DRAFT. Sub-regional Seminar on Ageing Preparedness in South East Asia and South Asia held in Jakarta, Indonesia 7-8 October 2009

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1 DRAFT Sub-regional Seminar on Ageing Preparedness in South East Asia and South Asia held in Jakarta, Indonesia 7-8 October 2009 A Lens into the Vulnerability of, and Support Mechanisms for, Elderly Populations in South East Asia Dr Theresa W. Devasahayam Introduction Population ageing is an inevitable demographic trend across the world, felt initially in the developed countries but showing signs in the developing countries especially in the later part of the last century. As countries develop, there is a concomitant increase in life expectancy that places a heavier demand on healthcare and social security systems as a result of the rising old dependency ratio. Population ageing is of immense concern to governments because of the assumption that increasing life expectancy places greater stresses on state resources particularly in respect to healthcare expenditure and social security systems, although this notion has been debated by scholars (Shang and Goldman 2008; Grignon and Huber 2006; Layte 2007; cf. Mujahid 2006; see also Mehta 1997). But there is a real concern among governments toward older persons falling into the poor category or lower income bracket because this group is more likely not to be able to afford healthcare services owing to rising costs. It is widely recognized that a disproportionate number of poor people include women. Although women form a greater proportion of the older persons cohort than men because of longer life expectancy, they are also more likely to be poorer than older men. Numerous factors have been singled out to explain the reasons for why larger numbers of older women are poorer than older men. First, they have had interrupted careers because of having been employed in the labour force for fewer years than men. Interrupted careers for women also mean greater economic deprivation because they are less likely to benefit from occupational pension schemes compared with men (Groves 1992; Walker 1

2 1992). Second, because of not working or not working over long periods unlike older men, older women are more likely to be dependent on others whether it is the family or the state for financial security. While it may be argued that women by and large are disadvantaged compared with men, it can be asserted that poor women face greater vulnerability in old age compared with women from more affluent backgrounds; should poor women have worked, they would have had lower-paid jobs compared with men, resulting in fewer savings and thereby reinforcing their greater vulnerability to poverty in old age. Because of this economic setback, generally older women face greater vulnerabilities than older men such as the inability to afford healthcare and social amenities sorely needed in old age. But it must be emphasized that older men are also disadvantaged: they tend to have weaker social networks and informal support. As in the case of poorer older women, the vulnerability of poorer older men intensifies if they are poor as they would not be able to afford institutional long-term care services unlike older, richer men in the event the former do not have relatives to assist them. This paper examines the vulnerabilities of both older men and older women among the poor in South East Asia. An underlying logic in the discussion is that the older person cohort is not a homogenous group. Instead the assertion here is that the concerns and problems of the poor among the older cohort need to be disaggregated based on various indicators such as gender and socioeconomic conditions. While recognizing the differential economic and social disadvantages of older men and women, the discussion also seeks to highlight the productive and positive experiences of this cohort. Seeking to understand the different concerns and interests of poorer older men and women in the South East Asian region, this paper demonstrates that although there may be common threads across national contexts, there are some experiences of the older cohort that are unique to a particular context. The paper concludes by discussing policy recommendations to address the gaps in healthcare and support systems for older persons. 2

3 Profile of Older Men and Women in South East Asia In South East Asia, overall figures show that the proportion of females is 55 percent. Of the oldest old, that is, women over the age of 80, women constitute 59 percent (Department of Economic and Social Affairs 2007). As in the rest of the world, the proportion of older women vis-à-vis the larger population has gradually inched its way up over the last fifty years a trend that is projected to continue into 2050 (Mujahid 2006). The tables below (see table 1) shows this trend as well. Of the cohort 60 and above, the trends have been consistently upward for males and females with the exception of Brunei Darussalam, Cambodia, Laos PDR, the Philippines, Timor-Leste and Vietnam since 1960 (see table 1). But clearly the trend is upward especially for the last two decades, with the exception of Cambodia and Laos PDR. Nevertheless, taking into account the projected percentage for 2010, the numbers of older women 60 years and above is consistently larger than older men in the same age cohort, with the exception of Brunei Darussalam. Table 1: Percentage of Males to Females in South East Asian Countries, 60 years and above, Country Percentage of Males Percentage of Females Brunei Darussalam Cambodia Indonesia Laos People s Democratic Republic Malaysia Myanmar Philippines Singapore Thailand Timor-Leste Vietnam Source: Data from ESCAP (2009). 3

4 The upward trend continues in the 80 and above cohort (see table 2) as in Myanmar, Singapore and Vietnam where females constitute more than 1 percent of the population. Based on projected figures of 2010, older women in every country in the South East Asian region outnumber older men with the greatest percentage difference recorded in Singapore followed by Thailand (see table 2). Table 2: Percentage of Males to Females in South East Asian Countries, 80 years and above, Country Percentage of Males Percentage of Females Brunei Darussalam Cambodia Indonesia Laos People s Democratic Republic Malaysia Myanmar Philippines Singapore Thailand Timor-Leste Vietnam Source: Data from ESCAP (2009). Following a universal trend, the life expectancy of females is higher than males because females have lower mortality than males in every age cohort and for most causes of death (Kinsella and Wan 2009). But while it has been shown across the world that the advantage women have in developed countries is not as great in the developing countries, this pattern could change if men in the developing countries continue to engage in unhealthy behaviour such as drinking and tobacco use; in this case, the gender gap in life expectancy would widen (cf. Kinsella and Wan 2009). 4

5 While women live longer lives than men, it has been frequently argued that they experience a greater number of vulnerabilities than men on different fronts. One of the obvious vulnerabilities singled out for older women is their economic position; that they would have spent fewer years than older men in the labour force means that they have fewer savings and, therefore, are vulnerable to income insecurity. As mentioned earlier, their limited years in the labour force stems from the fact that many women tend to have interrupted careers because of family commitments. In addition, that this trend has been recorded across the South East Asian region may be indicative of several other factors: shortage of suitable work for women, lack of necessary educational and skill qualifications, and employer discrimination (Mujahid 2006). Consistently among older persons, older men more than older women have been found to have more income in old age. They also tend to receive income from various sources such as pension schemes and investments more than older women. Arguments have been made that older women are not necessarily disadvantaged in this respect since older men are more likely to channel these financial resources toward covering joint expenses in the upkeep of the household which they share with their wives (Knodel 2005). But it must be highlighted that this is distinct from when older women have their own pension income. In the latter case, they are empowered as they have direct access to financial resources without having to rely on their husbands. Another point of difference between older men and women is that older men are more likely to be still engaged in the labour force in old age. This suggests that older men tend to be more financially secure compared with older women. In contrast, older women find it more difficult than older men to find work. As a result, older women tend to be dependent on social sources for income such as from spouses, dependents and relatives. Reliance on children as a source of income, however, tends to be irregular and unpredictable, thereby adding to the vulnerability of older women. But because of their dependence on others for financial support, among older women who have lost a spouse or who do not have children, their vulnerability is heightened. The unmarried older woman is also equally disadvantaged not having both a spouse and children to depend on. 5

6 In South East Asia, the extended family model continues to be the normative living arrangement for older persons, although the trend appears to show some changes for a variety of reasons (Zimmer and Kim 2001). The reason for the continued prevalence of the extended family model is because most countries in the region are considered developing, rather than developed, where there are lower levels of older persons living alone compared with developed countries (Kinsella and Wan 2009). Co-residence with adult children was found to benefit older persons as it relieves them of financial stress and, among poorer older persons co-residence may also be a poverty-reduction strategy. Because there have been shifts in terms of living arrangement in recent decades and that the extended family is no longer necessarily the normative model, older women may not necessarily have the support that was once received by the older generations. The drop in the number of working adults in some areas because of rural to urban and international migration may have led to smaller families and fewer individuals from whom older persons might have sought support. It must be highlighted, however, that there are certain contexts in which older men are more disadvantaged than older women. Among older widowed men, the probability of living with children is much lower than for older widowed women. Since living with family members determines the quality of support received by older persons, for a widowed man who lives alone, the quality of his life would be compromised compared to widowed women who are living with others (Mujahid, Pannirselvam and Doge 2008). Considering that older South East Asian men and women potentially face different vulnerabilities based on their gender, policies targeted at older persons need to be genderresponsive. In particular, older women have been found to be economically more vulnerable than older men while older men are more socially vulnerable than older women. By and large, older women are forced to depend on family members for economic support more than older men. But this has a downside as it breeds dependence and increases older women s vulnerability if the support of relatives is not available. 6

7 Challenges of Older Men and Older Women The process of growing old poses a number of challenges to both men and women. Disability in old age affects the quality of life. As in other parts of the world, more women than men who reach older age can expect to spend the remainder years of their lives in disability (see Kinsella and Wan 2009 for details). The economic impact of disability on older persons cannot be underestimated. For older women who have fewer financial resources than older men, morbidity is an obvious disadvantage which compromises the health of older women. Because they tend to rely on social sources for financial support more than older men, this has the potential of aggravating their vulnerability. In addition given the changing demographics of this region with shrinking family size, reliance on children in old age is becoming increasingly problematic. Conversely among older men, disability need not pose as a disadvantage to them to the extent it does for older women because the former are more likely to be financially solvent and are able to afford the necessary long-term care. In fact, men have been found to have more sources of income in old age than women. In addition, greater numbers of them tend to be engaged in wage work in old age compared with older women who have been found to struggle with securing suitable employment. Being engaged in wage work also suggests that the older (male) worker is more likely going to receive health insurance coverage from his employer. Because older women tend to be poorer than older men because of having fewer savings and if they have fewer sources of support for reasons mentioned above, there is an urgency for governments to ensure that healthcare and geriatric services for the older population is kept at an affordable rate so that women are not marginalized further. In addition, because the number of unmarried women is greater than unmarried men in the old age cohort (since older women would have lost their spouses to death), it is important that there are government measures in place to ensure that this group of older women would have access to nursing home care, if needed, especially in the case of those with severe disability. 7

8 In many countries, there are healthcare programmes to benefit the poorest in society, including the old. While this is laudable, it must be emphasized that it is the lower middle-class that has become more vulnerable with rising healthcare costs because welfare programmes tend to assist only the poor. In this respect, it is important for governments to step in to develop especially the national healthcare system to maintain affordability. Health With ageing comes failing health. Illnesses in old age tend to vary for men and women. While women are more prone to some diseases, men are more likely to contract a different set of ailments, although the likelihood of suffering from hypertension, heart disease, and some cancers increases for both (for details, see Kespichayawattana and Jatipunkul 2009). By and large, however, women have higher rates of disability than men (Kinsella and Wan 2009). If there is any other significant gender differences, women are more likely to report poorer health, as it is in the case of Thailand and Singapore (Sobieszczyk, Knodel and Chayovan 2003; Kespichayawattana and Jatipunkul 2009; Chan and Jatrana 2007). In addition, Thai older women are more likely to seek medical attention by way of routine medical check ups in the last twelve months compared with Thai older men (Knodel 2005). This might have a bearing on their awareness and, as such, are more likely to report health problems. Yet older men have higher mortality rates because they are more likely to engage in health-risk behaviours, as it has been documented in Thailand (Sobieszczyk, Knodel and Chayovan 2003). Because of living longer lives, women who suffer from disability in old age experience greater dependency on family members. They also face greater likelihood of not being able to receive adequate medical attention because of not having adequate financial resources. But their vulnerability needs to be understood within the larger problem of access to healthcare. In Indonesia, for example, it is virtually impossible for those aged 65 years and above to receive health insurance coverage although vulnerability to serious medical complications tends to arise among older persons in this age cohort (Arifianto 2006). 8

9 Some countries have healthcare programmes for the destitute In Thailand, for example, all government hospitals and health centres provide free medical services to persons aged 60 and above who own an elderly card (Kespichayawattana and Jatipunkul 2009). This scheme was retained in spite of the fact that universal health coverage was introduced in The Indonesian case is no different; as part of its social safety net programme, the poor have been issued health cards that enable them to access healthcare at no cost at all to themselves (Maliki and Prasetyo 2006). Singapore has similar plans to help those from poor families who cannot afford major surgeries although these programmes need not only be restricted to older persons. In order to keep healthcare costs low, full consumer choice of providers, and quality care, Singapore has shifted healthcare costs to individuals and employers ( accessed 16 September 2009). In the Medisave programme created in 1984, the employee contributes 6-8 percent of his/her monthly salary (depending on age) to an individual medical savings account (MSA), with a contribution matched by his/her employer. Medisave contributions are part of a broader compulsory savings programme in which employees and employers each currently contribute 16 percent and 20 percent of salaries respectively into the Central Provident Fund to cover the cost of hospitalization (Medisave), pensions and mortgages. What is unique about this programme is that the individual can use a personal Medisave account to pay for hospital expenses incurred by him/herself or any of his/her immediate family members. In other words, a working adult can choose to use his/her Medisave to cover healthcare costs incurred by his/her older parent. Essentially this ruling ensures that individuals take on the responsibility of covering the healthcare costs of their own relatives. To encourage prudent use and discourage unnecessary hospitalization, there are limits on how much Medisave funds can be used to cover daily hospital charges, physician fees and surgical fees. Generally the limits are sufficient to cover the bills of most patients staying in subsidized wards in public hospitals; but for those who opt for private hospitals or more expensive accommodation in public hospitals, cash co-payments are required. In addition, Medisave can also be used for expensive outpatient treatments such as chemotherapy, renal dialysis and HIV drugs. 9

10 Preparations for old age also impacts on health outcomes. It has been found that educational levels are strongly correlated with preparations for old age (Knodel, Ofstedal and Hermalin 2002). What this means is that having lower levels of education puts individuals at higher risk in old age preparation. Since generally women have lower levels of education than men, this puts them at greater risk in old age. In Thailand, among the present cohorts of older persons aged 60 and above, males are more likely than females to have made some old age preparation. Physical health is one area in which men would have made some preparations, the others being living arrangement, financial security and arrangement for a caregiver. Curiously if women make preparations for old age, they tend to look out for their mental health only (Prachuabmoh and Im-em 2009). But if the near and far away future elderly cohorts (aged 18-59) are taken into account, greater numbers of women than men have demonstrated to have made preparations for old age in terms of financial security and physical health, in addition to mental health. This stronger inclination to prepare for old age is bound up with higher levels of education and possibly higher levels of socioeconomic status among younger women in the subsequent generations (see also Knodel and Chayovan 2008). Thus, among the older cohort of coming generations, there is a great likelihood that the gender gap in old age preparation will be substantially narrower, and concomitantly they may enjoy greater numbers of healthy years compared to the previous generations. Gendered Provision of Care Although women enjoy a longer life expectancy often perceived to be a gender advantage, many end up as caregivers to their husbands, which may be perceived to be a disadvantage since they themselves would be left without a caregiver in old age. The provision of care to spouses is a disadvantage to older women for another reason; providing care to an ill older spouse especially by younger employable female members in a family imposes restrictions on their labour force participation, as it was documented to be the case in Indonesia (Magnani and Rammohan 2007). Among poor households, this means that the family has the potential of slipping into poverty. The positive role of older persons in the lives of their adult children cannot but be underscored. Older men are more likely to provide financial assistance to adult children 10

11 compared with older women probably because the latter would not have worked (Knodel 2005). This applies irrespective of whether children co-reside with the older parent (Knodel and Chayavon 2008). Older women are also caregivers to persons with HIV or AIDS (PHA). In Thailand, mothers more than fathers end up providing personal care such as performing personal hygiene, administering medicines, cleaning wounds, feeding, etc. more than fathers (Knodel and Saengtienchai 2005; see also Knodel and Im-em 2004). Particularly among the poor, any financial costs incurred in taking care of an AIDS patient would eat into the household budget, thereby impoverishing the household even more (Knodel 2009). The provision of care by older persons to grandchildren is also highly gendered. In households with both grandparents, the trend continues to be marked by a gender division of labour in which older women more than older men take on the role of childrearing for grandchildren. Widowed Women among the Oldest Cohort Women being left without husbands through death have resulted in female-headed households. While many widowed women may turn to children and other relatives for support, widowhood nonetheless may pose a psychological strain on women although it may be accentuated in the more male-dominated cultures such as in Vietnam where the patrilineal kinship system operates (Mujahid 2006: 17; Dube 1997). But in some countries as in Cambodia, these households tend to be more vulnerable because women possess less status and authority than men in society at large (Beaufils 2000) and, as a result, are more likely to have poorer quality housing, have problems with land ownership, and do not have the necessary funds to access healthcare (Zimmer and Kim 2001). Clearly when found in this situation, these households slip deeper into poverty should there be a lack of relevant politics targeted at this group. 11

12 Skip Generation Co-residence with grandchildren is also not uncommon in South East Asia with older women playing the caregiver role, as in the younger generation. In households with only one grandparent, grandmothers are more likely than grandfathers to live with the grandchild and to play the primary role of caregiver and nurturer, especially in the absence of a parent. In Thailand, older women are more likely to be heading a household characterized by a skip generation compared with older men (Knodel and Chayovan 2008). In households with both grandparents, the trend continues to be marked by a gender division of labour in which women more than men take on the role of childrearing, including providing care for grandchildren. Nonetheless, it must be recognized that the care provided by the older persons is critical to the well-being of the family (Kinsella and Wan 2009). Elisabeth Schröder-Butterfill (2004: 497) shows how Indonesian grandparents are not only important in providing childcare and undertaking domestic tasks, but also in playing the role of economic pillars in families. In households with both grandparents, the trend continues to be marked by a gender division of labour in which women more than men take on the role of childrearing, including providing care for grandchildren. The skip generation has also been found in countries hit by the AIDS epidemic. Knodel and Chayovan (2008) mention that the deaths of adult children forms the skip generation in a household where grandparents are forced to step in and provide care towards grandchildren who have lost their parents to this disease. Income Security Older men tend to be financially more secure compared with older women while older women tend to be dependent on social sources for income, as reiterated earlier on. In addition, men have been found to have more sources of income in old age than women. Work income is one such source; in this respect, older men face a clear advantage over older women because they are more likely to be able to find work (Sobieszczyk, Knodel and Chayovan 2003; Knodel and Chayavon 2009; Knodel 2005). Men are also more 12

13 likely to receive income from a range of other sources such as investments, savings, rental income or interest. Formal retirement income is yet another source of economic security for older men. In order to cope with the rising cost of living, it has been argued that it is critical to have more sources of income in old age (Masud, Haron and Gikonyo 2008), which is an advantage older men possess over older women. In Thailand, the likelihood of older men receiving income from other sources other than work income was much higher than for older women. In contrast in Malaysia, while it was found that the number of females who reported income from one or two sources was higher than older men who reported the same number of sources of income (Masud, Haron and Gikonyo 2008), for those reporting more than three sources of income, older men had an advantage over older women. Nonetheless, the amount of income men possess tends to be much larger than women s income, as it is the case documented for Malaysia. As in the Thai case, because older men are more likely to have worked and have access to retirement income or pension funds, they have also been found to report higher mean incomes compared with older women (Masud, Haron and Gikonyo 2008). In spite of having the desire to work, women have greater problems accessing the labour force in old age because of not having sufficient years of work experience. In a study conducted in Malaysia, women have greater problems accessing the labour force in old age as a result of low levels of labour force participation in their younger years (Masud, Haron and Gikonyo 2008). This affects them adversely as they are more likely to slip into poverty than older men. For this reason, older women in Malaysia tend to be financially more insecure than older men. In addition, since women are more likely not to have worked in their lifetime or at least record fewer years of work experience compared with men, older Malaysian women are more likely to depend on children (Masud, Haron and Gikonyo 2008). In the same study conducted in Malaysia, it was found that the amount of income received by way of transfers from adult children was much larger for women (US US617.64) than for men (US250-US529.41). 13

14 Institutional and Formal Forms of Support Because a large proportion of older persons depend on their adult children for income, particularly women, this is probably a reason for why institutional support for older persons in South East Asia is undeveloped (see also Kinsella and Wan 2009). The argument here underscores the advantage of institutional support schemes for older persons such as the pension because it is a stable source of income resulting in a measure of economic independence for beneficiaries (Marianti 2003). It is important, however, that such schemes are not attached to employment so that individuals, who have not worked which for the most part include women, will also benefit from such a scheme. In addition, institutional support schemes should have a wider coverage and include those who work outside the public sector. Such a social security scheme should encourage monthly contributions by such individuals so that by the time they reach retirement age, they will receive a measure of protection. Governments in the region are slow to realising that certain segments of society may not be able to access the pension system. For example, people in the informal sector do not tend to contribute to the pension scheme and, therefore, are more likely to slip into poverty in old age. In these countries, there is a need for setting up a non-means-tested pension system as a way to mitigate poverty in this group of older persons. Nursing homes and home care services for older persons are available in most countries in South East Asia but their numbers may not be as large as they are in countries in the West since there continues to be a great deal of shame attached to the use of these programmes. Because the demand for nursing homes has been relatively low, state involvement is largely absent (Kespichayawattana and Jatipunkul 2009). By and large, most nursing homes in the countries in the region are managed by private operators, serving a clientele from the more affluent, with a smaller proportion run by the public sector. In the larger countries in the region, nursing homes tend to be predominantly found in the urban areas. But with the growing proportions of older persons in the region, there will be a time in which governments will have to step in to provide these facilities as well to cater to the less affluent. While public campaigns may be initiated by governments to remove the stigma attached to the use of nursing homes so that older 14

15 people who are in dire need of such facilities will take up these services, at the same time governments should continue to promote the family as the basic site for eldercare in order to prevent the younger generation from abandoning their aged parents in a nursing facility particularly if these facilities become more affordable and there is a fast growing middle class. Pension/Social Protection Schemes In spite of most countries in the region having had in place public policies to protect older persons, institutional support for older persons tends to be patchy. The absence of a social security system in some countries may stem from the assumption of governments that such schemes may be redundant especially since the trend is that older persons are economically supported by family members (Masud, Haron and Gikonyo 2008). The exception, however, is Vietnam which not only has a universal (85 and above) and a means-tested (60 and above) social pension for the poorest among older persons but also social insurance which allows contributors to receive benefits or services in recognition of contributions made to the insurance scheme (Mujahid, Pannirselvam and Doge 2008). Among the countries in the region with pension schemes, they tend to have limited applications to civil servants as well as armed force personnel and the police. For example in the case of Thailand, social security originated in 1901 and applied to government officials although it was expanded to government workers in It was only in 1999 that a separate contributory scheme was developed for workers in the private sector. Targeted mainly at older persons is the social pension scheme together with the Old Age Cash Allowance Programme started in In 2007, the latter scheme covered more than 25 percent of the older population (Mujahid, Pannirselvam and Doge 2008). There is a gender dimension to pensions as older men more than older women report receiving pension income. This is of no surprise because men more than women are more likely to have worked in formal employment. But given the larger cohort of older men, those who receive pension income tends to be relatively small (Knodel 2005). 15

16 1. Widows who benefit from Pensions It has been argued before that widows, in particular, benefit from pensions. Because of inflation which reduces their purchasing power, older persons are forced to change their consumption patterns to make ends meet. In Indonesia, for example, the pension is usually not the older women s first attempt at ensuring income security in old age; many tend to strive towards generating other forms of income (Marianti 2003). But since securing work and a regular income is difficult for many older women because of the lack of marketable skills, a pension becomes critical to their survival. Nevertheless, the main benefit of the pension is that it provides a reliable source of income. It has been found that the greatest beneficiaries are widows with few economic commitments such as not providing economic assistance to relatives, not being in debt, not having to fulfill a mortgage, not having considerable health expenses, and so forth. In this case, the pension may be used mainly to cover daily expenses to help maintain a minimum quality of life. But if widows have other financial commitments, a pension would be negligible to help cover those costs. Widows have been found to report that one is better off with a pension than without a pension regardless of the amount received (Marianti 2003; see also Mujahid, Pannirselvam and Doge 2008). In addition, they benefit from social pensions much more than older men because of their larger numbers and adverse poverty situation. It has been noted elsewhere that more money in the hands of older women has led to their own empowerment, reducing their vulnerability to neglect, destitution, disrespect, abuse, family violence..[in addition] it has led to their improved status in the family and community (Mujahid, Pannirselvam and Doge 2008: 20). 2. Limited Coverage: The Case of Informal Sector (Women) Workers International Labour Organization (2007, as cited in Ofreneo 2008, accessed 17 September 2009) estimates document that about 150 million people, or 63.7 percent of the total labour force, work in the informal sector in South East Asia. In the Philippines, 76.3 percent of 16

17 the total employed work in the informal sector. Statistics from Indonesia, Thailand and Vietnam also show that the informal sector continues to grow (Lansberg 2007, as cited in Ofreneo 2008, accessed 17 September 2009). The informal sector is a highly gendered labour sector. In many countries, women tend to form the majority in the informal sector and, therefore, have no access to social protection schemes. Statistics on Asia show that on average 65 percent of women are employed in the informal sector (Ofreneo 2008, accessed 17 September 2009). Nearly all informal sector workers do not contribute to state-sponsored pension schemes and, therefore, lack a safety net in old age since accessing social pension schemes are linked to having worked before in the formal sector. In addition, informal sector workers also include agricultural workers since farm work need not be considered formal sector employment. While most countries do have social security schemes targeted at those employed outside the formal sector, Vietnam, however, has dealt with this problem by putting in place a Voluntary Social Insurance Scheme. The scheme which came into effect in 2008 covered farmers (Mujahid, Pannirselvam and Doge 2008). But the scheme is not completely reliable as a safety net for women. There are instances in which men farmers are considered as workers in the national labour force statistics but not women farmers because the latter may work on farms as family members rather than wage workers. Women farmers, thus, may be left out of schemes put in place by governments, thereby increasing their vulnerability in old age. Religious Institutions The role of religious institutions in helping poorer older persons must be highlighted. Among older persons in Indonesia, seeking assistance from religious institutions is also not uncommon especially among the poor. Small sums of money are distributed in the form of zakat during the fasting month of Ramadan or on Idul Adha (Scröder-Butterfill 17

18 and Kraeger 2005). Although this kind of charity prevents starvation, for the poorest poor, among whom many are women, it is not sufficient to cover medical care. The same case was found among poor women from Malaysia. Public Assistance Public assistance is another source of financial support for poor older persons, the majority of whom are women in Malaysia because of having worked in low-skilled jobs or not having worked at all (Masud, Haron and Gikonyo 2008). Although there is a statesponsored savings scheme in place, this is inadequate for old age protection as it tends not to be sufficient for the maintenance of daily living. Social assistance is also available to older persons in Vietnam to cover housing, subsidized healthcare, and low-interest credit for destitute older persons (Mujahid, Pannirselvam and Doge 2008). It is important to note, however, that the amounts are insignificant to the extent that they are insufficient to help pull the poor out of poverty. Nursing Homes and Home Care Services Nursing homes and home care services for older persons are available in most countries in South East Asia. As in much of the rest of Asia, seeking care from institutional facilities is rare and therefore, the number of nursing homes tends to be modest (Knodel and Chayovan 2009). By and large, there is a great deal of shame around the use of these services. In addition, older persons prefer to turn to children for care (Knodel and Chayovan 2009). Thus, while older men depend on their spouses, older women are more likely to turn to their children for care in old age. If they are unmarried, they are forced to turn to nursing homes, although there may be reluctant to do so, seeking the help of relatives first. In Indonesia, nursing homes and home-care has become available through the Department of Social Affairs (Do-Le and Raharjo 2002). But Indonesians do not utilize these services because it is perceived to be shameful to send an older relative to a nursing home. For this among other reasons, the number of nursing homes is not large in proportion to the population of the country. Unlike nursing homes, however, home-care 18

19 programmes managed by NGOs are fairly well-received. PUSAKA, a home-based care centre in Indonesia, is one such example (Do-Le and Raharjo 2002). Providing a range of services and assistance to poorer older persons, the programme has seen a measure of success although its members are mostly women and the gender stereotype linking women to the caregiving role has been reinforced. In contrast to Indonesia, attitudes toward using long-term institutional care for older relatives are fast changing in Malaysia. It has been argued that the falling birth rates resulting in fewer relatives at home to provide home care has been a critical reason (Poi, Forsyth and Chan 2004). The take up rate for nursing homes in Singapore similarly has seen a rise in recent decades. Singapore s model of nursing homes combines both the efforts from private stakeholders and funds from the public sector and, thus, is different from most countries in the region. While the majority of nursing homes are managed directly by what is called VWOs (voluntary welfare organizations) where a sizable chunk of the operating costs of these residential aged care services come from the government (see accessed 20 September 2009), there are also nursing homes run by private organizations. In order to ensure consistency in quality of care across the nursing homes, the government has generated a Framework for Integrated Healthcare for the Elderly to ensure the coordination of services in order to improve the quality of training and care provision (Sitoh 2003). Aware that there is a growing need for institutional long-term care among Singaporeans because of a fast greying population and that there are genuine cases of older persons requiring institutional care, the government has been concerned about the potential abuse of these facilities, leading to the abandonment of older persons. In view of this, the Singapore government has been emphatic in reinforcing filial piety and discouraging citizens from abandoning aged parents in nursing homes, evoking instead Asian values in upholding its position ( %20the%20suggestion%20on%20JB%20Nursing%20Homes.pdf, accessed 20 September 2009). For this reason, the government has also emphasized that older persons should be 19

20 integrated into the community and, as such, aged care facilities are located within housing estates. Informal Forms of Support Employment or transfers from adult children are critical sources of income for a large proportion of the current older population in South East Asia, as much as in the rest of Asia, and particularly the case for women (Grundy 1999; Lopata 1996; Kendig, Koyano, Asakawa and Ando 1999). For many older women, their spouses are the main economic source of income because the former are more likely to have worked while they themselves would not have worked because of family demands. As such, seeking out children for social assistance in old age is common and culturally acceptable. There are strong social, cultural and religious expectations for children to provide for the financial needs of older parents (Masud, Haron and Gikonyo 2008). In many countries in the region, younger people tend to have a positive attitude toward providing support toward their aged parents, perceiving this to be their duty (Jitapunkul 2001, as cited in Kuhirunyaratn et al. 2007). But because of the weakening of social sources of support, governments need to recognize that they will have to play a more active role in supporting older persons. Governments should create social security schemes to encourage the financial independence of older persons while at the same time continue to emphasize the family as the basic site for eldercare. Current policies have not achieved the financial security of older persons as the few schemes in place tend to reach out mainly to the destitute and poor. In addition, establishing a society security scheme suggests that older persons have more than one source of social support, thereby mitigating their vulnerability. Co-residence with children and relatives: What this means for older persons? Because women are more likely not to have worked in their lifetime or at least fewer years compared with men, they are more likely to co-reside with children. In Thailand, the proportion of older women living with a child is higher than for older men whereas the proportion of older men living with a spouse is much higher than for older women (Knodel and Chayovan 2009). The cultural pattern is to live with a married daughter or 20

21 near daughters with the cultural assumption that daughters are more likely to provide oldage support (Knodel and Ofstedal 2003). In contrast in Vietnam, especially in the North, the norm is to live with a married son, suggesting that daughters-in-law are expected to be the main caregivers of their parents-in-law (Long et al. 2000). An interesting divergence occurs in Cambodia where it was found that older persons are ten times more likely to co-reside with a widowed daughter than a widowed son presumably because women are able to play the caregiver role (Zimmer and Kim 2001). But it must be noted that the older persons seeking care consist of mainly women who form a disproportionately large segment of the older person population because of the country s history of political and civil unrest (Knodel and Zimmer 2009). This younger generation of women, however, is even more vulnerable than the current generation of older persons since these widowed women will not have the care and support provided by husbands and children. In Malaysia, co-residency continues to be the model since reliance on one s own savings and assets is insufficient as old-age support (Cameron and Cobb-Clark 2005). In relation to this, evidence from Indonesia and Singapore found that the likelihood of co-residence increases among older persons who do not work (Frankenberg, Chan and Ofstedal 2002). In the same study, interestingly it was found that the interests of adult children rather than the older persons were the primary motivation for co-residence. In the Philippines, inter-generational transfers are very common since formal sources of support for example social security are not available in the Philippines. Studies have found, however, that co-residence and transfers from children whether economic or materials are not gender-based (Natividad and Cruz 1997, as cited in Frankenberg, Chan and Ofstedal 2002). Instead generalized exchange occurs across different generations including siblings regardless of gender (Agree, Biddlecom and Valente 2005). In contrast in Thailand, inter-generational transfers are clearly gendered where older men face a relative disadvantage. Thai men face a lower likelihood of receiving monetary support from adult children compared with older women in spite of their having given their children more money previously (Sobieszczyk, Knodel and Chayovan 2003). It must be noted, however, that the amounts older women received were mainly symbolic 21

22 and, in most instances, so small to make a significant difference in their well-being. Older men, in contrast to older women, did receive material support on a regular basis mostly in the form of food (Knodel and Chayovan 2009), an inter-generational transfer which is gendered as it is assumed that they are unable to cook for themselves. From Indonesian data, it was found that financial transfers from children to older persons are connected to the older person s characteristics. In terms of gender, older fathers receive less financial transfers while older women who are divorced, separated, widowed or never married are more likely to receive larger financial transfers than those who are currently married (Cameron and Cobb-Clark 2005). To put it differently, women whose spouses are alive are less likely to be dependent on their children for financial transfers. In Thailand as in the Indonesian case, older married women than men were considerably more dependent on family members to support their households. Among the non-married, in contrast, there was little gender difference with both older men and women depending on children or relatives for assistance (Sobieszczyk, Knodel and Chayovan 2003). That both men and women among the unmarried were equally dependent on relatives may be the result of the lack of a spouse. Dependence on adult children for income in old age, however, has a downside; adult children may face an increasing burden as a result of the rising costs of living especially when they have their own families. In addition, having to provide for their own children also impacts on the amount adult children can give to their own parents (Masud, Haron and Gikonyo 2008). In another study conducted in rural Cambodia and Thailand, it was found that the larger the family size, the less likely a couple would provide monetary assistance to older parents (Zimmer, Korinek, Knodel and Chayovan 2007). Living alone from children and relatives Inter-generational transfers are also found among older persons living alone, the bulk of whom have been found to be women (Walker 1992). The act of not co-residing with an older father or mother does not preclude financial transfers. In Indonesia, it was found that unmarried children transferred more financial resources to their non-coresiding mothers than their married siblings. But this same cohort makes smaller transfers to their 22

23 fathers and coresiding mothers (Cameron and Cobb-Clark 2005). Needless to say, living alone is perceived to be a disadvantage because it is linked with feelings of loneliness and the inability to receive immediate attention should there be an accident or an acute health crisis (Knodel 2005). In addition, living alone can also suggest desertion although incidence of actual desertion is rare (Knodel 2005). Although there are older persons living alone, in most cases close relatives tend to live nearby or in the vicinity and tend to be in regular communication through telephone, as it is the case in Thailand (Knodel and Chayovan 2009). Childlessness: Implications and Repercussions Because the bulk of social assistance comes from children for many older persons, the incidence of experiencing economic deprivation may be much higher if a couple does not have children. But the vulnerability older women face because of the lack of children to depend on or de facto childlessness increases manifold compared with older men. The incidence of especially experiencing economic deprivation may be much higher for women because of not having worked. Particularly among those who do not have access to pensions, such as in the case of women who have not been married or have not worked themselves, they are at greater economic risk in old age. In Indonesia, out-migration of children, for example, has resulted in de facto childlessness (Scröder-Butterfill and Kraeger 2005). While older persons tend to depend largely on their children in old age, this has proven to be increasingly impossible especially when young people migrate for work. In particular, older persons are deprived of the immediate emotional and social support they would have received if their adult children were physically with them. The absence of children was most problematic for older persons who are constantly reliant on their children for emotional, practical and physical assistance. Older women particularly widows may be more vulnerable than older men particularly if their daughters migrate for work since they would have had closer ties with daughters than sons. In this case, these women lose their only immediate source of material assistance. 23