring for grandchildren
also found overwhelming support among older adults.
Concerning flows in the opposite direction, a majority of older adults
in Singapore and Taiwan felt that children should support their older parents.
In Singapore, the question was phrased with respect to a proposed law "to
make it compulsory for children to support their parents" (now officially on
the books as the Maintenance of Parent's Act [see Chapter 3]). More than
three-quarters of Singaporean elderly were in favor of such a law. Among the
20 percent who said they did not favor such a law, the main reasons were that
they did not want to force children to provide support and that they thought
providing support should be up to the individual. Interestingly, among those
who favored such a law, 87 percent said they would not bring their child to
court—the teeth of the law—if indeed the child refused to support the parent.
It appears that while most Singaporeans favor a public mandate to protect
traditional obligations of support, few are willing to have private conflicts
played out in a public sphere.
In Taiwan, 84 percent of older adults agreed with the statement, "When
parents get old, children should give them money for their living expenses,"
and only 7 percent disagreed. However, this sentiment may not mean the elderly
expect full support: 65 percent of Taiwanese older adults agreed that "elderly
people should be economically independent, rather than dependent on their
children" (24 percent disagreed and 11 percent were neutral). In a separate
analysis using 1989-1999 panel data in Taiwan, elderly respondents generally
held positive views on the availability of social support and their views were
relatively stable across the ten-year period (Cornman et al., 2001).
Of course, these norms and attitudes about filial support are facing
challenges. As younger cohorts with greater access to market sources of support
(such as private pensions) and with higher levels of education themselves
become older, they may place a higher value on independence, and family
support may decline in favor of state and market substitutes. For example, in
Taiwan between 1973 and 1985, expectations of future support from children
among reproductive-age women declined (Chang and Ofstedal, 1991). In the
Philippines, the cross-national Value of Children survey of 1975-76 showed
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196 The Well-Being of the Elderly in Asia
that more than 80 percent of married women expected support in old age
from both sons and daughters (Chen and Jones, 1989: 50). In contrast, a 1993
survey of reproductive-aged women found that slightly more than half said
they expected to live with their adult children in old age and only about one-
third expected to receive money or material goods from family (Biddlecom
and Domingo, 1996). Similar changes have occurred in Japan, where the
proportion of middle-aged women who indicated their expectation to be
supported by their children in old age declined from 70 percent in 1950 to
just 27 percent in 1986 (Kendig, 1989: 22). However, the degree to which
expectations translate into actual behavioral outcomes is a still a matter of
debate. For example, a study in Taiwan showed that between 1963 and 1991
norms for obligations to extended kin weakened while social contact with kin
increased (Marsh and Hsu, 1995). In short, although norms and attitudes
favoring kinship transfers both to and from the elderly remain strong in these
Asian countries, there are signs that future older generations will expect to be
less dependent on family members, especially adult children, for support.
Whether these changes in attitudes translate directly into declines in actual
resource transfers is likely to be influenced by future social and economic
developments.
Availability of Children and Social Contact
The availability of children with whom to exchange support is not a con
straint in these four Asian countries as it might be for countries that have
experienced low fertility rates for many decades. Fertility, while quite low
among present-day adults, was much higher for today's older generation (see
Chapter 2). Based on survey data, the family size of elderly adults ranges
from an average of 4.4 living children in Taiwan to 5.9 living children in the
Philippines. The vast majority of older persons in these countries either reside
with or adjacent to a child, or see a child daily (see Table 5.9). Because of
relatively large family sizes and the socioeconomic changes of the past couple
decades, some of the children of today's older generation also live far away
from them. In the Philippines, older people report about two children on aver
age who live outside their province, and in Thailand the figure is 1.5 children.
In Taiwan, older persons report two children on average who live outside
their neighboring village, town, or city. Also, nearly one in five older Filipi
nos has a child living overseas, illustrating the importance of international
labor migration for the Philippines (Rodriguez, 1998). This migration is a
predominantly female phenomenon: 14 percent of elderly Filipinos have at
least one daughter residing abroad and 8 percent have at least one son abroad.
In Taiwan and Singapore this phenomenon is weaker but still impressive:
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Intergenerational Support and Transfers 197
7 percent of older adults in Taiwan and 8 percent in Singapore have at least
one child living abroad.
The majority of older adults in these four Asian countries visit with
their non-coresident children on at least a weekly basis (see Table 6.1). Among
older adults with at least one non-coresident child, over half in the Philip
pines, two-thirds in Taiwan and Singapore, and three-quarters in Thailand
have weekly contact with a child. Interestingly, visits are not "one-way streets"
where children come to see parents, though that is the more common form. In
the Philippines and Thailand, older parents are almost equally likely to make
weekly visits to their children (47 percent in the Philippines and 55 percent in
Thailand said they visit a child at least weekly). A study in Singapore found
that children most often initiate visits, but a non-trivial proportion of older
adults also initiate visits with their children (Chan, 1999: 102). In short, most
older adults are involved in their children's lives either by virtue of sharing
the same household (see Chapter 5 on living arrangements) or by frequently
visiting with children. The nature of this involvement is another issue alto
gether. Are older parents sought out for advice or companionship or are they
serving as free childcarc providers, or perhaps both? Or are children provid
ing a service to their parents through these visits, either by checking to make
sure all is well or by providing more tangible support, such as preparing a
meal? The next few sections address more concrete types of transfers be
tween older adults and others.
Current Flows of Intergenerational Support
Table 6.2 shows the distribution of exchanges between older adults and oth
ers of money (first panel) and material goods (second panel). In Thailand and
the Philippines, almost all older adults—90 percent or more—reported that
they either receive or provide money or material goods in some form. Nearly
half or more of older adults in these countries provide and receive money or
material goods. Thus, many older persons in the Philippines and Thailand are
not so much dependent on family support as they are active participants in
family exchange networks, both giving and receiving resources. This pattern
is very distinct from Taiwan where less than 6 percent of older adults give and
receive money and less than 1 percent give and receive material goods.
Instead, older Taiwanese predominately receive money from others (62
percent). Overall exchange patterns in Singapore are qualified somewhat by
the different data measurement used; the survey asked solely about monetary
exchanges with coresident children. Even with this restriction, however, 25
percent of older adults in Singapore reported both providing and receiving
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198 The Well-Being of the Elderly in Asia
Table 6.1. Percent Distribution of Weekly Visits between Parents and Children
among Elderly Adults with at Least One Non-Coresident Child
Note: Totals do not all sum to 100.0 due to rounding error.
Parent has at least
weekly visit with a childYesNoOf those who visit at
least weeklyChild visits parentYesNoParent visits childYesNoPhilippines
(1996)584254464753Thailand
(1995)762574265545Taiwan
(1996)6634-----Singapore
(1995)6734------
money; and only 7 percent reported not being involved in any money ex
changes with children.
Elderly Who Receive Support
We now focus on each direction of resource transfers and examine some of
the important sociodemographic characteristics associated with receiving and
providing support (see Table 6.3). In general, the vast majority of older adults
in all four countries receive money support (ranging from 68 percent in Tai
wan to 91 percent in Singapore), similarly high percentages of older adults
also receive material assistance, the exception being Taiwan (15 percent).
The demographic characteristics in the gerontological literature usually
associated with lower levels of well-being—being older, female, less educated
or unmarried—are also associated here with a higher likelihood of receiving
support. However, no characteristic is significantly associated with receiving
money and material goods in all four countries. Receiving both types of support
from others is more common at older ages and among women in Taiwan and
Singapore. The elderly in rural areas more often report receiving money and
material support: the differentials are significant for money transfers in each
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Intergenerational Support and Transfers 199
Table 62. Percent Distribution of Money and Material Transfers Involving
Older Adults
Nate: Totals do not all sum to 100.0 due to rounding error.
See Notes for Table 6.2 at the end of this chapter.
Money TransfersReceived and providedReceived, did not provideProvided, did not receiveNeither received nor providedTotalTotal receivingTotal providingMaterial TransfersReceived and providedReceived, did not provideProvided, did not receiveNeither received nor providedTotalTotal receivingTotal providingPhilippines59.028.98.23.9100.087.967.269.421.26.72.7100.090.676.1Thailand49.338.85.46.5100.088.154.744.842.72.310.2100.087.547.1Taiwan5.662.24.028.2100.067.89.60.813.73.781.9100.114.54.5Singapore25.465.13.06.5100.090.528.4—~————_
country and for material support only in Thailand. Education is strongly
associated with the receipt of assistance but the patterns differ across countries.
In the Philippines and Thailand those with primary level education are more
likely to receive support than either those with no education or those with a
secondary or higher education. In Taiwan and Singapore, by contrast, the
pattern is linear, with those in the lowest educational category most often
receiving money or material goods. Overall, older adults who live with children
are much more likely to receive financial or material assistance. Differences
by marital status tend to be small; those that are statistically significant tend
to show a higher level of support for the unmarried, except for material goods
transfers in Thailand.
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202 The Well-Being of the Elderly in Asia
Who primarily provides support to older persons? Table 6.4 shows
that children are the most common sources of money and material support to
the elderly, with substantial gender differences by country. In the Philippines,
Thailand, and Singapore at least 94 percent of older persons who receive
money receive it from children (from about 4 children on average). The trans
fers in the Philippines and Thailand are slightly more likely to come from a
daughter than a son. In Taiwan the elderly are more likely to receive financial
support from sons (the Singapore data do not allow for separate determina
tions by gender). Although children are the providers of money for a simi
larly high fraction of older persons in Taiwan, fewer children tend to be in
volved in the support networks (2 children on average). Similar patterns are
observed for material assistance, except that both Singapore and Taiwan have
far fewer children involved in providing such support compared to the Phil
ippines and Thailand. Also, more daughters than sons tend to be involved in
providing material assistance in Taiwan (a reversal of the pattern for finan
cial support).
The involvement of other family members and friends in the support
networks of older persons is relatively small in Taiwan and Singapore. Eight
percent or less of the elderly in these countries receive money from people
other than children and 18 percent or less rely on others for material goods.
In Thailand, 12 percent identify people other than children for money trans
fers and 41 percent receive material goods from others, mainly grandchildren
(29 percent versus 9 percent who receive from siblings and 3 percent who
receive from other kin or friends). The Philippines stands out among the four
countries for the breadth of the support network. More than one-third of older
Filipinos receiving money identify people other than their children (20 per
cent from grandchildren, 16 percent from siblings, and 19 percent from other
family members and friends), and more than half receiving material assis
tance obtain some from people other than their children.
Thus, if one were to focus only on parent-child transfers, all four
countries appear similar in the importance of children as providers. More
children on average are involved in providing money support in the Philippines,
Thailand, and Singapore than in Taiwan, however, and sons tend to be the
primary providers of monetary support in Taiwan, whereas daughters tend to
be primary providers in the Philippines and Thailand. More children on average
are also involved in providing material support in the Philippines and Thailand
than in Taiwan and Singapore. The gender patterns in the Philippines and
Thailand still hold for material assistance, and daughters become more involved
on average than sons in Taiwan.
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204 The Well-Being of the Elderly in Asia
Gender differences are also reflected in who the elderly respondent
reports as being the most important provider of money or material support. In
results not presented here, slightly more Filipinos said a daughter was the
most important provider of money and material goods, and slightly more Tai
wanese said a daughter was the most important provider of material goods.
However, an overwhelmingly proportion (83 percent) of Taiwanese elderly
named a son as the most important provider of money support. Although large
proportions of all respondents report receiving support from others, it is im
portant to ascertain to what degree the money and material goods they receive
are adequate for their needs or expectations, and to what degree they rely on
these transfers as sources of income and consumption. Chapter 8 on eco
nomic well-being addresses these and other related issues.
The focus thus far has been on money and material goods. Assistance
with activities of daily living (ADLs), such as eating, dressing, or going to the
toilet, and instrumental activities of daily living (lADLs), such as shopping,
preparing meals, or doing light housework, is also an important form of sup
port. This type of assistance is often referred to as a transfer of time or ser
vice (i.e., informal care). Those who assist with ADLs and lADLs usually live
with or near the older person since, unlike money or material goods, one
cannot "send" this type of support. It is difficult to draw interpretations about
country and subgroup differences in ADL and IADL support with these data,
however, because related questions were asked quite differently among the
four surveys. Overall, fewer than one in ten older persons report receiving
help with an ADL: 3 percent in Thailand, 4 percent in Singapore, 6 percent in
Taiwan, and 8 percent in the Philippines. Levels of help received with lADLs
are much higher, ranging from 17 percent in Thailand, 18 percent in Singapore,
and 23 percent in the Philippines to 33 percent in Taiwan. As with money and
material support, children are reported as the most common or important non-
spousal providers of ADL and IADL support in the Philippines, Taiwan, and
Singapore (the Thailand survey did not distinguish between children and other
household members among those who provided ADL assistance). A separate
study analyzing 1989 survey data from Taiwan found that older adults often
receive a combination of types of support provided by more than one person
(Hermalin, Ofstedal and Chang, 1996: 428). For example, 49 percent of older
adults in Taiwan reported receiving both financial and IADL assistance, but
only 9 percent of these indicated that a single person provided both types of
support. Although the data on ADL and IADL support are limited here, Chap
ter 9 contains more discussion of the prevalence of functional limitations among
the elderly and how these limitations are related to their sociodemographic
characteristics.
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Intergenerational Support and Transfers 205
Elderly Who Provide Support
Although the literature usually focuses on support given to older adults, an
extensive set of questions was also asked in these surveys about the assis
tance that older persons provide to others. Results from Table 6.5 indicate
that 67 and 55 percent of older adults provide money to others in the Philip
pines and Thailand, respectively, and 76 and 47 percent of older adults in the
Philippines and Thailand provide material goods (such as food and clothing).
In Singapore, 28 percent of older persons provide money to others, and in
Taiwan, about 10 percent provide money to others (and only 5 percent pro
vide material goods). Across all four countries, providing support to others is
more common among those at younger ages, among men, the married, the
highly educated and older adults who live with children (especially unmar
ried children). These subgroup differences reveal a sort of mirror image to
those presented earlier for receiving support, and the effects are more consis
tent across countries. Women and those at older ages and lower education
levels are more likely to be on the receiving end of support and men and those
at younger ages and higher education levels are more likely to be on the pro
viding end of support. The same type of pattern is not evident, though, by
type of living arrangements: those living with children are more likely to be
engaged in both receiving and providing support.
The relatively strong link between older parents and their children with
respect to receiving support is weaker when it comes to older persons provid
ing support. Table 6.6 shows that of older persons providing money, less than
two-thirds give to children (65,61, and 52 percent, respectively, in the Philip
pines, Thailand, and Taiwan) compared to the overwhelming majority of older
persons who receive money or material goods from children (Table 6.4).
Among the elderly who provide money to children, fewer children on aver
age receive money from their older parents (e.g., 1.99 children in the Philip
pines) than the average number of children who provide money to their older
parents (e.g., 3.92 children in the Philippines, Table 6.4). A higher number of
children on average receive money or material goods from older parents in
the Philippines and Thailand than in Taiwan, and more children on average
receive material support from their parents in the Philippines and Thailand
than money support. In short, the network of children involved in family sup
port is larger for material goods transfers than money transfers, and network
size is smaller with respect to receiving support from elderly parents than
providing support to elderly parents. Similar gender patterns exist as with
receiving support: sons and daughters are about equally likely to get money
from parents in the Philippines and Thailand, but sons are more likely than
daughters to get money from parents in Taiwan.
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Intergenerational Support and Transfers 209
In general, the types of people who are provided some support by the
elderly are more diverse than the types of people from whom the elderly re
ceive support. The elderly in the Philippines and Taiwan are more likely to
give material support to relatives or friends other than children than to chil
dren. The elderly in Thailand and Taiwan are more likely to give financial
support to people other than their children than is the proportion of older
adults who receive financial support from that source, as shown in Table 6.4.
One of the most common forms of support provided by older persons
is giving time, especially in caring for grandchildren. Table 6.7 shows that 38
percent of all older adults in the Philippines and 23 percent in Taiwan say
they care for grandchildren. In Thailand, 32 percent of the elderly say they
provide childcare for the grandchildren who live with them (the survey ques
tion was about care for coresident grandchildren less than 10 years of age). In
Singapore, the survey questions asked about care for either coresident grand
children or non-coresident grandchildren who visited with the adult children.
Seventy percent of Singaporeans who lived with grandchildren said they pro
vided care for them, and 57 percent who had adult children visit said they
cared for grandchildren during those visits. Although survey questions were
phrased differently in each country, the evidence suggests that a sizeable mi
nority of older adults are providing assistance to their children and grandchil
dren via child care. When the performance of household chores such as cook
ing, shopping, and doing laundry is counted, an even higher proportion are
providing indirect time support to children and grandchildren (see Hermalin,
Roan and Perez, 1998). Data from earlier surveys in the mid-1980s in Fiji,
Table 6.7. Percent Distribution (of those with grandchildren) Providing
Child Care for Grandchildren
Cared for any grand
childrenCared for any coresident
grandchildrenDid not provide childcare
for grandchildrenPhilippines38-62Thailand-3268Taiwan23--77Singapore--7030
Note: Thailand and Singapore measures of childcare are for grandchildren who lived with
the elderly respondent (with the further restriction in Thailand to grandchildren under 10
years of age). Childcare measures in the Philippines and Taiwan surveys are with respect to
all grandchildren, regardless of where they live.
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210 The Well-Being of the Elderly in Asia
South Korea, Malaysia, and the Philippines showed that over half (between
54 and 71 percent) of older adults said they helped care for their grandchil
dren (Andrews et al., 1986: 67). While not directly comparable to the figures
presented above, 1992-1994 survey data from the United States indicate that
60 percent of adults with grandchildren provided some care for their grand
children (i.e., caring for grandchildren at least 1 hour in an average week or
have had a grandchild stay overnight at least once without his/her parents in
the past year) (Fuller-Thomson and Minkler, 2001).
Providing support to others has costs, especially because older persons
are more likely to be in poorer health and a more constrained economic situation
than their working-age counterparts. In the Philippines and Taiwan, questions
were posed about the extent and types of burden experienced in providing for
others. Of those providing support in the Philippines, 35 percent said they
experienced moderate to considerable financial difficulty, 25 percent
experienced moderate to considerable emotional difficulty, and 19 percent
experienced moderate to considerable time difficulty. In Taiwan, 24 percent
of older adults said they had encountered difficulties or worries in their efforts
to provide assistance to others. However, among those who experienced
difficulties, only 11 percent said they were bothered very much by these
difficulties, and most said these difficulties were financial (72 percent) and
fewer identified the difficulties as being time related (16 percent) or emotional
(32 percent). In general, these findings on the burden of providing support
parallel the overall patterns of providing support by the elderly. In the
Philippines, far more older adults give support to others, mainly family
members and especially adult children, than in Taiwan, where very few give
to others. For at least one in three elderly Filipinos who provide assistance,
these transfers are made with difficulty. In Taiwan, although about the same
proportion of elderly said they had experienced difficulties, far fewer said
they were bothered or burdened providing that support.
Transfer Amounts
Survey data from the Philippines, Thailand, and Taiwan on the amount of
money received and provided in the past year reveal interesting country dif
ferences (see Table 6.8). Although the majority of older persons in each coun
try reported receiving money in the prior year from family or friends, almost
half of older Filipinos said they received small amounts of money (less than
$40 (US) total) compared to only 19 and 29 percent of older Thais and Tai
wanese, respectively. In terms of providing money support, almost all older
Filipinos reported giving relatively large amounts of money ($40 (US) or more)
to others, followed by older Thais (74 percent) and Taiwanese (54 percent).
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212 The Well-Being of the Elderly in Asia
These data suggest that the money flows between older persons and
their support networks are mainly cash out-flows for older Filipinos, cash-
intensive flows for older Thais (relatively large money amounts both to and
from others that suggest a redistributive pattern), and cash in-flows for older
Taiwanese. These descriptive patterns may be limited by a tendency of people
to overreport what they do for others and underreport what they receive from
others (Roan, Hermalin and Ofstedal, 1992), and by the limited categories
available across countries to capture the magnitude of transfers.
As noted in the footnote to Table 6.8, more detailed information on
the amount of the exchanges was obtained in Taiwan. An analysis of this
information, not shown here, indicates that significant proportions of older
Taiwanese are involved in the lower and upper ends of the distribution—i.e.,
the giving and receiving of both small and large amounts of money is quite
common. Taiwan also asked their older respondents whether they had ever
spent more than $100,000 NT ($3,777 (US)) on the education or living ex
penses of their children, and 22 percent reported affirmatively.
Multiple Transfers
The focus thus far has been on overall levels of family support and on the
common recipients and providers of support. Analyses are based on transfers
that occur in dyads, between the older adult and another person, and the data
are cumulated to describe general transfer patterns that involve the elderly. A
different focus that sheds some light on the family network is to examine
transfer activity that involves more than two people. For example, earlier
figures in Table 6.2 showed sharp country differences in the degree to which
older persons were involved in two-way transfers of support (both giving and
receiving), ranging from the majority of older Filipinos engaged in this pattern
to a small minority of Taiwanese doing so. A prior study of parent-child transfers
in the Philippines and Taiwan found that most of these two-way transfers are
parts of multiple transfers; that is, transfers (including all types of currencies)
involving the elderly parent and two or more children (Agree, Biddlecom,
Chang and Perez, 1998). Among the elderly who are engaged in multiple
transfers—providing and receiving any type of resource with more than one
person (and not restricted to parent-child transfers)—those in Taiwan transfer
mostly between vertical generations, with almost all multiple transfers
following the pattern of adult children giving to the older parent who in turn
gives to grandchildren (Agree, Biddlecom and Valente, 1999). For example,
an adult child may give her elderly parent some material goods (food or
clothing) and the elderly parent gives a grandchild some money (perhaps for
educational purposes). In contrast, multiple transfers in the Philippines follow
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Intergenerational Support and Transfers 213
a more broadly distributed exchange pattern, with greater involvement of
"lateral" relatives, most importantly siblings. The most common pathway in
the Philippines for multiple transfers is from adult children to their parent and
then to the parents' siblings (34 percent of all multiple transfers) and secondarily
from adult children through their parents to grandchildren (27 percent of all
multiple transfers).
Multivariate Analysis of Transfer Patterns
Tables 6.9 and 6.10 show multinomial logistic models of money and material
transfer patterns for each country. The outcome variable has three categories:
giving and receiving support, only receiving support, and not receiving sup
port at all. The latter group includes older adults who are not involved in any
transfers at all and those who are only giving support, a small percentage in
each country (see Table 6.2). The reference category is only receiving sup
port, a common pattern in all four countries (see Table 6.2).
We estimate two sets of effects of the independent variables. The first
set of effects is the likelihood of making two-way transfers (giving and re
ceiving) compared to receiving only (the first column for each country), and
the second set of effects is the likelihood of not receiving support compared
to receiving only (the second column). In each case, the estimates are net of
the other outcome category.
For ease of interpretation, we present odds ratios rather than regres
sion coefficients. Odds ratios are the exponentiated values of the regression
coefficients. In the case of a categorical variable, the odds ratio indicates the
proportional change in the odds of making one type of transfer (e.g., both
giving and receiving money) versus only receiving money for someone in the
specified category relative to someone in the reference category. For an inter
val variable, the exponentiated value is the proportional change in the odds
ratio for a unit increase in the independent variable.
With respect to money transfers (see Table 6.9), the few significant
and consistent effects across all countries are that older adults with a secondary
level of education or higher and those who are employed are much more likely
to be making two-way transfers of money versus receiving money only (net of
not receiving). For example, older adults with secondary schooling or higher
are about 1.5 times more likely in all four countries to both give and receive
monetary support than they are to receive it only (ranging from 1.4 times
more likely in Taiwan and the Philippines, to 1.8 times more likely in
Singapore). Older adults who are currently working are 1.3 times more likely
in the Philippines to both give and receive resources than receive only, and
those living in Singapore are 3.1 times more likely to be making such two-
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216 The Well-Being of the Elderly in Asia
way transfers of money (Thailand and Taiwan fall in the middle). The elderly
with these characteristics probably have greater access to cash income and
other resources and are in a position to give money to kin. However, this is
not simply a matter of being able to provide money as the positive effect is for
both giving and receiving monetary support versus receiving only. Higher
education and current employment also make one more likely not to receive
money at all compared to receiving only.
Other notable effects are the negative association between age and
the likelihood of making two-way money transfers in the Philippines and Thai
land; and the negative relationship between age and not receiving money in
the Philippines, Thailand, and Singapore. The effect of age appears to be small,
but the unit change is in single years. Being female and unmarried (versus a
married male) makes one much more likely to be on the receiving end only of
money transfers—the exception is the Philippines, where gender and marital
status differences among the elderly do not matter much at all for money
transfers. Significant urban-rural differences disappear once other effects are
controlled for in the model (the exception being Taiwan). Interestingly, living
arrangement effects on transfer behavior are inconsistent and less strong across
countries, suggesting that coresidence with a child is not a singularly potent
explanation for the monetary exchanges that older adults report. It is worth
noting though that in Taiwan coresidence with an unmarried child increases
the odds that an older parent engages in giving and receiving money transfers
versus receiving only.
The last set of variables in Table 6.9 represents availability of people
with whom to exchange resources. When the older person has one or more
living children (an indicator of having any children available), she or he has
about half the odds in the Philippines and Thailand of simultaneously providing
and receiving financial support versus receiving only. In Taiwan, older adults
with any living children have .27 times the odds of providing and receiving
money compared to receiving only. There is little effect of the availability of
children on the likelihood of not receiving financial support versus receiving
only in any of the countries.
Of course, the availability of children may affect transfer behavior
depending on the gender of the children available. The next two variables,
number of living sons and number of living daughters, are included in the
model to identify gender-specific effects of intergenerational exchange.
Interestingly, the more sons or daughters an older parent has, the less likely
they are in Thailand, Taiwan and Singapore to both provide and receive money
compared to receiving only, and the magnitude of the effects is similar by
gender of the child. In the Philippines there is no statistically significant effect
of the number of sons or daughters on two-way transfers of money. In sum,
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Intergenerational Support and Transfers 217
the availability of children, regardless of gender, makes an older adult more
likely to receive money support only versus being more actively involved in
financial exchanges.
In contrast, the availability of children, measured as either having any
living children at all or as the number of sons or daughters an older person
has, makes little difference in the likelihood that an older adult does not re
ceive money support (versus receiving only). The exception is the Philip
pines, where the more daughters one has, the higher the odds of not receiving
money transfers at all compared to receiving only. It could be that given all
the other characteristics controlled for in the model, this effect represents
cases where the older parent is providing money only (a small category that is
combined with no money transfers at all into "not receiving"). However, the
evidence across all four countries suggests that having fewer children avail
able (sons or daughters) does not make one less likely to receive monetary
support.
The last variable included in the model is the number of other people
in the older person's network. The number of others in the network is defined
differently for each country given data limitations (see the note at the bottom
of Table 6.9), but in all four countries the variable is closely identified with
household size (minus any coresident children). A small but interesting result
is that the larger the number of other people (apart from children) in the elderly
person's network, the more likely he or she is not to receive money transfers
versus only receiving money, a finding that holds for Thailand, Taiwan, and
Singapore. We would expect to see the opposite effect of network size on
transfers given that a larger number of people with whom to exchange resources
increases the opportunities for such transfers. Since the size of network as
defined in each country will be greatly influenced by the number of
grandchildren, this small contrary effect may represent in part cases where
the older person is providing money to grandchildren (which as noted above
is combined with those "not receiving") and households where the large
number of younger children precludes cash transfers by the children's parents
to their own older parents.
Table 6.10 shows results from the multinomial logistic model of mate
rial transfers (Singapore is omitted because questions about providing mate
rial goods to others were not asked). In general, the effects of the sociodemo-
graphic variables on transfers of material goods do not differ significantly
from those found for money transfers. Higher education and employment have
the same positive effects on giving and receiving material goods, except that
the effects are not as consistent across countries as they are for money trans
fers. Age continues to have a negative influence on the likelihood of making
two-way material transfers or not receiving material support at all, relative to
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Table 6.10. Odds-Ratios for the Effects of Soc iodemographic, Health, and Family Structure
Factors on Directional Flow of Material Transfers"
CovariatesAgeGender/marital statusMarried maleMarried femaleUnmarried maleUnmarried femaleRural (versus urban)EducationNo formal educationPrimarySecondary or higherEmployed (versus not)Self-rated healthGoodFairPoorLiving arrangementAlone/Spouse onlyw/Married childw/Unmarried childOtherHas 1+ living childNumber of living sonsNumber of livingdaughtersNumber of others innetworkModel chi-squarePhilippines
R and P Not R0.95* 0.94***_0.56** 0.960.66 0.770.57*** 0.77*1.00 1.10-.1.18 1.181.73** 1.64***1.96*** 1.72***0.80 1.03..0.76 0.76**1.23 0.80-1.38 0.981.37 1.150.71 1.65*1.02 1.031.02 1.10*0.98 0.991655.81Thailand
R and P Not R0.95*** 0.%***_1.12 1.23***0.95 0.920.98 0.13*0.85* 1.01-0.90 1.19***1.14 1.60***1.11 1.35***1.15* 1.02_0.86 1.22"*0.58*** 0.87**_0.91 0.940.45*** 1.010.46*** 1.30*0.94 1.05*0.75*** 1.040.94"* 1.07***7530.00Taiwan
R and P Not R0.96*** 0.97_ _0.97 1.130.96 #0.89 0.641.03 1.12„1.25*** 0.831.37*** 1.631.08 0.620.95 0.94-0.98 #0.90 0.53..1.06 0.700.88 0.670.89 #0.94 0.790.97 0.990.99 1.06*2461.76
Dependent variable has thrte categories: rtceiving only (omitted), both rtceiving and providing (R and P) and not
receiving, rtgardless of whether providing money (Not R).
Number of others in network is measurtd as the sum of household members (not including childrtn), grandchildren
and living siblings (Philippines); the sum of spouse, grandchildrtn, siblings, nieces, nephews, and other rtlatives
whom the rtspondent sees rtgularly (Thailand); and the sum of household members (not including childrtn),
grandchildrtn, siblings, and other rtlatives and neighbors with whom R has rtgular contact (Taiwan).
*p<.05 **p<.01 ***p<.001; # pa_meter is not estimable
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Intergenerational Support and Transfers 219
only receiving. The interactive effect of gender and marital status is less con
sistent across countries for the exchange of material goods compared to money.
Filipinas. whether married or unmarried, are less likely than their married
male counterparts to be involved in two-way transfers of material goods rela
tive to receiving only. This was not the case for money transfers in the Philip
pines. In contrast, while gender and marital status affected whether older per
sons in Thailand and Taiwan engaged in two-way transfers of money, these
characteristics have no effect on two-way transfers of material goods. The
rather weak effects of living arrangements apply also to the exchange of ma
terial goods. The exception continues to be Thailand, where older adults
who live alone or with a spouse only are much more likely to be on the receiv
ing end of material support than either giving and receiving or not receiving
at all (the same occurred for the exchange of monetary support).
The availability of any living children and the number of living daugh
ters continue to be negatively associated with the propensity to engage in
two-way transfers of resources in Thailand. No such effects are evident for
either the Philippines or Taiwan. For the Philippines and Thailand, having
any living children and having more sons (Thailand) or daughters (Philip
pines) is associated with a higher likelihood of not receiving material support
at all compared to receiving only. Again, this effect may indicate a pattern of
the older adult being more likely to provide material support only (rather than
not being engaged in any material transfers at all). As we did with money
transfers, we encounter the small but interesting finding that in Thailand and
Taiwan a larger "other" kin network makes an elderly person more likely not
to receive material goods at all than to receive them only, and we interpret
this finding in a similar manner.
Conclusions
With countries and families facing changing demographic and social condi
tions, the nature of intergenerational support will certainly be transformed.
The support network for today's elderly in Asia is broad and centered on the
home, as indicated by both the large numbers of living children and the high
levels of coresidence. Yet all but a few Asian countries are expected to have
fertility rates below replacement level by 2015 (Lee and Mason, 2000), and
this is already the case in Singapore, Taiwan and Thailand (see Table 2.4).
Fertility below replacement ensures that future cohorts of elderly parents will
have smaller kin networks upon which to depend. Smaller and perhaps more
dispersed support networks may lead to a decline in intensive transfers of
space or time, such as coresidence or help with activities of daily living, but
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220 The Well-Being of the Elderly in Asia
transfers of other resources, such as money (which has no geographic limita
tions) or social contact (via visits or telephone calls) may persist at a high
level. The results from the multivariate analyses of transfer patterns certainly
indicate that among the older generation today, childlessness or having a small
number of sons or daughters is not associated with a greater likelihood of not
receiving money or material support at all.
At the same time, declining fertility and mortality rates mean there will
be fewer children for older parents to support but perhaps a higher likelihood
that their own elderly parents will still be alive and need support. The empiri
cal evidence presented earlier suggests that already older adults provide re
sources to a broader array of kin (e.g., parents, grandchildren, siblings) than
the network from which they themselves receive support (i.e., primarily adult
children). For example, 15 percent of older Thais providing financial support
to others are giving money to their own elderly parents. With rises in life
expectancy, this situation is likely to become more common.
The active role that the elderly play in providing support is particularly
important in Asia as industry shifts increasingly from family farming to wage
labor, and as the labor force participation of women rises. In Japan, for ex
ample, Morgan and Hirosima (1983) found that older parents were more likely
to provide childcare and housework if their daughters or daughters-in-law
were working outside the home. Current levels of childcare provided by grand
parents to coresident and non-coresident grandchildren are relatively high in
the four countries examined in this chapter. These levels may rise higher in
conjunction with increased demand (as female labor force participation rates
continue to rise) and an increased supply of elderly caregivers (as life expect
ancy increases and if age at retirement decreases).
Rising levels of education are also likely to alter the qualitative and
behavioral aspects of family transfers among older persons. Today's older
generation is relatively poorly educated and the gender differences in educa
tional attainment are quite large (Christenson and Hermalin, 1991). In con
trast, those who turn age 60 in the year 2020 will predominantly be literate
and the gender gap in educational attainment will have narrowed consider
ably. Analyses in this chapter indicated that secondary and higher levels of
education are positively associated with both giving and receiving money or
material goods. In fact, education had one of the few consistently strong ef
fects on transfers across all four countries. These findings suggest that the
family support systems of future elderly will be much more varied in terms of
patterns of support flows than the current ones tend to be. Rather than an
older generation being primarily on the receiving end in the family support
system, future cohorts will likely be both independent and active members of
family support systems. The current attitudes of middle-aged women in Asia
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Intergenerational Support and Transfers 221
about support when they are old indicate that this independent and active role
is already in the minds of many.
Limitations of the analyses in this chapter—and challenges for future
research—are that the magnitude and frequency of intergenerational trans
fers and the life course patterns in making and receiving transfers are still
relatively unknown. Resource flows analyzed in this chapter were with re
spect to the existence of transfers in the prior six months to one year from the
survey interview. Little is known about the frequency and magnitude of the
transfers occurring within this time frame. Although the simple dichotomies
used in the analyses (e.g., money was or was not received in the past year
from children or the amount received was "small" or "large") provide a sense
of the "bottom-line" regarding family transfers, the nature and nuances of
these transfers remain unclear. Future research needs to address much more
detail about these transfers, as suggested by the discussion in Chapter 4.
The analyses presented provide a snapshot of how intergenerational
transfers vary by individual and family characteristics and across four culturally
and economically distinct Asian countries. The longitudinal picture of how
and why transfers change across the life course is the next needed step in
research. Longitudinal data allow for more confident inferences about the
causal connections between individual and family characteristics and transfer
outcomes, as well as the effects of family support on dimensions of elderly
well-being, such as health status. Longitudinal data also enable one to observe
transitions over the life course in family support activity. For example, Chapter
8 (see Table 8.13) describes a large switch in the major income sources of the
elderly in Taiwan over time. Of the elderly receiving primary financial support
from children in 1989, only 54 percent continued to receive their primary
support from children in 1996 and nearly one-third had shifted to a pension or
retirement fund as their major source of income.
This example of change over the life course also raises the issue of
tradeoffs between private and public transfers. Longitudinal data allow for
both time sequencing of transfer behavior and testing of the degree to which
(and direction that) private family transfers respond to public transfers. Dur
ing the same period in Taiwan described above, two subsidy programs were
initiated to provide income to older people outside current pension and social
welfare programs. A recent study using the Taiwan panel data found that the
farmers' pension program, a monthly pension given to farmers age 65 years
and older who were not already receiving a pension, had a significant and
positive effect on the likelihood that older persons switched from private trans
fers (mainly income from children) as their main source of income in 1993 to
pension income in 1996 (Biddlecom et al., 2001). In contrast, the other pen
sion program initiated in the mid-1990s in selected counties and cities had
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222 The Well-Being of the Elderly in Asia
little effect on the move away from private transfer income as a main source
of support. These issues are important to examine given the current discus
sions in many Asian countries of new social security program development,
the repercussions that public support programs may have on existing patterns
of family support, and the resulting effectiveness of those public support pro
grams to improve elderly economic well-being (see Chapter 3 and Mason,
Lee and Russo, 2001).
The future of family support is not likely to be the simple "decline" or
"erosion" story often alluded to, wherein the dependent elderly become the
destitute elderly. The current snapshot of intergenerational transfers shows
that older adults in Asia are also family support providers—in the Philippines
and Thailand this was a substantial share of transfer activity—belying their
characterization as dependents. The small declines over time in confidence
with children, documented in Chapter 5, are paired with substantial levels of
social contact (initiated almost equally between parents and children) and
monetary and material goods transfers. The anticipated increases in the num
ber and percentage of elderly in Asia are occurring along with socioeconomic
and allitudinal changes that mean future cohorts of elderly will be belter edu
cated, have more experience working for pay outside the home, and have
fewer expectations of depending on children for support than the current co
hort. Finally, the paucity of evidence in Asia about how private transfers re
spond to public support leaves room for much speculation about how the
implementation and design of new and amended social security systems and
health care plans will reshape family transfer networks. In short,
intergenerational transfer systems are likely to respond to the continued de
mographic and socioeconomic changes taking place in Asia but there is noth
ing to suggest that the emerging patterns will not be responsive to the family
needs that accompany these changes.
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226 The Well-Being of the Elderly in Asia
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Intergenerational Support and Transfers 227
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NOTES FOR TABLES
Table 62
Variables were constructed from the questions below to form indicators of the
respondent receiving any money from other people, providing any money to other
people, receiving any material goods from other people, and providing material
goods to other people. All constructed indicators had the following values: o - no
and 1 = yes. The questions used to ascertain money and material goods transfers
for each country are listed below. When there were several questions that differed
only by the person or people referred to, we condensed the questions into one
question below and used "[PERSON(S)]" to indicate that the question refers to
specific people or types of people (e.g., father/mother or brother/sister).
Philippines:
Receive money: Outside of small gifts, did [PERSON(S)] give money either
regularly or from time to time within the past year? (Y) yes, (N) no.
Provide money: Outside of small gifts, did you give money to [PERSON(S)]
either regularly or from time to time during the past year? (Y) yes, (N) no.
Receive material goods: Outside of small gifts, did [PERSON(S)] give any
food, clothing, any personal belonging either regularly or from time to time
within the past year? (Y) yes, (N) no.
Provide material goods: Outside of small gifts, did you give any food,
clothing, or any personal belonging to [PERSON(S)] either regularly or
from time to time within the past year? (Y) yes, (N) no.
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228 The Well-Being of the Elderly in Asia
Thailand:
Receive money: Within this past year did [PERSON(S)] give you a total of
1,000 Baht or more? (1) yes, (2) no.
Provide money: Within this past year did you give a total of 1,000 Baht or
more to [PERSON(S)]? (1) yes, (2) no.
Receive material goods: Within this past year did [PERSON(S)] give you
food, clothes or personal belongings? (1) yes, (2) no. This question was
asked only about material goods from non-coresident children and relatives.
Provide material goods: Within this past year did you give any food,
clothing or personal belongings to [PERSON(S)]? (1) yes, (2) no. This
question was asked only about material goods provided to non-coresident
children and relatives.
Taiwan:
Receive money: Did any of your children or relatives give you or your
spouse money within the past year? (1) yes, (2) no.
Provide money: Have you or your spouse spent more than NTS 100,000 on
your children's educational expenses or their living expenses? (1) yes, (2)
no.
Have you or your spouse given money to your children or anyone else for
expenses other than educational expenses? (1) yes, (2) no.
Receive material goods: Does anyone send you personal belongings such as
food, clothes, or other material supports to accommodate the needs of your
daily life? [Presents for holidays, birthdays, or socialization are not
included] (1) yes, (0) no.
Provide material goods: Do you regularly send personal belongings such as
food, clothing, and material support to your family, relatives, or others to
accommodate their needs for daily life? [Presents for holidays, birthdays, or
socialization are not included] (1) yes, (0) no.
Singapore:
Receive money: Number of children providing cash allowance in the last 6
months (on a regular basis): number.
Cash contribution from related persons (grandchildren, brothers/sisters,
other relatives): (1) yes, (2) no, (3) not applicable.
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Intergenerational Support and Transfers 229
Provide money: In the household, are you involved in any of the following?
Provide financial assistance to children (1) yes, (2) no.
Receive material goods: Number of children providing accommodation
(including food and lodging, payment of rent, utilities, conservancy charges)
on a regular basis in the last 6 months: number.
Number of children providing rations (e.g., food, household necessities) on
a regular basis in the last 6 months: number.
Maintenance in kind (accommodation/rations) received from other related
persons/non-relatives (grandchildren, brothers/sisters, others) on a regular
basis in the last 6 months: (1) yes, (2) no, (3) not applicable.
Provide material goods: No questions available in the survey on this type
and direction of transfer.
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Chapter 7
WORK, RETIREMENT, AND LEISURE
Albert 1. Hermalin, Angelique Chan, Ann Biddlecom,
and Mary Beth Ofstedal
We begin our analysis of the dimensions of well-being with an explora
tion of the labor force activities of the older respondents, the factors
associated with work and retirement, and the nature and extent of their lei
sure. The focus on work marks a logical starting point as it represents for
many a major defining characteristic over much of their lives and has strong
influence on their assets and income as well as their health.
The study of labor force participation at older ages and the process of
retirement and subsequent "leisure" activities do not have a long tradition in
developing countries. Until relatively recently, most people in developing coun
tries worked in the agricultural sector or in other types of family-owned or
self-employed enterprises. This, coupled with moderate life expectancies,
meant that a high proportion of the population worked until late in life, adjust
ing as necessary for diminishing health or functioning. These arrangements
have led some observers to call into question the relevance for developing
countries of the concepts of work, retirement, and leisure used in more indus
trialized settings, as well as the measures typically used to classify activities
and people (Cain, 1991; Dharmalingam, 1994; Chen and Jones, 1989, Chap
ter 5). Aware of these economic and cultural factors, investigators designed
231
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232 The Well-Being of the Elderly in Asia
the surveys to capture the variety of work arrangements that might exist in
the countries under study. As described below, the detailed questions posed in
the surveys permit a reasonable distinction between those working, working
without pay and/or in a limited way, and not working. They also assessed the
leisure activities of the elderly in a direct manner and elicited a number of
attitudinal and preference items about work and leisure, which appear mean
ingful.
The four countries under study differ considerably in their reliance on
agriculture, with the proportion of the overall labor force so engaged varying
from zero in Singapore, to 13 percent in Taiwan, 45 percent in the Philip
pines, and 64 percent in Thailand as of 1990 (see Table 2.5 in Chapter 2). It
should also be noted that, within each country, those employed by the gov
ernment or by large-scale private enterprises experience retirement as a for
mal process of cessation from employment, with provision for continuing
income through specified arrangements involving the individual, the employer,
and/or the government. In contrast with the more open-ended work cessa
tion ages for farmers and the self-employed, mandatory retirement ages from
civil service employment were quite young throughout the region, often stipu
lated at age 60 for men and 55 for women (see Chapter 3).
Despite the absence of a sharp demarcation between work and retire
ment in agricultural communities, some settings have well-specified cultural
arrangements for the transfer of duties from elders to children and the provi
sion of assistance to parents. For example, Gallin (1966, 215-16) describes
how men and women in the Taiwanese village he studied gradually retired
from farm work and household tasks as they got older, often after age 50,
and observes that old age was generally a period of freedom and leisure.
However, continued study of the village revealed that with economic de
velopment and more off-farm employment, mothers-in-law were placed
in a less advantageous position vis-a-vis their daughters-in-law and sons,
and lost much of the support they previously enjoyed (Gallin, 1994). These
findings suggest that the nature of the local economy, in addition to cul
tural patterns, can influence support arrangements and work patterns at
older ages. Nevertheless, the recency of the economic transformation in
the region means that a high proportion of the current elderly are now or
were previously in agriculture (except for Singapore) or in the self-em
ployed or family-owned business sector. A cross-national study of labor
force participation rates at older ages by Clark et al. (1999) confirms a
strong positive relationship between the percentage of workers in agricul
ture and the percentage of older people in the labor force. This distinctive
aspect must be kept in mind when analyzing work and retirement pat
terns.
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Work, Retirement, and Leisure 233
Table 7.1 shows the type of current or last job by age and gender in
the four countries. Overall, the proportion of those over 60 whose current or
past employment was in agriculture or in a non-agricultural family business
was a majority in every country except Singapore, ranging from 55 percent
in Taiwan to 76 percent in the Philippines and 91 percent in Thailand. As
expected, these proportions are even larger in the rural areas. But even in the
urban areas, the proportions in non-agricultural, non-family occupations com
prise only a third or less in Thailand and the Philippines, a half in Taiwan, and
three quarters in Singapore.
At the same time it is worth noting that those aged 60-69 exhibit some
what less attachment to agriculture than those 70 and older do, and this is
particularly true of women. Recent advances in educational attainment and
economic development in these countries mean that future cohorts of elderly
will present a very different occupational structure than that shown in Table
7.1. As a result, future retirement ages will be the product of both this sharply
changing distribution of sectoral employment and of the changes in retire
ment within sectors. It is possible therefore to see a secular decline in the age
at retirement overall as more workers enter the private industrial and service
sectors, while the age at retirement within sectors advances. Failure to take
into account both the compositional shift and the sectoral dynamics can lead
to misleading inferences about the reasons for the secular decline and for
observed differences cross-culturally.
The past labor force patterns and the resulting low saliency of retire
ment for many as an expected phase of life also mean that there are relatively
few studies in the region of attitudes toward work and leisure. We know little,
for example, about preferred ages for retirement, the proportions of elderly
who would like to stop work (or return to work), and the range of leisure
activities undertaken by those currently working and retired. These dimen
sions, described further below, are central in assessing the well-being of the
elderly in terms of their activity level—a central component of our conceptual
framework. An older person who is employed may prefer to be retired but is
constrained to work by economic and family considerations. Conversely, one
who is retired may prefer to work but poor health or employer policies or
incentives may have dictated otherwise. If well-being is gauged in part by
acting in accord with one's preferences, the well-being of older persons with
regard to work and leisure cannot be determined from observing their current
status alone. This contrasts with measuring well-being in terms of economic
or health status, where there is a strong presumption that greater income and
assets and better health are desirable outcomes.
In a broader context, there may be tension between retirement behav
ior and the societal costs and benefits of that behavior as embedded in public
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236 The Well-Being of the Elderly in Asia
policies. Trends in retirement age, as well as the underlying dynamics and the
potential consequences of these trends, have received considerable attention
within more industrialized societies. One of the more striking aspects of work
ing patterns in recent decades has been the strong movement toward retire
ment at earlier ages in most industrialized countries (well documented by
Gruber and Wise, 1998;Kohlietal., 1991;KinsellaandTaeuber, 1993;Quinn
and Burkhauser, 1994). These trends, triggered in part by financial incentives
contained in existing pension programs, levels of individual wealth, and chang
ing values toward work and leisure, have created concerns about the eco
nomic viability of existing social security programs, and have led to efforts in
some places to delay retirement by regulation or altered incentives (World
Bank, 1994). Among our focal countries, Singapore advanced the age of
mandatory retirement from 55 to 60 in 1993 and to 62 in January 1999 (see
Chapter 3). Changes to delay retirement or the age of full entitlement have
also occurred in the United States and Japan, among other countries (Ogawa,
1994).
These changes are often contentious within a society, signaling com
peting interests across generations and raising tensions between individual
preferences and broader societal goals. They also serve as cautionary tales to
newly industrialized and less developed countries establishing new social se
curity programs, or modifying existing ones, about the difficulties of design
ing programs that can balance competing interests and operate effectively
over the long term.
Trends in retirement age and their potential consequences are closely
followed by researchers and policy leaders in many developing countries as
they try to anticipate labor force shifts and the changes they may necessitate
in social security programs. On one hand there is the expectation that as more
workers move into the modern sectors of the economy, familial arrange
ments for old-age support will not suffice and more formal systems will be
needed. At the same time there is a desire to sustain the existing familial
system and minimize the potential costs associated with some social security
plans, which could hinder the pace of economic development. Complicating
the situation in some developing countries has been the pressure to create
new jobs for the large cohorts entering the labor force, leading to a desire for
earlier retirement among older workers (Agree and Clark, 1991).
The remainder of this chapter pursues these several themes. The next
section presents a broad picture of labor force participation rates over the last
20 years in the region, as well as a closer look at the work patterns of the
older population. This is followed by the development and estimation of mod
els for assessing the factors associated with continued work versus retire
ment, and a look at the associated reasons and preferences given by respon-
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Work, Retirement, and Leisure 237
dents. These attitudes serve as a backdrop to an examination of the leisure
activities among older persons.
Trend and Levels of Labor Force Participation
Figure 7.1 displays the labor force participation rates by age from 1970 to
1990 for each of the four countries, as derived from census data or Interna
tional Labor Office estimates (Raymo and Cornman, 1999). In broad terms,
Taiwan and Singapore are quite similar in their overall patterns, while Thai
land and the Philippines present quite a different configuration. In the first
pair, men traditionally show much higher labor force rates than women but
this differential is reduced by 1990, with Singapore showing initial increases
for women by 1980. Women in Thailand and the Philippines, by contrast,
show a pattern of sustained high labor force participation rates dating to 1970
with the high rates in Thailand particularly notable. Among the men in Taiwan
and Singapore, participation rates drop quite sharply after age 50, with the
drop-off occurring somewhat later in Thailand and the Philippines. In all
cases participation rates by men at older ages seem to have gone down slightly
over time, a trend examined in more detail below. In Taiwan and Singapore,
where there have been sizable increases in female labor force involvement
over time, women show higher participation rates in 1990 than earlier years,
and this appears to be true to a modest extent in the Philippines as well. In
Thailand, on the other hand, where female involvement has been very high
for some time, there is an indication of earlier withdrawal by 1990, judging by
the lower participation rates at ages 65 and over in that year. Raymo and
Cornman (1999), who also present labor force transition rates based on these
data and census survival rates, have estimated trends in exit rates that are
similar to the patterns described here.
Table 7.2 shows the level of labor force participation of older persons
by age and gender, according to the survey data from the four countries. The
notes to Table 7.2 provide the questions asked in each country and the deci
sion rules used to define labor force activity. In each country it was possible
to identify those who were working without pay and in some countries to
identify explicitly those who regarded themselves as helping out on a family
farm or business but not working for a living, a category often noted in
ethnographic accounts. We opted for a conservative definition of labor force
activity by excluding those working without pay or claiming to be only "help
ing out." The excluded categories were deemed to represent a higher degree
of volition in the use of time and therefore to be more appropriately combined
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240 The Well-Being of the Elderly in Asia
Table 7.2. Percent Currently in Labor Force,* by Age and Gender
Gender/
AgeMale60-6465-6970-7475-7980+TotalFemale60-6465-6970-7475-7980+TotalTotal60-6465-6970-7475-7980+TotalPhilippines70.956.643.228.726.052.732.835.928.720.78.728.250.444.334.723.715.138.5Thailand66.253.433.819.811.648.048.130.418.814.22.529.257.040.625.716.56.137.7Taiwan56.131.620.513.15.432.020.810.16.23.11.411.238.423.014.48.33.322.5Singapore55.131.217.510.94.732.516.98.95.23.90.69.035.819.710.86.92.119.9
*The Labor Force Participation Rate is defined as currently working full or part time or
not working but looking for work. It excludes those who are working without pay.
See Notes for Table 7.2 at the end of this chapter for questions and precise definitions.
with those retired. The magnitudes involved are small; the proportions desig
nated as working without pay vary from 0.1 percent to 6.2 percent across
the four countries (see Table 7.3 below), inclusive of those who said they
were "helping out" but not formally employed, and those who said they are
working but receiving only material goods in compensation. These percent
ages reinforce the notion that the distinction between work and leisure is
meaningful among the groups examined.
Although in all four countries respondents in the "currently working"
category comprise a minority, labor force participation varies considerably
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Work, Retirement, and Leisure 241
across countries by age and gender. As suggested by Figure 7.1, Thailand
and the Philippines tend to resemble each other, as do Taiwan and Singapore.
In comparison to Taiwan and Singapore, participation rates in Thailand and
the Philippines for both men and women are higher; more of the men aged 60
to 64 are in the labor force; and the decline of participation with age is not as
steep. As expected, participation rates for women at aged 60 to 64 are much
higher in Thailand (48 percent) and the Philippines (33 percent) than in Tai
wan (21 percent) and Singapore (17 percent). Except for the Philippines,
participation rates for women decline faster with age than for men within
each country. The very gradual decline with age in labor force activity in the
Philippines for both men and women is quite distinctive in these data.
To examine in more depth the labor force activity in these countries at
the older ages, we contrast these survey data with a set of earlier surveys
from the mid-to late 1980s, as shown in Figure 7.2. (Because the earlier
definition included working without pay, our figures have been adjusted ac
cordingly.) The impression conveyed is one of stability in the levels of labor
force participation across this period. Indeed, among the men aged 60-64 in
the Philippines, Singapore, and Taiwan, the proportion in the labor force may
have increased somewhat. For Singapore at least this may reflect the change
in the age of retirement that took effect in the early 1990s (see Chapter 3).
For women, slight increases and decreases characterize the shifts, with the
increases occurring most often in the two younger age groups.
To provide a useful point of comparison, we contrast the level and
trends for the four countries with the picture among the more industrialized
nations. In the United States, for example, the 1992 labor force participation
rate was 56 percent for men aged 60-64, which is similar to 1995-96 rates in
Singapore and Taiwan for men at those ages, as shown in Table 7.2. How
ever, in 1964 the U.S. rate was 80 percent for men aged 60-64, illustrating the
sharp secular decline noted above. For U.S. women aged 60-64, the labor
force participation rate was about 40 percent in 1992, closer to comparable
levels in the Philippines and Thailand. For the past 25 years, the trend line for
U.S. women at these ages has been flat, with the increasing participation of
women in the labor force offsetting the tendency toward earlier retirement
(Quinn and Burkhauser, 1994).
Other industrialized countries also show trends toward earlier retire
ment for men, although the levels vary considerably. Japan is notable among
OECD countries in its high labor force participation rates, with over 70 per
cent of men aged 60-64, and a third of those 65 or older still in the labor force
in the mid-1990s, though both these levels represent declines since 1970
(Quinn and Burkhauser, 1994; Kinsella and Velkoff, 2001). For women, both
levels and trends vary across industrialized countries. In some, as noted for
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Figure 7.2. Percent of Older Males and Females in Labor Force,
by Age and Country: 1980s and 1995-1996
Males
80% -
70% -
60% -
50% -
40% -
20%
10% -
m
60-64 65-74 75+ 60-64 65-74 75+ 60^4 65-74 75+ 60-64 65-74 75+
Philippines Thailand Taiwan Singapore
D 1980s Data D 1995-1996 Data
Females
80% -70% •60% •50% -40% -30% -20% -10% -ilk_——_ ._m r-, I] Irru-60-64 65-74 75+ 60-64 65-74 75+ 60-64 65-74 75+ 60-64 65-74 75+Philippines Thailand Taiwan SingaporeD 1980s Data d 1995-1996 Data
Source: 1980s: Chen and Jones, 1989, Tables 5.1-5.3, 1989 Survey of Health and
Living Status of the Elderly in Taiwan; 1990s: Table 1.
Notes: For the 1990s, participation is defined as currently working, looking for work or
working without pay to make the definition accord with that used in the ASEAN surveys.
The 1984 Philippines survey was not a nationally representative survey of the older
population.
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Work, Retirement, and Leisure 243
the United States, there has been little change over the last 20 years, while in
others there have been declines at the older ages commensurate with the
changes among men. In a few countries such as Sweden and Norway the
trend for women aged 60-64 has been toward greater labor force activity. In
terms of level, these Scandinavian countries. Japan, and the United States
show the highest rates of labor force participation among women 60-64, in
the range of 40 to 50 percent.
Although labor force participation patterns are similar among the cur
rently industrialized countries, there is also enough variation to preclude pre
dicting the future path for other countries experiencing economic develop
ment. The case of Japan, for example, illustrates the potential for a distinct
trajectory despite a high level of industrialization. In addition, several observ
ers have noted that the trend toward earlier retirement among men appears to
be slowing in a number of countries (Quinn and Burkhauser, 1994). Although
the current levels of labor force activity observed in the four Asian countries
in this study find their counterparts in one or another of the industrialized
nations, these developing countries do not share similar histories. It is also
possible that the policies adopted in these countries and others at similar
levels of development will lead to different trends than those observed re
cently among the more industrialized nations, as discussed further in the
Conclusion.
Table 7.3 presents a more detailed picture of the labor force activity of
older men and women in the four countries by broad age group and urban-
rural residence. As suggested earlier, agricultural activities are an important
source of employment for the elderly in developing countries, and the pro
portion of older men and women currently working is higher in rural than
urban areas for each comparison except Singapore, which does not have a
rural sector. The proportion working without pay also tends to be higher in
rural than urban areas, with a large differential in Taiwan. The proportion
working full time, however, is not very different in the urban and rural sec
tors. The proportion working part-time is higher in the Philippines than else
where, for the comparisons available. As a proportion of those working, part-
time employment is more common at age 70-plus than at age 60-69. A higher
proportion of women than men who are working are working part-time,
though the difference in the Philippines is negligible. Though the higher labor
force activity rates for the Philippines and Thailand compared to Taiwan and
Singapore are partially accounted for by the differentials within the rural sec
tors, the former two countries also show higher rates in urban areas, particu
larly for women.
The role of cultural effects, in addition to economic and policy dimen
sions, is glimpsed in the differential labor force behavior of women in the
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246 The Well-Being of the Elderly in Asia
four countries. Until quite recently it was uncommon in Chinese societies for
married women to work outside the home, an injunction reflected in the high
proportion of women in Singapore and Taiwan who report never having
worked. At the opposite end of the spectrum, the greater gender equity on
this dimension in Thailand, and to a somewhat lesser extent in the Philippines,
is revealed by the very low percentage that never worked.
Table 7.4 presents some additional background on the current or last
job held by the older population in these countries and on their occupational
history. Among men who are currently working, farming or other agricultural
pursuits dominate except in Singapore, where sales and craftsmen and la
borer categories are the norm. The rather low educational level of older per
sons is reflected in the small proportions in professional/technical or adminis
trative/executive occupations, particularly in the Philippines and Thailand.
(The relative high percentage of men reporting administrative or executive
positions in Taiwan reflects both the large number of older Mainlanders in
government positions and the large number of mid-size, family-owned busi
nesses). Commensurate with these occupational distributions, a very high
proportion report being in their current job more than 30 years—around 70
percent in the Philippines and 50 percent in Taiwan and Thailand. And al
though the countries under study are cash economies, it is not unusual for
men to report that some of their wages were partially or totally in goods
rather than cash, another indication of the importance of agriculture for these
older men.
The job characteristics of currently working women are not very dif
ferent from those of men, although a slightly higher proportion of women
within each country are less involved in agriculture and more involved in
sales, seniees, and related occupations. Accordingly, women also display
somewhat shorter tenure in their jobs and they are somewhat more likely to
receive their wages in cash only. Overall, the pattern for men and women
suggests some division of labor, with wives and other older women more
actively involved in the market place and complementing farm earnings and
production.
The nature of the last job held by those now retired is shown in the
lower half of Table 7.4 for each country but Singapore, where the data are
not available. Contrasts with those working are influenced by the differences
in age of the retired versus the currently employed as well as by the influence
of the job on the probability and timing of retirement. Thus, among retired
men in the Philippines and Taiwan, a smaller proportion report their last job as
farming or agricultural than their currently working counterparts, and those
in the Philippines show somewhat shorter tenure. In Thailand, by contrast,
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Work, Retirement, and Leisure 247
both retired men and women show similar levels of concentration in agricul
ture and job tenure distributions as their currently working counterparts. The
influence of several job characteristics on retirement will be pursued more
fully below in the multivariate analysis.
Modeling the Retirement Process
A rapidly growing literature examines the process of retirement within the
more industrialized economies, especially during the past few decades as that
decision has become more voluntary. As Quinn and Burkhauser (1994) note,
the earlier literature viewed the transition to retirement as largely involuntary,
driven by poor health, layoffs, and mandatory retirement policies (see also
Quinn et al., 1990). As the growth of Social Security and pension benefits
began to influence the timing of retirement, however, researchers saw that
retirement was increasingly a labor supply choice involving a trade-off be
tween work and leisure. In addition to incorporating variables reflecting the
availability and/or value of pension and Social Security benefits, models of
retirement often included measures of health, asset income, job characteris
tics, local labor market conditions, and several family-related variables. These
models have been enriched by a life-course perspective that stresses the rela
tionship between employment and family life dynamics on such dimensions
as health care needs of family members, marital status, and reproductive
histories, and the employment status of relevant others (Szinovacz et al.,
1992; Shih, 1997, p. 35).
In addition to the nature and content of models of retirement, a num
ber of measurement and estimation issues must also be addressed. The con
cept of retirement has been defined in a variety of ways (Gustman et al.,
1995). In some analyses retirement is defined in terms of collecting pension
or related benefits regardless of work status; in others it is defined as leaving
any full-time job after a certain age. Many analyses that focus on current
labor force status include with the retired those working less than full time. In
this chapter we consider an older person retired if he or she is neither cur
rently working full or part time for pay, nor looking for work.
In modeling labor force behavior we are typically examining the oc
currence of an event over time, and the preferred mode of analysis is event
history or survival analysis, in which the hazard rate of the event occurring
during the period of risk is determined (Hayward et al., 1998; Hayward and
Grady, 1990). To determine these rates in a multivariate analysis requires
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250 The Well-Being of the Elderly in Asia
knowing not only the timing of the event in terms of age or calendar time, but
the status of any time-varying covariates. Many studies lack sufficient detail
and use instead a measure of current activity along with the hypothesized
determinants in a logistic or multinomial regression. Our study data fall be
tween these two structures. For the Philippines and Taiwan, retrospective
and/or panel data allow for some survival analysis, but the requisite detail is
lacking for Thailand and Singapore. Accordingly, in carrying out the com
parative analysis, we use cross-sectional data and logistic regression models
to examine the determinants of respondents' current retirement status. In
addition we supplement these analyses by providing several highlights of sur
vival analysis carried out from the Taiwanese data.
The determinants included in our model have been suggested above,
and are designed to capture the major factors reflecting preferences, needs,
and opportunities for employment. Gender is likely to be particularly impor
tant given men's and women's very different historical involvement in the
labor force and the types of occupations open to each. For this reason we
analyze the models separately for men and women. Age, health, education,
and urban-rural residence are included as indications of ability to continue
work, the wage rate and implicit benefits derived from employment, and
employment opportunities. In addition to these individual characteristics, we
use factors reflecting family structure, which is thought to be highly influen
tial in the decision to work or retire. We include marital status and work
status of spouse, which relate to needs and resources as well as the often
joint-decision process of retirement (Blau, 1998; Henretta et al., 1993). The
number and ages of children and living arrangements speak to the potential
for receiving support as well as the need for continued provision of income.
The class of worker and other dimensions of employment, as noted above,
are also likely to be influential. Farmers and those involved in family busi
nesses can withdraw gradually as age and health dictate and may choose to
do so because of the absence of a formal retirement plan; workers in other
sectors may be forced to retire because of mandatory age rules or may be
encouraged to retire early through the structure of the retirement program
provided by the employer or the government. In general, coverage under a
pension plan is likely to reduce incentives for continued employment and to
facilitate retirement.
The methods used for measurement and estimation are critical to esti
mating the effects of these factors. In many cross-sectional surveys, the
timing of key events is not determined, which means cause-and-effect rela
tionships cannot be distinguished clearly. Changes in living arrangements may
be jointly determined with changes in labor force activity, for example, or
poor health status may have arisen after retirement. These shortcomings may
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Work, Retirement, and Leisure 251
be addressed through detailed retrospective probing or appropriately designed
panel studies. In the absence of such data, analysis is sometimes restricted to
clearly exogenous factors or fuller models are interpreted with due caution as
to possible confounding effects. We lean to the latter approach here, omitting
some variables that are clearly jointly determined with retirement but includ
ing some where causation remains problematic. We believe that on balance
these facilitate comparisons across countries and set the stage for more re
fined analyses as the data become available. (See Agree and Clark 1991 and
McCallum 1992 for related but alternate models for developing countries.)
The next section presents both bivariate and multivariate analyses for
each country using the determinants discussed above, as well as pooled re
gressions for studying the extent to which country effects exist in addition to
the included factors.
Correlates of Labor Force Participation
Bivariate Analysis
Table 7.5 defines the measures used for determinants in the model and dis
plays their means and distributions, by gender and work/retirement status,
for each of the countries. The bivariate strength of each variable can be
gauged by contrasting the distribution or value according to work status. As
shown for each country, men and women who are retired have an older age
distribution and are more likely to be in poor health than those working.
Reflecting differential opportunities for continued work, those retired are also
more likely to be urban residents and to have been in a non-agricultural, non-
family employment in their last job. In every country but Singapore, those
retired are more likely to have pensions or severance pay arrangements than
those working (discussed further below).
Family variables also appear to be influential. To capture both marital
status and the employment status of the spouse we use a trichotomy that
interacts these two concepts. This reduces the strong co-linearity between
two separate variables where all those "not married" on the marital status
variable would be "not applicable" in the spouse working variable. At the
bivariate level, those retired are less likely to have a working spouse than
those currently working, for each of the contrasts, but they are also less
likely to be married (mainly because of their older age). Among those mar
ried, the proportions of those working and retired who have a working spouse
are as follows:
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252 The Well-Being of the Elderly in Asia
PhilippinesThailandTaiwanSingaporeMarried MenCurrently
Working.31.79.25.24Retired.31.35.14.09Married WomenCurrently
Working.64.75.50.45Retired.44.41.26.15
Except among men in the Philippines, married respondents who are
still working are much more likely than those who are retired to have a spouse
who is also working. Given the differentials in labor force participation of
men and women, older women who are still working are especially likely to
have a husband who is also working, but in Thailand working men are as
likely as working women to have a spouse who also works.
Among the other family variables, those retired are more likely to be
living with one or more married children, although, as noted, the cause-and-
effect implications of this variable cannot be fully determined from a cross-
sectional analysis because a move to join children may follow retirement.
Working men are more likely than retired men to have one or more children
still in school, reflecting their age as well as the need for continued support.
The pattern among women in this respect varies across countries. The po
tential for support from children is partially captured by the number of living
children and the average numbers suggest that those who are retired tend to
have larger families, though this does not occur in every country and some
differences are small.
Education is a personal characteristic expected to affect an individual's
preferences, needs, and opportunities for work, but the influences often op
erate in countenailing ways. Those with higher education are more likely to
be covered by a pension program and have greater economic resources,
promoting earlier retirement; but they are also more likely to have a higher
wage rate and derive more implicit benefits from work, leading them to post
pone retirement. From an opportunity standpoint, those in rural areas where
continued involvement in agriculture is possible often have lower education
than urban dwellers. These conflicting influences are revealed in Table 7.5 by
the general absence of any strong differentials in the educational distributions
of those working and retired, at least in the bivariate situation. Accordingly
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Work, Retirement, and Leisure 253
we turn to the multivariate analysis for a more detailed examination of this
covariate and the other determinants.
Multivariate Analyses
A clearer picture of the effects of each of the independent variables is found
in Tables 7.6 and 7.7, which present, for men and women respectively, the
results of logistic multivariate analyses for each country. In these tables the
dependent variable is retirement, coded 1 for not working, not looking for
work, or working without pay, and coded 0 for working for pay or looking
for work. The dependent variable in a logistic regression is the natural loga
rithm of the odds of a specific outcome—in this case retirement. For ease of
interpretation, rather than show the regression coefficients, we present their
exponentiated values. These can be understood, for a categorical variable, as
the ratio of the odds of being retired for someone in the specified category
relative to someone in the reference category. For an interval variable, the
exponentiated value is the proportional change in the odds ratio for a unit
increase in the variable. The relative odds presented in Tables 7.6 and 7.7
confirm in a broad sense the general patterns observed in the bivariate rela
tionships, but offer a more precise picture of the strengths of relationships
and their variation across gender and country.
In each country we see a significant monotonic increase in the likeli
hood of retirement as one moves to the older ages, relative to those 75 or
older, with the slope for men somewhat steeper than for women. The effects
of education are minimal, rarely significant, and not consistent from country
to country. In Singapore men with a secondary education are more likely than
men with a primary education to be retired; in Thailand men with secondary
education are less likely to be retired. Women with no formal schooling in
Thailand are more likely to be retired than women with a primary education,
but their counterparts in the Philippines are more likely to be working.
In the bivariate analysis, being in poor health was associated with
being out of the labor force. This relationship holds in the multivariate analysis
as well for each country and for both genders, but the effect is somewhat
more consistent and stronger for males than females. For example, the odds
of being retired among men in very good health in the Philippines, Taiwan, or
Thailand are 11 percent or less of the odds among those with fair or poor
health. Among women, this low a proportion is observed only in Taiwan. As
expected, the characteristics of the job exert a significant influence on work
status. Male elderly in non-agricultural/non-family jobs are more likely to be
retired than are those involved in agricultural or non-agricultural family
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able 7.5. continuedi-—i — OO ;vQ 1-*- vQ .-•NO —NO ON IO ONO r- -H m
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able 7.5. continuedi-ts to i0O oo ^^
— i NO CNoo i0 r-CN NO OCN vq — 'ro ON 00CN iO -Hto oo oo-; NO —ON IO NO— 1 — . NOCN O ~O r- roNO CN — *
ro NO poo in r-vo ** ooro I0 OSm oo
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ro iO ^^ r^ei ^^ ^^— i oo •*t r^ oo CNo NO r- i0 — • oo
r- o ^ ^ o p ONO OO OO Tt iO IO-!-inn .»iiii ON ^^liti TJe IOi0 •*ON IO r^ ON Tr NO
i0 ON OO i0 iO Tt
CN p — i Tt p ONro NO 3 NOi/1 r^ Cs ^ 5? ®^'09 ^ . . °i— i ON Tf NO CN OO
r^- — i ON — ' 00 — i— — ,>,_ p ONe .E a" 1B C ^^-^2 * S o.2 .2 .§ .2 i S o TJIf!!! si 1
I1.!!! u s
1 1 1 1 1 1 1 2C -" " t. r S 1- r;re3e3ooooa3 -^
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i0 Tj; p ON ^ |Q.-^ ON CN OO ON NO
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CN r^* i0 ^ CN oo
^t i0 p ^^ ^ — ioo CN ON ^H m ^^CN t ^ ON O O I0•^ i0 P °5 i0. ^ro r^ •— * ON ON I0^ IO Tf IO NO -^**} ^? H ^ tn ^— , e1 * >u = -=
M J= 2 «•
s « 3 j§a c° 8"u -r w «t> > CO *•o s w *r: t_ i_ -a•S ° ° N
u h U .S, aj 4, — ;» ,5 „ * * gUO « u O S PC>sz S8>sz § § g
X Z Z c
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Table 7.6. Odds-Ratios from Logistic Regression Coefficients for the Effects of
Demographic, Socioetonomic, Health and Family Characteristics on
Retirement, among Males Who Ever Worked
+ p<.10 *p<.05 **p<.01 ***p<.001
CharacteristicAge60-6465-6970-7475+Married, spouse workingMarried, spouse not workingNot marriedUrbanEducationNo formal schoolingPrimarySecondary or higherHealth ratingVery good
GoodFair/poorLast/current occupationAgricultural, family farm
Agricultural, non-familyNon-agricultural, family
businessNon-agricultural, non-familyHas pension fromlast/current jobLives with married childHas 1+ children still inschoolNumber of living childrenModel Chi-square(degrees of freedom)Philippines.12***.31**.70—1.22.63—1.421.21~1.08.06***.12***".13***
.16***.09***1.482.07**1.06.98175.5(17)***Thailand.15***.17***.48***~.18***1.02"3.24***1.31—.73.11***
.30***~.56*
.43*.18***2.73**.851.211.02753.2(17)***Taiwan.10***.27***.47***-.49***.73*~1.46*1.08—.80.07***
.16***~.55**
1.91 +.61**2.44***1.20.62*1.09**474.9(17)***Singapore.15***.17***.48***-.18***1.02~3.24***1.31~.73.11***
.30***~.56*
.43*.18***2.73**.851.211.02753.2(17)***
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Work, Retirement, and Leisure 259
businesses. For females, this relationship was clearest in the Philippines. Non-
agricultural/non-family jobs are most likely to be associated with mandatory
retirement ages and to be inflexible regarding work at older ages. In association
with type of job, we found that males and females in urban areas in Thailand
and Taiwan were more likely to be retired than their rural counterparts. The
urban-rural differential did not appear significant in the Philippines after taking
account of the other factors. Having a pension or severance pay is clearly
associated with a greater likelihood of retirement among Taiwanese and Thai
men and women, but not, in terms of significance level, among older Filipinos.
In Singapore, the surprising negative effect of pension coverage on retirement,
observed in the bivariate relationships, emerges in the multivariate as well.
The influence of pension coverage on labor force participation is com
plex because it is likely to reflect economic needs as well as skills and oppor
tunities for continued employment or reemployment after retiring at an older
age. In the Philippines, Taiwan, and Thailand many of those with pensions—
especially those receiving more than the minimal amount—are likely to be
governmental employees whose overall economic resources may be greater
than others, facilitating their withdrawal from the labor force. In Singapore,
the pattern is reversed: those with pension income or coverage show higher
labor force involvement than their counterparts. Although the reasons for this
are not entirely clear, they probably center around the fact that a high propor
tion of the population covered by the Central Provident Fund (see Chapter 3)
have regular attachment to the labor force and marketable skills, in contrast
to those without coverage, many of whom were casual, part-time, and/or
contract workers. The early age of mandatory retirement under the Fund
allows those receiving benefits to find relevant remunerative work or self-
employment. Hayward and Wang (1993), who found a similar effect of pen
sion income on employment in Shanghai, attributed this effect to the early age
of retirement and the potential to use the pension income in entrepreneurial
second careers.
Because including measures of both marital status and spousal work
status in the regression may introduce high levels of col mean tv we created
the following trichotomy to minimize this potential: married, spouse working;
married, spouse not working; and not married. As shown in Table 7.6, mar
ried men with working wives are much less likely to be retired than non-
married men in each country but the Philippines. Married men whose wives
do not work show little difference in work status from the non-married,
except in Taiwan, where they display a lower likelihood of retirement.
The pattern for married women with a working spouse is similar to
that for men. In each country but the Philippines they have a lower likelihood
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Table 7.7. Odds-Ratios from Logistic Regression Coefficients for the Effects of
Demographic, Socioeconomic, Health and Family Characteristics on
Retirement, among Females Who Ever Worked
p<.10 *p<.05 **p<.01
'p<.001
CharacteristicAge60-6465-6970-7475+Married, spouse working
Married, spouse not working
Not marriedUrbanEducationNo formal schooling
Primary
Secondary or higherHealth ratingVery good
GoodFair/poorLast/current occupationAgricultural, family farm
Agricultural, non-family
Non-agricultural, family
businessNon-agricultural, non-familyHas pension from
last/current jobLives with married childHas 1+ children still inschoolNumber of living childrenModel Chi-square
(degrees of freedom)Philippines.25***.28***
.37**--.93
1.90*1.26.61*
1.00.82
.60".36**
.44*.21***1.242.27***2.86*1.01101.4(17)***Thailand.13***.26***
.40***~.39***
1.41*2.39***1.32*
1.73+.32***
.54***"1.34
1.28.38***3.42+1.45***.66*1.06**645.2(17)***Taiwan.11***.25**
.30*~.57*
1.291.63*.90
1.31.06***
.12**"1.69*
.77.993.61**2.15***.45*1.18**134.3(17)***Singapore.17***.24***
.46*-.52*
1.56*inap.1.04
1.20.42**
.98"n.a..54**2.29***1.211.09*121.2
(13)***
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Work, Retirement, and Leisure 261
of retirement than the comparison category of unmarrieds. Married women
whose husbands do not work, however, are more likely to be retired than
their unmarried counterparts.
As hypothesized, living with a married child is positively associated
with being retired. This effect is strong and significant for females across
each of the four countries. For males, living with a married child has a signifi
cant positive effect on retirement only in the Philippines and Singapore. Liv
ing with a married child is assumed to reflect a larger social support structure
than living alone, living with a spouse only, or living with an unmarried child.
As noted, however, the direction of causality is not unambiguous in a cross-
sectional analysis.
Another measure of the family structure effect, having at least one
child in school, is negatively associated with retirement for men in Singapore
and Taiwan, perhaps an indication that they are working to help finance their
children's education. Children attending school are likely to be younger and
more dependent on their parents for financial support than those not in school.
Women in Taiwan and Thailand are also more likely to work if they have
children in school. On the other hand, women in the Philippines are less likely
to work if they have children in school, which may indicate they stay home to
take care of their children.
The greater the number of living children, the more likely are older
women to be retired in Singapore, Taiwan, and Thailand. A similar story can
be told for men in Singapore and Taiwan. This supports the argument that a
greater number of children provides a broader support network and reduces
the need to work. In the Philippines, however, number of children has no
effect on work status for men or women, nor does it seem to influence the
retirement behavior of Thai men.
Country Effects
A persistent theme in our comparative analyses is the discovery of any coun
try-based effects unrelated to either differences in the distribution of key
determinants or the way these determinants operate. In Tables 7.2 and 7.3 we
noted that the labor force rates were quite distinctive across countries, with
the Philippines and Thailand generally showing higher profiles of labor force
activity than Singapore or Taiwan. The multivariate analyses in Tables 7.6
and 7.7 indicate that, despite these differences in magnitude, the pattern of
effects is generally similar across the countries, judging by the magnitudes of
the odds ratios.
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262 The Well-Being of the Elderly in Asia
To examine whether other factors distinctive to each country might
account for the observed differences in overall labor force participation rates,
we pool the data from each country and replicate the model from Tables 7.6
and 7.7, with the addition of dummy variables representing country of resi
dence for those living in the Philippines, Taiwan, and Thailand. For those
residing in Singapore, we use an interaction term that includes pension status
to capture its particular effect in Singapore vis a vis the other countries. If no
other effects distinctive to each country are operating—that is, the countries
differ only in the distribution of the independent variables—the country-level
variables should not be significant. If these conditions do not hold, then we
would expect to find country effects.
Table 7.8 presents the results separately for men and women and, to
reflect the lack of a rural sector in Singapore, separately for urban and rural
residence. For urban residents, aside from the pension variable and the inter
action term, the other coefficients remain very much in line with their levels
in Tables 7.6 and 7.7. The country effects are quite prominent. Relative to
urban males in Thailand, those in the Philippines and Taiwan are less likely to
be retired. The country variable for Singapore cannot be interpreted without
reference to pension status and this will be pursued below. Urban women in
Thailand are more likely to be retired than those in the Philippines, but less
likely than those in Taiwan.
The overall pattern in the rural sector is similar to the urban among the
three relevant countries. Philippine men and women are more likely to still be
working than their Thai counterparts; Taiwanese men show little difference,
but Taiwanese women show a higher likelihood than Thai women to be re
tired, after taking into account the individual, family, and job characteristics
included in the model.
To make clearer the country effects and the special nature of pension
status in Singapore in relation to the other countries, Table 7.9 presents the
predicted probabilities of being retired for urban and rural men and women by
pension status, derived from Table 7.8. (These probabilities are calculated by
setting all the other independent variables at their mean level.) In each country
but Singapore, those with pensions are more likely to be retired than those
without pensions, though the differences are small among rural women. In
Singapore, men without pensions are 27 percent more likely to be retired and
women without pensions about 12 percent more likely to be retired than their
counterparts with pensions.
The predicted probabilities also indicate the differences across coun
tries in the propensity to be working or retired, taking into account all the
variables in the model. To illustrate the relative magnitudes across countries,
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Table 7.8. Odds-Ratios from Pooled Logistic Regressions for the Effects of
Country and Demographic, Socioeconomic, Health and Family
Characteristics on Retirement, by Urban-Rural and Gender
+ p<.10 *p<.05 **p<.01 ***p<.001
CharacteristicAge60-6465-6970-7475+Married, spouse workingMarried, spouse not workingNot marriedEducationNo formal schoolingPrimarySecondary or higherHealth ratingVery goodGoodFair/poorHas pension from last/current jobLives with married childHas 1+ children still in schoolNumber of living childrenCountry effectsPhilippinesThailandTaiwanSingaporeInteractionsSingapore * has pensionModel Chi-square (degrees offreedom)UrbanMale.14***.30***.43***--.39***.83—1.12—1.16.22***.41***~2.55***1.60***.66**1.07***.31***—.69*1.52*.14***865.7(17)***Female.17***.23***.34***-.70*1.45**~.90—1.25.48***.65*~2.18***1.94***1.66*1.02.62**~1.72**2.49***.21***336.5(17)***RuralMale.15***.27***.63**~.28***.65***—1.19~1.12.08***.18***~3.30***1.171.27.99.35***—1.16inap.inap.803.8(15)***Female.19***.32***.51***~.59***1.59***—1.03~1.43.39***.55***"1.041.73***1.071.05**.66***—1.91***inap.inap.397.2(15)***
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264 The Well-Being of the Elderly in Asia
the data in Table 7.9 are set forth as indexes, with the Philippines taken as the
reference point:
With pensionPhilippines
ThailandTaiwanSingaporeWithout pensionPhilippines
ThailandTaiwanSingaporeUrbanMale1.001.221.17.901.00
1.501.371.62Female1.00
1.071.13.971.00
1.141.261.32RuralMale1.00
1.401.45na1.001.882.01naFemale1.001.141.32na1.00
1.151.33na
Relative to the Philippines all the comparisons except Singaporeans
with pensions indicate a higher probability of retirement, confirming the high-
level of labor force activity in the Philippines observed in Tables 7.2 and 7.3.
In contrast, Singaporean men and women without a pension show the high
est probability of retirement among the urban elderly in the four countries.
Contrary to the impression from the gross measures of labor force participa
tion, Taiwanese urban men are somewhat less likely to be retired than urban
Thai men, whether or not they have a pension. Taiwanese women and rural
Taiwanese men on the other hand are more likely to be retired than their Thai
counterparts. In general, controlling for the other factors results in relatively
small differences across countries in the probabilities of retirement for women
in comparison to men.
It should be kept in mind that the country differences shown above
and in Table 7.9 are conditional on the average values and distributions de
rived from the pooled data. For individuals with a specific health, education,
or family status, the differentials across countries might shift. The reasons
for these distinct country effects cannot be determined without more re
search. They may reflect in part individual-level variables omitted from the
model or aspects of each country's level of economic development, policies,
or culture. With only four countries, it is not possible to test for specific
national characteristics that might be accounting for country differences.
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Work, Retirement, and Leisure 265
Table 7.9. Predicted Probabilities of Retirement by Urban-Rural
Residence, Gender, Pension Status and Country
na - not applicable
With pension/severancepay from current orprior jobsPhilippinesThailandTaiwanSingaporeWithout pensionPhilippinesThailandTaiwanSingaporeUrbanMen.736.901.864.666.522.782.713.845Women.819.880.927.796.675.771.853.894RuralMen.558.782.807na.277.522.559naWomen.628.718.829na.620.711.824na
Note: Probabilities are calculated after setting the other independent variables at their
mean values derived from the pooled sample.
Attitudes and Preferences Related to Work and Retirement
Reasons Given for Retirement
In the preceding sections we have inferred some of the dynamics for work
and retirement by examining the relative role of a number of individual, fam
ily, and job-related characteristics. Another approach to understanding the
factors at work is through direct questioning of respondents about their main
reason for stopping work. Questions of this type were posed to those who
had worked but were not currently working in each of the four countries.
Although some country-level differences in the form of question and proce
dures exist, the over-all patterns shown in Table 7.10 are quite revealing. The
reasons given fall primarily into four broad categories: reaching mandatory
retirement age (and secondarily, job-related aspects such as layoffs or plant
closings), health and/or the ability to perform the job (too old, or job too
demanding), economic sufficiency, and need to take care of family members.
These reasons are not mutually exclusive; for example, those who report that
they stopped working mainly because they reached the mandatory retirement
age may also have had sufficient economic resources at that point to retire.
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268 The Well-Being of the Elderly in Asia
The patterns of response differ sharply across countries and by gender. For
men, health-related reasons (health problems or the inability to fulfill the de
mands of the job) account for about 74 percent of the responses in the Phil
ippines and Thailand, with almost 18 percent mentioning mandatory retire
ment ages, lay-offs, or plant closings. In Taiwan, only 58 percent of the men
cite a health-related reason, while about half cite mandatory retirement or
another job- related reason. (In Taiwan multiple responses were possible.) In
Singapore by contrast, more than 83 percent of the men cited mandatory
retirement age as the reason for stopping work and almost 10 percent more
mentioned having sufficient funds for retirement, most likely stemming from
the accumulation in the Central Provident Fund.
For women the mix of reasons is quite different and some new ele
ments appear. In the Philippines, Taiwan, and Thailand, health-related rea
sons (health problems or job too demanding) remain substantial, particularly
in Thailand where this is reported by over 80 percent of the women. Manda
tory retirement age is not cited very often in any country, but the need to take
care of family members is a significant factor for about a fifth of the Philip
pine women and a third of the Taiwanese women aged 60 to 69. For Singapore,
the reasons given by women resemble those of men in that mandatory retire
ment age and sufficiency of economic resources predominate, with women
more often citing the latter reason than the men.
The differences by gender and by country are more distinctive than
those by age. Generally, the reasons for retirement given by those aged 70-
plus follow the pattern of those aged 60 to 69. In Taiwan, where multiple
responses were permitted, men and women over 70 mentioned both manda
tory retirement age and health problems more frequently than their younger
counterparts. The need to take care of family members is more frequently
given by women 60-69 in the Philippines and Taiwan than by those who are
older.
Table 7.11 compares the reasons for ceasing work given in the three
Southeast Asian countries with the reasons given in the earlier ASEAN round
of surveys (Chen and Jones, 1989). In the roughly ten-year period, the re
ported reasons have remained largely stable, with some notable shifts. In the
Philippines, a health-related constraint (including poor health and the related
dimensions of too old/job too demanding) is the most prevalent reason in both
surveys, but somewhat surprisingly the proportion of men who cite reaching
retirement age as the reason drops substantially during the period. In Singapore,
the movement is in the other direction, with sharp increases in the proportion
citing retirement age or sufficient financial means—as might be expected
with the greater penasiveness of the Central Provident Fund (see Chapter
3)—and concomitant declines in the proportion citing health-related reasons
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Table 7.11. Percent Distribution of Reasons Given for Retirement by
Those Not Working, Mid-1980s vs. Mid-1990s
Note: na (not available) included with other reasons.
PhilippinesReasonsReached Retirement AgePoor HealthToo Old / Job Too Demanding /Worked EnoughDomestic Reasons /Family, Children Oppose /Take Care of FamilySufficient Financial MeansOther ReasonsTotalThailandReasonsReached Retirement AgePoor HealthToo Old / Job Too Demanding /Worked EnoughDomestic Reasons /Family, Children Oppose /Take Care of FamilySufficient Financial MeansOther ReasonsTotalSingaporeReasonsReached Retirement AgePoor HealthToo Old / Job Too Demanding /Worked EnoughDomestic Reasons /Family, Children Oppose /Take Care of FamilySufficient Financial MeansOther ReasonsTotalMale19844246na5na71001996116564015100Male19861074nanana1610019951445291011100Male1986452361011510019958360092100Female1984463na14na1910019965411021221100Female1986175nanana241001995146361115100Female198614131032823100199550807323100
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270 The Well-Being of the Elderly in Asia
or domestic and family considerations. In Thailand the earlier survey had
relatively few comparable categories but the proportions citing health-related
reasons are similar for men and women in both years, and dominate all other
factors. Overall, Tables 7.10 and 7.11 reveal that financial incentives and
retirement age regulations are the main factors among Singaporean elderly,
while health and to a lesser extent family considerations are the main driving
forces in the Philippines and Thailand, with Taiwan occupying an intermedi
ate position. It should be kept in mind that reasons given for retirement often
involve a certain degree of rationalization and the responses must be weighed
against other evidence.
Attitudes and Preferences Related to Retirement
At the outset we noted that the well-being of older persons with regard to
work and leisure can be gauged in part by the degree of concordance between
their preferences and their actual activities. To this end it is relevant to measure
the older population's attitudes about the conditions under which it is appropriate
to stop working. Because the questions tapping attitudes about work versus
retirement varied across countries to capture local ways of thinking, we present
the actual questions asked as well as the responses in Table 7.12. In Thailand
and Taiwan the question of continued work is conditional on good health,
which is not explicitly mentioned in the Philippine version. In Singapore, the
question is phrased in terms of a set age because regulating retirement age
had been common there for some years. For all countries, the results point
strongly toward the attitude of working as long as one is able. The distributions
for Thailand, Taiwan, and the Philippines are very similar, with 68 to 85
percent expressing this preference across the three countries. These
preferences seem in accord "with the experience of the currently retired in
these countries as indicated in Tables 7.10 and 7.11, where health and related
reasons for stopping work predominate. But, even in Singapore, where the
Central Provident Fund and mandatory retirement ages have been in place for
some time, over 80 percent disagree or are not sure that the cessation of
work should be mandated by age.
It should be stressed that these are generalized attitudes that may be at
considerable variance from behavior, and which may grow discordant over
time. In the United States, for example, preferences for working at older ages
have continued to be widely expressed even as the retirement age declines.
The General Social Survey (National Opinion Research Center, 1996) asked a
sample of Americans currently working or temporarily not working for the
period 1973 to 1996: "If you were to get enough money to live as comfortably
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Work, Retirement, and Leisure 271
as you would like for the rest of your life, would you continue to work or
would you stop working?" From two-thirds to three-quarters of those under
age 60 say they would continue working, and about half to two-thirds of
those over age 60 respond the same way. (For further discussion of subjective
factors in retirement, see Inkeles and Usui, 1988.)
Plans for Retirement or for Returning to Work
Additional insight into older respondents' attitudes and preferences can be
gleaned from their expressed plans to stop working (if currently working) or
return to work if currently retired. Respondents who were currently working
in the Philippines, Taiwan, and Thailand were asked if they planned to stop
working, with those in the first two countries allowed to qualify their answer.
Four-fifths of those currently working in the Philippines and two-thirds in
Taiwan said that stopping work depended on circumstances, and about 90
percent of the time the contingency cited was health. The remaining respon
dents in each country were about equally divided between an unequivocal
"yes" and an unequivocal "no." In Thailand, where a "depends" option was
not available, 44 percent said they planned to stop working and 53 said they
did not, with the remainder unsure or not replying. Overall these responses
indicate that a clear plan to stop working at a certain age is not salient among
this generation of older workers. A majority see themselves working indefi
nitely, stopping only if their health status requires it.
Those who were currently retired in these three countries were asked
about plans or interest in returning to work. In Taiwan, where the question
was in terms of planning to go back to work, 96 percent said "no." In the
Philippines, where they were asked if they had any "interest" in returning to
work, 91 percent said "no." In Thailand, respondents who said they were
"fully retired"—a smaller base than used in Table 7.11 above—were asked if
they wanted to work. If they responded positively, they were asked if they
were physically able. The responses were:
Yes, want to and able 3 percent
Yes, want to but not able 54 percent
Do not want to 43 percent
This additional detail from Thailand suggests that many of the "no"
responses in the Philippines and Taiwan were prompted by health conditions
and the ability to perform the often-demanding duties of the jobs to which the
elderly might aspire.
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Table 7.12. Percent Distribution of Opinions about Stopping Work in Old
Age among Adults 64 Years and Older'
Question Posed in Survey, by Country and Year
Philippines (1996): "Some people feel that an elderly person
should continue to work as long as they can. Others feel that an
elderly person should stop working completely at a certain age.
What do you think?"
Should stop working completely at a certain age
Should continue to work for as long as s/he can
Depends on health
No opinion/ NI
Thailand (1995): "In your opinion, if an elderly is healthy and
strong, should s/he stop working completely or continue working
during old age?"
Should stop
Should continue
Depends
No answer/Missing
Taiwan (1993): "Some people feel that as long as an elderly person
is healthy, they can continue to work. People should 'live until an
old age, and work until an old age', doesn't matter the age. Some
people feel that an elderly person should stop working completely,
and to enjoy family life at home. What do you think?"
Should stop working completely
Should continue as long as health condition permits
Other
Missing
Singapore (1995): "In your opinion, do you think there should be an
age set for a person to stop working (i.e., retire)?"
Yes
No
Don't know/Not sure
11
85
1
2
15
68
12
4
17
74
3
6
18
39
43
a Age 64 years and above selected for comparability with 1993 Taiwan survey.
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Work, Retirement, and Leisure 273
To what extent are these attitudes and preferences consonant with
observed behaviors and what do they reveal about the well-being of the elderly
in terms of work and leisure? Although labor force participation rates at the
older ages tend to be high in comparison with industrialized countries, they
are not unduly different, and collectively they appear in accord with expressed
desires to continue working as long as health permits. This pattern is also
confirmed both by the emphasis placed on health and related dimensions as
reasons for retirement in all countries except Singapore, and by the regression
results in each country. Consequently, retirees show little inclination or ability
to return to work. Similarly, responses to plans to stop working are explicitly
contingent on health and related factors in the Philippines and Taiwan, and are
likely to be implicitly considered as well in Thailand.
The Process of Retirement
To this point we have examined the current status of elderly respondents with
regard to various facets of work. In this section we take advantage of the
panel data in Taiwan and the strong retrospective data there and in the Philip
pines to review several dimensions of retirement as a process over time.
Quinn and Burkhauser (1994) note that in the U.S. part-time work rises with
age and is a significant factor in the employment picture of older men and
especially older women. The proportion of older men and women working
part-time has been rising in the U.S. and in a number of other developed
economies. In these countries most of the part-time work at the older ages is
voluntary; in many cases it is part of an exit pattern from a full-time career
job to withdrawal from the labor force. This pattern has been the subject of
several studies (see Quinn and Burkhauser, 1994, p. 71-72). Although less is
known about the process of retirement in developing countries, our retro
spective data on work histories plus the panel information in Taiwan allow us
to sketch a few broad dimensions.
Table 7.3 showed the percentage currently working part-time. Ex
pressed as a proportion of those currently working, the figures for those
aged 60 and older are as follows:
PhilippinesSingaporeTaiwanPercentage Working Part TimeMale33.822.211.5Female34.945.720.4
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274 The Well-Being of the Elderly in Asia
Although strictly comparable data does not exist for Thailand, related
information in the survey suggests that the proportions working part-time
there might resemble the levels in the Philippines.
These percentages show that part-time work is a substantial aspect of
older age employment in these countries and should be considered in tracing
trends and developing policy. In the Philippines those working part-time were
asked if they ever worked full-time, and more than one-fifth of the men and
one-ninth of the women replied affirmatively. Schoenbaum (1995, Table 2.2),
who analyzed the job history data from the 1989 Taiwan survey, found that
among respondents who currently worked part-time or seasonally, more than
three-quarters of men and about three-fifths of women reported working
full-time in the past. Whether these patterns and changes reflect voluntary
labor supply decisions or constraints on the availability of jobs cannot be
determined from these data and must await further investigation.
We can also trace in part the retirement process of those already re
tired in the Philippines and Taiwan. In the Philippines those retired within the
past year were asked the number of hours worked on their last job, and if less
than 40 hours, whether they had previously worked full-time. For this select
group of retirees, 37 percent of both men and women reported working part-
time at their last job, similar to the proportion reported above for those cur
rently working. Of those who had been working part-time, only 14 percent
of the men and 4 percent of the women said they had worked full-time in the
past. It would thus appear that for many Philippine workers, as well as retir
ees, part-time employment, perhaps in more than one job, has been a way of
life under recent economic conditions rather than an exit strategy in the course
of retirement.
More detailed data, of a somewhat different nature, exist about the
retirement process in Taiwan. Schoenbaum (1995, Tables 2.3a and 2.3b)
used the somewhat limited retrospective histories in the 1989 Taiwan panel to
examine transitions from a worker's major sector (class of employment) or
occupation to current sector or occupation, including in each case being out
of the labor force at the latter date. He found that a very high proportion of
respondents exited the labor force, and only a small proportion had moved
from their major sector or occupation to a different one. For example, of the
entire sample of those who ever worked, only 9 percent of men and 5 percent
of women moved to a job in a different sector. Of those currently retired, 11
percent of men and 8 percent of women changed sector of employment
between their major and last job, and 22 percent of men and 9 percent of
women changed occupational category. Though these data cannot fully ac
count for intermediate jobs within the same occupation, they do suggest
limited work mobility before retirement.
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Work, Retirement, and Leisure 275
Shih (1997) provides other insights into the process of retirement via
her analyses of the 1993 panel data from Taiwan, which contain additional
information on occupational history, including job change within occupa
tions. In tracing the employment trajectories of respondents after age 50,
Shih found that 26 percent of men and 8 percent of women held more than
one job after age 50. Job change was even more common for Main lander
men than their Taiwanese counterparts: about half of them reported at least
one job change after age 50, a differential that may be explained by their
much greater likelihood of government employment and pension eligibility.
Defining retirement as being out of the labor force for 12 months or more,
Shih found that 11 percent of men and 3 percent of women returned to work
after retiring, again with a sharp contrast between Mainlander and Taiwanese
men (21 percent versus 5 percent). When these analyses are further restricted
to look at the non-farm sector only, Shih concludes that the job-change rates
of older Taiwanese approach those found in the United States.
Though the data available across the four countries are limited, they
do suggest that part-time employment is non-trivial among older workers,
and that the countries vary in the degree to which job changes and re-entry
after retirement occur, with Taiwan at least displaying a number of the job-
mobility features found in the more industrialized countries.
Leisure Activities of the Elderly
At the outset of the chapter we noted that the concepts of work, retirement,
and leisure, and the distinctions among them, are likely to be influenced by
the area's underlying economic structure, level of economic development,
and numerous cultural elements. Studies of leisure often point to the differ
ences in its nature and organization across societies according to cultural,
historical, and economic dimensions. (See, for example, Kelly, 1982, Chap
ters 6 and 7, for an overview and Shaw, 1994; Mercado, 1974; and Linhart,
1988, for specific countries in Asia.) The strong cultural base associated with
leisure may become embodied in language so that terms signifying work in
one culture may signify leisure in another context, complicating cross-cul
tural comparisons. (See Blair, 1991, for a terminological and language ex
ample.) Although common aspects of mass media and mass culture have
permeated most countries, leading to greater uniformity in the concepts and
range of activities constituting leisure, considerable variation persists.
As noted, we found generally strong preferences for work among
older respondents, but we also found substantial proportions retired, primarily
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276 The Well-Being of the Elderly in Asia
because of poor health or factors arising from their job (mandatory retirement,
lay-offs, etc.). Among those retired, we found little inclination to return to
work, in part out of awareness of their limited ability to do so. Assessment of
well-being requires some attention to the leisure activities of this older
population, both those working and those not working.
Leisure has been conceptualized and measured in a number of ways.
Veblen's simple definition of leisure as the "nonproductive consumption of
time" (Veblen, 1899, cited in Kelly, 1982) placed the emphasis on time spent
away from subsistence activities, or more positively, the discretionary use of
time (Kelly, 1982; Murphy, 1974). Others have emphasized the activities them
selves, identifying the sports, hobbies, events, and social interactions that
seem to capture leisure in a particular culture. Still others have focused on the
function of leisure to the individual as purposive behavior designed for self-
enhancement. This is captured by Dumazedier's definition
Leisure is activity—apart from the obligations of work, family, and
society—to which the individual turns at will, for either relaxation,
diversion, or broadening his knowledge and his spontaneous social
participation, the free exercise of his creative capacity. (Dumazedier,
1967, quoted in Kelly, 1982.)
From this perspective, leisure is distinct not only from remunerative work,
but from activities arising from obligations to family, friends, or church.
The questionnaires used in the four countries measure leisure among
the elderly mainly by assessing their activities, ranging from the more passive
to the more demanding in terms of physical activity or social involvement.
The activities fall into five major categories: reading newspapers and books;
watching television or listening to the radio; involvement in sports, regular
physical exercise, or hobbies—like gardening—with a high physical activity
level; participation in religious services or prayer; and involvement in a variety
of social clubs and community organizations. Here we do not include visiting
with family as a leisure activity per se, rather including it in Chapter 6 with
intergenerational relations because it is such an important dimension for many
elderly in terms of both time spent and emotional support.
Table 7.13 summarizes participation in leisure activities for those age
60 and older, defining in the notes the activities included for each country.
The most pervasive form of leisure reported by all elderly is regular television
viewing or radio listening, reported by over 80 percent of respondents in
Thailand and well over 90 percent in Taiwan and the Philippines. (This activ
ity was not asked about in Singapore.) It is of interest to note, given the fairly
low educational levels among the current elderly, that from a fifth to a third
also report reading newspapers and books at least once a week.
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Table 7.13. Percentage of Adults Age 60 Years and Older Engaged in
Leisure Activities by Work Status, Gender, Age, and Self-
Reported Health Status
Type of Leisure ActivityTotalReading newspapers/books"Radio/TV3Physical activity IPhysical activity IICReligious activityClubseCurrently workingReading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsRetiredReading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsNever workedReading newspapers/booksRadioA-VPhysical activity IPhysical activity IIReligious activityClubsPhilippines289730309528279632*32*9531*319731319528229721219820Thailand20838858915923**90**89**67**92*66**187887529155338674468533Taiwan35945811334544**97**49**13**29**55**37946213334616925664031Singaporen.a.n.a.n.a.n.a.6627n.a.n.a.n.a.n.a.6525**n.a.n.a.n.a.n.a.6530n.a.n.a.n.a.n.a.6822
continued
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Table 7.13. continued
Type of Leisure ActivityMenReading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsWomenReading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsAge 60-64Reading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsAge 65-74Reading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsPhilippines3196**34**34**92**2926982727982733*9734**34**9528309732329630Thailand30**88**90**62**90**63**12798555935523**88**89**62**92**65**218490609362Taiwan53**96**63**16**27**53**1392526403533**96**50**13**3543*409563133347Singaporen.a.a a.n.a.n.a.63**30**n.a.n.a.n.a.n.a.6824n.a.n.a.n.a.n.a.71**26n.a.n.a.n.a.n.a.6827
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Table 7.13. continued
X2: * .01 < p < .05 ** p < .01
Type of Leisure ActivityAge 75+Reading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsVery good healthReading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsGood healthReading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsPoor healthReading newspapers/booksRadio/TVPhysical activity IPhysical activity IIReligious activityClubsPhilippines18962121942636**95**37*37*94*35299830309727169524249328Thailand13718246874328**88**91**67**93**62188289579360117871428662Taiwan2489576304250**98**68**18**33**52**2996579364515793231928Singaporen.a.n.a.n.a.n.a.5527n.a.n.a.n.a.n.a.75**36**n.a.n.a.n.a.n.a.6926n.a.n.a.n.a.n.a.4423
Note: Chi-square results represent differences across categories. Asterisks, where
applicable, only show first category listed.
See Notes for Table 7.13 at the end of this chapter.
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280 The Well-Being of the Elderly in Asia
Various forms of religious activity are reported by over 90 percent of
the elderly in Thailand and the Philippines, equaling or exceeding radio/TV
involvement, while two-thirds of respondents in Singapore and one-third in
Taiwan indicate religious activities. Two measures of physical activity were
developed, a broad definition that includes "taking walks at least once a week"
in the Taiwan and Thailand survey, and a narrower definition that excludes
this activity for comparability to the Philippines survey, which did not explic
itly ask about "walking." Under either definition there is considerable varia
tion across countries. For the narrower definition (Physical activity II in
Table 7.13), the proportions range from 11 percent in Taiwan, to 30 percent
in the Philippines, to 58 percent in Thailand. When "taking walks at least once
a week" is added as a physical activity in Taiwan and Thailand, the overall
percentages rise to 58 percent and 88 percent respectively, putting physical
activity on a par with radio/TV and religious activities in Thailand.
Participation in social clubs and community organizations is also preva
lent among the elderly, and variable across countries, as might be expected
given differences in local infrastructures and cultural traditions. High partici
pation is recorded in Thailand (59 percent) and Taiwan (45 percent), but only
about a quarter of the elderly are so involved in the Philippines and Singapore.
Overall, the elderly in all the countries report engagement in a variety
of leisure and recreational activities, with each country displaying a some
what distinct profile. In Thailand, relatively high levels are reported for all
types of activities except reading; in the Philippines, radio and television and
religious activities predominate; and in Taiwan, radio and television and social
clubs are most popular, if a narrower definition of physical activity is used.
Table 7.13 also displays these levels of participation by several factors
most likely to affect them: work and retirement status, gender, age, and health.
These characteristics clearly overlap one another to a great extent. For ex
ample, retirees tend to be older and in poorer health than those currently
working, making any bivariate differences likely the result of multiple fac
tors. At a first approximation, the overall country profiles of activities de
scribed above hold within each of the sub-groups shown in Table 7.13, with
no sharp differentials across groups within countries.
Whether retirement leads to heightened recreational activity is highly
relevant to this chapter's focus. Although those retired will have more time,
they may be less able or less inclined to participate in more activities. These
competing influences cannot be sorted out from cross-sectional data, since
cohort differences and self-selection intervene. We use our panel data below
to study changes in behavior. Table 7.13 reveals generally little difference in
level of leisure activities between those currently working and those retired,
with the significant changes mainly in the direction of lower levels of activity
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Work, Retirement, and Leisure 281
among the retired. Those who never worked, a relatively small group, and
mostly females, show a somewhat distinct pattern relative to the other two
Gender differences, though not large, follow expected social and cul
tural traditions. Older women show lower levels of reading because of their
higher levels of illiteracy, and they are less likely to engage in physical activi
ties or social clubs, but show higher participation rates in religious activities.
The differences between those aged 60-64 and 65-74 are minimal, but
the level of leisure activities does diminish moderately among those 75 and
older. Leisure activities also tend to decline with declining health status, with
the drop-off most noticeable among those categorized as in "poor health."
The items shown in Table 7.13 do not exhaust the range of activities
often subsumed under leisure, and in Taiwan and the Philippines attention
was also given to social activities such as attending cultural events or going
out to eat with friends and family. The surveys in Thailand and Taiwan also
inquired about travel, with Taiwan identifying overnight and overseas trips.
The range of supplementary items covered and the proportions in
volved are shown below:
Percent of Those Age 60+ Participating in Various Social Activities
Measurement definitions:
Social activity
ActivitySocial activitiesCharity workChat with relatives, friends or
neighbors/drink tea sociallyTravelPhilippines23%--„—Thailand—--_27%Taiwan15%4%60%41%
Philippines: Attended social activities such as getting together with
friends, family, neighbors, going out to eat, walking for pleasure, went to
movies, or gambled with others at least once per week.
Taiwan: Participated in group activities (e.g., chess, cards, singing groups,
dancing, tai-chi, karaoke), attended concerts, or went on local tours or day-
trips at least once per week.
Travel:
Thailand: Traveled or went sightseeing in past year.
Taiwan: Went to places outside local areas for tours, on overnight tnps, to
Mainland China or overseas in past year.
Note: -- means not available.
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282 The Well-Being of the Elderly in Asia
These data indicate fairly frequent involvement in the Philippines (23
percent) and Taiwan (15 percent) with what might be termed semi-struc
tured social activities. In addition, a high proportion of Taiwanese (60 per
cent) report more informal types of interaction with friends and neighbors.
Only 4 percent in Taiwan are explicitly involved in charitable work, although
some of the club membership and activities may have this as a component. It
will be of interest to monitor trends in this kind of activity as countries give
more emphasis to involving the elderly (and others) in volunteer activities.
Travel is an important activity with 41 percent in Taiwan reporting
travel outside their local area over the course of the year and over one-quarter
of those in Thailand also reporting either local or longer distance travel.
The foregoing picture of the older population's involvement in leisure
activities, especially when coupled with the material in Chapter 6 on level of
family visits, suggests that the elderly are quite actively engaged with others
and in the world around them. This observation, however, comes with sev
eral cautions. First, our analyses do not provide insights on the degree to
which these various activities occupy the "free" time of the respondents, or,
more important, on the extent to which respondents derive meaning or plea
sure from participation in them. Are these activities undertaken as substitutes
for other preferred ways of spending time, or do they represent the older
persons' priorities? Chapters 9 and 11 touch on the level of loneliness and
isolation experienced by the elderly and indicate that these are far from trivial,
despite the activity levels displayed in Table 7.13. Further analyses on the
relation between activity and emotional well-being on several dimensions re
main to be undertaken.
Also, it should also be noted that the analysis represented by Table
7.13 is cross-sectional in nature and tells us relatively little about how the
level of leisure activities changes as a cohort moves from work to retirement,
or as older people experience some physical limitations. The panel data from
Taiwan permit some insights into these important transition issues and we
illustrate the potential by investigating whether those who retire change their
level of activity. A priori one might expect an increase in leisure activity with
retirement, as a result of more free time, but this might be countered by
increasing age and the fact that retirement is often prompted by ill health, as
shown in Table 7.10.
We compared the level of activity reported by the panel in 1989 (when
respondents were 60 or older) to that reported in 1996 (when they were 67 or
older) according to their work/retirement status at each point. Those who
were working in 1989 but retired in 1996 reported modest increases in their
involvement with clubs and associations, religious activity, and physical activity,
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Work, Retirement, and Leisure 283
and a slight decline in reading—changes that were similar to those reported
by respondents who were working in both 1989 and 1996. This latter group
showed a particularly large increase in the proportion involved in social and
community organizations over the seven-year period. On balance little evidence
indicates that retirement per se led to increased leisure activity, though this
initial analysis must be tested further with additional controls. Those who
were retired both in 1989 and 1996 reported slight declines in reading and
engaging in physical activity (using the physical activity measure from Table
7.13), but no changes in the other types of activities.
Overall, the use of the panel reveals little change in levels of leisure
activity over the seven-year period as a result either of shifting from work to
retirement or of aging per se (as observed in those who were retired at both
points). It is possible that period effects, such as the creation of more com
munity associations or more elderly outreach organizations, promoted greater
involvement in social clubs and associations—a surmise that could be ex
plored using independent information on the density of such organizations.
Conclusions
This chapter has used both aggregate and individual level data to develop a
comparative picture of the labor force patterns of the older population in each
country under study, and the factors affecting their labor force participation.
In addition, recent changes that might signal future trends are assessed. Be
cause the majority of those 60 and older in each country are no longer work
ing, we also look at the level and type of leisure activity they are engaged in,
and what is known about their preferences for work versus retirement.
At the aggregate level, the older population in the four countries show
two rather distinct profiles. The Philippines and Thailand have somewhat
higher labor force participation rates for men, and much higher rates for
women, than Singapore and Taiwan (Table 7.2). In the latter two countries,
substantial involvement of married women in the labor force is a relatively
recent phenomenon, as shown in Figure 7.1, which traces activity over the
life course from 1970 to 1990. These data, as well as comparisons with
similar data from the 1980s (Figure 7.2), indicate very little tendency toward
earlier retirement—which is contrary to the strong trends observed in most
industrialized countries over the past two or more decades. The current lev
els of labor force activity in the four countries under study overlap the levels
observed among the more industrialized countries, though they do not display
similar trends.
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284 The Well-Being of the Elderly in Asia
The survey data from each country were used to investigate the effect
of a set of factors representing preferences, needs, and opportunities for
employment, paralleling models used in more industrialized settings, as well
as the developing world (Tables 7.6 and 7.7). Beyond the expected strong
relationship with age, the logistic regressions in each country revealed that
poor health was a very important factor leading to retirement in each country
for both men and women (except Philippine women). Urban residence and
involvement in the non-agricultural, non-family sector also tended to promote
retirement; education had generally small and inconsistent effects.
Pension income or coverage had strong effects, but not in a similar
direction across all four countries. In Taiwan and Thailand, having pension
income or coverage was a strong positive factor in the likelihood of being
retired among both men and women. It was not a significant factor in the
Philippines, and it was a negative factor in Singapore—that is, Singaporeans
with pension coverage or income were more likely to be working than those
without such benefits. We traced these differences to the breadth of the
Singapore pension program, the skills of those covered, and the relatively
early age of retirement, although further investigation of the precise dynam
ics is clearly warranted.
We found that family factors also played a role in retirement. Men and
women who had a spouse working were much less likely to be retired (ex
cept in the Philippines) than the non-married, suggesting that joint decisions
often come into play. Generally, those living with a married child were more
likely to be retired, though the cause-and-effect relationship here is some
what ambiguous, as were those with greater numbers of living children.
To more formally pursue the comparative analysis, the survey data
were pooled to examine the presence of distinct country effects, after con
trolling for the other determinants, with an additional interaction term added
to represent the distinct effects of pension coverage in Singapore (Table 7.8).
The logistic regressions indicated significant country effects, which are cap
tured in Table 7.9 for those with and without pension coverage. Among urban
residents with pension coverage, Philippine and Singaporean men and women
are less likely to be retired than those in Taiwan and Thailand. But among
urban residents without pension coverage, Singaporean men and women show
the highest probability of retirement, while Philippine men and women show
the least, after taking into account other factors. The higher involvement of
Philippine elderly in the labor force also appears clearly in the rural areas.
The pooled multivariate analysis confirms the distinct labor force pro
file of the Philippines and the very sharp effects of pension coverage in
Singapore; but it diminishes, and in some cases reverses, the differences
between Taiwan and Thailand.
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Work, Retirement, and Leisure 285
The underlying theoretical focus on multiple dimensions of well-being
requires that emphasis be given to the older population's preferences about
work and leisure in studying labor force activity. Relevant to this goal is
studying the reasons workers give for retirement, as well as their expressed
desires about retirement. Tables 7.10-7.12 touch on these issues, and reveal
that among the current elderly, retirement as a voluntary and desirable stage
of life is far from normative. In the Philippines, Thailand, and Taiwan the
major reasons for retirement center around health problems or the job being
too demanding for the respondent's age or capacity. In Singapore, and to a
certain extent in Taiwan, the emphasis is on reaching a mandatory retirement
age, though the trend data for Singapore (Table 7.11) reveal an increase in the
proportion who retire because they are financially able to do so. These re
sponses coupled with the prominence of the attitude that people should work
as long as they are able (Thailand, Philippines, and Taiwan) and doubt about
the desirability of a mandatory retirement age (Singapore), suggest that pref
erences among the current elderly lean strongly toward continued employ
ment to the extent possible.
As Quinn and Burkhauser (1994) note, the literature of the 1940s and
50s described retirement largely as an involuntary process driven by poor
health, layoffs, and mandatory retirement policies. In the United States, a
trend toward more voluntary retirement appeared in the early 1960s, but it
was not until 1982 that more retirements were voluntary than involuntary,
according to a survey of Social Security beneficiaries. From this perspective,
the current older generation in the four countries appears to be at the stage
that characterized the U.S. and other industrialized nations 30 to 40 years ago
when retirement was less a matter of choice and more a matter of involuntary
factors centering around health and conditions of employment.
In the coming years, it is reasonable to expect a rapid transformation
of retirement toward a more voluntary process in these countries for a num
ber of reasons. One set of factors stems from the expansions and rationaliza
tions of the social security systems ongoing in each country (see Chapter 3),
which should increase the proportion of workers with coverage and the
amount of the benefits. The second broad force for change arises from the
new cohorts of elderly in coming years who will likely be better educated,
more often employed in the modern sectors of the economy, and in better
health, and will likely have different expectations and preferences about how
to spend the later years of life.
The move toward retirement as a more voluntary decision that bal
ances financial and other incentives to withdraw from employment against
incentives and benefits of continued work does not necessarily presage a
trend toward earlier ages at retirement in the four countries under study, or
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286 The Well-Being of the Elderly in Asia
others similarly situated. The trend data available for the four countries (Fig
ures 7.1 and 7.2) show very little change in labor force participation rates at
the older ages, in contrast to those observed in OECD countries. In addition,
the Asian countries which have historically mandated relatively early-age of
retirement for government employees and those in the modern sector, are
taking steps to increase the mandatory age of retirement and to develop pro
grams that induce firms to retain older workers and help older workers main
tain marketable skills. Policymakers in many of the newly industrialized and
developing countries are aware of the financial incentives in the pension and
social security systems of the more industrialized countries that contributed
to the sharp trend toward early retirement. They can benefit from this expe
rience in designing or modifying their own systems.
Although many older workers in the four countries reported leaving
the labor force because of poor health or job factors, they do not report
inactivity. The overview of leisure activities in Table 7.13 shows that a high
percentage of the older population is engaged in one or another form of lei
sure including more physical and social activities as well as more passive and
solitary pursuits. Surprisingly little variation was found in the level of involve
ment across basic categories of gender, health, and labor force activity. The
longitudinal analysis from Taiwan shows that leisure activity does not change
greatly with retirement, suggesting that participation in these activities tends
to be established earlier and maintained to the extent possible as a person
ages. These conjectures however need to be tested further with more refined
data that account for the amount of time devoted to various activities as well
as the degree to which leisure activity supports the emotional health of the
elder ry.
Several policy challenges flow from the current and emerging pattern
of labor force participation in tandem with the other aspects of well-being.
The high proportion of the current elderly who report they stopped working
because of poor health or their inability to meet job demands indicates the
need for policymakers to assure that health and related support facilities are
adequate and accessible and that recreational facilities are sufficient for those
with special needs. To the extent that current retirees have stopped work
without adequate financial resources, policymakers should assure that the
coverage and benefit levels under social security and pension programs are
adequate in conjunction with familial and other sources of support.
At the same time it is necessary to look ahead at those in their prime
working years. It will be necessary to fine tune retirement programs so that
they provide adequate income in the years after work but not inducements to
stop work too early, thereby generating higher costs and lost productivity
Policymakers should also promote programs that enhance the health and
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Work, Retirement, and Leisure 287
marketable skills of adult workers, increasing the number who will be able
and willing to work at older ages. Concomitantly, policymakers should rec
ognize that the older population's recreation and leisure interests, particularly
in combination with greater incomes and longer life expectancies, can be a
strong stimulus for the economy if the activities developed are accessible and
appropriate to this age group.
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NOTES FOR TABLES
Table 7.2 and Table 7.3
The questions used to ascertain current work activity for each country are as
follows.
Philippines
We would like to know about your current work situation. At present (during the
last month), would you say you are: (1) working, (2) have a job but are temporarily
laid off or absent, (3) not working but looking for work, (4) helping out with family
business, but not working for a living, (5) helping out in farm, but not working for
a living, (6) keeping house, (7) not doing any of the above.
The following recedes were used for the classification in Tables 7.2 and 7.3:
1 = currently working
2,3 = in labor force, not currently working
4,5 = working without pay
6,7 = not working
Additionally, those currently working less than 40 hours/week were coded as
working part-time, and those currently working 40+ hours per week were coded as
working full-time. Respondents who were not currently working but had worked
sometime in the past \vere identified as not working/retired, and those who had
never worked as not working/never worked.
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290 The Well-Being of the Elderly in Asia
Thailand
E1. Within this past week did you work to support yourself or family? (1) yes,
(2) no
E2. (If didn't work in past week) Why did you not work within this past week?
(1) retired, (2) old, (3) poor health/sick, (4) physical problem, (5) had an accident,
(6) other.
E3. (If didn't work in past week) Within the past year did you work to support
yourself or your family? (1) yes, (2) no
E13. Did/do you receive any compensation in terms of money or materials? (1)
money only, (2) material only, (3) money and material, (4) did not receive
compensation.
E4.1. (If didn't work in past week) Have you ever worked to support yourself
or family? (1) yes, (2) no
E44. Do you want to work? If so, do you think you are able to? (1) want to and
able to, (2) want to but not able to, (3) don't want to.
The following recedes were used for the classification in Tables 7.2 and 7.3:
IfEl=l and KH = 1 or 3, then R is currently working
If El = OandE3 = 1 andE2 = 3,4, or 5 andE44 = 1, thenRisinLF, not
currently working
If E1 = 1 and E13 = 2 or 4, then R is working without pay
If El = 0 and E4.1 = 1 and R is not in labor force, then R is not
working/retired.
If El = 0 and E4.1 = 2, then R is not working/never worked.
The definition of currently working in Thailand does not include those who
say they are working and yet only receive matehal goods. This is a different
definition that that used in the Philippines, Singapore, and Taiwan. We opted for
this distinction because the other countries began the series of questions about
employment with an overall question about current work status that included
categories similar to "unpaid family worker". The questionnaire in Thailand used a
different strategy of asking sequential questions first about work status in general
(related to "supporting oneself or one's family") and then questions about forms
of compensation. The slightly different definition for current work status that we
use for Thailand is an effort to identify those unpaid family workers who might
have been screened out of current work status if they had been asked the more
global work status question that was used in the other countries.
Note: The Thai questionnaire does not include questions to ascertain whether
R is currently working full or part-time.
Taiwan
Next we'd like to ask about your work. Are you presently working? (1) yes
(includes primary or secondary profession), (2) have a job but haven't worked in a
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Work, Retirement, and Leisure 291
while, (3) help out with family farm or business, not a formal job, (4) unemployed,
looking for work, (5) do housework (cooking, cleaning, shopping, childcare), (6)
none of the above.
The following recedes were used for the classification in Tables 7.2 and 7.3:
1 = currently working
2,4 = in labor force, not currently working
3 = working without pay
5,6 = not working
Additionally, currently working Rs were asked whether they were working full
or part-time, and this designation is reflected in Table 1. Respondents who were
not currently working but had worked sometime in the past were identified as not
working/retired, and those who had never worked as not working/never worked.
Singapore
Activity/occupational status: (1) working, self-employed; (2) working
employee/odd job; (3) working, unpaid family worker; (4) not working but looking
for work; (5) not working and not looking for work.
The following recedes were used for the classification in Tables 7.2 and 7.3:
1,2 = currently working
4 = in labor force, not currently working
3 = working without pay
5 = not working
Additionally, currently working Rs were asked whether they were working full
or part-time, and this designation is reflected in Table 1. Respondents who were
not currently working but had worked sometime in the past were identified as not
working/retired, and those who had never worked as not working/never worked.
Table 7.10
Tor the Philippines, combinations of responses were coded for 17 respondents.
These were assigned to the above response categories as follows:
1. If both health problems and family care were reported, health problems
were coded.
2. If both health problems and job demands were reported, health problems
were coded.
3. If both job demands and family care were reported, family care was coded.
4. If both reached mandatory age and health problems were reported,
mandatory age was coded.
bFor Taiwan, respondents were allowed to give multiple responses, so
percentages will not add up to 100.
Tor Taiwan, this category includes all reasons related to family.
Dashed (—) entries indicate that the category was not coded as one of the
response categories for that country.
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292 The Well-Being of the Elderly in Asia
Table 7.13
The following survey questions were used to ascertain types of leisure activities
in each country.
a. Mass media
Philippines: 1) Read newspapers, magazines or books at least once a week
2) listen to radio or watch TV at least once a week.
Thailand: 1) Within the past week, read any newspaper?
2) listen to the radio or watch any television?
Taiwan: 1) Read any newspaper, books, magazines, or novels at least
once a week
2) listen to radio/ tapes or watch TV/videos at least once per
week.
Singapore: Relevant questions not asked.
b. Physical activity (1st measure)
Philippines: 1) Do physical exercises such as jogging and outdoor
recreational activities like golf or fishing at least once per week
Thailand: 1) Walk at least once per week
2) Exercise (e.g., run, taichi, gardening, planting trees) at least
once per week.
Taiwan: 1) Take walks at least once a week
2) jogging, mountain climbing, playing ball or other physical
exercise outside the home.
Singapore: Relevant questions not asked.
c. Physical activity (2nd measure)
Philippines: 1) Do physical exercises such as jogging and outdoor
recreational activities like golf or fishing at least once per week
Thailand: 1) Exercise (e.g., run, taichi, gardening, planting trees) at least
once per week.
Taiwan: 1) jogging, mountain climbing, playing ball, or other physical
exercise outside the home.
Singapore: Relevant questions not asked.
d. Religious activity
Philippines: 1) Meditate or pray at home at least once a week
2) attend religious services.
Thailand: 1) In the past month, offer alms to Buddhist monks (or asked
someone else to do on own behalf)
2) pray or meditate at least once per week.
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Work, Retirement, and Leisure 293
Taiwan: 1) Chant sutras, pray and bur n incense, go to temple to offer
incense or study sutras, pray, or go to church at least once per
week.
Singapore: 1) Visit a church/temple/mosque in the past month?
e. Social clubs
Philippines: 1) Member of religious groups
2) business, professional or farm association
3) voluntary, welfare or aid group
4) political group
5) community center or social/recreational club
6) clan association
7) organization of retired elderly persons
8) other association/club.
Thailand: 1) Member of a cooperative group
2) housewife group
3) elderly group
4) funeral group.
Taiwan: 1) Belong to neighborhood association
2) religious association
3) farmers' association
4) political association
5) social services groups
6) village or lineage association
or 7) elderly clubs.
Singapore: 1) Ever used Senior Citizen's Club before?
2) Ever used Social Day Centre before?
3) visited a community centre in the past month
4) visited a Senior Citizen's Comer in the past month.
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Chapter 8
ECONOMIC WELL-BEING: INSIGHTS FROM
MULTIPLE MEASURES OF INCOME AND ASSETS
Albert I. Hermalin, Ming-Cheng Chang, and Carol Roan
As discussed in greater length in Chapter 4, a major concern in the study
of population aging is the effect of demographic and socioeconomic
trends on the economic well-being of the elderly. Many observers, though by
no means all, have concluded that factors of development would adversely
affect the status of the elderly by trapping them in more traditional and less
rewarding jobs, and separating them from their families as children migrate to
urban areas in pursuit of better jobs (see Cowgill, 1974 vs. Treas and Logue,
1986). Many of these speculations have their basis in the history of currently
industrialized societies; relatively little direct empirical experience has as yet
accumulated about the economic well-being of the elderly in developing and
newly industrialized countries. Even when attention has been given to the
material well-being of the older population in developing countries, the mea
sures employed have centered on their living arrangements or continued re
ceipt of some support from children or other family members. As noted in
Chapter 4 and elsewhere (Hermalin, 1995; and Hermalin, 1997), undue reli
ance on simple measures of coresidence may confuse "form" and "function"
by failing to describe the actual directions and magnitudes of support across
295
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296 The Well-Being of the Elderly in Asia
generations. Indeed Chapter 6, which examines the intergenerational transfer
system within each country, demonstrates that the older persons provide
considerable assistance to their children and others in a number of forms at
the same time that they are frequently recipients of money, material goods,
and time from others. Nevertheless, one cannot infer the economic well-
being of the elderly from their coresidence with children or their patterns of
exchanges. For this purpose one needs more objective measures of income
and assets, complemented by the elderly's own perception of sufficiency of
income and satisfaction with their economic status.
Direct measurement of economic status is also important from a policy
perspective. As a way of minimizing the high costs of "Western" systems of
social security and old-age care, policymakers in many developing and newly
industrialized countries would like to maintain to the degree possible tradi
tional family arrangements in which children provide considerable support
for their older parents. To this end, policymakers need to go beyond simple
measures of living arrangements and support to assess the economic well-
being of the older population in some detail. Otherwise they run the risk of
failing to identify (a) problems with traditional family arrangements, (b) groups
of elderly who are most vulnerable, and (c) additional programs that might
bolster existing arrangements.
Detailed economic data for the older population in developing coun
tries have not been frequently collected. However, the 1994-1996 round of
surveys reported on here did collect a variety of income and asset informa
tion. This chapter uses this data to describe the economic situation of the
elderly from a variety of perspectives, within each country and compara
tively, and to analyze characteristics associated with levels of economic well-
being. The next section describes the measures available and the plan of
analysis for the remainder of the chapter.
Measurement Issues Related to Economic Well-Being
The measurement of economic well-being of the elderly is complicated by a
number of conceptual and operational issues. Some of these are of a rather
general nature, common to most countries and age groups; others impinge
more directly on older age groups and countries with more complex living
arrangements. Income is often used as a prime indicator of economic well-
being, and in nearly all settings eliciting reliable estimates from a survey is
problematic. Non-response tends to be high and non-random; farmers and
the self-employed may have difficulty providing net income accurately, as
might those with multiple sources of income. Among the elderly these basic
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Economic Well-Being 297
issues may be compounded by memory problems, lower involvement in eco
nomic affairs, a multiplicity of sources, and perhaps the irregular flow of
some of them.
Household arrangements may present additional complications. Be
cause a high proportion of elderly individuals and couples in the industrialized
countries of the West maintain their own households, correspondence is gen
erally high between their income and that of the household. As a result, fairly
direct comparisons between their income level and those of other households
can be made, after adjusting for household size and perhaps other factors. In
many developing and newly industrialized countries (as well as Japan), how
ever, a high proportion of the elderly live with children, and many, whether or
not they coreside, receive financial support from their children (see Chapter
6; Hermalin, 1995; Knodel and Debavalya, 1997). As a result one needs to
distinguish between the income of the elderly respondent or couple and the
income of the household, and take account of allocations within the house
hold both direct and indirect (for example, one elderly couple coresiding with
children may have all their food and other expenses covered, while another
contributes substantially to the running of the household). Even the elderly
living alone may have certain expenses paid for by others, instead of or in
addition to receiving money income from children.
Beyond these considerations, a number of distinct dimensions of in
come can be operationalized and used in description and analysis. In addition
to the absolute level of income of the elderly unit or household, interest often
centers on relative measures that permit comparison with other families in
general or those in the same age range through attention to an appropriate
aggregate distribution (for example, identifying whether a family is in the top
or bottom 10 or 20 percent of a distribution). And, as suggested, the sources
of income among the elderly and the relationship between source and level
might also be gauged. Another measurement possibility is to assess the suffi
ciency of income in relation to expenditures or to some poverty level. At a
more perceptual level, inquiry can be made about the degree of satisfaction
with income or economic well-being.
Income, regardless of its complexity, is only one dimension of economic
well-being. The asset and debt situation of an elderly unit or household is also
a major determinant of the elderly's ability to obtain vital resources for living
and becomes more critical after retirement. Assets may serve as a current or
future source of income and may also be part of an exchange arrangement
with children. Obtaining accurate asset information in a survey can prove
even more difficult than income given problems of valuation, joint ownership,
and privacy, and questions on the topic often result in high levels of non-
response and misreporting. In recognition of these problems, the U.S. Health
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298 The Well-Being of the Elderly in Asia
and Retirement Survey, for example, has initiated several approaches for
reducing non-response and identifying the proper asset range through a series
of "unfolding" questions (Juster and Suzman, 1995; Juster and Smith, 1997;
Hurd, 1999). Beyond the measurement difficulties, cultural practices must
be taken into account. In Taiwan and other Chinese societies, it is not
uncommon for parents to subdivide their assets while alive, sometimes in
anticipation of the support they will be receiving from children. For example,
Li et al. (1993) found that 25 percent of older parents surveyed in 1989 in
Taiwan reported dividing all or part of their property.
The variety of measures implied by the foregoing can be collected at
some point in time, but interest also centers on changes in income and assets
over time. Although evidence of change can be approached through retro
spective questions, panel designs that obtain repeated measures are preferred
for their accuracy. The four surveys used here collected a variety of mea
sures of economic well-being that will be exploited in this analysis. In addi
tion, the panel data for Taiwan permits an examination of how income and
assets change for a cohort as it ages, and some of these dynamics will be
presented as well, with additional analysis in Chapter 12.
Collectively, the measures of income, expenditures, and assets de
rived from the surveys include the following, though not all the question
naires covered all the dimensions:
• Total income of respondent (and spouse)
• Total income of household from all income earners
• Household pooling arrangements for meeting household expenses
• Payment of household expenses by those not residing in household
• Major source(s) of income for respondent (and spouse)
• Ability of respondent (and spouse) to meet household expenses
• Satisfaction with current economic status
• Proportion owning their home and value of home (and land)
• Proportion owning other assets.
In obtaining the amount of individual (or couple) and household in
come, respondents were asked to report a specific amount, and if they could
not (or would not) do that, they were asked to select from a list of income
intervals. In each country, except Taiwan, this served to significantly reduce
non-response rates for individual/couple income, but not non-response for
household income. The response rates for the other measures of economic
well-being were quite high.
Because the sampling design called for interviewing only one elderly
respondent per household, it is important to be clear about the unit for which
the older person was responding. Given that married couples often pool income,
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Economic Well-Being 299
respondents in the Philippines, Thailand, and Taiwan who were currently
married and living with their spouse were explicitly asked to report their joint
income, their major source of income as a couple (although sources received
by husband and wife were recorded separately), and their joint perception of
income adequacy and satisfaction. In addition to potentially having two sources
of income, the elderly married often differ on other characteristics from the
elderly who are not married (i.e., widowed, divorced, or never married).
They are likely to be at a somewhat earlier life cycle stage, to be working, and
to have younger children. In addition, non-married older men will often be
quite distinct in their work histories, ages, and other characteristics from
older non-married females. Accordingly, in the tables that follow we often
stratify or control the results by marriage status and gender, creating three
categories of "economic units": married couples, unmarried males, and
unmarried males. It is important to note that these units have a variety of
living arrangements, ranging from residing alone, to living with children, or
living with others. Any reference to household income refers to the total
income of all household members as reported by the respondent.
Although the various dimensions of income and economic well-being
described above are all interrelated and do not form a distinct system, many
can be ordered in a heuristic and logical manner as suggested in Figure 8.1.
The figure helps make clear the interconnections among the income-related
measures and serves as a broad guide to the analyses presented.
According to the figure the direct income of the elderly "unit" is deter
mined by the characteristics of the respondent or couple and the sources of
income. These, along with the amount of income, determine whether there
are also forms of indirect support. The levels of direct and indirect support
determine the degree to which the elderly "unit" has sufficient income to
meet expenses, and this level of sufficiency, along with the amounts of in
come, determine the level of satisfaction the elderly have with their economic
well-being. The amount and nature of the assets owned will also influence the
sources and amount of income, and are likely to affect expressed levels of
satisfaction as well, but the dynamics between income and assets are not
reflected in Figure 8.1.
The following sections present analyses based on the economic mea
sures listed above and the logic of Figure 8.1. The next section presents an
overall picture of income levels of the elderly in absolute and relative terms.
This is followed by an examination of the major sources of support for the
elderly economic "units" and how the amount of income varies by source
and sociodemographic characteristics. We then turn to the level and impor
tance of indirect sources of support by examining household income and
pooling arrangements. This leads to an assessment of economic well-being in
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Economic Well-Being 301
terms of reported adequacy and satisfaction. The final sections report on
assets and provide some illustrative panel analyses for Taiwan.
Levels of Income in Absolute and Relative Terms
In this section we focus on the amount and the distributions of income for
the elderly economic units as reported for 1995 or 1996. We report on a
variety of indicators of both absolute and relative income in both local curren
cies and U.S. dollars to facilitate comparisons across the countries. Table 8.1
presents the basic data collected in each country showing the mean and me
dian of annual money income received by the elderly respondent or couple.
(The lack of clarity in Singapore as to whether married respondents were
reporting for themselves or for the couple should be kept in mind—see foot
notes to Table 8.1).
In each country, not surprisingly, married couples report higher in
come than unmarried respondents; but the difference between unmarried
males and females varies by country. In Taiwan and Thailand, males who are
widowed, divorced, or never married have substantially more income than
similar females, but in the Philippines and Singapore, men and women in
these marital statuses are not far apart. The proportion of all the units report
ing that they received no money income varied from 3 percent in Taiwan, to
8 percent in the Philippines, to 10 percent in Thailand (not asked in Singapore).
In each country the lowest category of income (or the lowest two in cases
with those reporting no income) contain one-fifth to one-third of all eco
nomic units. In Taiwan and Singapore, the distributions are quite highly
skewed, with a sharp drop off in proportions in the upper categories, but the
Philippines and Thailand show a more regular distribution across the whole
range. (Conversions into U.S. dollars are given in subsequent tables but it is
worth noting that by coincidence the Philippines, Thailand, and Taiwan have
very similar conversion rates of their basic unit—peso, baht, and New Tai
wan dollar, respectively- with each worth about .04 U.S. dollars in the period
covered.)
Table 8.2A presents more direct comparisons of elderly income across
countries by giving the averages in U.S. dollars, and sets the stage for assessing
its adequacy by presenting measures of average income for the population in
terms of GNP per capita or GDP purchasing parity per capita. The latter
attempts to incorporate differences in cost of living and related factors to
achieve more comparability in assessing relative welfare across countries
(see footnote to Table 8.2 and CIA, 1997. In comparison to GNP, the GDP
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Table 8.1. Mean, Median, and Percentage Distribution of Yearly
Income by Economic Unit: Philippines, Thailand, Taiwan,
and Singapore
PhilippinesIncomeMean (in Peso)MedianNo incomeLess than 2,5002,500 to 7,4997,500 to 17,49917,500 to 47 ,499More than 47,500Valid NMissing incomeMarried
Couples36,35115,0001.98.017.326.126.719.96235.3Unmarr.
Males1847610,00014.713.514.022.128.17.61422.9Unmarr.
Females186526,00014.620.318.619.617.49.64646.9Total28,21410.2187.712.917.423.423.714.91,2295.6TaiwanIncomeMean ($NT10,000)MedianNo incomeLess than $100,000$100,000 to $300,000$300,000 to $600,000$600,000 to $1 million$1 million and aboveValid NMissing incomeMarried
Couples27.820.51.726.841.620.65.73.61,80921.5Unmarr.
Males19.215.43.238.042.312.23.11.339519.3Unmarr.
Females13.810.37.855.426.18.51.6.558325.2Total24.016.83.133.738.717.24.62.82,78821.9
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Table 8.1. continued
See Notes for Table 8.1 at the end of this chapter.
ThailandIncomeMean (in Baht)MedianNo incomeLess than 5,0005,000 to 9,99910,000 to 19,99920,000 to 49,999More than 50,000Valid NMissing incomeMarried
Couples37,62215,0005.519.212.917.725.519.22,0696.7Unmarr.
Males16,5095,00013.534.212.814.017.08.637013.1Unmarr.
Females12,9713,75019.434.614.312.513.55.81,55413.9Total29,01610,00010.124.713.316.021.414.63,9939.4SingaporeIncomeMean (Singapore $)MedianLess than $3,000$3,000-5,999$6,000-8,999$9,000-11,999$12,000-14,999$ 15,000 & OverValid NMissing incomeMarried
Couples8,4496,78115.729.020.112.410.312.41,691.88Unmarr.
Males5,8984,70928.736.915.49.34.74.85410.5Unmarr.
Females5,2394,55629.838.919.65.24.12.51,7691.2Total6,9505,45122.533.719.49.47.37.73,9651.0
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304 The Well-Being of the Elderly in Asia
reduces the range of incomes across the four countries, and has a particularly
notable effect in raising the income levels of Thailand and the Philippines.
In terms of yearly averages in U.S. dollars, older economic units have
money incomes of about $1,100 in the Philippines and Thailand, $4,900 in
Singapore, and $8,800 in Taiwan. Income distribution patterns produce me
dian annual incomes that are less than one-half their means in Thailand and
the Philippines, and about three-quarters their means in Singapore and Tai
wan.
The GDP and GNP per capita measures permit a comparison of the
general living standards in each country against which to appraise the income
of the elderly. In terms of purchasing parity, the per capita GDP for
Singaporeans is the highest at $21,200; the Taiwanese have about 70 percent
of this amount, Thais have about one-third, and Filipinos have about one-
eighth. The GNP per capita figures assume the same sequence among the
four countries, with an even a stronger advantage for those in Singapore. The
first notable surprise comes from comparing the income of the elderly with
these national averages. Despite the overall economic advantage for Singapore,
the elderly there receive less absolute income than those in Taiwan, and de
spite much lower national income averages in the Philippines, the elderly
there have incomes equal to those in Thailand. Clearly a number of local
factors must be considered in comparing money incomes across countries.
Table 8.2B presents some relative measures based on these data. The
first four columns express the averages of the elderly and the population as
index numbers with the Philippines as 100. These reveal, as noted above, that
the Philippine elderly have about the same income as their Thai counterparts
although the country has only about a third of the GDP or GNP per capita.
Relative to the Philippines, Singapore shows much higher multiples of GDP
and GNP than it does for elderly income, while for Taiwan the differences in
elderly income relative to the Philippines are basically similar in magnitude to
the differences in overall GDP and GNP.
The last four columns express the money incomes of the elderly (both
means and medians) as a proportion of the two overall income measures in
their countries. The incomes of the elderly in Taiwan and the Philippines
assume a similar percentage of national average per capita income—roughly
40 to 50 percent in terms of the ratio of the median to average GNP. The
incomes of the elderly in Singapore and Thailand are also comparable in terms
of their proportion to the national average, but are significantly lower at only
about 15 percent of the per capita GNP. If we compare the mean elderly
income to GDP per capita, perhaps the most appropriate measure, the picture
is similar. The Philippine and Taiwanese elderly have proportions at the high
end, 42 and 60 percent of the overall average respectively, and Singapore and
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306 The Well-Being of the Elderly in Asia
Thailand are at the low end, with 23 and 15 percent respectively. The rela
tively poor position of the Thai elderly on this measure occurs in part because
of the low cost-of-living assumptions for Thailand implicit in the conversion
from GNP to GDP. Though one cannot extrapolate from the experience of
these four countries, it would appear that there is no simple relationship be
tween level of development and the well-being of the elderly as expressed in
these measures. It is true that Singapore, the most developed of the coun
tries, displays low absolute and relative income of the elderly, but Taiwan, the
second most well-developed economy, does very well in these respects.
Major Sources of Income
In keeping with the framework described in Figure 8.1 and the interest in
these countries in maintaining traditional support patterns, Table 8.3 intro
duces the question of the sources of support for the older economic units. It
provides the distribution of the major sources of income reported by the
respondents for themselves (and for themselves and their spouses).
Across all countries and types of economic unit, money from children
or other relatives is reported most frequently as the major source of income,
varying from a low of 31 percent in the Philippines to a high of 77 percent in
Singapore. Taiwan resembles the Philippines in this regard, with Thailand
midway at 55 percent. Singapore and Thailand evidence the greatest percent
ages on this source of income for each type of economic unit, with the
proportion among unmarried females reaching 90 percent for Singapore and
almost 80 percent for Thailand. In each of the four countries, unmarried
females are more likely to rely on children or other relatives than are married
couples or unmarried males, reflecting their generally lower attachment to the
labor force and lesser control over other potential sources of income. In the
Philippines and Thailand, unmarried males are more likely to rely on support
from children than married couples, but in Singapore and Taiwan, they are
somewhat less likely.
In each country but Taiwan, income from work is the second most
frequently reported major source of support among all economic units. If one
includes agricultural pursuits (shown separately for the Philippines and Taiwan)
with work, this combination is reported as the major source of income by
more than half of all the economic units in the Philippines, by over a third in
Thailand, about a quarter in Taiwan, and close to a fifth in Singapore. This
ordering of the prominence of work is consistent for each type of economic
unit, though a higher proportion of unmarried Singaporean than Taiwanese
males report work as their major source of income. Among unmarried females,
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Table 8.3. Major Source of Income: Percentage Reporting Each Source
by Type of Economic Unit and Country
1 Includes: rentals, savings, real estate, stock, annuity, severance pay.
b Includes: fanning, timber, fishing, animal husbandry.
Entire sampleWorkPension, retirement, CPF
Income from investments"Family business
Agriculture1*
Children or other relativesOtherMarried couplesWorkPension, retirement, CPF
Income from investments1Family business
Agriculturei'
Children or other relativesOtherUnmarried malesWorkPension, retirement, CPF
Income from investments*Family business
Agricultureh
Children or other relativesOtherUnmarried femalesWorkPension, retirement, CPFIncome from investments"Family business
Agriculturei'
Children or other relativesOtherPhil Thai Taiw30.0 37.9 20.49.1
1.92.3 29.2
4.4 5.94.6 -- 1.6
23.3 - 4.0
31.1 55.4 36.5~2.432.4 49.8 25.99.4
1.93.2 28.1
4.3 5.95.2 -- 2.0
29.8 -- 4.9
21.3 42.8 31.7-1.528.4 23.1 11.911.1
0.51.5 44.5
5.8 4.84.7 - 1.1
18.7 - 4.0
36.6 69.6 27.4-26.37.92.46.317.2 6.90.7 23.14.3 6.83.5 -- 0.5
12.8 - 0.8
47.2 77.8 59.0--2.9Sing17.62.2
1.876.61.824.82.7
1.569.51.421.74.4
3.566.34.16.30.81.789.71.6
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308 The Well-Being of the Elderly in Asia
only those in the Philippines and Thailand rely in significant proportions on
work as a major source of income. This accords with the labor force
participation rates given in Chapter 7.
Aside from income from children and work, the only other substantial
category is income from pensions or other retirement arrangements, and this
source is a major factor among the current older population only in Taiwan,
where it is reported by 29 percent of all economic units. As discussed in more
detail elsewhere (Shih, 1997), the prominence of retirement funds there can
be traced to the high proportion of Mainlanders among the elderly—Chinese
who migrated to Taiwan in 1949-50 following the civil war and who were
predominantly military personnel and officials eligible for governmental
pensions. Also, because many of the Mainlander men never married, the
proportion of the unmarried Taiwanese males reporting pensions as the most
important source of income is especially large. Moreover, starting in 1994, all
elderly in several cities and counties in Taiwan received special pension benefits
as a result of promises made in local elections, which may also increase the
proportion of those reporting pension as the major source of income. (More
detail on these special payments and their effect is given in Chapter 6 and
discussed further in Chapter 12.)
The infrequent reliance on pensions as the major source of support in
Singapore is surprising, and merits some comment. The Central Provident
Fund (CPF) in Singapore dates to 1955 and is among the highest in popula
tion coverage of any plan in Asia. According to Chan's analysis (1997), al
though it began mainly as a retirement program, the CPF soon evolved into an
umbrella program for multiple purposes—education, medical insurance, and
housing—which often meant that the amount available at retirement was in
sufficient or unavailable for regular living expenses. Of those with CPF ac
counts (about a third of the older population), over 60 percent report the
amounts as inadequate for old age, and only 7.5 percent used it for 25 percent
or more of their monthly living expenses (Chan, 1997, Table 2). Changes in
the minimum amount that must be set aside for retirement were recently
instituted, and studies now underway may show a change in the role of CPF
funds as a source of income for retirees. (See the Asset section below and
Chapters 3 and 7.)
Factors Affecting Levels of Income
This section investigates the degree to which levels of income vary by the
sociodemographic characteristics of the economic units and their major sources
of income. Tables 8.4 and 8.5 use three measures of income that facilitate
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Economic Well-Being 309
comparisons across characteristics and countries. Table 8.4 reports the ratio
of the mean and the median incomes of those in each sociodemographic
category to the overall mean and median incomes for each country. Table 8.5
reports the proportion of those in each sociodemographic category that fall in
the lowest tier of the income distribution, highlighting those who are particu
larly vulnerable as a result of low income. The characteristics investigated
include age, marital status/gender (type of economic unit), education, urban-
rural residence, living arrangements, self-reported health, and major source
of income. Where the economic unit is a married couple, the characteristics
of the husband are used for the age and education variables.
The characteristics analyzed in Tables 8.4 and 8.5 have been shown to
be closely associated with income over many studies, but the relationship in a
number of instances are complex and caution must be exercised in attributing
causality, particularly from cross-sectional data. Age, education, and, to a
large extent for these older groups, marital status/gender and location can be
considered determinants of income. However, for living arrangements, health,
and major source of income, influences run in both directions.
For example, if a widowed woman with insufficient resources moves
into the home of her married child, her income has affected her living ar
rangements. Similarly health and income have relationships that can vary
throughout the life course and by time and place. For those still of working
ages, income can exert a strong influence on health through the level of
resources provided for medical care. At older ages, health often affects labor
force participation (as shown in Chapter 7) and thus income. (See Smith,
1999 and Preston and Taubman, 1994, for additional discussion.) Level of
income and major source of income are also characterized by bidirectional
causality. Level of current and past earnings can affect whether or when
older people retire and whether they receive major support from their chil
dren. For these and other reasons, the differentials in income shown for these
characteristics should be viewed as reflecting the level of association, rather
than indications of cause. Our interest centers on how strong these associa
tions are, and the degree of similarity across countries.
The differentials in the indexes of mean and median income shown in
Table 8.4 are highly consistent from country to country. This shows up
graphically in Figure 8.2 in the similarity of profiles across countries. Also,
the differentials by characteristic offer few surprises. Income is higher among
the younger respondents or husbands (in the case of married couples, the age
and education of the husband was used to represent the couple and contrast
with the unmarried males and females), and declines quite steeply with age.
For example, the mean income of those 60-65 years old in the Philippines is
2.4 times the mean income of those 80 or older. (The ratio of one index to
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314 The Well-Being of the Elderly in Asia
another is also the ratio of one mean to another, given the definition of the
index.) As noted above, economic units consisting of a married couple have
consistently higher incomes than do unmarried males or females. Education
shows a sharp income gradient in each country, with the relatively small
number of those with secondary or higher education particularly advantaged
in comparison to their less educated counterparts. (The number of elderly in
each category can be gauged by the table in Appendix 8.A, which gives the
sample sizes.) Income tends to be lower among the rural elderly, but the
differences between those in capital cities versus other urban areas tend to be
smaller than the urban-rural differentials, and are not consistent from country
to country.
The last three characteristics address the relationships of living ar
rangements, health, and major source of income to income level. Given the
concern often expressed about the welfare of the elderly who are not inte
grated into families and the vulnerabilities of the "abandoned" elderly, it is
important to note that on every income comparison but one shown in Table
8.4, those living alone or as a couple do as well or better in terms of money
income than those living with married children. This is not surprising given
that more income is generally required to maintain a separate household, an
issue treated at greater length below. Those living with unmarried children
tend to report the highest income, almost certainly because they tend to be
younger and still in the labor force. The smaller numbers living with other
relatives or in other arrangements show no clear pattern, often lying interme
diate to the incomes reported in the other living arrangements. Overall, there
is rather little variation in relative income level across living arrangements or
in the pattern across countries.
In contrast, income varies consistently and strongly with self-reported
health status in every country except Singapore. In the Philippines, Taiwan,
and Thailand, those who report the highest health status (excellent or very
good) have twice or more the income of those in the lowest category, and
those at the middle level (who report their health as good or fair) have about
50 percent more income than those who report their health as poor. (See
Chapter 9 for further details on self-assessed health measures and distribu
tions.) As discussed above there are complex interelationships between health
and income, with income levels strongly affecting health over much of the
life span and health affecting income later in life. For Singapore, the lack of
strong differentials probably reflects the very high percentage of elderly who
live with their children, the tendency for nearly all elderly there to report their
health as good, and perhaps the wider availability of health services.
The last characteristic presented, major source of income, also speaks
to the adequacy of family support, given the predominance of children and
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Economic Well-Being 315
others as the major source of support reported in Table 8.3. (In Tables 8.4,
8.5, and 8.6 those reporting work, farm, or business as their major source
were combined, since income from labor could not be easily distinguished
from income as entrepreneur.) Older economic units who report children/
other relatives as their major source of economic support consistently report
lower total income than those with any other major source. It is important to
emphasize that total income is being analyzed in relation to the reported major
source. Those who report work as their major source, for example, may also
receive some of their income from children. Nevertheless, it remains the case
that the elderly who rely on family as the main provider of income are disad-
vantaged in the total amounts they receive in comparison to those whose
major source of income is another source. Among the three nonfamilial sources
of income, no clear patterns in income levels appear, but as shown in Table
8.3, major reliance on pensions is rare except in Taiwan and relatively few of
these elderly derive most of their income from investment or savings in any
of the countries.
Table 8.5 displays for the same sociodemographic characteristics pro
portions that fall in the lowest tier of the elderly income distribution—ranging
from the 22nd to the 37th percentile. (The use of bracketed income levels in
some countries made it impossible to adopt a uniform definition—like the
lowest third—for all four countries.) Given the interrelationships among the
income measures, the differentials and patterns in Table 8.5 largely follow
those in Table 8.4, but they present an alternate way of characterizing the
income position of a specific group. Among those economic units where the
respondent or husband is 80 years of age or older, about four in ten in Singapore,
almost half in the Philippines, and about two-thirds in Taiwan and Thailand
are in the lowest income tier of their country. Among unmarried females,
about half or more are in the lowest tier in the Philippines, Taiwan, and Thai
land. And among those relying on children or other relatives for major sup
port, over half in Taiwan and Thailand, 42 percent in the Philippines, and 27
percent in Singapore are in the lowest tier of income. For those with the
poorest self-reported health, the proportion in the lowest tier of income ranges
from a third in Singapore to more than a half in Taiwan. By contrast, among
those with the highest self-reported health, less than a quarter of the elderly in
each country are found in the lowest tier of income.
The characteristics shown in Tables 8.4 and 8.5 are closely interre
lated in many ways: those younger are more likely to be working and married,
for example. To estimate the effects of each characteristic on the income
position of the elderly unit, we performed logistic regressions in which the
dependent variable is the log-odds of being in the lowest income tier. Table
8.6 presents the odds-ratios derived from the regression coefficients, which
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Table 8.5. Percent of Respondents in Bottom Income Tier by
Sociodemographic Characteristics and Country
CharacteristicAge of R or husband<6565-6970-7980+Marital status/genderMarried coupleUnmarried maleUnmarried femaleEducation of R or husbandNo formalAny primarySecondary or moreLocationRuralUrbanCapital cityLiving arrangementsAlone/spouse onlyW/ married childW/ unmarriedW/ otherHealth StatusLowMiddleHighMajor source of incomeChildren/other relat.Work/businessPension/retirementInvestment, savings, otherTotalBottom Income TierPhil23.129.639.448.122.638.348.444.734.215.834.331.235.337.240.126.629.244.832.824.141.923.49.713.133.3Thai20.428.142.767.423.645.353.251.929.613.437.220.017.028.643.124.231.446.338.224.253.613.22.014.334.1Taiw27.629.941.962.628.541.263.255.933.08.550.033.023.430.846.422.235.851.941.024.754.316.533.929.536.8Sing11.816.927.443.615.728.729.826.019.78.1Inap.Inap.Inap.17.630.416.023.834.620.119.927.01.412.232.022.5
Notes: Bottom income tier is defined as follows: Philippines less than or equal to
5,000 Pesos per year. Thailand less than or equal to 4,000 Baht per year. Taiwan less
than 100,000 New Taiwan Dollars per year. Singapore less than 3,000 Singapore Dollars
per year. Inap. = not applicable.
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Table 8.6. Odds-Ratios for the Effects of Sociodemographic
Characteristics on Being in the Bottom Tier of the Income
Distribution, by Country
*p<.10 *p<.05 **p<.01 ***p<.001
Inap. = not applicable.
CharacteristicAge of R or husband<6565-6970-7980+Marital status/genderMarried coupleUnmarried maleUnmarried femaleEducation of R or husbandNo formalAny primarySecondary or moreLocationRuralUrbanCapital cityLiving arrangementsAlone/spouse onlyW/ married childW/ unmarriedW/ otherMajor source of incomeChildren/other relativesWork/businessPension/retirementInvestment, savings, otherModel Chi-Square(degrees of freedom)Odds-RatioPhil—1.161.361.67*-1.161.93***—.73*27***-.86.811.14—.78.66+—.58***.17***.29*121.4(15)***Thai-1.24*1.85***3.21***-1.85***2.26***—.70***,49***—.35***.24***.79*—.57***.67**—.21***.04***.16***1,231.3(15)***Taiw-1.131.36*2.39***-1.79***2.30***—.59***.17***—.39***.26***.62***—.54***.65*—.22***.51***.50***594.4(15)***Sing~1.181.79***3.07***-1.83***1.46***—1.02.37***Inap.Inap.Inap..72*—.62***1.04—.06***.691.84**477.4(13)***
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318 The Well-Being of the Elderly in Asia
can be interpreted as the odds of being in the lowest tier for the category
shown relative to the omitted category and controlling for the other indepen
dent variables. The independent variables used are those included in Tables
8.3 and 8.4 with the exception of health. Although, as noted, the cause and
effect directions are ambiguous for a number of the variables, this is particu
larly true of health.
A striking feature of the results is that in all countries but the Philip
pines, each of the variables continues to exert a strong and significant influ
ence on income position as observed in the bivariate relationships. That is,
those above age 70, unmarried, with lower education, residing in rural areas,
living with married children, and who receive their major source of income
from children are more likely than their counterparts to be in the lowest tier of
income. In the Philippines, however, this increased likelihood applies only to
those above 80, those with little education, and those with children as major
source of income.
To study the relationship of health to income and the effect of including
health, living arrangements, and major source of income on the more exogenous
variables, Appendix 8. B presents a set of multivariate analyses in which different
combinations of variables are regressed against income position. Panel A of
the Appendix repeats the multivariate analyses shown in Table 8.6 but adds
health status as an additional variable. A very consistent picture emerges. In
each country, the odds ratios for the variables shown in Table 8.6 remain
virtually unchanged in magnitude or significance level with the inclusion of
the health status variables. At the same time, the health status variable displays
a strong and consistent effect on income position. In each country those with
the highest self-reported health status are much less likely than those with the
lowest self-reported health to be in the lowest income tier, with the proportions
for the former group running from one-half to two-thirds, compared to the
latter. The results are significant at the 5 percent level in all the countries but
Taiwan. The persistence of the magnitude of the other variables and the
generally strong effect of health, suggest that health status is only weakly
associated with the other variables (as described in more detail in Chapter 9)
so that the relationship of health to income position is not dependent on the
other characteristics, and each maintains an independent effect on income
tier.
Panel B of Appendix Table 8.B introduces two reduced models to re
move the other variables—living arrangements, and major source of income—
which are likely to be endogenous with income level and position. Model 1
omits both health and living arrangements, while Model 2 omits health, living
arrangements and major source of income. Comparing Table 8.6 with Model
1 indicates a very consistent pattern: in each of the countries the odds ratios
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Economic Well-Being 319
for the variables in common remain virtually unchanged. Omitting living ar
rangements from the Table 8.6 specification has no effect on the remaining
variables.
When Table 8.6 is compared with Model 2, which omits both living ar
rangements and major source of income, the results are more complex. In Model
2, the effect of age on income position becomes more pronounced in each
country as does the effect of being unmarried (but only for females in
Singapore and Taiwan). In addition for the Philippines, the contrast between
those residing in rural areas and the greater Manila area is heightened in Model
2 (though still not significant), and the rural-urban contrast in Taiwan is also
heightened. Interestingly, there is little effect from omitting major source of
income on the gradients with education. Overall, the fully reduced Model 2
strengthens the effects of the four exogenous variables—age, marital status,
education and place of residence—on the current position of the elderly in
terms of income distribution.
The results in this section suggest that a number of sociodemographic
factors each exert a distinct effect on the money income of the elderly. Be
fore we can adequately characterize the economic situation of the elderly,
however, we must examine the prevalence and importance of their indirect
forms of support—those not captured by money income—and their asset
and debt positions.
Household Income and Indirect Sources of Support
At the outset it was noted that one source of complexity in assessing the
economic well-being of the elderly is their tendency to be embedded in other
households. Because a high proportion of the elderly live with children or
other relatives, they may benefit from the provision of housing, food, and
other material goods by virtue of shared arrangements. But sharing per se
does not guarantee enhanced economic welfare, because the elderly in such
arrangements may be providing resources to others from their income and
assets. Measuring indirect sources of economic support requires a fairly com
plete accounting of household income and expenditures that identifies all the
income earners and their incomes, as well as the pooling and transfer pro
cesses within the household. Although the questionnaires in the four coun
tries fall short of that goal, a number did identify key components of indirect
sources of support within the household, which will be reported on here. In
addition to complexities arising from intra-household exchanges, the elderly
who live alone as couples or individuals may receive economic support from
their children or others in the form of payment for major or ongoing expenses
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320 The Well-Being of the Elderly in Asia
such as housing or food. Some data on support of this nature were also
collected and will be included below.
A priori, we would expect to find a higher prevalence of indirect sup
port among those coresiding with children and others both because
coresidence facilitates this type of transfer and because lack of sufficient
funds can be a precipitating factor for the elderly to give up independent
living. This expectation is supported by Table 8.7A, which shows the propor
tion of older economic units receiving some type of indirect support (as
defined in the notes to the table) for those living with others and those living
alone. The table reveals the high level of indirect economic support for the
elderly in each type of economic unit and in each country—ranging from 44
percent for married couples in Thailand to 93 percent for unmarried females
in Singapore. For each type of unit and within each country, those living with
others are more likely to report indirect economic support than their counter
parts living alone, with the proportions receiving such assistance ranging
from 50 percent to over 90 percent among those coresiding. By type of
economic unit, unmarried females more frequently report receiving indirect
economic support than others, but they are less distinctive from unmarried
males in the Philippines and Thailand than in Singapore and Taiwan.
To what extent is this high level of indirect support targeted to assist
those older economic units whose money income proves insufficient? Table
8.7B gives a partial response to this by measuring the degree to which eco
nomic units in the lowest tier of income receive indirect assistance relative to
all the units in similar living arrangements. In the Philippines, Taiwan, and
Thailand there is evidence of an increased likelihood that units at the lower
end of the income distribution will receive indirect economic assistance, and
in most cases this tendency is stronger for those living alone. In Singapore,
indirect assistance does not appear to be targeted to those with lower in
comes, but it is here that 85 percent of all units at all levels of income receive
help of this kind. (In analyses not shown here that relate income position to
amount of indirect support received, we found for each country but Singapore
a clear gradient of increased support as one moved to lower income levels.)
Although the indirect economic support received was not valued mon
etarily, its high prevalence and its association with income levels indicate that
it is a significant factor in the economic well-being of the elderly. Additional
insights into how pooling and sharing arrangements enter into this assess
ment can be obtained by using the total household income when older eco
nomic units live with others, and by direct questioning concerning pooling
arrangements.
Tables 8.8A and 8.8B develop various relevant measures. Table 8.8A
shows for each type of economic unit the median income of those living
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Table 8.7A. Percent Who Have Others Pay for AH or Some of Their
Household Expenses (indirect support), by Type of
Economic Unit and Living Arrangement
Economic UnitMarried couplesLiving with spouse onlyLiving with othersAllUnmarried malesLiving aloneLiving with othersAllUnmarried femalesLiving aloneLiving with othersAllTotalPhil24534815696123676255Thai28494430837633837860Taiw30524613764844857953Sing45837832868066959385
Table 8.7B. Ratios of Those in Lowest Income Tier Receiving Indirect
Support to All Economic Units in Same Living
Arrangement
See Notes for Table 8.7A and 8.7B at the end of this chapter.
Economic UnitMarried couplesLiving with spouse onlyLiving with othersAllUnmarried malesLiving aloneLiving with othersAllUnmarried femalesLiving aloneLiving with othersAllPhil1.161.271.241.891.201.221.571.161.16Thai1.581.401.431.221.121.121.121.081.09Taiw1.271.221.242.021.081.351.091.061.07Sing1.181.121.14.851.051.03.971.001.00
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322 The Well-Being of the Elderly in Asia
alone versus those living with others. In the Philippines, those living alone
have lower median money incomes than those living with others, but in the
other countries the reverse is the case, with those living alone generally showing
higher incomes (except among unmarried females in Taiwan). A priori, one
might expect countervailing forces to be at work. Supporting a separate house
hold is generally more expensive than coresiding, leading to an expectation of
higher income among the independent elderly; but living alone may result
from the unavailability of children or other adverse circumstances, generat
ing an expectation of lower income.1 In the Philippines the adverse factors
appear to predominate, but in the other countries there is generally little dif
ference in income by living arrangement, suggesting a trade-off in these
countervailing forces.2
Table 8.8B looks at some of the household parameters for those living
with others. The median income of the household given in the first three
columns shows in every case that the income of the household is much
higher than just the income of the elderly unit residing there (as reported in
Panel A). Whether this extra income translates into direct benefits to the
elderly coresidents depends on a number of factors, including the size of the
household, the pooling and sharing arrangements, and the relation of the elderly
unit's income to the household income. Are older economic units with low
income also resident in households with relatively low income or is there a
reasonable degree of independence in these two measures of welfare? Column
(4) of Table 8.8B addresses this question in part by showing the proportion of
lowest-tier elderly economic units in the lowest tier of household income.
The figures in parentheses are the percentages of all households in the lowest
tier of household income. If these measures have a weak or nonexistent
association, one would expect about the same proportion in the lowest income
tier by economic unit to also be in the lowest category of household income.3
The results indicate that in Singapore the two proportions are in close
agreement, pointing to a weak association between couple or individual income
and the income of the household in which they reside. In other words, many
Singaporean older couples and individuals who appear to have low money
income are benefiting from being in households which are relatively well off.
This is less often the case in Taiwan and Thailand where over 40 percent of
economic units in the lowest tier of "unit" income are also in the lowest tier of
household income, and in the Philippines, the association between the two
levels of income appears very strong, with two-thirds of units in the lowest
tier of income also in the lowest tier of household income.
Assessing the potential benefits to older couples or individuals of
coresiding with others also requires attention to the direction of flows within
the households. How often do older economic units share their income with
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324 The Well-Being of the Elderly in Asia
others? The last column of Table 8.8B addresses this issue by examining the
proportion of coresiding households in which the elderly unit is the only
income recipient, strongly pointing to support of others within the household.
This measure also reveals the relative disadvantage of Filipino elderly: in a
third of all coresiding economic units, the respondents are the only income
recipients in the household, indicating they are providing for others as well as
themselves. In the other countries this is much more rare, occurring in only
7 to 14 percent of the cases.
Table 8.8C completes this overview of household income dynamics
by providing additional detail for the Philippines and Taiwan. When economic
units in the Philippines coreside in multiple-income households, there is an
average 1.0 to 1.3 income recipients in addition to the older couple or indi
vidual, and about 40 percent of the time some type of pooling of income
occurs. (In the remaining households, residents take care of assigned ex
penses or engage in some combination of assignment and pooling.) In Tai
wan, the average number of additional income recipients ranges from 1.3 to
1.5, and the pooling varies sharply by type of economic unit. Older married
couples coresiding with others earning income pay most of the household
expenses in about half the cases, while unmarried males or females pay most
of the household expenses only 18 and 13 percent of the time, respectively,
suggesting their much greater economic dependency.
Subjective Measures of Economic Well-Being
In addition to the array of income measures presented in the previous sec
tions, the surveys also obtained subjective assessments of their economic
situation from the respondents. Collectively the countries investigated the
perceived adequacy of the older couple's or individual's income relative to
their needs and expenditures, or inquired more generally about their satisfac
tion with their economic circumstances, though not all countries used both
lines of questioning.
Discrepancies between more objective measures of status and subjective
assessments have been observed in many behavioral studies and have been a
stimulus for theory and empirical research. For overviews of subjective
measures of well-being see Diener (2000) and Cummins (2000). For attempts
to reconcile objective and subjective economic measures or economic-oriented
models see Douthitt, MacDonald and Mullis (1992) and Kushman and Ranney
(1990).) Here discrepancies between objective and subjective measures of
economic well-being may arise in part from differences between the
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Table 8.8C. Additional Details on Pooling Arrangements for Economic
Units Living with Others
Philippines
Of Households with Multiple Income Recipients
Average Number of Income Recipients in Household besides Elderly
Married couples 1.0
Unmarried males 1.3
Unmarried females 1.2
Percent of Those with Other Income Recipients Pooling Income
Married couples 43.8%
Unmarried males 46.1%
Taiwan
Unmarried females 41.5%
Of Households with Multiple Income Recipients
Average Number of Income Recipients in Households Besides Elderly*
Married couples 1.5
Unmarried males 1.3
Unmarried females 1.5
•Based on identifying up to 3 other members of household with income
Percentage Distribution of Pooling Arrangements
for Those Residing with Other Income Recipients
Married
Couple
1. Respondent (and spouse) pay most of
expenses with no or some assistance
from others
2. Others pay most of expenses, respondent
(and spouse) give no or some assistance
3. Respondent (and spouse) and others in
household share expenses
Total
47.2
48.3
4.5
100.0
Unmarried
Male Female
18.3
13.1
79.6 85.2
2.2 1.7
100.0 100.0
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326 The Well-Being of the Elderly in Asia
respondents' current income levels and those experienced in the past,
comparisons with how well other elderly are doing, prior expectations of
how well-off they would be, or the degree of support expected from children
or other sources. The direction of the difference between the more objective
and subjective measures may be positive or negative, leading to expressed
dissatisfaction despite apparently comfortable circumstances, or expressed
contentment despite apparent shortfalls in the objective indicators. Given the
strong economic growth in the region, one might expect the latter contrast to
arise with some frequency if the older population has shared in the growth
and experienced improved living conditions.
Table 8.9A presents the distribution of responses in the Philippines,
Singapore, and Taiwan to questions assessing the adequacy of income related
to needs and expenditures. Sharp differences across the three countries emerge:
in the Philippines, almost a quarter of the respondents report considerable
difficulty in contrast to less than 5 percent in Singapore and Taiwan. Those
expressing some or considerable difficulty exceed 60 percent in the Philip
pines, compared to about 25 percent in Taiwan and 10 percent in Singapore.
The relative economic well-being of older units as conveyed by Table 8.9A
contrasts quite sharply with that portrayed in Tables 8.2A and 8.2B, where
the Philippines showed a much higher proportion of GNP per capita going to
the elderly than Singapore; and Taiwan elderly units had higher absolute in
comes (in U.S. dollars) than those in Singapore, despite lower GNP per capita.
These reversals reflect in part the effect of indirect sources of support as
well as differences in the overall standards of living, among other factors,
and demonstrate the importance of using multiple indicators of economic
well-being.
Table 8.9B investigates how the provision of indirect support inter
sects with the perception of inadequate income. Among those economic units
living alone in the Philippines and Taiwan, those receiving indirect support
more often express difficulty with insufficient income than those not receiv
ing this type of assistance, suggesting that indirect financial help at a distance
often arises from a perceived need but tends to fall short of alleviating that
need. In Singapore, there appears to be little differential in expressed diffi
culty between those with and without indirect support, except among unmar
ried females where those without support express more difficulty.
Among those who live with others there is generally less difference in
expressed difficulty with income shortfalls between those who do and do not
receive indirect support. The differences that do emerge—mainly in Singapore
(particularly for unmarried females) and among unmarried females in Tai
wan—reveal that those without indirect support more often report difficulty,
suggesting that even with coresidence, the needs of the elderly may be over-
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Economic Well-Being 327
Table 8.9A. Distribution of Sufficiency of Income: Philippines,
Taiwan, and Singapore
Enough money with some left overJust enough money, no difficultySome difficultyConsiderable difficultyPhilippines8.929.938.223.0100.0Taiwan7.966.521.64.1100.1Singapore8.481.58.02.1100.0
looked by other household members. Regardless of circumstances, the strong
negative assessment of the Philippine elderly about the adequacy of their
income stands out.
Table 8.9C displays findings for a broader measure—satisfaction with
economic situation or status—for Taiwanese and Thai elderly, the only two
countries using this item. (As noted in the footnote, the questions posed were
somewhat different in the two countries, making direct comparison between
them somewhat tentative.) Overall 17 percent of older Taiwanese respon
dents express some degree of dissatisfaction with their economic situation
and, as the top tier of the table shows, this percentage is closely related to
their relative income position. In Thailand, almost 30 percent of the units
report dissatisfaction, with a slight decrease in dissatisfaction reported among
those in the highest tier of income. Differentials in levels of satisfaction ap
pear not to be greatly affected by type of economic unit or living arrange
ment. In Taiwan, unmarried males and females living alone show somewhat
higher levels of dissatisfaction than those living with others, and this is true
for unmarried males in Thailand as well.
Though the subjective measures reviewed must not be taken out of
context of the other economic indicators, they do signal that perhaps 60
percent of Philippine's older couples and individuals find their economic situ
ation at least somewhat difficult, as do a fifth to a quarter of Thai and Tai
wanese. In Singapore, by contrast, only one in ten older respondents express
some degree of difficulty with the adequacy of their income.
Assets and Home Ownership
In assessing the economic status of the elderly, attention must also be given
to the nature and magnitude of their asset holdings and their debt position.
The level of assets held by older people is an indicator of their economic
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330 The Well-Being of the Elderly in Asia
success over their lifetime, may be influential in shaping the nature of their
intergenerational exchanges, and may be crucial in generating needed income
after withdrawal from the labor force.
As noted earlier in the chapter, the accurate measurement of assets
poses considerable difficulties and the data collected in the four-country sur
veys must be regarded as a first approximation to a complex situation. The
strategy generally adopted among the countries was to give most attention to
home ownership, the asset most widely owned by the elderly, ascertaining
both the details of ownership and the underlying values. For other assets, the
general approach was to determine ownership within particular categories,
the definition of which varied somewhat across the countries. Respondents
were asked to place values on these other assets in two countries, but these
data will not be used here.
Table 8.10 presents an overview of the asset situation of the older
population in the four countries, describing the proportion owning each cat
egory of assets as well as the proportion with debt (where available) and the
proportion without any assets.
In each of the four countries, the house the elderly reside in represents
the most widely held asset. Alone, or jointly with children, home ownership
by the older respondents ranges from 50 percent in Taiwan to over 80 percent
in the Philippines and Thailand. (The lower figures in Taiwan and perhaps
Singapore are discussed further below in connection with Table 8.11.) The
next five rows of the table provide the percentages owning specific categories
of assets. Ownership of real estate (house and/or land) other than place of
residence is reported by about 40 percent of Philippine respondents and 20
percent of Taiwanese, but by less than 10 percent of the Thai elderly. Philippine
and Taiwanese elderly also report significant interests in farms, fish ponds, or
ranches other than the one on which they reside. Together with the other real
estate interests, these figures suggest that assets associated with land or
agriculture-related enterprises are a major form of holding in both countries.
This is not surprising given the significant proportion of each country's older
population who are rural residents, but in Thailand, which has the highest
concentration of rural elderly, other real estate (which may also reflect interests
in agricultural enterprises) does not appear significant. In Thailand about a
third of the older economic units report cash savings or ownership of stocks
or bonds, a proportion that is slightly higher in Taiwan, but much lower (10.5
percent) in the Philippines. In Singapore, the profile of asset ownership is
quite different. Given that Singapore is a city, the survey did not specifically
ask about ownership of agricultural enterprises, and ownership of other real
estate is also likely to be insignificant. By contrast, more than two-thirds of
Singaporean elderly reported ownership of savings accounts of various kinds
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332 The Well-Being of the Elderly in Asia
and another 6 percent owned stocks or bonds—a difference highly attributable
to their participation in the Central Provident Fund (CPF) (described above
and in Chapters 3 and 7). A high proportion of Singaporeans who had
accumulations in the CPF reported withdrawing them, with many opting to
place all or some of their funds in savings accounts of various kinds. It is
worth noting that among the current elderly in all four countries, investment
in stocks or bonds is not very common, reflecting both the relative recency
of capital markets in these countries and the modest asset position of many
elderly.
The proportions owning assets in lines 1 through 6 are not of course
mutually exclusive and many elderly will own more than one type. Line 7a
presents the proportion of elderly who own none of the assets listed above as
a way of assessing the proportion who may have no resources to fall back
on. This proportion is 12 to 13 percent in the Philippines, Thailand, and
Singapore but rises to 26 percent in Taiwan. This latter figure is somewhat
misleading as it arises mainly from the lower proportion of home ownership
in Taiwan, which is associated with the practice of division of property be
fore death. It will be recalled from Tables 8.2A and 8.2B, that the relative
income of the elderly in Taiwan compares well with over-all per capita in
come levels, reinforcing the point that multiple measures of economic well-
being are needed to obtain a balanced picture. Line 7b shows the percentage
of older respondents or couples who do not own any of the assets shown in
lines 2 to 6 (including line 9 for Singapore). These respondents may or may
not own their home but they do not own any other financial assets. In Singapore,
one third of respondents are in this situation, more than 40 percent in Taiwan,
and in the Philippines and Thailand about 60 percent of the respondents or
couples have no financial asset, except possibly their homes. Further discus
sion of the characteristics of those without any assets is reserved for Chapter
11, which focuses on identifying the disadvantaged elderly from the perspec
tives of economics, health, and social relations.
Line 8 indicates the proportion of elderly units with household debt in
the Philippines and Thailand, the only two countries that measured this. About
two out of five respondents in the Philippines and one out of four in Thailand
reported debt, and in Thailand 10 percent had debt exceeding 25,000 baht
(equivalent to US$1,000)."
In addition to the issue of debt, a rounded picture of assets should take
into account the degree of control that these older persons have over their
assets. In the Philippines, homeowners were asked if they were free to sell or
mortgage their home/property, and 72 percent said yes. In Taiwan, respondents
who owned assets other than their home were asked if they were free to use
these assets in any way they desired, and 77 percent said yes, 9 percent said
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Economic Well-Being 333
no, and the remainder said they fully controlled only part of the assets. This
high level of control is somewhat surprising given that almost 40 percent
reported inheriting some of these assets.5 These respondents were also asked
about the adequacy of their assets to support them throughout their life, and
55 percent of those owning such assets said they were sufficient or more
than sufficient.
Lines 9 through 11 present indicators of other types of assets reflect
ing resources and/or lifestyle levels for the elderly. Line 9, "other valuables,"
represents a mixed group of assets that were identified in the survey but not
in a uniform manner. In all countries with data, these include jewelry, art
work, or similar valuables. In the Philippines this category also includes appli
ances, which accounts for the relatively high level. In Singapore the figure of
10.5 percent also includes those reporting owning or receiving income from
life insurance and annuities, or pensions (other than the Central Provident
Fund), or maintaining an accumulation within the Central Provident Fund,
items for which comparable information is not available for the other coun
tries.
To provide greater comparability on the subject of appliances and
household possessions, line 10 compares three of the countries on the pres
ence within the elderly unit's home (but not necessarily their ownership) of
one or more basic appliances such as a refrigerator, television, and air condi
tioner. This measure speaks more to the standard of living of the elderly than
to their asset position. Line 10 shows that almost all the elderly in Thailand
and Taiwan have such appliances in their households, while about a fifth of
those in the Philippines do not benefit from these basic items.
It should be noted that Table 8.10 does not address the ownership or
presence of cars or other vehicles—tangible assets that can be significant
components of total household wealth. In the survey, only 6.7 percent of the
respondents in the Philippines reported the presence of a car, truck, or jeep in
their household; the comparable figures for Thailand and Taiwan were 17
percent and 38 percent, respectively. Given these relatively low levels, which
may nor may not reflect ownership, it appears that this class of tangible asset
is a minor aspect of household wealth.
In assessing the asset position of the older population it is important to
go beyond the components of household wealth (home equity, tangible as
sets, and financial assets) to include their stake in social security and pension
programs to which they may be entitled. These future streams of income can
represent important resources, although their total value may not be convert
ible into cash or its equivalent. Where the amounts of the future payments are
known, it is possible to calculate their present value and combine this with the
value of other assets. For the United States, Smith (1999) has shown that the
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334 The Well-Being of the Elderly in Asia
present value of social security and pension payments is about equal to house
hold wealth, when considering mean values. For the median household, the
present value of social security exceeds that of household wealth and the
value of pensions alone are over 40 percent of the value of household wealth,
for those 51 to 61 years of age.
For the four Asian countries, the detailed amounts received or ex
pected are not known. The percentages given in line 11 represent the propor
tion of all older men and women who are either retired and receiving benefits
from a private or public pension (or have received a lump sum or limited
number of payments in the past), or still working and report expecting such
benefits upon retirement. As such the proportions are not independent of
those appearing in other lines of the table. For example, those in Singapore
who have accumulated funds in their CPF accounts and have withdrawn
these funds and placed them in a savings account would appear both in line 5
and line 11.
The data on line 11 show a wide variation in pension coverage across
countries and by gender. Almost half the men in Singapore have or can antici
pate such coverage, compared to a third in Taiwan, a fifth in the Philippines,
and less than 10 percent in Thailand. Among women, the proportions are
very low, except in Singapore where about 14 percent have or expect pension
funds or payments. (See Chapter 3 for further discussion of pension plans
and Chapter 7 for an analysis of the effect of pensions on retirement.)
As presented in Table 8.10, a significant proportion of the elderly in
these four countries own some type of financial resources, which tend to
consist primarily of their current residence. Given the agricultural background
of so many of today's older population in these countries, interests in farms,
fish ponds, and other real estate is quite common in the Philippines and Tai
wan, but somewhat surprisingly not in Thailand. Among other savings and
investment mechanisms used, the emphasis appears to be on savings ac
counts and other fixed deposits. This generation of elderly is little involved
with the capital markets. Though the impact of their assets cannot be deter
mined without an assessment of their value, the high proportion who own
only their home, and the significant proportion in the Philippines and Thailand
with household debt, suggests that most of the older population have not had
an opportunity to accumulate sizable savings or other assets, despite the gen
erally strong economic times they have lived in. Even in Singapore, with the
broad coverage under the Central Provident Fund and the high savings rate
embedded in this plan, the large proportion regarding their accumulations as
inadequate for old age and the small percentage using these funds as a major
source of income point to a generally weak asset position. In Taiwan, how
ever, more than half of the elderly report owning an asset other than their
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Economic Well-Being 335
home (line 7b) and over half of these respondents indicate that these assets
were sufficient for life-time support—indicating a strong asset position for
more than a quarter of the elderly.
Table 8.11 takes a close look at the nature of home ownership and the
characteristics of those that do and do not own their own homes. The first
row provides percentages of the elderly (a) who solely own their residence,
(b) who own it jointly with other household members (ascertained in the
Philippines and Singapore) or who contributed to their children's ownership
of it (ascertained in Thailand and Taiwan), (c) who do not own any part of it,
or (d) who have some other ownership position. The differential across the
four countries is significant if one focuses on sole ownership, with variation
from a less than 43 percent in Singapore to almost 80 percent in Thailand. But
incorporating joint ownership or direct assistance, the variation is smaller—
from 66 percent in Singapore to 85 percent in Thailand. In Chinese culture it
is not uncommon for parents to divide property with children while still alive
or at the death of the patriarch (see Li et al., 1993), and this may account for
the lower proportion of homeowners among the elderly in Taiwan and
Singapore.
These data demonstrate that a high proportion of the elderly, regard
less of current living arrangements, maintain an important asset through sole
or joint home ownership, or have a claim for continued support from some of
their children through the previous transfer of this asset. In Taiwan, for ex
ample, of those living in a house owned by their children, 66 percent gave all
or part of the cost or the house itself to the children, and this is true of 46
percent of the comparable group in Thailand.
Home ownership by sociodemographic characteristics tends to vary
in similar ways across countries, decreasing with age, increasing with educa
tion, highest among married couples, lowest among unmarried females (largely
widows), and highest in rural locations (reflecting lower housing prices and
fewer housing alternatives than in urban areas). In addition, home ownership
by the elderly tends to be lowest when they are living with married children or
others.
In each country there is a clear gradient of home ownership by self-
reported health status, with those reporting better health having higher levels
of ownership. The differentials are quite marked in each of the countries
except Thailand. Sharp differentials in the asset situation of the elderly with
health status have been reported in the United States as well (Smith, 1999;
Smith and Kington, 1997).
The interrelationship between home ownership and health is complex.
Those with more education and economic opportunities may be in a better
position than their counterparts to both accumulate assets and protect their
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able 8.11. continuech=p— f^**pinNO
OOOinNO^tspooPlace of residenseR.ralm ONO 06CN roON NOON NOi-HnNO C-Tf CNNO roOO TtON t^m•* t^CN NO— i in•*t CNr^m ror- m.u
5 3| -aLiving arrangementsin r-Tt vdCN CNCN OP ONCN t^f^ fel-^ inin t**-roooWl vQ„NO^O mON CNOO NOCAlene/rt.ple only
With married shildreCN TtON OCNfi NO•* -in ro•* CNp I-;ts inoo r-oq CNNO f^CNr-; Csvd r^iNO OOTtON OO— ts
oo r-cWith .nmarr. childre
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u•g-aS £Tt Tt — . inoo NO oo o— ^Tf O oo — i— i fS ts Or- NO -^ oqNO ro Tt r-in — i o NOro r- vi -Ht** 00 OO C-^* in r- r-;riS CN CN 00m r-; O invi i ON iri ciCN CNNO oq Tt pCN t^J CN TtON in -H ooSON ^ NO
r- oo NO*)Inrtme tierLewst
secend
rt-hstMain seurce ef inrtms i Idren/relati vsNO ONO r-^p ONin CN.ON ONON OOOO fe^r^ eNO inr^ NOp ^*CN in.NO OOCN r-^oo r-Earnin-s frrt work
Pensienrt sever, pay«NOTtinNOin00CNoo„^oNCNCNONNOoou
uoie•~c8
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Table 8.11. continuedOO O O •*r-^ d d CNCN •*O CN m Od ^ •* din — *in p CN r-;•^ CN — i mCN m -^r** r^- in ON^ ^ ^ r^vo CN m TtCN vq oq r-;^* ON re*- dCN — i •*ro ^* vq inTt r^ in vd-H Ov p pCN ON ^ m_ CN -i —•t CN in oqON m CN ONin Tt vO mLiving arrangementsAlene/rt.ple only
With married children
With .nmarr. children
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340 The Well-Being of the Elderly in Asia
health. Also, those with poorer health may not be able to sustain independent
living, requiring them to live with children and others. These reciprocal ef
fects can be sorted out to some extent with panel data that trace the same
individuals over time. In the U.S., for example, panel data reveal that those
experiencing diminishing health over time tend to have a lower net worth than
their counterparts who remain at the same level (Smith and Kington, 1997).
The remaining panels in Table 8.11 also reveal rather sharp differences
in home ownership by the income position and income sources of the elderly.
As with health, home ownership increases with income position, particularly
in the Philippines, Taiwan, and Singapore. Also influential is the source of
income; home ownership is lowest when the main source of income is from
children or relatives versus sources that point to more economic indepen
dence. As Table 8.4 and 8.5 showed, the sources of income are also related to
the amount of income received.
These differentials, though quite marked, should not mask the high
level of home ownership that exists in almost every category or the claims
that parents may have through joint ownership. The ownership patterns of
unmarried females, mostly widows, across the four countries illustrate the
level and suggest some of the ongoing dynamics for a group thought to be
particularly vulnerable economically. In the Philippines and Thailand over 60
percent of unmarried women have sole ownership of their place of residence
(regardless of living arrangement); in Taiwan, although only 19 percent of
unmarried females are sole owners, another 37 percent are living in a home of
a child for which they have provided full or partial financing; in Singapore 25
percent are sole owners but another 28 percent own the property jointly with
children. Many of the transfers by older widows in Taiwan and Singapore
probably occurred upon the death of their spouse as part of an arrangement
of long-term support.
The significance of this broad pattern of home ownership for the
economic well-being of the elderly depends in large part on the values of the
homes. Table 8.12 presents median home values by key sociodemographic
characteristics and country, for the respondents who own their current resi
dence for three countries which tried to obtain magnitudes. As the notes to
Table 8.12 make clear, these values were obtained with somewhat different
questions in each country and these differences should be kept in mind. It is
also likely that many older respondents have lived in their homes for a long
time and do not have a very accurate assessment of the market value. For
these reasons the values given in Table 8.12 should be taken as a first estimate
of the underlying values. Appendix 8.C reports on attempts to locate general
house and land values for the three countries.
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Economic Well-Being 341
In the Philippines the median value of home and land reported by
homeowners was 125,000 pesos, equivalent to about $4,900 U.S. This amount
represents about twelve times the median income of all elderly economic
units reported in Table 8.1. About two thirds of the reported value was the
value of the land itself, suggesting that the housing structures themselves are
quite modest. In Thailand, the median value of house and land is 270,000
baht, equivalent to $10,800 U.S. This value represents 27 times the median
income of all elderly units, indicating that this asset is an important financial
resource. As in the Philippines, more than two-thirds of this overall value in
Thailand was due to the value of the land. Taiwan, in keeping with its higher
per capita GNP, has an average house (and land) value of over one million
New Taiwan dollars, equivalent to nearly $41,000 U.S.—or about ten times
the median value in the Philippines and nearly four times the median Thai
value. In relation to current income reported in Table 8.1, the median Taiwan
house value represents nearly seven times the median income of all elderly
units.
By sociodemographic group, differences in house and land values gen
erally follow the patterns observed for income (Tables 8.4 and 8.5) and for
home ownership (Table 8.11), but with a few notable differences. Values are
higher in the youngest age group in the Philippines and Taiwan, with a clear
gradient by age in Taiwan. In Thailand, however, the older two age groups
report somewhat higher values. Also Taiwan and the Philippines show the
highest values for owners living with married children, but in Thailand that
occurs among those living with unmarried children. In Taiwan, unmarried
female homeowners have higher values than the other marital statuses, but
for the Philippines and Thailand, married couples report the highest value. In
all three countries, there is a sharp gradient of house/land value with educa
tion level (similar to the observed gradient of income with education) and
between amount of income, as measured by income tier, and home values.
Those whose main source of income is from pensions or investments also
tend to have more valuable homes, as do those with better health—which
parallels the relationship found between income and health and the pattern
observed in U.S. studies.
A distinct factor for house and land values is location, with those
owning a home in the capital cities reporting a median value about 10 times
that reported in the rural areas in the Philippines, 6 times the value reported in
rural Taiwan, and nearly 18 times the value reported in rural Thailand. It
should be noted, however, as shown in Table 8.11, that the proportion of the
elderly owning their own homes within the capital cities is quite low in com
parison with ownership levels in rural areas.
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344 The Well-Being of the Elderly in Asia
Changes in Economic Well-Being over Time
To this point we have presented a cross-sectional picture of the economic
well-being of the elderly in four countries on various dimensions as of 1995-
1996. The sources and levels of income as well as the asset mix for the older
population are likely to undergo several transitions over their later life cycle,
as they move from work to retirement, change dwellings, encounter health
problems, and respond to changes among family members. Relatively little is
known about the changes that occur to the economic condition of the elderly
as few countries have mounted the detailed panel studies that provide the
necessary information. Taiwan, however, has reinterviewed the original panel
several times since 1989, in addition to replenishing the sample at younger
ages, and we illustrate the potential for studying change from these data.
Table 8.13 compares the major sources of support in 1989 with 1996
for the approximately 2,400 elderly who were interviewed initially and sur
vived to be interviewed seven years later. In terms of sources of income,
over 70 percent of those who reported pension and retirement income as
their major source in 1989 still did in 1996. For the other sources there is
considerable mobility. Only about half of those who gave children as the
major source in 1989 report this source in 1996, many of them attributing
their major income at the latter date to pensions and retirement funds. It is
interesting to note from the marginal distributions that despite the aging of
this cohort, there is an overall decrease in the reliance on children over the
seven years. This may well be a temporary phenomenon related to the special
pension program provided in some cities and counties around 1995 for a
short period (see Chapter 6). A preliminary analysis of cohort and aging ef
fects on major sources of income shows that both factors are important.
Reliance on children as the major source declines with age, within cohorts,
and reliance on pension income increases. At the same time, younger co
horts, controlling for age, display lower reliance on children and more reli
ance on pensions than their older counterparts.
Figure 8.3 shows the changes in the distribution of responses on the
adequacy of income to meet expenses in 1989 and 1996, for the same cohort
of elderly in Taiwan. Treating the data as two separate cross-sections gives
the impression of very little change on this subjective measure of economic
well-being. In contrast, Figure 8.4, which presents the 1996 distributions as
a function of the 1989 response, shows considerable change. About two-
thirds of those who said they had enough money with some left over in 1989
report themselves as having "just enough" in 1996. Likewise, there is some
net shift to more difficulty for those reporting "just enough" in 1989. At the
same time, significant proportions of those who experienced some or much
difficulty in 1989 moved up to the "just enough" in 1989.
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348 The Well-Being of the Elderly in Asia
A similar degree of change in attitudes is found on the more subjective
question of satisfaction with current economic situation. The table below
shows shifts from satisfaction levels reported in 1989 to those reported in
1996. It is clear that many of those who were satisfied in 1989 became
neutral or dissatisfied in 1996, while many who expressed dissatisfaction in
1989 expressed more neutral or optimistic views in 1996. At the same time
the overall distributions in the two years were very similar.
Taiwan: Percent Distribution of Satisfaction with Economic
Situation in 1996, by Attitude in 1989
Attitudes
in 1989Attitudes in 1996Very
Satisfied
or
SatisfiedVery satisfied 67.4Satisfied 47.8Neutral 36.9Unsatisfied 20.2Very unsatisfied 6.5Total in 1989 40.9Neutral27.443.046.645.047.843.1Unsatisfied
or Very
UnsatisfiedTotal
in 19965.2 10.59.2 35.416.5 37.634.8 14.545.7 1.915.9 99.9
Additional discussion of these data are presented in Chapter 12. The
goal here is to illustrate how economic well-being is likely to fluctuate for
many of the elderly. One has a sense that the shifts observed represent a
complex adjustment process as some older people lose ground as earnings
cease, but are able to call on children or other resources to compensate if
needed. Further analysis of these transitions and their causes and consequences
are clearly in order if we are to gain deeper understanding of the underlying
dynamics, and fashion appropriate policies for assistance.
Conclusions
Attempts to appraise the economic well-being of the elderly have often de
pended on inferences derived from their living arrangements and whether
they were receiving money or material assistance from children or others. In
an effort to obtain a more direct assessment, this chapter has introduced an
array of income and asset data derived from surveys conducted in 1995-
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Economic Well-Being 349
1996 in the Philippines, Singapore, Taiwan, and Thailand. The results suggest
that more than one or two measures are needed to effectively analyze the
economic well-being of the elderly and fashion appropriate policies. The close
connections the elderly have with their children and the high proportion that
are embedded in other households require that both individual and household
income and asset dimensions be ascertained. In addition, the responsibilities
and allocations within households and the flows between households need to
be taken into account.
The main findings from this initial analysis reveal the following.
1. In terms of money income and proportion of income to GDP per capita,
the elderly in the Philippines and Taiwan appear to be better off than those in
Singapore and Thailand. But when levels of indirect support (which affect 50
percent or more of the older units in each country) and household income,
for those who coreside with others, are taken into account, the relative stand
ing of the older population in each country changes considerably. For ex
ample, in a third of households in which the Philippine elderly coreside, they
are the only income recipients; two-thirds of older Philippine units that are in
the lowest income tier of money income are also in the lowest income tier of
household income, when they reside with others.
2. The importance of these additional dimensions of economic status appear
confirmed by the subjective measures of economic well-being. Over 60 per
cent of Philippine elderly economic units express some difficulty with the
sufficiency of their income, compared to a quarter in Taiwan and a tenth in
Singapore. In terms of satisfaction with their economic situation, almost 30
percent of Thai older couples or individuals expressed dissatisfaction com
pared to 17 percent of their counterparts in Taiwan.
3. Examination of sources of income reveal that children are the most impor
tant source in all countries and across each type of economic unit, with
earnings from work the second most important source.
4. Many factors are related to the level of money income, including age,
marital status, gender, education, health, and urban-rural residence. Some
what surprisingly in view of the emphasis placed on living arrangements,
elderly units living alone generally have higher incomes than those living with
married children; and those whose main source of income are children or
other family members generally have lower incomes than those who rely on
other sources. Although these factors are interrelated, they all tend to retain
strong and significant effects in regression analyses (though to a lesser extent
in the Philippines compared to the other countries.)
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350 The Well-Being of the Elderly in Asia
5. A majority of the elderly in each country owns their current residence
(alone or jointly) and in Thailand and the Philippines the percentage is around
80 percent. This is the most frequently owned asset and from one-third
(Singapore) to three-fifths of the elderly (Philippines and Thailand) own no
other assets. In the latter two countries, a significant proportion of the elderly
also reports household debt. Involvement in the capital markets is negligible
among these elderly in all the countries.
6. Though the overall asset position of the elderly appears limited from the
data available, it is important to note that a high proportion, regardless of
current living arrangements, maintain an important asset through sole or joint
home ownership, or by having a claim for continued support from some of
their children through previous transfer of this asset. Home ownership by
sociodemographic group varies in similar ways across the four countries.
And, although there are differentials in ownership by age, marital status,
residence, and education, levels of ownership are quite high in almost every
category—even among older unmarried women, a group thought to be par
ticularly vulnerable economically. Sharp gradients in home ownership by health
status and income level are observed in a number of the countries, paralleling
patterns observed elsewhere.
7. In the Philippines, Thailand, and Taiwan, the median value of elderly
homeowners' house and land represents from 6 to 18 times the median in
come for all elderly, suggesting both that a home is a substantial asset for
many elderly and that there is considerable variation in the asset-income rela
tionship across countries.
8. The panel data from Taiwan indicate that the sources of income and the
economic well-being of the older population may shift considerably as they
age. Only by studying these older life-cycle patterns can we hope to obtain a
full picture of their economic well-being and the forces affecting it.
The multi-dimensionality of the economic well-being of the older popu
lation and the many forces at work present a challenge to policymakers seek
ing to fashion programs to aid those in need and sustain family sources of
support. The use of simple measures may lead to both unnecessary program
costs and ineffective targeting of those in need. Developing programs that
correctly target assistance and build structures for sustaining economic well-
being will require careful planning. Chapter 11 looks at identifying the elderly
who are economically disadvantaged, along with policy and program impli
cations; chapter 12 reviews the broader policy challenges for maintaining
economic well-being among the elderly.
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Economic Well-Being 351
ENDNOTES
1. From a dynamic standpoint, one would expect ongoing selection whereby
older economic units who cannot sustain independent households move in with
others, leaving behind both those with better resources s well as those without
opportunity for coresidence.
2. The much higher income in Taiwan of unmarried males living alone to those
living with others most likely arises from Mainlander soldiers and officials who
never married but are receiving relatively high pension income.
3. More formally, because the income of the economic unit is one component
of total household income, one would not expect complete independence.
4. The nature of the debt was not ascertained and it is possible that some of
the debt reflected amounts owing on the respondent's home, since home values in
these countries were asked in terms of market value but not explicitly net of
mortgages, see notes for Table 8.11.
5. The proportion with full control is lower among those reporting inheriting
all or some of their assets than for the total, but it was still 64 percent for this group.
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among the Elderly in South-East Asia: An Introduction." Asia-Pacific
Population Journal 12(4):December.
Kushman, John E., and Christine K. Ranney. 1990. "An Ordered-Response Income
Adequacy Model." The Journal of Consumer Affairs 24(2):338-339.
Li, Rose M., Yu Xie, and Hui Sheng Lin. 1993. "Division of Family Property in
Taiwan." Journal ofCross-Cultural Gerontology 8:49-69.
Preston, Samuel H, and Paul Taubman. 1994. "Socioeconomic Differences in Adult
Mortality and Health Status." In Linda Martin and Samuel H. Preston, eds.,
The Demography of Aging. Washington, D.C.: National Academy Press.
Shih, Shiau-ping R., 1997. "Private Lives within Public Constraints: Retirement
Processes in Contemporary Taiwan." Ann Arbor: Unpublished Ph.D.
Dissertation, University of Michigan.
Smith, James P. 1999. "Healthy Bodies and Thick Wallets: The Dual Relationship
between Health and Economic Status." Journal of Economic Perspectives
13:145-166.
Smith, James P., and Raynard Kington. 1997. "Race, Socioeconomic Status and
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Differences in the Health of Older Americans, 106-162. Washington, onal
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Treas, Judith, and Barbara Logue. 1986. "Economic Development and the Older
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U.S. Bureau of the Census. 1998. Statistical Abstract of the United States, 1998.
Washington, DC.
NOTES FOR TABLES
Table 8.1
Philippines: Respondents were asked to give an exact answer for yearly income.
A bracketing technique was used for those who had difficulty with this.
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Economic Well-Being 353
Thailand: Thai respondents were asked about exact yearly income. Those
who could not give an exact amount were asked to choose from a given set of
brackets income (as shown in the table.).) Mean and median income was calculated
by assigning the midpoint of the bracket range to those who only gave bracket
information and using the exact amount for those who gave exact information.
Taiwan: Taiwan respondents were asked about exact yearly income. Those
who could not give an exact amount were asked to choose from a given set of
income brackets (as shown in the table.) Mean income was calculated by assigning
the midpoint of the bracket range to those who only gave bracket information and
using the exact amount for those who gave exact information. Because of the high
proportion of respondents who gave bracket answers median income was computed
using linear interpolation of the bracket categories.
Singapore: Question on level of income refers to only the respondent's income.
However analysis of the data suggests that in some cases R is reporting both
respondent's and spouse's income. Because the Singapore respondents were
asked about monthly income the bracket endpoints were multiplied by 12 to convert
to yearly income. This will underestimate (or overestimate) income if income
varies greatly throughout the year.
Income mean was calculated by assigning midpoints to each of the categories,
the median was calculated using linear interpolation techniques.
Table 82B
Sources: GDP 1996 per capita: Central Intelligence Agency, 1997
GNP1995 per capita: U.S. Bureau of the Census, 1997, Table 1347 for
Philippines, Thailand, and Taiwan
GNP 1995 for Singapore: Singapore, Department of Statistics, 1998,
Table 1.1 (converted per rate below)
Conversion of means and medians to $US based on following exchange rates
(CIA, 1998):
Philippines: 25.7 Pesos = $1 US
Thailand: 24.9Baht = $lUS
Taiwan: $27.4 New Taiwan = $ 1 US
Singapore: $1.42 Singapore = $1 US
" GDP per capita based on purchasing power parity calculations utilizing
standardized international price weights so that $ 1,000 will buy approximately the
same market basket of goods in each country.
Tables 8.7A and 8.7B
Indirect support is defined as follows:
Philippines: Economic unit pays less than 75 percent of household expenses
Thailand: Respondent or spouse is not main provider for household and
does not pay all the household expenses.
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354 The Well-Being of the Elderly in Asia
Taiwan: For those living with others: Economic unit shares household
expenses or reports that someone else pays most or all of expenses.
For those living alone: Non-household member pays part or all of household
expenses.
Singapore: Economic unit reports receiving accommodations or rations from
children or maintenance in kind from anyone other than spouse.
Table 8.9C
Notes: In Thailand, the question was, "Generally, how satisfied are you with
your current financial or economic situation?" with the options "very satisfied,
satisfied, not satisfied," recorded.
In Taiwan, the question posed was, "In general, are you satisfied with your
current economic status," with the options "(1) very satisfied, (2) satisfied, (3),
neither, (4) unsatisfied, (5) very unsatisfied," recorded. In the table above options
(2) and (3) are combined into "satisfied" and options (4) and (5) combined into
"not satisfied."
Table 8.10
Line 1 - Represents joint or sole ownership of house and/or land where elderly
reside; see Table 11 for detailed notes. In the Philippines only 3.6 percent of
respondents owned the land only; in Thailand the comparable percentage was 3.2
percent. The separation is not relevant for Taiwan or Singapore.
Line 2 - Represents house or land ownership other than that of current
residence.
Line 3 - Does not include the farm or ranch on which the respondents reside.
Line 7a - Represents the proportions who do not own any of the assets listed
in lines 1 through 6. For Singapore, also reflects lack of ownership of the assets
described in line 9.
Line 7b - Represents the proportions who own none of the assets listed in
lines 2 through 6 (including line 9 for Singapore). The respondents may or may not
own their own home.
Line 9 - Represents a mix of other assets. In the Philippines it covers jewelry
and appliances owned by the elderly economic unit. In Taiwan, it covers only
ownership of jewelry and similar valuables, like artwork; in Singapore it includes
ownership of annuities and endowments, current accumulations in the central
Provident Fund and coverage by other pensions.
Line 10 - Represents the proportion of the elderly living in households with
one or more basic appliances such as refrigerators, electrical/gas stove, television,
air conditioner. The list varied across countries. The elderly do not necessarily
own the appliances, especially in situations where they live with others.
Line 11 - Represents the proportion of older male and female respondents
who have collected pension payments in the past, are currently collecting payments,
or expect to receive pension payments after retiring.
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Appendix 8.B. Alternate Specifications of Factors Affecting Being in
the Bottom Tier of the Income Distribution
Panel A: Odds-Ratios for the Effects of Demographic, Socioeconomic
Characteristics and Health Status
•p<.10 *p<.05 **p<.01 ***p<.001
Inap. = not applicable
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Economic Well-Being 359
Appendix 8.C. Notes on House and Land Values
An attempt was made to find independent house and land values for each of
the three countries shown in Table 8.12, in order to validate the levels reported and
if possible compare the housing values of the older people with the general
population. This proved very difficult; apparently sound indicators of housing
values are not a standard aspect of the accounting framework in these countries.
Neither regular surveys nor systematic reports of houses bought and sold could
be located. Complicating the situation is the great disparity between housing
values in major or capital cities and elsewhere, as reflected in Table 8.12. Partial
reports that are location-specific or weighted in non-representative ways can greatly
distort the averages and hinder comparisons.
In Taiwan, the annual survey of personal income (and expenditures) (DGBAS,
1990) asked land and house values for each household through the early 1990s but
this question was discontinued according to a personal communication because
the values reported appeared too low in terms of current market values. Many
householders apparently reported "registered values" (akin to assessed valuations),
which were not reflective of the market.
An analysis of the values reported in 1990 found that households in which
the head was 60 or older reported median values very close to those reported in
Table 8.12 for older respondents who own their home. Assuming this is the most
appropriate comparison group and allowing for the increases in overall values
since 1990, suggests that values reported in Table 8.12 might be a third lower than
those that would be reported by older household heads in the Survey of Personal
Income circa 1996. This must be treated as a rough estimate and it should be
recalled that the values in the Survey of Personal Income are themselves assumed
to be too low.
In the Philippines, the only data located were reports from the Housing and
Urban Development Coordinating Council on housing loans (mortgages) taken
out under the mortgage financing activity of the Home Development Mutual Fund,
a government savings institution for housing. In 1996, the overall mortgage loan
value for houses, houses plus lot, or lot only was 210,000 pesos, some two-thirds
larger than the value shown in Table 8.12. But almost 60 percent of the loans were
in the National Capital Region and the average value of these loans was only
225,000 pesos, considerably less than the average for Manila shown in Table 8.12.
This suggests that this program has a limited range of loan values that may not be
representative of the broader housing market and offers little guidance as to the
accuracy of the values shown in Table 8.12.
In Thailand, like the Philippines, only a few specialized reports could be located.
A table from the Agency for Real Estate Affairs showed for 1997 an average value
of 3.3 million baht for new single home units for Bangkok and vicinity. This is
somewhat lower than the value reported in Table 8.12. The same table however
reported an average of 1.25 million baht for the remaining provinces, much higher
than the non-Bangkok housing reported in Table 8.12. As the column of numbers
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360 The Well-Being of the Elderly in Asia
of respondents reporting shows, however, the data in Table 8.12 is heavily weighted
by older rural residents; the data from the Agency for Real Estate Affairs, on the
other hand, may emphasize urban housing, according to one communication. More
fugitive data from Thailand showed an average value of 4.1 million baht for second
hand homes sold in 1997-98 (presumably in Bangkok) by one company; and a
distribution of "homes for sale" in Bangkok and vicinity for 1996 indicated a
median value of about 833,000 baht, but it could not be determined how
representative this base was and whether the value of land was included. Overall,
the small amount of data located suggests that the values reported in Table 8.12 for
Bangkok are not greatly out of line, and that the values for other urban housing
may also be reasonable estimates.
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Chapter 9
PHYSICAL AND MENTAL HEALTH OF THE ELDERLY
Zachary Zimmer, Josefina N. Natividad, Mary Beth Ofstedal,
and Hui-Sheng Lin
Central to the study of gerontology and influential in its development have
been the changes in health that occur at older ages and the implications
of these changes for social and medical services, family relationships, and
public programs. It has long been recognized that mortality rates increase at
older ages, along with functional limitations and chronic diseases. But the
level of the underlying rates are far from fixed and there is considerable
variation over time and across groups, prompting intensive study of the em
pirical levels as well as underlying mechanisms from the standpoint of biol
ogy and biodemography (see Wachter and Finch, 1997). One facet of these
studies has been to develop a detailed profile of the health status of the elderly
population as the basis for gauging both their physical and mental well-being
and the social and economic implications of a growing older population.
In Asia, where the proportion of the population at older ages has been
low until recently and where older people traditionally resided with their chil
dren, fewer detailed studies have been conducted on the state of their health.
In addition, the health infrastructure there and in most developing countries
has been oriented toward problems of infectious diseases and maternal and
child health. An important start toward collecting more systematic data on the
health status of the elderly was a WHO-sponsored study carried out in 1984,
361
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362 The Well-Being of the Elderly in Asia
which surveyed older people in the Philippines, Malaysia, South Korea, and
Fiji (Andrews et al., 1986). A second WHO-sponsored study in the region in
1990 included five additional countries (or specified provinces) (Andrews
and Hennink, 1992). These studies, while significant in directing attention to
the health of the elderly in the Asia and Pacific regions, were often deficient in
terms of sample size and representativeness, limiting the inferences that could
be drawn at the national level or for cross-cultural comparisons. Several
other multi-country surveys of the elderly in Asia have also included some
items devoted to health status (for a review of these surveys, see Andrews
and Hermalin, 2000). These include the ASEAN-sponsored surveys of 1984-
1986 (Chen and Jones, 1989), which we have drawn on in several chapters
for over-time comparisons with the surveys reported here and will use again
below for assessing changes in health status.
The surveys conducted among the four focal countries of this study
in the mid-1990s each contained a wide range of questions about health con
ditions. Although the specific measures and amount of detail varied some
what across countries, the data permit close comparisons on many facets of
health. This chapter exploits these data to examine several health-related be
haviors and compare the countries on physical, emotional, and cognitive di
mensions of health, as well as on differences in levels of self-reported health.
In addition to overall country differences, the chapter examines how key
sociodemographic groups vary in their health and health behaviors within and
across countries.
Methodological Issues
Much of the data collected in gerontological research on the health of older
adults, especially studies that are representative of the broader population,
comes from responses that older adults give to survey questions. Accord
ingly, the validity and accuracy of these self-reported data are dependent
upon older respondents' understanding and knowledge of their health condi
tions and their ability and willingness to report this information accurately.
Despite careful attempts at questionnaire wording and at building good rap
port with respondents, any health-related data collected via questionnaires
have some inherent limitations. This section discusses some of the method
ological issues involved in collecting and analyzing this type of data.
As noted previously, health is a multidimensional construct and infor
mation on several different facets was collected from the respondents. Physical
health was measured by asking respondents whether they currently have
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Physical and Mental Health of the Elderly 3 63
specific medical conditions and/or limitations in the ability to undertake sev
eral basic activities of daily living (like walking, dressing, eating, and bathing).
Emotional health was examined by asking respondents about the presence of
several indicators of depression or by their level of loneliness. Respondents'
cognitive level was assessed by asking them to perform certain tasks such as
word recall, and/or by their ability to correctly orient themselves in terms of
reporting their age, the date, day of week, and so on. In addition, each survey
obtained an overall assessment of health by asking respondents to rate their
health on a four- or five-point scale. The wording of questions used in each
country often varied and for this reason we have included a special section
that lists all the questions used and the definitions employed in the analysis.
Major variations are also noted in the discussion and table footnotes.
These several dimensions not only represent different domains of the
complex structure of health, but they also intersect to varying degrees with
alternate perspectives on health. The literature often distinguishes the medical
definition of health, which stresses the absence of illness (approximated here
with the information on chronic illnesses), from the social definition of health,
which stresses how well individuals function within their social environment.
The latter of these perspectives implies that two individuals with the same
chronic conditions might be viewed as having different levels of health, de
pending on their physical and social environments. This insight is most rel
evant when appraising the implications of different reported levels of physical
functioning, because the degree of difficulty experienced in carrying out dif
ferent tasks will depend on the physical environment (e.g., the ease of bath
ing will be affected by shower accessibility) as well as social expectations
and traditional practices. The social aspect is also likely to be tapped by ques
tions on loneliness and sadness and other items designed to measure emo
tional health.
The information on health status used here is subjective in the sense
that it is reported by the respondents. But the questions on emotional health
and overall health are also subjective in the sense that they ask respondents to
make assessments or describe feelings rather than to report behaviors, to
undertake tasks (as with the word recall questions tapping cognitive health),
or to report diagnoses given to them by health practitioners. This subjectivity
should be kept in mind when reviewing the dimensions of health reported
here.
For example, self-assessments of health are likely to depend on re
spondents' expectations about what constitutes good health, the comparison
groups from which the respondents make their assessments, and inherent
cultural and linguistic factors. The small amount of research that has been
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364 The Well-Being of the Elderly in Asia
conducted on these factors suggests that they do affect self-assessments of
health. For example, Angel and Cleary (1984) compared reports of self-as
sessed health given by Hispanic Americans and found that the results differed
depending on whether the questionnaire was answered in English or Spanish.
Other researchers have found differences in the ways in which men and
women respond to self-assessed health questions (Wolinsky and Johnson,
1992). Also, it has been shown that people tend to rate themselves higher on
health with advancing age (Cockerham, Sharp and Wilcox, 1983), presum
ably because their reference group is subject to additional health problems.
Thus, an 80 year old inteniewed in the rural Philippines whose reference
group is comprised of relatively poor farmers may have a different evaluation
of his or her health than a 60 year old professional interviewed in Taipei.
Even the more "objective" health measures used here are likely to be
influenced by broader social and economic forces. Most important, reports
on the presence of chronic diseases depend heavily on the degree of access
that older individuals have to medical personnel that can carry out the relevant
examination and provide a diagnosis. The health infrastructure varies from
country to country, as described in Chapter 3, and also tends to vary across
regions within each country. The rural elderly, for example, may have fewer
health facilities nearby and less access to medical personnel than urban dwell
ers. On the other hand, special health initiatives such as Thailand's program
of free exams to all elderly or the universal health insurance program started
by Taiwan in 1995 may mitigate these differentials to some extent.
In addition to these broader environmental aspects, the individual char
acteristics of the elderly may greatly influence their access to and use of
health facilities. Those with greater resources and knowledge can be ex
pected to have higher utilization rates than others, unless offset with special
programs of the type noted above (see Chapter 10). Workers in more formal
sectors of the economy or working for larger firms may also have relative
advantages in terms of health care access than those not so employed. Edu
cational differentials also come into play in measuring cognitive level, since
performance in word and number recall tests tends to be highly influenced by
educational level (Uhlmann and Larson, 1991).
The relationship between socioeconomic status and health has been
subject to considerable study in the West (particularly in the United States and
United Kingdom) and is receiving increasing attention elsewhere. Although a
strong association has been demonstrated between socioeconomic status and
health, there has been some debate as to the direction of causality. Many
analysts have held that socioeconomic status affects health outcomes,
particularly at younger ages, but others have suggested that the direction of
causality runs the other way at older ages, or that there are underlying individual
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Physical and Mental Health of the Elderly 365
traits that influence both health and socioeconomic status (see discussions in
Anderson and Armstead, 1995; House et al., 1994; Smith, 1999; as well as in
Chapter 8 in this volume).
Models used to evaluate the effect of socioeconomic status on health
have identified several underlying mechanisms through which this effect may
occur. These include a set of psychosocial factors, including level of social
support, feelings of self-efficacy, psychological well-being, and stress; health-
related behaviors, such as smoking, drinking, exercise, and nutrition; as well
as health-related knowledge and access to and utilization of health services.
(See House et al., 1994 and Anderson and Armstead, 1995, for a more de
tailed description of these models.) Zimmer (1998) tests aspects of this model
for the influence of education on functioning in three of the Asian countries
under study here—the Philippines, Taiwan, and Thailand.
Although in this chapter we do not carry out a formal test of this
model, several of the analyses we present are relevant to these consider
ations. The main portion of the chapter examines health differentials on sev
eral sociodemographic characteristics—age, gender, urban-rural residence,
marital status, and education. These factors may have indirect effects on
health status through access and other intermediate factors mentioned above,
and they may also exhibit direct effects. In addition we provide evidence on
the nature of several risk behaviors and their relationship to sociodemographic
characteristics. (Related data on health are given in Chapter 10, which exam
ines patterns of health care utilization.)
Measures of emotional well-being may also be dependent upon cul
ture, language, and expectations, although, again, very little research has been
conducted to verify this. For instance, a question such as "Do you feel lonely?"
depends on an interpretation of what it means to be lonely, which might be
different in a society where older adults tend to have large families and coreside
with children than in one where they tend to live alone or with a spouse only.
It also depends upon the survey's success in translating the question into
different languages in a consistent manner.
Along with the measurement issues discussed above, we need to rec
ognize that, although the set of surveys being analyzed were constructed to
be comparable, each country had a fair degree of independence in finalizing
the way questions were asked. As such, many of the questions are similar but
they are not always asked in a uniform manner. For instance, the question
"How much difficulty do you have walking?" refers to 200 to 300 meters in
the Philippine and Taiwan surveys, and 1 kilometer in the Thailand survey.
Clearly, one would expect a higher proportion to report difficulties walking
the latter distance. Nonetheless, we might expect that an individual who re
ports "a lot of difficulty" walking 1 kilometer would also have problems
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366 The Well-Being of the Elderly in Asia
walking a distance somewhat shorter than that. As noted previously, question
wording for each of the measures is provided in the technical notes in Appen
dix 9. A, and major differences in question wording are also noted in the table
footnotes.
These various methodological issues should not deter us from the
important task of comparative analyses of health status among the elderly and
do not undermine the analyses being conducted in the Asian setting. How
ever, we must be sensitive to these issues of measurement and perception
when interpreting our results. What might appear to be large differences in
health between individuals in different settings may, in fact, be the result of
differences in question wording, interpretation, or perception. In the discus
sion that follows, we strive to provide an appropriate balance between these
considerations.
Health Risk Behaviors
As noted above, health risk behaviors have been advanced as powerful inter
mediate variables accounting for differentials in health status among socio-
economic groups. We thus begin the analysis by focusing on several risk
behaviors that are of particular relevance in the study countries, including
consumption of alcohol, tobacco, and betel nut. The surveys used in the
analysis included questions to ascertain the prevalence of smoking and drink
ing among older adults in the Philippines, Thailand, and Taiwan, and of betel
nut chewing in Thailand and Taiwan. For the present analyses we defined
drinking as consuming two or more drinks per day on average, to reflect
moderate or excessive drinking, and smoking and betel nut chewing as con
suming any amount.
Examining these risk behaviors of older adults is important for several
reasons. First, these types of behaviors can be detrimental to health. Smoking
and betel nut chewing are associated with increased risks of heart disease,
hypertension, and certain types of cancer, and excessive drinking is associ
ated with heart and liver problems. In addition, these risk behaviors may be
related to other types of behaviors or risks for which information is not
available, such as dieting, exercising, and obesity. Finally, there tend to be
strong socioeconomic and demographic patterns to risk behaviors in Western
industrialized societies. For example, in the United States adverse risk behav
iors are more prevalent among persons with lower education (Pamuk et al.,
1998) and men (National Center for Health Statistics, 1999), and in the United
States and United Kingdom among in those who live in rural areas (House,
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Physical and Mental Health of the Elderly 367
Lepkowski, Williams et al., 2000; Morgan, Armstrong, Huppert et al., 2000).
In this analysis, we examine whether similar patterns exist in Asian countries.
Table 9.1 presents the percent of elderly respondents in each country
except Singapore who report engaging in each risk behavior, by sociodemo-
graphic characteristic. The table provides results first for the total popula
tion, then for males and females separately. The data suggest that smoking is
most prevalent in the Philippines, followed by Thailand and Taiwan. Drinking
is also most prevalent in the Philippines followed by Thailand, and least preva
lent in Taiwan. Betel nut chewing is much more prevalent in Thailand than in
Taiwan. In fact, chewing is more common than smoking among the current
cohort of older Thais.
With regard to differentials on characteristics, several interesting pat
terns emerge. In general, men have a much greater tendency than women to
engage in these risk behaviors, except for betel nut chewing in Thailand, for
which the prevalence is about five times higher for women than for men.
(This will be examined in more detail below.) These risk behaviors tend to be
more prevalent among younger as opposed to older elderly, which may indi
cate cohort differences in the likelihood of undertaking these behaviors or
may be an artifact of selection due to longer survival of those who abstain
from risk behaviors. Again betel nut chewing in Thailand is an exception in
that it is more prevalent among those age 70 or older. Risk behaviors also tend
to be more prevalent among rural than urban residents.
The patterns for smoking and drinking by education level are more
complex. In the Philippines and Thailand, higher education is associated with
a lower prevalence of smoking, though not necessarily of drinking. In con
trast, in Taiwan those with the lowest level of education have the lowest
prevalence of smoking. This surprising pattern for Taiwan is largely a com
positional effect in that the prevalence of smoking is extremely low among
older women in Taiwan, who make up the bulk of those with no formal
schooling. In fact, higher education is associated with a lower prevalence of
smoking among Taiwanese males, consistent with the overall patterns for the
Philippines and Thailand, while no significant association was found among
Taiwanese women.
Another interesting pattern emerges when comparing betel nut chewing
and smoking in Thailand for men and women. As noted, the prevalence of
betel nut chewing in Thailand is high, with more than one-third of older adults
engaging in such behavior, including nearly half of those age 70 and older and
of those with no formal schooling. Closer examination of the data indicates
that betel nut chewing is primarily a custom among females in Thailand, and
especially among rural women with less education. To some extent, the
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Physical and Mental Health of the Elderly 371
prevalence rates of betel nut chewing among Thai women mirror those of
smoking among Thai men, as the following data make clear:
Betel Nut Chewing and Smoking in Thailand, by Selected
Characteristics
SexWomenMenEducationNoneNoneHighHighNoneNoneHighHighResidenceRuralUrbanRuralUrbanRuralUrbanRuralUrbanN1,13036152150357103176260%
Chewing702419414372%
Smoking1696171324035
In this table, "high" education is defined as secondary or higher (ex
cluding primary education). The table shows that in Thailand 70 percent of
low-educated rural women chew betel nut while 71 percent of low-educated
rural men smoke; and only 16 percent of such women smoke while 14 per
cent of such men chew betel nut. Betel nut chewing is almost nonexistent
among higher educated urban women (only 4 percent), as is smoking (1
percent). Among men in urban areas, the proportion chewing betel nut drops
to 3 percent or less and the proportion smoking drops to about one-third.
Also notable in Thailand is the increase in betel nut chewing with advancing
age: fully 80 percent of women age 70 or over who have no education and
live in rural areas chew betel. (Data not shown.) Thus, there appears to be a
strong cultural inclination among rural residents in Thailand for women to
chew betel and men to smoke, particularly among those with little education.
Physical Health
We turn now to an examination of the health status of older adults, beginning
with their physical health. Physical health indicators include both chronic
conditions and difficulties in conducting functional tasks. As noted previ
ously, in examining chronic conditions we are looking at health from the
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3 72 The Well-Being of the Elderly in Asia
medical perspective, while in examining functional tasks we are looking at
health from a social perspective.
With chronic conditions it is useful to distinguish those that are life
threatening, such as heart disease or cancer, from those that are often debili
tating but rarely cause death, such as arthritis. Although some older people
may be well aware that they have life-threatening health problems, others
may have them without clear indications or diagnoses. For instance, some
individuals may have life-threatening conditions that are asymptomatic in the
early stages; others may have symptoms but lack the health care access
necessary for a diagnosis. Also, because in some cultures including the Phil
ippines diagnoses for serious illnesses such as cancer are commonly with
held from patients, a professional medical diagnosis does not always guaran
tee patient awareness. On the other hand, the debilitating conditions that we
consider here (arthritis, incontinence, cataracts, vision problems, stomach
problems), by definition, are more readily apparent to an older individual
through their discomforting effects. Hence, we might consider the following
cross-classification of chronic diseases:
Life threateningDebilitatingEasy to detecte.g., strokee.g., arthritis,
incontinenceDifficult to detecte.g., heart disease,
cancer, diabetesnot applicable
The importance of such a classification is that conditions more diffi
cult to detect are more likely to be underreported by those with limited access
to a health care system, a situation common among many older adults in
developing countries. On the other hand, we would expect less reporting bias
for conditions that are easy to detect. Thus, we must be cautious when
interpreting differences in prevalence rates of self-reported chronic condi
tions across countries and across subgroups within countries.
Table 9.2 reports prevalence rates for 13 chronic conditions across
four countries, by gender and age group. It should be noted that, the question
asking about chronic conditions was quite different in the Singapore survey
than in the Philippines, Taiwan, and Thailand surveys. In the latter three coun
tries respondents were asked to indicate whether or not they currently had
any illnesses presented in a list. Singaporean respondents were asked whether
they were currently receiving treatment from a doctor for any longstanding
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378 The Well-Being of the Elderly in Asia
illnesses and, if so, to name them. (See Notes for Tables for exact question
wording.) The Singapore question format is likely to result in considerable
underreporting of chronic conditions, particularly the debilitating conditions
that often do not require ongoing treatment from a doctor. For this reason,
we included only life-threatening conditions for Singapore and, even for these,
cross-country differences involving Singapore must be interpreted with cau
tion.
A cross-country comparison of the results in Table 9.2 indicates that
Taiwan has the highest reported prevalence rates for more than half of the
conditions, the exceptions being arthritis, tuberculosis, lung disease, inconti
nence, and vision and hearing problems. In some cases, the prevalence rates
for the overall population are substantially higher in Taiwan than in the other
countries. For instance, while more than 17 percent report heart disease in
Taiwan, the total is about 13 percent in Thailand, 9 percent in the Philippines,
and only 6 percent in Singapore. Conversely, rates for arthritis, lung disease,
incontinence, and vision problems are highest in the Philippines. (The propor
tion of Filipinos reporting arthritis is twice that of the Taiwanese, and the
Thai rate is close to that of the Philippines.) These latter conditions often
have serious debilitating consequences and are easy to detect, whereas many
of the other conditions require diagnosis. Hence, the pattern seems to be that
Taiwan has the highest rates for diseases that are more difficult to detect,
while the Philippines has the highest rates for some of the more apparent
diseases.
The higher prevalence rates for most conditions in Taiwan may be
attributed to several factors. First, the older Taiwanese may have greater
access to health diagnostics because they tend to enjoy a higher standard of
living than their counterparts in other countries (which is often associated
with more frequent doctor visits), and because their national health care sys
tem offers aggressive screening programs, local health care facilities, and
more recently, the Universal Health Insurance program. Also, a selection ef
fect may increase their prevalence rates: earlier diagnosis and better medical
care lead to increased survival, which translates into a larger old-age cohort
surviving to report chronic diseases.
In terms of gender, the results indicate that women in all countries
tend to have higher prevalence than men for most conditions. It is particularly
interesting that women report higher rates of heart disease in the Philippines,
Thailand, and Taiwan, which is opposite the pattern normally found in the
U.S. (Kramarow et al., 1999). This may be because women are diagnosed
earlier, manage their disease better, and therefore have longer survival. Women
are less likely than men to report strokes in these three countries, a pattern
that is consistent with United States findings (Kramarow et al., 1999).
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Physical and Mental Health of the Elderly 379
When we look at patterns within five-year age groups, they remain
generally the same: the Taiwanese have the highest prevalence rates for many
diseases, with this apparent disadvantage increasing with age. For certain
debilitating diseases like arthritis, however, Taiwan has the lowest rates across
all age groups. In fact, the reporting of arthritis is much lower in Taiwan,
particularly among persons age 70 or over, than would be expected among
persons of comparable age in Western industrialized countries. For example,
a 1995 health survey in the U.S. found the prevalence of arthritis among
people age 70-plus years to be 63 percent for women and 50 percent for men
(Kramarow et al., 1999).
One interesting observation is that among Thai respondents aged 60 to
64, about 22 percent of women report heart disease, compared to just over 6
percent of men. Differences in heart disease rates between Thai men and
women are smaller for other age groups, and one possible explanation for the
large gender difference in the youngest age group may be a significant differ
ential in health care utilization. As shown in Chapter 10 Thai women are more
likely than men to use preventive and outpatient services, although these dif
ferences alone do not seem large enough to account for their much higher
reporting of heart disease.
In Tables 9.3A and 9.3B we collapse the data into categories of life-
threatening and debilitating conditions, respectively, and present the percent
age of respondents who report having one or more of the examined condi
tions in each group. With the exception of those shown by age group in the
top panel, the percentages are age-standardized within each country (see
Appendix 9.A for details on age-standardization) and shown by selected so-
ciodemographic characteristics. Focusing first on life-threatening conditions
(Table 9.3 A), we see that Taiwanese report the highest prevalence and Filipi
nos the lowest, with Thais and Singaporeans falling in the middle. The high
rate among Thais is due mainly to the high prevalence of heart disease among
women. With regard to age patterns, the results are mixed. There is a ten
dency for older persons to report lower prevalence of life-threatening condi
tions in the Philippines, Thailand, and Singapore, but these age differences
are significant only for Singapore. This pattern likely reflects greater access
to health services and awareness of health problems among younger than
older persons. In Taiwan, we see a more expected pattern, whereby the
prevalence of life-threatening conditions increases significantly with age, at
least through age 70-74.
Turning to the age-standardized results, we find a significantly higher
prevalence of life-threatening conditions for women in Thailand, but no
significant gender differences in the other countries. In addition, we find
significantly higher prevalence levels in urban than in rural areas for the three
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382 The Well-Being of the Elderly in Asia
Table 9.4. Percent Reporting Difficulty Performing Selected Activities
of Daily Living (ADL), by Age and Gender
ADL/
Age groupWalking60-6465-6970-7475+All agesEating60-6465-6970-7475+All agesBathing or toileting60-6465-6970-7475+All agesDressing60-6465-6970-7475+All agesMale7.96.211.119.010.46.11.45.64.64.55.14.110.613.27.64.14.75.811.26.1PhilippinesFemale6.66.310.920.710.94.33.34.9554.44.62.94.115.56.84.74.14.49.75.7All7.26.311.020.110.75.12.55.25.24.54.83.46.914.67.14.44.35.010.35.9Male8.78.417.327.413.62.31.14.28.13.42.73.06.212.15.12.20.74.57.43.2ThailandFemale11.112.817.833.417.91.72.21.011.74.03.34.94.917.17.21.0121.010.23.2All9.910.917.631.015.92.01.72.410.33.73.04.15.515.16.21.61.02.69.13.2
countries with an urban/rural distinction. Education is also positively associated
with reporting life-threatening conditions in the Philippines and Singapore.
Differential patterns of access to and utilization of health care may be
responsible for the seemingly increased risk of disease among urban residents
and those who are more highly educated, although extended survival of
individuals in these groups may also play a role.
With regard to debilitating conditions (Table 9.3B), which are easier to
recognize in the absence of clinical diagnoses, at least three-fifths of the
elderly in the three countries for which data are available report suffering
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Physical and Mental Health of the Elderly 383
Table 9.4. continued
See Notes for Table 9.4 at the end of this chapter.
ADL/
Age groupWalking60-6465-6970-7475+All agesEating60-6465-6970-7475+All agesBathing or toileting60-6465-6970-7475+All agesDressing60-6465-6970-7475+All agesMale3.33.03.711.54.92.41.32.56.22.83.33.94.812.15.53.33.34.110.94.9TaiwanFemale2.74.16.212.45.91.21.32.67.12.84J5.35.916.77.72.73.75.512.15.6All3.03.44.811.95.31.81.32.56.62.83.94.55.314.46.53.33.54.711.55.2SingaporeMale0.52.35.28.33.50.30.31.92.91.20.81.35.05.72.7—————Female1.53.68.913.56.60.01.31.84.01.70.83.24.510.54.6—————All1.03.07.211.45.10.20.81.93.61.50.82.34.78.53.7—————
from one or more of these conditions. The Filipino elderly have the highest
prevalence at 65 percent. Within each of the three countries, the prevalence
increases monotonically with age, and women experience debilitating condi
tions at higher rates than men. Consistent with our expectation that debilitat
ing conditions tend to be easier to detect than life-threatening conditions in
the absence of medical diagnosis, the more educated show lower prevalence
and no urban/rural differences are found for the Philippines or Thailand—
patterns that differ sharply from those observed for life-threatening condi
tions. (In Taiwan, however, the rural elderly report fewer debilitating condi
tions than urban elderly.)
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384 The Well-Being of the Elderly in Asia
The second dimension of physical health that we examine is func
tional limitation. To assess functional limitation, we use four indicators of
ability to perform activities of daily living (ADLs)—walking around the house,
eating, bathing and toileting, and dressing. Table 9.4 presents the percent
reporting difficulty in performing each activity. Singapore, which has data
for only three of the four measures, is included in the table where applicable.
In general, the most commonly reported difficulty was walking around
the house, with Thai elderly showing the highest percentage (about 16 per
cent) and the Taiwanese and Singaporean elderly reporting much lower preva
lence of this problem (about 5 percent). The Filipino elderly have the highest
percentages reporting difficulty with eating, bathing, and dressing, while the
elderly in Singapore show the lowest levels for difficulty with eating and
bathing/dressing.
With regard to gender differences, women report more difficulty walk
ing around the house in Thailand and Singapore, but the pattern is mixed in
Taiwan and the Philippines. For the remaining ADL indicators there are no
consistent patterns associated with gender. In terms of age, however, ADL
difficulty generally increases with age in all countries, with a substantial jump
often observed for the oldest age group.
In Table 9.5 we present the percentages reporting difficulty with one
or more ADL by selected socioeconomic characteristics. The percentages
are age-standardized within countries (with the exception of those shown by
age group in the very top panel). Overall, Thais and Filipinos report higher
levels of ADL difficulty than Taiwanese and Singaporeans—a differential that
may be partly accounted for by environmental factors, particularly housing
conditions, which tend to be more favorable in the relatively more developed
countries of Taiwan and Singapore.
When we examine patterns by the sociodemographic characteristics,
we see in all countries strong increases in ADL difficulty by age, particularly
above age 70. Women tend to report higher levels of difficulty than men,
except in the Philippines, where there is no significant gender difference.
Urban-rural residence and marital status are unrelated to ADL difficulty, and
the results for education are mixed. No significant association between edu
cation and ADL functioning is found in the Philippines or Thailand, while
different patterns are found in Taiwan and Singapore. In Taiwan higher edu
cation is associated with lower difficulty, a result also found in the United
States (Kaplan, Strawbridge, Camacho, and Cohen, 1993; Guralnik, Land,
Blazer et al., 1993). However, in Singapore the pattern appears to be curvilin
ear, whereby those with no education and with secondary or higher levels
both report slightly higher levels of functional impairment than those with
primary education.
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Physical and Mental Health of the Elderly 385
Table 9.5. Percent Reporting Difficulty Performing One or More ADL, by
Selected Sociodemographic Characteristics (age standardized)
CharacteristicUnstandardized60-6465-6970-7475+Age-standardizedMaleFemaleChi-square (p-value)UrbanRuralChi-square (p-value)Not marriedMarriedChi-square (p-value)No formal schoolingAny primaryAny secondary+Chi-square (p-value)Philippines13.58.48.015.324.913.713.40.02 (.881)14.812.61.33 (.248)14.113.50.10 (.751)14.212.514.10.80 (.672)Thailand17.210.712.218.933.215.318.79. 17 (.002)17.017.20.02 (.888)18.116.90.99 (.321)17.317.216.40.1 3 (.938)Taiwan7.34.15.16.416.06.38.55.25 (.022)7.66.41.24 (.266)8.36.53.34 (.068)9.56.34.319. 15 (.000)Singapore*5.91.23.78.112.94.37.111.56 (.001)——6.15.30.94 (.332)6.24.27.16.27 (.044)
'Singapore results are based on three AIM v results for other countries are based on four
ADI.s as defined in previous table.
See Notes for Table 9.5 at the end of this chapter and Appendix 9.A for a description of
age-standardization.
Emotional and Cognitive Health
Surveys in three of the countries—Thailand, Taiwan and the Philippines—
collected data on emotional health, although with some differences in ap
proach. They all asked respondents to self-assess their emotional state by
reporting whether or not they experienced certain affective feelings within a
specified time period. Both Taiwan and the Philippines used a subset of mea
sures from the Centers for Epidemiological Studies-Depression Scale (CES-
D) (Radloff, 1977). The exact items that were used in each country differed
somewhat and are listed in Appendix 9.A. The Thai survey included only a
single indicator for emotional health, asking how lonely the respondent felt
during the year prior to the survey.
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Table 9.6. Ratio of Mean Scores on Indicators of Depression
and Loneliness, by Selected Sociodemographic
Characteristics
CharacteristicTotalRatioMean/percentAge 60-64Age 65-69Age 70-74Age 75+MaleFemaleUrbanRuralNot marriedMarriedNo formalschoolingAny primaryAny secondary*Philippines(ratio of
depressive
symptoms)1.002.410.930.981.021.100.871.090.971.021.070.951.161.010.82Taiwan(ratio of
depressive
symptoms)1.002.010.920.881.121.180.861.170.991.011.240.891.250.880.76Thailand(ratio of %
feeling
lonely)1.005.720.930.991.051.090.931.060.801.041.090.951.110.980.69
Notes: For the Philippines and Taiwan, the ratio is defined as the mean number
of depressive symptoms for the subgroup of interest divided by the mean
number of depressive symptoms for the total sample. For Thailand, the ratio is
defined as the percent reporting feeling sometimes or very lonely for the
subgroup of interest, divided by the percent reporting this feeling for the total
sample.
See additional Notes for Table 9.6 at the end of this chapter.
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Physical and Mental Health of the Elderly 387
To standardize data presentation given the differences in measures,
the results are shown as ratios of the mean for each subgroup to the overall
mean for the country. Thus, ratios above one indicate that respondents in the
group in question had a higher average level of depressive symptoms (i.e.,
worse emotional health) than the average of all respondents in the country,
and ratios below one indicate that the group in question had lower than aver
age depressive symptoms (i.e., better emotional health). Given the lack of
common measures, we are unable to compare absolute levels of emotional
health across the three countries. However, using the ratio approach, we are
able to compare the direction of differences in emotional health on any given
indicator across countries.
The data in Table 9.6 show very similar patterns of emotional health
across the three countries. In all countries emotional health tends to decline
as age increases. Hence, not only are the elderly gelling physically weaker
with age, but they are also emotionally less healthy. In addition, women,
those not currently married (primarily widowed), and those with lower edu
cation all tend to report poorer emotional health. Rural residents also appear
to be at somewhat of a disadvantage with regard to experiencing loneliness in
Thailand, but urban-rural differences are essentially non-existent for the other
countries. Levels of depression and loneliness among older Asians have been
little studied to date, but the differentials observed in Table 9.6 suggest the
need for greater attention to these aspects of emotional health.
Data on cognitive functioning were collected in the Philippines, Tai
wan, and Singapore. The Taiwan and Singapore surveys contain different
subsets of items from the Mini-Mental State Exam (Folstein, Folstein and
McHugh, 1975), including basic orientation tests, as well as number and
word recall tests. The Philippines survey contains only a word recall test.
The exact tests used in each country are listed in Notes for Tables at the end
of this chapter. The cognitive scores represent the number of correct re
sponses on all of the items for a given country. Because, as with emotional
health, cognitive functioning was measured somewhat differently across the
countries, these results are also presented in ratio form.
As shown in Table 9.7, in all three countries persons over 70 years of
age and with less education had average scores below their respective coun
try means—differences consistent with those found in the United States
(Herzog and Wallace, 1997). These relationships are particularly strong in the
Philippines and Taiwan. Adjusted for age, there are no appreciable differences
by gender, rural-urban residence, or marital status.
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388 The Well-Being of the Elderly in Asia
Table 9.7. Ratio of Mean Cognition Scores, by Selected
Sociodemographic Characteristics (age standardized)
CharacteristicTotalRatioMeanAge60-6465-6970-7475+Age-standardizedMaleFemaleUrbanRuralNot marriedMarriedNo formalschooling
Any primary
Any secondary+Philippines1.003.131.161.030.960.780.991.011.050.960.981.000.821.01
1.16Taiwan1.004.131.101.070.950.761.070.911.000.990.921.040.841.03
1.26Singapore1.008.771.041.020.970.941.030.98_-0.991.020.981.04
1.07
Notes: For all countries, the ratio is defined as the mean number of correct responses
for the subgroup of interest, divided by the mean number of correct responses for the total
sample. Ratios above one indicate that the subgroup scored higher on average than the
overall sample, and ratios below one indicate that the subgroup scored lower.
See additional Notes for Table 9.7 at the end of this chapter and Appendix 9.A for
description of age-standardization.
Self-Assessed Health
Measures of self-assessed health that ask respondents to rate their overall
health on a scale from excellent to poor have become ubiquitous in surveys of
older adults. The reason is clear: self-assessed health is a simple and eco
nomical question about health that tends to capture a broad array of health
dimensions. Self-assessed health has been found to be sensitive to variation in
objective health status (Farraro, 1980). When individuals are asked to assess
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Physical and Mental Health of the Elderly 389
their health on a general scale, they seem to consider a multitude of health
criteria, including chronic, functional, emotional, and cognitive disorders. In
addition, at least on a subconscious level, they may be taking into account
other more sensitive criteria about health that are difficult to detect in surveys
or even in medical examinations. Indeed, a number of studies have found
self-assessed health to be a powerful predictor of mortality, beyond the ef
fects of more objective health indicators such as disease and disability (Idler
and Benyamini, 1997).
Because of the global nature of the measure and the fact that it can be
captured with a single question, self-assessed health is a widely used measure
in studies of health around the world and perhaps the most commonly used
measure for cross-cultural comparisons. Nevertheless as a subjective mea
sure it is vulnerable to influence by cultural norms, and sensitive to the actual
phrasing of both the question and the response categories—which even if
translated similarly in English, may not mean the same thing in native lan
guages across countries. In the four countries examined here, the questions
were asked quite similarly. However, the response categories were somewhat
different in that Singapore used four categories, whereas the other three coun
tries used five categories. For purposes of cross-country comparison, we
collapsed categories into three levels, which we label as high, moderate and
low health. The exact questions and the mapping of responses into these
categories are given in the Notes for Tables.
Table 9.8 presents the percent that report high, moderate, and low
levels of self-assessed health in each country by age and gender. Older adults
in Thailand and Taiwan tend to rate their health more favorably—that is, they
are more likely to report a high assessment and less likely to report a low
assessment—than do those in Singapore and the Philippines, where moderate
self-assessments predominate. It should be noted that for Singapore (where
the response categories differed) only the top one of four categories was
regarded as high self-assessed health compared to the top two of five catego
ries for each of the other countries. Therefore, it is possible that the distribu
tion shown for Singapore elders is biased downward to some extent.
In addition to these comparisons across countries, comparisons within
countries are revealing. For example, despite changing reference groups, in
creasing age is associated with lower self-assessed health in all countries.
The age pattern is most notable in the Philippines, where the percent who rate
their health as low increases from about 10 percent among those age 60 to 64
to about 27 percent among those 75 and older. With respect to gender, men
tend to rate their health more favorably than do women. In all but two age
groups (70-74 in Singapore and 75+ in the Philippines), high self-assess
ments are more prevalent among men than women.
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390 The Well-Being of the Elderly in Asia
Table 9.8. Self-Assessed Health Status, by Age and Gender
Age
Health RatingAll agesHighModerateLow60-64HighModerateLow65-69HighModerateLow70-74HighModerateLow75+HighModerateLowPhilippinesMale18.567.913.624.666.78.718.672.29.217.071.111.99.561.528.9Female13.071.715.414.475.210.514.171.414.513.675.211.29.664.825.5Total15.270.114.619.071.39.715.971.812.315.073.511.59.663.626.8ThailandMale41.051.97.045.250.54.343.152.44.639.449.511.130.157.112.8Female30.357.112.629.357.813.035.253.910.928.060.611.327.557.415.1Total35.254.710.137.254.18.738.753.28.133.255.511.228.657.314.2
Table 9.9 presents the age-standardized percentage of respondents
who report low self-assessed health. Here again we see that women generally
report worse health than men, but the gender difference is significant only in
Thailand and Singapore. In addition, rural residents tend to report poorer
health than their urban counterparts in both the Philippines and Thailand.
(The urban/rural differential is in the same direction for Taiwan, but is small
and not statistically significant.) With regard to marital status, there is a slight
tendency for married people to report better health, but the difference is
significant only in Taiwan.
Of all the sociodcmographic characteristics considered, education
shows the strongest association with poor self-assessment of health, with
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Physical and Mental Health of the Elderly 391
Table 9.8. continued
See Notes for Table 9.8 at the end of this chapter.
Age
Health RatingAll agesHighModerateLow60-64HighModerateLow65-69HighModerateLow70-74HighModerateLow75+HighModerateLowPhilippinesMale36.954.68.538.355.56.240.353.85.936.954.98.229.254.316.5Female25.265.49.431.064.15.024.567.97.520.568.710.821.161.717.3Total31.659.58.934.659.85.634.059.56.629.860.89.325.257.916.9ThailandMale17.568.414.122.071.16.920.565.913.69.267.523.313.167.819.1Female14.666.618.815.670.214.218.264.916.914.065.620.410.864.524.7Total15.967.416.618.870.610.619.365.415.311.866.521.711.765.922.4
significant differences observed in all four countries. In the Philippines, Thai
land, and Taiwan, those with no formal schooling are two to three times more
likely than those with the highest education to report poor health. For Singapore
the education pattern appears to be curvilinear, with those in the lowest and
highest education categories reporting less favorable health ratings than those
in the middle category. Although this result is somewhat surprising in light of
education patterns for the other countries, it is consistent with the education
patterns observed for chronic conditions and ADL functioning described ear
lier. To the extent that higher educated persons are in fact less healthy or at
least perceive themselves to be less healthy than their less educated peers, the
reports of poorer self-assessed health are reasonable.
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392 The Well-Being of the Elderly in Asia
Table 9.9. Percent Reporting Low Assessments of Health, by Selected Socio-
demographic Characteristics (age standardized)
CharacteristicTotalMale
Female
Chi-square (p-value)Urban
Rural
Chi-square (p-value)Not married
Married
Chi-square (p-value)No formal schooling
Any primary
Any secondary+
Chi-square (p-value)Philippines14.614.1
15.10.23 (.629)11.8
16.7
6. 12 (.013)15.9
13.6
1.30 (.254)18.414.4
8.0
11.60 (.003)Thailand10.17.2
12.6
33.93 (.000)7.4
10.6
7.20 (.007)9.2
10.7
2.30 (.129)12.1
9.6
4.018.23 (.000)Taiwan8.98.6
9.40.49 (.484)8.7
9.4
0.36 (.549)11.3
7.7
10.56 (.001)12.2
7.05.3
3 1.22 (.000)Singapore16.614.5
18.5
9.79 (.002)-17.1
15.9
0.83 (.363)16.714.5
21.7
8.64 (.013)
See Notes for Table 9.9 at the end of this chapter and Appendix 9.A for description of age-
standardization.
Table 9.10 examines trends over time comparing our survey results
from 1995 and 1996 with the results from the ASEAN surveys conducted in
1986 in the Philippines, Thailand, and Singapore and the baseline Taiwan
elderly survey conducted in 1989. Although they provide a useful point of
comparison, the results should be interpreted with caution. Different sam
pling techniques and methods of data collection may compromise compara
bility of the two sets of studies. In addition, response categories for self-
assessed health differed across studies for all countries except Singapore.
For example, we define poor health in Taiwan as those reporting fair or poor
in 1989 and those reporting not so good or poor in 1996. With these cautions
in mind, the results suggest that there have been improvements in self-as
sessed health in the Philippines and Singapore, where the percent reporting
very good/good health increased and the percent reporting poor health de
creased. There is also evidence of improvement in Thailand where, although
no change took place in the percent reporting very good/good, there was a
decline in the percent reporting poor. Taiwan is the only country to show an
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Physical and Mental Health of the Elderly 393
Table 9.10. Trends over Time in Self-Assessed Health
See Notes for Table 9.10 at the end of this chapter.
Country and YearPhilippines198619961996 age standardizedThailand198619951995 age standardizedTaiwan198919961996 age standardizedSingapore198619951995 age standardizedSelf-Assessed Health RatingVery Good/Good Poor35%505135353539333367838411%1514413435233232511
unfavorable shift in self-assessed health, with a higher proportion reporting
poor and a lower proportion reporting very good/good health in the later
period.
As noted above, self-assessed health has proven to be a very powerful
global measure of health. Individuals tend to assess their health by appraising
the aggregate of their objective health conditions, such as whether they have
any chronic conditions or functional limitations, as well as their mental health.
These health conditions are in turn associated with a number of sociodemo-
graphic traits that reflect variations in access to medical care, knowledge
about illness, resources, and levels of social support. As a result it is not
surprising that a number of these sociodemographic characteristics also dis
play a strong association with self-assessed health, as shown in Table 9.9. It
is also plausible that cultural factors may influence the way in which individu
als assess their health (Angel and Thoits. 1987). To examine these issues in
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394 The Well-Being of the Elderly in Asia
more detail, we turn to a multivariate analysis of the factors influencing self-
assessed health.
In this last stage of the analysis, we use an ordinal logistic regression
technique to simultaneously estimate the effects of sociodemographic char
acteristics, health behaviors, and physical and mental health status on self-
assessed health, separately for each country. An ordinal logistic regression
model is a proportional model that can be used for dependent variables with
more than two categories that contain an inherent ordering. The model is
similar to a bivariate logistic model in that it estimates the log-odds of obtain
ing one response versus another when collapsing the dependent variable into
any two categories (Agresti, 1996). (Indeed, a bivariate logistic regression is
a special case of an ordinal logistic regression for a two-category dependent
variable.)
The dependent variables used in the present analysis correspond to the
measures of self-assessed health shown in Table 9.8, coded such that l=high,
2=moderate, and 3=low. Table 9.11 presents results from the regression models
in the form of odds-ratios. Given the coding on the dependent variable (i.e.,
that an increase in value implies a less favorable rating), an odds-ratio above
one indicates that the group in question rated their health less favorably on
average than their respective counterparts, all other things being equal, and an
odds-ratio below one indicates that the group rated their health more favor
ably.
We expect the presence of physical, emotional, and cognitive health
problems to be strongly associated with poorer health assessments. Further
more, we expect the other factors—sociodemographic characteristics and
health behaviors—to be associated primarily through actual health status. For
example, as shown in the bivariate analyses for self-assessed health, women
tend to rate their health less favorably than men. However, women also had
poorer outcomes than men on the physical, emotional, and cognitive out
comes in general, and this may account in large part for their poorer self-
assessments. Likewise, health risk behaviors are generally associated with
negative health outcomes, which in turn are associated with poorer health
ratings. Hence, when health status is controlled, as in the following multivari
ate analyses, the effects of sociodemographic and health behavior factors
should be reduced.
Turning to the results, we find somewhat mixed effects of sociode
mographic characteristics on self-assessed health across countries. The ef
fect of age on self-assessed health is generally not significant, controlling for
the other factors, except in Singapore where persons aged 65-69 report more
favorable ratings than those age 60-64. The strong age effects that were
observed for the other countries in the bivariate analyses in Table 9.8 are
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Physical and Mental Health of the Elderly 395
likely explained in large part by the health factors included in the model. The
finding for Singapore seems somewhat surprising, but it is plausible in light
of the argument by Cockerham and colleagues (1983) discussed earlier in the
chapter. That is, those who are in reasonable health at older ages may actually
report their health more favorably than those in reasonable health at younger
ages, because the older respondents' reference group is less healthy. Hence,
once underlying health differences are controlled in the multivariate models,
we would expect the negative age effect to be substantially reduced if not
reversed.
The gender effect is also not significant except in Thailand where,
other things being equal, females report less favorable health than males.
Marital status is not a significant factor in any country. Persons in rural areas
report less favorable health ratings than those in urban areas in Thailand and
Taiwan. However the rural effect that was observed for the Philippines in the
bivariate analysis (Table 9.9) disappears in the multivariate analysis, suggest
ing that much of the urban-rural difference among older Filipinos is accounted
for by differences in actual health status and the other characteristics shown.
With regard to education, both the Philippines and Taiwan show sig
nificant effects. In the Philippines, those with no formal schooling have lower
self-assessed health than those who had primary schooling, but those with
more than primary education do not necessarily fare better. In Taiwan the
education effect is in the expected direction for those with the highest educa
tion, but there is no significant difference between those with no formal
versus primary education. The effect of education is in the expected direction
for Thailand, although the differences are small and not statistically signifi
cant. For Singapore, the coefficients again suggest a curvilinear effect as
observed in the bivariate analysis, although as with Thailand the effects are
small and non-significant.
We include both living arrangements and existence of children as indi
cators of social support. In Asia, where living with a child is the norm, those
who have no children or who live in alternative living arrangements may
report less favorable health because there may be no ready sources of imme
diate help, or because they feel more dejected and lonely. On the other hand,
those who have children but are not living with them may be somewhat
healthier individuals who are able to live independently and do not require care
from children. The results are supportive of both of these hypotheses. In
Singapore persons who do not live with a child report worse health, and this
is particularly true for those who live with a spouse only or in other arrange
ments. The same direction of effects is found in the Philippines, although the
differences are not significant. The reverse is observed in Thailand where
those who do not live with children report more favorable health, especially
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398 The Well-Being of the Elderly in Asia
those who live with a spouse only. The number of living children is not
associated with self-assessed health in any of the countries.
With regard to the health risk behaviors, the only behavior that shows
a significant effect on self-assessed health (when controlling for other fac
tors) is betel nut chewing. Persons who chew betel nut in both Thailand and
Taiwan report less favorable health than those who do not chew betel nut.
Lastly, with respect to health factors, the results show that all of the
dimensions of health status considered here are significant predictors of self-
assessed health in all countries. This finding reinforces our earlier contention
that each health dimension influences a person's global assessment of their
health. Of the health measures, functional limitations have the largest effect
The presence of one or more ADL limitation is associated with a three-fold
increase in the likelihood of reporting less favorable health in Thailand, Tai
wan, and the Philippines, and a seven-fold increase in Singapore. The pres
ence of debilitating and life-threatening health conditions is also strongly pre
dictive of poorer self-assessed health in all countries. Emotional health is also
significantly associated with self-assessed health, in that those reporting higher
numbers of depressive symptoms (Philippines or Taiwan) or feelings of lone
liness (Thailand) are more likely to report less favorable health. And finally,
cognitive status is associated in the expected direction, in that those with
higher cognitive scores report more favorable health assessments.
Conclusions
The foregoing analyses have provided a detailed examination of the current
health status of older adults in the study countries across several dimensions.
We examined several indicators of physical health, as well as emotional and
cognitive health, self-assessed health, and key health behaviors.
It is useful to step back from the detail for a moment to answer the
question: How do older Asians fare with respect to their health? Despite the
common impression of widespread illness and disability among the older popu
lation in developing countries, our findings suggest that the elderly in the four
study countries are faring quite well. The prevalence of life-threatening con
ditions is quite low, although as discussed earlier and again a bit later, part of
this is due to lack of diagnosis for older persons who for various reasons do
not seek or receive treatment. Overall, about three-fifths of the elderly have
one or more debilitating conditions. However, it appears that these conditions
do not interfere with daily life activities. Indeed, the vast majority of elderly
report no ADL difficulties, ranging from 83% in Thailand to 94% in Singapore.
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Physical and Mental Health of the Elderly 399
The elderly appear to be doing well with respect to emotional health,
as well,at least as reflected in the survey measures. The average number of
depressive symptoms experienced by elderly Filipinos and Taiwanese is quite
low (2.4 of 7 symptoms in the Philippines and 2.0 of 10 in Taiwan) and the
percent reporting strong feelings of loneliness in Thailand is extremely low (6
percent). Finally, in terms of self-assessed health, the elderly view their health
in quite positive terms. Only a small proportion in each country reported fair
or poor ratings of their health (ranging from 9 percent in Taiwan to 17 per
cent in Singapore), with the remainder rating their health as good to excellent.
An important part of the investigation focused on within-country health
differentials by various sociodemographic characteristics. On this point, the
patterns we observed were generally consistent with our expectations and
similar across countries. Health problems tended to increase with age and be
more prevalent among women than men, with the exception of some life-
threatening conditions. These patterns are consistent with those found in the
United States and other developed countries where disease prevalence in
creases sharply with age in later life, men have higher prevalence than women
of life-threatening illnesses (and thereby higher mortality rates), and women
have higher prevalence of debilitating conditions and functional limitations.
In addition, we observed lower assessments of health among the eld
erly in rural compared to urban areas. Somewhat surprisingly, however, we
did not find a disadvantage among rural residents for the more objective
measures of physical health (chronic conditions, functional limitation), nor
for emotional or cognitive health. One exception relates to emotional health,
for which the proportion reporting feeling lonely was somewhat higher among
rural than urban respondents in Thailand. Furthermore, for life-threatening
conditions we actually observed the opposite effect, whereby urban residents
in the Philippines, Taiwan, and Thailand reported higher prevalence rates than
their rural counterparts.
One possible explanation for these results may be related to selective
rural to urban migration of the elderly. As noted in Chapter 2, these countries
have experienced rapid urbanization in recent decades, due in large part to the
migration of young people from rural to urban areas for employment oppor
tunities. To the extent that older persons move to urban areas to live with or
near their children when their health begins to deteriorate and they are in need
of care, we would expect the health of older persons who remain in rural
areas to be the same or better than their counterparts in urban areas, as our
results show. A second possible explanation is related to the aberrant findings
associated with education and has to do with differential access to health
services in urban versus rural areas. (This is discussed in more detail below.)
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400 The Well-Being of the Elderly in Asia
The multivariate analysis of self-assessed health revealed that global
ratings of health are influenced by all components of physical, emotional, and
cognitive health examined here. For every country, all of these measures
exhibited strong effects on self-assessed health in the expected direction,
with ADL limitation showing the most pronounced effect. Hence, it appears
that in each country this measure operates as intended by capturing the multi-
dimensionality of health.
In addition to the differentials in health status within countries, we
also focused on cross-country comparisons in overall levels of health. Al
though rigorous comparisons are hampered due to differences in measures
across countries, we can still draw some tentative conclusions. First, with
regard to physical health, it appears that older persons in the Philippines and
Thailand report higher levels of debilitating conditions and functional limita
tions than those in Taiwan and Singapore. This is particularly true with re
spect to ADL limitation (Table 9.4), for which the percentages reporting any
limitation are extremely low for both Taiwan and Singapore. With respect to
self-assessed health, the proportion giving fair or poor ratings is lowest in
Taiwan, followed by Thailand and the Philippines. (Singapore has the highest
percent with low assessments, but the different response categories make
such a comparison problematic.)
Hence, it appears on the basis of these measures that the health of the
elderly across countries corresponds to the countries' level of economic de
velopment—that is, lowest in the Philippines and then Thailand and highest in
Taiwan and Singapore. Nevertheless, it should be noted that these differences
are not large, particularly those relating to debilitating conditions and self-
assessed health.
Although not the primary focus of the chapter, perhaps one of the
most important findings has to do with the association between socioeco-
nomic status (SES) and reporting of chronic conditions. Evidence from stud
ies in the United States and other more developed countries would lead us to
expect higher SES to be associated with lower disease prevalence (House et
al, 1994; Pamuk et al., 1998; Rogers, Rogers and Belanger, 1992). However,
we found quite a different pattern with regard to life-threatening conditions in
these Asian countries. For Thailand and Taiwan we found no association
between education and the reporting of life-threatening conditions; for the
Philippines and Singapore, we found higher levels of education associated
with greater prevalence of life-threatening conditions. Also, with regard to
cross-country differences (for the three countries for which this comparison
is possible), the prevalence of life-threatening diseases appears to be lowest
in the least economically developed country (the Philippines) and highest in
the most economically developed one (Taiwan).
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Physical and Mental Health of the Elderly 401
As discussed, we hypothesize that these differences largely reflect
differences in access to and utilization of health services. Older persons with
higher education are more likely to seek and/or receive medical treatment (as
shown in Chapter 10), and therefore have more opportunity to learn about an
existing illness. The fact that these differentials are largely confined to the
life-threatening conditions (which we have argued are more difficult to self-
diagnose) lends credence to this explanation. Nevertheless, these findings
have important policy implications in that they suggest the need to improve
access for those less well served under the current health care systems.
Although the chapter has painted a fairly complete picture of health
among older Asians, it should be emphasized that this picture is merely a
snapshot of health status during a time of dramatic demographic and socio-
economic change. As noted in Chapter 3, the impending growth in the num
ber and proportion of older persons in these countries has policymakers con
cerned about the associated increase in disease and disability prevalence, and
the concomitant requirements for informal and formal health care. However,
the precise implications of population aging for future levels of health and
health care utilization depend on whether the increases in life expectancy that
have been experienced are accompanied by an increase or decrease in health
problems in later life. This is an extremely complex issue that in turn depends
on a number of factors, including the changing socioeconomic composition
of the elderly population, the health behaviors of individuals throughout their
lives, and expansion in health technology and/or access to health services.
This issue has been the subject of much recent research in the United States,
which suggests that the rates of disease and disability in older age have de
clined in recent years (Crimmins, Saito and Reynolds, 1997; Freedman and
Martin, 1998; Manton, Corder and Stallard, 1993). Although the answer to
this question for the countries under study (and indeed most of Asia) is un
known at this point, the current chapter provides a useful baseline for moni
toring future trends in health status and behaviors. The chapter is also useful
in that it has shed light on some of the dynamics of health. Understanding
where health disparities exist in a population helps health care professionals
and policy makers to identify specific groups or areas where services and
interventions may be targeted.
In the coming years these countries and most others in the region will
face not only increasing numbers and proportions of people over 60 years of
age, but a higher proportion of people in the oldest age range—80 years and
above. As a result, even with favorable trends in the rates of disability, these
countries can expect larger numbers of older citizens with life-threatening
chronic conditions and functional limitations, possibly taxing health infra
structures that as yet are imperfectly designed to address such problems.
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402 The Well-Being of the Elderly in Asia
To develop policies and programs that can provide needed services in
an efficient manner will require careful studies that monitor the health behav
iors, access to and utilization of health services, and health status of future
cohorts of elderly. Those studies should build on past efforts to identify the
best strategies for probing these complex issues in terms of survey design,
questionnaire wording, response categories, and related dimensions. In addi
tion, such studies should be standardized and coordinated across countries
so as to maximize the benefits of comparative analyses.
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Physical and Mental Health of the Elderly 403
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404 The Well-Being of the Elderly in Asia
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NOTES FOR TABLES
Table 9.1
Smoking refers to current smoking (of any amount) at the time of the survey.
Betel nut chewing refers to current chewing (of any amount) at the time of the
survey.
The variable for drinking is intended to reflect moderate to heavy alcohol
consumption. The measures vary somewhat across countries as follows:
Philippines
Respondents are coded yes for moderate/heavy drinking if they consume 2 or
more drinks on a frequent basis (at least several times per week) or if they drink
less frequently but consume 4+ drinks on average each time.
Thailand
Respondents are coded yes for moderate/heavy drinking if they drank almost
every day during the past month. No information is available on amount consumed.
Taiwan
As with the Philippines, respondents are coded yes for moderate/heavy
drinking if they consume 2 or more drinks on a frequent basis (at least several times
per week) or if they drink less frequently but average 4+ drinks each time.
Tables 92-9.3
Questions used to measure current prevalence of conditions in each country
include:
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Physical and Mental Health of the Elderly 405
Philippines
"I will read the following list of illnesses. Please tell me if you ever had each
condition. If yes, do you still have this condition?"
High blood pressure
Diabetes
Heart disease
Cancer
Lung problems (bronchitis, emphysema, asthma, pneumonia
or other respiratory problems)
Arthritis, rheumatism
UTI, RTI, STDs, kidney problems
Cataracts
Tuberculosis
Stroke, cerebral hemorrhage or cerebral thrombosis
Thailand
"I would like to ask about illnesses you had within the past 6 months."
High blood pressure
Heart problem
Diabetes
Cataracts
Arthritis
Tuberculosis
Asthma
Cancer
Paralysis*
Kidney/urinary tract problem
*Used in place of stroke in the Thai tabulations.
Taiwan
"I am going to mention some illnesses that are common among middle-aged
and elderly people. Please tell me whether at present you have any of these
illnesses."
High blood pressure
Diabetes
Heart disease
Stroke
Cancer or malignant tumor
Bronchitis, pneumonia, other respiratory ailment
Arthritis or rheumatism
Cataract
Tuberculosis
Kidney disease
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406 The Well-Being of the Elderly in Asia
Singapore
"Are you currently receiving regular treatment from a doctor for any long
standing illness? If yes, what is the illness?" (Respondents can report more than
one. Responses are coded as follows:)
Heart condition
High blood pressure
Diabetes
Long-standing chronic breathlessness
Stroke
Arthritis (stiff painful joints)
Fractured bones
Cancer
Other
Additional Notes
Cases with missing data on a given condition were excluded from the
prevalence calculation for that condition. Cases with missing data on one or more
condition were coded as missing on the count of condition recedes and excluded
from calculations involving this variable (Tables 9.3Aand 9.3B).
The count of life-threatening conditions is based on four conditions: cancer,
heart disease, stroke, and diabetes.
The count of debilitating conditions is based on five conditions: stomach
problems, arthritis, incontinence, vision problems, and cataracts.
The different questions employed in Singapore are likely to result in an
underestimate of the prevalence of each condition relative to the other countries.
The underestimate may arise in two ways. First, the respondent must be receiving
regular treatment to be asked about prevalence, and second, the respondent must
be able to name all of the conditions with which he/she is afflicted. In contrast,
respondents in the other countries are read a list of conditions and asked whether
they currently have each one, regardless of whether they are receiving treatment.
In addition, the fact that the question confounds utilization with prevalence
(only those receiving regular treatment for the condition are asked about prevalence)
is likely to affect the distribution of prevalence by key covariates. That is, to the
extent that younger persons are more likely to seek treatment, their prevalence will
be overestimated relative to that of older persons. Similar problems may occur for
sex and education.
This issue was deemed to be less of a problem for the life-threatening conditions,
so these were included in Tables 9.2 and 9.3 A.
Tables 9.4-9.5
In the Philippines, Thailand and Taiwan, respondents were asked how much
difficulty they had performing several Activities of Daily Living. Those reporting
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Physical and Mental Health of the Elderly 407
that they had any difficulty performing an activity are reflected in Tables 9.4 and
9.5. The specific activities queried for each country include:
Philippines: walking around the house; eating; taking a bath or going to the
bathroom; putting on clothes
Thailand: walking around in the house; eating; taking a bath or going to the
bathroom; putting on clothes
Taiwan: moving about the house; eating; bathing; dressing and undressing
In Singapore, the interviewer was instructed to record through observation
and check with the respondent or family member the respondent's status with
respect to ADLs. The dimensions measured included:
Mobility status
Feeding
Toileting
Personal grooming and hygiene (includes bathing and dressing)
Respondents who used special equipment (e.g., walking aids, wheelchair, or
urinal) or required assistance to perform any of the above activities were coded as
having the specifiedADL limitation in Tables 9.4-9.5. Items 3 and 4 were combined
into "difficulty bathing or toileting." There is no information on difficulty eating
for Singapore.
Note that the Singapore method yields a somewhat stricter definition of
limitation than that used in the other countries, which is based on difficulty rather
than equipment or aids.
Table 9.6
The following questions were used to query depressive symptoms in the
Philippines and Taiwan:
Philippines
"Every person experiences an array of different emotions. In the past week,
have you ever felt any of the following? If yes, how often in the past week did you
feel like this: seldom, sometimes, or most of the time?"
Did not feel like eating
Sleep was restless
Happy*
I was a burden to others
Sad
Could not shake off the blues
Enjoyed doing something*
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408 The Well-Being of the Elderly in Asia
Taiwan
"Everyone has mood changes. In the past year, have you experienced the
following situations or feelings? If yes, does this happen to you rarely, sometimes,
often, or chronically?"
Not interested in eating
Doing anything was exhausting
Sleep poorly
In a terrible mood
Lonely
People weren't nice to you
Anguished
Unable to gather energy
Joyful*
Life was going well*
Persons who reported experiencing the specified feelings sometimes or more
often are assigned a code of 1 for that item. Persons reporting experiencing the
feeling rarely or seldom are coded 0. The items are then summed to obtain a
depressive symptom score. Positive affect items (indicated by * in the above list)
are reversed coded prior to summing.
Questions were asked of self-respondents only. Cases with missing values on
one or more items were coded as missing on the overall score.
Thailand
For Thailand, a single indicator of loneliness is used, based on the following
question: "Within this past year, how lonely did you feel: very lonely, lonely
sometimes, not lonely at all?"
Persons who report feeling very lonely or lonely sometimes are coded as
lonely on the variable shown in Table 9.6.
Table 9.7
Cognition tests were conducted with self-respondents only. Self-respondents
with missing data on a given item were coded as having given an incorrect response
for that item. Items comprising the cognition scores for each country include:
Philippines
Word Recall (maximum score= 10). Respondents were read a list of 10 words
and asked to repeat as many as they could remember.
Taiwan
Word Recall (maximum score=10). Respondents were read a list of 10 words
and asked to repeat as many as they could remember in any order.
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Physical and Mental Health of the Elderly 409
Number recall (1=correct, 0=incorrect). The interviewer listed 5 numbers and
respondents were asked to repeat them in reverse order.
Singapore
Immediate number recall (1=correct, 0=incorrect). The interviewer read a 4-
digit number and respondents were asked to repeat it. The respondent was then
told that they would be asked the number again a little later.
Current age (1=correct, 0=incorrect). Respondents were asked to state their
age.
Birth date (1=correct, 0=incorrect). Respondents were asked to provide their
birth date.
Day of week (1=correct, 0=incorrect).
Today's date: day, month, year. Each component was coded l=correct,
0=incorrect.
Spatial orientation (1=correct, 0=incorrect). Respondents were asked what
part of the house they were currently in.
Recognition (1=correct, 0=incorrect). Respondents were asked to identify the
interviewer (not necessarily by name, but simply as an interviewer).
Delayed number recall (1=correct, 0=incorrect). Respondents were asked to
recall the 4-digit number that was read to them at the beginning of the section.
Tables 9.8-9.9
The following questions were used to measure self-assessed health in each
country:
Philippines
"How would you rate your health at the present time? Would you say it is
excellent, very good, good, fair, or poor?"
For the above classification, excellent and very good were combined to form
the first category, good and fair were combined to form the second category, and
poor represents the third category.
Subjects for whom full interview was done by proxy are excluded from
tabulations.
Thailand
"What is your opinion about your health in general?" Interviewer: Read the
answers. Very healthy, rather healthy, moderate, rather weak, weak.
For the above classification, very healthy and rather healthy were combined
to form the first category, moderate and rather weak were combined to form the
second category, and weak represents the third category.
Subjects for whom health section was done by proxy are excluded from
tabulations.
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410 The Well-Being of the Elderly in Asia
Taiwan
"Regarding your state of health, do you feel it's: excellent, good, average, not
so good, or poor?"
For the above classification, excellent and good were combined to form the
first category, average and not so good were combined to form the second category,
and poor represents the third category.
Subjects for whom interview was done by proxy due to health reasons are
coded as having poor self-assessed health. Other subjects interviewed by proxy
are excluded from the tabulations.
Singapore
"How would you rate the state of your health at present? Very good, good,
not too good (e.g., minor illness, general weakness, etc.), or poor (sick)."
The latter two categories were combined to form the "poor" category in the
above classification.
Table 9.10
Response categories differed across countries and years. The following coding
strategy was employed to maximize comparability:
Philippines:
Very good/good Poor
1986 coding Good Poor
1996 coding Excellent, very good, good Poor
Thailand
1986 coding Very good, good Poor
1995 coding Very healthy, rather healthy Rather weak, weak
Taiwan
1989 coding Excellent, very good Fair, poor
1996 coding Excellent, very good Not so good, poor
Singapore
1986 coding Very good, good Poor
1995 coding Very good, good Poor
The age distribution of the sample from the earlier survey in each country is
used as the standard for the age-standardized figures. Age distribution is classified
as: 60-64,65-74,75+.
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Physical and Mental Health of the Elderly 411
Appendix 9A Procedures for Age Standardization in Tables 9.3A,
9.3 B, 9.5,9.7 and 9.9
Age standardization was conducted separately for each country by weighting
the cases in SPSS as follows:
1. Weighted age distribution (5-year groups through 75+) for total sample is
used as standard.
2. Weight is generated separately for each sociodemographic characteristic,
and crosstabs are then run using the specialized weight.
3. Weight is defined as the ratio of:
% of total sample in age group X
% of subsample in age group X
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Chapter 10
PATTERNS OF HEALTH CARE UTILIZATION
Mary Beth Ofstedal andJosefina N. Natividad
As detailed in Chapter 2 and noted elsewhere throughout this volume, all
the countries under study have experienced tremendous reductions in
both mortality and fertility in recent decades. These changes have led to new
challenges for these countries, primarily resulting from a rapidly aging popu
lation. Because older persons have high per capita health care needs (Binstock,
1997), growth in this segment of the population will increase demand for
both acute and long-term care services (Soldo and Manton, 1985). The im
pending growth in both the number and proportion of older persons in Asia
thus has policymakers concerned (Hermalin, 2000; Interministerial Commit
tee on the Ageing Population, 1999; Ogawa and Retherford, 1997). To com
plicate matters, until recently the health infrastructures in the study countries
have been primarily oriented toward problems of infectious diseases and
maternal and child health (see Chapter 3). In order to plan for and implement
health services for the older population, it is important to gain a better under
standing of the determinants of health and health care utilization in later life in
each of these countries.
413
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414 The Well-Being of the Elderly in Asia
The major objective of this chapter is to examine the levels and deter
minants of health care utilization both within and across countries. The sur
veys contain information on the use of a variety of health care services,
ranging from preventive care and routine outpatient care, to hospitalization
and specialized community services for the elderly. For within-country com
parisons we will focus on variation in service use across subgroups defined
by selected sociodemographic, economic, and health characteristics. We also
examine cross-country variation to assess the extent to which differences in
economic development and health care programs are reflected in differential
levels and patterns of health service utilization.
The theoretical framework that we draw on for this analysis is a be
havioral model originally developed by Andersen (1968) and since modified
by Andersen and his colleagues (e.g., see Aday and Andersen, 1974; Andersen
and Newman, 1973). It is the most commonly used model for research on
health services utilization (Wan, 1989), and has been used in many studies in
the United States (Wolinsky and Johnson, 1991; Wan, 1989).
This behavioral model postulates three basic sets of factors influenc
ing the use of health services: need, predisposing factors, and enabling fac
tors. The need component hypothesizes that people seek services when they
are ill or perceive themselves to be at risk of illness. Need is typically mea
sured by indicators of health status, including presence of chronic diseases,
functional limitation, and self-perceived health. The predisposing component
asserts that some individuals have a higher propensity to use health services
than others, based largely on their health beliefs and degree of familiarity with
and trust in the medical system. Predisposition is often operationalized in
terms of demographic characteristics (e.g., gender and age), characteristics
representing position in the social structure (e.g., ethnicity and education),
and level of social connectedness (presence of spouse and children), as well
as measures of health beliefs (not available in these surveys). Predisposing
characteristics are thought to be more salient to the use of outpatient care
than to in-patient hospitalization, the latter of which is often associated with a
life-threatening health event and, as such, is more a matter of necessity than
choice (Wan, 1989). Finally, the enabling component argues that the likeli
hood of utilization among individuals who have the need and predisposition to
use health senices is influenced by their ability to access the services. En
abling factors may take the form of individual or family-level characteristics
such as the availability of health insurance or financial resources, or knowl
edge of and connnections to service providers, as well as community-level
factors such as the availability and accessibility of health care facilities and
personnel.
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Patterns of Health Care Utilization 415
Figure 10.1. Determinants of Health Services Utilization
NEED OR ILLNESS LEVEL
PREDISPOSING CHARACTERISTICS
Age
ENABLING CHARACTERISTICS
Self-perceived health
Life-thrtatening conditions
Debilitating conditions
ADL limitations
Gender
Income
Employment
Education
Urbanicily
Social suppoit from spouse, childrtn
UTILIZATION OUTCOMES
Prtventive services
Outpatient cart from traditional psctitioners
Outpatient cart from Western medical doctors
H capitalization
Unmet need for services
Health system
Figure 10.1 presents the conceptual framework for our analysis of
health care utilization and identifies how we operationalize determinants and
outcomes. Although we classify the characteristics into distinct dimensions
along the lines of previous work (e.g., Wolinsky and Johnson, 1991), it is
important to point out that several of the factors may correspond to more
than one dimension, particularly in countries that have less formalized and
developed health systems. For example, although the Andersen model argues
that education increases predisposition to seek medical treatment, education
may also be an enabling factor to the extent that it provides information on
how to gain access to the medical system and capitalize on health benefits.
Likewise, having social connections may predispose a person to seek treat
ment, but social connections may also be enabling to the extent that spouses
and children facilitate treatment by recommending providers, scheduling ap
pointments, paying for health services, or providing transportation to health
facilities. In both of these examples, the hypothesized direction of the effect
is the same regardless of whether the factor is viewed as a predisposing or
enabling influence.
There are a number of other factors, however, for which hypothesized
effects would work in opposite directions. Most importantly, to the extent
that measures of health status or illness level do not fully capture need, age
and education may be viewed as proxies for need, as well as predisposing
factors. For example, in Chapter 9 we observed a negative association between
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416 The Well-Being of the Elderly in Asia
age and health status for most indicators and a generally positive association
between education and health status. For these variables, the predisposing
and need effects would work in opposite directions, with younger, employed
and more educated persons having higher predispositions for health care
utilization but less need for health care. In addition, in Chapter 7 we found
that poor health is a major factor for retirement. Thus, work status may also
function as a proxy for need, perhaps more than as an enabling factor in these
countries given that health benefits for the elderly are not tightly linked to
employment as noted in Chapter 3. To the extent that work status serves as a
proxy for need, we would expect to find higher utilization for retirees than for
the currently employed.
Ideally, use of health services would depend entirely on need and indi
vidual preference. However, previous research suggests that there are a num
ber of barriers to using health senices (Pasley, Lagoe and Marshall, 1995;
Greer, Mor, Morris et al., 1986), including lack of knowledge or awareness
of the need for care (lack of physician diagnosis), inability to pay for care,
and inability to access the care. Inability to access care may result from a
physical or cognitive disability, or a lack of health service resources. Re
search in the United States has identified organizational determinants of the
kind and amount of health care used, including physician supply (Pasley,
Lagoe, and Marshal, 1995), the number of hospital beds (Fisher, Wennberg,
Stukel, and Sharp, 1994), and availability of community services (Greer, Mor,
Morris et al., 1986). As indicated in Chapter 2 (Table 2.5), the countries vary
dramatically with respect to supply of health personnel and services, with
Taiwan and Singapore considerably more favorable supply of both physi
cians and hospital beds than either Thailand or the Philippines. Unfortunately
we are not able to incorporate community-level health resource factors into
the present analysis directly, although both urbanicity and country may serve
as proxies for some of these factors.
Finally, features of both the health care systems and the social support
structures in the Asian countries under study may affect their utilization pat
terns, distinguishing them from one another and from patterns observed in
the United States. Informal care is still largely the norm in these countries,
and the health infrastructures are still in the process of adapting to the service
needs of older persons. Also, although all of the countries have at least some
public health programs for older persons, the coverage and benefits vary
greatly. These variations are described in detail in Chapter 3 and summarized
below. To the extent that we observe variation in the levels and patterns of
utilization across countries, this may reflect at least in part differences in the
accessibility and affordability of health services in the countries.
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Patterns of Health Care Utilization 417
Health Insurance Coverage
As discussed in Chapter 3, each country has at least some programs in place
to provide health services to older persons, and some of these programs have
been in place for many years. The programs in Thailand and Taiwan are
perhaps the most generous. Thailand provides medical care to older persons
free of charge, and Taiwan's Universal Health Insurance program provides a
range of health services at very low cost to persons of all ages. Singapore's
program has been much more restricted in that, until very recently, the major
health insurance program (Medishield) provided coverage only to persons
under age 75. The Philippines provides targeted health care services to older
persons at no cost in designated government hospitals, but lacks a compre
hensive health insurance scheme to cover a broader range of services.
Although none of the surveys include questions to fully ascertain the
extent of respondents' health insurance benefits, most of the surveys have
items on whether respondents have used medical benefits to which they are
entitled or about who paid for medical expenses incurred over a recent pe
riod. The relevant data are presented in Tables 10.1-10.4 and are briefly sum
marized below.
At the time of the Philippines survey in 1996, health insurance for the
elderly in that country was very limited. The national health insurance pro
gram was signed into law in 1995 but became operational only in 1998. For
the period covered by the survey, the existing health insurance system was
Medicare, a program primarily for workers in the formal sector (including
those retired from formal employment who had completed a specified mini
mum number of years of contribution prior to retirement), with some cover
age for dependents. Furthermore, services covered by Medicare were limited
to inpatient care and subject to capitation.
Although the Philippine survey does not have a direct question about
health insurance coverage for all respondents, there is a question about whether
any medical costs incurred during the past year were paid for by public or
private insurance or provided for free. Hence, for those who reported any
utilization or any medical costs in the past year (84 percent of the total sample),
we have information on how those medical costs were covered. Table 10.1
presents the percent reporting that their medical costs were covered by some
type of health insurance (column 1) or were provided for free (column 2),
according to selected sociodemographic characteristics. As shown in the top
row of the table, the overall percentage of Filipinos who reported that their
medical expenses in the previous year were covered at least in part by public
(i.e., Medicare) or private health insurance is 6.2 percent. An additional 16
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Table 10.1. Percent for Whom Medical Care Costs in Past Year Were
Covered by Health Insurance or Provided at No Charge,
by Selected Sociodemographic Characteristics:
Philippines
CharacteristicTotalMaleFemaleChi-square (p-value)Age 60-64
Age 65-69
Age 70-74
Age 75+
Chi-square (p-value)Not marriedMarriedChi-square (p-value)ManilaOther urbanRuralChi-square (p-value)No formal schooling
Any primary
Any secondary+
Chi-square (p-value)Currently working
RetiredNever workedChi-square (p-value)Sample sizeHealth Insurance6.28.94.37.97 (.005)4.9
5.57.1
8.0
2.33 (.506)4.67.53.23 (.072)4.69.44.49.05 (.011)2.2
5.2
12.2
17.56 (.000)4.2
7.17.13.22 (.199)Free Services16.017.914.71.69 (.194)16.3
17.2
15.1
15.0
0.53 (.912)17.015.20.52 (.470)30.616.013.615.78 (.000)18.0
14.9
17.5
1.31 (.521)19.6
14.411.45.94 (.051)973
Note?. Sample is restricted to respondents who reported any health service use (for
hospitalization, outpatient care, dentist, medications) in the year prior to the survey.
Those reporting that any pan of their medical expenses in the past year were covered
by health insurance or Medicare are coded as having health insurance coverage.
Those reporting that they used one or more types of health services but had no
associated costs are coded as having received free health services.
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Patterns of Health Care Utilization 419
percent reported that there was no charge for their services (presumably
these are low income individuals who qualify for free health services).
In the Philippines, we find sharp differentials in insurance coverage
according to gender, place of residence, and education. The proportion of
men with coverage is more than twice that of women (8.9 percent versus 4.3
percent): the proportion of those residing in urban areas outside Manila is
twice as that of those residing either in Manila or in rural areas (9.4 percent
versus 4.6 percent or 4.4 percent); and the proportion of those with any
secondary or higher education is almost six times that of those with no for
mal education (12.2 percent versus 2.2 percent). Both the urban/rural and
education differentials likely reflect the tendency of those in the outlying ur
ban areas and/or with higher education to have jobs in the formal sector that
offered health insurance under Medicare. There appears to be a monotonic
increase in coverage with age, perhaps associated with increases in medical
care costs reimbursable by Medicare, but the difference across age groups is
not significant. Marital status and current work status likewise showed no
significant differentials.
With regard to free services, those residing in Manila were substan
tially more likely than those elsewhere to receive such services, and those
who were currently working were somewhat more likely than their non-
working counterparts. With regard to the latter finding, it may be the case
that certain health screening services are offered to employees at their work
place for nominal or no charge. Although we have no way of determining the
insurance status of older Filipinos who did not use services during the previ
ous year, it is unlikely that this remaining group (16 percent of the sample)
differed substantially from their peers who did use services.
As noted in Chapter 3, Thailand offers free medical services for older
persons and also has a Health Card program targeted toward marginalized
workers (farmers in rural areas, the self-employed, employees of small firms,
and seasonal workers). The survey data indicate the extent to which older
persons are aware of and make use of these benefits. Respondents were
asked whether they had heard of the health card and the program of free
medical services for elderly and, if so, whether they had made use of these
programs. Results from these questions are shown in Table 10.2.
Focusing first on the Free Medical Care for the Elderly program (middle
two columns), the results indicate that awareness of this program among the
respondents is high—84 percent. The percentage of respondents who had
ever used these benefits is substantially smaller—39 percent overall, or 46
percent of those who are aware of the program. The reasons for lack of
program use are not known; however, given that the vast majority knew
about the services, we can rule out lack of awareness as a primary reason.
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420 The Well-Being of the Elderly in Asia
Table i0.2. Percent Who Are Aware of and Have Used Public Health Insurance
Programs, by Selected Sociodemographic Characteristics: Thailand
CharacteristicTotalMale
Female
Chi-square (p-value)Age 60-64
Age 65-69
Age 70-74
Age 75+
Chi-square (p-value)Bangkok
Other urban
Rural
Chi-square (p-value)No formal schooling
Any primary
Any secondary+
Chi-square (p-value)Currently working
Retired
Never worked
Chi-square (p-value)Free Medical Care for ElderlyAware of
Program84.485.2
83.7
!.%(.! 62)88.4
88.5
82.5
73.1
119.80 (.000)52.280.7
88.5
374.81 (.000)75.1
89.1
81.6
133.05 (.000)87.483.2
64.0
45. 12 (.000)Ever Used
Program39.336.6
41.510.94 (.001)31.444.4
48.6
38.7
80.60 (.000)7.2
18.2
45.1
296.04 (.000)37.1
42.8
15.1
85.49 (.000)35.2
42.7
20.0
39.51 (.000)Health Card ProgramAware of
Program58.261.9
55.120.67 (.000)69.9
62.8
50.5
37.3
270.07 (.000)22.8
51.8
62.9
25 1.24 (.000)40.3
66.6
59.0
250.01 (.000)65.7
54.4
28.4
90. 17 (.000)Family Has
Health Card14.414.414.4
0.00 (.987)17.8
13.7
13.4
10.0
29. 16 (.000)1.8
8.916.4
72.73 (.000)10.0
17.2
6.8
50.68 (.000)15.9
13.5
9.96.46 (.040)
Notes: Proxy respondents (n=160) were not asked these questions and are, thus, excluded from the
above tabulations. Persons who have no knowledge about the program are not asked whether they use
the program. In the above tabulations, it is assumed that such persons do not use the program, and they
are thus coded as non-users.
Both awareness and use of the free medical program varies according
to sociodemographic characteristics. Awareness is higher among those who
are younger, who reside outside of Bangkok, who have at least primary edu
cation, and who are currently or formerly employed. With the exception of
persons living outside Bangkok, all of these groups are more likely to be
exposed to information and publicity about these programs through employ
ers and the media. The finding regarding higher awareness and use in areas
outside Bangkok is consistent with findings in an evaluation study by
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Patterns of Health Care Utilization 421
Kamnuansilpa and colleagues (2000). They attribute this pattern to two pos
sible factors. First, older persons in urban areas are more likely to have other
health insurance coverage (and, thus, overall rates of coverage do not differ
substantially between urban and rural areas). Second, there may be less will
ingness or ability on the part of urban municipal authorities to achieve high
coverage rates compared to those in rural areas (Kamnuansilpa,
Wongthanavasu, Bryant, and Prohmmo, 2000). With regard to actual use of
this program, we again see marked differences. Women are more likely than
men to have used the free medical program, as are those between the ages of
65 and 74, rural residents, persons with at least primary education, and those
who are retired. These patterns likely reflect a combination of need, aware
ness, and predisposition for health service usage.
Turning to the results for the Health Card Program (right two col
umns in Table 10.2), the results indicate that the overall level of awareness
and particularly use of this program is considerably lower than that for the
Free Medical Care for the Elderly program. Just under three-fifths of the
respondents are aware of the Health Card program and only 14 percent use
the program. Despite the lower overall levels, however, the sociodemographic
patterns of awareness and use are quite similar for the two programs. As with
the Free Medical Care program, awareness and use of the Health Card pro
gram is highest among younger respondents, those residing outside Bangkok,
with primary or higher education, and who are currently or formerly em
ployed. One difference in patterns is that there is a sharp decline with age in
awareness of the Health Card Program, and a corresponding decline with age
in program use. In contrast, the age decline in awareness of the Free Medical
Care program was much less pronounced, and use of this program tended to
increase with age (at least through age 70-74). Another slight difference is
that men are more aware of the Health Card Program than women, although
use of the program appears quite equitable by gender. Women and men were
about equally likely to know about the Free Medical Care program, although
use was slightly higher for women.
We turn now to Taiwan, which instituted a Universal Health Insurance
(UHI) program in 1995, a year prior to the survey. As described in Chapter 3,
UHI provides health insurance coverage for the entire population, covering
preventive services and most inpatient, outpatient, and in-home medical care.
Within one year of its implementation, UHI had enrolled more than 92 percent
of the population (Chiang, 1997), and data from the 1996 Taiwan survey
presented in Table 10.3 show that 98 percent of respondents age 60 years or
over were enrolled. As also shown in the table, there are essentially no differ
ences in enrollment patterns among the older survey respondents according
to sociodemographic characteristics. Ethnicity is the only characteristic that
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Table 10.3. Percent Enrolled in Universal Health Insurance
Program, by Selected Sociodemographic
Characteristics: Taiwan
Characteristic
Total
Male
Female
Chi-square (p-value)
Age 60-64
Age 65-69
Age 70-74
Age 75+
Chi-square (p-value)
Native Taiwanese
Mainlander
Chi-square (p-value)
Not married
Married
Chi-square (p-value)
Taipei
Other urban
Rural
Chi-square (p-value)
No formal schooling
Any primary
Any secondary+
Chi-square (p-value)
Currently working, self-employed
Currently working, employee
Retired
Never worked
Chi-square (p-value)
Percent
97.9
97.8
98.1
0.32 (.569)
97.9
97.9
98.4
97.5
1.13 (.769)
98.2
96.7
4.82 (.028)
97.4
98.2
2.30 (.129)
97.3
97.9
98.3
1.09 (.580)
97.9
97.6
98.6
1.92 (.383)
98.7
98.4
97.7
97.8
1.76 (.623)
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Patterns of Health Care Utilization 423
shows a statistically significant difference, and even here the difference is
very small (98.2 percent for Taiwanese versus 96.7 percent for Mainland-
ers). Hence it appears that, at least from the perspective of the elderly in
Taiwan, the program has been quite successful at enrolling participants across
the board.
As evaluated in a separate study, the introduction of UHI appears to
have had a dramatic impact on utilization of health services, resulting in a
rapid increase in utilization of both outpatient and inpatient care (Cheng and
Chiang, 1997; Chiang, 1997). The increase in service use was found to be
largest among the previously uninsured, although slight increases were also
observed in use of physician services by those with previous health insur
ance. Nevertheless Chiang (1997) reports that, by the end of the first year of
the program, the utilization patterns of the previously uninsured were very
similar to those of the previously insured.
Finally, the Singapore survey included a question to ascertain respon
dents' primary source of coverage for medical expenses, regardless of whether
they had recently used health services or incurred any medical expenses. The
distributions for source of coverage are presented in Table 10.4 by sociode-
mographic characteristics. As shown in the top row of the table, less than
one-fifth of older Singaporeans report that they mainly rely on their own (or
their spouse's) Medisave accounts or some form of supplemental health in
surance (14 percent and 2 percent, respectively). By far the most common
situation is to rely on another family member's (typically a child's) Medisave
account (61 percent overall). This pattern no doubt reflects the strict age
limit for health benefits under the Medisave/Medishield plan, as noted in Chapter
3. The remaining respondents are split between those who have no provision
for medical care expenses (8 percent) and those who rely on either their own
savings or support from others to cover their medical expenses (15 percent).
The main source for coverage of medical expenses among Singaporean
elderly is strongly patterned on sociodemographic characteristics. Men are
more likely than women to rely on their own Medisave funds and less likely to
rely on others' Medisave funds. This is probably because women are older
than men on average, are more likely to be widowed, and less likely to have
ever been employed; as a result, their Medisave funds are more limited. In
deed, we also see strong patterns by both age and marital status, whereby
older persons and those not married rely less on their own funds and insur
ance coverage and more on others' than do their younger and married coun
terparts. The patterns according to education and work status are also as
expected. Those with high levels of education and who are currently working
are more likely to rely on their own Medisave funds and less likely to rely on
those of their children. Finally, the pattern by ethnicity shows that Indian
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Table 10.4. Percent Distribution for Main Source of Coverage for Health and Medical Care
Expenses, by Selected Sociodemographic Characteristics: Singapore
CharacteristicTotalMaleFemaleChi-square (p-value)Age 60-64
Age 65-69
Age 70-74
Age 75+
Chi-square (p-value)MarriedNot marriedChi-square (p-value)ChineseMalay
IndianChi-square (p-value)No formal schooling
Any primary
Any secondary+
Chi-square (p-value)Currently working
RetiredNever workedChi-square (p-value)Source of CoverageNone7.86.78.87.8
7.2
7.7
8.77.08.77.95.1
10.58.6
6.7
5.310.8
6.58.2Savings/
Support
from Oth.14.916.113.814.4
14.1
13.0
17.614.315.415.411.9
14.515.0
14.8
14.117.4
15.911.6Other's
Medisave
Account61.251.469.749.4
64.0
68.5
69.455.167.563.362.8
40.667.3
56.3
30.424.1
65.377.1Own/Spouse
Medisave
Account14.022.96.325.2
13.1
8.93.120.67.211.518.8
30.88.1
19.6
41.144.4
9.72.6Suppl.
Medical
Insurance2.12.91.43.2
1.6
1.8
1.33.01.21.91.4
3.60.9
2.5
9.23.2
2.70.5Total100.01000100.0229.6 (.000)100.0
100.0
100.0
100.0
241.0 (.000)100.01 00.0148.4 (.000)100.0100.0100.0102.7 (.000)100.0
100.0
100.0
410.8 (.000)100.0
100.0100.0772.1 (.000)
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Patterns of Health Care Utilization 425
elderly are much less likely to rely on others' Medisave accounts than Chi
nese or Malay elderly. This is probably because most older Indians in Singapore
are male and many have no family members in Singapore on whom to rely for
health care coverage; hence they are forced to rely on their own resources to
a large extent.
Although the data on health insurance coverage are limited and lack
comparability across countries, they nevertheless highlight the varied scope
of the health care programs in place in the study countries. These variations
will be important to keep in mind throughout the remainder of the chapter as
we examine similarities and differences across countries in health seeking
behaviors and levels and patterns of health service use.
Health-Seeking Behaviors
We begin our examination of health care utilization by addressing the question
of what older individuals usually do when they become ill. Do they tend to
seek medical treatment when faced with an illness and, if so, of what sort?
This issue is important because early detection of medical problems can pre
vent or at least reduce further complications, thereby improving the overall
health of the population and possibly reducing medical costs.
Two of the surveys included questions to ascertain what respondents
usually do (Thailand) or where they seek treatment (Singapore) when they
become ill. Respondents answered in their own words, and the answers were
coded into one of the following categories: rest or do nothing, obtain and
administer medications on own (self-medicate), seek the care of a traditional
practitioner, or seek treatment from a Western medical doctor. The exact
wording and distributions for these questions are shown for the total sample
and by key sociodemographic and health characteristics in Tables 10.5 (Thai
land) and 10.6 (Singapore).
The results in Table 10.5 suggest that the most common behavior
among older Thais is to self-medicate (48 percent), followed closely by seek
ing treatment from a Western medical doctor (44 percent). The proportion
that use a traditional provider as their usual method of treatment is extremely
small (less than 1 percent), and the proportion who rest or do nothing is also
modest (8 percent). Health-seeking behaviors differ for a number of the sub
groups represented in Table 10.5. Men are slightly more likely than women to
either self-medicate or do nothing, whereas women are more likely to seek
Western medical care. The pattern by age is not clear, although persons age
70-74 are slightly more likely than those in other age groups to seek treatment
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Table 10.5. Percent Distribution for Usual Method of Treatment When Ill, by Selected
Sociodemographic Characteristics: Thailand
For complete survey question, see Notes for Table 10.5 at the end of this chapter.
CharacteristicTotalMaleFemaleChi-square (p-value)Age 60-64
Age 65-69
Age 70-74
Age 75+
Chi-square (p-value)UrbanRuralChi-square (p-value)Not marriedMarriedChi-square (p-value)ChineseThai -ChineseOther ThaiChi-square (p-value)No formal schooling
Any primary
Any secondary+
Chi-square (p-value)High health rating
Moderate health rating
Low health rating
Chi-square (p-value)No chronic conditionsDebilitation conditionsonly
1+ life-threatening
conditionChi-square (p-value)Method of TreatmentRest, Do
Nothing7.69.56.16.8
7.2
7.7
9.69.47.27.67.79.56.67.77.5
7.2
11.99.5
6.7
5.514.96.8
6.9Self-
Medicate48.149.546.948.2
49.8
43.8
49.250.147.649.347.440.450.348.252.646.5
41.047.7
49.0
44.643.450.2
42.5See
Traditional
Practitioner0.60.60.60.6
0.5
0.3
0.90.70.60.30.80.70.50.60.4
0.61.70.6
0.41.91.30.4
0.9See Western
Medical
Doctor43.740.446.444.4
42.4
48.2
40.339.744.642.844.249.542.643.539.545.6
45.442.3
43.9
48.140.542.5
49.7Total100.0100.0100.027.6 (.000)100.0
100.0
100.0
100.0
19.8 (.019)100.0100.08.95 (.030)100.0100.04.3 (.230)100.0100.0100.05.1 (.527)100.0
100.0
100.0
3 1.9 (.000)100.0
100.0
100.0
29.0 (.000)100.0100.0
100.060.9 (.000)
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Patterns of Health Care Utilization 427
from a Western doctor and least likely to self-medicate. Persons in urban
areas are slightly more likely than their rural counterparts to rest or to self-
medicate, whereas those in rural areas are more likely to seek Western medi
cal care. Health-seeking behavior appears to be influenced by education, in
that those with primary or secondary education are more likely than those
with no education to seek Western medical care, and less likely to self-medi
cate. This may reflect greater awareness of and/or access to Western medi
cal services among educated persons, or possibly stronger beliefs in the ben
efits of such services. Those with secondary or higher education are also
more likely to report that they rest or do nothing when they become ill. There
are no significant differences by marital status or ethnicity.
There are also strong and expected patterns according to self-assessed
health and chronic conditions (both indicators are previously defined in Chapter
9, Tables 9.8 and 9.3a-b, respectively). Persons with high self-assessments
are more likely than their unhealthier counterparts to rest or do nothing when
faced with an illness, and less likely to seek care from a Western doctor.
Those who rate themselves low are more likely than those with moderate or
high ratings to seek Western medical care and less likely to either self-medi
cate or rest/do nothing. The pattern with respect to chronic conditions is
very similar. Those with no chronic conditions are more likely to self-medi
cate or rest/do nothing than their less healthy peers. Self-medication is the
most likely form of treatment among those with debilitating conditions only,
whereas Western medical treatment is the most common form for those with
life-threatening conditions. As argued in Chapter 9, a partial explanation for
this pattern is that individuals may become aware of their life-threatening
conditions only through contact with the medical system. In addition, once a
life-threatening condition is detected, the patient is likely required to continue
treatment or at least undergo routine monitoring by a physician. For these
reasons, it is not surprising that those reporting life-threatening conditions
are more likely than others to seek care from Western medical doctors and
less likely to self-medicate or not seek any treatment.
The Singapore survey included a somewhat different question to get
at the issue of usual method of treatment; specifically it asked older respon
dents what type of facility they usually use when they become ill (see Table
10.6). The suggestive nature of this question (implying that individuals do
seek treatment at some type of facility) led to an extremely high proportion of
respondents reporting Western medical facilities (90 percent overall), although
a small proportion did report that they either self-medicate (7.5 percent) or
rest or do nothing (0.5 percent). The proportion of older persons reporting
that they usually seek treatment from a traditional practitioner is slightly higher
in Singapore (2.1 percent) than in Thailand (0.6 percent).
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Table 10.6. Percent Distribution for Usual Place/Method of Treatment When Ill, by
Selected Sociodemographic Characteristics: Singapore
CharacteristicTotalMaleFemaleChi-square (p-value)Age 60-64
Age 65-69
Age 70-74
Age 75+
Chi-square (p-value)MarriedNot marriedChi-square (p-value)ChineseMalay
IndianChi-square (p-value)No formal schooling
Any primary
Any secondary+
Chi-square (p-value)High health rating
Moderate health rating
Low health rating
Chi-square (p-value)Main source of medicalcoverageNoneOwn savings/support from
othersOwn/spouse Medisave
Other's MedisaveSupplemental medical
insuranceChi-square (p-value)Method of TreatmentRest, Do
Nothing0.50.60.40.2
0.4
0.1
1.20.40.60.60.30.10.6
0.30.21.7
0.3
0.22.30.40.4
0.00.5Self-
Medicate7.57.77.38.87.7
7.4
5.58.16.87.95.2
6.27.3
7.7
8.512.07.5
2.912.84.37.9
5.87.9See
Traditional
Practitioner2.11.62.41.5
2.2
2.7
2.21.92.22.41.0
0.02.02.4
1.71.9
2.1
1.94.02.51.7
1.84.4See
Western
Medical Dr90.090.189.889.5
89.7
89.7
91.189.690.489.193.4
93.790.1
89.6
89.784.3
90.0
95.080.992.890.0
92.387.1Total100.0100.0100.03.2 (.368)100.0
100.0
100.0
100.0
22.5 (.007)100.0100.02.9 (.405)100.0100.0
100.014.8 (.021)100.0
100.0
100.0
3.6 (.724)100.0
100.0
100.0
53.0 (.000)100.0100.0100.0
100.0100.050.7 (.000)
For complete survey question, see Notes for Table 106 at the end of this chapter.
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Patterns of Health Care Utilization 429
With regard to patterns of treatment by sociodemographic character
istics, there are essentially no differences by sex, marital status, or education.
Those age 75 or older are slightly more likely than their younger counterparts
to seek treatment at a Western medical facility, and slightly less likely to self-
medicate. In addition, Indians and Malays appear to have a slightly higher
tendency to use Western medical doctors and lower tendency to use any of
the other methods compared to the Chinese. The differences by age and
ethnicity are quite small, but statistically significant.
More substantial differences are found with respect to self-assessed
health and source of medical care coverage. As in Thailand, Singaporeans
who rate their health most poorly are more likely than others to seek care
from a Western medical facility. Those with the highest health ratings, in
contrast, are more likely than others to self-medicate and least likely to see a
Western doctor. There are also strong differences in usual method of treat
ment according to main source of medical coverage. Most important, per
sons who report no coverage are substantially less likely than those with
some type of coverage to seek care from a Western medical doctor, with the
most preferred alternative being to self-medicate. Yet, it is noteworthy that
more than 80 percent of those who have no source of medical coverage still
report that they usually seek treatment from a Western medical facility when
sick. There must therefore be some other mechanism in place that allows
them to obtain medical services. Older persons with supplemental medical
insurance have a slightly lower than average propensity for using Western
medical care (87 percent versus 90 percent for the total sample), and a slightly
higher propensity to use traditional practitioners.
The foregoing analyses have given us an idea of how older adults in at
least two of the countries respond to illness. We now focus more explicitly on
actual behavior with respect to health service use by examining utilization
levels over a specified period for several types of services.
Use of Specific Medical Services
All of the surveys gathered some information on respondents' use of health
services during a specified period prior to the interview, with the period rang
ing from the past month to the past year depending on the country and the
type of service in question. The Philippines, Thailand, and Taiwan surveys
asked whether respondents had recently received various types of preventive
services, sought treatment from traditional practitioners and/or Western medical
providers, and been hospitalized. The Singapore survey was more limited on
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430 The Well-Being of the Elderly in Asia
health services, but it did include a question on recent hospitalization. We
examine each type of service in turn in the following sections.
Preventive Care and Outpatient Services
Preventive care is a high priority for the health care programs in each of the
countries. When administered effectively, preventive care can lead to early
detection of major health risks or conditions, often preventing or at least
delaying the onset of serious chronic conditions and associated health impair
ments. Preventive services are also major tools for the management of exist
ing and already diagnosed chronic diseases. Taiwan has had a national health
program in place for many years to screen for diabetes and high blood pres
sure. In addition, both the Philippines and Thailand have formulated govern
ment policies and programs for offering preventive services at low or no cost
to older persons (although these have been difficult to implement in the Phil
ippines). Given the priority placed on preventive care in these countries, each
of the surveys collected information on use of various types of preventive
services, with the Philippines and Thailand garnering the most detailed infor
mation. Both the Philippines and Taiwan asked about services received during
the past year, whereas Thailand asked about services received in the past 6
months. Because these types of services tend to be provided on an annual or
less frequent basis, we would expect the level of use observed in Thailand to
be deflated relative to the other countries.
Table 10.7 shows the percent receiving specified services in each
country by age and sex. As shown here, by far the most common type of
preventive care received is a blood pressure check. Roughly half of all re
spondents in the Philippines and Thailand and over four-fifths in Taiwan re
ported having a blood pressure check during the specified period (see figures
in bottom panel of Table 10.7). (Note that in Taiwan, interviewers were in
structed to include blood pressure checks that were performed at home or at
a pharmacy.) A blood test (primarily for diabetes and/or high cholesterol) is
also a common preventive service in Taiwan, where about half reported hav
ing one during the past year. The percentages were much lower in Thailand
(21 percent overall) and the Philippines (9 percent).
The Philippines and Thailand surveys also obtained information about
a number of other forms of preventive care. For the most part, only a small
minority reported receiving these other examinations. Urine checks, lung or
other x-rays, and eye or ear examinations were reported by about 10 to 20
percent of respondents, and less than 10 percent received fecal checks, skin
exams, rectal exams, and breast exams/pelvic exams/pap smears.
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Patterns of Health Care Utilization 431
In both the Philippines and Taiwan, there is little difference between
men and women in their use of any of the preventive services. In Thailand,
however, there is a fairly strong pattern by gender, which is also dependent
on age. Among those in the younger age group, women are considerably
more likely than men to receive several types of services. In contrast, among
those aged 70 or above, there is little gender difference for most services, but
where it does occur it is in the opposite direction. There is not clear pattern
by age group. Among Filipino and Thai males, there is slight tendency for
higher use among those in the older age group for most types of services. In
Taiwan, older men are also slightly more likely than younger ones to get a
blood pressure test, but this difference is quite small (86 percent versus 83
percent). The age pattern for women is somewhat different. In Thailand,
younger women have higher propensities than older women for most types
of screening exams, with the exceptions of eye/ear, skin and rectal exams. In
the Philippines, younger women also have higher propensities for getting a
blood pressure test and a blood check, but there is essentially no difference
by age for the other examinations. Taiwanese women show no differences
by age.
Table 10.8 presents the percentage of respondents who used any type
of preventive service during a period prior to the survey (6 months or 1 year),
according to selected sociodemographic characteristics. Overall, the propor
tion that used one or more types of preventive services ranged from about
three-fifths in the Philippines and Thailand to just under nine-tenths in Tai
wan. Recall that although the Philippine and Thai surveys included the same
set of preventive services, the reporting period is twice as long in the Philip
pines. If the reporting period in Thailand had been 1 year rather than 6 months,
it is likely that the percent using any preventive service (as well as the spe
cific types) would have been somewhat higher. Taiwan, which asked about
only two types of preventive services, has by far the highest utilization rates
for preventive care. This attests to the success of their long-standing health
screening programs and perhaps also of the newly established Universal Health
Insurance program.
In terms of sociodemographic differentials, Thai women have higher
utilization rates for preventive services than Thai men. There is a general
tendency for utilization to increase with age in both Thailand and Taiwan,
although it drops slightly in the oldest age group in both countries. (This may
reflect either reluctance on the part of health professionals to screen the
oldest-old or reluctance or inability on the part of the oldest-old to seek pre
ventive services.) In addition, urban Thais are more likely than their rural
counterparts to use preventive services, but no urban-rural differences are
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Table 10.8. Percent Using Any Preventive Service during Prior 6-12
Months, by Selected Sociodemographic Characteristics
CharacteristicTotalMale
Female
Chi-square (p-value)Age 60-64
Age 65-69
Age 70-74
Age 75+
Chi-square (p-value)Urban
Rural
Chi-square (p-value)Not married
Married
Chi-square (p-value)No formal schooling
Any primary
Any secondary+
Chi-square (p-value)High health rating
Moderate health rating
Low health rating
Chi-square (p-value)No chronic conditions
Debilitation conditions only
1+ life-threatening condition
Chi-square (p-value)Philippines
(prior year)60.659.2
61.6
0.73 (.394)60.5
66.0
58.2
56.9
6.29 (.098)61.7
59.8
0.48 (.489)62.359.2
1.28 (.257)53.0
61.5
65.5
8.68 (.013)55.2
61.0
66.3
4.72 (.094)53.1
60.9
77.1
31.21 (.000)Thailand
(prior 6 months)56.951.1
61.7
50.65 (.000)55.7
58.5
62.2
52.5
18.09 (.000)63.155.5
15.94 (.000)55.0
58.0
3.93 (.047)52.6
57.9
67.3
24.53 (.000)48.3
60.6
65.1
72.01 (.000)29.3
53.8
81.4
366.97 (.000)Taiwan
(prior year)85.686.7
84.3
3. 56 (.059)82.5
87.0
88.6
85.3
12.80 (.005)86.0
84.7
0.83 (.361)83.2
86.7
6.68 (.010)81.2
87.3
91.2
38.04 (.000)82.1
87.5
86.9
14.51 (.001)77.9
86.8
94.0
107.51 (.000)
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Patterns of Health Care Utilization 435
observed for the other countries. Married persons in both Thailand and Tai
wan are slightly more likely than those not married to use preventive services;
these differences are small but statistically significant. There is a strong asso
ciation between use of preventive services and education in all countries,
with higher levels of education associated with greater use of services.
The associations between use of preventive services and self-assessed
health and chronic conditions are similar to those observed for usual method
of treatment when ill (Tables 5 and 6). Specifically, those with the highest
health ratings tend to report the lowest levels of preventive service utilization
and those with the lowest ratings tend to report the highest utilization. An
exception is Taiwan, for which there is little variation in utilization by self-
assessed health. In all three countries, the percent using preventive senices
increases as health conditions worsen—from no conditions, to debilitating
only, to life-threatening conditions. This suggests that preventive-type ser
vices are being used not just to screen for disease but to monitor existing
health problems. It is also likely, however, that some individuals learn about
their medical conditions as a result of the preventive care screening.
In Table 10.9 we shift to an examination of outpatient visits with tra
ditional and Western medical providers. In this case, the reference period for
the Philippines remains one year, but decreases to just one month for Thai
land and Taiwan. Overall, the percent seeking outpatient treatment from a
traditional provider during the specified period was quite low, ranging from 1
percent in Thailand to 14 percent in Taiwan. The percent seeking outpatient
treatment from a Western medical provider is substantially higher. Taiwan
has the highest rates of outpatient utilization—over 50 percent of respondents
reported receiving outpatient treatment from a Western medical provider in
the prior month compared to 29 percent in Thailand. In the Philippines, for
which the reporting period was an entire year, 42 percent receiving outpatient
treatment. As noted previously, the introduction of Universal Health Insur
ance in 1995 in Taiwan resulted in a substantial increase in utilization, which
may be a significant factor in the high level of outpatient care reported in this
survey the following year. As noted, use of traditional providers is also higher
in Taiwan than the other countries.
A few sociodemographic differentials are worth noting. First, women
are significantly more likely than men to receive outpatient care from a West
ern medical provider in Thailand and from a traditional practitioner in Taiwan.
The only significant urban-rural differential is in Thailand, where rural elderly
are more likely than their urban counterparts to receive outpatient care from
a Western provider. This is contrary to what one would generally expect in a
developing country, but likely reflects the success of Thailand's health card
program in rural areas throughout Thailand, as described in Chapter 3. Some
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438 The Well-Being of the Elderly in Asia
significant but fairly weak associations are observed in relation to education,
whereby use of traditional providers declines with increasing education in the
Philippines and Taiwan, and use of Western medical providers generally in
creases with education in the Philippines and Thailand. An exception to this
pattern occurs for older Thais with secondary level education, for whom the
percent receiving outpatient treatment from a Western provider is lowest.
With respect to associations with health status, the results are consis
tent with those for other utilization outcomes. Persons with low or moderate
self-assessed health tend to have higher levels of outpatient utilization from
both traditional and Western providers, although these differences are not
significant in the Philippines. Health conditions show a similar pattern: outpa
tient treatment by Western health providers increases with the seriousness of
health problems. This pattern is quite marked and statistically significant in all
three countries, and likely reflects both the greater need for outpatient care
among those with life-threatening conditions and the greater awareness of
the presence of life-threatening conditions among those who receive medical
care. This pattern is also observed in relation to outpatient care from tradi
tional practitioners in Taiwan, but is not significant in the other countries.
Hospitalization
Of all the utilization measures, inpatient care, or hospitalization, provides the
best opportunity for cross-country comparisons. Each of the surveys in
cluded a question to ascertain whether respondents had been hospitalized
within the year prior to the interview. The similarity of both question wording
and reference period allows us to investigate cross-country differentials more
explicitly than in previous analyses. We begin with descriptive tabulations of
the percent of respondents who were hospitalized in the past year by socio-
demographic characteristics. We then conduct multivariate logistic regres
sion analyses to examine the effects of predisposing, need, and enabling fac
tors on hospitalization within each country (see Figure 10.1) and to compare
them across countries. Finally, we estimate a logistic regression model for
which the data are pooled across countries to determine differences among
them in the level of hospitalization, net of the other factors.
Table 10.10 presents the percentage of respondents who were
hospitalized within the prior year, in total and by sociodemographic
characteristics for each country. Overall, hospitalization rates are highest in
the Philippines and Taiwan (about 19 percent), moderate in Thailand (14
percent), and lowest in Singapore (8 percent). In Thailand and Taiwan, the
percent hospitalized increases monotonically with age and these patterns are
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Patterns of Health Care Utilization 439
statistically significant. Given that health problems tend to increase with age
in the study countries (as shown in Chapter 9), these patterns are reasonable;
they are also consistent with the age pattern of hospitalization among older
persons in the United States (National Center for Health Statistics, 1999—
Health, United States). In Singapore there is also evidence of an increase in
hospitalization with age, with the sharpest increase occurring between ages
60-64 and 65-69, after which the rates appear to level off. We found no
significant differences by gender or urban-rural residence in any of the
countries. The latter finding is surprising because we expected hospital care
to be more accessible in urban than in rural areas.
We found a significant curvilinear association with education in both
Thailand and Singapore. Those with no education have moderate levels of
hospitalization; those with primary education have the lowest levels of hospi
talization; and those with secondary or higher education have the highest
levels in these countries. In contrast, education is unrelated to hospitalization
in the Philippines and Taiwan.
With regard to the health factors, the results are generally in the ex
pected direction. In all countries except the Philippines, persons reporting
low health ratings or one or more life-threatening conditions have the highest
hospitalization rates, and those reporting the best health on these measures
have the lowest hospitalization rates.
The fact that the sociodemographic and health characteristics are
themselves correlated makes interpretation of bi van ate associations somewhat
difficult. To address this problem, we turn to a multivariate analysis of
hospitalization in which we estimate net effects of the predisposing, need,
and enabling factors shown in Figure 10.1. As noted previously, we first
estimate country-specific models to determine the similarity and difference in
patterns of predictors across countries. We then pool the data from all countries
and add appropriate interaction effects (as suggested by the country-specific
analyses) to test whether there are country differences in the level of
hospitalization and in the factors associated with hospitalization, net of the
other factors. The dependent variable in these analyses is a dichotomous
indicator of hospitalization during the year prior to the survey. We use logistic
regression models for these analyses and present results in the form of odds-
ratios in Table 10.11 (country-specific results) and Table 10.12 (pooled results).
Independent variables are listed in the tables according to the factor they
correspond to, as designated in Figure 10.1, beginning with predisposing
characteristics, followed by need and then enabling characteristics.
Focusing first on the predisposing factors, we see that with the ex
ception of a slightly elevated level of hospitalization among persons age 75 or
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Table 10.11. Odds-Ratios for the Effects of Predisposing, Need and Enabling Factors on
Hospitalization: Results from Country-Specific Logistic Regression Models
+ p<.10 *p<.05
***p<.001
CharacteristicAge (vs. 60-64)65-6970-7475+Female (vs. male)Education (vs. any primary)No formal schoolingAny secondary-*-Married (vs. not married)Living arrangement (vs. w/child)Lives aloneLives with spouse onlyOther arrangementNumber of living childrenHealth rating (vs. medium)LowHigh# life-threatening conditions# debilitating conditions1+ADL difficultyRural (vs. urban)Income (vs. moderate)LowHighMissingWork status (vs. curr. working)RetiredNever workedPseudo R2Philippines0.890.860.621.170.941.041.330.801.231.131.05*1.051.271.65**1.011.79**1.251.100.770.451.52*0.64.042Thailand1.031.081.43*0.961.25*1.52*1.191.371.180.961.04*1.030.67***1.67***1.30***1.55***1.051.251.41**0.891.66***0.66.082Taiwan1.021.231.160.72*0.891.031.281.40+0.880.901.001.75**0.48***1.54***1.22***1.97**1.021.070.65*0.981.41*1.06.092Singapore1.341.140.790.861.281.68*0.780.921.551.591.023.50***0.27**2.59***n.a.1.30***inap.0.961.250.741.67*0.81.181
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Patterns of Health Care Utilization 443
over in Thailand, the positive effect of age observed in the bivariate analyses
essentially drops out in the multivariate models. In fact, in the Philippines and
among those age 75 or over in Singapore, there is a slight tendency for lower
hospitalization among older persons (the direction hypothesized in terms of a
predisposing effect), although these effects are not statistically significant.
Women are less likely than men to have been hospitalized in Taiwan, but no
significant gender differences are found in the other countries. With regard to
education, the curvilinear pattern observed in the bivariate results for Thai
land and Singapore holds up in the multivariate models as well. For both
countries, persons with no education and those with secondary or higher
schooling are more likely to have been hospitalized than those with primary
education. The size of the odds-ratios is remarkably similar for the two coun
tries, although the effect for the uneducated in Singapore is not statistically
significant. It may be that the effect of low education is picking up an element
of need that is not adequately controlled in the models, whereas the effect of
high education is indicative of both a stronger inclination to seek hospital
treatment and better access to such treatment among higher educated indi
viduals in Thailand and Singapore. Social support appears to have little influ
ence on patterns of hospitalization except for number of living children in the
Philippines and Thailand, where higher numbers are associated with a slightly
higher likelihood of having been hospitalized. However, neither marital status
nor living arrangements exhibit significant effects in any of the countries.
Indicators of need for hospital services include self-assessed health,
separate counts of life-threatening conditions and debilitating conditions, and
a dichotomous indicator of any ADL limitation (defined in Tables 9.4 and
9.5). The effect of self-assessed health is in the expected direction in most
countries, with those reporting poor health having the highest levels of hospi
talization and those reporting good health having the lowest levels. An excep
tion is the Philippines, for which self-assessed health is unrelated to hospital
ization. In addition, those with low health ratings in Thailand were no more
likely than those with moderate health ratings to have been hospitalized during
the prior year. In Singapore, the association between self-assessed health and
hospitalization is extremely strong—those who report low ratings are about
3.5 times as likely to have been hospitalized than those with moderate health
ratings, and persons with high health ratings are about one-quarter as likely to
have been hospitalized than those with moderate ratings.
Except for debilitating conditions in the Philippines, all of the other
need indicators are important determinants of hospitalization in all of the coun
tries, with effects in the expected direction. Higher numbers of life-threaten
ing conditions and debilitating conditions and having one or more ADL limita
tions are all associated with increased hospitalization.
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444 The Well-Being of the Elderly in Asia
Last we turn to the enabling factors. Consistent with the bivariate
results, we find no difference between urban and rural residents in hospital-
ization rates, other factors being equal. Again, this is somewhat surprising in
that we had expected better access to hospitals in urban compared to rural
areas. It may be the case that the density of hospital facilities is not much
different in rural than in urban areas in these countries, or that other rural
barriers commonly hypothesized (e.g., long distance to medical facilities and
associated transportation problems; lack of awareness of or familiarity with
facilities) are not important issues.
Looking at income, we see somewhat different patterns for Thailand
and Taiwan. Consistent with the enabling hypothesis, older Thais with higher
incomes have higher levels of hospitalization than do those with moderate
levels of income, other things being equal. Singapore also shows a tendency
in this direction, but the effect is not statistically significant. These patterns
suggest that insufficient income may be a partial barrier to hospital care in
Thailand and Singapore, although the differentials by income are not large. In
contrast, among older Taiwanese, those with high income are less likely than
those with moderate income to have been hospitalized in the prior year. Per
sons with low incomes have a slightly elevated level of hospitalization, but the
difference relative to those with moderate incomes is not significant. This
pattern may reflect greater need for hospital care on the part of lower income
individuals in Taiwan. A similar pattern is seen for the Philippines, but again
the effects are not statistically significant. These patterns suggest that low
income is not a barrier to hospital care in the Philippines or Taiwan.
Finally, the findings relating to work status indicate that retired per
sons have higher levels of hospitalization than their currently employed coun
terparts. These effects are remarkably similar in all four countries. This find
ing is consistent with our earlier supposition that work status may serve more
as a proxy for need than as an enabling factor in these countries. Thus, the
higher rates of hospitalization among retirees may be due to their poorer
health status and thus greater need for hospital care. Although several indica
tors of health status are included in the model, they may not fully account for
differentials in health between employees and retirees.
Taken together, the results suggest that need factors are consistently
important (and probably the most important) predictors of hospitalization in
all of the countries. For the Philippines, the only other variables that show
significant effects are work status (perhaps also a proxy for need as argued
above) and number of living children, and the lack of strong predictors of
hospitalization is reflected in a very low explained variance (4.2 percent as
indicated by the pseudo R2 statistic for logistic regression). The models ex-
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Patterns of Health Care Utilization 445
plain slightly more of the variance in hospitalization for both Thailand and
Taiwan (8 and 9 percent, respectively), and considerably more for Singapore
(18 percent). Predisposing factors seem to have little effect in any of the
countries, supporting the argument made earlier that the more critical health
problems associated with hospitalization make predisposition toward medical
care a less salient factor in hospital utilization.
We now turn to results of the pooled logistic regression model. For
this analysis we combine data from the four countries and conduct a weighted
analysis so that each country contributes equally to the model estimation. The
weighting scheme is the same as that used for pooled analyses in Chapters 5
and 7, and is described in the Appendix. The independent variables used for
the pooled models are the same as those used in the country-specific models,
except for number of debilitating conditions, which is not available for
Singapore. Because we are interested in assessing the relative importance of
predisposing, need, and enabling factors, we first estimate three models, each
of which contains the variables representing only one of these dimensions.
We are also interested in examining overall country differences and determin
ing the extent to which these differences are moderated once compositional
differences with respect to predisposing, need, and enabling factors are taken
into account. To this end we estimate a fourth model that contains only the
country variables, and finally a fifth model that includes all of the variables
simultaneously. We tested for a number of country interactions that were
suggested from results of the country-specific analyses, and the sixth model
includes all interactions that were found to be statistically significant. Results
from all six models are shown in Table 10.12.
Focusing first on the predisposing model (Model 1), the results indi
cate that, net of other factors, hospitalization rates are higher among persons
age 70-74 (compared to those 10 years younger), those who live indepen
dently (either on their own or with a spouse only), and those who have a
larger number of children. Because we expected older persons to be more in
need of hospitalization, it is surprising that persons 75 years or older do not
experience higher rates of hospitalization than found for their 70-74 year old
counterparts. The lack of effect for the 75-plus group appears to be driven
by the Philippines and Singapore, for which this age group had lower rates of
hospitalization than those age 60-64, although the differences were not statis
tically significant. In Singapore this is likely due to the relative lack of health
insurance coverage for the oldest-old, as noted in Chapter 3 and earlier in this
chapter. In the Philippines, where hospitalization costs are largely borne by
the patient and the family, this finding may indicate less access to financial
resources among the oldest-old. The finding that those living independently
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448 The Well-Being of the Elderly in Asia
have higher rates of hospitalization is contrary to the hypothesis that social
connectedness promotes health services use. However, independent living is
more common in Taiwan where the rate of hospitalization is also higher, so it
is possible that living arrangements is largely reflecting a country effect in
this model.
Turning to Model 2, all of the need characteristics are strong predic
tors of hospitalization in the expected direction. Persons with poor health
self-ratings, with higher numbers of life-threatening conditions, or with any
ADL difficulties all have higher probabilities of hospitalization than their re
spective counterparts. In addition, those reporting high health ratings are less
likely than those reporting medium ratings to have been hospitalized in the
prior year.
The results of Model 3 suggest that hospitalization rates are higher for
respondents who live in rural as opposed to urban areas, and who are retired
rather than currently employed. The rural-urban difference may again be
partly a function of uncontrolled country differences, in that all of Singapore
is urban and Singapore has the lowest rates of hospitalization. The higher
rates of hospitalization among retired compared to currently working respon
dents is consistent with the country-specific results in Table 10.11 and may
reflect, at least in part, uncontrolled differences in health status.
Strong overall country differences are evident in Model 4. Both the
Philippines and Taiwan have elevated levels of hospital use compared to Thai
land. Older Filipinos were about 27 percent more likely than older Thais to
have been hospitalized in the year preceding the survey, and older Taiwanese
were about 40 percent more likely than their Thai counterparts. The differ
ence between the Philippines and Taiwan is small and not statistically signifi
cant. On the other hand, Singapore has a substantially lower level of hospital
ization compared to all of the other countries.
An examination of the pseudo A'r. statistics indicates that none of the
individual models explain much of the variance in hospitalization. Of the four
models, the need factors in Model 2 account for the largest amount of ex
plained variance in hospitalization (6 percent). The finding that need is a bet
ter predictor of utilization than either predisposing or enabling factors is con
sistent with research findings in the United States (Wan, 1989). The other
sets of factors account for less than two percent of the variance in hospital
ization, with predisposing characteristics (Model 1) accounting for the least
amount of variance (less than 1 percent).
Model 5 controls for all of the variables simultaneously. Controlling
for need, enabling, and country differences, the only predisposing characteristic
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Patterns of Health Care Utilization 449
that continues to show a significant association with hospitalization is number
of children. The effect of number of children is partially explained by these
other factors—the odds-ratio (OR) drops from 1.05 to 1.03—but other things
being equal, the likelihood of hospitalization increases as the number of children
increases. Need factors remain strong predictors of hospitalization, and their
odds-ratios change very little when other variables are added to the model.
With regard to the enabling characteristics, the rural-urban differential observed
in Model 3 is substantially reduced when other factors are controlled, although
the risk of hospitalization remains slightly elevated for rural compared to
urban residents (OR=1.16, p < .05). The effects for work status are also
slightly moderated, but remain significant in the full model. Interestingly, the
country effects are almost identical in the unadjusted and adjusted models.
The differential for Singapore is slightly reduced in the controlled model (OR
increases from .54 to .58), but those for the Philippines and Taiwan are
identical across the two models. This suggests that the observed country
differences are not due to compositional differences in the populations, at
least with respect to the characteristics considered in this analysis. To the
extent that we have adequately controlled for need in these models, the presence
of country differences would seem to indicate either differential access to
hospital care across countries (an enabling effect) or cultural differences in
the tendency to seek or receive inpatient care.
Finally, as indicated in Model 6, the effects of several characteristics
were found to significantly differ in Taiwan and Singapore. Specifically,
whereas no gender difference was evident in the Philippines, Thailand, or
Singapore, women had significantly lower rates of hospitalization than men in
Taiwan. In addition, those with a high level of income in Taiwan had lower
levels of utilization than those with a moderate level of income. In Singapore,
the currently married had significantly lower rates of hospitalization than un
married persons. Once the interaction between marital status and Singapore
is included, the main effect of marital status becomes significant, indicating
that in the other three countries married persons have a higher likelihood of
hospitalization than unmarried persons. Lastly, Singapore is the only country
for which we find an effect for education, and the effect is in the expected
direction. Specifically, older Singaporeans with secondary or higher levels of
education are more likely than those with primary education to have been
hospitalized in the past year. This finding is consistent with the hypothesis
that educated individuals may be more predisposed to seek hospital care and
that they may have better resources (financial and otherwise) that enable
them to do so.
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450 The Well-Being of the Elderly in Asia
Unmet Need for Health Services
An important policy issue in regard to health care services and utilization is
the adequacy of existing programs for meeting the needs of the older popula
tion. In the previous analyses we described what older adults usually do
when faced with an illness, examined actual levels of utilization for several
types of services, and investigated how these behaviors are related to a range
of sociodemographic characteristics. The results suggest that need plays a
predominant role in health care utilization and that predisposing and enabling
factors play a relatively minor role. The lack of strong socioeconomic grada
tions in utilization levels suggests that health services are distributed fairly
equitably across the older populations in these countries. However, the analy
ses have not addressed the extent to which these senices satisfy the needs of
older persons. We attempt to address this question now, at least in part, for
the two countries that provide information regarding unmet need for medical
care.
Both the Philippines and Taiwan surveys included a question asking
respondents whether, during the prior year (Philippines) or the prior three
months (Taiwan), they had ever considered seeing a doctor when they were
ill but decided against it. If respondents answered affirmatively, they were
then asked to report why they had not sought treatment, and the interviewer
recorded all responses. These were categorized into reasons such as "illness
wasn't serious enough," "obtained medications on my own," "couldn't find a
doctor," and "medical care too expensive." For purposes of this analysis we
used a fairly conservative definition of unmet need by focusing only on re
spondents who reported a problem with access among their reasons for not
seeking care. The primary reasons that met this criterion included the follow
ing: concerns about the cost of treatment, lack of transportation, lack of a
provider, provider was too far away, and no one to come along on the visit.
Table 10.13 presents the percentage of respondents in the Philippines
and Taiwan who report unmet need under this definition. The exact question
wordings and coding specifications for unmet need are provided at the bot
tom of the table. Given the much shorter reporting interval for Taiwan, we
expect the percentage of Taiwanese who report unmet need to be lower than
that for the Philippines, and this is indeed the case. However, the difference is
much larger than what we would expect to be due to the different intervals.
Nearly one-quarter of older persons in the Philippines report unmet need, a
figure six times larger than that for Taiwan. Based on these percentages it
appears that unmet need is a moderate problem in the Philippines and some
what less of a problem in Taiwan.
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Table 10.13. Percent with Unmet Need for Medical Care, by Selected
Sociodemographic Characteristics
Note: Based on the following questions:
CharacteristicTotalMaleFemaleChi-square (p- value)Age 60-64Age 65-69Age 70-74Age 75+Chi-square (p- value)Not marriedMarriedChi-square (p- value)UrbanRuralChi-square (p- value)No formal schoolingAny primaryAny secondary+Chi-square (p- value)Currently workingRetiredNever workedChi-square (p- value)Philippines
(past year)23.925.622.61.50 (.220)21.923.221.729.16.03 (.110)26.721.54.68 (.030)22.525.01.07 (.301)41.122.012.658.47 (.000)25.224.816.45.82 (.054)Taiwan
(past 3 months)3.82.15.927.61 (.000)2.72.94.86.012.96 (.005)6.02.816.47 (.000)3.44.82.91 (.088)6.72.41.142.96 (.000)18.814.411.019.18 (.000)
Philippines: E24. "In the last year have you felt ill and thought about going to
see a doctor, but didn't?" If yes, and reason is due to problems with access to
care (e.g., cost concerns, no transportation, couldn't find doctor, too far, etc.),
R is coded as having unmet need for medical care.
Taiwan: CIS. "In the past three months, have you been in discomfort and
thought about seeing a doctor, but didn't go?" If yes, and reason is due to
problems with access to care (e.g., cost concerns, no transportation, couldn't
find doctor, too far, etc.), R is coded as having unmet need for medical care.
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452 The Well-Being of the Elderly in Asia
The next question is whether unmet need is equitably distributed, or
whether certain groups are more vulnerable than others. In the Philippines,
the only factor with a large differential is education: those with no education
are more than three times as likely as those with secondary or higher educa
tion to report unmet need; those with primary education fall in between.
Unmarried persons (predominantly widowed) are just slightly more likely
than their married counterparts to report unmet need; and those currently
working or retired are marginally more likely than those who never worked to
report unmet need. Perhaps equally interesting is the lack of differences by
gender, age, and urban/rural residence.
In Taiwan we see more differentiation on these characteristics than in
the Philippines. Women report higher levels of unmet need than men (nearly
three times); the level of unmet need increases fairly sharply with age; and, as
in the Philippines, unmarried persons experience greater unmet need than
those currently married. Rural respondents report a slightly higher level of
unmet need than urban respondents, although this difference is not statisti
cally significant at a .05 level. As in the Philippines, we see marked differen
tials in unmet need according to education level and work status.
It is interesting to note that the reasons given for unmet need differ
substantially between the two countries. As shown in Table 10.14, the over
whelming reason reported for unmet need in the Philippines is related to the
prohibitive cost of care (95 percent of those defined as having unmet need
reported this as a reason). In contrast, less than one-third of older Taiwanese
with unmet need reported cost concerns as a reason for not receiving care.
On the other hand, the primary barriers to care in Taiwan relate to geographic
factors (distance, transportation) and lack of social support. These appear to
be relatively minor factors in the Philippines.
Table 10.15 shows results of multivariate analyses predicting unmet
need in each country. As independent variables we use the same sociodemo-
graphic and health factors as used in previous analyses. Focusing first on the
Philippines, we see that once other factors are controlled, women are less
likely to report unmet need than men. Education operates in the expected
direction, in that those with no education report the highest levels of unmet
need and those with secondary education report the lowest levels. Similarly,
persons with high income are less likely to report unmet need than those with
moderate levels of income, although no excess risk is observed among per
sons with low levels of income. Health indicators also operate as expected in
the Philippines. That is, those with high health ratings are less likely to report
unmet need than those with medium ratings; and the likelihood of reporting
unmet need increases with the number of life-threatening conditions and is
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Patterns of Health Care Utilization 453
Table 10.14. Percent Reporting Specified Reasons for Unmet Need,
among Those Reporting Unmet Need
ReasonNo money, cost too highDon't have/know of doctorDistance to clinic/facilityNo transportation/don't know how to
find clinic/facilityNo one to accompanyPhilippines
(n=293)95.02.015.810.312.2Taiwan
(n=136)30.93.122.547.540.4
Note: Percentages for reasons sum to more than 100% because multiple responses
were allowed.
higher among those with one or more ADL limitations. Age, marital status,
living arrangements, number of children, place of residence, and work status
are all unrelated to unmet need in the Philippines.
The results for Taiwan highlight some interesting differences and simi
larities to patterns found in the Philippines. First, education, self-rated health,
and other health factors show similar associations with unmet need in both
countries. Income is also associated with unmet need in both Taiwan and the
Philippines; however, low-income Taiwanese have an elevated risk of unmet
need relative to those with moderate incomes, and the risk is only slightly
(insignificantly) reduced among those with high incomes.
Several interesting differences are also observed. In Taiwan, women
are substantially more likely than men to report unmet need, whereas the
reverse is true in the Philippines. In addition, those living alone in Taiwan
have higher rates of unmet need than those living with a child, which may be
associated with the commonly reported access problems in Taiwan related to
lack of transportation and lack of someone to accompany the older person to
the health care facility. Finally, older Taiwanese who never worked have lower
levels of unmet need than those currently working, other things being equal.
The direction of effect is the same for the Philippines, but the odds-ratio is
not statistically significant. It may be that employment itself is somewhat of a
barrier to medical care if workers feel that they cannot afford to take time off
for a trip to see their doctor or visit a health clinic.
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Table 10.15. Odds-Ratios for the Effects of Predisposing Need, and Enabling
Factors on Unmet Need: Results from Country-Specific Logistic
Regression Models
p<.10 *p<.05 **p<.01
'p<.001
CharacteristicAge (vs. 60-64)
65-69
70-74
75+Female (vs. male)Education (vs. any primary)
No formal schooling
Any secondary+Married (vs. not married)Living arrangement (vs. w/ child)
Lives alone
Lives with spouse only
Other arrangementNumber of living childrenHealth rating (vs. medium)
Low
High# life-threatening conditions
# debilitating conditions
1+ ADI , difficultyRural (vs. urban)Income (vs. moderate)
Low
High
MissingWork status (vs. curr. working)
Retired
Never workedPseudo R2Philippines
(Past Year)0.96
0.78
1.010.72*2.58***
0.59*0.901.11
0.76
0.991.021.35
0.55*1.42*
1.27
1.51*0.940.91
0.58**
0.640.79
0.73.095Taiwan
(Past 3 Months)0.91
1.13
0.892.27**1.96**
0.710.842.33**
1.50
1.060.962.87**
0.44*1.82
1.47***
2.12*0.982.05**
0.86
0.670.73
0.57*.175
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Patterns of Health Care Utilization 455
In general the results based on the limited measures available suggest
that unmet need for medical care is not a major concern among older adults in
the Philippines and Taiwan. A large majority of older adults in both countries
feel that they are able to obtain medical care when they need it. Yet, the
proportion reporting concerns in this regard is not trivial, particularly in the
Philippines, and further investigation of the issue with more detailed data
would be valuable. The reasons cited for unmet need in both countries pro
vide useful insights into areas of health service utilization that could be im
proved. In the Philippines, the primary concerns have to do with out-of-
pocket costs for services. The National Health Insurance program, which
went into effect in the Philippines in 1998 (two years after the survey), may
go far to alleviate this problem, although continued monitoring will be impor
tant. The concerns expressed in Taiwan suggest that expansion of health
facilities and transportation services would go far toward alleviating prob
lems with access to medical care for older adults.
Conclusions
Inasmuch as the elderly tend to have higher than average per capita health
care needs, countries with rapidly aging populations, such as those studied
here, face the challenge of responding to an increased demand for health
services. Using the Andersen behavioral model for health services utilization,
we find that need factors (self-assessed health, number of life-threatening
conditions, the presence of ADL difficulty) tend to be the most consistent and
significant predictors of preventive, outpatient, and inpatient health service
utilization among the older populations in the four countries. Moreover, given
the proclivity of these respondents to seek outpatient treatment from Western
rather than traditional medical providers, a high future demand for Western-
type medical senices may be anticipated in these countries.
In the face of these demands, preventive care services—which help
people monitor and manage chronic conditions as well as lower their risk for
future diseases—will be an increasingly significant area for development. We
found evidence of receptivity to preventive-type services in Thailand, Tai
wan, and the Philippines (where data are available), with more than half of the
respondents in all countries reporting the use of a preventive service within
the prior 6-12 months. We found that the need factors (self-rated health;
chronic, debilitating, and life-threatening conditions) are all significantly re
lated to the use of preventive services, suggesting that those who feel unwell
or have diagnosed diseases are more likely to seek these services. Some of
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456 The Well-Being of the Elderly in Asia
the enabling and predisposing factors are also worth noting. For example.
education generally increases the likelihood of using preventive senices in all
three countries, as does being married in Taiwan, or being female, being
married, and residing in an urban area in Thailand. In Thailand, Taiwan, and
the Philippines the oldest-old are the lowest users of preventive services. All
these patterns help identify groups that could be targeted for preventive care.
The level of development of the health care system is also evident in
the utilization rates reported in each country. For instance, in the Thailand and
Philippines surveys, which both had extensive lists of preventive services
from which to choose, less than one-quarter of respondents reported the use
of any service except blood pressure check, which about one-half reported.
Presumably this is because a blood pressure check is the most readily avail
able and the least expensive both to the patient and the health care system. In
the Taiwan survey, which listed only blood pressure check and blood test,
much higher proportions of respondents reportedly availed themselves of
both these services. Taiwan also had substantially higher levels of utilization
of outpatient services than either the Philippines or Thailand, and this was
true for both traditional and Western medical services.
With regard to hospitalization, need factors are the primary determi
nants in all four countries, as seen in both the country-specific and pooled
logistic regression models. The only other factor that consistently shows a
significant effect both within country and in the pooled analysis is work
status, with the retired significantly more likely than those currently em
ployed to have been hospitalized in the prior year. In these Asian countries,
work and retirement may have different implications for health status than
they do in other Western countries in that these retirees are disproportionately
comprised of those who can no longer work for health reasons. Thus retire
ment is likely to be a proxy for health care need.
As described in Chapter 3, each of the four countries has health
programs to address the provision and financing of health care sen ices
While Thailand and the Philippines have special programs that target the elderly
sector, Taiwan and Singapore offer more comprehensive programs that cover
the entire population, including the elderly, through Medisave in Singapore
and the Universal Health Insurance Program in Taiwan. In the Philippines,
only about 6 percent of the elderly survey respondents reported that their
medical costs in the prior year were covered by national health insurance, and
only 16 percent reported that their medical services were provided at no
charge. Less than 40 percent of Thai respondents reported using Thailand's
special program of free medical care for the elderly and only about 14 percent
reported enrollment in the national pre-paid health insurance program, despite
high levels of awareness of both programs. Use of the medical savings program
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Patterns of Health Care Utilization 457
(Medisave) is quite high in Singapore, where about 75 percent of respondents
report that either their own Medisave account (14 percent) or another family
member's account (61 percent) serves as the primary source for medical
expense coverage. In Taiwan, enrollment in the Universal Health Insurance
Program—the most extensive of the public programs examined—is nearly
universal among the elderly (98 percent of respondents).
One indication of the likely effect of such differential coverage and
benefits in health insurance may be inferred from comparing both the propor
tions reporting unmet need for medical senices in Taiwan and the Philip
pines, and from the reasons cited by respondents for not availing themselves
of needed health care. While only 4 percent of the Taiwanese elderly reported
unmet needs the corresponding figure for Filipinos was 24 percent. Further
more, whereas older Taiwanese tend to cite reasons for not using needed
services that are related to physical access to a health facility (i.e., distance to
facility, no transportation, no one to accompany), an overwhelming propor
tion of older Filipinos (95 percent) cite cost considerations (i.e., no money,
cost too high). Yet, the rates for use of inpatient services (hospitalization) are
almost identical in the two countries, indicating that a lack of health insurance
coverage does not deter Filipino elderly from seeking this service when a
critical need arises. However, we do not know the impact on Filipino elderly
of eschewing preventive or outpatient care until hospitalization is required,
however, nor the impact on the elderly or their families of bearing out-of-
pocket hospital expenses.
Overall, results of the analyses presented in this chapter portray a
fairly positive picture of the state of health services for the elderly in the four
countries. Need for medical care plays a dominant role in determining who
receives health services, and socioeconomic indicators appear to play only a
minor role. In addition, the level of unmet need for medical care appears to be
quite low in Taiwan and to a somewhat lesser degree in the Philippines.
Yet, as noted in Chapter 3 and throughout the volume, the main chal
lenges for these countries lie ahead, as they continue to transform their health
systems to provide a stronger emphasis on geriatric care and attempt to keep
pace with the accelerating demand for health care services that will result
from rapid population aging. Whether they will be able to meet this challenge
remains to be seen, although the foresight that officials in these countries
have displayed to this point with respect to anticipating the challenges associ
ated with population aging will serve them well. Given the changing land
scape of health care demands and the recent (and ongoing) initiation of new
health programs, it will be important to monitor trends in health care utiliza
tion and unmet need among the elderly in Asia in the coming years as one
means of evaluating the success and impact of these programs.
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458 The Well-Being of the Elderly in Asia
REFERENCES
Aday, Lu Ann, and Ronald M. Andersen. 1974. "A Framework for the Study of
Access to Medical Care." Health Services Research 9:208-220.
Andersen, Ronald M. 1968. A Behavioral Model of Families' Use of Health
Services. Chicago: Center for Health Administration Studies.
Andersen, Ronald M., and John F. Newman. 1973. "Societal and Individual
Determinants of Medical Care Utilization in the United States." Milbank
Memorial Fund Quarterly 5 1 : 95- 124.
Binstock, Robert H. 1997. "Issues of Resource Allocation in an Aging Society." In
Tom Hickey, Marjorie A. Speers and Thomas R. Prohaska (eds.). Public Health
and Aging. Baltimore, MD: Johns Hopkins University Press.
Cheng, Shou Hsia. and Tung Liang Chiang. 1997. "The Effect of Universal Health
Insurance on Health Care Utilization in Taiwan: Results from a Natural
Experiment." Journal of the American Medical Association 278:89-93.
Chiang, Tung Liang. 1997. "Taiwan's 1995 Health Care Reform." Health Policy
39:225-239.
Fisher, E. S., J. E. Wennberg, T. A. Stukel, and S. M. Sharp. 1994. "Hospital
Readmission Rates for Cohorts of Medicare Beneficiaries in Boston and New
Haven." New England Journal of Medicine 33 1(15):989-995.
Greer, D. S., V. Mor, J. N. Morris, S. Sherwood, D. Kidder, and J. Birnhaum. 1986
"An Alternative in Terminal Care: Results of the National Hospice Study."
Journal of Chronic Diseases 39( l):9-26.
Hermalin, Albert I. 2000. "Ageing in Asia: Facing the Crossroads." Comparative
Study of the Elderly in Asia Research Reports, No. 00-55. Ann Arbor, MI:
Population Studies Center, University of Michigan.
Interministerial Committee on the Ageing Population. 1999. Report of the
Interministerial Committee on the Ageing Population. Singapore: Ministry
of Community Development.
Kawnuansilpa, Peerasit, Supawatanakom Wongthuanavasu, John Bryant, and Aree
Prohmmo. 2000. "An Assessment of the Thai Government's Health Services
for the Aged." Asia-Pacific Population Journal 15( 1):3-18.
National Center for Health Statistics. 1999. Health, United States, 1999. Hyattsville.
MD: National Center for Health Statistics.
Ogawa, Napjorp, and Robert D. Retherford. 1997. "Shifting Costs of Caring for the
Elderly Back to Families in Japan: Will It Work?" Population and Development
7?ev/ew23(1):59-94.
Pasley, B. H., R. J. Lagoe, andN. O. Marshall. 1995. "Excess Acute-care Bed Capacity
and Its Causes — The Experiment of New York State." Health Services Research
Soldo, Beth J., and Kenneth Manton. 1985. "Changes in the Health Status and
Service Needs of the Oldest Old: Current Patterns and Future Trends."
Milbank Memorial Fund Quarterly 63 :286-323 .
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Patterns of Health Care Utilization 459
Wan, Thomas T. H. 1989. "The Behavioral Model of Health Care Utilization by
Older People." In M.G Ory and K. Bond, (eds.), Research Methodology:
Strengthening Causal Interpretations of Nonexperimental Data. DHHS
Publication No. (PHS) 90-3454. Rockville, MD: U.S. Department of Health and
Human Services.
Wolinsky, Fredric D., and Robert J. Johnson. 1991. "The Use of Health Services by
Older Adults." Journals of Gerontology 46(6):S345-357.
NOTES FOR TABLES
Table 10.5
Thailand question asks (H12): Usually, when you do not feel well, have a fever,
catch a cold or other minor sickness that does not need hospitalization, where
do you go for treatment, or what method do you use the most often?
1. Rest, do not take medicine, "take it easy"
2. Buy the medicine myself
3. Go to health center
4. Go to state hospital
5. Go to private hospital
6. Go to private clinic
7. Go to traditional doctor
8. Go to monk or astrologer
9. Other (specify)
Table 10.6
Singapore question asks (X3a): When you are sick, which facility do you usually
use? (Check only one)
1. None
2. Self-medicate
3. Traditional medicine practitioners
4. Govt/polyclinic/OPD
5. Accident & Emergency Dept.
6. Govt specialist/outpatient clinic
7. Private GP/specialist clinic
8. Company doctor
9. Other (specify)
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Chapter 11
THE VULNERABLE AND THEIR
POTENTIAL DISADVANTAGES
Albert I. Hermalin, Mary Beth Ofstedal, and Kalyani Mehta
The vulnerability of the older population is a persistent theme within
gerontology. This arises quite naturally from consideration of the bio
logical processes and underlying socioeconomic dynamics. Despite the abil
ity of many older people to maintain robust health to advanced years, frailty
and health-induced limitations increase with age. Transitions to older ages
also produce social and economic threats that can arise from insufficient
income and loss of economic power, widowhood, and diminished contact
with children.
These general concerns have often been translated into identifying the
groups among the elderly that are most vulnerable to these processes and that
may be at greatest disadvantage. In many societies this has led to a focus on
the oldest-old, on those who may have limited resources—the less educated
and women, and on those with limited support networks—the widowed,
those with few or no children, or the isolated rural elderly. Of course, a given
group may face multiple threats, which is especially true for women, who
tend to have lower education, less labor force experience, a higher likelihood
of being widowed, and diminished family power.
The general strategy of our analyses in the previous six chapters has
been to treat the well-being of the elderly more generally, examining the full
461
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462 The Well-Being of the Elderly in Asia
range of outcomes associated with social support, work, income and health,
and the factors associated with these different outcomes. In this chapter we
reverse the procedure, identifying specific adverse outcomes for each di
mension and measuring the extent to which groups thought to be particularly
vulnerable to experiencing these outcomes are doing so relative to the over-all
population of the elderly.
Proceeding in this fashion can be particularly helpful for policy and
program decisions. It can illuminate which identifiable groups within a soci
ety are not being served well by existing programs, indicate the magnitude of
the problem through the group size and its relative disadvantage, and suggest
possible remedial actions, ranging from specific local actions to changes in
major national social security and health programs. It can also indicate how
the current mix of needs might change in the future with the emergence of
new cohorts of elderly with different sociodemographic characteristics.
Methods and Measurement Issues
In carrying out the analytical strategy of this chapter the metaphor of medical
screening is useful: deciding who will be tested, for which conditions, and
what diagnostic tests will be employed. These three elements are critical to
the goal of identifying the vulnerable groups and measuring the degree of
their disadvantage: defining the sociodemographic groups to be examined;
selecting from among the disadvantages those to which they are most vulner
able; and establishing indicators to test the degree to which they are disadvan-
taged relative to the total older population or other groups.
Table 11.1A lists the vulnerable groups, which represent demographic
and socioeconomic categories of people likely to have above-average levels
of one or more disadvantages. These vulnerable groups are identified on the
basis of a priori knowledge about the process of aging, previous studies, or
reports in the mass media. Also shown in the table is the percentage that a
given group represents of all the elderly in each of the four countries.
The groups are defined across a range of dimensions, from the basic
biological processes establishing sex and age, to location and social status, to
a number of family-related dynamics such as marital status, numbers of chil
dren, and living arrangements. For many of the groups the defining charac
teristics are established at birth or early in life; but for several, like the wid
owed or divorced, late life events may be the source of group membership.
In every case the meaning of belonging to a particular group is also a function
of the cultural and socioeconomic setting, which greatly affects social status.
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The Vulnerable and Their Potential Disadvantages 463
education level, and other key life dynamics. Similarly, disadvantages associ
ated with a particular group may result from events that accumulate across
the life span. For example, lack of education is likely to diminish employment
opportunities, marriage prospects, and access to health services, resulting in
a profile at older ages of lower earnings and assets, a smaller social network,
and poorer health. Rudkin (1993, p. 224), in her analysis of gender differ
ences in economic well-being among the elderly in Indonesia, attributes the
disadvantage of older women to economic disadvantages experienced through
out adulthood. Other disadvantages observed may result from events occur
ring at older ages, such as loss of spouse, children moving away, and a
diminished agricultural economy.
In terms of relative size, Table 11.1 A shows that some of the groups
are currently major components of all the elderly, such as those age 70 or
over, women, and rural residents in Thailand and the Philippines, while others
are relatively small proportions, such as those living alone or without living
children, widowed men, and those who have never been married or who are
currently divorced and separated. The percentage of the older population
who have no formal education varies considerably from a low of 19 percent
in the Philippines, to 67 percent in Singapore. Observers are often surprised
by this contrast given Singapore's current high income level (see Chapter 8)
and high education levels among youth and young adults (Hermalin 1995).
However, past migration patterns for Singapore as well as differences in
educational opportunities that existed in each country prior to World War II
help account for these differences. As a result of these special histories, it
should be kept in mind that discussions of those without formal education
refers to the modal elder in Singapore, but to only one-fifth of those in the
Philippines. Also, it is important to remember that the groups are not mutually
exclusive; many individuals will fall into multiple categories, such as older,
low-educated women living in rural areas. And it should be noted that the
relative sizes of the groups are likely to change substantially over time with
continued socioeconomic development. For example, one may expect, given
current marriage and fertility trends, that a higher proportion of the future
elderly will be never married women and/or have no children. At the same
time, group characteristics may change. For example, those who do not
marry may be among the more highly educated. Changes in both the size and
characteristics of those falling into a given sociodemographic category must
be taken into account in considering policy and program implications.
Table 11.1B lists the indicators of economic, health, and social disad
vantage used and shows their proportion among all elderly in each country.
The indicators for economic disadvantages include being at the lower end of
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464 The Well-Being of the Elderly in Asia
the income scale for both personal and household income, difficulty in meet
ing expenses (or subjective feeling of dissatisfaction with income), reliance
on children as sole or main source of financial support, and a weak asset
position. (The high percentage with low income in Taiwan arises from the
categories employed in reporting and coding income, which did not allow for
finer subdivisions at the lower end of the scale.) Although we attempted to
measure the nature of the disadvantages the same way in each country, some
differences in the underlying data prevented identical definitions. The major
variations are indicated in the footnotes to Table 11. IB and indicators of dis
advantages for each country are defined in Appendix 11 .A.
The indicators for health disadvantage cover both self-rated health
and various types of conditions, ranging from the presence of chronic condi
tions, limitations in activities of daily living (ADLs) and instrumental activities
of daily living (lADLs), and vision and/or hearing impairment. For three coun
tries, an assessment of cognitive ability was possible through the use of word
recall questions or similar screening, and a subnormal level is used as defined
in Appendix 11. A.
We found relatively few comparable indicators of social disadvantage
across countries. The three shown in Table 11. IB focus on the frequency of
visits with children, the size of the social network, and measures of expres
sions of depression or loneliness, all of which are defined in Appendix 11. A.
Ideally one seeks "semantic independence" between the definition of
the sociodemographic group and the disadvantage. That is, all older persons
should be exposed to the risk of all the disadvantages, although some groups
may have a higher probability of actually experiencing a particular disadvan
tage. Semantic independence characterizes the groups and disadvantages de
fined in Tables 11.1A and 11.1B with the exception of those without children,
who by definition cannot have children as their sole or main source of in
come, or by definition have a zero measured frequency of contacts with
children. In these cases, no measure of the relative level of disadvantage is
shown. In other cases, there are expected levels of association between the
group and the disadvantage simply because the groups were chosen to ex
plore the level of vulnerability as might occur, for example, between age and
health limitations, or living alone and depression. It should be noted, never
theless, that for some groups potential selection effects could arise which
produce ambiguity in attributing cause-and-effect. Thus, those rural elderly
who may have options to join children in urban areas but choose to remain in
their rural homes may be selected for those in better health and economic
circumstances. Related examples are noted below.
The third component of the strategy is devising a measure of relative
disadvantage that will capture the differential vulnerabilities among the various
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The Vulnerable and Their Potential Disadvantages 467
groups. The measure used here is a risk factor, defined as the ratio of the
proportion disadvantaged in a specified sociodemographic group relative to
the proportion disadvantaged among those not in the group. As developed
formally in Appendix ll.B, this is equivalent to the ratio of the odds of being
in a specified sociodemographic group among all those with a given
disadvantage, to the odds of being in that group among the total population.
As defined, the risk ratio is independent of the size of the group or other
compositional elements. A ratio of 1 means that both those in and out of the
group have the same risk for the particular disadvantage; ratios greater than 1
indicate a proportionate level of heightened risk for those in the specified
sociodemographic group; ratios of less than 1 indicate a relative degree of
diminished risk facing those in the group.
The risk factors developed are relative in a number of important ways.
The measures developed indicate whether, for a certain disadvantage, a given
group is worse off than those within the country who are not in that group.
On an absolute level, those appearing disadvantaged in one country may be
better off than the relatively advantaged in another country, given the range of
economic development and average incomes across the countries. Also, a
given person or group who appears disadvantaged currently may still be bet
ter off than he or she was at earlier ages, given the generally strong economic
growth that has occurred over time.
The risk factors as defined were calculated for each of the sociode
mographic groups listed in Table 11.1 A, on each of the indicators of disad
vantage listed in Table 11. IB. This results in a large matrix of risk factors for
each country, where the columns represent the sociodemographic group and
the rows the type of disadvantage. The detailed results are available from the
chapter authors in the form of three tables for economic, health, and social
disadvantages that compare all four countries. Table 11.2 repeats the first
portion of this matrix, illustrating for the Philippines the relative risk faced by
each sociodemographic group on each of the economic disadvantage indica
tors. In addition, the first row for each country presents the percentage of all
elderly in each group, while the first column presents the percentage of all
elderly with the stated disadvantage.
Using an example from Table 11.2 for the Philippines, those 70 years
or older are 90 percent more likely than those under age 70 to have no assets
(risk factor equal 1.90), while the rural elderly are only 63 percent as likely to
hold no assets than those residing elsewhere. On several of the other mea
sures of economic disadvantage, however, the rural elderly have a higher risk
than others.
The data in Table 11.2 also enable one to calculate the percentage of
those in each sociodemographic group that experiences each disadvantage.
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The Vulnerable and Their Potential Disadvantages 469
The formula, presented in Appendix ll.B, is a function of the relative risk
factors, the proportion of the total population who experience a given disad
vantage, and the proportion of the total population who are in the specified
sociodemographic group. Another measure of potential interest that can be
derived from the data in the matrix is the proportion of the disadvantaged
who are part of each sociodemographic group, although it should be noted
that a given disadvantaged person may belong to more than one sociodemo
graphic group. The formula for this measure is also presented in Appendix
ll.B.
The risk factors presented in the matrix can be used to examine the
profile of risks facing a given sociodemographic group within each country,
to compare different groups within countries, and to compare groups across
countries. To facilitate these comparisons, the next two sections present a
series of figures derived from these data that focus on country-specific and
cross-national profiles, respectively.
As noted above, the sociodemographic groups analyzed are not mutu
ally exclusive. To gauge the relative vulnerabilities of the different groups we
then present a multivariate analysis for the major types of disadvantage and
an analysis of the groups most likely to experience multiple types of disad
vantage.
Research Findings
Country-Sped fic Profiles of Risk Factors
This section presents a series of figures designed to highlight the risks of
disadvantage within each country. Figures 11.1 to 11.4 display separately for
each country the risk factors for the sociodemographic groups (shown in
Table 11.1 A) on the indicators of the economic, health, and social disadvan
tage (shown in Table 11. IB). Each broad dimension of disadvantage is pre
sented in a separate figure. For example, Figures 11.1A through 11.1C show
the relative risks of specific disadvantages for each sociodemographic group
in the Philippines, with Figure 11.1 A focusing on economic disadvantage,
Figure 11.1B on health disadvantage, and Figure 11.1C on social disadvan
tage. Parallel sets of figures are shown for each of the other countries.
Recall that, as defined, a relative risk of 1 means that the group faces
the same risk of experiencing the disadvantage as those not in the group. For
this reason, the figures highlight deviations from this equality point, with
relative risk greater than 1 indicating excess risk. In the form presented, the
figures focus attention on sociodemographic group profiles of relative risks
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470 The Well-Being of the Elderly in Asia
within each country. (Source data for these figures are given in the tables in
Appendix ll.C.)
Figure 11.1 A. which illustrates relative risks of economic disadvan
tages in the Philippines, shows at first glance that only those with no educa
tion face significant excess risk on each of the indicators of disadvantage.
For the other groups, excess risk tends to vary across indicators, illustrating
again the value of using multiple measures Those age 70 or over have signifi
cantly heightened risk of low income, lack of assets, and reliance on children
as the sole source of income. Rural residents face excess risk primarily for
lack of household possessions and the perception of inadequate income; they
are less likely than urban dwellers to have no assets or to rely on relatives for
sole financial support. The sociodemographic groups based on gender and
family dynamics show that widowed women have a relatively high risk of
relying solely on children for income, as well as facing low income and lack
of assets. All women parallel the profile of the widowed women in a some
what muted fashion. By contrast, widowed men show minor levels of rela
tive disadvantage on these measures. Older Filipinos without living children
show a very high relative risk of having no assets and a moderate risk of low
income; for those who live alone the major risk is having few household
possessions. Although these two groups are likely to overlap to a fairly high
degree, it can be assumed that some of those who live alone have children,
but have the economic resources as well as a desire to maintain their own
households. The economic profile of this subset may differ considerably
from those who reside alone primarily because they have no living children.
The profiles for relative risks of health disadvantages for the Philip
pines, presented in Figure 11.1B, are quite different from the economic pro
files in Figure 11.1 A. As might be expected, those age 70 or over show
substantially higher risks than others on almost every indicator. On vision or
hearing impairment and ADL limitation, their risks approach three times those
of the younger cohort. The only other group with a clear pattern of higher
risks is those with no education, who are at particular risk in the area of
subnormal cognitive ability. This health risk also appears substantially higher
among those who live alone. Widowed men, widowed women, and all women
share similar profiles, with little excess risk on any of the health disadvan
tages—a pattern also exhibited by those with no living children. Rural resi
dents show a higher risk than urban dwellers on poor self-rated health, but
are very similar on all the other measures.
The profiles for social disadvantages in the Philippines, presented in
Figure 11.1C, are quite different from the previous two. For this dimension
of disadvantage, the two distinctive groups are those living alone and those
without living children, as might be expected given the nature of the indicators
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antages for SoDUterate or No
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474 The Well-Being of the Elderly in Asia
used. Those living alone have 3 times the risk of others of having less than
monthly contact with any child or having a small social network. Those with
no living children have 16 times the risk of others of having a small social
network. This follows given the overlap between the definition of the groups
and the disadvantage indicators. Those living alone often have no living
children, which contributes to their excess risk for lack of monthly contacts;
also because the measure for small social network includes both the size of
the current household and the number of non-coresident children, the risk
will be substantially higher for those living alone and those without living
children. It is also worth noting that some cause-and-effect ambiguity
characterizes the relationship between these indicators and living alone. That
is, many may be forced to live alone because they have little contact with
their children and/or they have a small social network. The patterns observed
for these two sociodemographic groups in terms of social disadvantages
parallel those in the other countries, with some differences in magnitude as
noted below. With regard to infrequent contact with children, the only other
sociodemographic groups with significant excess risk are those age 70 or
over and those with no education. Widowed men and widowed women, it is
interesting to note, have much lower risks than those not in these categories
for having infrequent contact with their children and small social networks,
reflecting no doubt the tendency for widows and widowers to live with their
children. Rural residents also have lower risks of these disadvantages than
urban dwellers. With regard to depression the pattern is quite different: each
of the sociodemographic groups shows higher risks than their counterparts
except for widowed men and those with no living children, with particularly
high values for those with no education, those living alone, and women,
widowed or otherwise. The sharp difference between the relative risk of
depression for those living alone versus those with no living children is
somewhat surprising, given that both groups face limited social contact; and
it is also surprising to note that the risk of depression is as high in a number of
other sociodemographic groups as it is among those living alone, suggesting
that a number of factors beyond limited social contact are operating. It thus
appears that the risk of depression is as high or higher among groups other
than those living alone or without children, or stated otherwise, that depression
among the elderly in the Philippines is not necessarily just a reflection of
limited social contact.
The relative level of economic disadvantage among the
sociodemographic groups in Thailand is illustrated in Figure 11 2 A Similar to
the Philippines, no groups show excess risk on every measure, and the profile
of disadvantages varies somewhat by group. The rural elderly experience
very high relative risk for having low personal and household income and a
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476 The Well-Being of the Elderly in Asia
lack of household possessions, and have significant risk for the perception of
inadequate income. Those age 70 and over, by contrast, show high relative
risk for no assets and to a lesser extent for reliance on children and low
income, while those with no education display some excess risk on every
measure except inadequate income. Those living alone show very high relative
risks for low personal and household income and few household possessions,
but are not at greater risk than their counterparts on any other of the economic
indicators. Similarly, those with no living children have noticeably higher risks
only on low income and the absence of assets. As in the Philippines, the
profiles of all women and widowed women in Thailand resemble each other,
with excess risk on low income, reliance on children, and absence of assets,
while widowed men show only minor disadvantage on these indicators.
Relative risks of health disadvantages for the Thai sociodemographic
groups are shown in Figure 11.2B, and as the graphs show, the most distinc
tive feature is the general lack of excess risk. It is true that those age 70 or
above have a significantly heightened risk of experiencing an ADL limitation,
and that this group along with those with no education and women (widowed
or otherwise) have modest excess risk on more than one measure. Neverthe
less, the general pattern is one that indicates similarity rather than difference
among risk levels.
The relative risks of social disadvantages among groups in Thailand
are shown in Figure 11.2C. As with the Philippines, the greatest excess risks
are lack of contact with children or small social networks found for those
living alone and those without children, respectively. The only other group
for which the risk for these disadvantages is moderately high is that with no
education. The risk of feeling "lonely" (depressed) is extremely high for those
living alone and moderately high for widowed women. Surprisingly, loneli
ness is much lower than average for those without living children, a pattern
similar to that found for depression in the Philippines.
Economic disadvantages among socioeconomic groups in Taiwan,
exhibited in Figure 11.3 A, show that those who live alone and those with no
living children have significant excess risk on almost every measure. In fact,
the only clear exception, the lower than average risk among those living alone
of relying on their children for income, almost certainly reflects this group's
tendency toward having no children who might support them. Those with no
education, widowed women, and all women also display significantly height
ened risks—particularly for economic reliance on family and no assets—but
widowed men are very close to average on every disadvantage. The remain
ing groups display excess risk on only one or two indicators.
The pattern of health disadvantages in Taiwan, displayed in Figure
11.3B, indicates much higher than average risks on almost every measure for
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raphic GroupsLivs Alom
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The Vulnerable and Their Potential Disadvantages 479
those 70-plus years of age and among those with no education. Widowed
women and all women also have significant excess risk on IADL limitations,
and some excess risk on the other health indicators. The other groups, how
ever, display little heightened risk for health disadvantage. ADL and IADL
limitations are of below-average risk for those living alone and those with no
living children, which in the case of the former group may reflect that living
alone usually requires freedom from serious limitations.
The pattern of social disadvantages in Taiwan, shown in Figure 11.3C,
indicates that those who live alone have much higher risks for infrequent
contact with children and a small social network, as we have come to expect.
But those without living children have only a slightly elevated risk of having a
small social network, similar to the risk shown for widowed men and women.
The other groups tend to be at or below average on these measures of con
tact and network size. For depression, however, all groups except rural resi
dents and widowed men show moderate to significant excess risk.
The most distinctive economic disadvantage in Singapore, as shown
in Figure 11.4 A, is the significantly heightened risk for low levels of personal
and household income among those age 70-plus, living alone, or without
living children. In addition, these groups have (lightened risk for having no
assets, which is also true of every other group except widowed men. Also,
those living alone and without living children have much higher than average
risk of perceiving their income as inadequate.
The distinctive groups in terms of high risks of health disadvantages
in Singapore are those age 70 or more, particularly on the risk of experiencing
ADL or IADL limitations. Those with no education have much higher risks of
displaying subnormal cognitive ability. Widowed women and all women show
a pattern of moderate to high risks on a number of the health disadvantages.
(See Figure 11.4B.)
The pattern of social disadvantage in Singapore is quite striking. Those
who live alone and those without living children show exceedingly high risks
on all social disadvantage indicators. But the remaining sociodemographic
groups display average or below-average risks on the indicators. It should be
noted that for Singapore the third indicator, "no one to turn to," is based on a
single question about having a confidant or advisor, which will be associated
somewhat with the size of one's network. This contrasts with the measures
of depression in the Philippines and Taiwan, which are based on a scale of
several more general questions. In addition, the definition of social network
size is more restricted in Singapore than elsewhere because of the absence of
data on the extended family (see Appendix 11 .A).
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486 The Well-Being of the Elderly in Asia
Cross-Country Profiles of Relative Risks
The previous section focused on comparing the different sociodemographic
groups on each type of disadvantage within each country. Also of consider
able interest is whether the profiles of sociodemographic group disadvantage
are similar across countries, or whether there are distinctive patterns in one
or more countries.
The relative level of disadvantage experienced by any group will de
pend on the individual histories experienced by members of that group over
their lifetimes, in interaction with the social and economic conditions they
faced at each point, as well as more recent policies that may influence the
location of children, the degree of support from family, and the level of sup
port through public programs. Sharp cross-country differentials in the level
of disadvantage for a particular group may point to either long-standing cul
tural practices in a country that promote or hinder the well-being of that
group, or the policies across countries that act differentially on the welfare of
certain groups.
To highlight these cross-country patterns the relative risk measures
for each category of disadvantage are averaged, giving each sociodemographic
group within a country a single value for each of the economic, health, and
social dimensions. These values are displayed in Table 11.3 and are presented
graphically in Figure 11.5. (Because the relative risk factors are not a function
of any compositional elements, the figures shown are simple arithmetic aver
ages for each type of disadvantage.)
For each dimension of disadvantage, Figure 11.5 permits visual com
parison of risk profiles across countries by sociodemographic group. The
top panel, which displays average risks associated with economic disadvan
tage, shows a number of similarities and differences across countries. The
most striking difference is the extremely high economic risk of the rural
population in Thailand, compared to the Philippines and Taiwan. Another sharp
difference is the excess risk in Singapore for many of the fertility and family-
based statuses—those living alone, without living children, and never mar
ried, separated, or divorced women. In all countries, those age 70 or older are
at a relative disadvantage as are those with no education. In all countries
widowed women are at greater economic risk than widowed men. It is of
interest to note that the patterns of economic disadvantage for the Philippines
and Thailand resemble each other, as do those for Taiwan and Singapore,
although the precise levels vary in the ways noted.
The average health risks displayed in the second panel of Figure 11.5
show more similarity across countries. The most clearly disadvantaged group,
as might be expected given the focus on health-related limitations, are those
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488 The Well-Being of the Elderly in Asia
age 70 or over, and the magnitude of the disadvantage is quite similar across
countries, varying from 2.1 to 2.6 according to Table 11.3. The only other
groups consistently disadvantaged are those with no education and, to a lesser
degree, widowed and all women.
The profiles of social disadvantage shown in the third panel of Figure
11.5 are also quite similar across countries. In every case the groups with
very high relative risks are those living alone and those without living chil
dren. Family statuses related to these—men and women who never married,
separated, or divorced—also show a very high average social risk, except
among women in Taiwan. The patterns are also similar for the remaining
groups in the Philippines, Thailand and Taiwan, with each of these countries
showing somewhat higher risks among the age 70-plus group, those with no
education and, except in Taiwan, among women. By contrast, rural residents
show slightly lower average risks than their counterparts in the three coun
tries for which this category is relevant.
Examination of Table 11.3 and Figure 11.5 shows that the sociodemo-
graphic groups selected as potentially vulnerable do indeed tend to have ex
cess risk (greater than 1) on at least one of the three broad dimensions of
disadvantage. Yet few groups exhibited disadvantage on all of the dimensions,
and variation in risk level is even more evident in the detailed measures that
comprise each disadvantage (shown in Figures 11.1 to 11.4). Certain groups
stand out in expected ways: those 70-plus years of age have higher health
risks than those younger; those living alone and those with no living children
have much higher risks of social disadvantage than their counterparts. For
the economic dimension, the pattern is more mixed: the level of disadvantage
for certain groups tends to vary by country, and to vary considerably across
the specific measures. Those with no education comprise the one group that
displays a consistently higher risk than their counterparts on all dimensions,
with the exception of the risk of social disadvantage in Singapore. Though
their disadvantage in economic terms is not surprising, their high risk for
health and social disadvantage is a more open question (see Chapters 6 and 9
for more detailed analyses of the effect of education). Two other groups that
tend to be above average on all three dimensions are those age 70 or older and
women, though the level of excess risk for the latter group was slight in a
few instances.
A more formal way of looking at the risk level is to determine the
proportion of each sociodemographic group that reports disadvantages in at
least two of the three broad dimensions—economic, health, and social.
Individuals in each sociodemographic group were first examined to determine
whether they had at least one disadvantage within each dimension. Those
with one or more disadvantages on two or three dimensions were then identified
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492 The Well-Being of the Elderly in Asia
and their proportion of all those in the group calculated. Table 11.4 presents
these results and shows, in the last row, the proportion of all the elderly for
which this is true. The proportion of all elderly with disadvantages in two or
more dimensions was close to one half in the Philippines, Thailand, and Taiwan,
but only slightly more than one-quarter in Singapore.
Relative to the overall proportions, those living alone or those without
living children are more likely to have disadvantages on two or more dimen
sions. This can be attributed, in part, to the high percentage that will experi
ence at least a social disadvantage, given the close connection between these
characteristics and some of the measures employed. Other groups that tend
to be above average are those with no education and those age 70-plus. Rural
residents, on the other hand, are close to the overall average. Women are
somewhat more likely than all elderly to experience disadvantages in two or
more dimensions, and widowed women are more likely than widowed men.
Among the never married, separated, or divorced, women in Thailand and
Singapore are much more likely than men to experience disadvantages across
dimensions. The situation is reversed in Taiwan, arising no doubt from the
special situation of the large number of unmarried Mainlander men discussed
in Chapter 2.
As noted previously, the considerable overlaps among the sociode-
mographic groups hinders the foregoing analyses from distinguishing which
individual characteristics are most predisposed to being disadvantaged on the
indicators employed. To reduce these overlaps, the next section uses multi-
variate analyses to identify the characteristics that appear most salient.
Multivariate Results
Moving to a multivariate analysis necessitates a change in the measures of
disadvantage employed. The risk ratios used in the previous sections are
measures of each sociodemographic group's vulnerability relative to its
counterpart, and as such cannot be directly used as an individual-level dependent
variable. At the individual level, we could conduct logistic regression analyses
predicting the log-odds of having a specific disadvantage, and this would
closely approximate the risk ratio approach employed in the descriptive
analyses. However, running separate logistic regression models for each
disadvantage indicator and for each country would produce an unwieldy array
of results that would be difficult to summarize. Accordingly we adopt two
simpler measures: (1) a count of the number of specific disadvantages each
respondent reports within each broad dimension; and (2) a count of the number
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The Vulnerable and Their Potential Disadvantages 493
Table 11.4. Percent of Each Sociodemographic Group That Experiences
Disadvantages in Two or More Dimensions, by Country
* Fewer than 25 cases in sociodemographic group.
Sociodemographic
GroupAge 70+RuralNo educationLives aloneNo living childrenWomenWidowedWomenMenNever married,separated ordivorcedWomenMenAU ElderlyPercent with Disadvantages
in Two or More DimensionsPhil57.150.664.273.071.849.856.151.653.8*47.5Thai58.547.259.669.887.955.662.456.070.754.948.5Taiw56.446.856.479.292.650.360.148.947.881.045.1Sing36.0-30.054.862.231.132.524.064.341.827.9
of dimensions in which each respondent reports at least one disadvantage. As
an example of the first type of measure, a respondent who reported difficulty
in meeting expenses and low personal and household income, but did not
report any of the other economic disadvantages, would have a value of 2 on
the number of economic disadvantages. Because the indicators of disadvantage
differ in number across countries, as well as domains (e.g., Singapore has
only four indicators of economic disadvantage, whereas the other countries
each have five; Thailand has only four indicators of health disadvantage while
the other countries have six), the dependent variables used in the first set of
measures differ in terms of their ranges. However, the second measure
described above (i.e., the number of dimensions) falls in a consistent range
from 0 to 3.
Results from the mullivanalc regression models are shown in Tables
11.5-11.8. The dependent variable used in the analyses reported in Tables
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494 The Well-Being of the Elderly in Asia
11.5-11.7 is the number of disadvantages a person has within each broad
dimension—i.e., economic, health, and social disadvantages. We estimate
separate regression models for each country using the same set of indepen
dent variables (with the exception of the exclusion of rural residence for
Singapore). The dependent variable used in the analysis reported in Table 11.8
is the number of different dimensions in which a person experiences at least
one disadvantage. We examined several different functional forms for the
dependent variable in these models (including non-linear transformations, or
dinal logistic, and multinomial logistic models), and results of these various
methods did not differ in any important way from those obtained from OLS
regression models. Hence, for ease of interpretation, we present the OLS
results here. The independent variables included in the models are the charac
teristics for each of the sociodemographic groups that have been examined in
earlier tables. With respect to marital status, we distinguish three groups:
persons who are currently married; those who are widowed; and those who
are never-married, separated, or divorced. Because we are interested in ex
amining whether marital status (and particularly widowhood) affects men
and women differently with respect to economic, health, and social disad
vantages (and indeed the descriptive analysis has provided some evidence of
this), we have included interaction terms between gender and marital status
in the models. To interpret gender and marital status effects in these models,
it is thus necessary to examine the coefficients for these variables in connec
tion with one another and with the interaction coefficients.
With regard to economic disadvantage, the only factors that are sig
nificant predictors across all countries are age and education (see Table 11.5).
Other things being equal, those age 70 years or over have a higher number of
economic disadvantages than those age 60-69, as do persons who have no
formal education compared to those with some education. Widowhood is
also often associated with higher economic disadvantage; note the significant
positive coefficients for the main effect of widowhood for the Philippines,
Thailand, and Taiwan. Widowed women in Taiwan appear to be particularly
vulnerable, as indicated by the significant positive coefficient for the interac
tion effect for widowed female. Persons who are separated, divorced, or
never married are also more economically disadvantages! than their married
counterparts in Taiwan. This is also the case in the Philippines, although only
among men; for Filipino women in this category, the strong positive coeffi
cient for separated/divorced/never married is counterbalanced by the strong
negative coefficient associated with the interaction term for other unmarried
female (i.e., the "net" effect of being separated, divorced, or never married
for Filipino women is +. 11, which is obtained by adding .85 and -.74). Rural
elderly appear to be more economically disadvantaged than urban elderly in
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Table 11.5. OLS Regression Coefficients for the Effect of Socio-
demographic Characteristics on Number of Economic
Disadvantages, by Country
p<.10 *p<.05 **p<.01
p<.001
Independent VariableAge 70+ (vs. 60-69)Rural residence
(vs. urban)No education (vs. 1 +
years of education)Number of living childrenNone
1+Female (vs. male)Marital statusMarried
Widowed
Sep/divorced/
never marriedWidowed female
Other unmarried femaleLiving arrangementWith 1+ child
Alone
Spouse only
OtherInterceptR-squarePhil0.15*0.23***0.46***-0.01-0.010.27**
0.85**0.20
-0.74*0.06
0.17
0.100.59***.12Thai0.27***0.21***0.17***0.080.13**0.38***
0.16-0.06
0.190.21**
0.09*
-0.030.69***.10Taiw0.11**0.040.25***0.020.020.21**
0.33**0.28**
-0.0020.78***0.37***
0.37***0.61***.16Sing0.16***inap.0.06*0.23**0.12***-0.07+
-0.020.08
0.160.28***
0.20***
0.11 +0.29***.05
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496 The Well-Being of the Elderly in Asia
the Philippines and Thailand, but not in Taiwan. Singapore is the only country
for which being childless is associated with greater economic disadvantage,
once other factors are taken into account. Finally, in all countries except the
Philippines, living alone and living with a spouse only are both associated with
a higher number of economic disadvantages relative to living with a child.
Living in an "other" arrangement (generally with more distant relatives or
non-relatives) is also associated with greater economic disadvantages in Tai
wan and to some extent in Singapore.
Turning to health disadvantages in Table 11.6, age, gender, and educa
tion appear to be the dominant factors. In all countries, those age 70 years or
over have a significantly higher number of health disadvantages than those
60-69 years of age, other things being equal. Gender is also a significant
predictor, with women having more health disadvantages then men. Lack of
education is associated with a greater number of health disadvantage in all
countries except Thailand, although the effects of education are not very
strong in the Philippines and Singapore. Finally, two other unique and some
what surprising effects for Thailand are worth noting. Both rural residents
and those with "other" living arrangements in Thailand have fewer health
disadvantages than their respective counterparts who are living in urban areas
and with children.
With respect to the social disadvantages shown in Table 11.7, the
results mirror those in the figures, indicating that the availability of living
children and living arrangement are primary factors. As noted previously, this
is to a large extent definitional, because living children and household mem
bers are considered a part of one's social network, having no children and/or
living in small households result in smaller social networks. In addition, lack
of regular contact with children is one of the social disadvantages, and those
without children by definition cannot have contact with them. Hence, it is not
surprising that those who have no living children and those who are not living
with children report significantly higher numbers of social disadvantages in
all countries. Of perhaps greater interest is that, net of these availability fac
tors, a number of other factors show significant associations with social
disadvantage, although these effects are not always consistent across coun
tries. For example, education is a significant predictor of social disadvan
tages—those with no formal education have higher numbers of social disad
vantages than those with some education. This pattern is observed in all
countries except Singapore, for which education is unrelated to social disad
vantage. In addition, older age is associated with greater social disadvantage
in Thailand, but not in any of the other countries. On the other hand, persons
in rural areas (who are often portrayed as being left behind by their children)
have significantly fewer social disadvantages than their urban counterparts in
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Table 11.6. OLS Regression Coefficients for the Effect of Socio-
demographic Characteristics on Number of Health
Disadvantages, by Country
p<.10 *p<.05 **p<.01 ***p<.001
Independent VariableAge 70+ (vs. 60-69)Rural residence(vs. urban)No education (vs. 1+ yearsof education)Number of living childrenNone1+Female (vs. male)Marital statusMarriedWidowedSep/divorced/never marriedWidowed femaleOther unmarried femaleLiving arrangementWith 1+ childAloneSpouse onlyOtherInterceptR-squarePhil0.44***0.010.13+-0.17--0.22*—0.100.09-0.12-0.10—-0.100.03-0.140.54***.06Thai0.26***-0.07*-0.001-0.04-0.22***—0.03-0.13-0.12+-0.07—-0.07-0.07+-0.11**0.55***.04Taiw0.43***-0.020.34***-0.05~0.21***—0.040.120.05-0.42+—-0.05-0.07-0.020.42***.11Sing0.68***map.0.11*0.07-0.12*—0.04-0.080.010.07—-0.04-0.02-0.060.40***.09
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Table 11.7. OLS Regression Coefficients for the Effect of Socio-
demographic Characteristics on Number of Social
Disadvantages, by Country
p<.10 *p<.05 **p<.01 ***p<.001
Independent VariableAge 70+ (vs. 60-69)Rural residence (vs. urban)No education (vs. 1+ years
of education)Number of living childrenNone1+Female (vs. male)Marital statusMarriedWidowedSep/divorced/never marriedWidowed femaleOther unmarried femaleLiving arrangementWith 1+ childAloneSpouse only
OtherInterceptR-squarePhil0.02-0.020.06+1.14***~0.02—-0.050.31*-0.01-0.130.24***0.22***
0.32***0.14***.34Thai0.05**-0.15***0.06***1.17***--0.02—0.08*0.43***0.08*-0.21*0.40***0.10***
0.26***0.28***.30Taiw0.03-0.10***0.08***0.85***—-0.02—0.04-0.070.05-0.050.35***0.28***
0.21***0.15***.20Sing0.002inap.0.021.60***—-0.01—0.07**-0.002-0.030.14*0.40***0.13***
0.26***0.07***.57
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The Vulnerable and Their Potential Disadvantages 499
both Thailand and Taiwan. Widowhood is also associated with greater social
disadvantage in Thailand and Singapore, and widowed women in Thailand
appear particularly disadvantages! in this respect (note the significant positive
coefficients for both all widowed and widowed female). Finally, Filipinos,
Thais (particularly Thai men), and Singaporean women who are separated,
divorced, or never married are also at greater risk of social disadvantage than
their married counterparts.
Table 11.8 presents results for regressions predicting the number of
different dimensions of disadvantage. In all countries, persons who are older
(age 70-plus), uneducated, childless, and living alone experience disadvan
tages in more dimensions than their respective counterparts. In addition, those
living with only a spouse or in "other" arrangements have disadvantages in
more dimensions than those living with a child in all countries except Thai
land. Given the interaction terms between sex and marital status in the model,
the main effect of sex (female) can be interpreted as the average difference
between married women and married men in the number of dimensions of
disadvantage. In this regard we see that married women experience disad
vantages in more dimensions than married men in all countries except the
Philippines. Widowed persons in Thailand and possibly Taiwan are also at
higher risk of experiencing multiple dimensions of disadvantage, as are sepa
rated, divorced, or never married men in the Philippines, Thailand, and Tai
wan and separated, divorced, or never married women in Singapore.
Although not presented here, we also examined ethnic differences in
Taiwan and Singapore, the two countries for which such differentials are
most pronounced. As expected, we found lower economic disadvantage and
higher social disadvantage among Mainlanders in Taiwan. For Singapore,
Malays showed greater economic and health disadvantages than the majority
Chinese; Indians exhibited more disadvantages on all dimensions, but social
disadvantage was the only outcome for which the effects were statistically
significant. The inclusion of ethnicity in the models for Taiwan and Singapore
did not modify results for other factors in any significant way.
Summary of Disadvantages Faced
by the Sociodemographic Groups
Given the amount of detail presented in the previous sections, it is useful to
take stock of the main findings before considering the policy and program
implications. It should be recalled that the sociodemographic groups exam
ined were selected based on our knowledge of the aging process and our
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500 The Well-Being of the Elderly in Asia
Table 11.8. O LS Regression Coefficients for the Effect of Sociodemograph ic
Characteristics on Number of Different Dimensions Disadvan-
taged, by Country
p<.10 *p<.05 **p<.01 ***p<.001
Independent VariableAge 70+ (vs. 60-69)Rural residence (vs. urban)No education (vs. 1+ years of
education)Number of living childrenNone
1+Female (vs. male)Marital statusMarried
Widowed
Sep/divorced/never marriedWidowed female
Other unmarried femaleLiving arrangement
With 1+ child
Alone
Spouse only
OtherInterceptR-squarePhilippines0.22***0.13*0.30***0.30+0.030.05
0.53*0.12-0.340.30*
0.21*
0.15*1.03***.11Thailand0.25***-0.08**0.12***0.61***0.20***0.29***
0.23*-0.06
-0.100.19**
0.04
0.021.19***.13Taiwan0.24***-0.030.31***0.45***0.12**0.13+
0.28*0.11
-0.230.55***0.33***
0.26***0.94***.18Singapore0.35***Inap.0.08**0.71***0.10*0.05
-0.120.02
0.32*0.43***0.22***
0.26***0.64***.12
understanding of the sociocultural and economic trends within the region—
both of which suggest that these groups are more vulnerable to deleterious
economic, health, or social outcomes. We would therefore expect to see
these groups dis advantaged on one or more indicators within each dimen
sion.
Table 11.9 summarizes findings by presenting a bird's-eye view of the
multiple regressions, wherein an asterisk denotes that a significant disadvantage
was observed for that group for the specified domain of disadvantage, and a
question mark denotes that the significance was borderline. The advantage of
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The Vulnerable and Their Potential Disadvantages 501
focusing on the multiple regressions is that they indicate which of the
characteristics, net of the others, are associated with higher risks of
experiencing a disadvantage.
Table 11.9 indicates that indeed each of the groups examined does
experience a significant disadvantage in at least one country on one or more
dimensions, but the groups differ considerably in the frequency with which
they encounter a disadvantage, and in the type of disadvantage experienced.
Those age 70 years or over are disadvantaged on the health dimension relative
to those age 60-69 in every country, as might have been expected; but, they
are also consistently disadvantaged on the economic dimension as well. The
most surprising result perhaps centers on the rural elderly in the three rel
evant countries. Despite considerable concern often expressed about the iso
lated rural elderly in the face of heavy urban migration of the young, they
show no disadvantage on the social dimension (even displaying an advantage
in Thailand and Taiwan, as shown in Table 11.7), nor on health, and show a
disadvantage on the economic dimension only in the Philippines and Thailand.
All the foregoing analyses point to the above average risks experienced by
those who had no formal education relative to their educated counterparts.
This shows up in Table 11.9 as a significant disadvantage on each domain in
nearly every country, and in the likelihood of multiple disadvantages. As ex
pected, those living alone or without living children display a consistent social
disadvantage within each country, but only those living alone tend to experi
ence a consistent economic disadvantage. Neither trait, net of other factors,
is associated with above average health risks.
Women as a group most often experience a disadvantage in the realm
of health, joining those 70 years and older and those with no education as the
only groups with above average risks on this dimension. They also are likely
to experience an economic disadvantage in Thailand and Singapore. Among
the marital statuses singled out, widowhood is most often associated with an
economic disadvantage, while for those who have never been married or are
separated or divorced, both economic and social disadvantages show up se
lectively across the countries. In both cases, the disadvantages are likely to
affect the men as well as the women in these statuses.
Despite the strong effects observed for many of the sociodemographic
characteristics in the regression models it is important to note that, together,
the groups and characteristics represented in the models capture only a small
amount of the variance across all the elderly. This can be seen by examining
the R2 measure of amount of variance explained in the bottom row of Tables
11.5-11.8. This is particularly true for the health dimension, for which the
amount of variance explained ranges from 4 percent for Thailand to 11 per
cent for Taiwan, and for the economic dimension as well, for which the
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The Vulnerable and Their Potential Disadvantages 503
explained variance ranges between 5 and 16 percent. For the social disadvan
tages, a much higher percentage of the variance is explained, suggesting that
for these measures the significant sociodemographic groups do capture much
of the problem; however, the limited number of indicators for this dimension
and the special definitional issues need to be kept in mind. Nevertheless, it is
clear that for economic, health, and social disadvantages as defined here,
vulnerability is a much more complex phenomenon than often thought. Al
though they do differentiate those at higher risk for certain disadvantages, the
characteristics often used to identify groups that are most vulnerable in old
age tell only a small part of the story.
Another implication of Table 11.9 is that, although there are a few
variations in patterns across countries, by and large the likelihood of a socio
demographic group experiencing an above average risk on each dimension is
quite similar from country. This suggests that these heightened risks reflect
either underlying bio-demographic factors (like older age on health) or com
mon socioeconomic dynamics across countries (like the persistent disadvan
tage of those with no education). These patterns and the dynamics that give
rise to them must be considered in advancing policies and programs that will
address the heightened risks.
Policy and Programmatic Implications
This overview of the above average levels of disadvantage faced by certain
sociodemographic groups in each country raises the question of the extent to
which programs and policies address these shortfalls. Chapter 3 presented a
description of both the broader retirement and health insurance programs in
operation and the more specific programs established to address the health,
social, and economic problems often faced by the elderly. We saw that al
though all countries view the family as the first line of defense in providing
assistance and support, each has established a number of programs that as
sist the elderly in a variety of ways. Several of these programs address the
disadvantages reviewed in this chapter, such as community centers to pro
mote social contact or special income supplements to assist the poor elderly.
As the countries seek to enhance and strengthen these programs they
will need to evaluate how well each program is accomplishing its goals.
Program evaluation is a complex and subtle task involving a host of measures
including the effectiveness of the program in reaching its target group, the
impact of the program on that group, and the relationship of cost to benefits.
In many cases such evaluations have not yet been undertaken and no systematic
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504 The Well-Being of the Elderly in Asia
data have been gathered on program performance. One element of program
evaluation that can be assisted by information from surveys is the degree to
which potential recipients of assistance are aware of the program and the
level of utilization and satisfaction they report. Each of the surveys conducted
in 1995 and 1996 contained some questions designed to tap respondent
knowledge about available programs. It should be emphasized that these results
represent only a minor component of a comprehensive evaluation. Low
awareness of a program, for example, may signify a new program that is not
yet widely available or a program that is not salient for many respondents
(such as knowledge of day care centers for those without limitations). In
some circumstances, however, low awareness may signify to administrators
that programs are not properly distributed across the target population or that
the programs are not adequately promoted to the relevant public, and thus
guide program enhancement. Table 11.10 presents a broad oveniew of the
programs included in each country's questionnaire organized according to
the four categories of programs (other than pensions and health insurance)
established in Chapter 3: those providing free or subsidized medical services;
those focusing on residential and long-term care needs; those providing senices
to enhance daily life; and those providing economic assistance.
Because each country used the surveys to address knowledge and in
some cases utilization of the programs of special interest to them, and be
cause program structures vary by country, direct comparisons among coun
tries are problematic. It should also be noted that in Singapore the surveys
were directed not to elderly respondents but to those who were identified as
the principal caregiver of the respondent if such a person existed (only 5
percent of cases identified a principal caregiver).
As Table 11.10 indicates, in the Philippines the questions center around
knowledge of the program to designate and register those elderly eligible for
several services (described in Chapter 3). About 61 percent of respondents at
the time of the survey were aware of this program and about half of those
had registered. Among the eligible elderly, about one-fifth had made use of the
free medical and dental sen ices and two-fifths had taken advantage of dis
counts on medicines. In terms of services designed to enhance daily life, over
half of the respondents had availed themselves of discounts on transporta
tion, lodging, and related services, but they made only light use of discounts
for entertainment and cultural admissions and the waiver of training fees.
Slightly more than one-fifth of the eligible elderly did use the provision for tax
exemption. Without additional data one does not know how many eligible did
not have a tax obligation and thus found this provision unnecessary and how
many simply did not avail themselves of this benefit. This distinction also
applies to some of the other provisions. Also, some of the 51 percent of the
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The Vulnerable and Their Potential Disadvantages 505
elderly Filipinos who were aware of the program but elected not to register
for it are likely to have been ineligible for services. This information is needed
to appraise the adequacy of the outreach efforts. In Chapter 10, the aware
ness and use of medical care services are examined further, and sharp differ
entials suggest that additional outreach is needed for those who are less edu
cated and those who live in rural areas.
In Thailand emphasis on program knowledge was devoted to knowl
edge and use of the government's program of free medical services, as well
as use of the household health card (see Chapter 3). A large proportion (84
percent) of elderly reported knowing of the free health services in 1995—a
few years after program initiation—and almost half reported having used it.
These results provide encouraging evidence that the program is reaching its
target audience. (An update of the program is given by Kamnuansilpa et al .
2000, and more details from the survey are reported in Chapter 10.) The data
in Chapter 10 show higher awareness and utilization of the program in rural
areas and also higher utilization by the less educated than in urban areas or the
more educated. About 72 percent of the elderly reported the existence of an
elderly social group or club in their village or community, but only 19 percent
reported belonging to such an organization. In terms of economic assistance,
only about one-third knew of the availability of a special allowance to the
poor elderly, and only 5 percent of these reported receiving benefits. In ap
praising such data, one must also determine the proportion of all elderly who
might be eligible, and that information is not available from the survey.
The Taiwan survey asked respondents whether they knew about a
fairly long list of types of "elderly welfare services," many of which encom
passed several specific program activities. For those who reported knowl
edge, they were asked if they did not need the service, needed it but have not
used it, have used it, or "other" responses. Table 11.10 reports on the percent
who knew of selected programs, and among those knowing, the percent
using them. An exception is that for persons who were aware of residential
and long-term care facilities, those reporting a need as well as some use are
shown. Of the 63 percent of respondents who reported awareness, almost
three-quarters reported need or use (mostly need rather than actual experi
ence). Almost half reported knowledge of the special medical care programs,
but only 13 percent of these reported use. In terms of respondents' knowl
edge of programs designed to enhance daily life, almost two-fifths were aware
of day care programs, over half were aware of educational programs, and
more than 90 percent were aware of discount tickets for entertainment and
transportation. Utilization for these groups is quite modest, however, repre
senting 14, 24, and 32 percent of those knowledgeable, respectively. Almost
all the elderly were aware of special pension or income assistance programs,
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508 The Well-Being of the Elderly in Asia
but only about one-third report receiving any of these benefits. (For addi
tional discussion of the special pensions made available in some cities and
counties of Taiwan, see Chapters 6 and 8.)
As noted, in Singapore questions on knowledge and use were asked
only of primary caregivers for the small percentage of elderly (around 5
percent) who reported having a caregiver. Table 11.10 shows the proportion
of principal caregivers that reported awareness of different types of services.
The results suggest considerable variation in awareness across programs.
Somewhat surprisingly given the nature of this population, awareness of spe
cial medical services like home nursing services or home medical care is
fairly modest; knowledge of old age or nursing homes is high, but knowledge
of respite care (providing short-term stays for elderly so caregivers can gain
a period of respite) was reported by only 14 percent of caregivers. Knowl
edge of programs to enhance daily life also varies in Singapore, with 70
percent aware of senior clubs but relatively small proportions aware of ser
vices appearing more relevant to the elderly in question. Given the small num
bers involved, we do not report the figures on percent utilizing these senices
individually in Table 11.10. Utilization was below 5 percent for many of the
programs listed and none exceeded 10 percent.
Though the data in Table 11.10 must be \iewed as a preliminary over
view of levels of awareness and utilization of select programs addressing the
older population in the four study countries, they can serve as the initial
building blocks for more thorough evaluations. Careful evidence-based stud
ies of programs, which following the medical model are becoming more
widespread in the social sector (Calkins, 1999; Sheldon and Chivers, 2000),
are needed to inform policy makers about the programs most in need and the
most effective way of providing these services. Evaluation research can be
useful at many phases of program development, from targeting client groups,
assessing needs, obtaining client feedback, ascertaining accessibility and bar
riers to use, and improving efficiency and cost-effectiveness. And they can
be employed at the national, community, and organizational levels. Given the
projected rapid growth in the number of older persons and the competition
for limited resources with other societal goals, one can expect that evaluation
research will come to be an increasingly important component in the develop
ment and operation of programs addressing the needs of the elderly.
Conclusions
This chapter combines an analysis of the well-being of select sociodemographic
groups along three broad dimensions with an overview of their knowledge
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The Vulnerable and Their Potential Disadvantages 509
and use of several programs intended to address shortfalls in family and
individual provisions and in broader social welfare programs. The strategy
for the first part was to select potentially vulnerable groups and measure their
relative risk of disadvantage using indicators of unfavorable economic, health,
and social circumstances. A major finding from this analysis is the variation
that exists across the groups, with some evidencing higher relative disadvantage
on only a few indicators and others facing problems across the board. Among
the former, rural residents appear to be better off in terms of the health and
social dimensions than is often expected. At the other end, those who have no
formal education tend to be disadvantaged on all dimensions and in all countries.
Women as a group display higher than average health risks within each country
and higher economic disadvantages in two of the countries. Men and women
who are widowed, never married, separated, or divorced also frequently display
above average risks on several dimensions. Another important finding is that
while many of the groups analyzed have above average risks on one or more
measures, collectively they account for only a small proportion of the variance
in the disadvantages examined here, with the exception of the social
disadvantages.
The objective of the second part of the analysis was to examine older
persons' knowledge and utilization of several programs intended to address
these disadvantages. In Chapter 3 we described an array of policies and pro
grams in the areas of special medical services, long-term care, and assistance
with problems of daily living and economic hardships. Many of these inter
sect with the measures of disadvantage analyzed here, such as special subsi
dies to low-income elderly or community centers and activities to enhance
social life. It is worth stressing, however, that there is no one-to-one corre
spondence between the programs reviewed and the disadvantages examined.
This is particularly true in the area of health: the disadvantages examined in
this chapter have centered on the presence of diseases and limitations, while
the relevant programs speak mainly to special services to those with existing
problems, rather than prevention. Programs that might lessen the prevalence
and severity of health conditions are often oriented toward younger adults,
encouraging preventive practices for diseases with clear etiologies. It should
also be noted that the disadvantages analyzed here are quite selective and do
not address the full gamut of potential needs. This is particularly true in the
realm of psychological and emotional well-being, where concerns such as
feelings of independence, accomplishment, and involvement with family and
community affairs are not covered.
Nevertheless, it is encouraging to note that, despite having philoso
phies that look to the family as the major provider of services and support of
elders, all these countries have been developing programs intended to assist
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510 The Well-Being of the Elderly in Asia
older people and their caregivers in handling problems that tend to emerge late
in life. Collectively, these programs reflect responsiveness to a wide range of
needs and willingness to innovate and experiment in the provision of services.
As these programs become established, it is important that appropriate
evaluations guide improvements in effectiveness and cost-efficiency. Pro
gram evaluation is often a complex, multi-faceted task, as described above,
but several elements have been touched on in this chapter. One is the clear
identification of the primary target groups and careful assessment of their
needs. The sociodemographic groups analyzed here are often thought to be
vulnerable, and assessing the level and nature of their disadvantages, as illus
trated here, is a key step. Some groups will need many services, while others
may derive greater benefit from a more focused program. Opportunities also
exist to experiment with special programs that might address multiple needs
for specific groups, like an income-generating home-based program for
women, especially those relatively isolated. Such a program might not only
ameliorate economic disadvantages, but might also be a mechanism for in
creasing social contact and distributing special health services. Of course,
most programs will be community based, as many of those not in a particular
vulnerable group will also require assistance. Another element of program
evaluation is assessing the awareness and use of programs, and satisfaction
with services, among potential and actual users. Surveys among the general
older population as well as special subgroups—like users—can be of signifi
cant assistance in this aspect of evaluation.
Policymakers in the countries under study and others that have under
gone rapid socioeconomic change in recent decades will also face the task of
adjusting their policies and programs to the changing characteristics of the
future elderly. The gains in education and the movement to more urbanized
and industrial societies mean that future elderly will be more knowledgeable
on average, have experienced higher standards of living, and have different
expectations and orientations than the current elderly. In spite of these advan
tages, however, smaller family sizes and higher rates of singlehood and di
vorce are likely to undermine traditional sources of social support. These
trends challenge policymakers to adapt current programs and develop inno
vative new programs to address changing needs.
REFERENCES
Calkins, Evan. 1999. New Ways to Care for Older People: Building Systems Based
on Evidence. New York: Springer Publishing.
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The Vulnerable and Their Potential Disadvantages 511
Hermalin, Albert 1.1995. "Aging in Asia: Setting the Research Foundation." Asia-
Pacific Research Reports, No. 4, East-West Center, Program on Population.
Kamnuansila, Peerasit, Supawatanokorn Wongthanavasu, John Bryant, and Aree
Prohmmo. 2000. "An Assessment of the Thai Government's Health Services
for the Aged." Asia-Pacific Population Journal 15(1):3-18.
Rudkin, Laura. 1993. "Gender Differences in Economic Well-Being among the
Elderly of Java." Demography 30(2):209-226.
Sheldon, Brian, and Rupatharshini Chilvers. 2000. Evidence-Based Social Care: A
Study of Prospects and Problems. Dorset, U.K.: Russell House Publishing.
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516 The Well-Being of the Elderly in Asia
Appendix 11.B. Derivation of Relative Risks for Sociodemographic
Groups and Related Measures
A. As stated in the text, the relative risk for a given sociodemographic group is the
proportion disadvantaged in that group relative to the proportion disadvantaged
among those not in the group. This is equivalent to the ratio of the odds of being
in a specified sociodemographic group among all those with a given disadvan
tage, to the odds of being in that group among the total population. The notation
and algebra below formalize these relationships.
In S-D Group Not in S-D Group Total
Number in Each Group V O T
Proportion Disadvantaged kr I
Number Disadvantaged krV lO krV+rO
Percent of Disadvantaged in S-D Group s =
Percent of Total Population in S-D Group p =
krV kV
krV + rO kV + O
V + O " T
Relative Pusk as Defined — = k
r
V V_
This is equivalent to the ratio of the odds of being in S-D Group among All Disad
vantaged to the odds of being in the S-D Group among Total Population
Odds of being in S-D Group among Disadvantaged:
~rO~-O
Odds of being in S-D Group for Total Population:
(2) Odds = V/T _ V_ O _ _V
0/T ~ T T ~ O
Odds Ratio: y
(3)Odds = Ql=0_ = [
(2) V/O
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The Vulnerable and Their Potential Disadvantages 517
B. Percent of Sociodemographic Group Who Experience a Given Disadvantage
Using the notation above, the percentage of a specified sociodemographic group
who experience a particular disadvantage is:
*•-*
This proportion can be derived from knowing k (the relative risk), the propor
tion of the population in the sociodemographic group, and the percent of the
total population disadvantaged, as follows:
V
% of population in S-D group = p = —
O
% of population not in S-D group = (1-p) = —
% of total population disadvantaged krV + rO = krp + r( 1 - p) = D
Then: r(kp + l-p) = D
r[p(k-l) + l] = D
D
r = —
K = -™
which is a function of p (the percentage of the population in the S-D group),
D (the percentage of the total population who is disadvantaged), and k (the
relative risk).
C. Percent of All with a Particular Disadvantage Who Are in a Given Sociodemo
graphic Group
krV Te P
krV + rO V 01" I
Y+?1T p+(1-p)k
which is a function of the relative risk and the proportion in a given sociode
mographic group.
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518 The Well-Being of the Elderly in Asia
D. Numerical Illustrations
The interrelationships among the measures defined above may be illustrated with
the data presented in Table 2.
For the Philippines, the sociodemographic group of those who are illiterate or
without formal education, given in row I, is 19.38 percent of all elderly. The
first column indicates that 23.06 percent of all elderly have the disadvantage
of inadequate income. The relative risk factor of inadequate income for those
without education is 1 .77, as shown in the table entry. This means that they
are 77 percent more likely to have inadequate income than those with education.
In terms of the notation developed above:
k = 1.77
p = proportion of population in S-D group = .1938
1 -p = proportion not in S-D group = .8062
D = proportion of total population disadvantaged = .2306
Then according to B above, the proportion of those without education that
have inadequate income is:
kD 1.77(.23Q6) _ .408 _
p(k-l) + l ~ .1938(1.77-1) + ! ~ 1.149 ". .
From C above, we can also derive the percent of all those with inadequate
income who have no education. This is given by:
. __ P __ = _ .1938 _ = :
Conversely, if s and p are known, then from A:
j_ .298
k__UL_^702_
_p_ ~ .1938 ~ -
1-p .8062
.
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Chapter 12
CAPTURING CHANGE: TRANSITIONS AT OLDER AGES
AND COHORT SUCCESSION
Albert I. Hermalin
In the opening chapter of this volume we positioned this work as a study
in social change, namely, an examination of the effects of rapid sociode-
mographic transformations on the well-being of the current older population.
In keeping with this focus, the previous chapters have looked at measures of
economic status, health, work and leisure, and key institutions like living and
support arrangements, and analyzed how these levels vary across demo
graphic and socioeconomic characteristics of the current older population.
The degree of change in overall levels of well-being and the key institutional
supports was assessed by contrasting current levels with those observed for
earlier dates. These comparisons were hindered by the lack of detailed earlier
studies and one goal of the current research is to provide fully documented
benchmarks so that future comprehensive and representative surveys of the
type utilized here will generate the trend data that trace the evolution of the
role of the elderly along with the transformations of their societies.
It is also important for scholars and policymakers to anticipate potential
major changes by carrying out appropriate analyses of current information.
The differentials in the various dimensions of well-being by sociodemographic
characteristics also speak to the question of change, albeit more indirectly. If
the elderly with characteristics likely to become more frequent in the future—
519
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520 The Well-Being of the Elderly in Asia
like higher education—behave differently than others, this can be taken as a
harbinger of the direction of change in the future older population. These
characteristics represent selected inherited and acquired traits of individuals
as well as aspects of their familial arrangements. Insofar as these
characteristics account for the observed level of variation in specific
dimensions of well-being, the degree of their influence, when combined with
the relative frequency of the trait in the population over time, can help account
for the observed trends in well-being and most importantly, provide a
mechanism for looking ahead to the changes that may take place in the future.
In demographic terms we are describing a form of cohort projection in which
estimates of the future size and age composition of the population are combined
with estimates of the "rates" in question (e.g., the rate of childbearing at each
age) to form the overall population estimate (in this case, the future fertility
level). We illustrate the applicability of this strategy and its limitations, to
issues of population aging below.
Another type of change that must be considered in studying popula
tion aging is the transitions that occur over the later life course. Older people
are not static in terms of many key characteristics, needs, and preferences.
We associate aging with certain key transitions like the movement from good
health to lower level of functioning, from work to retirement, and perhaps
from independent living to coresidence with children or other arrangements.
Understanding when these transitions are likely to occur, and how they differ
by sociodemographic characteristic are important inputs to sound policy for
mation and to scientific understanding of the aging process. For example, if
we contrast 75-80 year old respondents with those 65-70, how much of the
difference on dimensions of well-being arises from events occurring as the
older group aged and how much results from their differences as a cohort
when they were 10 years younger?
To adequately measure the key transitions experienced by older people
and the factors associated with these changes generally requires well-designed
panel studies in which representative samples are carefully reinterviewed over
time since it is doubtful that the detailed longitudinal data needed can be obtained
reliably through a single retrospective interview. Many of the cutting edge
studies in the United States, like the Health and Retirement Study (.luster and
Su/nian. 1995) or the Longitudinal Study of Aging (Kovar et al., 1992), rely
on panel designs, a number of new panels are getting underway in Europe,
and there are several examples in the developing world as well (see Andrews
and Hermalin, 2000).
Panel data also appear essential for addressing a host of fundamental
cause and effect questions concerning the elderly. The dimensions of
economics, health, and level of activity, which we have been analyzing, are
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Capturing Change 521
intricately interrelated, along with some of their major determinants, such as
living arrangements and intergenerational support. Does coresidence with
children promote physical and emotional health or does poor health lead to
coresidence? Does poor health lead to earlier retirement, or does withdrawal
from the labor force prove deleterious to health? How do savings and assets
influence retirement and what is the effect of retirement on assets? These and
a number of other fundamental questions are almost impossible to sort out
adequately from cross-sectional data without heroic assumptions.
As noted in Chapter 1 and elsewhere, the surveys utilized in this study
are in the main cross-sectional in nature. Only in Taiwan was a panel design
implemented from the outset, with periodic follow-ups and the incorporation
of new cohorts over time as the original sample aged. In Singapore, the 1995
respondents were followed up to the extent possible in 1999, and in the Phil
ippines steps are underway to follow up the 1996 respondents in select re
gions. These additional data were generally not available to incorporate fully
into this volume though select findings from the Taiwan data were incorpo
rated at several points. We do however report briefly below on several recent
analyses that highlight the importance of these longitudinal data and the in
sights they can provide in understanding the dynamics of population aging.
This chapter follows the themes outlined above. First we combine the
differentials in well-being observed by sociodemographic characteristic with
available knowledge of how future cohorts of elderly will differ from their
contemporaries to draw inferences about the opportunities and challenges
these changes will pose for policy and program development. After that, the
emphasis shifts to intracohort change and the insights this provides by pre
senting several examples of transitions that occur over the later life course
and a discussion of their implications.
Cohort Succession and Its Implications for Population Aging
One source of societal change is the difference among successive birth co
horts in their size and characteristics. Differences in size, reflecting changes
in fertility, are of course at the root of changing age structure and thus speak
to the very definition of population aging. Chapter 2, in providing current data
and projections of the number and proportions of the people at older ages in
the future, discussed some of the implications that arise from the dynamics
of size. The data there point to a very rapid increase in the size of the older
population and a particularly sharp increase in the numbers at the oldest ages.
For East and Southeast Asia combined, there will be 340 million more people
aged 60 and older in 2030 than 1995, and 48 million more aged 80 and older
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522 The Well-Being of the Elderly in Asia
over the same period with the proportion aged 60 and older growing from 9
to 21 percent of the population (Table 2.2). The changing numbers and pro
portions elderly pose a challenge to policymakers in terms of social welfare
policy, the size and nature of the health infrastructure, as well as many other
fronts.
It is also possible to look ahead to see how the future elderly may
differ on other characteristics from the current elderly and reflect on the
possible effect of these differences on key societal institutions and their im
plications for policies and programs. It is clear from our stress on the rapid
social, economic, and demographic changes that have occurred in Asia over
the last 30-40 years that future cohorts of elderly will be quite different on
many characteristics from today's elderly. In general they will be more ur
ban, better educated, working at more skilled occupations, but with fewer
children. Future older women in particular are more likely to have non-agri
cultural labor force experience and more education than their current coun
terparts. In a number of countries the future elderly will have a higher per
centage of divorced and never married individuals. Though these broad trends
are clear, the amount of change can be more precisely demonstrated for
characteristics that became fixed in early to middle adulthood, since it then is
possible to project forward the composition of the future elderly on these
characteristics (Hermalin and Christenson, 1992).
Table 12.1, for example, shows the projected number of children that
will have been born to women 60 and older in Taiwan between 1980 and
2020. The top portion illustrates the basic cohort analysis, carrying forward
the average number of children born to each five-year birth cohort of women
as they age. The bottom portion gives the average number of children by
broader age groups at each calendar point, obtained by combining the five-
year averages according to the number of women reported or projected at
each point.
Even this simple illustration provides some interesting trends. Women
in the 60-69 age group started to show a decrease of about half a child every
five years starting in 1980, and will end up with 2.5 children ever bor n (and a
slightly smaller number still living) in 2020. By contrast, women 70 and over,
did not start to show significant declines in their completed fertility until the
year 2000, and will end up with an average of about 3.5 children ever born in
2020. These differences are, of course, a reflection of the past fertility expe
rienced by these cohorts, and we are in effect tracing the implications of past
behaviors and events into later years. These simple projections can help iden
tify which groups of older people may face diminished familial support be
cause they have few adult children to depend upon and when this will occur.
As such it is a valuable planning tool for governments and other institutions.
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524 The Well-Being of the Elderly in Asia
A characteristic that is relatively fixed by early adulthood and which
can be very revealing for planning and assessing social change is education.
Figures 12.1 and 12.2 present the percentage of adult males and females
respectively, with at least a secondary education, by birth cohorts (i.e., the
five-year period in which they were born), for five Asian countries—South
Korea, Philippines, Singapore, Taiwan, and Thailand. Among the current elderly
who were born mainly before 1935, the percentage achieving a secondary
education was quite low, especially among females. This level of education
will increase among the later born cohorts who will become the elderly in the
coming decades. South Korea and Taiwan in particular show rapid progress
in making secondary schooling available; the gains in the Philippines and
Singapore have been more modest, and Thailand has lagged behind in this
respect. Given the importance of education for health status and behaviors,
resources, expectations and attitudes, the changing educational profile of the
future elderly must be given due weight in anticipating the speed of change
and social welfare demands.
These educational profiles can also be used to suggest some of the
social and economic cleavages facing the elderly. As example, we can calcu
late the probability of a difference in the level of schooling in an encounter
between an older and younger individual drawn randomly from their respec
tive cohorts. For the distribution of male secondary schooling for Taiwan
(shown in Figure 12.1) this exercise is presented in Table 12.2 for a randomly
selected pair in which the older male is 65-69 and the younger is 40-44, for
select years between 1980 and 2000. This age pair was selected to roughly
simulate the educational level of the son of the elder male, or the educational
level of a younger worker vis a vis an older worker.
As shown, in 1980 the most frequent outcome of the four possibili
ties, comprising 70 percent of the cases, is that neither the older or younger
male has a secondary education. This proportion declines over time, and by
the year 2000, the most frequent outcome, in 42 percent of the cases, is that
only the younger male has a secondary education.
Although family interactions are not random encounters, this simple
simulation suggests that insofar as educational status differences (with their
implied differences in attitudes, outlooks, and resources) are a source of inter-
generational tensions, we can expect these to increase over the next several
decades (see Hermalin and Christenson, 1992, for additional discussion).
Several things follow from these examples:
1. The characteristics of today's elderly and their needs and preferences
while certainly meriting attention from policymakers and program man
agers, may be a poor guide to optimum arrangements for the future as
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Capturing Change 527
Table 122. Projected Outcomes of the Likelihood of Completing Senior High
School in Randomly Selected Pairs of Older and Younger Taiwanese
Males, 1980-2000
Source: Hermalin and Christenson, 1992
Completed Senior High SchoolOlder male only (age 65-69)
Younger male only (age 40-44)
NeitherBothTotal19800.103
0.170
0.7020.0251.00019850.126
0.226
0.6010.0471.00019900.128
0.296
0.5010.0761.00019950.115
0.357
0.4330.0951.00020000.085
0.423
0.4040.0891.000
successive cohorts with very different characteristics come along (also
see Rowland, 1994 and Hugo, 1996).
2. The sharp cleavages across cohorts evident in many countries because
of rapid socioeconomic development are in themselves a prime contribu
tor to some of the generational tensions and the emerging intergenera-
tional accommodations.
3. For countries that have experienced relatively rapid socioeconomic de
velopment over the last 20-30 years one might expect the differentials
across generations on key statuses, like education, to diminish by the
middle of the next century and hence the degree of social change arising
from this source may slow down. Of course other factors and events
will continue to impinge on the elderly and society at large (exemplified
by the current economic crisis in Asia) and these may have implications
for intergenerational relations.
A major characteristic fixed early in life with important consequences
for the status of the elderly is gender. Here of course we have a trait that does
not differ much across birth cohorts but which changes substantially in com
position as cohorts age, due to differential mortality by sex (including at times
major war losses) and in places, migration. As a consequence, the older popu
lation is predominantly female, and the degree of feminization advances rap
idly with age. As of 2000, the United Nations estimates that about two-thirds
of the oldest-old—those aged 80 or more—were females in contrast to about
55 percent for those 60 or older (United Nations, 1999, p. 11). For Europe,
both figures are even higher, roughly 70 and 60 percent, respectively, and in
Asia, they are slightly lower.
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528 The Well-Being of the Elderly in Asia
The implication of this pattern for the well-being of the older women
depends on many factors. In many parts of the developing world at present,
older unmarried women are "vulnerable" in a number of respects, with few
economic resources of their own and largely dependent on children and other
family members for financial and emotional support and assistance in the
case of illness or limited functioning.
Future patterns of mortality at older ages are difficult to predict, and
trends in differential mortality add another layer of complexity, but current
projections assume either a continued gender differential in life expectancies
or some widening. It is worth noting, however, that these projections may be
unduly conservative with respect to many developing countries. Insofar as
we see a steady increase in the education of women (as suggested by the
figures just presented) relative to men, the strong association between educa
tion and survival suggests a possible further widening of mortality differen
tials and therefore, as Martin (1999) has noted, a heightened feminization of
the elderly in the future. At the same time overall declines in mortality at older
ages will decrease the proportion of women widowed.
The well-being of these future cohorts of women (and men) will de
pend on many characteristics, including several critical ones that are not
fixed relatively early in life. Marriage patterns are under rapid change in many
parts of Asia, with both women and men marrying at later ages; and rising
proportions of women of reproductive age still unmarried. [Whether these
changes reflect a postponement of marriage or increases in proportions of
women never marrying is under some debate (see Raymo, 1998, for an analysis
of Japan).] In addition, in some countries divorce rates are rising and are no
longer negligible. These changes in patterns of family formation and dissolu
tion, if sustained and magnified, can have substantial effects on the sources
and amounts of intergenerational flows of assistance and hence on the needs
of future cohorts of the elderly, as well as on rates of fertility and the pace of
population aging.
Another change occurring in parts of Asia, not unconnected to the
changes in marriage, is the level of women's labor force participation. In
some Asian countries, like Japan and Thailand, women have been quite active
in the labor force for 30 years or more, while in others, like Singapore and
Taiwan, it was common until recently for women to stop working upon
marriage. Table 12.3 shows the levels of labor force participation rates for
women aged 45-49 for years around 1970, 1980, and 1990 for select Asian
countries. By 1990, from 36 percent to 81 percent of women at this middle
adult age were in the labor force and these proportions overlap with the range
found in several OECD countries, pointing to greater variation within regions
than across regions on this dimension.
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530 The Well-Being of the Elderly in Asia
These trends have several overlapping economic and social implications.
described below.
• Improvements in education and increased labor force participation should
improve both women's current economic well-being and their economic se
curity in old age, through accumulation of assets and coverage in available
pension or social security programs.
• At the same time, because women tend to be the primary caregivers for
aging parents, and to have disproportionate responsibility for minor children
and household tasks, increased labor force participation will place more de
mands on women's time. Whether the strains of trying to simultaneously
fulfill the roles of mother, worker, and elderly caregiver will hasten changes
in current support and family arrangements needs to be carefully monitored.
[Raymo and Cornman, 1999; Ogawa and Retherford, 1997; Tsuya and
Bumpass, 1998.]
• Insofar as evolving marriage and divorce patterns lead to sizable num
bers of unmarried and/or childless elderly, this may further undermine reli
ance on traditional forms of intergenerational assistance, and create pressure
for new social arrangements and programs that can effectively replace fam
ily-based support.
Another dimension under rapid change in Asia with implications for
the well-being of the older population is the level of urbanization. Future
levels of urbanization depend on relative birth and death rates in urban and
rural areas as well as the movements that take place across these areas, so
precise projections are difficult. Nevertheless taking into account past trends
and underlying dynamics the United Nations (2001, Table 14) projects that
Asia as a whole will advance from 37 percent of its population urban in 2000
to 53 percent in 2030. This rapid rate of urbanization will also occur for the
older population but at a somewhat slower rate.
Hugo (1996) sees several deleterious consequences from these trends.
Given the selective out-migration of the young from rural areas and a ten
dency for urban to rural return migration as older people retire, older people
in the future, who will have on the average fewer children, are more likely to
be at a substantial physical distance from their children, limiting the children's
ability to provide day-to-day care if needed. In addition, he notes that the
increasing formalization of urban economies may make it difficult for the
elderly with poor skills to compete for jobs; that the pressures on housing
may make it less possible for them to live with their children; and, that the
increased labor force participation of women outside the home may limit their
ability to provide care to elderly.
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Capturing Change 531
Countering these potential negative effects, some commentators have
noted that in some Asian countries the elderly in rural areas have well-devel
oped social organizations for exchanging support among friends and neigh
bors, and that the high cost of housing in cities may promote coresidence
with children. It may also be easier and economically efficient for programs
to provide advanced health care and recreational facilities in urban environ
ments, where there are sufficient numbers of elderly to justify the
infrastructural costs.
In our previous analyses urban-rural differentials were noticeable on
several dimensions of well-being. These include:
Living Arrangements: Rural elderly are more likely to live alone or with a
spouse only than urban counterparts.
Labor Force Participation: Urban elderly retire at an earlier age than rural
elderly.
Economic Status: Rural elderly are more likely than urban to be in the bottom
tier of the income distribution but more likely to own their homes.
Health Status: Rural elderly more often display poor health behavior, such as
smoking, alcohol consumption and betelnut chewing, than the urban elderly.
They report poorer self-assessed health but less often report life-threatening
conditions. The latter may be due to poorer access to healthcare and/or
lower utilization. Average health status based on several indicators did not
show a disadvantage for the rural older population.
Healthcare Utilization: Differentials in utilization between the urban and rural
elderly varied considerably across countries and in terms of specific ser
vices considered.
These findings and the discussion above suggest that, although con
tinued rapid urbanization over most of Asia is expected in the coming years,
the implication of this trend for the overall well-being of the elderly is not
obvious. There are reasons to expect additional strains on the elderly on some
dimensions, but there are also potential gains to their health and well-being as
they and their children become more urbanized.
It is possible to combine the relationships observed in the previous
chapters with the projected and expected changes in the composition of the
future older population in terms of key demographic and socioeconomic
characteristics to paint at least a partial picture of the changes that may occur
in levels of well-being and familial support patterns. And some of the previous
discussion drew on this potential. But this strategy must be employed with
caution, and mechanically derived forecasts of this type can also be misleading.
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532 The Well-Being of the Elderly in Asia
It requires the strong assumption that the differentials and effects of the
sociodemographic characteristics will persist into the future. As example,
while we found a strong gradient with education on income and health, and in
some of the countries, on the propensity to coreside independently of children,
inferring how a more generally educated older population will behave in 2020
or 2030 is difficult. Although the more educated can be expected to be in
better health than the less educated, so that there might be some improvement
in overall health, the future highly educated elderly are also likely to demand
more sophisticated health care services, and, as already observed, to be greater
consumers of preventive health services so that the overall pressures on the
health infrastructure will continue to be high (leaving aside pressures arising
from numbers and age distribution, as mentioned earlier). In addition, the
needs and make-up of those with a specific sociodemographic characteristic
may change considerably. As illustration, among the current older populations
those with little education are the modal group given the limited educational
opportunities when they were young. In the future, those with little education
will be much less prominent and those who failed to obtain sufficient education
while opportunities were opening up, are likely to be quite different in many
ways from today's elderly with little education, suggesting a very different
profile in terms of health, income, family relationships and other key outcomes.
Reading the future is also perilous because social change can also
arise from broad shifts in norms, value, and behaviors that cut across groups
We have, for example, pointed to the major changes in marriage patterns
ongoing in a number of countries, which are leading to postponements and
perhaps avoidance of marriage by many young adults. This is a sharp break
from previous patterns and it is tempting to project this pattern into the future
in thinking about the well-being of the elderly, without spouses or children.
But the relative recency of the new marriage patterns also cautions that fur
ther changes in these social arrangements may emerge in the coming years
and that predicting institutional trends must be done cautiously. In the next
chapter we take an explicit look at some key attitudes and the degree of
intergenerational cleavage that exists.
Transitions over the Later Life Course
The previous section stressed the social change that can arise from the
succession of cohorts and the differences among them in size, key
socioeconomic traits, and possibly in their behaviors and attitudes. It is also
important to give attention to the changes that occur throughout the life cycle
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Capturing Change 533
as members of a single cohort age, and from the standpoint of population
aging, to examine closely the transitions that occur over the later life course.
Knowledge of the transitions that occur on key dimensions of well-being is
important both for understanding the factors precipitating these changes and
for fashioning policies and programs that deal adequately with the timing and
nature of these transitions.
As noted above, this knowledge is best obtained through panel studies
that reinterview a sample of respondents at regular intervals. Such data are as
yet not widely available in Asia, but this design is receiving increasing atten
tion and a number of countries have initiated such studies (Andrews and
Hermalin, 2000). Among our four countries, the Taiwan study has
reinterviewed their 1989 respondents in 1993, 1995 (abbreviated interview),
1996, and 1999; Singapore has reinterviewed the 1995 respondents in 1999;
and reinterviews are underway for select regions of the Philippines. The key
transitions of substantive and policy interest are those involving changes in
living arrangements, economic statuses (including support arrangements),
physical and mental health, and labor force participation.
Some discussion of transitions has been presented for Taiwan for the
retirement process in Chapter 7 and for changes in economic status and
support arrangements in Chapters 6 and 8. In this section we focus on changes
in living arrangements and health over the later life course and revisit certain
aspects of economic changes.
Table 12.4, adapted from Frankenberg et al. (forthcoming), presents
the transition rates for changes in living arrangements for Taiwan (from 1996
to 1999), Singapore (from 1995 to 1999), and for comparison, Indonesia
(from 1993 to 1997). The overall distributions in terms of whether they coreside
with a child or not are shown, along with the transition rates from one ar
rangement to another for those in each category at the earlier date. In each
country a very high percentage of the elderly (in this case those 55 or older)
are residing with a married or unmarried child at wave 1, as observed in
Chapter 5. Over the three to four year follow-up, the overall percentage chang
ing status is similar across all three countries, ranging from 13 percent to 17
percent. Also similar are the transition rates within each category of resi
dence. Of those living with a child at wave 1, only 13 to 16 percent do not
coreside with a child at wave 2. By contrast, of those not coresiding at wave
1, 19 to 22 percent change to coresident status at wave 2. It is interesting to
note that despite the greater tendency for older people to change in the direc
tion of coresidence, the overall proportion coresiding with a child at wave 2
decreases in each country. This comes about because of the very high pro
portion who are already coresiding, so that even a small rate of change out of
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534 The Well-Being of the Elderly in Asia
Table 12.4. Transitions in Living Arrangements over Three- to
Four-Year Periods for Those 55 Years and Older at
Baseline: Indonesia, Singapore, and Taiwan
Indonesia, 1993-1997n=1683Coreside with ChildDoes Not CoresideTotalSingapore, 1995-1999n=1827Coreside with ChildDoes Not CoresideTotalTaiwan, 1996-1999n=3648Coreside with ChildDoes Not CoresideTotalWave 1
% Dist. of
Coresidence752510089111007624100Transition
Rate to New
Status.13.19.15.13.20.13.16.22.17Wave 2
% Dist. of
Coresidence663410080201006633100
Note: Table includes only respondents with at least one living child at baseline.
this category reduces the observed overall levels of coresidence. It is impor
tant for policymakers and other observers of coresidence trends to keep this
dynamic in mind and not interpret declines in coresidence trends as necessar
ily evidence of rapid abandonment of this form of living arrangements.'
The analysis of transitions by Frankenberg et al. (forthcoming) also
examines the factors associated with persistence and change in living ar
rangements. Although the factors vary somewhat across country and by type
of transition, an important finding is that the characteristics of the children in
terms of age, whether or not in school, and whether or not working, are quite
influential in determining the baseline arrangements and subsequent changes,
and need to be considered along with the characteristics of the elderly.
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Capturing Change 535
Tracing transitions in health is particularly important to understand the
factors associated with the onset of chronic illness and loss of functioning,
and the progressions that take place for those with some disability. As dis
cussed in Chapters 4 and 9, a fundamental issue in population aging is whether
increases in life expectancy will be accompanied with increases in disability
at older ages. If so, such changes are likely to put great pressure on health
systems in terms of costs and needed personnel and facilities. Although some
earlier studies in the United States pointed in this direction (Colvez and
Blanche!, 1981; Verbrugge, 1984) a series of more recent studies utilizing
different sources have shown declines in both the prevalence and incidence
of disability in the 1980s and 1990s (Freedman and Martin, 1998; Manton et
al., 1997; Manton and Gu, 2001). The evidence utilizes analyses of declining
rates among successive cohorts at advanced ages, but also the changes that
occur as people age, demonstrating that there can be movement in and out of
states of disability over short periods of time.
Similar studies outside the United States are limited and are especially
rare in developing countries. The panel data in Taiwan, however, allow analy
sis of changes in prevalence and on the transition levels in and out of states of
disability. We utilize the analysis by Zimmer and Lin (2000) to illustrate these
possibilities. Table 12.5 shows the changes that occurred by 1996 for the
respondents first interviewed in 1989 in term of the level of their functional
limitations, based on what tasks they can perform and the difficulty encoun
tered in performing them. The table shows that there is substantial movement
in and out of states of functional limitation; 35 percent of those with mild
limitations in 1989 reported no difficulties in 1996. Though the likelihood of
becoming free of difficulties declined sharply for those starting with more
severe levels of limitation, the proportions experiencing some improvement
were still notable: over a fifth of those starting with moderate or severe limi
tations reported some degree of improved functioning in 1996. At the same
time, the strong relationship between the level of functioning at outset and the
probability of dying in the follow-up period should be noted. Data of this
type, coupled with knowledge of the characteristics of the respondents and
the reasons for the limitations experienced, can prove very helpful in fashion
ing programs for prevention and treatment.
A final example of the added insights that can arise from panel data
focuses on a measure of economic well-being. Chapter 8 presented an ex
ample of shifts in sources of support and reports of income adequacy for the
Taiwan respondents between 1989 and 1996. In Table 12.6 we show the
degree of change in an individual's (or couple's) monthly income over a four-
year period for Singapore (1995-1999) and Taiwan (1989-1993). Overall the
data suggest considerable movement in income levels over time.
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Table 12.6. Gross and Net Changes in Income Levels over Four-Year
Periods in Singapore and Taiwan
Panel A: Level and Change in Income: Singapore, 1995-1999
Chi-square=539.04 (df=8), p< 0.001.
"Figures are given in Singapore dollars. S$100= NTS1,857 = US$57.
Panel B: Level and Change in Income: Taiwan, 1989-1993
Chi-square=571.05 (df=12), p< 0.001.
Monthly individual
income in 1995"<$500$500-999$1,000-1,499$1,500-1,999$2,000+TotalChange in IncomeDecrease--37.348.057.550.720.1Same62.835.621.421.349.348.4Increase37.127.230.621.3-31.5Total100.0100.0100.0100.0100.0100.0Income Level199552.030.511.02.64.0100.0199946.927.613.25.46.9100.0
Monthly income
of R and spouse
in 1989b< $3,000$3,000-4,999$5,000-9,999$10,000-14,999$15,000-19,999$20,000-49,999$50,000+TotalChange in IncomeDecrease...29.134.646.151.247.162.535.0Same49.924.930.820.315.646.737.532.4Increase50.146.034.633.633.16.3—32.6Total100.0100.0100.0100.0100.0100.0100.0100.0Income Level198916.412.222.318.411.416.82.5100.0199321.314.021.713.610.016.82.7100.0
Figures are given in Taiwanese new dollars (NT$). NT$100= SS5.39 = US$3.09.
Source: Chan et al., forthcoming.
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538 The Well-Being of the Elderly in Asia
For Singapore, shown in Panel A, elderly with the lowest income lev
els at baseline are most likely to remain at that income level. Specifically, of
those reporting monthly incomes of less than SS500 in 1995, 63 percent
reported the same income level in 1999 and 37 percent reported an increase in
income level. Of those elderly who reported monthly incomes above SS2000,
51 percent reported a decrease in income level by 1999. Individuals earning
between S$ 1000-1499 experienced a great deal of change over time. Be
tween 1995 and 1999, 48 percent of them experienced a decrease in income
levels, 21 percent reported the same income level, and 31 percent experi
enced an increase in income level. Focusing on the last two columns, we see
the net result of these changes in terms of aggregate income distributions
which point to a modest upward shift in incomes. The two distributions
however are rather similar, as reflected in an Index of Dissimilarity of only
8.O.2
For Taiwan in Panel B, the proportions experiencing a decline, in
crease and no change in income were about equally split. The larger number
of income categories in Taiwan display a strong association between level of
income at baseline and direction of change. The lower the income reported in
1989, the more likely that respondents would report a gain in one or more
categories in 1993, and conversely, the higher the category in 1989, the more
likely that there would be a decrease in 1993. Overall, the number declining
was somewhat larger than those increasing, so that the aggregate distribu
tions shown in the last two columns show somewhat greater concentration
in the lower income categories in 1993, but the Index of Dissimilarity be
tween the distributions is only 6.9.2
Considerable income mobility over short periods of time has also been
observed in the United States and Netherlands, for those 50-60 years of age
(Burkhauser et al., 1999). The likelihood that many individual older people
and households will face substantial shifts in income over time, despite stabil
ity in the overall income distribution, should alert policymakers that programs
for short-term financial assistance may be needed, particularly if support
from the family or other sources may not be forthcoming. At the same time it
should be kept in mind that these short-term fluctuations may not presage
fundamental economic or program deficiencies and that more major alter
ations may not be necessary.
Panel data that can trace responses are a valuable tool for policymakers
in determining the effectiveness of new or substantially altered programs and
in identifying reasons for their success or failure. Chapter 6 described the
situation in Taiwan where a new farmers' pension program (and other special
pension initiatives in some areas) had some effect on the proportion of the
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Capturing Change 539
elderly who relied on children as their primary source of support. Although
repeated cross-sectional surveys can capture the overall or net effect of a
program initiative, panel data, by focusing on the same individual as they
encounter and respond to the program, can elucidate more clearly the factors
associated with program involvement and its effects on the individuals and
their families. This information can prove valuable not only for assessing the
effectiveness of a program but for identifying possible changes needed to
enhance effectiveness. This type of data will become increasingly important
as countries introduce or modify social security, health, and community pro
grams, as described in Chapter 3.
Conclusions
This chapter has illustrated how various types of change can be captured or
anticipated and the importance for policymakers of paying special attention to
these dynamic aspects of population aging. Change occurs as different co
horts of varying size and characteristics succeed each other, and it occurs
within cohorts as individuals undergo important transitions in their behaviors
and conditions. Change also arises from broad transformations in institutions
and in norms and values. Some changes can be better anticipated than others,
and the implications of some changes are easier to discern than others. But a
careful program to anticipate the most likely changes and to monitor change
at regular intervals can pay big dividends to policymakers who wish to fash
ion effective programs and to adjust policies that are losing effectiveness.
These suggestions are pursued in more detail in our concluding chapter.
ENDNOTES
1. From a mathematical standpoint one can calculate the "tipping point" at
which continued differentials of the type shown between the tendency to move
into and out of coresidence would start to lead to an increase in the observed
overall rates of coresidence (Hermalin and Ofstedal, 2001).
2. The Index of Dissimilarity is a measure of the difference between two
distributions. It ranges in value between 0 (for two identical distributions) to 100
(for two distributions that have no overlapping values in any category). It is
defined as one half the sum of the absolute differences in percentages in each
category of the two distributions.
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540 The Well-Being of the Elderly in Asia
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Tsuya, Noriko O., and Larry Bumpass. 1998. "Time Allocation between Employment
and Housework in Japan, South Korea, and the United States." In Karen
Oppenheim, Noriko O. Tsuya, and Minja Kim Choe, eds., The Changing Family
in Comparative Perspective: Asia and the United States, 83-104. Honolulu,
HI: East-West Center.
United Nations. 1999. World Population Prospects: The 1998 Revision. Volume
II: The Sex and Age Distribution of the World Population. New York: United
Nations.
United Nations. 2001. World Urbanization Prospects: The 1999 Revision. New
York: United Nations.
Verbrugge, Lois M. 1984. "Longer Life but Worsening Health? Trends in Health
and Mortality of Middle-Aged and Older Persons." Milbank Memorial Fund
Quarterly/Health and Society 62 :475-519.
Zimmer, Zachary, and Hui-Sheng Lin. 2000. "Changes in Prevalence and Transition
Rates of Functioning Difficulties, and Limitation Severity, Among Older Adults
in Taiwan: 1989 to 1996." Comparative Study of the Elderly in Asia Research
Report No. 00-57, Population Studies Center, University of Michigan,
September 2000.
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Chapter 13
MAKING THE CHOICES: POLICIES AND RESEARCH
FOR THE COMING YEARS
Albert I Hermalin
One of the major goals for this volume, set out in Chapter 1, was to
discern the policy and program challenges that emerged from the
trends and interrelationships observed in the course of our analyses. As noted
at the outset, officials in Asia have been prescient in sensing the potentially
major effects of population aging and much of the research in the region has
been prompted by this awareness. More generally, the worldwide phenom
enon of population aging has generated a number of policy-oriented forums
and reports, focusing either on specific issues like health or retirement pro
grams, or tackling a wider spectrum of possible consequences. Recently the
World Bank (1994), OECD (1998), Marmor and De Jong (1998), United Na
tions (1999), United Nations (2000), Mason et al. (2001) have examined this
area.
Our own attempt to identify major policy issues, while informed by
these sources, will be drawn largely from the framework set out earlier in this
volume and by the findings from our analyses, and will be more constrained
than these specialized studies. To this end, this concluding chapter summa
rizes the major findings and the conclusions that flow from our framework
and analyses; identifies major areas of uncertainty facing policymakers, cen
tering on future family dynamics and economic growth; reviews the broader
strategies available to policymakers; and discusses the research needed to
assist policy and program development and to reduce areas of uncertainty.
543
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544 The Well-Being of the Elderly in Asia
Major Findings and Their Implications
This section highlights the major findings of the previous chapters, with spe
cial emphasis on the level of well-being on each dimension, changes over
time where these are available, and the factors associated with the differential
outcomes. As illustrated in Chapter 12, the differential effects of the
sociodemographic characteristics, combined with knowledge of trends in the
distribution of these characteristics, allow researchers and policymakers to
anticipate some of the changes that will occur to future cohorts of older people.
As each of the prior analytic chapters contains a fairly detailed summary, this
overview will be selective, painting a broad picture, utilizing references to
the more detailed tables, and emphasizing those aspects with major relevance
for policy and future research.
Demographic Trends
The demographic, socioeconomic and policy background provided in Chap
ters 2 and 3 have several important implications. Most directly, the demo
graphic projections of the rate and nature of population aging facing East and
Southeast Asia, and the four focal countries, indicate that there will be rapid
increases in the numbers and proportions at older ages, particularly among
the oldest-old (those aged 80 or over). In East and Southeast Asia combined,
those 60 or older will be almost three times larger in 2030 than 1995, and
those 80 or older will be almost four times larger over the same span (Table
2.2). The magnitude of these changes will place great strain on general health
and community facilities serving the elderly and will necessitate particularly
rapid expansion in personnel and services dealing with chronic diseases and
the needs of those at advanced ages. The demographic changes will also re
quire close attention to assessing how well the retirement and health care
programs now available to the large working age population will perform as
this generation retires in the coming years. Chapter 3 is partially reassuring
on this count in demonstrating that the countries under study have been initi
ating and modifying their basic social welfare programs for some time, with
major modifications still underway in some countries. At the same time, sig
nificant gaps in coverage and implementation remain in a number of instances
and these will require continued efforts. Additional discussion of these im
portant policy levers is taken up in the final section of this chapter.
Chapter 2 also demonstrates that there are important trends in depen
dency ratios underway that have implications for future policy. In East Asia,
the total dependency ratio (the ratio of those under age 15 and 65 or over to
those aged 15-64) declined substantially between 1960-65 and 1990-95 but
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Policies and Research for the Coming Years 545
will remain rather level over the next 35 years; in Southeast Asia the decline
between 1960-65 and 1990-95 was modest, but sharper declines are projected
over the next 35 years (Table 2.3). Table 2.4 shows that among the four focal
countries, the total dependency ratio is projected to continue to decline in the
Philippines until 2020, but it will start to increase in the other three countries
between 2000 and 2030. In the eyes of a number of observers these trends can
have important effects on savings and economic growth (as discussed in Chap
ter 4, and further below) and thus on the willingness and ability of govern
ments to support programs and policies oriented to the elderly.
Living Arrangements and Exchanges
Turning to the empirical results from the surveys, we begin by looking at two
key institutional arrangements in Asia that are thought to be critical in deter
mining the well-being of the elderly—the degree to which older people coreside
with children, and the extent to which they are supported by children. As
developed in Chapter 4, the conceptual framework we employ views these
two institutional settings as intermediate factors in determining elderly well-
being and not as ends in themselves. Indeed, as noted at several points below,
they can be misleading guides to how well the older population is faring, and
of the changes underway in these societies.
With regard to living arrangements, described in Chapter 5, there is
currently a high level of coresidence but some indications of decline over
time in Taiwan and perhaps Thailand. Across the four countries, the percent
cores id ing with a child ranges from a low of 69 percent in Taiwan to 85 percent
in Singapore (Table 5.1). These percentages coresiding are not simply a
function of economic development; the high percentage in Singapore, the
most advanced country economically, suggests that other factors such as
population density, cost and availability of housing and land are important.
When one uses an expanded definition of coresidence, the proportions closely
involved with children go up even higher. Adding in those who live nearby a
child or who see a child at least weekly, the proportions range from 91 percent
in Taiwan to 96 percent in Singapore (Table 5.7). However, when one
distinguishes whether the elderly are living with a married or unmarried child,
the figures are quite different. The proportion living with a married child ranges
from about two-fifths in Taiwan and Singapore to one-half in the Philippines
and Thailand (Table 5.2). Many older parents are living with unmarried
children, which raises questions about the direction of support, insofar as
parents may be more likely to provide financial support and other assistance
in such cases. This may have important implications for the future as young
adults continue to delay marriage and childbearing.
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546 The Well-Being of the Elderly in Asia
The differentials in living arrangements across sociodemographic
groups are quite complex and differ across countries. Among the key
relationships: for those not currently married (the widowed, separated and
divorced and never married), the proportion living alone is higher in rural
areas than in urban areas, and the proportion living alone is particularly high
among those who never married. Among those currently married, the
proportion living with a spouse only is higher in rural areas than urban areas.
The effect of education on living arrangements differs across countries. These
and related patterns suggest that there may be substantial shifts in living
arrangements as children reach adulthood and leave the parental home, and
that the relative resources of parents and children can strongly influence the
patterns of coresidence. As noted in Chapter 12, fully understanding these
dynamics requires observing older respondents as they age, and obtaining
sufficient information about the characteristics of both parents and children.
The complex patterns observed across countries on living arrangements, and
several other dimensions, suggest that there is not a single Asian pattern and
that differences across cultures and by level of economic development must
be taken into account in anticipating future changes.
From a policy standpoint, the current level of coresidence of the elderly
with their adult children provides some reassurance that precipitous changes
in living arrangements are not underway so that major new programs need not
be hurried. At the same time, the trends observed in Japan and Korea, and to
some extent in Taiwan, indicate that these current arrangements can shift
quickly. A number of the factors associated with levels of coresidence (like
income, and number of children) are changing in ways that may promote less
coresidence with married children. The higher level of coresidence with
children in urban areas points to the importance of housing availability and
prices, and suggests that careful attention to housing policy and incentives
can prove influential in affecting residence outcomes. At the same time, as
stressed at several points, policymakers would do well to move beyond
focusing on the presence of children to ascertain the direction and magnitude
of the exchanges of material and emotional support that is ongoing between
parents and children.
As shown in Chapter 6, older people are engaged in a wide variety of
exchanges with children and other kin, but primarily with their children.
Though a high proportion receives frequent visits from children, and money
and material items, they also do a good deal for their children in the same
manner. Older parents see their non-coresident children frequently, the pro
portion with weekly visits ranging from about three- fifths to three-quarters
(Table 6.1). This speaks to a high degree of emotional support. At the same
time, older parents are frequently performing services for their children and
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Policies and Research for the Coming Years 547
grandchildren, by providing childcare or by taking on major responsibility for
one or more household chores like shopping, cooking, or cleaning. A high
proportion of the older respondents received money (over the last six months
or year) from others (mostly children), and everywhere but Taiwan a high
proportion also received material items-such as food and clothing (Table 6.3).
The proportions receiving such support are as high or higher than similar data
from the mid-1980s for the Philippines and Thailand, and at about the same
level for Singapore and Taiwan. Except in Taiwan and Singapore, a high per
centage of older people were also providing funds or material items to their
children or other family members (Table 6.5).
The foregoing data capture only a part of the complex exchange and
transfer system in which older people in Asia are engaged. For example, in
trying to ascertain the economic well-being of the elderly by looking at their
income and assets, Chapter 8 also ascertained the degree to which they were
receiving indirect support forms of support—that is, either they were living
with children or others without paying a share or a fair share (as best as we
can determine) of the expenses, or living alone or as a couple and having
others pay some or all of the household expenses, like rent. Using these mea
sures the proportion receiving indirect support ranged from about 50 percent
in the Philippines and Taiwan to 60 percent in Thailand, to 85 percent in
Singapore (Table 8.7A). Another way to get a picture of resource allocation
for older individuals (or couples) who live with others is to ask about the
number of income recipients in the household and the way that household
expenses are met. This varied across countries. Among older Filipinos who
live with others, the older individual or couple is the sole income recipient 33
percent of the time, quite strong evidence that the older people are supporting
the others in the household, at least to some extent. This percentage ranges
from only 7 to 14 percent in the other three countries (Table 8.8B). In the
Philippines, even when there are other income recipients, the older respon
dents report pooling their income for meeting expenses over 40 percent of the
time—again showing a high degree of involvement. In Taiwan, by contrast,
the contribution of the older person or couple depends very much on their
status. If there is an older couple living with others, the elderly pay most of
the expenses about half of the time; but if it is an unmarried elderly person
(with income) living with others with income, the others pay most of the
expenses in 80 percent of the cases (Table 8.8C).
These data suggest that Asian families have worked out a variety of
financial and exchange arrangements, and the emotional bonds that sustain
them, in response to the rapidly shifting demographic and socioeconomic
conditions they have been living through. The qualitative data collected by
the project through focus group discussions and other means clearly reflect
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548 The Well-Being of the Elderly in Asia
that there is general awareness of rapid social change which has impacted on
family dynamics in a number of ways. We take up this broader theme in more
detail below but the following quotes from Williams et al. (1999) illustrate
not only awareness that relationships and the nature of exchanges have
changed, but also a desire to adjust to new circumstances:
Older Singaporean Woman:
Yes. The old parent [sic] are stranded. Sometimes their
[needs] are also not taken care of. The [younger generation]
are thinking about themselves only. In the morning go to
work and in the evening come back home. They don't bother
to know whether their elders have eaten or not. [It's] worse
if they have their own children, we the old people become
their target. We gave them all our love when they were young,
but when they grow up they oppose us.
Older Taiwanese Woman:
It is really difficult to be a mother-in-law these days. There
is a lot of difference between the education we received un
der the Japanese, and the education we have now in Taiwan.
Then, there is the generation before us that did not receive
any education at all. So all three generations are different,
which makes it hard to communicate. We have to respect
our elders, and we have to respect our children.
Adult Age Child, Singapore:
Whenever I have a (major) decision to make, I will consult
them (parents) first. If I want to buy something (important) I
would ask them, whether the thing is good or not. If they say
don't, then I don't get it. If in their opinion it is good, then I
will buy it.
Older Taiwanese Man:
It's not good to retain decision-making power. The young
people should also have it. The old people have the right to
make suggestions to them, because old folks have experi
ence. But it's not so good for them to have decision-making
power . . . Old folks' plans and thinking are a matter of the
past.
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Policies and Research for the Coming Years 549
Economic Well-Being
In addition to shedding light on the income and expense pooling arrange
ments within families, Chapter 8 demonstrates quite clearly the need to go
beyond simple measures of living arrangements or provision of support in
order to gauge the economic well-being of the older population. Table 8.5
which shows the percent of elderly respondents or couples in the lowest tier
of the income distribution, demonstrates that in each of the four countries, the
elderly living with married children have the highest proportion in the lowest
tier of income. Furthermore, those whose major source of income is from
children or other relatives have the highest proportion in the lowest tier, com
pared to those who have support from other sources (with one exception in
Singapore).
These findings suggest the complex dynamics that may be at play. For
a substantial number of older people, living with married children will be
prompted by insufficient income (as well as by other problems like poor health).
Likewise, insufficient income after retirement or at other times may be the
precipitating factor in children providing money to their parents. From a policy
standpoint, these findings should alert policymakers not to assume that all is
well just because older people are coresiding with and/or receiving financial
support from children. It is important to go beyond these broad indicators to
actually examine their economic well-being, taking into account the com
plexities entailed, as noted in our previous examples and as further expanded
below.
Table 8.5 also demonstrates that there is a very strong gradient of in
come with education and with self-reported health status, with the proportion
in the lowest income tier declining sharply with higher levels of education or
health status. Since education tends to be established early in life, its rel
evance to income can be taken as a cause, and multivariate analyses (not
shown here) confirm its strong effect on income position in later life. The
relation of health to income is more complex and we know that low income
can be an important contributor to poor health. The relationship is likely to
shift with age and for the older respondents in our study, the relation of work
to health (see Chapter 7) and other evidence suggest that poor health is con
tributing to low income, though more research is needed to understand this
interelationship.
A final point on the economic dimension is the need to be alert to the
differences that can result from the use of different indicators of economic
well-being. In our study we used a variety of measures including objective
measures of income and assets, as well as some subjective measures of well-
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550 The Well-Being of the Elderly in Asia
being. The objective and subjective measures tell a very different story. For
example, whereas Singapore has the highest GDP per capita, the actual aver
age (mean) dollar income of the elderly is almost twice as high in Taiwan.
Consequently, the ratio of average income to GDP per capita is much higher
in Taiwan than Singapore (Tables 8.2A, 8.2B). In addition, the Philippines
and Thailand have almost the same level of average dollar income per indi
vidual or couple among their older citizens, but the ratio of income to GDP
per capita is much higher in the Philippines than in Thailand (Table 8.2B).
At first glance, this evidence suggests that older people in Singapore
are not well off economically, and more generally that there is no simple
relationship between level of economic development and relative economic
well-being among these Asian countries. But the picture that emerges when
taking subjective measures of well-being into account is quite different. In
three of the countries (Philippines, Taiwan and Singapore) respondents were
asked the degree to which their income was sufficient to meet their expenses
and the results show that over 60 percent of the older people in the Philip
pines said they had some or considerable difficulty compared to 26 percent in
Taiwan and only 10 percent in Singapore (Table 8.9A). Thailand did not use
this measure but asked respondents about satisfaction with their current eco
nomic situation, as did Taiwan. In Taiwan 17 percent said they were not satis
fied, not very different from the 26 percent who said they had some or consid
erable difficulty. This compares with 29 percent in Thailand who said they
were not satisfied (Table 8.9C).
The ranking of the countries in terms of economic well-being from the
subjective data is very different than the ranking suggested by the objective
data. The subjective data point to the older residents of Singapore enjoying
the highest level of economic well-being and those in the Philippines the low
est, with the elderly in Taiwan and Thailand occupying intermediate posi
tions. The difference between the two rankings appears due to indirect forms
of support and patterns of household allocation, as discussed above. Judging
by other evidence, the subjective data may better capture the actual differen
tials across countries than the seemingly direct income measures. These find
ings caution researchers and policymakers to utilize a variety of measures in
making assessments of the economic well-being of the elderly and in fashion
ing programs, to insure that they are accurately capturing the full array of
economic interrelationships currently operating within their countries.
Health Status and Health Care Utilization
There is general awareness that health is a multidimensional construct and
that it is possible to measure different facets of this construct, such as subjective
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Policies and Research for the Coming Years 551
assessments of overall health, the presence of specific symptoms, the degree
of difficulty in executing the activities of daily living (ADLs), or the
instrumental activities of daily living (lADLs). In the four country study we
used a number of these measures and as Chapter 9 indicates, they tend to
point in the same direction in terms of level of well-being and cross-country
differences. We present the overall appraisal first, before highlighting a few
methodological cautions.
Despite the common impression of widespread illness and disability
among the older population in developing countries, our findings suggest that
the elderly in the four study countries are faring quite well. The prevalence of
reported life-threatening conditions is quite low, although part of this may be
due to lack of diagnosis for older persons who for various reasons do not seek
or receive treatment. On the other hand, about three-fifths of the elderly have
one or more debilitating conditions. However, it appears that these conditions
do not interfere with daily life activities. Indeed, the vast majority of elderly
report no ADL difficulties, ranging from 83 percent in Thailand to 94 percent
in Singapore (Tables 9.3a, 9.3b, 9.5).
The elderly appear to be doing well with respect to emotional health,
as well. The average number of depressive symptoms experienced by elderly
Filipinos and Taiwanese is quite low (2.4 of 7 symptoms in the Philippines
and 2.0 of 10 in Taiwan) and the percent reporting strong feelings of loneli
ness in Thailand is extremely low (6 percent) (Table 9.6). (As Ingersoll-Day-
ton et al. (2001) caution, however, from their work among Thai elderly, psy
chological well-being is a multi-dimensional concept that cannot be captured
in a single question.) Finally, in terms of self-assessed health, the elderly view
their health in quite positive terms. A relatively small proportion in each country
reported fair or poor ratings of their health (ranging from 9 percent in Taiwan
to 17 percent in Singapore), with the remainder rating their health as good to
excellent (Table 9.9).
Beyond this broad assessment, there were some puzzles and intriguing
findings that have implications for policy and future research. The percentage
who report having or having experienced a life threatening condition—which
includes cancer, heart disease, stroke, and diabetes—was much lower in the
Philippines and Thailand, with the lowest levels of per capita income, than in
Taiwan, and about the same level as Singapore. Within countries, a distinct
age gradient appeared only in Taiwan. Most surprisingly, prevalence rates
appeared higher in urban areas and among the more educated (Table 9.3A).
We believe that these patterns reflect mostly differences in access to health
and medical facilities and hence differences in the level of diagnoses and an
individual's knowledge of his or her condition. (In the case of urban-rural
differences, part of the differential may be due to selective migration, in which
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552 The Well-Being of the Elderly in Asia
older rural people who develop illnesses move to the city to obtain help from
children and better medical treatment.) From a policy viewpoint these find
ings suggest the need to improve access to those who are less well served
under current health care systems. From a methodological perspective, they
point to cautions in the types of questions that should be employed in assess
ing the health of the elderly, particularly in societies with high levels of in
equality to health care access.
Confirmation of this latter point is provided by looking at the preva
lence of one or more debilitating conditions, defined as experiencing stom
ach problems, arthritis, cataracts, incontinence, and vision problems. These
are conditions that older people are likely to be aware of whether or not they
have been to a health facility. The results are quite different. The Philippines
and Thailand (marginally) showed somewhat higher rates than Taiwan; there
was a clear gradient with age and little difference between urban and rural
levels; and those with low education showed higher rates than those with
more education (Table 9.3b). It is also worth noting that older women re
ported higher rates of debilitating conditions than men (as they did somewhat
for the life threatening conditions) -a pattern that has emerged in other stud
ies. In absolute terms, three-fifths to two-thirds of the older respondents re
ported one or more debilitating conditions. Despite this high prevalence, only
a relatively small proportion of the older respondents reported difficulty in
performing one or more ADLs, as noted above, and only a small percentage
assessed their over-all health status as poor.
Although this is a generally favorable picture, there are a number of
challenges ahead for policies and programs. The apparent inequality in ac
cess has been noted; attention also needs to be given to the high percentage
with one or more debilitating conditions. In addition, the current older popu
lation of these countries is still quite young in the sense that there are rela
tively small numbers and proportions over 80. As noted above, this will change
markedly in the coming years, with large increases in the number of elderly
and in the numbers who are at advanced ages. This will present a challenge to
health systems both to expand their over all capacity and to develop the ex
pertise and resources to address the special needs of the elderly.
Chapter 10 provides relevant input by analyzing the patterns of health
care utilization across countries, the potentially high demand for services, the
receptivity of the older population to preventive health programs, and the
differentials in utilization arising from costs and health program provisions.
The results reveal that need factors (as against prediposing or enabling fac
tors) are the prime determinant of preventive, outpatient, and inpatient health
senice utilization in the four countries. In addition, the analysis points to a
proclivity to seek outpatient treatment from Western rather than traditional
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Policies and Research for the Coming Years 553
providers, pointing to high future demand for this type of service in the four
countries. Further evidence of increasing demand was the receptivity to pre
ventive-type services and the higher use of such senices among the more
educated. The four countries studied have very different forms of health cov
erage for the elderly at present (see Chapter 3) and this paves the way for
important cross-national comparisons as well as important longitudinal stud
ies as these countries modify their programs over time. It is revealing that in
Taiwan, where enrollment in the Universal Health Insurance Program is nearly
universal among the elderly, only 4 percent reported unmet need for medical
services (with reasons centering on distance to facility, lack of transportation,
etc.) while in the Philippines, where health care coverage is much more lim
ited, 24 percent indicated unmet need for services, with costs cited as the
predominant reason. The host of challenges posed by population aging to
public health systems and health service financing has started to receive spe
cial treatment, as shown in the overview by Hickey et al. (1997).
Work, Retirement, and Leisure
When we ask about the well being of the elderly in terms of work and leisure
there is a somewhat different conceptual issue than for economics or health.
With the latter two dimensions, more income or assets or better health clearly
point to higher levels of well-being. In the realm of work and leisure we must
also consider older individuals' preferences. Do those working prefer to stop?
How many not working would prefer to work at an appropriate job? These
and related questions about work and leisure were pursued in Chapter 7.
Labor force participation rates at ages 60 or older in the four countries
show two rather distinct profiles. The Philippines and Thailand have some
what higher rates for men and much higher rates for women than Singapore
and Taiwan (Table 7.2). In the latter two countries substantial involvement of
married women in the labor force is a relatively recent phenomenon. Trends
over time from censuses and surveys indicate very little tendency toward ear
lier retirement, which is contrary to the strong trends observed in most indus
trialized countries over the past two or more decades (Figures 7.1 and 7.2).
Other analysts, however, using somewhat different measures discern a clearer
trend to early retirement over recent decades in Asia and Southeast Asia. Mason
et al. (2001), while noting the lack of data on retirement for Asia comparable
to those for OECD countries, report on trends in the median age of retirement
and the retirement hazard rate by age which point to earlier retirement. As
noted in Chapter 7, this may be due to the shifts over time in the proportions
working for government or large industry vs. agriculture, and the lower retire
ment ages in these sectors. In the coming years it will be important to trace the
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554 The Well-Being of the Elderly in Asia
retirement trends by industry in Asia in order to separate the effects of these
sectoral shifts from the age of retirement trends within sectors.
Bivariate and multivariate analyses of factors representing preferences,
needs, and opportunities for employment reveal that poor health is a very
important factor associated with the cessation of work in each country for
men and women (except for Philippine women) (Tables 7.6 and 7.7). The
importance of health for employment was also revealed when older respon
dents no longer working were asked their reasons for retirement. In the Phil
ippines, Thailand, and Taiwan the major reasons given centered on health
problems or the job being too demanding. In Singapore (and to an extent
Taiwan) reaching a mandatory retirement age was emphasized, and a signifi
cant number also said they retired because they were financially able to do so
(Table 7.11). Respondents also expressed the attitude that people should work
as long as they were able and did not appear in favor of a mandatory retire
ment age (asked in Singapore) (Table 7.12). Taken together these findings
suggest that preferences among the current elderly lean strongly toward con
tinued employment to the extent possible. At a general level, the retirement
process in these countries appears similar to the pattern observed in the United
States in the 1940s and 1950s in being largely an involuntary process driven
by poor health, layoffs, and mandatory retirement policies. In the U.S. it was
not until 1982 that more retirements were voluntary than involuntary (Quinn
and Burkhauser, 1994).
Although many older workers report leaving the labor force because
of poor health or difficult jobs, they do not report inactivity. Our study of
leisure activities reveals that a high percentage of the older population is en
gaged in one or another form of leisure, including the more physical activities
as well as the more passive and solitary pursuits. As illustration, 30 to 88
percent of respondents report some form of physical activity at least once a
week, while 33 to 95 percent across the countries report religious activities
(Table 7.13).
The Vulnerable Elderly
A persistent theme within gerontology is whether there are certain
sociodemographic groups who are particularly vulnerable to the disadvan
tages associated with aging. Chapter 11 explored this question by selecting
potentially vulnerable groups and measuring their relative risk of disadvan
tage using indicators of unfavorable economic, health, and social circum
stances. A major finding from this analysis is that there is considerable varia
tion across groups, with some evidencing higher relative disadvantage on only
a few indicators and others facing problems across the board (Figures 11.1 to
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Policies and Research for the Coming Years 555
11.5). Rural residents, for example, appear to be better off in terms of health
and social dimensions than expected, while those with no formal education
tend to be disadvantaged on all dimensions and in all countries (Figure 11.5).
Women as a group display higher than average health risks within each coun
try and higher economic disadvantages in two of the countries. Men and women
who are widowed, never married, separated or divorced also frequently dis
play above average risks on several dimensions. It is important to note, how
ever, that although several groups with above average risks on one or more
measures were identified, collectively they tended to account for only a small
proportion of the variance in the disadvantages examined (Tables 11.5, 11.6,
11.7, 11.8). Thus policymakers addressing the needs of the older population
need to go beyond identifying a few sociodemographic groups that are par
ticularly disadvantaged.
Chapter 11 also presented data on the extent to which older respon
dents were aware of and used some of the programs in each country intended
to address the special needs of the older population (Table 11.10). These data
are one element of the more comprehensive program evaluation that
policymakers and program managers will need to initiate to make sure that
programs are reaching the desired target population, that they are having the
desired impact, and that they are cost effective.
Anticipating the Future: Demographic, Social, and Economic Trends
and Their Interconnections
An underlying motif of this monograph is the impact of change, both retro
spectively and prospectively. What has been the impact on the well-being of
the elderly of the rapid demographic, social, and economic changes of the last
30 years that has characterized much of East and Southeast Asia; what further
changes are in store; and what effects might be expected from them? Govern
ment leaders need both to respond to emerging issues and to anticipate future
trends in order to fashion appropriate programs in a timely and cost effective
manner. In doing so, they have the daunting task of making sure that pro
grams designed to address one set of issues do not prove unintentionally dys
functional for other aspects of population aging.
Chapter 12 and earlier sections of this chapter have partially grappled
with these questions by examining the types of change that might be expected
through cohort succession and intra-cohort transitions, and by examining some
of the policy implications that flow from our analyses.
In this section we take a broader perspective by looking at several key
institutions and examining their likely trends, and how these forces interact
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556 The Well-Being of the Elderly in Asia
with one another. More specifically, we inquire how the demographic trends,
changing family structures and norms, and levels of economic development
are likely to play out in the coming years. In so doing, we attempt to join what
the United Nations (1983) termed the broad humanitarian issue of the effect
of population aging on the welfare of the elderly with the economic theme of
the relation of the demographic trends to economic growth and development.
The Informal Support System
As developed in Chapter 4, a major factor generating concern about the well-
being of the elderly in rapidly developing societies is the potential impact of
these changes on long-standing arrangements in which financial, physical,
and emotional support for the elderly are provided largely through the family,
particularly children. Much of the uncertainty about the future centers on the
persistence and resilience of family modes of support, with some analysts
expecting continuing strong ties despite the adverse demographic and socio-
economic forces, while others anticipate substantial change towards patterns
observed in more industrialized countries.
Although it would be difficult to predict the future shape of family
relationships in precise terms in the coming years, several trends, which can
inform policy, appear to be emerging. At the most general level, the family is
undergoing a series of accommodations on several fronts. This would be ex
pected on sociological grounds. The family is a basic social institution orga
nized to serve the collective and individual needs of its members, and it will
adjust to changing forces to maintain these functions. One corollary of this,
given the embeddedness of these arrangements in societal values and norms
and the complex set of emerging demographic and socioeconomic forces, is
that the responses are likely to be selective, with greater and more rapid change
in certain dimensions than others. In terms of the theory discussed in Chapter
4 that relates modernization trends to changes in family structure, our analy
sis suggests that the effects of economic development will depend very much
on the micro-institutional structure in place within each country. In addition,
the broad empirical generalizations associated with "modernization" theory
provide limited guidance over the short to medium run of the specific and
selective adjustments likely to evolve in response to changing conditions.
One line of evidence for the developing accommodations are the pat
terns of support and exchange described above and in Chapter 6. Older par
ents are receiving a high degree of support of various kinds in the four coun
tries but they are also providing considerable assistance, both financially (in
some countries) and with their time to their children and grandchildren.
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Policies and Research for the Coming Years 557
Attitudes and expectations about living with children in old-age and
receiving support from them have also been interpreted as evidence about
possible changes underway in long-standing arrangements. The World Bank
(1994), for example, reviews reported attitude levels on these dimensions
across countries at different levels of economic development to suggest that
informal support systems tend to weaken at higher levels of per capita in
come. But it must be cautioned that little research has been done in tracing
within countries the extent to which these expectations are borne out. As an
example, in the data reported by the World Bank (1994, Table 2.2) from data
collected in the mid-1970s (see Kagitcibasi, 1982; Bulatao, 1979), only about
a third of Singaporean parents expected financial help from children when
they became old, yet as we have reported, a very high percentage of older
Singaporeans in the mid-1990s are coresiding with children and receiving
financial assistance. Despite this caveat, attitudinal data can be revealing,
especially when it is collected over time and when it contrasts parents and
children on the same measures.
One of the longest time series on attitudes related to support of the
elderly are the series of surveys conducted since 1950 by the Mainichi News
papers in Japan. Ogawa and Retherford (1993) analyzed responses to the norm
of filial duty, measured by the question "What is your opinion about children
caring for elderly parents," and to expectations about old-age support reflected
in the question, "Are you planning to depend on your children in your old
age," addressed to married women under age 50.
With regard to the norm of filial duty they find that attitudes changed
rather slowly in Japan between 1963 and 1986 with the proportion replying
"good custom" or "natural duty" fairly stable between 75 and 80 percent (but
with a gradual shift from the first option to the second). Between 1986 and
1990, however, this combined proportion fell sharply from 75 to 50 percent,
and the proportion responding "unavoidable" or "not a good custom" rising
from 12 to 34 percent. Based on these trends and a related analysis of the
predictor variables, the authors conclude that this pattern of normative change
indicates a cultural lag, "whereby changes in norms of filial care for elderly
parents have lagged behind changes in underlying socioeconomic and
demographic conditions. In homogeneous, highly integrated societies such as
Japan, these norms tend to be widely shared. When they change with a lag,
latent receptivity to change can build up in the population, with the result that
normative change may proceed swiftly once it begins This normative
shift appears to have been precipitated by the rather sudden emergence of
government concern about the problem of population aging, by concomitant
policy changes aimed at containing rapidly rising social security costs, and by
extensive mass media coverage of these developments." (p. 595)
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558 The Well-Being of the Elderly in Asia
The patterns of change observed about expectations for support in old
age are quite different. Here the authors report a steady decline over time with
little evidence of lags or sudden shifts. The proportion planning to depend on
children in their old age decreased from 65 percent in 1950 to 18 percent in
1990. The related analysis of sociodemographic characteristics associated with
expressed expectations reveals that within specific categories of these char
acteristics the adjusted percentages expecting support changed little over time,
which they regard as consistent with the hypotheses "that expectations of old-
age support from children adjust continuously to changes in underlying so-
cioeconomic and demographic conditions. The large decline in the overall
observed percentage expecting old-age support occurs because of composi
tional shifts of population into socioeconomic categories characterized by
lower expectations of old-age support from children." (p. 595)
Long-term time trends on similar attitudes are not available in the four
focal countries but a shorter time series for Taiwan on a similar question on
expectations for support shows an even sharper pattern of decline than in
Japan. In Taiwan, the proportion of ever married women aged 20-39 who
reported expecting to be supported by sons in old age declined from 51 per
cent to 18 percent between 1973 and 1985. Unlike Japan, there were sharp
declines over this period within the two lower educational categories so that
the time trend standardized for educational distribution still displayed a con
siderable decrease (Chang and Ofstedal, 1991, Table 3). This signifies that
the observed change in attitudes occurred broadly across socioeconomic groups
and was not primarily a function of changing composition.
Although policymakers need to be attentive to the changes in related
attitudes, norms, and values, they also need to recognize that these changes
are selective, and that many elements of the normative and behavioral struc
ture remain in place. In Taiwan, for example, a question on whether it is im
portant to have a male heir asked of the same group found that the proportion
confirming that it was important declined only from 89 to 68 percent from
1973 to 1985, with a smaller change for the trend standardized by education
(Chang and Ofstedal, 1991, Table 3).
Marsh (1996) conducted a repeated cross-sectional sample in the city
of Taipei in 1963 and 1991 with about 500 male household heads between the
ages of 20 and 69 on a range of attitudes and behaviors to ascertain the mag
nitude and nature of the social change that had taken place in Taiwan over
this period. Several of the questions on obligations and expectations bear on
the questions of living arrangements and support as well as traditional obliga
tions. On the expectation of living with married sons in a large household,
those reporting that it was "very desirable" or "desirable" declined from 77
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Policies and Research for the Coming Years 559
percent to 57 percent over the period. Those who said children should defi
nitely bear most of their living expenses (or do so if possible), if they do not
coreside, declined from 58 percent in 1963 to 30 percent in 1991. Similar
sharp declines were recorded in response to a checklist of obligations that
children have to their parents: those reporting that helping parents with chores
at home or with their work was an obligation declined from 99 to 76 percent
over the period, and those acknowledging economic aid as an obligation de
clined from 86 percent to 67 percent (Marsh, 1996, Chapter 6). Marsh (1996,
Table 6.5) also finds a decline in his sample of those who think it is important
to have a male heir. In 1963, 93 percent said this was "important" or "very
important" contrasted with 66 percent giving these responses in 1991; but the
proportion who chose "very important" declined sharply, from 70 percent in
1963 to 32 percent in 1991, indicating a strong shift in the intensity with
which this norm is held.
Useful insights into the patterns of persistence and change are revealed
when comparing the attitudes of parents and children on the same attitudes.
In Taiwan, during the 1993 wave of reinterviews, all the children of a subsample
of respondents were asked the same questions on attitudes and exchanges
posed to their parents. A comparison of the responses of parents and children
show areas of agreement and disagreement. When asked who an elderly couple
should live with, about two-thirds each of the parents and of the children
selected a married child, as against living on their own (or other arrange
ment). Similarly, when asked whom the widowed elderly should reside with,
over 80 percent of the children (currently coresiding) and of the parents (who
had coresiding children) indicated a married child. But on the question of
whether a widow or widower should be able to remarry, a high percentage of
parents expressed the traditional negative altitude, while close to half the chil
dren were in favor (Cornman, 1999). These comparisons indicate that on some
key attitudes dealing with the living arrangements of older parents, the younger
generation in Taiwan appears as traditional as the older, while on others, there
appear to be sharp differences emerging.1
Additional evidence for the series of accommodations in intergenera-
tional relationships now underway can be gleaned from the series of focus
group discussions held in each country in the early stages of the project (Journal
of Cross-Cultural Gerontology, 1995). Several examples were provided ear
lier in discussing family decision making and exchanges. The quotes below
indicate an awareness by both the older generation and the generation repre
sentative of their children that changing social and economic conditions have
brought about strains at the family level but they also point to some of the
adjustments and accommodations that are developing in response.
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560 The Well-Being of the Elderly in Asia
Older Filipino Woman:
"It's really different now. Before, the kids can easily be taught,
they know how to respect the elderly. Now, they all end up
disrespectful. There is no more distinction between the eld
erly and the kids. There are very few who still know how to
respect. . . And the kids will say 'That was before, now it's
different "
Older Taiwanese Woman:
"Living with married son and daughter-in-law, while they
are doing things, the elderly should not interfere with them.
Leave them alone because they have their own private life.
This can maintain emotional affection between the elderly
parents and the children's generation."
Adult Age Woman, Thailand:
"We are annoyed with fussy parents but we just leave the
house when they complain. We come back when we no longer
feel angry. What can we do since they are our own mothers."
Older Thai Woman:
"Our children have to go to work. So we have to look after
the grandchildren. Otherwise, they can't go to work. It has
to be like that."
Adult Age Woman, Thailand:
"We feel secure having (elderly parents) with us. Moreover,
when we are out to work, there is someone home to look
after the house and our children ... If we have grandparents
with us, we can leave our children all day long and go to
work since both are cared by them."
Adult Age Woman, Singapore:
"For my case, the advantage is that .... like when I come
home, everything is ready, food is cooked. It is not like tak
ing her as a maid, but these elderly might feel that they are
boarding at our home so they want to please us although we
are happy that they are with us. So they do all these. My
advantage is that she looks after my child. If I ask other people
I won't know if they are happy. So that's my advantage."
Just as past socioeconomic and demographic changes have led to the
series of accommodations now ongoing, future trends in these forces will
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Policies and Research for the Coming Years 561
undoubtedly influence family relationships in the years ahead. While much
remains uncertain, several key trends appear clear. On the demographic front,
the future elderly will have fewer children than the current elderly, and the
continued pressures from growing urbanization and more emphasis on
technical and professional jobs make it unlikely that the high proportion of
elderly coresiding with children currently observed will be sustained, though
the degree and rate of change are likely to vary considerably across countries,
depending on emerging tastes for privacy and independence as well as the
urban housing market among other factors.
These potential declines in the levels of coresidence should not be
interpreted as necessarily reflecting emotional distance or tension between
the generations. As pointed out in Chapter 12 in discussing trends in educa
tion, the current elderly are transitional in this regard, and in the future older
parents and children are more likely to resemble each other in terms of levels
of education and hence in the lifestyles, attitudes and preferences associated
with a given level of education. Such convergence may serve to reduce cer
tain aspects of intergenerational tension observed at present and to pave the
way for new kinds of family accommodations appropriate to the emerging
conditions. More specifically, a pattern of "intimacy at a distance," which
characterizes much of the West, is likely to become more prevalent in Asia,
with frequent visits between children and parents and exchanges of financial
and other assistance as needed, but lower levels of actual coresidence.
Economic and market conditions will also be influential in shaping
future family residence patterns. Continued economic growth, particularly
when associated with more options for housing, may reinforce the sociode-
mographic trends in bringing about changes in levels of coresidence. In this
regard it should be noted that slowing population growth may reduce some of
the pressures on housing costs in urban areas, despite continued urbanization,
and that current high levels of coresidence reflect in part the cost and avail
ability of housing as well as a means of providing support to an older popula
tion that benefited only to a limited extent from the sustained economic growth
many Asian countries have experienced.
Population Aging and Economic Growth
The second broad issue associated with population aging is its impact on
economic growth. As described in some detail in Chapter 4 there are a num
ber of subtle interrelationships between population growth and structure and
several dimensions of an economy. In some instances, the policy implications
are quite clear while in others there are still unresolved questions. Neverthe
less, it will be advantageous to policymakers to fully appreciate the issues
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562 The Well-Being of the Elderly in Asia
involved, even when the development and implementation of specific pro
grams needs to await further research or the resolution of political and finan
cial priorities. We touch here on two important areas, labor force and retire
ment policy and programs and actions related to older age financial support,
with the caveat that each of these topics has many ramifications that are cov
ered in more detail by the studies cited earlier that focus on policy and pro
gram issues.
Chapter 4 pointed out that one way population aging can affect eco
nomic growth is through its effect on the dependency ratio or its related mea
sure, the economic support ratio (the ratio of economically active individuals
to the total population). Other things equal, increasing the number who are
economically active per capita will increase income per capita (Mason et al .
2001). The rapid demographic shifts that occurred in East Asia from 1965-
1990 had the effect of reducing the dependency ratios, as described in Chap
ter 2, and this boost to the economic support ratio contributed in part to their
rapid economic growth according to several observers (see Mason et al., 2001;
Bloom and Williamson, 1998). But the future demographic trends in this re
gion are projected to increase the dependency ratio, acting as a deterrent to
growth unless appropriate policies and programs counteract these trends, as
discussed further below.
In Southeast Asia as a whole, the demographic trends point to decreas
ing dependency ratios over the next 30 years, providing the potential for a
"demographic gift" in terms of economic growth from this source if appropri
ate policies are in place to capitalize on this opportunity (Mason et al., 2001;
Bloom and Williamson, 1998). Among our focal countries, this demographic
trend is most pronounced for the Philippines, as is the caveat that this is not a
sufficient condition, and requires appropriate social and economic policies to
realize this potential.
A second important economic dimension associated with population
trends is the aggregate rate of savings, also discussed in Chapter 4. Higher
rates of savings can translate into increases in capital and thereby promote
economic growth (see the discussion in Mason et al., 2001, pp. 120-127). As
with the labor force patterns, several observers find evidence that the age
structural changes associated with the demographic transition toward an older
population can promote a period of higher aggregate savings rates (Lee et al.,
2000). But this relationship is quite dependent on the public and private insti
tutions in place for smoothing consumption over the life cycle. Countries that
rely on transfers—either from children to parents or in the form of a pay-as-
you-go social security system—may be generating transfer wealth but not
sufficient real wealth over the transition to enhance capital and economic
growth. As Lee (2000, p. 27) states, "life-cycle wealth can be held in the form
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Policies and Research for the Coming Years 563
of transfer wealth or capital. Capital, of course is productive and raises out
put, while transfer wealth has no such effect, and so it is a matter of great
concern to society in which of these forms life-cycle wealth is held."
The models and analyses behind these insights still leave a number of
important unanswered questions about the motivations for savings and how
the private behaviors of each generation may react to the initiation of public
programs of different types. Nevertheless, they, together with the labor force
trends, point to several important policy considerations which we turn to next.
Policy Strategies in an Uncertain World
The foregoing section makes clear that the countries we have been analyzing,
as well as others in East and Southeast Asia and beyond, face an extended
period of continuing demographic, social, and economic change which will
have major repercussions. Although the details cannot be fully known in ad
vance, their general contours are often discernible. Faced with this uncertain
future, policymakers need to develop both a broad strategy for program de
velopment as well as more detailed guidelines for addressing specific issues.
We start with the components of the broader perspective.
Broader Perspectives
The analysis of the welfare of the elderly in the four focal countries shows
that there is no imminent crisis. A high percentage of the older population is
living with children and/or receiving economic and other support from them.
With regard to health, the prevalence of reported life-threatening conditions
is quite low. The vast majority of the elderly report no difficulties with the
activities of daily living (ADLs), and generally assess their physical and emo
tional health quite positively. These findings provide breathing space for offi
cials to gather systematically the data to evaluate current efforts, and to fash
ion plans and programs to meet current and emerging needs.
At the same time there is no room for complacency. Depending on the
measures used and the specific country under investigation, our data reveal
that perhaps one fifth to one fourth of the elderly are facing a fair degree of
economic hardship; there appear to be significant numbers without adequate
access to health care and with debilitating conditions; separation from the
labor force for many is driven by poor health; and some elderly are under
strain from providing support to children and grandchildren financially or in
the form of household maintenance or childcare. Additional pressure for ac
tion arises from a rapidly changing demographic picture, which will greatly
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564 The Well-Being of the Elderly in Asia
increase the number and proportion of older people in the coming years, par
ticularly those at advanced ages. In addition the future cohorts of elderly will
be quite different in their characteristics, experiences, and expectations than
the current elderly, requiring policymakers to look carefully at shorter term
needs as well as those likely to come to the fore in the years ahead.
As input to developing both the broader guidelines and more specific
programs, officials need to support and avail themselves of continual, care
fully executed research that will allow them to monitor important trends and
understand key interrelationships. Though one often pays lip service to the
need for closer ties between research and policy, the arena of population ag
ing, with the rapid changes underway in basic societal parameters and institu
tions, coupled with the complex options involved, will clearly benefit from
the strongest possible stream of relevant research. The situation is made more
challenging with the realization that different components of key institutions
may be changing at different rates, that measuring and understanding the
changes are key inputs into important policy and program decisions, and that
these decisions may well influence the speed and nature of future changes in
the coming years. In particular, little is as yet known about how families will
respond in terms of financial and physical support as retirement and health
programs become more fully implemented. We postpone discussion of the
specific aspects of a research agenda to the next section, but some examples
of important policy-relevant insights from existing research seem appropriate
here.
A persistent theme of our analysis is that there are many changes un
derway in family relationships and accommodations and it is important to
monitor the magnitude and nature of these changes in developing new pro
grams. But this broad statement provides little specific guidance as to what
exactly should be measured. An important finding summarized earlier in this
chapter is that simple measures of the level of coresidence among the elderly
or the proportion receiving support from children may mask economic and
other needs that older people face. In our analyses, those living with married
children were more often in the lowest tier of the income distribution than
those in other arrangements, as were those who relied on children as their
main source of support. These findings demonstrate the importance of going
beyond more superficial and indirect indicators, and monitoring more directly
the various dimensions of well-being. This advice becomes more salient for
the future, as new cohorts of elderly and their children are likely to develop
new support and residence patterns in response to their characteristics and
interests.
Another research insight stems from the economic-demographic analy
sis reviewed in Chapter 4, which points to the role of the demographic transi-
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Policies and Research for the Coming Years 565
tion experienced by most countries in East and Southeast Asia over the last
30-40 years as contributing to their high levels of savings and economic growth.
This line of analysis suggests that the "demographic gift" these countries ex
perienced will shift to a "demographic burden" for many, serving to depress
growth and saving levels. If so, countries should not postpone needed new
health, retirement and service programs until more robust economic times
return, but should proceed under conditions of more modest growth, particu
larly insofar as appropriately designed retirement programs may themselves
promote higher savings and investment levels. As the previous section notes,
however, there are still several unanswered questions about the degree to which
programs can promote additional aggregate savings and this important topic
merits continued careful research.
Admittedly, the complex issues associated with new program develop
ment and implementation focusing on the older population and the conse
quences of population aging have grown more complicated in the wake of the
Asian financial crisis of 1997 which strongly affected a number of countries
in East and Southeast Asia. As Atinc and Walton (1998) note, there are sev
eral social consequences of the crisis such as increased numbers of individu
als and families in poverty, possibly heightened income inequality, and higher
rates of joblessness. These developments combined with reduced government
revenues add to the issues vying for policymaker attention while constraining
the options for new program initiatives. Chapter 3 took note that the uncer
tain economic climate has led Taiwan and Thailand to postpone or scale back
planned new retirement programs, and no doubt has contributed to the in
creased scrutiny of health care costs in several countries.
There are several areas where actions necessitated by the economic
crisis overlap with programs addressed to the elderly and population aging.
As example, a significant portion of the poor and low income elderly are in or
associated with low income families, so attention to the poorer elderly can
redound to the benefit of the families and vice versa. From a broader perspec
tive, policy initiatives that address structural aspects of unemployment, such
as upgrading of job skills through education or vocational training, will con
tribute to heightened economic activity needed to adjust to the changing age
composition. The strengthening of the financial markets should facilitate the
implementation of defined contribution and provident fund type pension pro
grams which depend on investment returns to a large extent and, more gener
ally, enhance the savings and investment climate.
Perhaps the most difficult decisions faced by government officials center
on the nature and extent of the social welfare programs providing health care
coverage, retirement income, and related benefits. There are several tensions
and challenges confronting policymakers. One is between the desire to maintain
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566 The Well-Being of the Elderly in Asia
the informal support arrangements that provide financial, emotional, and
physical support to the elderly versus the realization that the informal system
has many gaps and is likely to erode further in the face of ongoing demographic
and social changes. A specific challenge is how to fashion programs that
complement the informal support system, but do not hasten cosily and
deleterious weakening of family support. Beyond these are the more formal
challenges of deciding on the types of programs to initiate, their breadth of
coverage, when to introduce specific features, and how to gauge their short
and longer term costs and impact.
Chapter 3 described the policies and programs underway in the four
countries under study here. It would appear that overall the countries are fur
ther along in meeting health care needs than in fashioning or fully implement
ing retirement programs. On the latter dimension, Taiwan is still debating the
nature of the nationwide program it wishes to initiate; Thailand has just intro
duced a very modest program that will not pay any benefits until 2014; the
Philippine program appears to be underfunded and to have major gaps in
coverage and compliance; and the Singapore program, though long in exist
ence and broad in coverage, has not succeeded as yet in converting the strong
savings generated into adequate retirement support, given the competing uses
of the funds. By contrast, on the health front, Thailand has greatly increased
the proportion of population covered by some form of health care during the
1990s; Taiwan introduced a Universal Health Insurance plan in 1995, which
is highly utilized; the Philippines restructured and broadened its health care
program in 1998; and Singapore has just introduced long-term care insurance
into its mix of payment plans and insurance options.
This capsule review suggests that programs to provide old-age finan
cial support will receive special attention in the coming years, and several
aspects of the health system, such as cost containment and public versus pri
vate provision of care, will require continuing scrutiny. The design, imple
mentation and analyses of retirement and health programs involve the skills
and insights of actuarial, economic, and health specialists, but they also in
volve political and social issues that address questions such as income redis
tribution effects, cross-generational transfers, and public versus private insti
tutional involvement. Several studies that discuss these and related issues
were noted at the outset of this chapter, and a detailed review is beyond the
scope of this volume or chapter. In keeping with this section's focus on devel
oping a broad perspective, several observations can be offered.
There is no simple checklist of dos and don'ts that will be applicable to
all countries. In fashioning new or enhanced programs, each country needs to
take into account its current and emerging social and economic arrangements,
as well as the nature and effectiveness of the programs in place. Also, it is
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Policies and Research for the Coming Years 567
unlikely that a single program can achieve the multiple goals associated with
an old-age security plan. As the World Bank (1994) analysis points out, such
plans should support savings, poverty alleviation, and insurance needs asso
ciated with old age as well as prove beneficial to the economy as a whole. For
this reason they advocate a multi-pillar approach that combines different types
of mandatory plans or mixes of mandatory and voluntary plans to achieve the
multiple goals. As an example, many of the countries in the region have a
large informal work sector which is not likely to be covered by existing retire
ment programs nor those under development. In many cases, these low in
come people also come from poorer families so there is limited opportunity
for family support. Special attention to this group, outside the more formal
retirement programs, may be required. Another group that may require spe
cific assistance are married women who often experience lower wages and
more sporadic work histories. In the future, attention may need to be paid to
the increasing proportion of women who never marry and to examine whether
their earning levels and their retirement program coverage will provide ad
equate income once they leave the work force. Since the most suitable combi
nation and the most appropriate timing will vary from country to country,
comparative research becomes a very valuable tool in the design and im
provement of old-age retirement and health programs. Policymakers should
not only examine the different types of programs within their own region,
which as noted vary considerably, but look to other regions as well. In Latin
America, for example, several countries have initiated provident fund social
security programs, which give individual workers considerable choice in how
their funds are invested, and the relative success of such programs should be
examined and monitored.
Comparative research can reveal subtle differences in program struc
ture and operation that can have major cost implications. A dramatic illustra
tion of this is provided by Burkhauser et al. (1997) in comparing the labor
force participation rates in the United States and the Netherlands for men
between the ages of 51 and 61, and the sources of income for those not work
ing, as of the early 1990s. Their data show that while employment rates are
similar in the two countries at ages 51 through 53, they diverge sharply there
after: by age 61, less than 17 percent of men in the Netherlands are still work
ing compared to 66 percent in the United States at that age. The authors argue
convincingly that differences in institutional arrangements—the generous dis
ability system and mandated employer pensions in the Netherlands—rather
than differences in health status are mainly responsible for the observed dif
ferences.
At one level, this example highlights the importance of giving care
ful attention to the precise structuring of a broad program covering multiple
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568 The Well-Being of the Elderly in Asia
risks and the ways that different elements overlap, as well as the level of
enforcement in the disbursement of benefits. At a more general level, it sug
gests that policymakers need to be willing to experiment and be innovative in
the design of new programs but also be willing to quickly alter programs that
are not working. As recent history in the United States, France, and Germany
illustrates, political constraints can make it difficult to substantially remodel
a program once it is entrenched. Admittedly, it is not easy to walk a fine line
between innovation, caution, and decisive action. Continual and careful moni
toring and evaluation of programs can assist with the difficult choices by
identifying those programs which are working well, those that need attention,
and what gaps remain to be filled.
Beyond the broader guidelines and perspectives reviewed in this sec
tion, the literature suggests several areas where more specific actions might
be considered, and these are addressed next.
More Specific Guidelines
A prime concern about population aging stems from its potential effect on
economic growth through the diminished ratio of those actively employed to
those at the more dependent younger and older ages, as discussed in some
detail in Chapter 4 and referred to above. Awareness of this age-structural
effect has led to a number of recommendations that might serve to enhance
both the size of the labor force as well as the level of its composite skills.
There are several steps that policymakers might consider to sustain the size of
the work force, though not all apply with equal force to each country.
First, discussed to some extent in Chapter 1, is labor immigration
from other countries. Among the four countries under analysis here, Singapore
has an explicit policy for utilizing workers from abroad, Taiwan is also mak
ing increasing use of foreign workers, while Thailand is both sending its citi
zens abroad while receiving others, and the Philippines has been sending rela
tively large numbers abroad. A well-developed program of labor immigration
and emigration can be of economic benefit to both receiving and sending
countries, but there are also various limits set by political and cultural consid
erations, and the analyses by the United Nations (2000), McDonald and Kippen
(2001), and Atoh (2000) suggest that this strategy is only a partial solution to
labor supply needs for most countries.
A second set of strategies focuses on enhancing the supply of domestic
workers by encouraging later ages at retirement (and reducing inducements
to early retirement), facilitating part-time work among the older population
and increasing opportunities for women to participate fully in the labor force.
Considerable attention has been devoted in recent years to understanding the
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Policies and Research for the Coming Years 569
retirement decisions of older workers and how they are influenced both by
their personal characteristics as well as by the tax and financial incentives
associated with pension and social security plans, and the operations of the
labor market (see National Research Council, 2001, Chapter 3 for an overview).
Maintaining older workers in the labor force has several advantages (as noted
by Mason et al., 2001), including reducing societal and family costs for old-
age support, as well as their direct contribution to overall economic production.
These considerations point to policies that examine mandatory retirement ages
among civil servants and others, direct or indirect tax provisions that provide
incentives to retire early, and the provisions of the disability, pension, and
social security programs that may contain financial or other inducements for
earlier separation from the labor force. Gruber and Wise (1999) show a strong
relationship across eleven industrialized nations between the wage replacement
rate workers can achieve at the earliest retirement date, the "tax force" against
these earnings and what they term the unused labor capacity between ages 55
and 65 (i.e., the proportion of persons aged 55 to 65 not in the labor force).
This finding suggests that attention to these subtle interconnections can pay
large dividends in retaining more of the older labor force.
Additional benefits can flow from reducing rigidities in the labor
market that limit the ability of older workers and others to remain gainfully
active. With regard to older workers, such policies would center around dis
crimination in their hiring or retention, as well as encouraging employers to
provide more opportunities for part-time work for those who want to reduce
their work hours, and also to allow adjustments in levels of pay and duties
where there are declines in capabilities that arise with age (Mason et al., 2001,
p. 90).
In many countries, women are underutilized in the labor force due to
discriminatory practices in hiring, promotion, or retention, and sometimes by
tax policies that adversely affect working married couples. And minority groups
in some countries may also find their participation in the labor force limited
in ways that harm their welfare as well as overall economic growth. In a
demographic environment in which the numbers at prime working age will be
relatively reduced, both basic equity and prudent policy dictate that
policymakers do everything possible to facilitate the appropriate employment
of all those wishing to work.
Beyond numbers, economic growth will depend on the physical and
human capital that the labor force has at its disposal. The complex relationship
of population aging to saving, investment and physical capital was discussed
above and in chapter 4. There are several steps that policymakers can undertake
to enhance human capital. Most directly, of course, attention to the level of
educational attainment and the quality of and opportunities for advanced
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5 70 The Well-Being of the Elderly in Asia
training in various fields will be crucial to the overall skills of the labor force
in the coming years. To this end, increasing the opportunities for secondary
and tertiary education for young women as well as young men becomes crucial.
As shown in Chapter 12, several countries in East and Southeast Asia have
made great strides in this regard while in others the opportunities for younger
cohorts are only marginally improved compared to earlier ones.
In addition to formal education, countries can improve the aggregate
human capital of workers by encouraging employers to provide on-the-job
training, through adult education programs, and, more generally, by fostering
policies and plans for lifetime learning. Singapore launched a program in
1998 with some of these elements, creating an endowment fund administered
by the National Trades Union Congress to support training for members tak
ing approved courses (Straits Time, 2000). Such programs should not only
increase overall production, but over time will allow older workers to main
tain job skills in the face of shifting requirements, to compete more success
fully against younger workers, and will encourage them to remain in the labor
force longer.
In discussing a number of the labor force and retirement program
adjustments discussed above, Lesthaeghe (2000) cautions that these are not
policies that will solve economic consequences of population aging over the
long term. Given that there are limits to how high one can raise retirement
ages, and to the percentage of working age people that can be in the labor
force at any one time, he regards them as "pain relievers" which can buy time
against some of the economically deleterious effects of population aging, but
cannot eliminate the very long term consequences, if fertility remains low
and immigration is not a viable option.
The emphasis on formal education and post-employment training and
education demonstrates that policymakers are well advised to adopt a life
cycle approach to many issues on population aging and not think solely of
programs that address the elderly. This is particularly true in the realm of
health. Investing in teaching younger people good health habits and investing
appropriately in programs to prevent illness and injury to persons of all ages
can substantially reduce the proportion of older people who will need expen
sive medical and physical care in the future. The relatively high proportion of
the current elderly who report retiring because of health conditions suggests
that there is room for substantial improvement in the overall health of the
labor force, with commensurate gains in productivity as well as savings in
future health costs.
There are, of course, many other aspects of health care provision for
the elderly and health care costs which will occupy policymakers in the coming
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Policies and Research for the Coming Years 571
years. A number of these have been touched on previously and in earlier
chapters. These include continued attention to how best to provide health care
coverage to the population at large and to older residents in particular, and to
insure that costs are kept within appropriate bounds; how to increase the number
of facilities and health care workers specializing in geriatric medicine and
services, given the projected rapid increase in the numbers at advanced ages;
and more generally how to restructure health care systems oriented to primary
care and infectious diseases to contend with the growing prevalence of chronic
diseases while addressing the continuing burden of infectious ailments. Mason
et al. (2001) note that insofar as the higher projection of the population at
older ages stems from gains in older age longevity (as distinct from fertility
declines), countries can expect to devote a higher proportion of their gross
national product to health expenditures. Even if health care costs at the
individual level do not increase with age, the higher proportion of the
population at advanced ages, and the heavy expenses associated with the
terminal year of life, will drive up aggregate health expenditures. Expenditures
are also likely to rise from increased demand for advanced health care from
future cohorts of more educated and professional elderly.
The countries under review here and others in Asia have demon
strated substantial flexibility in a number of respects in addressing health
care coverage and costs. In some countries that focus on employer-based plans,
parents as well as children are eligible dependents, providing a mechanism
for extending coverage. As a variant of this, in Singapore children can pay
their parents' health expenses from their own Medisave accounts. In other
places, countries have adopted a multi-tier system which provides direct cov
erage to the elderly (and sometimes their families) in addition to employer-
based plans. This can serve as an effective way to reach the rural elderly or
those in the informal sector.
As described in Chapter 3, countries have also shown innovation in
setting up nursing and residential facilities for the elderly in need of such
care, often forging partnerships with voluntary, and charitable organizations,
and at times, by providing oversight to private providers. The special needs
arising from chronic diseases and old age disabilities suggest that innovative
approaches and collaborations can prove effective, and one might expect more
such models in the future.
A major unknown in anticipating the future health care costs associated
with population aging is the extent to which family members will provide
physical care and other services for elderly who require assistance. An analysis
by Mayhew (2000) of future health care costs in both more developed (MDCs)
and less developed countries (LDCs) concludes, among other things, that health
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572 The Well-Being of the Elderly in Asia
care costs as a percentage of GDP will expand rapidly in the LDCs over the
next 50 years to the levels currently observed in MDCs and that the number of
disabled will grow substantially. But he projects that increases in LDCs of
disability-related expenditures will be modest, on the assumption that most
physical care will be provided by the family and community. This is a strong
assumption and demonstrates that in the crucial area of health, as well as a
number of others, anticipating future developments in family arrangements
and fashioning appropriate policies in the light of expected trends becomes a
major challenge to government officials. It is appropriate then to conclude
this overview of policy considerations by focusing on programs that can sustain
and enhance family support for the older population.
As noted in Chapter 1, and several other points in this volume,
policymakers in Asia are desirous of maintaining and strengthening the tradi
tional family and other informal support mechanisms for the elderly, while
moving ahead with new and amended programs that respond to the changing
demographic and socioeconomic environment. This dual strategy has been
endorsed by many analysts (World Bank, 1994; Mason et al., 2001; United
Nations, 2000) in providing countries more time to adjust to the rapid rate of
population aging and limiting the social and economic dislocations that might
otherwise occur. The countries we have been analyzing vary in their level of
economic development, their urban-rural balance, and other major dimen
sions so that the levers available differ accordingly. Traditionally, the provi
sion of financial and emotional support to older family members, and physi
cal care, if needed, was facilitated by the high level of extended family living
arrangements. Accordingly, one avenue of policy has been to encourage and
assist children to live with or near older parents. In Singapore, as described in
Chapter 3, this has taken the form of a number of direct incentives in terms of
tax rebates, and preferential housing choices, made possible by the strong
role of the government in controlling housing and the urban character of the
country. In the other countries, direct housing incentives are more difficult
though some attention to housing architecture and neighborhood structure is
appearing in Taipei, and the Philippines makes use of tax incentives to en
courage children to live with older parents.
A second approach in evidence is for governments to provide direct
financial and health care support to needy elderly as a way of reducing pres
sures on the family. As noted in Chapter 3, each country provides small pen
sions to elderly who fall below some poverty threshold, and has mechanisms
to provide health care coverage to the elderly, with special provisions for
those whose income or status do not qualify for the modal plans (i.e., the very
low income elderly or those without family members to pay premiums of
provide coverage). These steps are important because poorer elderly are often
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Policies and Research for the Coming Years 573
associated with poorer families. Providing basic income and health care to
the elderly reduces tensions and problems within the family and makes it
more likely that the family will be able to maintain more personal forms of
assistance. Programs that address these needs may become even more impor
tant in the coming years since many of the retirement and social security pro
grams in place omit the rural and informal sector and/or provide relatively
small amounts of retirement income.
A third strategy for assisting the older population while serving to
sustain close family ties is through the provision of a variety of community
services, ranging from home health care to adult day care and recreation cen
ters. These services not only enhance the physical and mental health of the
elderly, but they serve to reduce the caregiving burden for children who often
are dual wage earner couples juggling job requirements with the education
and care of their own young children.
The challenge to policymakers in the coming years will be to adjust
the array of such programs to the changing pattern of family relations and
changing sociodemographic environment. New needs will arise as several
old ones persist. As we have stressed at several points, families are going
through a series of accommodations in accordance with their changing size
and socioeconomic characteristics. By monitoring these evolving features,
policymakers can stay attuned to needs that are emerging as well as those that
may require less attention. As example, in the coming decades, future cohorts
of elderly are likely to be more economically secure on average and to value
privacy and independence. Housing policies that provide coresidence may
therefore be less salient or feasible. At the same time, there will also be in
creases in the numbers at advanced ages that are likely to require more per
sonal and physical care. This will require developing a mix of family and
community assistance. Urban planning and housing policy can enhance the
possibility of having a child live nearby, and promote transportation systems
that enable the elderly to get around and utilize facilities of interest and use to
them. Communities will also need to expand the number and range of ser
vices provided to the elderly, particularly to those persons facing disabilities
of various kinds. In cases where family members are providing intensive physi
cal care to disabled elderly, respite care will become more important as the
size of families decreases and there are fewer members to share the time and
emotional burden of such care. Countries will also have to give more atten
tion to both the financial and service provision of long-term care. In develop
ing an appropriate array of programs that provide assistance and services,
policymakers will face the challenging task of designing these efforts so that
they complement what families and the elderly are already doing, and do not
substitute for these private actions, thus lessening or negating their net effect.
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574 The Well-Being of the Elderly in Asia
Further down the road, the continuation of the lower marriage and
fertility trends now in evidence means that a significant number of future
elderly will not have children or spouses to provide financial, emotional, or
physical assistance if these needs arise. This will call for a new mix of ser
vices appropriate to this group, with perhaps innovative housing arrangements
that facilitate mutual support among friends and neighbors.
Meeting the wide array of broad and specific challenges reviewed
above will depend on the political will, talent, and resources that current and
future officials bring to the task. Their task will be made easier if there is an
appropriate research agenda in place that can provide the information and
insights that can guide them in charting an effective course of action. Our
concluding section discusses the elements of such an agenda.
Developing a Research Agenda
The speed of population aging projected for Asia along with the continuing
social and economic changes are unique on the world scene and present an
unparalleled opportunity to study a major societal transformation at close range
with the tools of modern social science. The fruits of such studies will also be
invaluable to officials who must develop policies and programs in a rapidly
shifting and uncertain environment. At the same time it is well to realize that
there is no simple one-to-one correspondence between research and policy.
Rarely will a single research project or set of projects fully direct policy or
program development of any complexity. At one level, specific policies and
programs often entail political and ideological dimensions that are not reduc
ible to research questions, while at another level, they require attention to a
myriad of details for which research can offer only broad guidance. By the
same token, policy needs should not be the major driving force of research,
which must also respond to the path of basic science and seek to address key
emerging questions.
Nevertheless, within their respective spheres there is an opportunity
for much overlap and productive interaction, and as previously noted, popula
tion aging, more so than many fields, can benefit from an active dialogue
between policymakers and researchers. Hermalin (1999, Table 1) noted sev
eral ways that research can assist policy and program development which
covered the following dimensions:
1. By providing estimates of needs, preferences and costs. Estimates from
surveys, service statistics, censuses and vital registration systems can pro
vide information on mortality levels at advanced ages, disability levels,
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Policies and Research for the Coming Years 575
labor force participation rates, health status, health care utilization and
costs, housing quality, income deficiencies, needs for personal care assis
tance, and recreational and other sen ices.
2. By providing knowledge of key interrelationships and identifying target
audiences for various services. Information on differentials across socio-
demographic groups and understanding cause and effect relationships of
key characteristics (like income and health, health and living arrange
ments) are essential for formulating sound policy.
3. Monitoring changing norms and family accommodations, and generating
the database for projections of costs and needs. Knowledge of changing
norms and family relationships are important inputs into anticipating the
types of programs most needed to sustain family support. Estimates of
future characteristics of the elderly in terms of education, marital status,
and family size help identify emerging needs and shifting priorities
4. Using comparative research to study socio-cultural context and variations
and program performance.
5. Using research to evaluate program performance and generate needed
changes. This would include monitoring the efficiency and effectiveness
of various services, as well as the attitudes toward existing services and
the effect of new programs on existing modes of support.
This broad overview does not define the specific types of research
that should be undertaken. These will vary over time to some extent, with the
nature of the most pressing issues and with local conditions and resources,
but several general observations seem in order. Not all the needed research
will require costly new initiatives. Countries can generate important insights
by fairly straightforward extensions of data already being collected. For ex
ample, labor force surveys undertaken regularly in many countries contain
useful data on work status and reasons for not working but often the data are
not tabulated in any detail for ages above 55 or 60; similar potential exists in
providing more detail at older ages for data collected in censuses and through
vital registration. In some countries the registration of deaths and the record
ing of causes of death is still incomplete. Attention to upgrading the system,
and studying the trends in mortality at older ages can provide valuable data
about the potential future burden of disability and the needs for related ser
vices. Another underutilized resource in some countries is the service and
program statistics generated from health and retirement programs in place,
and these can be particularly insightful when merged with data from popula
tion based surveys.
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576 The Well-Being of the Elderly in Asia
Andrews and Hermalin (2000) in their overview of research on aging
in the Asia-Pacific region also point out the potential of enhancing regular
data collection efforts by adding a few questions designed to make them much
more valuable for studying population aging. In censuses, for example, dis
tinguishing the nominal head of a household from the economic head would
assist in measuring the economic status of older people, and learning how
long each person has lived in the household would be of value in studying
living arrangements. Similarly, adding a few health questions focused on the
presence of disabilities can produce valuable data at low cost. Another way to
enhance the value of existing data is to make available micro-samples of cen
sus data or data sets of other surveys to allow individual-level analysis to be
carried out, which go beyond the information available in published tables.
Beyond the more efficient use of data at hand or within reasonable
reach, however, it remains true that understanding many of the important
dynamics related to population aging will require mounting special surveys
of appropriate age groups. As is clear from the analyses carried out in this
volume, there are a number of dimensions involved in assessing the well-
being of the elderly, a large number of characteristics which impinge on them,
and many subtle interrelationships to be sorted out. Measuring these factors
at any point of time requires a carefully designed probability sample survey
of the appropriate population (e.g., those 60 and older, and in some settings
those 50 and older, depending on the particular interests) that appropriately
probes each relevant topic. Moreover, as discussed in Chapter 12, many of
the questions of prime interest in studying the older population can only be
addressed through longitudinal data, both to accurately capture the many
transitions that older people encounter, as well as to sort out the subtle cause
and effect connections between related variables. Given the subtlety of the
information needed, this usually points to utilizing a panel design with
reinterviews at appropriate intervals, rather than relying on retrospective
reporting of complex histories. A panel design is also a powerful vehicle for
tracing the reactions of individuals and families to new programs and policies,
which are important inputs to assessing the effectiveness of programs and
identifying changes that will enhance their impact.
At the same time, panel studies that trace cohorts over time will not
capture the overall changes among the older population resulting from new
cohorts with different characteristics advancing in age. To get around this it is
possible to combine panel studies with repeated cross sections by adding new
birth cohorts as the original panel ages, and this design is being employed in
the Health and Retirement Survey in the United States (Juster and Suzman,
1995) and in the Taiwan panel survey utilized in this volume (see Chapter 1
and Appendix A for brief description).
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Policies and Research for the Coming Years 577
As Andrews and Hermalin (2000) note however, although panel stud
ies are attractive in the range of data they produce and the insights they pro
vide, they are costly and difficult to execute and should not be approached
lightly. (See also Scott, 1995.) Nonetheless, well designed and executed panel
studies can address many important research and policy issues. These include
monitoring changing norms and attitudes relevant to population aging; under
standing the transitions older people undergo as they age and the interrela
tionships among the key factors; and assessing the effectiveness of programs
and possible changes needed by observing the responses to these programs
and the reasons for differential response. Panel studies are likely to be in
creasingly valuable in studying active life expectancy and understanding the
causes and risk factors that affect disability as well as mortality, and deriving
the policy implications that flow from these relationships (Olshansky and
Wilkins, 1998). Another important benefit that will emerge as more countries
engage in similar panel studies is the ability to undertake cross-national com
parative research that can help assess the effectiveness of national programs
in a broader perspective. A recent report from the National Research Council
(2001) stressed the practical as well as theoretical benefits of comparative
international research. It is also important to note that the cost of a panel
study may not be high in contrast with a series of ad hoc surveys that yield
more limited insights.
Researchers and policymakers will also want to make appropriate
use of qualitative data collection strategies in the form of participant observa
tion, case studies, in-depth interviews and focus group discussions to assist
other forms of data collection and analysis in providing a coherent picture of
societal arrangements and the changes underway (Andrews and Hermalin,
2000; Knodel, 1995). Qualitative data can reveal the frames of reference people
are bringing to current issues and thus assist in the development of effective
survey questions. They can also serve to amplify analyses of survey data by
probing some of the family dynamics and altitudes not fully captured in the
often contrained range of survey questions.
Looking Backward and Looking Forward
As this is written, plans are underway for the United Nations to hold its Sec
ond World Assembly on Aging in Madrid in April 2002, exactly 20 years after
the first such meeting in Vienna. It will take stock of the extent to which the
broad World Plan of Action developed in 1982 (United Nations, 1983) has
been implemented across countries, and identify needed policies, programs,
and research appropriate to future trends in population aging.
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578 The Well-Being of the Elderly in Asia
The first Assembly, though widely attended by representatives of coun
tries at all levels of economic development, focused chiefly on concerns fac
ing the industrialized countries which had been experiencing low fertility',
while making clear the issues emerging for the less developed economies,
especially those which had already started to reduce their fertility over the
previous decade. The projections of a sharply growing older population for
those countries have already materialized along with some of the attendant
problems predicted for this transformation. The countries of East and South
east Asia were attentive participants at the 1982 Assembly and, as shown,
many began at an early date to launch research and to fashion programs and
policies to address their rapidly growing older populations.
Concomitant with the demographic trends of the last 20 years and the
socioeconomic repercussions, there has been an outpouring of multi-disci
plinary research related to population aging and the physical, emotional, and
economic health of older people. We know much more about the formal de
mographic processes and their interrelationships with other societal dimen
sions, about how to study the many subtle factors involved, and about the
challenges associated with fashioning policies and programs that address
emerging problems that compete with other national priorities. One expects
that the 2002 World Assembly will recognize this progress and motivate a
renewed focus on population aging issues that builds on these past accom
plishments.
The experience of East and Southeast Asia in terms of research and
action over the last 20 years will doubtlessly contribute substantially to the
ongoing deliberations. As this volume illustrates, much has been learned and
many important policies have been initiated, but formidable challenges on
many fronts remain. The history of these regions over the last half century, in
guiding the social and economic development of their societies, in pioneering
fertility and family planning programs and research, and in their early atten
tion to population aging, gives confidence that they will make great strides in
the next 20 years in understanding the repercussions of this demographic trans
formation and in adjusting to the societal challenges posed.
ENDNOTE
1. For analysis of the degree ofe parent-child agreement within families see
Cornman, 1999 and for comparisons between Taiwan and Baoding, PRC, see
Cornman et al., forthcoming.
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Policies and Research for the Coming Years 579
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Appendix A: Survey Design Information and
Methodological Notes
As noted in Chapter 1, the key surveys carried out in each country which form the
bases for most of the analyses in this volume were coordinated efforts rather than
replications of the same questionnaire and design. The underlying National Insti
tute on Aging grant did not provide funding for data collection in each country, so
that country-specific constraints, interests, and opportunities were reflected in the
size, design, and scope of each survey, while trying to meet the common goals
established through workshops and a suggested core questionnaire. There is con
siderable overlap in the subject matter and questions among the surveys conducted
in the Philippines, Taiwan, and Thailand. Singapore, due to particular constraints,
had the shortest questionnaire and as noted throughout the text, a few items of
interest were omitted and hence unavailable for comparative analyses. In general,
the following topics were covered by each of the surveys:
1. Household Roster
2. Background Characteristics
3. Marital History
4. Social and Economic Exchanges
5. Health, Health Care Utilization and Health Behaviors
6. Residence History
7. Occupational History
8. Activities and General Attitudes
9. Economic and Financial Well-Being
10. Emotional and Instrumental Support
The basic survey design for each country is described briefly in the paragraphs
below, along with the sources for additional information, where available. Infor
mation about accessing these and related data utilized in this volume is described
in Appendix B.
The basic characteristics of the sampled population 60 years of age and
older by gender and age, and the relevant sample sizes are presented in Chapter 2
(Tables 2.7 and 2.9). In each country the age and sex distribution of the sample
data were compared with published population level data. In Singapore and Thai
land, sample survey weights were based on census data, constraining the compari
sons to close agreement; in the Philippines and Taiwan, the weights employed
were not based on population distributions and there was generally close agree
ment between the sample and population distributions. The only notable deviation
was in the Philippines, where there was a slightly higher proportion of older people
in the sample than in the population.
583
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584 Appendix A
Proxy respondents, under clearly defined rules, were used in the Philip
pines, Taiwan, and Thailand for selected respondents who were unable or unwill
ing to be interviewed. For those 60 and over, the proportion requiring the use of
proxies ranged from 5 percent in Thailand to 8 percent in Taiwan. This propor
tion, however, increased sharply with age, approaching a fifth to a quarter of re
spondents aged 80 or over in the three countries. As the older populations in Asia
age rapidly, as described in Chapter 2, this aspect of survey design will require
more scrutiny. As expected, the major reasons for the use of proxies centered on
health related problems, including serious illness, cognitive problems, and severe
hearing loss.
As indicated in the detailed write-ups below, response rates for the surveys
were 85 percent or higher in each country but Singapore. In that country the re
sponse rate was approximately 60 percent, with the major reason for unsuccessful
interviews arising from the inability to locate or contact an older individual at the
address provided, despite three visits.
The Philippines
The 1996 Philippine Elderly Survey (PES) was a countrywide, nationally repre
sentative sample of those 50 years of age or older. A multi-stage design was used,
where the country was first divided into four strata [Luzon (excluding the Na
tional Capital Region); Mindanao, Visayas, and the National Capital Region], one
or more regions (or comparable subdivision) were selected within each stratum,
with probability proportional to size. Interviews were conducted in all provinces
within the region, with selected households in barangays within those provinces
The barangay is the smallest political subdivision, and generally represents rural
villages or urban neighborhoods that until 1973 were called barrios. The mea
sures of size needed for selection were based on the Integrated Survey of House
holds (ISH), a national sampling frame originally developed in 1980 to collect
household information on employment and other socioeconomic characteristics.
It consists of 2,100 barangays (primary sampling units) selected proportional to
size in each of the 14 regions of the country. Within each of the selected barangays,
a list of all households is updated on a regular basis. The PES survey conducted
interviews in 5 regions and 25 provinces and 228 barangays (or sub-barangays).
In order to sample people aged 50 and above, PES interviewers were sent
out to the households on the ISH list to determine whether or not there was an
eligible respondent. Regional estimates of the ratio of number of households to
the number of elderly were used to estimate the number of households that would
have to be screened within a given sample barangay. As the survey results started
to come in, it became evident that the barangay estimated ratios differed from the
regional estimate and varied greatly even among barangays within the same stra
tum of a given urban or rural domain. Thus for some barangays the screening
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Appendix A 585
sample sizes were increased to ensure a large enough sample of the elderly popu
lation. To take the sampling design into account, sampling weights were constructed.
Proxy respondents were used when the eligible respondent was not able to
be interviewed or required assistance. Almost 8 percent of the interviews with
those 60 or older required a proxy either for all or part of the interview or to assist
the selected respondent. In carrying out the PES, 5,896 households were screened,
completed interviews were carried out with 2,285 selected respondents 50 years
or older, and in 2,702 households there were no eligible respondents. Of the re
maining households, refusals to complete the screen or interview occurred in about
one third, and the other two thirds mainly constituted households or eligible indi
viduals who could not be located or contacted after several callbacks. Based on
the known refusal and eligibility data, it is estimated that the survey achieved an
85 percent overall response rate.
A major portion of the expense for carrying out the survey was provided
by the National Institute on Aging under the grant to the overall project. The sur
vey was conducted under the auspices of the Population Institute of the College of
Social Sciences and Philosophy, University of the Philippines, under the direction
of the late Dr. Lita Domingo, and assisted by Dr. Josefina Natividad, Prof. Grace
Cruz, and staff members E. C. Cabegin, F. Arguillas, M. Kabamalan, and M. J.
Baltazar. Dr. Ana Tabunda of the Statistical Center of the University of the Philip
pines prepared the detailed sampling plan and the weights. Dr. Aurora Perez guided
initial analyses and dissemination of survey results. A report of this study is forth
coming as: Perez, Aurora E., and Josefina Cabigon (eds.), The Filipino Elderly.
Population Institute, University of the Philippines.
Thailand
The Survey of the Welfare of the Elderly in Thailand (SWET) is a stratified,
multi-stage national probability sample of persons aged 50 years old and over
who are usual residents in the private households. The sampling frame used for
SWET was the 1990 population census. The 72 provinces of Thailand were
allocated to 13 strata, with Bangkok constituting one stratum, and the others
containing 5 to 7 provinces. In these latter strata, 2 provinces were selected
systematically and these further subdivided into urban and rural administrative
areas. In the urban areas, selection was based on blocks and households; in the
rural areas, selection was based on districts, villages, and then households. Within
Bangkok, blocks were selected and households within blocks. (The detailed
procedure, along with the questionnaire, and basic tabulations are provided in the
reference below.) Although the sample of SWET was originally designed to be
approximately self-weighting, deviations in the selection probability during
fieldwork and inaccuracies of the measures of size employed during the design
stage made it necessary to apply design weights based on the 1990 population
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586 Appendix A
census to the individual respondents in the sample. Two types of questionnaires,
household and individual, were used to collect information for SWET. The
household questionnaire collected information on all usual members of household.
This was used to identify eligible respondents for the individual interview. To be
eligible, the respondent had to be 50 years old or over and usually live in the
sample household. For households with more than one eligible respondent only
one randomly selected respondent per household was interviewed The fieldwork
was carried out from April to October, 1995, with members from the Ministry of
Public Health mainly serving as the supervisors and assistants. The household
response rate was 94 percent for household (7,930 household interviews out of
8,425 household selected for the survey), and 97 percent for individuals (7,920
eligible respondents were identified and selected for an individual interview of
which 7,713 persons were successfully interviewed but 5 cases proved to be under
50 years old resulting in a sample of 7,708 respondents). Proxy respondents were
used for 5 percent of respondents aged 60 and above.
The survey was carried out jointly by the Ministry of Public Health, the
Health Systems Research Institute and the Institute (now College) of Population
Studies, Chulalongkorn University. Financial support was partly provided by the
Thai government through all three organizations and partly by the U.S. National
Institute on Aging, through this project grant. The individuals in Thailand mainly
responsible for the development, execution, and basic data processing of the sur
vey include Professor Napaporn Chayovan, Ms. Siriwan Siriboom, and Ms. Busarin
Bangkeow of the College of Population Studies, Chulalongkorn University, and
Dr. Chanpen Chopropawan of the Health System Research Institute.
Additional details on the sampling design, questionnaire, and basic tabula
tions may be found in: Chayovan, Napaporn and John Knodel. "A Report on the
Survey of the Welfare of the Elderly in Thailand." IPS Publication No. 248/97.
Institute of Population Studies, Chulalongkorn University. March, 1997.
Taiwan
Taiwan is the only one of the four countries to have started with a panel design,
with a major baseline survey of those 60 and older in 1989 and major follow-ups
in 1993 and 1996. (More limited follow ups were also conducted in 1991 and
1995.) In 1996, a second panel was initiated consisting of those 50-66 years in
that year to develop a representative panel of those aged 50 or older. A detailed
statement of the original sampling plan is provided in the reference to the 1989
survey below, and the full questionnaires for the 1989 and 1996 rounds are pre
sented in the references listed.
The 1989 survey utilized a three-stage selection process, in which 56
townships were selected proportional to size from the 331 townships, which were
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Appendix A 587
arranged into 27 strata. Within townships, blocks formed the second stage, selected
proportional to size, and within each block two eligible respondents were selected
randomly, utilizing the household register of each sampled township as a sampling
frame. Those no longer living at their registered address were traced to their new
residence anywhere in Taiwan. The 1989 survey identified 4,412 older adults of
whom 4,049 were successfully interviewed, for a response rate of 92 percent. In
the 1993 follow-up, 3,155 survivors of the original panel were successfully
interviewed, 582 had died and 312 refused or could not be located, leading to a
response rate of 91 percent.
The 1996 survey consisted of two parts, the follow-up interviews of those
now 67 years and older and a new panel of those 50 to 66 years. Of the original
1989 panel, 2,669 were successfully interviewed, 1,047 had died, and 333 refused
or could not be located, producing a response rate of 89 percent. For the new
panel, the selection procedures followed the original design after some updating
of the basic measures of size. Of those aged 50 to 66, 2,462 respondents of the
3,032 selected were interviewed, for a response rate of 81 percent. When the two
portions of the 1996 survey are combined and properly weighted, they produce a
representative sample of those 50 years old and older.
Proxy respondents when needed have been used in the Taiwan survey, and
in 1996,8 percent of interviews with those 60 or older required the use of proxies.
Due to the nature of the household register which includes institutions as special
households, the Taiwan surveys were able to include institutionalized respondents
as well as the non-institutionalized but because of their small number and the fact
that the surveys in the other countries are restricted to the non-institutionalized
older respondents, they are excluded from the analyses presented in this volume.
Funding for all the surveys has been provided by a number of Taiwanese
governmental agencies, including the National Health Department, the National
Health Research Institute, and the Taiwan Provincial Government. The National
Institute on Aging, through this project grant, has provided small amounts of supple
mental support. The surveys have been carried out by the Taiwan Institute of Fam
ily Planning (recently reconstituted as the Center for Population and Health Sur
vey Research) under the direction of Dr. Ming-Cheng Chang, Dr. Hui-Sheng Lin,
and Mr. Yi-Li Chuang. Other staff members contributing significantly over the
life of the panel study include: Li Chi, Mei-lin Lee, Shu-Hui Lin, Yu-Hsuan Lin,
and Hsia Yuan Liu.
Questionnaires and additional details can be found in:
Taiwan Provincial Institute of Family Planning, Population Studies Center, Uni
versity of Michigan, Institute of Gerontology, University of Michigan. 1989.
" 1989 Survey of Health and Living Status of the Elderly in Taiwan: Question
naire and Survey Design." Comparative Study of the Elderly in Four Asian
Countries Research Report No. 1, Population Studies Center, University of
Michigan, Ann Arbor.
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588 Appendix A
Chang, M.-C., and A. I. Hermalin. 1996 Survey of Health and Living Status of the
Middle-Aged and Elderly in Taiwan - Chinese-English Questionnaire (A):
Survey of Those 50-66 Years of Age; (B): Survey of Those Over 67 Years of
Age." Taiwan Provincial Institute of Family Planning and Population Studies
Center, University of Michigan.
Singapore
The sampling frame for The National Survey of Senior Citizens in Singapore, was
the National Database on Dwellings in Singapore, maintained by the Department
of Statistics. The department's customized two-stage stratified design, based on
house type, was used to select a representative sample of 8,000 dwelling units,
comprising 4,000 households with at least one Singaporean Citizen or permanent
resident between 55 and 74 years of age and 4,000 households where there was at
least one person 75 years or older. Those aged 75 and above were over-sampled to
ensure a sufficient number of respondents in this age group for analysis. For house
holds with more than one senior citizen, a computer-generated random number
was used to select the actual person to be interviewed. The survey was carried out
through face-to-face interviews between February and October, 1995 with selected
senior citizens at their homes using a structured questionnaire. Up to three visits
were made if the respondents could not be contacted at the first and second visits.
Proxy respondents were not used. In addition to the elderly respondents, their
caretakers were also interviewed either face-to-face or with a telephone interview.
From the list of 8,000 selected households with older residents, a total of 4,750
were successfully interviewed. This gave a response rate of approximately 60%.
Of the unsuccessful interviews, 70% were due to failure to contact or locate the
senior citizen at the given address and 30% were due to refusal to be interviewed.
To enable the findings from the sample to be applied to the target population, the
sample was weighted by age group, ethnic group and sex using the 1990 Singapore
Census of Population. The survey was carried out by a committee jointly chaired
by the Ministry of Health and the Ministry of Community Development, with
representatives from the Department of Statistics, the Ministry of Labour, and the
National Council of Social Service.
Basic tabulations from the survey were published in: Ministry of Health,
Ministry of Community Development, Department of Statistics, National Council
of Social Services, Ministry of Labour. "The National Survey of Senior Citizens
in Singapore 1995." November, 1996.
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Appendix A 589
A Note on Pooling Data across Countries
At several points in the volume the data from the four countries are pooled in
carrying out a multivariate analysis in which country per se is introduced as a
separate independent variable in addition to the sociodemographic characteristics
of the respondents. As described in the text, the aim is to see whether there are
distinct country factors affecting the outcomes of interest, which may reflect so
cial, cultural or economic factors that remain unmeasured in the models.
In carrying out the analyses of pooled data, consideration had to be taken
of the difference in sample sizes and population sizes across the four countries, as
described above and earlier in the volume. To pool the data as given would mean
each country would have very different weights either in terms of number of re
spondents or in terms of the proportion of older respondents represented in the
sample. Accordingly a sensitivity analysis was conducted in which the regression
models were estimated using two different strategies: one in which weights were
developed to produce equal sample sizes across countries, and one in which the
weights produced equal sampling fractions for each country. The country effects
were consistent under both weighting strategies and the decision was made to use
the first adjustment—equalizing the sample sizes in the pooled analyses presented
in the volume. The approach is analogous to an analysis of variance experiment
where one is examining a country fixed effect, along with the effect of other
covariates on a certain outcome.
Note: This appendix was prepared by Carol Roan, Albert Hermalin, and Ann
Biddlecom.
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Appendix B: Guide to Archived Data
Many of the data used for this research are maintained in the Data Archive, Popu
lation Studies Center, University of Michigan. They include several of the surveys
conducted in the project countries beginning in 1984 and transcripts of focus group
sessions conducted during 1991-92. A list of the data resources currently avail
able is given below. Release of additional data is expected in the future. Those
interested should inquire at the address shown below for a current listing and
instructions for requesting data.
ASEAN Surveys
From the set of surveys sponsored by the Association of Southeast Asian
Nations (ASEAN):
• 1984 ASEAN Survey of the Elderly: Philippines
• 1986 ASEAN Survey of the Elderly: Singapore
• 1986 ASEAN Survey of the Elderly (SEC APT): Thailand
Surveys of the Elderly in Project Countries 1989-1996
• 1989 Survey of Health and Living Status of the Elderly in Taiwan
• 1993 Follow-up Survey of the Health and Living Status of the Elderly
and Near-Elderly in Taiwan
• 1996 Survey of Health and Living Status of the Middle Aged and
Elderly in Taiwan
• 1995 Survey of the Welfare of the Elderly in Thailand
• 1996 Philippine Survey of the Elderly
Focus Group Transcripts
In 1991 -1992 the project conducted focus group sessions in the four project coun
tries. The sessions resulted in 86 focus group discussion transcripts (21 in
Singapore, 21 in Taiwan, 18 in Philippines and 26 in Thailand). All focus groups
were conducted in the native languages (which in some cases in Singapore in
volved English mixed with the native language). Most were also transcribed in the
native language except for several in Singapore where translation was done in the
course of transcription. The following table shows the number of transcripts avail
able at the Population Studies Center.
590
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Appendix B 591
Original language English translation
Singapore — 21
Taiwan 21 21
Philippines 13 18
Thailand 26 26
Note: There are no original language transcripts for Singapore, and 5 are unavail
able from the Philippines.
All English transcripts are in ASCII form and formatted for use with the Ethnograph
software. They can be easily reformatted for use with standard word processing
programs. Original language versions are based on various word processing pro
grams appropriate to the language. With some exceptions, the transcripts indicate
relevant characteristics of the area where they took place, date of data collection
and characteristics of the focus group participants: sex, place of residence (urban
or rural), socioeconomic status (high or low) and type of participants (elderly or
adult). To maintain confidentiality, no full names or addresses of participants are
included.
For additional information about the data and how to obtain them, please contact
the Population Studies Center, University of Michigan. Requests should include
the following: name, affiliation, purpose of the request. As one condition of ap
proval, users must sign an agreement that they will not distribute the data to any
other individuals or organizations. In some cases, additional restrictions may ap
ply.
Inquiries to:
Data Archive
Population Studies Center
University of Michigan
426 Thompson St
Ann Arbor, MI 48106-1248
Phone: (734)998-7154
e-mail: [email protected]
web: www.psc.isr.umich.edu/dads/
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Appendix C: Project-Related Publications
Publications from the project "Rapid Demographic Change and the Welfare of
the Elderly" include a large number of articles, reports and dissertations. These
are listed on the project website at: http://www.psc.isr.umich.edu/asia/.
An important component of this output is the series "Comparative Study of the
Elderly in Asia Research Reports," which is produced and distributed by the
Population Studies Center, University of Michigan. The series covers research
in four countries, Philippines, Singapore, Taiwan and Thailand. In some cases,
it also reports on other countries in the region and on methods developed
through the project using data from the four countries.
The Research Reports are listed below. They can be ordered in two ways:
• Electronically at http://www.psc.isr.umich.edu/pubs/series.html
Many of the reports are available in pdf format and can be downloaded
from this site.
• By contacting: Publications, Population Studies Center, 426 Thompson St.,
Ann Arbor, MI 48106-1248
Revised versions of some reports have appeared as journal publications. In this
case, the citation is shown in brackets.
No. 89-1. "1989 Survey of Health and Living Status of the Elderly in Taiwan:
Questionnaire and Survey Design."
No. 90-2. Chayovan, N., J. Knodel, and S. Siriboon. "Thailand's Elderly
Population: A Demographic and Social Profile Based on Official
Statistical Sources."
No. 90-3. Knodel, J., W. Sittitrai and T. Brown. "Focus Group Discussions for
Social Science Research: A Practical Guide with an Emphasis on the
Topic of Aging."
No. 90-4. Hermalin, A.I., M.-C. Chang, H.-S. Lin, M.-L. Lee and M.B.
Ofstedal. "Patterns of Support among the Elderly in Taiwan and
their Policy Implications."
No. 90-5. Hermalin, A.I. and B. Christenson. "Some Census-Based
Approaches to Studying Changes in the Status of the Elderly."
[Published in Asian and Pacific Population Forum 6(2):35-
67(Summer 1992), PSC Reprint No. 395]
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Appendix C 593
No. 90-6. Christenson, B. and A.I. Hermalin. "Demographic Decomposition
of Elderly Living Arrangements: A Mexican Example." [Published
in Journal of Cross-Cultural Gerontology 6:331-348(1991), PSC
Reprint No. 356]
No. 90-7. Lopez, M.E. "The Filipino Family as Home for the Aged."
No. 91-8. Chang, M.-C. and M.B. Ofstedal. "Changing Attitudes toward Old-
Age Support in Taiwan: 1973-1985."
No. 91-9. Casterline, J.B., L.J. Domingo, H. Eu, and M. Kabamalan. "The
Position of the Elderly in the Philippines: Preliminary Statistical
Analysis of the ASEAN Survey Data."
No. 91-10. Casterline, J.B., L. Williams, A.I. Hermalin, M.-C. Chang, N.
Chayovan, P. Cheung, L. Domingo, J. Knodel, and M.B. Ofstedal.
"Differences in the Living Arrangements of the Elderly in Four
Asian Countries: The Interplay of Constraints and Preferences."
No. 91-11. Christenson, B. and A. I. Hermalin. "Comparative Analysis of the
Changing Educational Composition of the Elderly Population in
Five Asian Countries: A Preliminary Report."
No. 91-12. Knodel, J., N. Chayovan and S. Siriboon. "Familial Support and
the Life Course of Thai Elderly and Their Children." [Published in
Tamara Hareven (ed.), Aging and Generational Relations over the
Life Course: A Historical and Cross-cultural Perspective, Berlin:
Walter de Gruyter and Co. (1995), pp. 438-461. Also in Tamara
Hareven (ed.), Aging and Generational Relations: Life Course and
Cross-Cultural Perspectives, New York: Aldine de Gruyter (1996),
pp. 217-240.]
No. 92-13. Knodel, J., N. Chayovan and S. Siriboon. "The Familial Support
System of Thai Elderly: An Overview." [Published in Asia-Pacific
Population Journal 7(3): 105-126(1992), PSC Reprint No. 399]
No. 92-14. Hermalin, A.I., M.B. Ofstedal and M.C. Chang. "Types of Supports
for the Aged and Their Providers in Taiwan." [Published in Tamara
Hareven (ed.), Aging and Generational Relations over the Life
Course: A Historical and Cross-cultural Perspective, Berlin:
Walter de Gruyter and Co. (1995), pp. 400-437. Also in Tamara
Hareven (ed.), Aging and Generational Relations: Life Course and
Cross-Cultural Perspectives, New York: Aldine de Gruyter (1996),
pp. 179-215.]
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594 Appendix C
No. 92-15. Domingo, L.J. "The Filipina Elderly in Development: Status and
Prospects."
No. 92-16. Domingo, L.J. and J.B. Casterline. "Living Arrangements of the
Filipino Elderly."
No. 92-17. Li, R.M. and H.-S. Lin. "Factors in Elderly Transfers of Property to
Children in Taiwan." [Published in Journal of Cross-Cultural
Gerontology, 8:49-69(1993), PSC Reprint No. 403]
No. 92-18. Hermalin, A.I., M.B. Ofstedal and C. Li. "Kin Availability of the
Elderly in Taiwan: Who Is Available and Where Are They?"
No. 92-19. Williams, L. and L.J. Domingo. "The Social Status of the Elderly
Within the Household in the Philippines."
No. 92-20. Knodel, J., C. Saengtienchai and W. Sirtitrai. "The Living
Arrangements of Elderly in Thailand: Views of the Populace."
[Published in Journal ofCross-Cultural Gerontology, 10(1-2):79-
lll(April 1995). PSC Reprint No. 461]
No. 92-21. Hermalin, A.I., M.B. Ofstedal and M.-L. Lee. "Characteristics of
Children and Intergenerational Transfers."
No. 92-22. Mehta, K., A.E.Y. Lee and M.M. B. Osman. "Living Arrangements
in Singapore: Cultural Norms in Transition." [Published in Journal
of Cross-Cultural Gerontology, 10(1-2): 113-143(April 1995)]
No. 93-23. Domingo, L.J., M.M.B. Asis, M.C.P. Jose, M.M.M. Kabamalan.
"Living Arrangements Among the Elderly in the Philippines:
Qualitative Evidence." [Published in Journal ofCross-Cultural
Gerontology, 10(1-2):21-51(April 1995)]
No. 93-24. Siriboon, S. and J. Knodel. "Thai Elderly Who Do Not Coreside
with Their Children." [Published in Journal ofCross-Cultural
Gerontology 9:21-38(1994), PSC Reprint No. 428]
No. 93-25. Knodel, J. "Population Aging and Fertility: Some Implications for
Thailand."
No. 93-26. Lee, M.-L., H.-S. Lin and M.-C. Chang. "Living Arrangements of
the Elderly in Taiwan: Qualitative Evidence." [Published in
Journal ofCross-Cultural Gerontology 10(1-2):53-78(April 1995)]
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Appendix C 595
No. 94-27. Li, R.M, L. Duberstein and H.-S. Lin. "An Exploration of Life
Insurance among the Elderly in Taiwan." [Published in Journal of
Cross-Cultural Gerontology 11(1): 81-108 (March 1996)]
No. 94-28. Williams, L., H.-S. Lin and K. Mehta. "Intergenerational Influence
in Singapore and Taiwan: The Role of the Elderly in Family
Decisions." [Published in Journal of Cross-Cultural Gerontology
14:291-322(1999)]
No. 95-29. Zimmer, Z. and H.-S. Lin. "Leisure Activity and Well-Being among
the Elderly in Taiwan: Testing Hypotheses in an Asian Setting."
[Published in Journal of Cross-Cultural Gerontology 11: 167-186
(March 19%)]
No. 95-30. Shih,S.R. andY.-L. Chuang. "Opportunities and Constraints for
Older Workers in Taiwan."
No. 95-31. Knodel, J. and C. Saengtienchai. "Family Care for Rural Elderly in
the Midst of Rapid Social Change: The Case of Thailand."
[Published in Social Change 26(2): 98-115 (June 1996)]
No. 95-32. Schoenbaum, M. "The Health Status and Labor Force
Participation of the Elderly in Taiwan."
No. 95-33. Hermalin, A. "Setting the Research Agenda on Aging in Latin
America: Lessons from Asia."
No. 96-34. Zimmer, Z., X. Liu, A.I. Hermalin, andY.-L. Chuang. "Educational
Attainment and Transitions in Functional Status Among Older
Taiwanese." [Published in Demography 35(3):361-375 (August
1998)]
No. 96-35. Cornman, J.C., A.I. Hermalin, C. Roan, M.-C. Chang. "Values,
Accommodations and Tensions in Taiwanese Families: The
Perspectives of Adult Children and Their Aging Parents."
No. 96-36. Roan, C.L., A.I. Hermalin, and M.B. Ofstedal. "Intergenerational
Contact and Support in Taiwan: A Comparison of Elderly Parents'
and Children's Reports."
No. 96-37. Liu, X., A.I. Hermalin and Y.L. Chuang. "The Effect of Education
on Mortality among Older Taiwanese and its Pathways." [Published
in Journal of Gerontology: Social Sciences 53B (2):S71-S82 (1998)]
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596 Appendix C
No. 96-38. Hermalin, A.I., M.B. Ofstedal, R. Freedman, M.C. Chang and C.
Roan. "Methodological Considerations in Aligning Independent
Surveys of Parental Support from Older and Younger Generations,
with Illustrative Data from Taiwan."
No. 97-39. Mehta, K. and P. PL. Cheung. "Retirement: Cross-Cultural
Perceptions and Preparation by Near Elderly in Singapore."
No. 97-40. Kramarow, E. and W. S. Yang. "Educational Differentials in
Mortality: An Examination of Taiwanese Data."
No. 97-41. Chan, A. and P. Cheung. "The Interrelationship between Public and
Private Support of the Elderly: What Can We Learn from the
Singaporean Case?"
No. 97-42. Knodel, J. and N. Chayovan. "Persistence and Change in the
Living Arrangements and Support of Thai Elderly."
No. 97-43. Knodel, J., P. Amornsirisomboon, and J. Khiewyoo. "Living
Arrangements, Family Support and the Welfare of the Elderly:
Findings and Implications of the 1994 Survey of Elderly in
Thailand."
No. 97-44. Raymo, J. and J.C. Cornman. "Labor Force Status Transitions
across the Life Course in Taiwan, Singapore, Thailand, and the
Philippines: 1970-1990." [Published in Journal of Cross-Cultural
Gerontology 14:221-244 (1999)]
No. 97-45. Saengtienchai, C. "Archiving Qualitative Data on Aging:
Experiences of the University of Michigan Data Archives."
No. 97-46. Ingersoll-Dayton, B. and C. Saengtienchai. "Respect for the Elderly
in Asia: Stability and Change."
No. 97-47. Traphagan, J.W. "Age Grades and Contesting Entrance into Old
Age in a Japanese Hamlet"
No. 98-48. Knodel, J. and C. Saengtienchai. "Studying Living Arrangements
of the Elderly: Lesson from a Quasi-Qualitative Case Study"
[Published in Journal of Cross-Cultural Gerontology 14(3): 197-
220 (1999)]
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Appendix C 597
No. 98-49. Chang, M.-C. and A.I. Hermalin. 1996 Survey of Health and
Living Status of the Middle-Aged and Elderly in Taiwan - Chinese-
English Questionnaire (A): Survey of those 50-66 Years of Age."
No. 98-50. Chang, M.-C. and A.I. Hermalin. 1996 Survey of Health and
Living Status of the Middle-Aged and Elderly in Taiwan - Chinese-
English Questionnaire (B): Survey of Those Over 67 Years of
Age."
No. 98-51. Hermalin, A.I. "Setting the Agenda for Research on Aging in
Developing Countries."
No. 98-52. Hermalin, A.I., C. Roan, and A. Perez. "The Emerging Role of
Grandparents in Asia."
No. 99-53. Knodel, J., N. Chayovan, S. Graiurapong, and C. Suraratdecha.
"Ageing in Thailand: An Overview of Formal and Informal
Support."
No. 99-54. Ofstedal, M.B., J. Knodel, and N. Chayovan. "Intergenerational
Support and Gender: A Comparison of Four Asian Countries."
[Published in Southeast Asian Journal of Social Science 27(2):21-
42 (1999)[
No. 00-55. Hermalin, A.I. "Ageing in Asia: Facing the Crossroads."
[Forthcoming in Hallym International Journal of Aging}
No. 00-56. Hermalin, A.I. "Challenges to Comparative Research on
Intergenerational Transfers." [Published in Southeast Asian
Journal of Social Science 27(2):9-20 (1999)]
No. 00-57. Zimmer, Z., and H.-S. Lin. "Changes in Prevalence and Transition
Rates of Functioning Difficulties, and Limitation Severity, Among
Older Adults in Taiwan: 1989 to 1996."
No. 00-58. Biddlecom, A.E., A. I. Hermalin, M.B. Ofstedal, M.-C. Chang, and
Y.-L. Chuang. "Tradeoffs between Public and Private Economic
Support of the Elderly: Results from a Natural Experiment in
Taiwan."
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598 Appendix C
The following project publications are available as reprints from the Population
Studies Center:
No. 394. Knodel, J., N. Chayovan and S. Siriboon. "The Impact of Fertility
Decline on Familial Support for the Elderly: An Illustration from
Thailand," Population and Development Review 18(1):79-103,
1992.
No. 419. Hermalin, A.I. "Fertility and Family Planning Among the Elderly in
Taiwan, or Integrating the Demography of Aging into Population
Studies," Demography 30(4):507-571, 1993.
No. 460. Knodel, J. "Focus Groups as a Qualitative Method for Cross-
Cultural Research in Social Gerontology," Journal of Cross-
Cultural Gerontology 10(1-2):7-20(April 1995)
No. 462. Milagros, M.B.A., L. Domingo, J. Knodel, and K.Mehta. "Living
Arrangements in Four Asian Countries: A Comparative
Perspective," Knodel, John and Napaporn Chayovan. "Family
Support and Living Arrangements of Thai Elderly." Asia-Pacific
Population Journal Vol. 12, No. 4
No. 472. Knodel, J., C. Saengtienchai and Walter Obiero. "Do Small
Families Jeopardize Old Age Security? Evidence from Thailand,"
BOLD 5(4): 13-17 (August 1995)
No. 549. Knodel, J., and N. Chayovan. "Family Support and Living
Arrangements of Thai Elderly." Asia-Pacific Population Journal
12(4):51-68 (December 1997).
No. 589. Chan, A., M.B. Ofstedal, and A.I. Hermalin. "Changes in
Subjective and Objective Measures of Economic Well-Being and
Their Interrelationship among the Elderly in Singapore and
Taiwan." Social Indicators Research 57(3) (March, 2002)
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Index
Note: Page numbers for Figures, graphs,
Achenbaum, W.Andrew, 102
ADLs (Activities of Daily Living), 84,
513, 551; health and, 363, 382-
85, 398, 400, 443, 453;
Instrumental (IADLs), 126, 189,
204, 479, 514; intergenerational
support and, 189-90, 191, 204
adult children, coresidence with. See
coresidence
age. See sociodemographic factors
age relationships, 39, 104. See also
intergenerational support; parent-
child relationships
aging, 117, 173; biology of, 105;
demography of, 101-5, 106;
dependency ratio and, 33-35;
fertility rates and, 26, 27, 28, 29;
gerontology, 17-18, 101, 104-5,
361,554; in place, 4, 150;
research on, 104-6, 119-22,
574-77; world context for, 26-
37. See also elderly; population
aging
Agree, Emily M., 251
agriculture, 50, 232, 233, 246-47
alcohol consumption and health, 366-
71
ancestor worship, 43
Andersen, Ronald M., 414-15,455
Andreoni, James, 124
Andrews, Gary, 119, 576, 577
Angel, Ronald, 364
anthropology, 104
archived data, 20, 590-91
arthritis, 379
and tables are italicized in index.
ASEAN (Association of Southeast
Asian Nations) surveys, 19, 119,
147, 194, 590; health status and,
362, 392; retirement and, 268
Asher, Mukul G, 69, 75, 95
Asia, fertility decline in, 26, 27. See
also Southeast Asia; and specific
country
assets, 188, 297-98. See also
homeownership; income and
assets
Atinc, Tamar Manuelyan, 565
Atoh, Makoto, 11,568
Averting the Old Age Crisis (World
Bank), 8
baby-boom cohort, 114
Bartlett, H., 88
Battistella, Graziano, 12
Becker, Gary, 124
betel nut and health, 366-71, 398
biology of aging, 105
birth rates, 8, 14. See also fertility
rates
bivariate analysis: of income, 318; of
work and retirement, 251-53. See
also multivariate analysis
Bloom, David E., 115,562
Buddhism, 38, 40, 42, 60, 88
Burkhauser, Richard V., 247, 273,
285, 567
Caldwell, John C., 112
Caldwell, Pat, 112
Cambodia, 186
599
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600 Index
caregiving. See children,
intergenerational support
Casterline, John B., 19
causal connections, 132-33, 250-51,
309,520-21,576
census data, 19, 575. See also data
collection
Central Provident Fund (CPF,
Singapore), 71, 95, 268, 308,
333; health insurance and, 13,
83; mandatory retirement and,
259, 270; savings and, 75, 334
Chan, Angelique, 308
Chayovan, Napaporn, 67, 123
childcare, 9, 189, 195, 209-10, 220,
547
children, 3, 58, 123; cohort succession
and, 522, 523; education of, 5,
261; filial support, 195-96, 557-
58; hospitalization and, 449;
intergenerational support and,
189, 217; parental support for,
563, 564; in rural households,
159-60; social contact with,
196-97, 198, 496, 546; support
for aged parents from, 67, 120-
21, 252, 306, 315, 344, 395, 464,
557
children, coresidence with. See
coresidence
China, 6, 11,41, 112, 186
Chinese Civil War, 41
Chinese ethnicity and culture, 335; in
Singapore, 18,43, 158, 162; in
Taiwan, 275, 298, 499; in
Thailand, 38-39, 40, 87
Choe, Minja Kim, 112
Christianity, 60. See also religion
Civil Servant Medical Benefits
Scheme (Thailand), 78, 80
Civil Servant Plan (Thailand), 70, 72,
97n.6
Civil Servant Retirement Regulations
(CSRR, Taiwan), 71, 73-74
civil servants, 95
Clark, Robert L., 232, 251
Cleary, Paul D., 364
Coalition of Services to the Elderly
(COSE), 93
Cockerham, W.C., 395
community-based programs, 85, 90-
93,503-10
community organizations, 280, 283
community service, 13, 90, 573
conceptual framework, 107-10
Confucian values, 43. See also
Chinese ethnicity and culture
constitutional provisions, 66-67
consumption, 116, 117
Conversion Scheme (Singapore), 89
co-payment principle, 82-83
coresidence, 143, 150-64, 168, 179-
81,561; defined, 144-45;
economic support and, 163, 177-
78,297; ethnicity and, 155, 156,
158, 162; gender and marital
status of children and, 123, 154—
62, 163-64, 167-70, 177-78,
181; generational depth and,
152-54, 160, 167; income and,
175, 177-78, 320, 322, 324, 349;
intergenerational transfers and,
192; parent's age and, 174;
policies and programs and, 545-
46; privacy and, 49, 144, 149;
retirement and, 261, 284;
transitions in, 533-34; trends in
study countries compared, 120,
147-49, 557
Cornman, Jennifer C., 54, 237
costs, of programs for elderly, 66,
417, 571-72
Cowgill, Donald O., 110
CPF accounts. See Central Provident
Fund
cross-cutting issues, 132-33
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Index 601
cultural tradition, 94, 275, 298. See
also political and cultural setting
data collection, 18-20, 575-77. See
also surveys of the elderly
DaVanzo, Julie, 122
day care for elderly, 90, 92, 93
death rates. See mortality rates
Deaton, Angus, 129
debt, 37, 40, 297, 334, 350
democracy, in Thailand, 38
demographic change, 1, 44-48, 115-
16. See also sociodemographic
factors
demography of aging, 101-5; defined,
102-3; responses to, 6-12; social
sciences and, 104-5, 106
Demography of Aging (Martin &
Preston), 102
Department of Public Welfare
(Thailand), 88, 91, 93
Department of Social Welfare
(Taiwan), 88
dependency ratios, 33-35, 48, 58,
544-45; economic growth and,
115-16, 562
depression (mental state), 386-87,
398,399,474,551
developing countries, 125, 236, 295,
571-72. See also specific country
domestic helpers, 152
Dumazedier, Joffre, 276
Duncan, Otis D., 102
Dyson, Tim, 112
East Asia, 27, 29, 30-31; dependency
ratio in, 33-35. See also specific
country
Easterlin, Richard A., 114, 115
economic activity, gender and, 53, 54.
See also labor force participation;
work and retirement
economic assistance, 85, 93-94, 163.
See also social welfare programs
economic crisis of 1997, 6, 49, 73, 81,
96, 565
economic development/growth, 2, 4,
5-6, 49, 57, 326, 569; aging
policy and, 14, 561-63; aging
population and, 28, 110, 114-18,
119; demographic trends and, 33,
35; family life and, 112; savings
and, 565. See also modernization
economic disadvantages, 480, 483,
489, 494-95, 501; indicators for,
463-64, 512; in Philippines, 470,
471
economic well-being, 5, 16, 107, 129-
30, 295-351; GNP, 49, 57, 304,
305; homeownership and, 327,
330-43; household income and
indirect sources for, 319-14;
income levels and, 301-6; living
arrangements and, 328-29, 337,
339; marital status and, 298-99,
301; measurement issues for,
296-301; policies and programs
for, 549-50; sociodemographic
factors affecting, 308-19, 335,
336-39, 355-58; source of
income and, 306-8; subjective
measures of, 324-27; work and
leisure, 233. See also income and
assets
economists, and aging, 104
education, 49, 50, 55, 199, 220, 532;
of children, 5, 261; distribution
of, 56-58; health and, 365, 366,
367, 371, 382, 390-91, 395, 400;
health care utilization and, 415,
419,423,427,435,438,439,
443, 449, 452, 456; health
services and, 415, 419, 423, 456;
income and, 370, 314;
intergenerational transfers and,
214, 217, 558, 561; labor force
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602 Index
participation and, 5, 246; literacy
and, 52, 54; living arrangements
and, 166, 167, 169-70, 171, 173,
174, 175, 178, 179; policy and
programs for, 546, 549, 555, 570;
retirement and, 252, 253; social
disadvantages and, 488, 496; in
study countries compared, 56,
524, 525-27; training for elderly,
92-93; vulnerability and, 463;
women and, 10. See also
sociodemographic factors
elderly: changing characteristics of,
52-54; defined, 18; economic
status of, 129-30; support
provided by, 205-10; support
received by, 198-204. See also
aging; population aging
elderly card program, 80
elderly unit, income of, 299. See also
income and assets
Eldershield (Singapore), 79, 84, 96
emotional and cognitive health, 363,
365, 385-88, 546; depression,
386-87,398,399,474,551
employment, 250, 453. See also labor
force participation; work and
retirement
ethnicity, 421,423, 499; coresidence
with children and, 155, 156, 158,
162. See also specific ethnic
group
Europe, 8, 10-11, 28-37, 33-35, 115.
See also specific country
European Union, 96
Evergreen Academies, 92
familial support, 6, 37, 39, 41, 43, 49,
89, 197, 566; future of, 556-61;
government programs and, 65-
66, 94, 509, 572-73; income and,
185, 314-15; investment strategy
and, 190; living arrangements
and, 120-22, 143, 162, 163;
living kin and, 58-59;
modernization and, 556;
patri lineal, 41-44, 156. See also
children; intergenerational
support; kin/kinship
family arrangements, 13, 16, 111,
120, 575; economic well-being
and, 296; modernization and,
4- 5; retirement and, 250, 251-
52, 261, 284; social security
and, 236; societal change and,
111-13
Family Service Centers, 94
farmers' pension program, 221
Federation of Senior Citizens
Association of the Philippines, 91
fertility rates, 3, 44-45, 219, 220,
522, 523; decline in Asia, 26, 27,
28, 29, 44, 60; dependency ratios
and, 48; economic growth and,
115; in Philippines, 28, 44,45,
151, 153; policies promoting, 8-
9
Fiji, 185,209
filial piety, 42, 43, 59-60
filial support, 195-96, 557-58. See
also intergenerational support
financial crisis of 1997. See economic
crisis of 1997
financial transfers. See money
exchange
Finch, Caleb E., 105
Five Year Plans (Thailand), 67
focus group sessions, 19-20, 122,
547, 559, 577; archives of, 590-
91; quotes from, 548, 560
foreign workers, 10-12, 568
Frankenberg, Elizabeth, 533, 534
Freedman, Ronald, 112
Freedman, Vicki A., 112
Free Medical Care for the Elderly
program (Thailand), 419-21
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Index 603
Fricke, Thomas E., 112-13
Fries, James F., 130
future trends, 2, 15-17. See also policy
strategies
Gallin, Bernard, 232
Gallin, Rita, 232
GDP (gross domestic product), 304,
305
gender, 42, 182n.5, 253, 281, 527; of
children, and coresidence, 154-
58; economic activity and, 53, 54;
health and, 378, 379, 394, 395,
399, 496; health care utilization
and, 421, 425, 431-33, 443, 449;
income and, 299, 334; inter-
generational support and, 190-91,
202, 204, 205, 214, 216; labor force
participation and, 240-46; marital
status and, 54-56; mortality rates
and, 3-4, 52; retirement and, 248-
49, 250, 253,254-57, 264, 266-69,
274; vulnerability and, 463. See
also women
General Social Survey (United States),
270
geronotology, 17-18, 101, 104-5,361,
554. See also aging
GNP (gross national product), 49, 51,
304, 305
Goode, William J., Ill, 113
government policy. See policies and
programs
Government Security Insurance System
(GSIS, Philippines), 68, 70
grandchildren, 58, 195,209,217
Gray Dawn (Peterson), 8
Gruber, Jonathan, 569
guest workers, 10-11. See also labor
migration
Handbook of Aging and the Social
Sciences (Binstock et al.), 104
Handbook of Theories of Aging
(Bengston & Schaie), 106
Hareven, Tamara K., Ill
Hashimoto, Akiko, 122
Mauser, Philip M., 102
Hayward, Mark D., 259
health, 262, 361-402, 535; ADLs and,
363, 382-85, 398, 400, 443, 453;
chronic conditions, 371-79, 427,
513, 552; debilitating conditions,
381-83, 443, 552; education and,
365, 366, 367, 371, 382, 390-91,
395; emotional and cognitive,
363, 365, 385-88, 398, 399;
lADLsand, 126, 189,204,479,
514; life-threatening conditions,
372, 379, 380, 382-83, 399, 400,
427,438; methodological issues
for, 362-66; physical, 371-85;
policymakers and, 401-2, 570;
risk behaviors, 366-71, 470; self-
assessed, 363-64, 388-98, 400,
427,438, 443, 551; socio-
demographic characteristics and,
365, 394, 396-97, 399;
socioeconomic status and, 364-
65, 400; surveys of, 361-62, 385,
388-89; urban-rural difference
in, 387, 395, 399, 496; work
status and, 416, 423, 444, 453,
554. See also under specific
study country
Health and Retirement Survey (United
States), 19, 298, 520, 576
Health Card Program (Thailand), 78,
80,419-21
health care programs, 75-85, 95-96,
570-72; costs of, 571-72; long-
term care needs, 85, 87-90, 96;
policymakers and, 566, 570-71;
in study countries compared, 13,
76-82. See also health insurance
programs; specific study country
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604 Index
health care utilization, 17, 130-31,
401,413-57; Andersen behavioral
model, 414-15, 455; education
and, 415, 419, 423,427, 435, 438,
439, 443, 449, 452, 456; gender
and, 421, 425, 431-33, 443, 449;
health-seeking behaviors and, 425-
29; hospitalization, 77,438-50,
456,457; outpatient sendces, 435-
38; policy recommendations for,
401, 552-53; predisposing factors
in, 414-16, 456; preventive care,
430-35, 455; surveys of, 429;
unmet needs and, 450-55; urban-
rural difference in, 419,444, 531;
Western vs. traditional, 425,427,
429, 455
health disadvantages, 486, 490, 496,
497, 509; indicators for, 464,
513-14; in Philippines, 470, 472;
in Singapore, 484; in Taiwan,
476, 481; in Thailand, 477
health insurance programs, 417-25,
456-57; in Philippines, 13, 76,
78, 417-19, 455, 456; in
Singapore, 13, 79, 82-85, 95,
417, 423-25, 456-57; in Taiwan,
13, 79, 81-82, 86-87, 364, 421-
23, 456, 457, 553; in Thailand,
417, 419-21. See also health care
programs
health sciences, 105-6
health services, 50, 52, 86-87, 401,
416
health status, 17, 130-31, 388,414,
549; analyses and, 120; home-
ownership and, 335, 337, 339,
340, 341, 343; income and, 309,
311, 314, 315, 318, 341; leisure
and, 233. 279, 280; living
arrangements and, 772, 776;
policy recommendations for,
550-52; retirement and, 253,
268, 270, 271, 284, 286; urban-
rural difference in, 531
heart disease, 379
Hermann, Albert I., 8, 28, 119, 189;
policy and research strategies
and, 574, 576, 577
Hickey, Tom, 553
Hill, Martha, 124, 125
Hinduism, 38, 43, 60
Hirosima, Kiyosi, 220
Hohn, Charlotte, 8
home health services, 86-87
homeownership and assets, 327, 330-
43, 350, 359-60; health status
and, 335, 537, 339, 340, 341,
343; pension and, 333-34
Hong Kong, 119
hospital beds, 416
hospitalization, 77, 438-50, 456, 457;
nursing homes, 85, 87-90
household, 41-42; chores in, 209;
composition trends in study
countries, 146, 148, 149-54;
defined, 123; economic status
and, 129-30, 297; income and,
298, 299, 319-24, 525, 349. See
also living arrangements
household possessions, 333
housing, 89, 150-51, 546, 572. See
also coresidence; living
arrangements
Hugo, Graeme, 530
human capital, 569. See also labor
force participation
lADLs (Instrumental Activities of
Daily Living), 126, 189, 204,
479, 514. See also ADLs; health
illiteracy, 52, 55, 54
immigration policy, 10-12. See also
migration
income and assets, 116, 296-324,
355-55, 474; factors affecting,
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Index 605
308-19, 349; from family, 185,
314-15; health care utilization
and, 444, 453; household and
indirect, 319-24; living
arrangements and, 173, 174,175,
177-80, 377, 314, 318-24, 328-
29; marital status and, 298-99,
301, 306, 307, 370, 314; measure
of, 129, 301-6; from pension
programs, 221, 284, 307, 308,
333-34, 344; policy
recommendations for, 547, 549-
50; sources of, 306-8, 345;
sufficiency of, 346-48;
transitions in, 535-38. See also
economic well-being;
homeownership; and under
specific study country
independent living, 121, 164-67, 169,
171, 173, 180, 322. See also
coresidence
Indians, in Singapore, 43-44, 425,
429, 499; coresidence and, 155,
158
Indonesia, 7P3, 194, 534
industrialization, 4,110, 111-12
industrialized countries, labor in, 241,
243, 285. See also OECD
countries; and specific country
informal support systems, 556-61,
566. See familial support;
intergenerational support
Ingersoll-Dayton, Berit, 551
inheritance, 40, 41
institutional arrangements, 1, 16, 146.
See also policies and programs
insurance. See health care programs;
health insurance programs
Integrated Geriatric Care
(Philippines), 77
intergenerational support, 5, 14, 107,
185-222, 530; background for,
190-94; changes in, 559-60;
children and social contact, 189,
196-97,198; Chinese filial piety
and, 42; current flows of, 197-
219; economic growth and, 116-
18; economic well-being and,
185; elderly who give support,
205-10; elderly who receive
support, 198-204; filial support,
195-96, 557-58; income and,
296; living arrangements and,
122-23, 143, 144; material
goods, 125, 126, 187-88, 197,
198-204, 205, 217-19;
measurement of, 123-27, 187-
90; monetary transfers, 125, 188-
89, 192-94, 197-204; motivation
for, 191-92; multiple transfers
and, 212-13; multivariate
analysis of patterns in, 213-19;
norms and attitudes about, 186,
194-96; patterns of, 104; in study
countries compared, 188, 193-
219; time transfers, 126, 187,
189-90; transfer amounts and,
210-12. See also familial
support; and under specific study
country
International Labor Office, 237
Islam, 37, 38, 43, 60
Japan, 9, 11, 26, 96; coresidence in,
149, 179; filial care in, 196, 557-
58; labor force participation in,
236, 241, 243; research on aging
in, 119, 122; Taiwan compared
to, 41, 558
jobs, retirement and, 253. See also
labor force participation; work
and retirement
Joint Selection Scheme (Singapore), 89
K; 11 M i m: i MSI I pa. Peerasit, 80, 86, 421
kin/kinship, 37, 39, 123, 191, 196;
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606 Index
Chinese patrilineal, 41^44, 154;
network, 58-59, 125, 220. See
also family; intergenerational
support
Kinsella, Kevin, 119
Kippen, Rebecca, 10, 11, 12, 568
Knodel, John, 122, 123
Korea, Republic of, 11, 185-86, 210;
coresidence in, 149, 179;
education in, 524, 525-26
labor force participation, 53, 54, 128,
231, 237-47; in agriculture, 50,
232, 233, 246-47; bivariate
analysis, 251-53; correlates of,
251-64; in industrialized
countries, 241, 243, 285;
multivariate analysis, 253-61; in
study countries compared, 237-
41; survey questions, 289-91; by
women, 11, 14, 50, 220, 237,
240-46, 283, 528-30, 569.
See also work and retirement;
and under specific study
country
labor migration, 10-12, 196, 568
Labor Standards Law (Taiwan, 1984),
71, 74
land ownership, 330, 341, 359-60
language, 37, 39, 44
Latin America, 28
Lee, Ronald D., 116, 117, 562-63
leisure activities, 275-83, 286, 554;
health status and, 233, 279, 280;
in study countries compared,
277-82; work and, 128, 232,
236, 286
Lesthaeghe, Ron, 10, 570
Li, Rose M, 298
life course perspective, 114, 247
life expectancy, 3, 14, 27, 53, 535;
mortality rates and, 26, 45, 52,
106, 130, 577
Lillard,LeeA., 124
Lin, Hui-Sheng, 111, 112, 535
literacy, 52, 54
living arrangements, 16, 120-22,
143-82, 250, 395; children's
gender and, 154-58;
determinants of, 162-70;
economic status and, 129;
education and, 166, 167, 169-70,
171, 173, 174, 175, 178, 179;
generational depth and, 152-54;
household composition and, 148,
149-54; income and, 173, 174,
175, 177, 179-80, 311, 314,
318-24, 328-29; institutional,
145-46; living alone, 164-67,
171,772, 173, 180,322,474;
living with spouse, 150, 166-67,
772, 174, 180; measure of, 121-
22, 122-23, 144-46; monetary
transfers and, 275; multivariate
results, 164, 170-78; odds-ratios
in, 171, 772, 175, 776-77;
policies and programs and, 545-
46; urban-rural difference and,
159-60, 167, 169. See also
coresidence; homeownership;
household; and under specific
study country
logistic regression analysis, 170, 171,
772, 176, 394, 454; for
hospitalization, 442, 446-47; of
retirement, 253, 258, 260, 263,
284
Logue, Barbara, 110
Mainlanders (Taiwan), 56, 275, 499
Maintenance of Parents Act (1995,
Singapore), 67
Malay, in Singapore, 43, 44, 425, 429,
499; coresidence and, 155, 156,
158, 162
Malaysia, 122, 185-86, 210
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Index 607
Manila, Philippines, 419
Manton, Kenneth G, 110
marital status, 54-56, 57, 150, 499,
528; gender, coresidence and,
123, 154-62, 163-64, 167-70,
177-78, 181; homeownership
and, 340, 341; hospitali/ation
and, 449; income and, 298-99,
301-3, 306, 307, 370, 314, 327;
monetary transfers and, 214;
retirement and, 250, 251-52,
259, 261. See also spouse;
widowhood
marriage, 9-10, 50
Marsh, Robert M., 558
Marshall, Victor W., 106
Martin, Linda G, 102, 119, 528
Martin, Philip L., 12
Mason, Andrew, 116, 118, 571
Mason, Karen O., 112
mass media, 1, 49, 292
material goods exchange, 125, 126,
187-88; intergenerational, 197,
198-204, 205, 217-19
matrilocality, 39, 156-57
Mayhew, Leslie, 571
McDonald, Peter, 10, 11, 12, 112, 568
medical services, 85, 86-87, 378, 401.
See also health care
Medifund (Singapore), 79, 84
Medisave (Singapore), 79, 83-84,
423-25, 456-57, 571
Medishield/Medishield Plus
(Singapore), 79, 83, 417
men, retirement age and, 264. See also
gender; patrilineality
mental health. See emotional and
cognitive health
migration, 56; labor, 10-12, 196, 568;
rural-to-urban, 4, 50, 399, 530-31
military, in Thailand, 38
Ministry of Community Development
(Singapore), 90, 93
Ministry of Health (Taiwan), 92
Ministry of Public Health (Thailand),
80, 86, 91
modernization, 41, 49, 66, 110, 556;
family organization and, 4-5,
112. See also industrialization;
urbanization
money exchange, intergenerational,
125, 188-89, 192-94, 197-204,
210-17; from children, 210-12;
to children, 205, 206-8; odds
ratios and, 213-15
Morgan, S. Philip, 220
mortality rates, 3, 115, 220, 389, 528,
575; life expectancy and, 26, 45,
52, 106, 130, 577
multiculturalism, 42-43
Multi-Tier Housing Scheme
(Singapore), 89
multivariate analysis/results: of
income, 318; in living
arrangements, 164, 170-78; of
retirement process, 247; unmet
medical needs and, 452; for
vulnerable groups, 492-99; of
work and retirement, 253-61
Muslim areas, 37, 38, 43,60
mutual-help schemes, 90
National Academy of Science (US),
105
National Council of Social Services
(Singapore), 89
National Demographic Survey, 147
National Health Insurance Program
(Philippines), 13, 76, 78, 417-19,
455, 456
National Research Council (US), 577
National Survey of Senior Citizens
(Singapore), 588-89
Natividad, Josefina, 87
need, support and, 191-92
Netherlands, 538, 567
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608 Index
network of support, 125, \26.Seealso
familial; intergenerational
support; kin/kinship
Ngin, ChorSwang, 122
Norway, 243
nursing homes, 85, 87-90
odds ratios, 454, 467; health and, 394,
396-97; for hospitalization, 442,
446-47; in income, 315, 317,
357-58; in living arrangements,
171, 772, 175. 776-77; material
and money transfers and, 213-
15, 218; retirement and, 258,
260, 263
OECD countries, 241, 286, 528, 553.
See also industrialized countries;
and specific countries
Ofstedal, Mary Beth, 189
Ogawa, Naohiro, 557
Okunishi, Yoshio, 11
OLS regression models, 494, 495,
497-98, 500
outpatient services, 435—38
Overseas Filipino Workers (OFW), 76
ownership. See homeownership; land
ownership
Palmore, Erdman, 110
panel studies, 576-77
parent-child coresidence. See
coresidence
parent-child relationship, 37, 40, 124,
558-59: filial piety, 42,43, 59-60
parent-child transfers. See
intergenerational support
parenthood, 8, 9
Parish, William L., 112
part-time work, retirement and, 273-74
patrilineality, 41-44, 154
patrilocality, 40, 156, 158
Paxson, Christina H., 129
pension income, 221, 284, 307, 308,
333-34, 344
pension programs, 13, 14, 250, 262,
265; labor force participation
and, 259, 264; social security
and, 247, 285. 286, 333-34. See
also Central Provident Fund;
work and retirement
personal responsibility, 82
Philippine Elderly Survey (PES),
584-85
Philippines, 2, 18, 37, 133; ADLs in,
382-85, 400; chronic health
conditions in, 373-79;
Constitution of, 66-67;
coresidence in, 147, 149, 153,
158; daily life services in, 90-91;
demographic trends in, 46, 48;
disadvantages in, 470—74;
economic assistance programs in,
93; economic growth in, 562;
education in, 56, 171, 253, 463,
524, 525-26; emotional health in,
385-88; fertility rate in, 28, 44,
45, 151, 153; filial support in,
195-96; GNP in, 49; health, self-
assessed, in, 389-93, 395-98;
health and risk behavior in, 366-
71; health care programs in, 76-
77, 78, 86, 87, 430-38, 553;
health insurance in, 13, 76, 78,
417-19,455,456;
homeownership and assets in,
331-37, 341,342-^(3, 359;
hospitalization in, 438-45, 448-
49; income in, 302, 304-8, 310-
12, 315-19, 322-27, 349, 355-
58; intergenerational support in,
185-86, 190, 194-95, 197, 199-
203, 204; labor force
participation in, 54, 237, 238,
241-46, 289, 553; labor migrants
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Index 609
from, 11-12, 196; leisure
activities in, 277-82; living
arrangements in, 164-66, 167,
320-25, 322, 323; material
support for elderly in, 188, 218,
219; matrilocality in, 156; money
transfers in, 193-94, 210-75,
217; mortality rates in, 45,52;
pension income in, 284; political
and cultural setting for, 36-37;
programs for elderly in, 95, 504-
7; religion in, 60; retirement in,
248-49, 250, 259, 262, 264, 266,
268, 269, 271-72, 274;
retirement program in, 566;
social security programs in, 68-
69, 70; support from parents in,
205-9, 210, 222; transitions in,
533; unmet medical needs in,
450-55; vulnerable groups in,
463, 465-68
physical activity, 276, 277-79, 280,
283, 292. See also ADLs; lADLs
physician services, 52, 416
policies and programs, 1, 17, 65-97,
109; community based, 85, 90-
93; constitutional provision for,
66-67; cost involved in, 66;
cross-cutting issues and, 132-33;
demographic responses to, 6-12;
economic assistance, 85, 93-94,
129; health and medical, 75-85,
86-87, 94-95; long-term care,
85, 87-90; non-demographic
responses, 12-15; social security
retirement programs, 68-75; for
vulnerable groups, 503-10. See
also specific policies and
programs
policymakers, 1, 5, 13-15, 94, 133,
558; economic well-being and,
14, 296, 565; family support and,
13, 65; health issues and, 401-2,
566, 570-71; mortality rates and,
130-31; population aging and,
120; research and, 119;
retirement programs and, 236,
286-87; social change and, 539;
sociodemographic trends and, 1,
6, 94, 114; vulnerable groups
and, 508, 510. See also policies
and programs
policy strategies, 544-78; community
services and, 573; for
coresidence, 545-46, 561;
demographic trends and, 544-45,
564-65; economic growth and,
561-63, 565; education and, 549,
561, 570; family bonds and, 547-
48, 556, 566, 572-73; for health
care, 550-53, 566, 570-72;
income and assets and, 547, 549-
50; informal support system and,
556-61, 566; intergenerational
exchanges and, 546-48, 559;
labor force and, 568-70; research
agenda and, 574-77; retirement
age and, 553-54, 568-69
political and cultural setting, 36-44;
Philippines, 36-37; Singapore,
42-44; Taiwan, 40-42; Thailand,
38-40
population aging, 1; demographic
responses to, 6-12; economic
development and, 114-17; future
patterns of, 2; non-demographic
responses to, 12-15. See also
aging; elderly
population policy, 8. See also policies
and programs
population studies, 20, 103
Population Studies Center (University
of Michigan), 20
Preston, Samuel H., 102
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privacy and coresidence, 49, 144,
149, 191
programs. See policies and programs
Provident Fund Act (Thailand, 1987),
70
Provincial Factory Workers
Retirement Act (Taiwan, 1957-
1984), 74
psychologists and aging, 105
Quadagno, Jill, 111
qualitative data, 577. See also focus
group sessions
Quinn, Joseph F., 247, 273, 285
radio listening, 276, 277-79
Raymo, James M., 54, 237
reading, 276, 277-79, 283
real estate ownership, 330. See also
homeownership and assets
recession. See economic crisis of 1997
recreation. See leisure activities
religion, 36-37, 38, 43, 44, 60
religious activity, 277-79, 280, 292
research on aging, 119-22; agenda
for, 574-77; disciplinary
perspectives, 104-6
"Research Reports on the Elderly in
Asia," 20, 592-97
residential care, 85, 87-90
Retherford, Robert D., 557
retirement age, 14, 233, 553-54, 568-
69; mandatory, 128, 259, 265,
285-86, 554, 569; in Singapore,
236, 259, 270, 554; social
security programs and, 68, 74.
See also work and retirement
retirement funds. See pension income
retirement process, 247-51
Roan, Carol I., 189
Roman Catholicism, 36-37, 60
Rudkin, Laura, 463
rural areas, 4, 18, 56, 159-60, 233,
245. See also agriculture; urban-
rural difference
rural-to-urban migration, 4, 50, 399,
530-31
Saengtienchai, Chanpen, 122
savings rate, 116, 118, 129, 330-32,
565; in Singapore, 75, 334
Schoenbaum, Michael L., 274
Schoeni, Robert F., 124
self-assessments, in health, 363-64,
388-98, 400, 427, 438, 443, 551
Senior Citizen Council of Thailand,
91-92
Senior Citizens Act (Philippines,
1991), 87
Senior Citizens Center Act
(Philippines, 1994), 91-92
senior citizens' clubs, 90-93
Senior Citizen Welfare Law (1980,
Taiwan), 67
Shanghai (China), 259
Shih, Shiau-ping, 74, 275
Singapore, 2, 52, 95, 133, 521; ADLs
in, 382-85, 400; aging
population in, 6, 45,48; assets
and savings in, 330, 332, 334;
Chinese character of, 18, 43, 158,
162; chronic health conditions in,
373-79; coresidence in, 147,
150, 151, 158, 159-60, 175, 178,
182n. 1, 557; demographic trends
in, 26, 47; disadvantaged in, 479,
483-85; economic assistance
programs in, 94; education in. 56,
253, 463, 524, 525-26;
emotional health in, 385-88;
ethnic differences in, 42-44, 425,
429, 499; fertility rates in, 8-9,
44-45; GNP in, 49; health, self-
assessed in, 389-93, 395-98;
health care in, 87, 423-25, 427-
29, 571; health insurance in, 79,
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Index 611
82-85, 95,417; health status and
income in, 314, 315;
homeownership in, 337, 335,
338-39, 340; hospitalization in,
438-45, 448-49; income in, 301,
303-7, 308, 370-77, 373, 376-
77, 322, 326-27, 355-55, 537-
38; intergenerational support in,
195, 197, 198-203, 204; labor
force participation in, 54, 237,
239, 241-246, 291, 553; labor
migrants in, 11, 12, 196-97;
leisure activities in, 277-80;
living arrangements in, 165, 166-
67, 320, 321-22, 534, 572;
marriage trends in, 9-10;
material and monetary support in,
188, 189, 193, 194; pension
status in, 262, 284; political and
cultural setting for, 42-44;
programs and policies in, 13, 67-
68, 93, 94, 96, 506-7, 508, 566;
residential care in, 88-90;
retirement age in, 236, 259, 270,
554; retirement in, 245-49, 250,
264, 267, 268, 269, 272, 566;
social disadvantages in, 479, 485;
social security programs in, 77,
74-75; support from parents in,
205, 206-8, 209; Survey of
Senior Citizens in, 588-89;
transitions in, 533; vulnerable
groups in, 463, 465-66
Singapore, multiculturalism in, 42-43.
See also Indians; Malay, in
Singapore
Singapore, pensions in. See Central
Provident Fund (CPF)
Singapore Action Group of Elders
(SAGE), 93
Smith, James P., 333
smoking and health, 366-71
social activities, 281-82
social alliance, 37
social change, 1, 65, 110-14, 123,
519-39; cohort succession and,
521-32; education levels and,
524, 525-27, 532; family
dynamics and, 548; health care
and, 531; income levels and, 535,
537-39; living arrangements and,
533-34; sociodemographic
factors in, 519-20;
socioeconomic, 4, 5, 49-52;
urbanization and, 530-31;
women and, 528-30
social clubs, 90-93, 276, 277-79,
280, 283, 293
social contact with children, 196-97,
198, 496, 546
social disadvantages, 473, 478, 485,
488, 575; study countries
compared, 491, 498-99; in
Taiwan, 479, 482
social sciences, 104-5, 106
Social Security Act (Thailand, 1990),
70, 72-73, 78, 80,81
social security programs, 13, 68-75,
222, 236; pay-as-you-go, 116,
117; pension benefits and, 247,
255, 286, 333-34; in Philippines,
68-69, 70, 76; in Singapore, 71,
74-75; in Taiwan, 77, 73-74; in
Thailand, 69-70, 72-73
Social Security System (Philippines),
68-69, 70, 76
social welfare programs, 5, 15, 66,
89-90, 544, 565; economic
assistance, 93-94. See also
policies and programs; and
specific program
sociodemographic factors, 1,17, 26-
37, 55, 57, 198; economic well-
being and, 308-19, 335, 336-39,
355-55; health and, 365, 394,
396-97, 399; living arrangements
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612 Index
and, 165-70, 172, 176;
policymakers and, 6, 114;
retirement and, 258. 260, 263;
social change and, 519-20. See
also specific factor
socioeconomic change, 4, 5, 49-52
socioeconomic status and health, 364-
65, 400
Soldo, Beth J., 124, 125
South-Central Asia, 26, 27
Southeast Asia, 27, 26, 29, 30-32,
154; dependency ratio in, 33-35.
See also ASEAN surveys; and
specific country
South Korea. See Korea, Republic of
Spain, 36, 37
spouse: living with, 150, 166-67, 772,
174, 180; retirement and, 250,
251,259, 261,284. See also
marital status
Sri Lanka, 28
Studio Apartment Scheme
(Singapore), 89
study countries, sociodemographics of
respondents in, 54-59. See also
Philippines; Thailand; Taiwan;
Singapore
support obligations, 186, 194-96. See
also familial support;
intergenerational support
surveys of the elderly, 19-20, 38;
archives of, 20, 590-91;
characteristics of samples in study
countries, 54-59; contents, 583,
585-88; on health, 361-62, 385,
388-89, 392; survey designs, 583-
88; in the US, 19,298, 520, 576.
See also ASEAN surveys
Sweden, 243
Taiwan, 2, 9, 18, 133, 535; ADLs in,
382—85, 400; aging population
in, 45, 48; assets in, 334-35;
chronic health conditions in,
373-19; cohort succession in,
521, 523; coresidence in, 123,
145, 147-48, 152, 158, 160, 178;
disadvantages in, 476-77, 479,
480-82; economic assistance
programs in, 94; economic well-
being in, 298; education in, 56,
524, 525-27; emotional health in,
385-88; ethnic differences in,
275, 499; family obligations in,
112, 196, 558-59; fertility rates
in, 44-45; GNP in, 49; health,
self-assessed, in, 389-93, 395-
98; health and risk behavior in,
366-71; health care programs in,
86-87, 430-35; health insurance
in, 13, 79, 81-82,86-87,364,
421-23,456,457, 553; home
care in, 92; homeownership in,
331, 332-33, 334-35, 338-43,
359; hospitalization in, 438-45,
448-49; income in, 301, 302,
304-8, 310-11, 313, 315-18.
320, 323-21, 355-58, 537, 538;
income satisfaction in, 344-48,
350; intergenerational support in,
195, 197-204; labor force
participation in, 54, 237, 239,
241-46, 290-91,553; labor
migrants from, 11, 196-97;
leisure activities in, 277-82, 286;
living arrangements in, 164-67,
323, 534; material support for
elderly in, 187, 188; monetary
support in, 193, 194, 210-12;
mortality rates in, 52; outpatient
services in, 435-38; patrilocality
in, 156, 158; pension program in.
95, 221,284; policies and
programs in, 67, 505, 506—7;
political and cultural setting, 40—
42; religion in, 60; residential
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Index 613
care in, 88; retirement in, 232,
248-49, 250, 259, 262, 264, 267,
268, 271-72, 274-75; retirement
program in, 566; savings rate in,
116; social disadvantages in,
478-79; social security programs
in, 71, 73-74; sociodemographic
trends in, 26, 47, 533; support
from parents in, 205, 206-8;
surveys in, 586-87; unmet
medical needs in, 450-55;
vulnerable groups in, 465-66
tax exemption, 93
television viewing, 276, 277-79
Thailand, 2, 45, 48, 52, 122; ADLs in,
382-85, 400; asset ownership in,
330; chronic health conditions in,
373-19; Constitution of, 67;
coresidence in, 123, 145, 147-
48, 149, 156, 158, 159-60;
disadvantaged in, 474-78;
economic assistance programs in,
93-94; education in, 58, 253,
524, 525-26; elderly in labor
force in, 54; emotional health in,
385-88; family support in, 39,
197; GNP in, 49; government of,
38; health, self-assessed, in, 389-
93, 395-98; health and risk
behavior in, 366-71; health care
programs in, 77, 78, 80-81, 86,
96, 364,425, 430-38; health
insurance programs in, 417, 419-
21; health status and income in,
314; homeownership in, 331,
335-37, 341, 342-43, 359-60;
hospitalization in, 438-45, 448-
49; immigrant labor in, 11-12;
income in, 301,303, 304-7,
310-12, 315-/7, 320-23, 329,
355-58,474; labor force
participation in, 238, 241, 242,
244-45. 246-47, 290, 553;
leisure activities in, 277-82;
living arrangements in, 765, 166-
67, 320, 323; material and
monetary support for elderly in,
188, 189, 193-94, 197, 199-204,
210-12; pension program in, 13,
95, 284; political and cultural
setting of, 38-40; programs for
elderly in, 505, 506-7;
residential care in, 87-88;
retirement in, 248-49, 250, 259,
262, 266, 268-72, 566; rural
elderly in, 18, 56; savings in,
330; social security programs in,
69-70, 72-73; social services for
elderly, 91; sociodemographic
trends in, 6, 26, 46; support from
parents in, 205-8, 209, 222;
survey in, 585-86; vulnerable
groups in, 465-66, 474-76;
working women in, 237
Thornton,Arland, 111, 112-13
time transfers, 126, 187, 189-90, 204,
209
tobacco smoking and health, 366-71
Top-Up Scheme (Singapore), 84
transfer systems, 116-17. See also
intergenerational support
travel and leisure, 281
Treas, Judith, 110
Tsuya, Noriko, 530
UHI. See Universal Health Insurance
Uhlenberg, Peter, 8
United Kingdom, 366
United Nations, 10, 28, 44, 530, 568;
aging population projections by,
12, 102; Economic and Social
Commission for Asia and Pacific,
119; World Assembly on Aging,
5,110,577-78
United States, 28-J/, 36, 122, 149,
535; baby-boom cohort in, 114;
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614 Index
dependency ratios in, 33-35,
115; Health and Retirement
Survey in, 19, 298, 520, 576;
health care in, 414, 416; health
status in, 335, 340, 366, 399,
400, 401; income in, 333-34,
538; labor force participation in,
241, 243, 567; retirement in, 236,
270-71, 273, 285, 554; transfers
in, 117, 191
Universal Health Insurance (Taiwan),
13, 79, 81-82, 86, 456, 566; cost
of, 417; enrollment in, 421-23,
457, 553
University of Michigan archives, 20
urban areas, coresidence in, 150-51,
186
urbanization, 4, 50, 110, 111, 399,
530-31
urban-rural difference, 4, 56, 57, 216,
341; health and, 387, 395, 399,
496; health care utilization and,
419, 444, 531; income and, 314;
in labor force participation, 243,
245; in living arrangements, 159-
60, 167, 169; policy
recommendations for, 551-52;
retirement and, 259, 262-64,
265. See also rural areas
Value of Children Survey
(Philippines), 195-96
Veblen, Thorstein, 276
Village Welfare Assistance Centers, 93
volunteer welfare organizations
(VWOs), 89-90
vulnerable groups, 17, 131-32, 461-
510; economic disadvantages for,
129, 463-64, 470, 471, 474-76,
480, 483, 489; health
disadvantages in, 464, 466, 470,
472, 476-77, 481, 484, 490;
methods and measurement issues
for, 426-29; multivariate results,
492-99; in Philippines, 470-74;
policy and programs for, 503-8,
554-55; relative risks of, 486-
92, 516-18; risk factors for, 467-
69; in Singapore, 479, 483-85;
social disadvantages for, 466,
470, 473-14, 478-19, 482, 485,
491; in Taiwan, 465-66; in
Thailand, 474-76; women in,
528, 555.
Wachter, Kenneth W., 105
Walton, Michael, 565
Wang, Wei, 259
wealth accumulation, 117,118
welfare programs. See social welfare
programs
well-being, 16, 107. See also
economic well-being; health
Westernization, 5, 49, 66, III. See
also modernization; urbanization
Western vs. traditional medical care,
425, 427, 429, 455
WHO. See World Health Organization
(WHO)
Whyte, Martin K., 112
widowhood, 52, 53, 54, 58, 174-75;
disadvantages in, 492, 494, 499.
501; homeownership and, 340;
vulnerability of, 470, 474. See
also marital status
Williams, Lindy, 548
Williamson, Jeffrey G, 115, 562
Willis, RobertJ., 124
Wilson, Chris, 112
Wise, David A., 569
women, 40, 196, 233, 281; fertility of,
220, 522, 523; labor force
participation of, 11, 14, 220, 237,
240-46, 283, 528-30, 569;
marriage and, 9, 10, 50;
matrilocality and, 39, 156-57;
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Index 615
retirement and, 259-61; social
change and, 528-30;
vulnerability of, 528, 555. See
also gender; widowhood
work and retirement, 231-87;
attitudes and preferences
related to, 265-73; bivariate
analysis of, 251-53; country
effects, 261-65; education and,
252, 253; gender and, 248-49,
250, 253, 254-57, 266-69, 274;
health and, 253, 268, 270, 271,
280, 453, 456; leisure and, 128,
275-83, 286; multivariate
analysis of, 253-61; policy
recommendations for, 553-54;
retirement process, 247-51, 273-
75; study countries compared,
234-35, 254-55, 260, 261-65,
283-85; urban-rural difference
and, 259, 262-64, 265. See also
labor force participation;
retirement age; pension
programs; and under specific
study country
work ethic, 43
work status, health and, 416, 423,
444, 453, 554
World Assembly on Aging (UN), 5,
110, 557-78
World Bank, 69, 557, 567
World Health Organization (WHO),
119,361-62
Wu, S. C, 88
Yeo Cheow, 83
Zimmer, Zachary S., 365, 535
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\
UNIVERSITY OF MICHIGAN
39015060636282
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