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By Chow Zi Siong
Singapore is an ageing nation. Four key aspects of health and ageing are worth examining: The built environment, healthcare financing, long-term care facilities, and intergenerational support. Elderly Singaporeans may be fortunate to live in a well-connected ecosystem with the necessary facilities, but there are challenges in ensuring that they can consistently afford their needed healthcare. Furthermore, it is increasingly difficult to rely on loved ones for support. This brief report also questions the limits of individual responsibility and family-community support, the two key principles which underpin Singapore’s approach towards ageing.
Policy challenges in ageing Singapore
Singapore is an ageing nation. In 2018, 13.7 per cent of Singapore citizens and permanent residents were aged 65 and above. This is anticipated to reach 18.7 per cent in 2030 and 40 per cent by 2050. Furthermore, the old age support ratio – the ratio of individuals aged 20 to 64 to those aged 65 and over – has declined from 13.5 in 1970 to 4.5 to 2018. This means that, over time, there are fewer young and middle-aged economically able individuals to support the elderly, who are generally less financially capable of supporting themselves.
Compounding this situation is the fact that 6.6 per cent of elderly Singaporeans have disabilities in at least one out of five activities of daily living, a figure almost double that of that in 1997. These activities of daily living refer to essential activities for self-care, and include eating, bathing, dressing, transferring, toileting. It has been projected that Singapore will rank as the fifth oldest and least fertile country globally by 2050.
There are four salient aspects of an ageing Singapore: The built environment, financing, long-term care facilities, and intergenerational support. This brief report will provide an overview of these areas, critically evaluate the respective progress and gaps, and offer recommendations moving forward.
The built environment
It is well established that the built environment has links with health behaviours and outcomes. For example, environments that are regarded as more walkable are associated with higher physical activity amongst the young and old.
In Singapore, over 80 per cent of the elderly population reside in public housing. To this end, the state has ensured public housing integrates social and health facilities and has elderly-friendly features. The latest series of projects in Kampung Admiralty area is a testament to this, featuring 100 units with a two-storey medical centre that ensures continuity of care, childcare centre, exercise facilities, dining and retail outlets, and a hawker centre. In 2012, the Enhancement for Active Seniors Programme was rolled out to optimise living conditions within each existing unit. Slip-resistant treatment to floor tiles were made, grab bars within each unit were installed, and additional ramps were constructed.
In addition, Singapore’s public transport network has elderly-friendly features. Mass Rapid Transit (MRT) stations have ample ramps and lifts, barrier-free facilities, tactile guidance systems and wheelchair-accessible toilets. Buses are all wheelchair-accessible and bus stops are barrier-free access. In 2018, 95 per cent of residents lived within 400 metres to the nearest MRT station and have close access to taxi and bus stops.
(Research) gaps: It would be useful to consider residential satisfaction to evaluate progress of the built environment. Research to date – including in ageing Hong Kong – suggests that satisfaction is a critical determinant of elderly well-being and succcessful ageing.
In Singapore, the latest nationwide household survey in 2013 showed that 80 per cent of elderly respondents were enthusiastic about ageing in their place of residence and over 95 per cent reported a sense of belonging to their public housing towns and neighbourhood. Key reasons provided include good place, strong economic value, great sense of community and social connection, and strong familiar support between them and their married children. These reasons are consistent with the broader literature espousing the importance of services and facilities, architecture and urbanism and social connectivity with regards to residential satisfaction.
However, there are challenges too. A 2015 nationwide survey revealed that 35 per cent of elderly respondents desired for health facilities in their immediate proximity to help age well. Furthermore, 25 per cent wanted new exercise facilities and public parks in their neighbourhood. This was because the ease of access helps them keep fit and continue to be independent, and they enjoy being close to semblances of nature. These findings are also not surprising when viewed in the context of elderly preferences to continue staying in their homes. 70 per cent of them wanted to stay on in order to take care of their spouse, and less than 10 per cent would want to move to a residential aged care facility.
With healthcare financing, personal responsibility is emphasised whilst efficiency of the system is promoted. This does not, however, abdicate the state of its responsibility in helping the indigent. Three themes guide healthcare financing: A commitment to financial discipline through upfront caps on health care spending, a conservation of public monies through targeted subsidies determined through means testing, and deliberate government efforts to drive efficiency through market mechanisms while intervening to address market failures such as information asymmetry and moral hazards.
Concretely, Singapore finances health care through a “S+3M” model: S for subsidies, especially for hospitalisations and chronic conditions; and the 3Ms represent Medisave, MediShield Life and MediFund. Co-payment features prominently in this model, and the Singapore government bears only a third of total healthcare spending.
- Medisave is a mandatory national health savings account for all citizens and permanent residents of Singapore. Contribution rates for Medisave start at 8 per cent and progressively rise to 10.5 per cent as a person ages, in line with higher expected healthcare expenditure in one’s later years. Limits are placed on how much individuals can withdraw out of their Medisave. Medisave is also used to pay for the premiums of MediShield Life, which is a compulsory basic national insurance scheme designed to address catastrophic medical conditions.
- MediShield Life can be supplemented with private insurance termed integrated shield plans and is intended to pool risk and mitigate financial risk for catastrophic illnesses.
- Finally, MediFund is an endowment scheme for the indigent with limited resources despite the combination of subsidies, Medisave and MediShield life. MediFund disburses additional subsidies on a means-tested, case-by-case basis. In good economic times, the government injects top-ups into MediFund, which has grown from an initial S$200 million endowment to S$3 billion today.
(Research) gaps: While the Singapore model which champions efficiency and individual responsibility has served the majority of population well for the past few decades, cracks have begun to surface. This is in light of the adequacy of support, epidemiological changes, and social expectations.
In 2014, even though 60 per cent of Singaporeans aged 55 and above had sufficient funds in their Medisave accounts, the others do not have insufficient savings for their basic healthcare needs. Furthermore, MediShield premiums have increased and there has been an increase in MediFund applications over the years. In 2017, the number of approved applicants increased by 3.8 per cent compared to 2016, when there were already 1.14 million applicants. In light of the declining old age support ratio, this means that more elderly citizens will face difficulties in meeting their healthcare finances despite existing help.
From an epidemiological perspective, there has also been a rise in non-communicable chronic diseases. In 2018, cancer, pneumonia, heart diseases – the top three causes – made up about two-thirds of deaths. These conditions are among the costliest to manage. In addition, in 2012, it was reported that the elderly were four times more likely to be hospitalised and each hospitalisation episode was 8.2 days compared to the general population’s 5.8 days.
In analysing whether a health system is relevant to the country, some health economists assert that the population’s expectations need to be considered. In that regard, Singapore’s economic success, coupled with a global-minded populace, has led to high expectations of the healthcare its citizens should receive. Not only do citizens expect quality healthcare, they also expect it to be affordable and equitable.
The guiding principle of individual responsibility has contributed towards an efficient healthcare system that functions on market forces: Singapore’s healthcare has consistently been ranked as one of the most efficient globally. It keeps cost low while maximising health outcomes such as life expectancy, low infant mortality rate, and prevalence of major illnesses. However, given that the ultimate goal of the healthcare system is to serve the population as far as possible, the reliance on market forces and individual responsibility has been called into question.
Economists have long stated that market forces do not ensure equitable distribution of public goods and services. In the healthcare context, social norms about fairness often prohibit the allocation of resources based on price alone. Therefore, it is imperative that sufficient social benefits are provided to ensure individuals obtain the healthcare they need.
Long-term care facilities
These facilities exist alongside primary care and general hospitals to provide for the healthcare needs of the elderly. They include community hospitals, nursing homes, rehabilitation centres, palliative care centres, and home services. Many of these are operated by voluntary welfare organisations (VWOs), some of which receive government subsidies. Over the last three years, occupancy rate of these facilities have been rising.
(Research) gaps: In light of the increasing demand for intermediate and long-term care services, the government has responded swiftly to increase their supply and affordability. For example, since 2015, it has committed to double the number of community hospital beds and expand nursing home capacities by 70 per cent. Furthermore, the government has increased assistance for such health services recently in the form of a voluntary insurance specific to such services.
However, there are still two systemic challenges. The first is that financial schemes are not set up to include most individuals in need. They only capture the poor and the poorest – individuals only qualify if their per capita monthly household income falls below S$2200 – and the maximum subsidy of 80 per cent is only available for those whose per capita monthly household income fall below S$600. This means that many patients still seek hospitalisation for their long-term care needs. This results in less efficient and effective care as hospitals are not optimised for this type of care.
The second challenge is that VWOs are increasingly finding it difficult to hire and to retain skilled manpower due to the sheer salary gap between hospitals and the VWO sector. While altruism and working for job satisfaction have been the traditional motivations for employees, the growth of hospital sectors brings these motivations into question.
Intergenerational support is a key pillar in Singapore’s approach to managing an ageing population and refers to support provided by children to their parents. There are four major types of support: Financial, material, time, and emotional. Material support refers to receiving daily essential items such as food and clothes. Time support refers to household help, mobility help, and physical care help. In a 2011 nationwide survey, 75 per cent of the elderly respondents received financial support. In addition, women are more likely to receive and to provide financial support. Critically, 18 per cent of the respondents did not receive any financial support from their children. The proportion of elderly receiving other forms of support is much lower: For example, only 30 per cent received time support.
On the policy front, the government has introduced several measures to encourage stronger family ties and support. These include public housing grants for children applying to live near their parents, tax rebates for children looking after their aged parents, and priority for married children to live with or near their parents.
(Research) gaps: It is heartening to note that the elderly continue to receive various forms of support from their children. However, it needs to be pointed out that the proportion of elderly receiving financial support declined from 91 per cent in 1995 to 75 per cent in 2011. The proportion receiving non-financial support is low too. Given that Singapore’s policies heavily favour family as the first line of support, these are worrying facts. Policies that allow for better work-life balance may thus be necessary to enable families to better support their elderly parents.
Amongst the three major ethnic groups, the lack of emotional support among the Chinese compared to the Malays and Indians warrant further research. This is because previous research has suggested that despite high co-residence rates, many elderly Singaporeans still feel lonely, and that this loneliness was associated with all-cause mortality.
Conclusion and recommendations
This brief report sought to outline and critically review four key aspects of health and ageing in Singapore. Living in a rich nation which has solid infrastructure in place, the elderly are provided with some financial assistance to help meet their needs. While individual responsibility and family-community support has guided Singapore’s approach towards ageing, there are limitations.
While the Singapore government’s efforts to enhance the built environment must be commended, there is still room for improvement. A 2019 cross-sectional study in Japan, another ageing Asian country, showed that walkability of an environment was not positively associated with overall moderate-to-vigorous physical activity. The reverse was in fact true. This begs the question: While current approaches in Singapore may be favourable, could making the environment slightly less walkable actually improve certain health behaviours such as physical activity?
In addition, policymakers may want to research the changing dynamics of intergenerational support to inform the design of relevant interventions. For example, there have been increasing female participation in the workforce. Considering that men have been traditional breadwinners, this means that there may be less time available for adults to be caring for their parents. Investigating how decreased time might impact caregiving would be informative.
With healthcare financing, there needs to be more valid ways of means testing. Total financial capability is assessed based on a combination of wealth and income. This means that there are many elderly Singaporeans who are wealthy because they owm properties which have appreciated over the years, but are in reality poor due to little savings and limited allowances from their children. And for long-term care, the government might want to consider providing more direct financial support to the VWOs to aid them in their manpower challenge. Having more inclusive subsidies would also go a long way in ensuring equity, efficiency and effectiveness of care.
Finally, an overarching area worth exploring would be comparative studies across Asia. Given the ageing trajectory and similarities in sociocultural and economic factors across these countries, such studies may help Singapore develop standardised measures and approaches in ageing policy. For instance, Malaysia is also a multi-ethnic country that acknowledges the importance of going beyond ethnicity in intergenerational programmes. However, socioeconomic inequalities exist between ethnic groups in these two countries. Therefore, it might be worthwhile to understand how both countries approach these differences in the context of population ageing.
Chow Zi Siong is a public health researcher. His interests lie in the social drivers of health, obesity, mental health, and statistics. The views expressed in this article are the author’s own and do not represent the organisation he is working for.