Book reviews for The Journal of Pension Economics and Finance reflect reviewers' own views and in no way represent the views of the institution(s) with which they are affiliated.
Live Long and Prosper is the authoritative fourth instalment in a series from the World Bank East Asia and Pacific Regional Reports, with the previous titles examining employment, education, and gender equality. The comprehensive report, produced and reviewed by international experts, addresses drivers and strategies on population ageing and its demographic, social, economic, labor force, health, and healthcare implications. The balanced and constructive tone marks another notable advance since the Bank's 1994 global report ‘Averting the old age crisis’. The work is supported by excellent graphics, a goldmine of up-to-date data, and attention to the remarkable diversity in the region.
The report begins with the fundamental fact that East Asia led by China already has more older people than any other region in the world. The countries can be roughly described by the speed and pattern of population ageing stretching from already ageing societies such as Japan and South Korea to emerging ageing economies such as China, Malaysia, Thailand, and still relatively younger populations in Cambodia, Laos, Myanmar, and the Philippines. The region is also at varying stages of economic development: some countries will ‘become old before getting rich’, hence they are facing particular challenges in their readiness for social welfare and health systems responses.
The first part of the report reviews common demographic and epidemiological transitions in the region, notably rapid changes with longer life expectancies and lower fertility. It reflects on the cultural preferences for elderly co-residence that is relatively common in the region and trends towards smaller households, with China and Thailand given as examples of declining elderly co-residence rates as countries become richer. However, care should be taken in interpreting this traditional indicator as a weakening of household intergenerational support: as in the West, separate households also can signify an increasing trend of older persons having preferences and financial means to remain independent.
The second part of the report turns to the labour market as older people's main source of income. In Cambodia, Indonesia, Timor-Leste and Vietnam, over 60% of the income of people aged 60 and above was from their own labor. The notion of ‘work until they drop’ in the rural areas is quite alarming, with rural men and women working into their 70s. The report presents four main labor market strategies for continuing productivity: facilitating female labour force participation, accommodating productive working lives in formal or informal workforce such as through flexible work arrangements, and upgrading skills of older workers and integration. The fourth and different strategy, namely promoting immigration of younger workers, was suggested for aged East Asian and Pacific economies such as Singapore and Hong Kong. Notably, household savings in the region are robust but expanding the social pension complemented with contributory schemes will be crucial as a social protection system to ensure financial sustainability in the region.
The third and last part of the report focuses on health care delivery and long-term care in the region. The health sector in the region commonly has ‘hospital centric’ treatment, but increasing incidence of non-communicable diseases (NCDs) and multiple comorbidities among older persons requires health systems to strengthen primary health care for prevention and screening, especially in countries with low resources. The report recognises that continuity of care with timely referral to tertiary care and rehabilitation are effective for chronic care management. Examples are given of successful universal coverage providing equitable access in the region that substantially reduces catastrophic out-of-pocket expenditures among older persons. Improving older patient self-management with support for family caregivers and community-based care would enhance sustainable strategies. The report illustrates the need for a range of social and health-related long-term care including home care, adult day care, nursing home, and end of life care. The last section briefly notes the way forward, including examples of the expansion of ageing related surveys and the introduction of Active Ageing Indexes as indicators of work, participation, and the enabling environment for older persons. The report provides a preliminary exploration of the role of technology which is at an early stage in the region. This would be one of the future research areas that could be usefully investigated for improving health, social and long-term care.
Overall, the report captures the main challenges of population ageing, with informative cross-country statistics and valuable examples of policy practices from case country studies in the region. One of the key messages in the report worth reiterating is that ageing is not just about old people and productive ageing requires action through the life course. Effective responses require behavioural and lifestyle changes across the lifespan and health prevention in preventing or delaying the onset of non-communicable diseases. The introduction of ‘sin taxes’ for tobacco in the Philippines, Indonesia, Tonga, and Vietnam were presented as examples of cost-effective strategies for reducing risks for NCDs.
It is encouraging to see the role of women in the workforce being addressed in the report, as gender inequalities are the key determinants of female poverty adversely impacting health and functional limitations in later life. In terms of health status, the report briefly mentions mental health and wellbeing measures in addition to physical measures. Depression can be common due to personal loss, loneliness, and increasing illness, especially among poor, rural, and less educated elderly. Social and spiritual health in later life is crucial, but often insufficiently addressed; family and community continue as the mainstay in contributing to the wellbeing of older persons.
An underlying message in the report is the importance of empowering older persons to enjoy their later life. Multi-sectorial approaches are advanced for fostering positive attitudes, providing economic opportunity to remain productive, and supporting age-friendly public space. In this valuable report the World Bank has made a strong case for action in the social, economic, and physical environments that can enable older persons to remain independent and actively engaged in society. An ageing population can live longer and also thrive and prosper.
