THE FUTURE OF
AGEING
Published byInternational Longevity Centre Singapore
A Tsao Foundation Initiative© Tsao Foundation, 2014
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The ILC Global AllianceSymposium 2013

THE FUTURE OF
AGEINGThe ILC Global AllianceSymposium 2013
21 June 2013 - Singapore

Publishers
International Longevity Centre Singapore
The International Longevity Centre Singapore (ILC Singapore) aims to promote the well-being of older people andcontribute to national development through supporting policy, practice and capacity building by enabling a “connecting of thedots” between community, practitioners, academia, policy makers and the private sector through the creation of relevant
stakeholder platforms as well as high impact research that strives to inform policy, facilitate cogen policy-action translation,and promote quality, effective practice in Singapore and internationally.
ILC Singapore is a member of the ILC Global Alliance, a multinational research and education consortium which aims toaddress longevity and population ageing in positive and productive ways, typically using a life course approach, highlighting
older people’s productivity and contributions to family and society as a whole.
As an initative of the Tsao Foundation, ILC Singapore’s mission is to drive for constructive change in how society approaches
and responds to ageing.

Tsao-NUS Ageing Research Initiative
In collaboration with the Faculty of Arts and Social Sciences, National University of Singapore, the Tsao-NUS Ageing Research
Initiative was established in 2009 to spearhead ILC Singapore’s research on ageing. Under the direction of Associate Profesor
Angelique Chan, a leading researcher in the field of ageing in Singapore and internationally, numerous studies are alreadyunderway, and new, strategic partnerships - such as with the Duke-NUS Program in Health Services and Systems Research incommunity long term care service programme evaluation - are continually being forged.

Tsao Foundation
Established in 1993, the Tsao Foundation is a not-for-profit organisation dedicated to promoting successful ageing. Throughits three major initatives - the Hua Mei Centre for Successful Ageing, Hua Mei Training Academy and International Longevity
Centre Singapore - the Foundation pioneers and provides community-based, primary healthcare and social services, promotes
capacity-building in eldercare skills, and brings together practitioners, researchers and policy-makers to generate ideas andsystems which enable the actualization of the physical, social and mental wellbeing of people as they age.
The Foundation promotes access to affordable healthcare, economic security and the social participation of adults in line with
the World Health Organization’s concept of active ageing, and frames its activities within an interdisciplinary, intergenerational
and life course perspective.
With innovation, excellence and constructive change as its core values, the Foundation’s goal is to enable people to age well,regardless of life stage, health status or physical ability.

Acknowledgement
We would like to acknowledge the funding and support of the Tsao-NUS Ageing Research Initiative.

Contents
Foreword ............................................................................................................................................................... 4
Dr Robert Butler Memorial Lecture: The Future of Income Security ..................................................... 5Professor Mukul Asher,
Professorial Fellow, National University of Singapore andCouncilor, Takshashila Institution, Bangalore
Future of Long Term Care Financing in Japan and The Netherlands ......................................................13
Kunio Mizuta, President, ILC, Japan
Marieke van der Waal, Director, ILC, The Netherlands
The Future of Health and Healthcare in an Ageing World:
A Focus on Brazil, Dominican Republic and the United States ..............................................................20
Dr. Louise Plouffe, Director, ILC, Brazil
Dr. Rosy Pereyra, President, ILC, Dominican Republic
Dr. Kavita Sivaramakrishnan, Associate Director, ILC-USA
Predictors of Successful Ageing: A Longitudinal Study of Elderly Israelis .............................................26
Dr. Sara Carmel, ILC, Israel
Hava Tovel, ILC, Israel
Victoria H. Raveis, New York University
Empowerment and Social Participation of Older People in The Future:
Focus on India and the U.K..............................................................................................................................30
Peter Barnett
Policy Advisor to Baroness Greengoss, House of Lords, London
Noreen Siba, Managing Director, ILC-UK
Anjali Raje, Executive Director, ILC-India
Empowerment and Social Participation of Older People
in South Africa and Argentina in The Future ................................................................................................37
Dr. Monica Ferreira, President, ILC, South Africa
Dr. Lía Susana Daichman, President, ILC, Argentina
Lifelong Learning in France and in Europe ...................................................................................................43
Dr. Françoise Forette, ILC, France
Marie-Anne Brieu, ILC, France
Meghan Shineman, Consultant

Foreword
Tsao Foundation celebrated its 20th year in 2013. As we embark on our next decade as an organization, we arecommitting to a new and transformative future of ageing by embracing a new way of looking at it- not just from the lens of asick, disabled and poor elderly, but from the lens of an ageing population and a longevity that will allow all kinds of elders tocontinue to grow and develop their potentials.
As the world’s population grows and ages, we will be faced with complex challenges that will require innovativeand inclusive responses. As part of our 20th year anniversary, the International Longevity Centre Singapore hosted and coorganised with the Tsao-NUS Ageing Research Initiative, the ILC Global Alliance Symposium 2013 focused on “The Future ofAgeing” and brought together researchers, scientists and advocates from the ILC Global Alliance network to highlight thesechallenges and expand the dialogue on how best to address and prepare for what lies ahead.
This publication is a compilation of speeches and reports presented at the symposium, beginning with the Dr Robert
Butler Memorial Lecture. The topics within this publication reflect the breadth of the field of ageing and as such cover a range
of issues and topics from different regions.
Yet, within these diverse papers are common themes central to the future of ageing. A major theme spanningthese works is the need for a social approach to ageing that recognizes and respects the social capital of the elderly. Thisapproach also promotes empowerment, engagement, self-efficacy and lifelong learning – all topics explored from different
perspectives within this compilation. An important facet of the social approach to ageing is intergenerational interactions andexchanges. As discussed in the following papers, to wholly realize the social capital of the elderly, there must be platforms forcommunication and interaction between generations. Underpinning the social approach is the need for sustainable elderly
care frameworks. This theme includes the need for innovative solutions to providing old-age income security, the importanceof sustainable long-term care systems, as well as the need to strengthen elderly health care while supporting the creation ofage-friendly environments.
In order to meet the needs of the elderly in an inclusive and empowering way, the future of ageing requires
transdisciplinary, collaborative and innovative solutions that promote the rights and needs of the elderly. The papers within
this compilation strive to shed light on these needs and offer ways forward that address the complexities and challenges ofthe future of ageing.

Susana Harding
Director
International Longevity Centre Singapore
Tsao Foundation

4

Professor Mukul
Asher
Professorial Fellow, National
University of Singapore
Councilor,Takshashila
Institution, Bangalore

Dr Robert Butler Memorial Lecture:
The Future of Income Security
I. Introduction

Good
Morning
distinguished ladies
and gentlemen. It
is an honor to be
invited to deliver
theInternational
Longevity Centre (ILC) Singapore’s Robert Butler memorial
lecture on the future of old age income security. This is an
issue of increasing importance economically, socially, andpolitically.
I am grateful to Dr. Mary Ann Tsao, president for the ILC
Singapore, for this honor. The presence of key officials of
ILCs Global Alliance is a testimony to Dr. Mary Ann Tsao’s
leadership and to the quality of professional staff of the ILC
Singapore.
It is entirely appropriate that this lecture is in the memory ofRobert Butler, who was among the pioneers in recognizing
the need for a rigorous multi-disciplinary approach tolongevity studies. The influence of his scholarly and popular
publications (Butler 1975, 1985, 2011) among scientists andresearchers from many disciplines has been immense.
His life-long pursuit in understanding the ageing processfrom a scientific and policy perspective, and his role as an
idea-entrepreneur, not just in the United States, but alsointernationally, has now been institutionalized, helping todevelop future generation of multi-disciplinary scholars
focusing on ageing. Very few scholars are able to leave sucha rich and enduring legacy behind. He founded an ILC at
the Mount Sinai Medical Centre in 1990, and this gathering
demonstrates the spread of ILCs internationally.
His concept of ‘productive ageing’, focusing on public
policies and private behavior to enable individuals to havegood quality life has now become part of the conventional
wisdom.
He emphasized that research and policies on ageing issues
concern individuals of all ages, and not just the old. This
point has also been recently emphasized by Börsch-Supan(2013), labeling the proposition that the economics ofageing is only about the old as one of the myths.
The rest of the lecture is organized as follows. An overview
of global ageing trends is presented in Section II. These
trends arise from a combination of decline in fertility rates
and increase in life expectancy. The importance of each of
the two factors may vary across countries and even for thesame country at different periods of time. This is followed
by a discussion of how ageing impacts on the resource
requirements in Section III. Section IV discusses avenues
1

for funding and financing-mix, and is followed by concluding
remarks in Section V.

II. Global Ageing: An Overview
The most recent data on population projections is from therevised 2012 population projections of the United Nations(UN). The UN projections, which focus on chronologicalage of the population, are conventionally used for analyzing
ageing trends. Sanderson and Scherbov (2007), however,argue that as individuals live longer, both the traditional
chronological concept of ageing, which they term
‘retrospective age’ and forward looking concept termed‘prospective age’, should be used for policy formulation andanalysis. While the traditional concept measures how many
years a person has lived, the ‘prospective age’ measures thenumber of expected years left to live by the individuals.With
increasing longevity, a fifty year old person, who currently
has a much longer life expectancy than a same age person in
1990, may well make different saving, investment, labor force
participation and other relevant economic and personal
decisions. The differing behavioral decisions in turn havedifferent implications for public policies and social attitudes
towards ageing.
The data on ‘prospective age’ are however not publishedby UN and other international agencies. The focus in thissection therefore is on ‘retrospective age’. Nevertheless,policy implications of the ‘prospective age’ concept, whichis consistent with Robert Butler’s concept of ‘productive
ageing’, will be incorporated in the analysis in this lecture.
According to the medium-variant projections of the United
Nations, the global population will increase from 7.2 billion
in mid-2013 to 8.1 billion in 2025, and to 9.6 billion in 2050,
increasing by one-third in just thirty-seven years (Figure 1).
There is, however, considerable variation in the projected
global population size by the variant chosen1, especiallyafter the year 2050. Thus, the projections suggest that thedifference in population between the low and high variant
will be 10 billion people in the year 2100. Under theconstant fertility assumption (2.50 during 2010-15 period),
the corresponding differential in population projection will
be around 20 billion people. These projections bring out
the grave implications for the carrying capacity of the earth
unless the fertility rates are significantly moderated.
The above suggests that even at an aggregative level, there
is considerable uncertainty in population projections, withserious implications for public policy options, and behavioral
responses of various stakeholders in the society. They
also strongly suggest the need to strengthen population
projections and research capabilities in individual countries.
Flexibility and reversibility of public policies, including thoseThe high variant assumes half a child more per woman than the medium variant while low fertility assumes half a child less than the medium variant.
5

Figure 1: Population of the world, 1950-2100, according todifferent projections and variants

Source: United Nations Department of Economic and Social Affairs/ Population Divison, World
Population Prospects: The 2012 Revision, Key Findings and Advance Tables

involving old age income security, should therefore be
given due weightage. As an example, keeping institutional
retirement age and pension benefit schedules relatively
constant, and lack of flexibility in labor markets facilitating
employment of older workers even as longevity increases
would imply diversion of greater of society’s income andproduction to meet the needs of the elderly.
Uncertainty in population projections, lack of reliability
and timeliness of underlying morbidity and mortality data,
particularly at a disaggregated levels, and possible impact ofhealth technologies on life expectancy, which the United
Nations projections do not take into account, will makegreater competence in the price discovery process forvarious financial products or instruments deployed by public
and private sectors, including those related to pensions andhealth care, increasingly essential.
Number of Elderly and Pace of Ageing:
Select indicators of the number of elderly by regions arepresented in Tables 1A and 1B, on the basis of which thefollowing observations may be made.

6i.

The projections indicate that the ageing phenomenon
is global and its extent is accelerating. Globally, thenumber of individuals above 60 (henceforth theelderly) is projected to increase from about 765
million in 2010 to 2021 million in 2050; an increaseof two and a half times in just forty years, while theproportion of elderly will nearly double from 11 percent of the total population in 2010 to 21 per centin 2050. This implies rapid pace of ageing leaving lessscope for gradual adjustments to the ageing society.

ii.

Most of the increase in the number of elderly will
be in less and in least developed regions, whichhave lower incomes and institutional capacities toaddress the challenges of the ageing society. Thus,
the share of elderly in more developed regions

will decline from thirty-five percent of the global
elderly in 2010 to only twenty-one percent in 2050.
By 2050, the so-called ‘old-old’ (i.e. those above
80 years) will constitute about a fifth of the elderly
as compared to fourteen percent in 2010. In moredeveloped regions, however, the old-old will comprise
thirty percent of the total elderly by 2050. This trend
is significant as this group of elderly will require
disproportionate share of the resources going to theelderly. As Figure 2 suggests, public health expenditure
as share of GDP per capita increases with age in OECD
countries (Maisonneuve and Martins Oliveira, 2013).
The diamonds represent the median.The boxes are the
2nd and 3rd quartiles of the distribution of expenditureacross countries. The whiskers are the 1st and 4thquartiles. The reasons for such dispersion and how tominimize the dispersion need to be better understood,
particularly in low and middle-income countries.This isessential for pricing health insurance products, and fordeveloping strategies for risk sharing among different
stakeholders. More robust databases and researchcapabilities will however be needed to pursue this task.
Recent developments in Japan help illustrate thechallenges awaiting other rapidly ageing countries.
Japan celebrated 50 years of universal health coveragein 2011. In 2013, to address rising costs of medicines,
the Central Social Insurance Health Care Committee(CSIHCC) proposed using “… economic valuation in
granting the health insurance coverage and setting theprices” (Okamoto 2014). Under the proposal, economic
evaluations will be undertaken to ascertain the cost of
prolonging quality adjusted life by one-year for chronic
diseases when certain medicines are to be covered byinsurance.This is a major departure from universal access.
iii. The feminization of the elderly is evident from the dataon sex ratio (number of men per hundred women)of 83.3 for those above 60 and only 59.8 for thoseDr Robert Butler Memorial Lecture : The Future of Income Security

Figure 2: Public health expenditures by age groups as share of GDP per capita

Source: Maisonneuve, C. & Martins Oliveira, J., 2013

above 80. This is the outcome of higher life expectancy
for women than for men. Globally, in 2010-15, life
expectancy of women at age 60 was four years higher
than for men. This suggests that old-age retirement
income security arrangements must have provisions
for survivors’ benefits as while women live longer thanmen, their labor force participation rate as a group is
usually lower than that for men. Thus, globally, whilemore than two-fifths of men over sixty were still
participating in the labor force, the corresponding
proportion of women was only one-fifth. The labor
force participation rates tend to vary inversely withincome. As per capita incomes in less and in least
developed countries grow, they will begin to exhibit
trends similar to those found in more developed regions.
iv. The data suggests that the tendency of the elderly
to live independently tends to increase significantlywith per capita income. Thus, circa 2010, while
nearly three-fourths of men and women in moredeveloped regions were living independently, thecorresponding global average was about two-fifths.
Thus relying primarily on family and community informal arrangements for providing old age income
security becomes less feasible as rapid ageing occurs
and per capita incomes rise. Independent living widens
choice, the primary benefit of higher income, but it
increases the need for formalization of retirement
arrangement, and raises costs of their provision.
v.

The global ageing trends will have significant labormarket implications.The old age support ratio (numberof persons aged 15 to 64 years per person aged 65
years or over) for the world will fall from 8.6 in 2010
to 4 in 2050, implying that there will be less numberof workers to support the aged. Greater labor market
flexibility and other institutional arrangements will beneeded to reduce the proportion of average lifespanspent without participating in the labor market. Suchextended labor market engagement is consistent withButler’s concept of productive ageing, and with researchthat suggests that labor market participation performs

an anchoring function, helping to keep the mind active
and providing social interaction opportunities (BörschSupan, 2013).
Ageing trends in five most populous countries:
The ageing trends in the five most populous countries of
the world suggests that the world will face challenges infinancing old age and facilitating productive ageing in thesecountries on an unprecedented scale. The number of
elderly in China is projected to increase from about 193
million in 2013 to over 450 million by 2050, while in India it
is projected to increase from 103 million in 2013 to almost
300 million by 2050.The United States, Indonesia, and Brazil
will have about 109, 68, and 67 million elderly persons by
2050 respectively (Table 2).
Population projections for Africa:
The population projections for Africa also suggest
unprecedented challenges in financing old age income
security. The population of Africa is projected to increaseabout five-fold over this century, and that of Sub-SaharanAfrica about six-fold. The old age population in Africa
isprojected to increase by nineteen times, to 795 million,
over this century, and that of Sub-Saharan Africa by overtwenty-two times. Nigeria will witness an eight-fold increasein population, and a twenty-five-fold increase in old-age
population over this century. It is expected to surpass Brazil
to be counted among the five most populous countries in
2100. (United Nations, 2013).

III. Ageing and Resource Requirements
An overview of the global and regional trends in ageingstrongly suggests that societies will need to allocate
additional resources for the aged. Productive ageing policies
will also require high level of organizational and coordination
capabilities by all stakeholders in the society.
This section briefly reviews the projections of additional
expenditure (as a share of GDP) needed to address the7ageing trends. Even as the need for broader productive
ageing policies and programs is recognized, the projections
primarily focus on costs of pensions, healthcare, and longterm care. Even for these areas, the main focus is on
financial costs, and not broader economic costs. Thus,
the opportunity costs of “unpaid” or “voluntary” care, so
prevalent in the not-for- profit sector, and in civil-society
organizations, are usually not estimated2.
The focus of public policies for provisioning of old age
income security is usually on pensions, healthcare, and longterm care arrangements. For the European Union (EU 27),
age related expenditure on these three areas is projected
to rise from 20.3 percent of GDP in 2010 to 24.5 in 2060,
requiring additional 4.2 percent of GDP (Roy, Puhani, andHsieh, 2013).
As may be expected, the average hides wide variations inresources needed for individual countries. Such projections
for non-OECD Asian countries are not available. The
age related expenditures are however expected torise as coverage and benefit levels increase, and as stateintermediation acquires greater prominence.
For analyzing resource needs for ageing, ‘life expectancy
at 60’ is a relevant indicator. For 2010- 15, it is projected
globally to be 18 years for men, and 22 years for women(Table 1B). The differences in life expectancy are positively
correlated with income levels. As the current low andmiddle- income countries progress towards higher income
levels, the differential may however narrow among regions,but widen among men and women.
The tendency for the elderly to live independently is also
positively correlated with income. Globally, about two fifths
of elderly men and women exhibit this tendency (Table 1B).
The East Asian welfare model which emphasizes family as
the main provider of retirement income security appears
oversimplified as empirical evidence in East Asia alsosuggests that in some economies such as Taiwan, significant
proportion of the elderly are living alone, and much of theeconomic support from non-government sources has been
replaced by the support from the state (Li, 2013). A higher
proportion of elderly living independently imposes not justfinancial challenges, but challenges related to delivering
public services to them as well.
Many Asian countries hope to rely on increasing labor force
participation of the elderly to finance old age. Globally, only
about two-fifths of elderly men, and one-fifth of elderly
women are participating in the labor force (Table 1B).
This ratio, however, declines with rising incomes, a trend
which low and middle income Asian countries are likely to
exhibit as their per-capita income increases. Nevertheless,obtaining at least a portion of income in retirement fromlabor market activities will be essential, requiring changes
not only in the functioning of the labor markets, and tax
provisions for the elderly, but also attitudinal changes by
the stakeholders.
Two broad avenues for funding requisite resources arethrough reducing expenditure needs, and through raising
additional resources. It may be useful to distinguish between
funding and financing for the old age.
Funding involves allocating society’s total economic
resources to meet the needs of the ageing population.
To the extent cost compression and expenditure-needs
reducing measures are effective, the requirements for
additional funding will be lower. Each society however willneed to find additional resources to meet ageing challenges,
but their size will vary among different societies.
Financing refers to different methods or instruments,
such as social or private insurance, mandatory savings,
government budgetary financing, employer provision3, etc.
Financing mix is important as it impacts on where theultimate economic burden lies and how the risks of funding
the aged are distributed among different stakeholders.
Avenues for Funding Resources and Financing – Mix :Two broad avenues for funding concern reducing
expenditure needs, or more accurately reducing the growthrate of increases in funding needed to meet the ageing
challenges; and to raise conventional and non-conventional
government revenues, including taxes.
It should be recognized that the primary source of economic
security for both the young and the old is dependent on thecurrent level of GDP and its trend rate of growth (Barr andDiamond, 2008). Merely putting aside money for retirement
is thus not adequate; the pension savings must also be
utilized productively through financial intermediation.
Levy and Schady (2013) have emphasized the importanceof sustainable economic funding in a recent survey ofsocial policies in Latin America; “Social policy, in our view,should also contribute to productivity growth, or at least
not hinder it. In the end, one cannot sustain a welfare state
on stagnant productivity, particularly since the costs of thatwelfare state will increase rapidly as the region’s population
ages and its epidemiological profile evolves towards morecost pathologies” . . . “Higher average per capita incomesare needed if only to provide the revenue base from whichsocial programs can be financed - a key point in a region
that in the past suffered much from unsustainable fiscal
deficits.”
The above message is particularly instructive in the current
global economic environment that has led to diminishedThis is an area meriting greater research efforts.
The economic burden however may be partly or wholly shifted to employees and others as employers alter other elements of the overall staff costs ofthe company.
4
Towers Watson’s Global Pensions Assets Study (GPAS) 2014, covering 13 countries/economies indicates that pension assets as at end of 2013 were
nearly USD 32 trillion, equivalent to slightly more than four-fifths of the GDP of the sample countries. Investing these assets in a manner which enhanceslong term growth rate of these countries could help generate real resources to fund ageing needs. It is in this context that the issue of allocation of savings by global financial and capital markets assumes significance.
2
3

8

Dr Robert Butler Memorial Lecture : The Future of Income Security
growth prospects, increased importance of fiscal anddebt sustainability, increasing difficulties in generating highreturns from the pension assets4, search for more reliable
macroeconomic theory and policy guidelines, and rising
global inequalities. (IMF, 2013).
Reducing Expenditure Needs:
Policies conducive to productive ageing facilitate at least
three avenues for reducing the expenditure needs. First,
they could lead to better understanding the underlying
reasons for certain diseases being more prevalent in theelderly, reducing their incidence and treatment costs.
Second, they could assist in keeping individuals economically(and socially) active for a longer period. Increasing theeffective retirement age5 has been one of the significant
policy responses in Europe, U.S, Japan, Singapore, and the
U.K. Other Asian countries, most notably China, India andIndonesia, may also consider reforms designed to increase
effective retirement age to reduce the number of years forwhich financing is needed in old age. The gradual rather
than abrupt shift from full time work to retirement also
merits serious consideration.
Third, awareness of productive ageing facilitates more
informed debates about ageing and equitable sharing ofresources and amenities between generations. This is anarea where ILCs are playing a vital role. The state also has a
responsibility to initiate high quality expertise and empiricalevidence based debate among all the stakeholders.
Fourth, Social Security needs of increasing number ofcross border workers also need to be addressed. Officially
recorded remittance flows to developing countries reachedan estimated $401 billion in 2012, growing by 5.3 percent
compared with 2011. Remittance flows are expected to
grow at an average of 8.8 percent annual rate during 20132015 to about $515 billion in 2015 (Table 1: Estimates andprojections for remittance flows to developing countries,
Migration and Development Brief, World Bank,2013). Stockof immigrants is projected to increase from about 216
million in 2010 to 400 million by 2040 (Sutherland, P. 2013,
Migration is Development).
In analyzing labour migration,Holzman and Koettl (2014) haveargued that “… legal and human rights based considerations
are increasingly joined by economic considerations that help
underpin the social policy objectives with a more analyticaland empirical framework”. They propose a framework foranalyzing portability of pension and health benefits acrossborders which incorporate risk pooling, pre-funding andredistribution to improve efficiency and fairness. Such aframework can be used both as a substitute and compliment
to totalization agreements.
The totalization agreements involve recognition of social
security contributions made by citizens of the two

respective countries. They therefore help protect social
security benefit rights of workers who divide their working
career between two or more countries. They are akin to
Double Taxation Treaties (DTAs) involving income taxation.
In Asia, the Philippines and India have been active in pursuing
totalization agreements. It will be necessary to review thesocial security provisions for cross border workers foreach provident and pension fund scheme. This will be achallenging task.
Fiscal Space: Definition and Options
The discussion so far strongly suggests that countries willneed substantial fiscal space. Fiscal space may be defined as“…the financing that is available to government as a result ofconcrete policy actions for enhancing resource mobilization,and the reforms necessary to secure the enabling
governance, institutional and economic environment forthese policy actions to be effective for a specified set ofdevelopment objectives.” (Roy, Heuty and Letouze, 2007).
The above definition explicitly recognizes that if additional
budgetary expenditure, including that for social protection,
is not spent productively with outcome orientation, thenthe desired impact will not occur. In countries with low
coverage and large informal sectors, budgetary financed
and mostly non-contributory, but means, asset, or pension
tested social pensions grants will be needed.
In many Asian countries, the coverage of pension andhealthcare programs is relatively low. For extending
coverage, social pensions, involving non-contributory
benefits financed from budgetary revenue are potentiallyan important source. But these require fiscal space andorganizational capacity by the public sector to deliver thesepensions to the intended beneficiaries.
Estimates of fiscal costs of adequate social pensions alone
are large. In New Zealand, fiscal costs in 2009-10 were 4.3
percent of GDP and are expected to increase to 8 percent
of GDP by 2050. In Australia, the fiscal costs of means
tested pensions were 2.7 percent of GDP in 2009, andare projected to be 3.9 percent of GDP in 2050 (Bateman
and Piggott, 2011). ILO has estimated that modest social
pensions in low and middle- income countries would bearound 1 percent of GDP in the short run; but its estimates
for a complete social protection package range from 3.7
percent to 10.6 percent of GDP (Barrientos, 2009). Evenif additional resource needs are equivalent to around 2
percent of GDP, this will require substantial reforms inpublic financial management in countries with total fiscal
revenue to GDP ratio of around 20 percent6.
An argument may be made that without reforming existing
formal systems and realizing real resources savings,
additional fiscal (and private expenditure) space would be
difficult to create without significant distortions elsewhere.
Some countries such as U.K, India, Singapore, as well as somestates in US have been reforming civil service schemes tobring about greater equity and sustainability. Progress will

This is usually lower than the institutional or statutory retirement age.
There is anecdotal evidence that state officials collect tax-like levies from individuals and businesses that do not get deposited in the state treasury, andare therefore not included in conventional measures of tax revenue. This implies that real tax burden in an analytical sense may well be much higher, which
may reduce the scope for further increases in raising fiscal resources.
5
69

depend on improving design, and administrative features ofpension schemes, with a view to leveraging small parametricchanges, which cumulatively will have a signification impact
on sustainability and fairness of the current pension andhealthcare schemes.
Additional Avenues:
Additional avenues to generate resource savings and fiscal
space and finance for funding expenditure on the aged arebriefly noted below.
There is considerable scope for economic resource savings,
which can be obtained through increased professionalism
in the design, administration and structure of provident andpension funds, and health care systems, among others. The
Philippines SSS (Social security system), for example, exhibits
administrative costs of around 7 percent of contributions,while the estimate for Malaysia’s EPF (Employee Provident
Fund) is around 3 percent. A reduction in costs of the SSS
through process and system reforms could thus improve
benefits. The SJSN Law of Indonesia (2004) has insufficient
clarity on financing, benefits etc., and does not adequately
address the need for appropriate organizational incentive
structures. This neglect may generate contingent fiscal
liabilities. Skypala (2014) has argued that separating charges
for fund investments and for administration by pension
fund managers could reduce pension management costsin the UK, thus improving benefits. There is a strong casefor exploring various avenues for reducing administrationand compliance costs of pension and health care programs.
Enhancingcompetence
togenerateresourcesfrom unconventional sources such as utilizing
state assets (land, property rights such as airspace, oil and mining resources, and carbon trading,among others) efficiently. This is likely to involve:i.

Better coordination among and between pension
and healthcare sectors for increased resource savingsand greater policy coherence (Bali and Asher 2012).

ii.

Conventional tax reforms, and improving compliancelevels and efficiency. In Europe, US, and the U.K,
corporate tax reforms, particularly those provisions
designed to protect the tax base have becomea priority. The aggressive corporate tax planningis exemplified by reports that Google shifted€ 9 Billion to Bermuda as part of its global tax
planning (Houlder, 2013) In 2012, OECD created aforum on VAT (Value Added Tax) to help counter
aggressive tax planning of VAT by the businesses.
( h t t p : / / w w w. o e c d . o r g / c t p / c o n s u m p t i o n /firstmeetingoftheoecdglobalforumonvat.htm)

iii. Sovereign Wealth Funds (SWFs); set up to smoothen
excess of current receipts over expenditure arising fromenergy resources, trade surpluses, and other sources,and between generations represent another avenue forfunding old age needs. In Asia, South Korea, China andSingapore have been adept at using the SWFs to fund10

future expenditure needs, including those of the aged.
iv. Financial innovations, particularly at the pay-out
phase, are accumulation schemes. The conventional
practice of relying on annuities will be inadequate
given limited financial instruments to mitigate
longevity risk, and due to uncertainties in longevity
trends due to uncertainties in medical technology
breakthroughs. Such innovations, which reducetransaction costs of service delivery and provide
better risk sharing between the insurance company,
the individual, and the government, will be needed.
Some high income countries have attempted to finance old
age by developing instruments which convert real estate
into a retirement consumption stream.They have had somesuccess, but greater research and innovations in this area
is essential for it to play a significant role. In developing
Asia, individuals and households will need to bear a greater
proportion of increased share devoted to old age financing.
Promoting its secure and stable policy and regulatoryenvironment for long term savings by the individuals should
therefore be an important instrument for financing old age.
But this needs to be undertaken without creating fiscal
risks which ultimately must be borne by the citizens.

IV. Concluding Remarks
In a remarkably short period of time, Robert Butler’s conceptof productive ageing has inspired policymakers, researchersand other stakeholders to address the challenges arisingfrom global ageing.
It is increasingly recognized that the issue of ageing does
not just concern the aged but persons of all ages. Thisimplies that finding economic resources, i.e. funding, for theaged will need to involve ways to sustain growth, improve
productivity, finding ways to economize on resources,
reduce expenditure needs, and raise additional resourcesfrom conventional and nonconventional sources.
The needs of the increasing old-age population living
longer and the rising expectations of both the young andthe old are at odds with the difficult global and domestic
economic environment. There is a serious risk to social
cohesion and state-people implicit contract if the urgencyof addressing it is not recognized, and no effective initiatives
are forthcoming.
The challenges in evolving appropriate policies, finding
adequate resources, and sustaining public support andcohesion which could facilitate productive ageing, should
however not be minimized. The role of ILCs will be criticalin enhancing research capabilities and in contributing toanalytically rigorous and empirical-evidence based public
policy debates concerning issues related to productive
ageing. The governments must be held accountable if they
fail to create policy environment and provide requisite
resources for facilitating such debates, and for notincorporating relevant findings in productive ageing policies
and programs.

Dr Robert Butler Memorial Lecture : The Future of Income Security

References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.

Asher, M., and Bali, A. (2012). “Coordinating Healthcare and Pension Policies: An Exploratory Study,” ADBI Working Paper No. 24, Asian Development
Bank InstituteAsher, M. G., “Social Pensions for the Elderly in Asia: Fiscal Costs and Financing Methods”. In Social Protection for Older Persons: Social Pensions in
Asia, edited by S. W. Handayani & B. Babajanian, Manila: ADB, 2012. pp.23
Barrientos, A., “Social Pensions in Low-Income Countries.” In Closing the Coverage Gap: The Role of Social Pensions and other Retirement Income
Transfers, edited by R. Holzman, D.A. Robalino and N. Takayama, Washington, DC: World Bank, 2009
Barr, N., and Diamond, P., Reforming Pensions: Principles and Policy Choices, New York and Oxford: Oxford University Press, 2008. Available at http://
www.oxfordscholarship.com/view/10.1093/acprof:oso/9780195311303.001.0001/acprof-9780195311303
Bateman, H., and Piggott, J., “Structuring the Payout Phase in a Defined Contribution (DC) Scheme in High Income Countries: Experiences ofAustralia and New Zealand.” Paper presented at the Economic Research Institute for ASEAN and East Asia
(ERIA) Social Protection Workshop. Singapore, 5–6 March 2011.
Borsch-Supan, A. (2013). “Myths, scientific evidence and economic policy in an aging world,” The Journal of the Economics of Ageing, forthcoming.
Butler, R. N., Why Survive? : Being Old in America. New York: Harper & Row, 1975
Butler, R. N., The Longevity Prescription: The 8 Proven Keys to A Long, Healthy Life. USA: Penguin Group USA, 2011
Butler, R. N., and Gleason, P. H., eds. Productive Ageing: Enhancing vitality in later life. New York: Springer Publishing Company, 1985
Fogel, Robert W., et al. The Changing Body: Health, Nutrition, and Human Development in the Western World since 1700. Cambridge: Cambridge
University Press, 2011
Holzman, R. and Koettl, J. (2014), “Portability of Pension, Health, and other Social Benefits: Facts, Concepts and Issues”, CESifo Economic Studies
Advance Access, , Oxford University Press, Munich. Available at: http://cesifo.oxfordjournals.org/content/early/2014/01/12/cesifoift017.full.pdf ,Accessed on: 02/24 /2014.
Houlder,V. “Google shifts €9bn to Bermuda,” Financial Times, October 11, 2013
International Monetary Fund, (2013). “World Economic Outlook”, Washington D.C., October. Available at http://www.imf.org/external/pubs/ft/
weo/2013/02/pdf/text.pdf
Levy, S., and Schady, N. (2013). “Latin America’s Social Policy challenge: Education, Social Insurance, Redistribution,” Journal of Economic Perspective,
27 (2), 193-218
Li, W.D.H. (2012). “East Asian welfare model refocus? A case study on economic support for the elderly living in Taiwan,” International Journal ofSocial Welfare, 22 (3), 260-268
Maisonneuve, C. and Martins Oliveira, J. (2013) “Public spending on health and long-term care: a new set of projections,” OECD Economic Policy
Papers No.06, OECD Publishing, Paris. Available at http://www.oecd.org/eco/growth/Health%20FINAL.pdf
Okamoto, E. (2014) “ Farewell to free access: Japan’s universal health coverage”,East Asia Forum, Available at http://www.eastasiaforum.org , accessed
Feb 2014.
Roy, A., Puhani, S., and Hsieh, A. “European Demographics and Fiscal Sustainability”, Global Demographics and Pension Research, Credit Suisse, 17January 2013, available at https://plus.credit-suisse.com/r/VUrElj, accessed June 2013.
Roy, R., Heuty, A., and Letouze, E. (2007). “Fiscal Space For What? Analytical Issues from a Human Development Perspective,” UNDP Paper for the
G-20 Workshop on Fiscal Policy, Istanbul, June 30 – July 2.
Sanderson, C. W., and Scherbov, S. (2007). “A new perspective on population ageing,” Demographic Research, Max Planck Institut for Demographic
Research,Vol. 16, 27-58
Skypala, P. (2014), “UK funds geared up for fees price war”, Financial Times, Available at: http://www.ft.com/intl/cms/s/0/6eac4f0a-8526-11e3-86f7
00144feab7de.html#axzz2uDaA4axo, Accessed on: February 24, 2014.
Towers Watson, “Global Pension Assets Study 2103”, January 2013, available at http://www.towerswatson.com/en-ZA/Insights/IC-TypesSurveyResearch-Results/2013/01/Global-Pensions-Asset-Study-2013
United Nations. (2013). World Population Prospects: The 2012 Revision. Available at http://esa.un.org/unpd/wpp/index.htm

TablesTable 1A: Select Indicators of the Aged by Region

Area
World
More developed
regionsa
Less developed
regionsb
Least developed
regionsc

Population aged 60 years or overNumber
Proportion of total(millions)
population
2010
2050
2010
2050
764.9
2020.4
11.1
21.2
270.8
417.4
21.8
32

Share of old-old(80+)1
2010
2050
14.2
19.4
19.6
29.6

60+
83.3
74.6

80+
59.8
50.4

494.1

1602.9

8.7

19.4

11.2

16.7

89.2

69.9

44.5

183.3

5.3

10.1

8.7

11.3

89.5

82.0

Sex Ratio, 2010

More developed regions comprise all regions of Europe and Northern America, as well as Australia, Japan and New Zealand.
Less developed regions comprise all regions of African, Asia (excluding Japan) and Latin America and the Caribbean, as well as the regions ofMelanesia, Micronesia and Polynesia.
c
The least developed countries, as designated by the United Nationals General Assembly in 2011, comprise 48 countries including 33 in Africa, 9 in Asia, 1
in Latin America and the Caribbean and 5 in Oceania. The least developed countries are included in the less developed regions.
1
Persons ages 80 years or over (the ‘old-old’) as a percentage of the population aged 60 years or over.
Source: United Nations Department of Economic and Social Affairs/Population Division, World Population Prospects: The 2012 Revision; accessed August
2013.
a

b

11

Table 1B: Select Indicators of the Aged by Region
Area

Life Expectancy atage 60, 2010-2015

Proportion living independently, 60 years
or over (percentage),circa 2010

Old Age Support
Ratio1

Proportion in labor
force, 60 years orover2 (percentage),circa 2010

Men
18
21

Women
22
25

Men
40
75

Women
39
73

2010
8.6
4.2

2050
4.0
2.3

Men
42
26

Women
20
15

Less
Developed Regionsb

18

20

28

25

11.2

4.6

50

22

Least
Developed Regionsc

16

17

12

13

16.2

9.2

68

43

World
More
Developed Regionsa

More developed regions comprise all regions of Europe and Northern America, as well as Australia, Japan and New Zealand.
Less developed regions comprise all regions of African, Asia (excluding Japan) and Latin America and the Caribbean, as well as the regions of Melanesia,
Micronesia and Polynesia.
c
The least developed countries, as designated by the United Nationals General Assembly in 2011, comprise 48 countries including 33 in Africa, 9 in Asia, 1
in Latin America and the Caribbean and 5 in Oceania. The least developed countries are included in the less developed regions.
1
Number of persons aged 15 to 64 years per person aged 65 years or over2
Proportion of persons aged 60 years or over who are economically active, as estimated and projected by the International Labor Organization (ILO).
Source: United Nations Population Division, available at http://www.un.org/en/development/desa/population/publications/pdf/ageing/2012PopAgeinga andUnited Nations Department of Economic and Social Affairs/Population Division, World Population Prospects: The 2012 Revision.
ab

Table 2: Select Demographic Indicators of Five Most Populous Countries
Country 2013

China
India
USA
Indonesia
BrazilTotal
60+
Population*
1385.6
192.6(13.9)
1252.1103.9 (8.3)
320.1
63.2 (19.7)
249.9
20.2 (8.1)
200.4
22.4 (11.2)

2025
80+

Total
Population
22.2 (1.6) 1449.0
10.0 (0.8)
11.8 (3.7)
2.0 (0.8)
3.2 (1.6)

1418.7
350.6
282.0
217.5

2050
60+

80+

289.3 (20.0) 29.3 (2.0)

Total
Population
1385.0454.4 (32.8) 90.4 (6.5)

156.6 (11.0)
86.4 (24.6)
33.9 (12.0)
35.7 (16.4)

1620.1
400.9
321.4
231.1

296.5 (18.3)
108.2 (27.0)
67.7 (21.1)
66.9 (28.9)

14.4 (1.0)
2.7 (1.0)
15.2 (4.3)
5.2 (2.4)

60+

80+

37.2 (2.3)
9.6 (3.0)
31.7 (7.9)
15.8 (6.8)*Population figures are in millions
Note: Numbers in parentheses denote the percentage of country’s population over 60/80 years in a given years
Source: United Nations Department of Economic and Social Affairs/Population Division, World Population Prospectus: The 2012 Revision, Key Findings andAdvance Tables

Speaker Biography

Prof Mukul Asher

12

Mukul G Asher is a Professorial Fellow at the Lee Kuan Yew
School of Public Policy at the National University of Singapore. He
obtained BA from University of Bombay (India), and M.A and Ph.D.
from Washington State University (USA). His research focuses on
public financial management, social security reforms in Asia, and geoeconomics issues, particularly India’s external relations with the restof Asia. He has published extensively in national and international
journals; and has authored or edited more than ten books. He ison the Editorial Advisory Board of the International Social Security
Review. He has been a consultant to several Governments in Asia
on tax policy and pension reforms; and to multi-lateral institutions
including the Asian Development Bank, and the World Bank. He has
been active in Executive Development Programs and has been alead faculty for such programs for Government officials from several
countries including India, Indonesia, Brunei, Sri Lanka, and Kazakhstan.

Future of Long Term Care Financing in Japanand The Netherlands

Kunio Mizuta
President, ILC, Japan

Marieke van der
Waal

Introduction

The OECD writes
in her 2011 reporton Long Term Care
(LTC) that there areat least four reasons
why pressure on
long-term care grows. First, the demographic transformation
occurs due to the rapid ageing of populations. Both Japanand The Netherlands experience increasing life expectancy.
Also both countries had a baby boom after the Second
World War. The baby boom generation starts to retire andwithin ten to fifteen years the baby boom generation will
get frail. Therefore the amount of frail older people will
increase rapidly. Secondly, OECD observes a change inthe societal models, such as declining family size, changes
in residential patterns of people with disabilities and risingfemale participation in the formal labour market. These arelikely to contribute to a decline in the availability of informal
caregivers, leading to an increase in the need for paid care.
Third, as societies become wealthier, individuals demand
better quality and more responsive social-care systems.
People want care systems that are patient-oriented and thatcan supply well coordinated care services. Fourth, OECDobserves a technological change that enhances possibilities
for long-term care services at home but this may requirea different organization of care. Therefore the care service
organizations and their performance must change. Will
this increase the costs? The changes will create upward
pressure on the demand for long-term care services and, asa consequence, the human and financial resources necessary

Director, ILC,
The Netherlands

to provide long term care (OECD, 2011).
In this paper ILC Japan and ILC The Netherlands focus
on their long-term care system and their future needs.
Japanese and Dutch data on health and long-term care aredescribed to discuss both systems in order to learn. The
paper ends with conclusions and options to deal with thecoming future.

Demographics
In Japan and The Netherlands the population of people
above 65 years increases and between 2010 and 2025, thenumber of people aged 75 and older is growing rapidly. Chart
1 shows data of the increasing population above 65 years inJapan. Chart 2 shows similar data of The Netherlands.
The most challenging issue for long-term care will be theincreasing number of people 75 years and older. In Japan
this group has yet almost doubled from 7.17 million in 1995
to 14.07 million in 2010. It is expected to increase to 21,8
million in 15 years (2025). However, the number will flatten
out after this period and will settle around 22 million (chart
1). Similar as in Japan, The Netherlands has an increasing
number of people 65 years and older (chart 2).This number
will double from 1995 to 2040. After 2040 the amount ofpeople above 65 years and older will decrease. After 2055
the number of persons 80 years and older will decrease in
the Netherlands (no data shown).
Both countries experience a growth in the number of older
inhabitants and therefore an increasing number of people

Chart 1: Change and projections in the elderly who are over 65 years old and 75 years old in Japan(numbers, ratio among the whole population)
Over 65
Over 75

Year 1995
18,260,000(15.0%)
7,170,000 (5.7%)

2010
29,240,000(22.8%)
14,070,000(11.1%)

2025
36,580,000(30.3%)
21,790,000(18.1%)

2040
38,680,000(36.1%)
22,230,000(20.7%)

National Institute of Population and Social Security Research, “Population Projection for Japan”, (January 2012)

Chart 2: Change and projections in the elderly who are over 65 years old and 75 years old or 80 years
old in The Netherlands (numbers, ratio among the whole population)
Over 65
Over 75
Over 80

Year 1995
2,033,576 (13.2%)*
475.757 (3,1%)

2010
2,538,328 (15,3%)*647.994 (3,9%)2025
3,786,220 (21,8%)
1,806,955 (10.4%)
983.942 (5,6%)

2040
4,720,560 (26.5%)
2,579,804 (14.5%)
1.554,742 (8,7%)

Central Bureau of Statistics online database (Statline)* no data available

13

who will become frail and in need of long-term care. Japanand The Netherlands need to consider if their long-termcare system is sustainable for the future to come. For Japan’slong-term care system it is essential to consider how thiscountry can prepare themselves in the coming years. Therenational policy is to make the system sustainable so it will
be likely that Japan is able to continue taking care of older
people properly in Japan later on. In the Netherlands in2013 a new policy on long-term care is brought out to deal
with the same issue of sustainability.

Long-term Care System in JapanThe Japanese Long-term Care Insurance System started
in 2000 in response to the increased care needs of older
person. Also, family size was shrinking and the family
caregivers were getting old themselves, so it became
more difficult for families to care by themselves. Before
2000 there had been actually a tax-funded long-term carescheme already in place, which was founded by municipal
governments. Because this scheme was funded entirely bytax, the amount of services the municipalities can provide
was limited and the service was often limited to low-income
person. As a result, many older people who needed care
for a long time found a way to get care within the medicalcare insurance system. Due to this shift, the spending of
the medical care insurance system increased to much. Thus
it was necessary to establish a long-term care insurance
system, which not only meets the needs of the elderly but
also encourages their independence. The new system is asocial insurance system, which makes clear the relationshipbetween benefits and responsibilities. Beneficiaries canchoose various service providers including the private
sector. Since its introduction in 2000, the Long-term Care
Insurance System has prevailed widely. People who receive
the long-term care insurance system service increase from1.84 million which was in 2000 to 4.13 million in 2013
(Ministry of Health, Labour and Welfare, 2013).

Figure 1.

14Long-term Care System inThe Netherlands
The Dutch Exceptional Medical Expenses Act (AWBZ) isa national insurance scheme for long-term care that has
undergone several changes since its installation in 1967.
Over the years the core remained the same: the act isestablished to provide care for people who cannot provide
in their basic care needs independently. This can be theconsequence of a physical, psycho-geriatric or psychiatricailment, or a mental, physical or sensorial handicap. Most
expenses within the AWBZ are made for (frail) older
people, with or without cognitive limitations or physical/
functional limitations. Care can be provided both at theclient’s home or an institute where the client has it’sresidence. Long-term care is not given in hospitals. When
any kind of care is given in the hospital, the care is fundedthrough the Health care Insurance Act (ZVW).The fund for
the AWBZ is established through fees paid by employees
and the government.
Every person who wants to be eligible for AWBZ fundingneeds to be assessed by the Centre of Needs Assessment(CIZ). The CIZ assesses the care need of an individual
according to a “funneling model”.With the use of this model,
the care needs of a specific patient are assessed, on whicha decision is made. A positive decision (indication) gives
access to care paid by AWBZ. The amounts paid to longterm care providers are standardized amounts for every
indication setting (the kind and the amount of care needed).
In 2008 “care-severity packages” had been developed for
those who have an indication AWBZ for inpatient care ,which was phased in to determine the budgets for inpatientcare long-term care facilities (i.e. nursing homes, elderly
homes, institutions for mentally and physically handicapped
and mental care institutions). (Rolden en Van der Waal,
2012).

Future of Long Term Care Financing in Japan and The Netherlands

Financing the Long-term Care System inboth countries
In Japan the funding of benefits for the long-term careinsurance system after excluding co-payment is provided
by insurance premiums (50%) and public funds (50%). For
the public funds, the national government pays 25% and theprefectures and municipalities pay 12.5% each. The insurers
are local governments.
Insured persons are citizens who are over 40. People who
are over 65 pay 20% of the premiums whereas people whoare between 40 and 64 pay 30%. When one wants to use
the service, he or she will need to pay 10% of the service
fee as co-payment (Figure 1). Long-term care insurance
services are provided when people aged 65 or over who
require care, and when people aged 40-64 develop certain
diseases, such as terminal cancer and rheumatoid arthritis.
(Ministry of Health, Labour and Welfare, 2011)
In the Netherlands every citizen older than 15 years ofage with a taxable income has to pay an income-related
contribution to the AWBZ (2013 12,65% of the income witha maximum of a little bit more than € 4,000 per person peryear). In addition, for most long-term care services coveredby the AWBZ income-related co-payments are required.
When the expenses made by the AWBZ fund exceed thebulk of the incoming fees, the deficits are compensated by
the National government through a contribution by thenational treasury (Rolden,Van der Waal, 2012)

The percentage of GDP spent on long-term services
covered by AWBZ increased from 0.8 percent in 1968 to
2.0 percent in 1980 and further to 3,8 percent in 2009.
This is 23 billion euro’s. Part of this increase, however, isdue to an expansion of AWBZ coverage (Rolden, Van der
Waal 2012).
Japan in detail: Social Security System and Financei.

Changes in Social Security Expenditure in JapanThe total expenditure of pension, medical insurance andwelfare including long-term care insurance combined isincreasing drastically. In 1990 the amount was 47.2 trillion
yen, which rose to 109.5 trillion yen in 2012. All of thesesystems are funded by premiums and tax. The welfare
system, which includes long-term care insurance costs, isthe least expensive of the three systems, nonetheless, its
increase is most remarkable and the expenditure rose to
20.6 trillion yen in 2012 while it was 4.8 trillion yen in 1990.
(Chart 3)ii.

Tax Revenue and Expenditure of General Account inJapan

In 2000, tax revenue was 50.7 trillion yen and total
expenditure was 89.3 trillion yen while in 2012, it was
42.3 trillion yen for tax revenue and 90.3 trillion yen for
expenditure. Tax revenue has been 40-50% of the total
expenditure and the shortfall is compensated by bond(debenture), which also means debt. Japanese government’s

Chart 3: Total Social Security Expenditure to National Income (trillion yen)
Total Amount of Benefits
Pension
Medical Care
Welfare and others

1990
47.2
24.0
18.4
4.8

100.0%
50.9%
38.9%
10.2%

2000
78.1
41.2
26.0
10.9

100.0%
52.7%
33.3%
14.0%

2012 (budget base)
109.5
100.0%
53.8
49.1%
35.1
32.1%
20.6
18.8%

Ministry of Health, Labour and Welfare, Change in Social Security Benefits, 2012

Chart 4: Breakdown of General Account Expenditure (trillion yen)
F.Y.2000

F.Y.2012

Tax revenue

50.7

42.3

Total expenditure

89.3

90.3

Breakdown ofexpenditureSocial security, etc.
Culture, education and science promotion

19.7
6.7

22.0%
7.5%

26.9
5.2

29.7%
5.8%

Bond expenditure
Local government finance
National defense
Public works
Other

21.5
15.9
4.9
10.2
10.45

24.0%
17.7%
5.5%
11.5%
11.7%

21.9
16.6
4.7
4.5
10.474

24.3%
18.4%
5.2%
5.0%
11.6%

Ministry of Finance, General Account Tax Revenue, Change in total amount of expenditures and amount of government bond issuance,
http://www.mof.go.jp/tax_policy/summary/condition/003.htm

15

debt increased to over 1,000 trillion yen in March 2013
and that is around 230% of GDP, which is the highest in theworld. Expenditure for social security was 22% in 2000 andincreased in 2012 to 29.7%. It is clear from the breakdownof expenditure that the government’s expenditure had
decreased for each item except social security related andbond expenditure (Chart 4).
iii. Comprehensive Reform of Social Security and Tax
ReformJapanese social expenditure (22.4%) is higher than that of
the United States (19.2%) but lower than European nations(France 32.1%, Netherlands 24.1%, Sweden 29.8% andthe United Kingdom 24.1%). Also, if you focus on burden,
there is the same trend in the international comparison for
the ratio of tax and social insurance premium to national
income. Japan (39.9%) is higher than the United States(30.3%) but lower than European nations (France 60.1%,
Germany 53.2%, Sweden 62.5% and the United Kingdom
45.8%).
Due to the current situation in Japan where social
expenditure and the ratio of taxation and social security
spending to national income is somewhat lower than Europe,
the Japanese government decided that there is room forincreasing tax. The legislative bill for the “Comprehensive
Reform of Social Security and Tax” which aims to increase
the consumption tax from the current 5% to 8% in 2014
and 10% in 2015 had passed the Diet (National Parliament)
in 2013. Increase in the insurance premium is also expected.
Under this tax reform, 80% of what is gained from theincrease will be used mainly as extra funding to cover theincrease in social security expenditure due to the increasein the elderly population. It will reduce the burden on thegeneral tax revenue and it can be used to reduce the debt
as well. The Japanese government is targeting changing thefinances to a budget surplus by 2020. The remaining 20%
will be used for enhancing and improving the social security
including medical and the long-term care (MHLW, 2012).
The Netherlands in detail: costs and usage of the system
There are three important health care laws in the
Netherlands: the Health Insurance Act (ZVW), theExceptional Medical Expenses Act (AWBZ) and the Social
Support Act (WMO). Basically, medical care is arranged
through the ZVW, long-term care through the AWBZ, andsocial and supportive services through the WMO. The total
amount of money spend on health care is 87 billion. In 2010
the Netherlands counted 16,6 million inhabitants, including
2,5 million people at age 65 and older.
In the Netherlands the health care expenditure per person
per year is increasing for the medical care (ZVZ), long-termcare and public health (is part of government responsibility).
In chart 6 the costs per person per year per domain are
given. In 2010 the health care costs for a civilian is morethan 5.000 euro per year. Important to notice is that healthcare expenditure per Dutch citizen has risen with almost
1,000 euro’s in 5 year time. During the time of writing,politicians are having pre-election debates with rising healthcare expenses as a major subject. Different politicians areemphasizing that increasing costs should be contained while
approaches differ.

Chart 5: Social Expenditure, Ratio of tax and social insurance premium to National Income (2009)
Social Expenditure
Ratio of Taxation tax and social insurance
premium to National Income

France
32.1
60.1

Japan
22.4
39.9

Sweden
29.8
62.5

U.K.
24.1
45.8

U.S.A
19.2
30.3

International Comparison of National Burden Ratio http://www.mof.go.jp/english/tax_policy/publication/tax004/E_0710.pdf OECD,
National Accounts, Revenue Statistics, etc.
Note: Data for Japan are estimated figures as of FY2012, and those for other countries are actual figures as of 2009.

Chart 6: Sources and domains of health care expenditure in Euro
Source of finance
Government
ZVW
AWBZ
Other
Domains
Expenses for cure
Expenses for care
Policy & overhead
Total expenses

2000
413
825
915
792
2000
1,683
1,135
128
2,946

Central bureau of statistics, Statline, 2012

16

2006
502
1,635
1,418
772
2006
2,489
1,654
184
4,327

2007
655
1,690
1,404
807
2007
2,643
1,725
188
4,556

2008
689
1,965
1,348
847
2008
2,830
1,835
184
4,849

2009
739
2,068
1,404
874
2009
2,955
1,948
182
5,085

2010
751
2,132
1,462
898
2010
3,041
2,021
180
5,243

Future of Long Term Care Financing in Japan and The Netherlands
In 2010 600,000 people used long-term care in the
Netherlands. In that year around 340,000 people received
care in their own home. The remaining clients receive carein an institution like nursing homes. The clients who can get
care covered from the AWBZ are not only older persons,but also persons with a mental or physical handicap asthese handicaps are part of AWBZ coverage as well. There
are around 150,000 voluntary workers active in long termcare. In 2010 the total costs of the long-term care in the
Netherlands amounted to more than EUR 23 billion.
In the last decade two major changes have been madeconcerning the AWBZ. Since 2007, some services are nolonger provided through the AWBZ, but through the Social
Support Act (WMO) that mainly instrumental assistance(e.g. help with cleaning) and the provision of aiding tools(such as wheel chairs) provide. In 2013 the National
Government decided that nursing care (wound dressing,
injecting, teaching self-care) and geriatric rehabilitation will
be part of the Health Care insurance Act (ZVW). In futurea policy will be enrolled that citizens pay their own costs
for residence in elderly homes and nursing homes.Then the
AWBZ fund will only consist of personal care (help withshowering, dressing, shaving, going to the toilet), counseling(help with organizing day-to-day practical matters, suchas making coffee or filling in forms), improving skills or
behavior (to be able to do your own personal care as longas possible yourself) and short-term residence in certain
institutions (Rolden,Van der Waal 2012).

Reform of Medical and Long-term Care
Services
The Japanese government is planning to proceed withstructural reform in the areas of medical and long-term carein order to make the service delivery system more effective.
Japanese acute phase medical care is supported by fewer
numbers of doctors and nurses by international standards,
and some hospitals have severe working environments. At
the same time, it has been pointed out that there are somepatients who do not necessarily require medical care andas a result, it makes the average length of stay in a Japanesehospital quite long (chart 7). The average length of stay in
the Netherlands is 5.8 days and is quite low due to strict
hospital discharge policies and availability and acceptabilityof (long-term) care at home, rehabilitation centers or inelderly homes and nursing homes.

Chart 7: Average inpatient hospital stay (day)Average length hospital stay (in patientand acute care)

France12.7

Germany
9.6

Netherlands
12,5 *

Japan
32.5

U.K.
7.7

U.S.A.
6.2

OECD Health Data 2012 Average length of stay: in-patient and acute care. Last data available in Netherlands are data 2001. Since 2002 theNetherlands registries length of stay in acute care.

Figure 2.

http://www.mhlw.go.jp/english/social_security/dl/social_security01.pdf.

17

In Japan the nowadays policy focusses on, “selection andconcentration” by reducing the number of beds andallocation of more doctors and nurses to acute care
hospitals. After acute care, it is necessary to collaborate
with sub-acute hospitals and rehabilitation hospitals, andtry to encourage patients to go back to normal life as soon
as possible. One of the challenges is to focus on where theolder people can go after discharge from hospital. For thischallenge, setting up an integrated community care system
is in progress in about 10,000 areas (one area is similar tothe size of middle school district) all over Japan. One of
the main pillars of this system is enhancing home medicalcare. That is to strengthen the function of clinics which is incharge of home medical care including end-of-life care, andenhancing home-visit nurses. Another pillar is enhancing
long-term care at home which includes providing more
residential services and providing better care management.
(Figure 2)
In the Netherlands the reform of the long-term care is
subject of discussed at this moment in our lower house.
The minister of Health send a letter to the lower house on
the 25th of April 2013. In this document he announces theneed for reforms due to changing organizations that delivercare, the ageing population and people’s changing wishes
concerning quality of life and quality of care. Living in yourown house instead of living in an elderly home or nursing
home is getting the norm. The worries of our parliament
concern loneliness, need of social support and care needs.
The reform is not only based on modernizing the long-termcare but also decreasing the rising costs. Figure 3 shows
the costs of AWBZ from 1972 till 2012 in billion Euro’s(Ministry of Health 2013).
Also compared to other countries the costs for long-termcare are increasing. Therefore the government has decided
a mind shift is needed. From 2014 care will be given only
when you are frail and when you have no or not enoughinformal social support. The local government becomes
responsible for the formal social support (WMO) andthe long-term care. Nursing will be paid by the Medical
Insurance Act (ZVW). Last year there was a huge debate
on housing and if the client in future pays it’s own rent.
The housing cost in elderly and nursing homes are paid by
AWBZ. This debate has turned into a policy that access toelderly and nursing homes is limited to severe frail people
who need intensive care.This means that almost 25% of the

Figure 3.

18

clients will not pass the criteria anymore to get access toelderly or nursing home in future. From 2014 clients thatare not frail enough will get the care they need (under the
new criteria) at home. For the current clients in the elderly
and nursing homes things will remain the same. Off course
people who can afford it can pay for residency in a private
elderly home.

Future of Long-term Care System
Judging from demographics and the performance of thelong-term care insurance system, it is expected that there
will be far more demand for services in 2025 than now
in both countries. In Japan 2012, 4.52 million people used
the service but it is expected to increase to 6.57 million
people in 2025 which is 1.5 times more. (Chart 8). To meetthis pressing demand, various measures to raise funds andpromote efficiency for medical and long-term care costs
are being introduced. As previously mentioned for Japan,
those are increasing the consumption tax, raising insurance
premiums, cutting-down the average length of hospital
stays, and enhancing mechanisms to support the elderly
at the local level. As mentioned before in the Netherlands
mechanisms are set to support the elderly at there own
homes and at local level. Access to elderly homes andnursing homes becomes more difficult. If we can work forthese measures successfully, it is possible that we can makethe long-term care system sustainable.

Discussion
The need of care will increase due to increasing numbers ofolder people.This implies a focus on an adequate workforce.
Both countries have low fertility rates. This means thatthe workforce of people we need to work in long-termcare will compete with other sectors that are importantfor economic growth and stability. A shortage of workers
needed in the long-term care is a serious question to deal
with.
While the workforce - seen as total amount of people whoare able to work per country - is decreasing, the amount ofincome for the health care and long-term care is decreasing
while health care and long-term care needs are increasing.
Measures need to be taken concerning raising pension age,increasing export of products, decreasing the costs of careby informal care givers. In the EU there is a working groupcalled ESFAGE (www.esfage.eu). They discussed thesematters and gave six examples of dealing with an ageing
society: work longer and retire later, have more babies,
work smarter/be innovative and increase productivity,
reduce barriers to employment, start working at younger
ages, bring in more migrant workers.

Future of Long Term Care Financing in Japan and The Netherlands

Chart 8: Comparison of the numbers who used and are expected to use the long-term care insurance
system in Japan in year 2012 and 2025
2012

2025

Users

4,520,000

6,570,000 (1.5 times)• Decrease of 3% as a whole due to long-term care prevention andseverity prevention• Decrease of hospitalization (transition to long-term care) : increase of
140,000

In-home long-term care
Residential services
Long-term care facilities
Long-term care staff

3,200,000
330,000
980,000
1,490,000

4,630,000 (1.5 times)
620,000 (1.9 times)
1,330,000 (1.4 times)
Between 2,370,000 to 2,490,000

Source: Ministry of Health, Labour and Welfare, “Vision Sought by the Comprehensive Reform of Social Security and Tax”, 2012

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Central Bureau of Statistics online database (Statline.nl). The Netherlands, 2012
Central Bureau of Statistics online database (Statline.nl). The Netherlands, May 2013
Ministry of Health, Labour and Welfare. The current situation and the future direction of the Long-term Care Insurance System in Japan, 2011
Ministry of Health, Labour and Welfare. Change in Social Security Benefits in Japan, 2012
Ministry of Health, Labour and Welfare.Vision sought by Comprehensive Reform of Social Security and Tax, Jan 2012
Ministry of Health, Labour and Welfare. Long-term Care Insurance Report, Jan. 2013
Ministry of Finance (Japan). General Account Tax Revenue, Change in total amount of expenditures and amount of government bond issuance, 2013
Ministry of Health (Netherlands). Reform of the long-term care: policies for a sustainable future. 2013
National Institute of Population and Social Security Research. Population Projection for Japan, Jan. 2012
OECD. Help wanted? Providing and paying for long-term care, 2011
OECD database on National Accounts, Revenue Statistics, etc., 2013
OECD Stat Extracts (http://stats.oecd.org/), Health Care, Health Care utilisation, Average length of stay: in-patient and acute care, 2013
Rolden H. and Van der Waal M. Coordination of health care services in the Netherlands. Institute of Future Welfare Japan, 2012

Speaker Biography

Ms. Marieke van der Waal

Marieke van der Waal (1965) studied Human Nutritionat Wageningen University. After her studies, she researched
quality of care for the chronically ill. She continued her career
as a program secretary at NWO-Medical Sciences (nowZonMw). Her move to NWO characterises the common
thread in her career pattern. Marieke has great affinity
with scientific research. However, she does not focus on
the execution of research itself but on the exploitation of
newly acquired knowledge so that it may benefit society. In
2002 she became director of the Netherlands Public HealthFederation. In her capacity as Director of the Netherlands
Public Health Federation Marieke kept focused on thecontent of the field in her dedication to raise awareness andfunding in order to improve public health in the Netherlands.

Since 2008 Marieke has been working on projects for the Diabetes Federation and the Dutch Institute for Healthcare
Improvement (CBO). As of April 1, 2010 she is Director of the Leyden Academy on Vitality and Aging and ILC Zorg voor
Later. Current know-how on ageing issues are placed increasingly in the context of higher life expectancy and healthy ageing.
It is important for (future) leaders to be informed on new insights, innovations and to be guided on how to use this new
knowledge in their own environment. Marieke van der Waal is eminently capable, together with Rudi Westendorp, to bring to
the attention of policy makers and (future) leaders research findings on ageing issues and innovations in the field of healthcare of the elderly and its public use. Marieke is also a member of the supervisory board of the Welfare Foundation Lelystad.
19

Dr. Louise Plouffe
Director, ILC, Brazil

Dr. Rosy Pereyra
President, ILC, Dominician
Republic

The Future of Health and Healthcare in an
Ageing World: A Focus on Brazil, Dominican
Republic and the United States
Introduction

Dr. Kavita
Sivaramakrishnan

Appropriate healthservices are an
essential
adjunct
Associate Director, ILC-USA
to extending lifeandpreserving
functional capacityand quality of life at
all ages. Throughout
the course of our lives all of us may require disease
prevention, curative procedures, treatment of injuries,
rehabilitation, control of chronic conditions, supportive
management of disability and palliative services. Services
required in younger life typically focus on prevention
and cure through medical services and hospital care.
The care needed by older persons are much morevaried, both because the health status of older people
is more heterogeneous and because needs change withadvancing age. Health services for older adults can be
more complex; timely intervention is more critical toprevent a downward spiral of problems that could beirreversible; and “care” that is as much social as medical
becomes increasing more important than “cure”.The ideal
health system for an ageing world is a comprehensive
and coordinated continuum of care – that is, care that“continues” over a person’s health trajectory (prevention,
treatment, rehabilitation, control, palliation) and that“continues” across settings. This complete network ofhealth services is essential to preserve the health andfacilitate the contributions of older people, and to manage
a society’s health care expenditures cost-effectively.
Achieving this ideal range of health services is a policy
challenge facing all countries. Systems and practices haveemerged in several countries that can provide ideas to beadapted by other countries.Yet most developed countries
still face problems in delivering equitable, effective andsufficient health services for an ageing population, owing
to entrenched models of care delivery and financing,and inappropriate workforce composition and training.
Developing countries are striving to establish healthcare systems that meet the diverse needs of their entire
populations in ways that are economically, socially andpolitically sustainable. Many of them are now fast ageing
and while also dealing with still prevailing infectious
diseases: the double burden of infectious and chronic
disease within a context of large health inequalities.
This paper examines the overall health status and thestatus of health care for older adults in two “moderately
ageing” (ECLAC, 2010) developing countries, Brazil and theDominican Republic, who have remarkably similar estimatesof life expectancy, both at birth and at age 60 (UNDESA,

202012). The situation in these countries is compared withthat in the United States of America (USA). This country
faces common as well as unique challenges compared toother developed nations, at the same time as it offers someexamples of excellent care practices for older persons
which, unfortunately, are not available for most. This reportdraws largely on the responses provided by the ILC member
organizations in these countries to a short questionnaire, as
well as on other background reference material.

Health Status of Older Adults
World-wide demographic changes are reflected in a major
epidemiological transition, with chronic, non-communicablediseases (NCD) common in later life becoming a major
health priority. In Brazil, chronic disease accounted for 74
percent of all deaths in 2008 (World Health Organization,2011). Progress has been made in reducing smoking-related
cardiovascular and respiratory disease deaths, as a result ofhighly successful anti-tobacco measures and improvementin access to primary health care (Gragnolati et al, 2011).
However, as Brazilians have become more urbanized andwealthier, an increasing number of them have adopted theunhealthy life styles common in developed countries which
are leading to higher rates of diabetes and hypertension(Schmidt et al, 2011). Negative changes in health behaviours
are now resulting in increasing disability in later adulthoodfor both men and women: new findings from the SABE
study in the city of São Paulo show that from 2000-2010
persons aged 60-64 years gained two years of life, but lost
three years of life expectancy in good health (Colluci, 2013).
Older Brazilians experience considerable healthinequalities owing to large disparities that are reflectedlargely between the poorer Northeast states and the more
affluent Southern states (Kalache, 2010). Within cities, both
infectious and chronic diseases are more prevalent in lowincome neighbourhoods (Riley et al, 2007; Schmidt et al,2011).
The Dominican Republic is one of the poorer countries
in Latin America, and the epidemiological transition is lessadvanced here than in Brazil or the United States. In Santo
Domingo, the capital of the Dominican Republic, many
chronic illnesses are as prevalent among older persons asin the United States; however, rates of obesity, diabetes andhypertension were associated with greater affluence, while
anemia and physical impairments were inversely related toincome (Acosta et al, 2011). Also, most chronic conditions
were more prevalent among women than men.
About 80 percent of older US Americans live with at least
one chronic condition (Centers for Disease Control andPrevention, 2011) and one in nine individuals aged 65 years
old or more lives with Alzheimer’s Disease (Alzheimer’sThe Future of Health and Healthcare in an Ageing World: A Focus on Brazil, Dominican Republic and the United States
Association, 2013). Obesity, paralleled by diabetes, hasrisen steadily over the last two decades (Barnes, 2011),
resulting in health problems for increasing numbers ofageing Americans. Also, as in Brazil, race, gender and related
economic disparities are the major predictors of healthinequality throughout life (Komisar, Cubanski & Neuman,2012). Older persons “of colour” (black and Hispanic) areexperiencing disproportionately higher rates of chronic
illness and disability than whites, and lower incomes topay for needed care. Women typically live longer than men
but have less economic capacity to obtain needed healthservices. Socio-economic disparities in access to healthcare may increase as health costs in the US escalate as aresult of factors such as the high costs of new technologies
and a payment structure that rewards both more and morecostly services (Farrell et al, 2008).

Existing Health Care Policy Framework
Both Brazil and the Dominican Republic have enshrined
the rights of older persons and have specified measures toensure their protection in national legislation. However, thesecountries differ in important ways in the implementationof the legislation and the net effect. In the Dominican
Republic, the rights of older persons and the measures
to ensure their protection by the State are guaranteedby law since 1998 (law 352-98) (HelpAge Internationaland UNFPA, 2012). The Social Security System wasestablished in 2002, with a three-tiered health care regime(contributory, partially-contributory, non-contributory)
based on employment category. The right of older persons
to health care is recognized through the provision of noncontributory health care to persons who are older, disabledor unemployed. However, although the legislation is already10 years old, the non-contributory component of the Social
Security System has not yet been implemented. The interim
measure – a National Health Insurance Card – is distributed
selectively based on political affiliation, and covers about 52
percent of older Dominicans only.
Since 1988, Brazil has a two-tiered health care system whichguarantees the right to publicly-funded health care for all
citizens through the Single Health System (Sistema Único
de Saúde – SUS) while allowing a parallel private health caresystem.About 75 percent of Brazilians of all ages rely on the
SUS (Lima-Costa et al, 2011).The right of older Brazilians tohealth care, including preferential treatment, was instituted
in the 1996 National Policy on Older Persons, and later
reinforced in the 2003 Statute of the Older Person (whichis equivalent to a Bill of Rights of older persons). In addition,
the Government of Brazil enacted a National Policy on
the Health of Older Persons (2006) with the objective
to restore, maintain and promote the autonomy of older
persons. The National Health Plan (2012-2015) renews thiscommitment. Thus Brazil has in place a more stable andencompassing health policy framework in favour of older
persons than the Dominican Republic.
The Dominican Republic does not have a universal publichealth system such as Brazil, but provides public healthcare coverage through the federally-funded Medicare

program for persons over 65 years of age and for younger
persons with permanent disabilities. Older adults with
sufficient incomes supplement Medicare with private healthinsurance. Medicare is comparable to the Dominican healthinsurance system, although Medicare does not cover allof the costs for hospitalization, physician visits and othermedical services. For low-income American older persons,state-funded Medicaid helps with expenses not covered by
Medicare. Nevertheless, health care constitutes a large andgrowing portion of personal expenses for older Americans
as both Medicare premiums and the cost of non-insured
health services increase.
Primary Care Health Services
All three countries have given priority in their public systems
to primary health care services. The introduction of public
primary care in developing countries in recent decades has
yielded clear benefits to the health of older persons.
Through the Health Insurance Card, older Dominicans
have free access to medical attention and to prescription
medications. Older Brazilians similarly have free accessto a physician and to medication for chronic conditions
through the Statute of the Older Person, plus other healthpromotion and disease and injury prevention services
provided in the National Policy on the Health of Older
Persons, including targeted vaccination campaigns, booklets
to support self-care, education to prevent osteoporosis
and falls and subsidies to purchase other medications
and continence supplies. These ageing-specific service
provisions build upon the Family Health Care Program
established in 1994 that registers all SUS beneficiaries witha local health administration and provides home visits by amulti-professional team Gragnolati et al., 2011). State andmunicipal governments in Brazil follow federal policies andadd measures of their own. For example, the Municipalityof Rio de Janeiro has a free mobile eye clinic offering eye
examinations and free prescription glasses for persons aged
40 and older as well as referrals for ophthalmological care.
In the Dominican Republic and Brazil the increase in primarycare services has reportedly improved the health andquality of life of older people. Nevertheless, these services
are far from perfect. As mentioned earlier, the Dominican
Health Insurance Card is only an interim measure, andcoverage is incomplete and politically biased. In Brazil,
accessing the SUS services can be difficult, for reasons suchas inaccessible transport, poor physical infrastructure of theneighbourhood, difficulty in making appointments, lack ofpriority treatment, long waiting times and a lack of home
visits by health professionals (Amaral et al., 2012).
US Medicare provides access to many medical services,
including prevention and diagnostic services, outpatient andpost-acute care and prescription drug benefits. Nevertheless,there are deductibles for these services. Concerns aboutpaying medical bills and accumulating medical debt leadsome low and middle-income persons to delay or forego
medical treatment (Komisar et al., 2012). Another issue ofconcern is the dearth of primary care physicians to meetthe needs of ageing Americans (Sussman & Altman, 2009).
21

An effective model of primary care in the US is Guided
Care® (Boult et al., 2008) which helps primary carepractices meet the complex needs of patients with multiple
chronic conditions. In this evaluated model, a trained nurse
works closely with patients, physicians and other providers
to provide coordinated, patient-centered care (www.
guidedcare.org).
Concerns about rising Medicare costs are driving authorities
to support disease prevention and health promotion amongolder adults. One example is the Pioneer Accountable Care
Organisations initiative, which encompasses 32 healthcareorganizations nationwide and aims to improve health for
Medicare patients through status assessments, controlling
blood pressure and diabetes and scrutinizing immunization
rates and take-up of preventive services (EIU, 2012).
Geriatric Services
Geriatric specialists are required to assess and treat more
complex health problems of older persons but especiallyto educate and to guide general medical practice. All three
countries report a shortage in the supply of geriatricians
and in geriatric services.
The need for geriatric specialists and for better general
medical training in geriatrics has prompted action recently inboth the Dominican Republic and in Brazil. After relying formany years on foreign-trained geriatricians, the Dominican
Republic has established a specialization in geriatric medicine
in the country’s two medical schools. It is reported that thepresence of trained geriatricians in hospitals has led to an
improvement in the care of older persons and consequent
reductions in costly hospital admissions. Brazil’s 2012-2015
National Health Policy has committed to providing training
in geriatric care to health care professionals throughdistance education. Geriatric reference centres have been
established in many states, especially in the richer southernstates. As part of the broader, comprehensive Age-Friendly
State of Sao Paulo initiative, a significant initiative underway
is the transformation of one hospital in the State of Sao
Paulo into the largest medical centre in Latin America
specialized in the care of older patients and make 10 large
private and public hospitals “age-friendly hospitals”.While it
is too early to evaluate the effectiveness of this initiative, it
is already being replicated.
In the United States, only approximately 1 percent ofphysicians specialize in geriatrics and the numbers are
decreasing, notwithstanding the increase in the older adult
population (Sussman & Altman, 2009). Both the supply andthe demand of geriatric specialists are low. Demand for
geriatricians in institutions and medical practices is low inpart because the procedures performed by geriatricians
are not highly reimbursed. Supply is low partly because
the negative stereotypes of older adults and lower income
relative to other specialties make it a less attractive choicefor physicians.

Home Care/Home Support
As in the vast majority of countries, the Dominican Republic,
Brazil and the United States strongly favour care within theolder person’s home. However all three provide minimal
public assistance to control disease and maintain functional
wellbeing. Mostly, older persons remain in the community,
whatever their condition, with only the help of family either
for lack of support services or for lack of income to pay foravailable services.
In the Dominican Republic, 81 percent of older persons
live in extended families and only 14 percent live alone.
Thus, the Solidarity Card, which provides a meagre foodallowance to about 28 percent of poor older persons,contributes a little to the budget of families that support
an older person. A very small number of older people
benefit from domiciliary visits by a team composed of ageriatrician, a geriatric nurse and a social worker of thetwo medical schools offering geriatric training. Voluntary
service organizations are virtually non-existent, private
home care services are unaffordable for the vast majorityof older people and there are no public home care services.
A few public adult day centres provide community support,
but they are insufficient to meet current and growing needs.
In Brazil, the old-age pension (both the rural pension
and the Benefit of Continued Provision) is also indirectly
subsidizing home support of older adults because theincome gives older people the capacity to share resources
with family members in exchange for services. Somemunicipalities or private health services include geriatricday centres among their services. Another public service
available is caregiver training programs and educational
materials offered to enhance the care provided by informal
and formal caregivers. Nevertheless, the mainstay of care
at home, i.e., family caregivers, is eroding, as the numberof women available to provide care at home is declining(Camarano, 2008). Many of the initiatives implemented aspart of the Age-friendly State of Sao Paulo are aimed atpromoting the health of older people.
In the United States, Medicare covers post-acute home care,
but long-term care is not a service insured by Medicare andfew people have private insurance to help cover costs ofhome care. Informal care and support, by family and friends
is the norm. It is reported that 65 percent of older persons
in the community rely solely on unpaid help (Stone, 2000,
cited in He et al., 2005). Outside the formal health system,
a number of “ageing-friendly” community initiatives havedeveloped to strengthen community support to enableageing in place and access to needed local services haveemerged in recent years (Scharlach, 2012). The AARP has
recently become involved in working with officials andpartners to facilitate and guide communities to become
more age-friendly, in alliance with the WHO Global
Network of Age-Friendly Cities.
An example of an innovative project within the healthsystem is the nurse-driven model “Living Independently

22

The Future of Health and Healthcare in an Ageing World: A Focus on Brazil, Dominican Republic and the United States
for Elders” (LIFE), which was established in 1998 by the
University of Pennsylvania School of Nursing. Under thismodel, all aspects of a patient’s care are coordinated bya team that includes nurse practitioners, a geropsychiatricnurse, a home health nurse practitioners, home care nurses
and day centre triage nurses (Sussman & Altman, 2009).
Institutional CareThe Dominican Republic and Brazil differ somewhat withrespect to long-term institutional care provisions. As indeveloped countries, the Dominican Republic counts
some 5 percent of older adults living in 46 long-termcare residences most of which are private philanthropic
or private for-profit. This surprisingly high percentage ofolder people living in institutional facilities may be related
to the fact that many young people are emigrating. These
institutions are regulated, although it is claimed that in many
instances, regulation is limited to administrative measures(HelpAge International and UNFPA, 2012). Institutional carein Brazil is rare and policies in this area are very timorous.
An estimated 0,5 percent of older Brazilians reside incare institutions, which also comprise public, private
philanthropic and private for-profit facilities (IPEA, 2011).
Institutional care is available in only 28.8 percent of Brazilian
municipalities (over 6000). According to the National Policy
and the Statute for Older Persons, older people are eligible
for institutional placement only if they are indigent andcompletely lacking family support. Existing public facilities
are inadequately funded and monitored and the quality ofresident support and care is lacking (Giacomin, 2012).
In the United States, approximately 4 percent of persons
aged 65 and older live in nursing homes, and another 2.5
percent reside in housing that provides supportive services;
the vast majority are aged 80 and older (Department of
Health and Human Services, 2011). Medicare does notcover institutional care, and few Americans have private
insurance for long-term care costs. Thus, the majority ofnursing home residents rely on state support throughMedicaid because they either have low incomes, or they
have spent down their assets (Komisar et al, 2012).

Conclusions: Looking to the Future
Disease trends in the three countries examined here do
not portend significant improvements in the health of theincreasing older populations in the near future. The current
landscape of health policies and services suggests thatboth the Dominican Republic and Brazil will be the victimsof their own success as improved primary care services
increase the number of older persons living longer who will
eventually require care and support for disability and frailty.
However, there is a dearth of services required to support
and care for older persons with chronic or increasingly

complex needs as they age. In the Dominican Republic andin Brazil, both service infrastructure and financial coverage
are lacking for care beyond primary and acute care. In the
US, major barriers include a system that is organized aroundthe provider rather than the patient, as well as inadequate
public health care coverage. Meeting the needs of older
persons in the US health care system will entail adjusting
existing laws, financing and reimbursement mechanisms,
insurance policies and practice models that protect existing
provider practices and constrain innovations in health caredelivery.
Taking into account the variations in service capacity among
the countries examined here, some directions are proposed
to guide policy for the future.
•
•
•
•

•

•

Strengthen health promotion and disease prevention
and self-care programs for older adults.
Continue to strengthen primary care by improving thegerontology and geriatrics training in all streams of
medicine and in all health professions.
Implement proven care practices to favour
comprehensive and flexible management of healthservice offered by health professional teams.
Foster local coordinated networks of community
support services. This includes creating more agefriendly settings and services to prolong and enhancefunctionality and wellbeing. These services should
support both the older person and the informal
caregiver.
Increase the availability of affordable/subsidized goodquality institutional care based on assessed levels
of individual health needs. This will include adopting
cost-effective models of public/private long-term carefinancing that exist already in some countries.
Invest in research to evaluate the implementation andthe impacts of new health policies and practices on
wellbeing and on health system costs. Because Brazil
has a particularly strong capacity for data collection
and research, this country can contribute significantly
to the evidence base for policy in countries withemerging economies.

In conclusion, there has been significant progress in somedeveloping countries such as the Dominican Republic andBrazil to establish access to health care, and to develop
health care services targeted to older persons. It isnecessary for these countries now to keep building the care
continuum as these older adults advance in age, and to do
so in tandem with the creation of age-friendly environments.
In the United States (and other developed countries withsimilar problems of entrenched health care delivery andfinancing), the challenge is to create sufficient incentives toallow the full implementation of effective models of care.

23

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.

24

Acosta, D., Rottbeck, R., Rodrigues, J. G., González, L. M., Almánar, M. R., Minaya, S. N., Del C Ortiz, M., Ferri, C. P., & Prince, M. J. (2010). The prevalenceand social patterning of chronic diseases among older people in a population undergoing health transition. A 10/66 Group cross-sectional
population-based survey in the Dominican Republic. BMC Public Health, 10(344). HTTP://www.biomedcentral.com/1471-2458/10/344
Administration on Ageing (2011). A Profile of Older Americans: 2011. Washington, DC: US Department of Health and Human Services. Retrieved
from http://www.aoa.gov/Ageing_Statistics/Profile/2011/
docs/2011profile.pdf
Alzheimer’s Association (2013). 2013 Alzheimer’s disease facts and figures. Chicago/New York: Alzheimer’s Association.
Amaral, F. L. J. dos Santos, Motta, M. H. A., da Silva, L. P. G., & Alves, B. (2012). Fatores associados com a dificuldade no acesso deidosos com deficiência
aos serviços de saude. Ciência & saúde coletiva, 17(11):2991-3001.
Barnes, A. (2011). The epidemic of obesity and diabetes. Texas Heart Institute Journal, 38(2):142-144.
Boult, C., Reider, L., Frey, K., Leff, B., Boyd, C. M., Wolff, J. L., Wegener, S., Marsteller, J., Karm, L., & Scharstein, D. (2008). Early effects of ‘Guided Care’ on
the quality of health care for multimorbid older persons: A cluster-randomized controlled trial. Journal of Gerontology A BiolSci Med Sci, 63(3):321327.
Camarano, A. A. (2008). Cuidados de longa duração para a populaçãoidosa. Sinais Sociais, 3(7):10-39.
Centers for Disease Control and Prevention (2011). Healthy ageing. Helping people to live long and productive lives and enjoy a good quality of life.
Atlanta: Centers for Disease Control and Prevention.
Colluci, C. (2013). Idosos de São Paulo perderam anos de vida saudávena última década. Folha de S. Paulo, 02/06/2013. Retrieved from http://www1.
folha.uol.com.br/equilibrioesaude/2013/06/1288217-idosos-de-sao-paulo-perderam-anos-de-vida-saudavel-na-ultima-decada.shtml
ECLAC (2010). Ageing, human rights and public policies. Santiago de Chile: ECLAC
Farrell, D., Jensen, E., Kocher, B., Lovergrove, N., Melhem, F., Mendonca, L., & Parish, B. (2008). Accounting for the cost of US health care. A newlook at
why Americans spend more. McKinsey Global Institute Retrieved from http://www.mckinsey.com/insights/health_systemsand_services/accounting_for_the_cost_of_us_health_care
Giacomin, KC (2012). Envelhecimento populacional e os desafios para políticas públicas. In MV Berzins and MC Borges 9eds). Políticas públicas paraum país que envelhece. São Paulo: Martinari, pp. 15-44.
Gragnolati, M., Jorgensen, O. H., Rocha R., & Fruttero, A. (2011). Growing old in an older Brazil: implications of population ageing on growth, poverty,
public finance and service delivery. New York: World Bank.
HelpAge International and UNFPA (2012). Ageing in the twenty-first century: A celebration and a challenge. New York and London: UNFPA and
HelpAge International.
IBGE (2012). Estatísticas do Registro Civil 2011, Tabela 2.6. Rio de Janeiro: IBGE.
IPEA (2011). Infraestrutura social e urbana no Brasil subsídios para uma agenda de pesquisa e formulação de políticas públicas: Condições defuncionamento e infraestrutura das instituições de longa permanência para idosos no Brasil. Rio de Janeiro: IPEA.
Kalache, A. (2010). Implications for the health sector of the ageing process in Brazil. Unpublished background paper prepared for the Workshop on
Ageing in Brazil, World Bank, Brasilia, April 6-7, 2010.
Komisar, H., Cubanski, J., Dawson, L., & Neuman, T. (2012). Key issues in understanding the economic and health security of current and future
generations of seniors. Issue Brief, March 2012. Kaiser Foundation.
Lima-Costa, M. F., Leite Matos, D., Passos Camargos,V., & Macinko, J. (2011). Tendências en dez das condiçoes de saude de idosos brasileiros:evidências da Pesquisa nacional por amostra de domicilios (1998, 2003, 2008). Ciência & saúde coletiva, 16(9):3689-3696.
Riley, L. W., Ko, A., Unger, A., & Reis, M. G. (2007). Slum health: diseases of neglected populations. BMC International Journal of Health and Human
Rights, 7:2.
Scharlach, A. (2012). Creating ageing-friendly communities in the United States. Ageing international, 37:25-35.
Schmidt, M. I., Duncan, B. B., Silva, G. A., Menezes, A. M., Monteiro, C. A., Barreto, S. M., Chor, D., & Menezes, P. R. (2011). Chronic non-communicablediseases in Brazil: burden and current challenges. Lancet, 377 (June 4):1949-1961.
Stone, L. (2000). Long-term care for the elderly with disabilities: Current policy, emerging trends and implications for the 21st century. Millbank
Memorial Fund. Cited in: He, W., Sengupta, M.,Velkoff,V. A.,& DeBarros, K. A. (2005). U.S. Census Bureau, Current Population Reports, P23-209, 65+ in
the United States: 2005. Washington, DC: U.S. Government Printing Office.
Sussman, J. & Altman, S. (2009). How will we meet the health service needs of an ageing America? Policy Brief. Findings from the 16th Princeton
Conference. Sponsored by The Council on Health Care Economics and Policy, May 20-21, 2009.
UNDESA, Population Division (2012).World Population Ageing and Development, 2012. Wall Chart. Retrieved from www.unpopulation.org.
World Health Organization (2007). Age-friendly cities: A global guide. Geneva: WHO.
World Health Organization (2011). NCD country profiles 2011. Retrieved from http://www.who.int/nmh/publications/ncd_prfiles2011en/

The Future of Health and Healthcare in an Ageing World: A Focus on Brazil, Dominican Republic and the United States

Speaker Biography
Louise Plouffe is the Senior Researcher at the International Longevity Centre-Brazil.After obtaining her Ph.D. (Psychology)
from the University of Ottawa in 1983 and completing a year of research at Carleton University (Ottawa) as a Post-Doctoral
Fellow of the Gerontology Research Council of Ontario, Louise began her career teaching gerontology at the Université duQuébec en Outaouais. She then left academia to conduct aging policy research and analysis in the Government of Canada
for 20 years and at the World Health Organization for 3 years. As research manager for the National Advisory Council on
Aging and for the Division of Aging and Seniors, Public Health Agency of Canada, she has contributed to the translation of
gerontological knowledge into recommendations for Canadian and international government policy, and has helped increase
public awareness of aging in Canada. Louise played a leading role in developing WHO`s Age-friendly cities guide (2007)
and in publishing scholarly articles about the initiative in co-authorship with Dr. Alexandre Kalache. She was a member of
the Canadian Institutes of Health Research- Institute of Aging Advisory Board from 2000-2006. She currently serves as theVice-President of the Canadian Association on Gerontology. In recognition for her accomplishments Louise has received theContribution in Gerontology Award from the Canadian Association on Gerontology (2012), the Margaret Griffiths Award forvolunteer service from the Ottawa Council on Aging (2012), and the Award for Knowledge Development and Transfer fromthe Public Health Agency of Canada (2011).
Rosy Pereyra, M.D. Autonomuous University of Santo Domingo.
Post-Grade Geriatrics, London, England.
President of Grand Father’s Institute and ILC-DR Geriatrician in the private sector.
INPEA’s representative.
Geriatrican, Otorrino and Specialities Center, Santo Domingo, 1984-1994.
Professor of Geriatrics, CETEC University, 1983-1985.
Professor of Geriatrics, UTESA University, 1984-1985.
Professor of Geriatrics, Post-Grad. Internal Medical Padre Billini Hospital, 1985-1986.
General Director for the Protection of Children and Ministry of Health and Social Assistance, 1986-1996.
PAHO Consultant in the area of Geriatrics, 1984-1986.
President, Dominican Society of Geriatrics and Gerontology, 1990-1992.
Creator and Promoter of the Code of Rights of the Older Dominican, 2008.
Dr. Louise Plouffe and Dr. Rosy Pereyra

25

Dr. Sara Carmel
ILC, Israel

Predictors of Successful Ageing:
A Longitudinal Study of Elderly Israelis

Hava Tovel
ILC, Isarel

Introduction

The global increase inlongevity has raised
New York University
the proportion ofolder citizens in the
populations of mostnations, creating newneeds and challenges
on the personal,
familial, and societal levels. One of the main challenges isto reduce the years of living with disabilities by maintaining
and enhancing independency and quality of life in the later
years of life.

Victoria H. Raveis

The purpose of this longitudinal study was to assess thepart that the aged individual plays in shaping his future
and the course of his life in later years. We examined how
various resources and coping patterns that people acquire
over the course of their lives contribute to their successful
aging, following a decline in health and/or function. The
coping patterns we studied were divided into two groups
that differ from one another along the time axis: proactive
coping, which precedes the decline in health/functioning andconstitutes preparation for potential scenarios of loss ofhealth and/or functioning in later years, and reactive coping,which comes into play following such losses.
We hypothesized a negative association between a decline
in health and/or function and successful aging, positive
associations between coping patterns and successful aging,positive associations between certain personal resources
and coping patterns, and finally a long-term influence of
personal resources and coping patterns on successful aging
in the presence of a decline in health and function that
occurred over the course of one year.

Methods
Sample and process
We assumed that a significant number of people aged 75
and over would experience a decrease in health and/or
physical functioning over the course of one year. Based on
this assumption, participants were randomly recruited fromthree Israeli cities Haifa - located in the North, Tel-Aviv atthe center, and Beer-Sheva in the south. Altogether, 352(34.4%) persons were Haifa residents, 330 (32.3%) Tel Aviv
residents, and 340 (33.3%) Beer-Sheva residents. Altogether,
1,216 elderly persons, aged 75+, were interviewed atbaseline (T1).
The 2nd wave of interviews (T2) was carried out after a
one-year interval, and included 1,019 participants (83.8% of
the original group). Among the 194 participants who werelost to follow-up, 45% refused to continue participation,
34.5% were no longer able to participate due to health/cognitive disability, 13.9 % passed away, and 6.2 % were lost26

due to communication problems (no answer to repeatedphone calls, or not at home when contacted).
All of the participants were interviewed in their homesby skilled interviewers. The interviews were based on
structured questionnaires composed of closed questions.
At baseline, the selected participants were aged 75 years andolder, independent in daily functions (ADL), mentally andcognitively competent, and able to respond to questions in
Hebrew or Russian. Their average age was 81 ranging from75 to 96. Women comprised 45.2 % of the sample.
Study variables
Five groups of variables were included in the questionnaire:(a) successful aging was evaluated by a combined measure of
subjective wellbeing (SWB) including satisfaction with life
[2 different scales - Carmel’s scale (1997) and Neugarten etal’s scale (1961)], happiness [Lyubomirsky, S. & Lepper, H.S.
(1999)], the morale scale [the Philadelphia Geriatric Center
Positive Morale Scale (Lawton, 1975)], will-to-live [Carmel,
2001], and depression [the Hebrew version of the GeriatricDepression Scale (GDS-SF), Zalsman, Aizenberg & Sigler(1998(]; (b) health and function was assessed by measures ofself-rated health, function according to ADL and IADL anda function-specific scale [Hebrew version of the SF ShortForm Health Survey, Lewin-Epstein et el. (1998)], changes inhealth and function during the year preceding the interview,and self evaluation of vision; (c) demographic characteristics
included age, gender, and family status; (d) personal resources
included education, income, self-efficacy (feeling capable ofhandling life problems), function-specific self-efficacy, social
support [2 scales – Carmel’s (1997) and the Berlin Social
Support Scale, Schwarzer et al., (2003)], and satisfaction
with health services; and (e) coping patterns [2 scales ofreactive coping [Freund & Baltes’ SOC questionnaire(2002); Worsch et al.’s Goal-Management Scale (2003)], and3 scales of proactive coping [Sorensen & Pinquart’s (2001)
Preparation for Future Care Needs (PFCN); the Proactive
Coping Inventory (PCI, Greenglass (1999); and Friedemannet al’s. (2004) Long Term Care Planning scale], each of which
included a number of dimensions.

Main Findings
Health and Successful Aging
Most of the results supported our hypotheses. Statisticallysignificant linear correlations were found between all scoreson health and function and the scores on all measures ofwellbeing in the expected direction. That is, the betterthe health/functioning of a subject, the higher the level ofreported wellbeing. In addition, significant correlations were
found between a decline in health/functioning and a decline
in wellbeing indicating that the steeper the deteriorationin health/functioning, the worse the reported decrease in
wellbeing.

Predictors of Successful Ageing: A Longitudinal Study of Elderly Israelis
Personal Resources and Successful Aging
As hypothesized, we found positive associations between
most of the resources measured at Time 1 and the
combined index of SWB measured at Time 2.The higher thescores on personal resources including reported feelings ofself-efficacy in handling life problems, function-specific selfefficacy, social support, and economic status, the higher thescores on wellbeing. Level of education did not correlatewith the combined measure of wellbeing.
In order to evaluate the unique contribution of each factor(resources measured at Time 1 and Time 2) to SWB (asmeasured at Time 2) while controlling for the other factors,
we used a two-step hierarchical model in multivariate
regression analyses. In the first step, only gender (which wasstatistically related to all scores of wellbeing, with lower
scores for women), decline in health, and decline in function
were entered into the regression equation. In the second
step, all resources were added, as measured at Time 1 andTime 2.
We found that from all the resources, the contribution ofself-efficacy (Time 2), economic status (Time 2), and social
support (Time 2), were statistically significant predictors of
wellbeing as measured at Time 2. By adding the personal
resources to the multivariate analysis, the predictive powerof the model increased from the 43% of prediction in thefirst step to 64.5% in the second step, and the negative
effects of decline in health and in function weakened.
Patterns of Coping and Successful Aging
We examined the effect of reactive coping and proactive
coping on SWB in the presence of a decline in health andfunction in a similar two-step multivariate analysis. The
variables of gender and decline in health/function wereentered in the first step, and all coping patterns as measured
at Time 1 and Time 2 were added to the analysis in thesecond step. From the group of reactive coping patterns
we found that when controlling for all included variables,
only reengagement in new goals and optimization of theexisting means and strategies had a significant contribution
to the explanation of wellbeing. From the proactive coping
patterns, becoming aware of future decline in health/function, expectation of future care and taking care of
one’s health, as well as a general measure of proactive
coping were statistically significant. This model remained
statistically significant and the explanatory percentage for
SWB rose from 43% to 53%, while the negative influence ofthe decline in health and function weakened.
Resources, Coping Patterns, and Successful Aging
Following Decline in Health and Function
The final analysis was similar to the previous two-stepanalyses, but in the second step we added resources andproactive and reactive coping variables. We found that theresources and coping patterns included in this model added
25% to the prediction of SWB (from 43% to 68%) of SWB
in the second year of the study.
Among the resources and coping patterns, statisticallysignificant contributions to the prediction of SWB (atTime 2), included self-efficacy, function specific self-efficacy,

economic status, social support, satisfaction with healthservices, becoming aware of future needs, expectation of
future care, and gathering information. However, the moreelderly persons reported becoming aware of need for carein the future, and expected needing future care (as measured
by some of the dimensions of proactive coping), the lower
they scored on SWB, while the more they became activeby gathering information regarding their future needs, their
SWB increased.These results indicate that proactive coping
patterns should be divided into two groups. One group
covers awareness of and expectations for future care needs.
The other group includes decisions made and actions taken
to change life circumstances in order to be able to deal
effectively with future care needs.While becoming aware of
future needs for care probably causes worry and therefore
weakens elderly persons’ wellbeing, an active involvement
in finding solutions for future needs strengthens theirwellbeing.
In general, the correlations among the different patterns ofcoping and SWB were much weaker than the correlations
between personal resources and SWB. Significant
correlations were also found between personal resources
and both patterns of coping (reactive and proactive).
Contrary to our expectations, we found that the moreresourceful people were and the more they reported
feeling that they are capable of dealing with difficulties in life,
the less they reported being involved in proactive coping
such as planning for future care needs.

Conclusions
The conclusions drawn from these findings indicate firstof all that a decline in health/function after only one year
is common among people aged 75 and up. The decline inhealth/function has a significant negative effect on theirwellbeing. However, while facing decline in health and/or function, this negative effect on wellbeing is reduced
when elderly people possess personal resources such as
economic means, social support, and most important, abelief in their ability to handle problems occurring in theirlives (self-efficacy), as well as when they use the appropriate
and effective coping patterns.
It is important to point out that during the year of ourstudy, health and function declined, and the self-reported
level of wellbeing decreased, as did self-efficacy and the useof effective reactive coping patterns.We can say that for thisage group, the decline in health/function linked with aging
is joined by a decreasing ability to cope with these losses.
Both of these processes result in an overall negative effecton wellbeing among older persons.
Furthermore, the negative associations found between
personal resources and some of the proactive coping
patterns, and the negative correlations found between someof the proactive coping patterns and wellbeing, indicate thatpeople who have more social and psychosocial resources
and rely upon their abilities to cope with future losses,
are more optimistic about their future and, therefore, lesslikely to prepare themselves for negative events.Those who
become aware of future needs, but are not taking actions to27

prepare themselves, have lower levels of SWB.

Recommendations
The results of the first two stages of the study lead us to
the following recommendations: In order to address thechallenges of old age, it is important to increase awarenessof the fragility of adults aged 75 and over and to invest
in prevention of decline in their health, functioning, andwellbeing.
On the level of health, functioning, and nutrition, it isimportant to conduct frequent evaluations in order to detectrisk factors and decline as early as possible.We recommend
initiating programs for maintaining and enhancing health andfunctioning in this age group. Some of these interventions canbe implemented through medical surveillance, medications
and treatment, along with education and training programson screening, nutrition, and physical activity.These means forpromoting good health have become common knowledge.
Our study adds the importance of interventions directed
toward strengthening psychological factors to be used
before, during and after facing a decline in health and/or
function. Our findings indicate that self-efficacy in general,and specifically the more specific functional self-efficacy, play
an important role in maintaining older people’s subjective
wellbeing. In addition, certain patterns of proactive coping
behaviors contribute to SWB. Such beneficial resources andcoping patterns can be strengthened through appropriate
interventions.
Some of these interventions can also be introduced into
the existing social clubs, day-care centers, assisted living
facilities, and supportive communities, which may reduce
their cost. However, as many old persons do not use thesefacilities, it is important to create new and attractive venues
to encourage more of the aged population to participate
in preventive and empowering activities. Such interventions
are mostly performed in group situations, thus serving theadditional function of becoming support groups. In ourstudy as well as in previous research, social support has
been found to be one of the most important predictors ofsuccessful aging.

28

In order to achieve best results in the most effective andefficient ways, all new interventions should be evaluated andcontrolled. We also recommend conducting pilot studies inthe various nations that would include multidisciplinaryinterventions to promote health, functioning, and wellbeing.
Such programs are described in existing international
literature with reported proven contributions to improved
abilities for dealing with age-related losses.
Another location for such interventions could be dedicatedcenters, set up to provide comprehensive treatment by
multidisciplinary teams of professionals. At such centers,
old persons would undergo a comprehensive evaluation
resulting in a personal treatment program. Similar centers,
which focus on medical aspects, have been establishedby some Israeli sick funds. Despite the high costs to run
these centers, if managed effectively and efficiently by
qualified professionals they can lead to longer periods of
independence and significantly improved quality of life for
elders. Such achievements will have positive outcomes forsociety at large, for family members who will be relievedof some of the responsibility of caregiving, and for theworkforce which will benefit from less absenteeism due tocare obligations.
All of these investments on various societal levels will
result in significantly reduced expenses for elders and theirfamilies, medical and welfare services, and society at large.
The purpose of this study was to examine the factors
affecting successful aging on the personal level. However,
our conclusion and recommendations to initiate regulated
interventions act to reconnect the individual to society, andexpress the approach that a person does not have to age
alone. Society uses socialization processes to prepare its
members to enter social roles along the life course fromchildhood to adulthood and then to retirement. Society
should also assist people to enter the realm of aging byhelping them to develop capabilities to deal with theinevitable losses of old age.
Acknowledgment: This study was supported by a grant from the U.S.Israel Binational Science Foundation (BSF-No. 92-00114). The authors
gratefullyacknowledge this support.

Predictors of Successful Ageing: A Longitudinal Study of Elderly Israelis

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Carmel, S. (2001). The will to live: Gender differences among elderly persons. Social Science & Medicine, 52, 949-958.
Carmel, S. (2009). The will to live as an indicator of wellbeing and a predictor of survival in old age. In Poon, L. & Cohen-Mansfield, J. (Eds.):
Understanding wellbeing in the oldest-old. Cambridge University Press (In press).
Carmel, S. & Mutran, E. (1997): Wishes regarding the use of life-sustaining treatments among elderly persons in Israel: An exploratory model. Social
Science & Medicine, 45 (11), 1715-1727.
Friedemann, M. L., Newman, F. L., Seff, L. R., & Dunlop, B.D. (2004). Planning for long-term care: Concept, definition, and measurement. The
Gerontologist.
Freund, A.M. & Baltes, P.B. (2002). Life-management strategies of selection, optimization and compensation measurement by self-report and constructvalidity. Journal of Personality and Social Psychology, 82(4), 642-662.
Greenglass, E. R., Schwarzer, R., & Taubert, S. (1999). The Proactive Coping Inventory (PCI): A multidimensional research instrument. Online
publication available at: http://userpage.fu-berlin.de/~health/greenpci.htm
Lawton, M.P. (1975). The Philadelphia Geriatric Center Morale Scale: A revision. Journal of Gerontology, 30, 85–89.
Lewin-Epstein, N., Sagiv-Schifter, T., Shabtai, E.L. & Shmueli A. (1998):Validation of the SF-36 Short-Form Health Survey in the adult population of
Israel. Medical Care, 36(9), 1361-1370.
Lyubomirsky, S. & Lepper, H. S. (1999): A measure of subjective happiness: Preliminary reliability and contrast validation. Social Indicators Research, 46(2), 137-155.
Neugarten, B.L., Havighurst, R. J. & Tobin, S.S. (1961). The measurement of life satisfaction. Journal of Gerontology, 16, 134-143.
Schwarzer, R., Knoll, N. & Reicman, N. (2003). Social support. In Kaptein, A. & Weinman, J. (Eds.): Introduction to health psychology. Oxford: Blackwell.
Sorensen, S. & Pinquart, M. (2001). Developing a measure of older adults’ preparation for future care needs. International Journal of Aging and Human
Development, 53(2), 137-165.
Ware, J.E. (1993). SF-36 Health Survey: Manual & Interpretation Guide. Boston: The Health Institute, New England Medical Center.
Wrosch, C., Scheier, M., Miller, E., Schulz, R. & Carver, S. (2003): Adaptive self-regulation of unattainable goals: Goal disengagement, goal reengage
ment, and subjective wellbeing. Personality and Social Psychology Bulletin, 29 (12), 1494-1508.
Zalsman, G., Aizenberg, D. & Sigler, M. (1998). Geriatric Depression Scale Short Form:Validity and reliability of the Hebrew version. Clinical
Gerontologist, 18, 3-9.

Speaker Biography
Sara Carmel is a professor of medical sociology
and gerontology at Ben-Gurion University of the Negev,
Israel, where she has served for many years as Head of
the Department of Sociology of Health and Gerontology
and of the Center for Multidisciplinary Research in Aging.
She is also the President of the International Longevity
Center – Israel, Chairperson of the Fund for Researchin Aging at the Ministry for Senior Citizens, and former
president of the Israel Gerontological Society. Prof.
Carmel established and directed the first MA programsin Sociology of Health and in Gerontology in Israel, as
well as the Israel National Fund for Research in Agingat the Ministry of Senior Citizens. She has carried out
Dr. Sara Carmel
numerous large-scale national studies and surveys in
Israel and in a number of European countries. Prof. Carmel is the author of more than 150 scientific publications including
three edited books, and has served on national and international committees for academic and policy affairs. She hasserved as a member of European Community committees on aging, immigration and health such as ERA-AGE and COST.
Her recent research includes will to live, health, well-being and survival; end-of-life care related preferences and practicesof various groups of patients and medical personnel; doctor-patient relationships and communication; caregiving; andevaluation of health and welfare services.

29

Peter Barnett
Policy Advisor to Baroness
Greengoss, House of Lords,
LondonEmpowerment and Social Participation ofOlder People in The Future: Focus on India
and the U.K.

Noreen Siba
Managing Director,
ILC-UK

Anjali Raje

1.The current
state of play inIndia and theUK

Executive Director,
ILC-India

The world today isincreasingly ageingand while somedeveloped
nationshave foreseen thiseventuality
andinitiated action to address the issue, there are countries,
especially in the developing world, such as India, which have
not yet fully awakened to this longevity revolution!
The Indian government has belatedly begun some serious
initiatives in terms of policy-making, projects and programmes
for the well-being of the elderly, by drafting legislation toprotect the interests of senior citizens (as they are referred
to in India) and in general responding to the needs of theolder people. But the level of commitment is still too low
and not adequate enough to meet the needs of a country
which will have 315 million older persons over the age of
sixty by 2050! (1). Indian society too is still slumbering as
far as the issue of population ageing is concerned. Advocacy
efforts by voluntary organizations and by Senior Citizens
Organisations are only slowly penetrating the minds andconsciousness of the Indian population. The proportion of
the population aged 60 and over in India today (88 Million) is
8.8% of the total population and this is projected to increase
to 20% (315 million) by the year 2050 (2). Similarly the lifeexpectancy at birth for males in 1996 was 61.6 years and forfemales it was 62.2 years, and today, in 2013, it is 66.08 years
for males and 68.33 years for females.
In comparison, in the face of a rising older population, the UK
has gone a long way down the road of social and economic
progress, with consequent benefits to many. However insome cases certain minority groups, including some older
people, have been marginalised and left on the sidelines.
In the UK the plight of older people, in terms of lack ofsocial wellbeing and isolation, especially in rural areas and on
run-down inner city estates, is well understood. However,in some key policy areas the majority of older people
have in the main been protected from any recessionary
economic fallout, as a 2010 Parliamentary Briefing Note(3) informed us. It reported that much of the UK’s total
public spending on benefits is focussed on older people andin 2009/10, State benefits and the NHS accounted for justunder half of government expenditure. In 2010/11, 65% of
UK Department for Work and Pensions benefit expenditure
went to those over working age, equivalent to £100 billion or
one-seventh of total public expenditure. Growing numbersof elderly people also have an impact on the NHS, where
average spending for retired households is nearly double
30

that for non-retired households: in 2007/08 the averagevalue of NHS services for retired households was £5,200
compared with £2,800 for non-retired. These averages
conceal variation across older age groups, with the costof service provision for the most elderly likely to be muchgreater than for younger retired people. The Department of
Health estimates that the average cost of providing hospitaland community health services for a person aged 85 years
or more is around three times greater than for a person
aged 65 to 74 years.
Cynically many people believe this favouring of older people
by UK Politicians is in fact simply because of the ‘grey’ vote.
For, in this respect, compared with their younger peers,
older people in the UK seem to be much empowered. At
the 2010 UK General Election (4) only 44 per cent of those
aged 18-24 voted and 55 per cent of those aged 25-34.
Contrast this with the 76 per cent of those aged over 65
who voted and it is clear to see why older people’s opinions
and favour weigh heavily on the mind of the UK politicalclass, especially with the looming prospect of another hung
Parliament at the 2015 General Election.
So in the UK it is older people that have benefited the mostin recent years from Government tax and benefit policy
largesse, but have they been empowered? The answer isgenerally that they have not! In the main this is because older
people have been seen as a burden ‘deserving’ of charity
and not necessarily as a benefit, or a source of value andopportunity. Thus, rather than being invested in as a sourceof social capital, economic value and growth, they havebeen maintained at a survival level, just above the poverty
line. In support of this ‘value’ theme, a 2012 International
Longevity Centre-UK (ILC-UK) report entitled Retirementin flux: Changing perceptions of retirement and later life (5),argued that retirement is changing and what it means to bea citizen in an ageing society is in a turbulent state of change.
In addition to arguing that older people should expect towork longer and draw upon property wealth to help fundcare costs, the report commented that society needs toabandon the notion that retirement marks the point where
older people’s contributions are no longer necessary or
valuable. We will return to employment later, but the reportasserts that older citizens have a responsibility to remain in
the labour market, where possible, to enable skills retention,
minimise the fiscal burdens on taxpayers and remain active
in our communities.
If not in actual employment, older people can still remain
occupied, active and empowered. As part of an active
retirement many older people are eager to volunteer
in later life and such opportunities must therefore beappropriate, flexible, enjoyable, and oriented towards
utilising the skills older people have developed during theirworking life – especially in terms of mentoring younger
people, in both the hard and softer skills of life-management.

Empowerment and Social Participation of Older People in The Future: Focus on India and the U.K.
Examples are participating in Local Government or as
School Governors or similar. In the UK engagement withand by older people is at the heart of the work of the BethJohnson Foundation (BJF) (6), who among their other aims
seek to shape communities to enable older people to age
well by giving older people a voice; by respecting their views,
experiences and contributions; by empowering them toaccess the knowledge and support they need to age well andthen supporting them to personally influence policies andactivities affecting the health and well-being of older people.
The generations working together are very central to thework of BJF and its Centre for Intergenerational Practice,which aims to bring people together in purposeful, mutually
beneficial activities which promote greater understanding
and respect between generations and contributes to building
more cohesive communities. Intergenerational practice isinclusive, building on the positive resources that the young
and old have to offer each other and those around them.The
centre seeks to underpin the development and promotionof intergenerational practice as a catalyst for social change
by supporting managers, practitioners and volunteers inthe Voluntary and Community Sector, policy makers, andregional and national government to develop stronger
and more resilient communities. As part of this approach
the BJF Centre sponsors the Intergenerational Futures All
Party Parliamentary Group which was established in the
UK Parliament in 2009. (The Group is chaired by Baroness
Greengross, Chief Executive of ILC-UK.) In addition to
MPs and Peers, the Intergenerational Futures APPG has
Associate members who represent many wide-ranging,external youth and older people’s organisations with aninterest in intergenerational issues, who have come together
to promote understanding of the impact of policy onintergenerational relationships and the way in which policy
affects people at different life stages.
Helping other older people is also very much on the UK
volunteering agenda, for example the SilverLine older
people helpline (7) are currently looking for volunteers fortheir telephone befriending service as it goes nationwide
over 2013. (More about SilverLine and its work in Part 3.) A
website called “the Amazings” (8) hosts courses run by older
people to teach the skills that the following generations
might have missed out on. They offer friendly, informal,
classes and courses where younger people can learn skills
such as carpentry, sewing etc directly from people withlifetime know how. Classes take place everywhere, fromcoffee shops, to pubs etc, and the vision is a marketplace andplatform for wisdom with the potential to change learning;
the opportunity to re-think retirement; the possibility ofbringing together communities. There are many other areas
where older people can volunteer their skills – for example
for those who like Cookery there is the Casserole Club (9),mentioned later in section 2.
So what evidence is there of the social exclusion of older
people in the UK and what are its potential effects? Those
working in the statutory and the voluntary sector are deeply
concerned about the impact of isolation and loneliness onolder people, because SilverLine contend it has been shown
to shorten life, creating depression, hastening the onset ofdementia, and causing physical effects such as malnutrition.

A very recent April 2013 report from the UK Office of
National Statistics (ONS)(10), entitled Measuring National
Well-being – Older people and loneliness, examined the wellbeing of older people and provided an analysis of reported
feelings of loneliness by people aged 52 and over using
2009–10 data from the English Longitudinal Study of Ageing(ELSA). Among its conclusions the report noted that, while
66 per cent of respondents reported being lonely hardly
ever or never, 25 per cent said they felt lonely sometimes.
A higher percentage of those aged 80 and over reported
feeling lonely some of the time or often when compared toother age groups (46 per cent of those aged 80 and overcompared with the average of 34 per cent for all aged 52
and over). A 2012 ILC-UK paper, entitled: Is Social Exclusion
still important for older people? (11), found that the numberof people aged 50 plus being socially excluded from decent
housing, public transport and local amenities rose sharply
over a six year period from 2002 to 2008. ILC-UK inferredthat as people age they are more likely to become moresocially excluded than less. They found that over one in six
people in their fifties (18%) were socially excluded in two
of more areas of their life in 2008 – up from 13% in 2002.
The research also found that in 2008 almost 38% of those
aged 85 or older faced some two or more kinds of social
exclusion, for those aged 60-64 years old, the figure was
12.4%.
Loneliness is part of the web of ‘social exclusion’ that someolder vulnerable citizens experience; a nasty mix of living
alone, no access to transport, low income and fear.According
to Loneliness –the state we’re in (12), a 2012 report ofevidence compiled for the Campaign to End Loneliness(CTeL), a number of research studies conducted at different
times in different parts of the UK, suggest that 5–16 percent of the older population is lonely. Using these studies, it
is possible to estimate that overall about 10 per cent of thegeneral population aged over 65 in the UK is lonely all ormost of the time, equating to over 900,000 older people.
This figure has remained the same over decades despite alarge number of organisations doing great work to reduceloneliness felt by older people. The research tells us thatmany older people have little contact with friends and family.
17 per cent of older people are in contact with family, friends
and neighbours less than once a week and 11 per cent arein contact less than once a month. Those who live alone are
more likely to be lonely. In the UK about 3.8 million older
people live alone and 60 per cent of women and nearly halfof the general population aged 75 and over live alone. It is
predicted that between 2008 and 2033 there will be a 44
per cent increase in the number of 65–74-year-olds living
alone, a 38 per cent increase in those aged 75–85 and a 145
per cent increase in those aged 84+.
As mentioned earlier, the greater mobility of modern
families has also in many cases directly lead to increased
isolation and loneliness. Loneliness amongst older people
and impact of family connections, a survey conducted in
Scotland by WRVS (13), revealed the fragmented nature offamilies today and the large number of over 75 year olds
whose closest children live a substantial distance away, often
leaving them very isolated. For 10 per cent of older people,
their nearest child lives more than an hour’s drive away (40miles plus). All over the UK the declines in job security and31

labour-market restructuring have increased pressure on thefamily and reduced location choices as younger people move,from the rural areas where they were born and broughtup, away from their families into the towns and cities foreducation and work. As the parents they left behind inthat move get older, their children are no longer around toprovide companionship and informal care when required. 82
per cent of children who have moved away from their older
parents have done so for work reasons. Three quarters of
the WRVS sample agreed that it is harder for people today
to juggle working commitments and family life. 17 per centof older people would like to see their children more often,
however, half of these people feel that their children are
simply too busy to visit.

2. What is in the best interests of older
people, their well-being and quality of life?
How should ILC centres seek to influence/
determine policy in this regard?
The International Longevity Centre Global Alliance (ILC
Global Alliance), a multinational consortium of member
organizations, has a major role to play here in helping
societies to address longevity and population ageing in
positive and productive ways, by highlighting older people’s
productivity and contributions to family and society as
a whole. Collectively ILC’s cover a broad range of policy
agendas, including high priority areas for the future, while
the local ILC’s work autonomously to study how greater
life expectancy and increased proportions of older people
impact their countries and to seek to offer solutions to
mitigate the effects of those impacts.
In India the rights of an older person are seen as the means
towards the empowerment of the elderly, a means to help
them lead lives with dignity, participation, self-fulfilment
and independence. And yet, though Daniel Thursz (14) has
rightfully stated that ‘opportunities must be created for selfdetermination of and collective action or participation byolder persons’ as part of the process of empowerment, it isalso equally important to remember that in countries where
food, clothing, shelter, money and health services are themore important concerns of those for whom mere survival
is a herculean task, the concepts of self-determination andparticipation as the rights of the older persons, may beconstrued as ‘unwanted luxuries.’ But looking at the larger
picture, unless the older persons are empowered with theserights of self-determination and participation, their right to aqualitative old age might be severely impacted. So the needfor these rights is equally important and necessary even insocieties where poverty and underdevelopment prevail.
James T. Sykes, in his article “Second Opinion” in the book
“Empowering Older People- An International Approach”(15) feels that the concept of ‘empowerment’, unfortunately,
embodies elements of the patronizing that set elders aside as
individuals to whom “we” give certain authority or standing.
We cannot, by our actions alone empower people to haveand use power responsibly. It is only when elders, and peopleof any age, feel that they have the capacity to act responsibly,
without qualification by age, wealth or special status, thatthey will have the sense of autonomy that will enable them32

to develop the confidence that they have value, a legitimate
worth, a place in society, something to share with others
and a rightful place in society. Human Rights thus are thesecurity net which empowers every individual and preventthe concept of ‘charity’ from arising. An older person has
the right to be empowered, to assume responsibility, to be
active and participatory, to be independent and to lead alife of dignity and self-fulfilment. No one has the ‘power’ to‘empower older people -it must be established within them.
In the modern world one way of increasing social
participation could be the use of the internet, social media
and Skype etc. In a 2012 paper, Nudge or Compel? Can
behavioural economics tackle the digital exclusion of older
people? (16), ILC-UK looked to see if ‘nudge’ tactics canbe used to reduce or remove the behavioural barriers thatprevent older people getting online. The report highlighted
that over 7.5 million adults have never used the internet,
with the majority of non-users being older, having disabilities
or in the lowest social classes. Looking at the behaviouraltraits which accompany internet usage among older people,
among its results it found that: People who reported using
the internet tended to report feeling more in control ofvarious aspects of their lives; People who didn’t own acomputer were more likely to feel that they were unable
to learn a new skill and people who reported not using theinternet were more likely to say that they ‘often’ felt isolated
from others.The same pattern was found for loneliness.The
report went onto to recommend that service providers
could attract older customers by finding ways of discounted
installation and connection deals, and initial periods of freeinternet access and by the use of imagery of both older andyounger people.
Some start-up founders are taking it further, using theinternet to help bridge the age gap. The brains behind theCasserole Club (9), for example, urge members to “dosomething great with an extra plate”, sharing spare portionsof uneaten meals with people nearby who find it difficult tocook every day. The concept isn’t aimed only at the elderly
but it is that offline generation that is benefiting most: thesite’s founders report that more than 80 per cent of diners
are over 80 and without regular access to the internet. For
those who aren’t on the internet, Casserole helps those
who are offline to order meals and connect and pair up withlocal people - In fact most of the diners who registered had
been met personally and supported through phone and text.
Regarding Financial Exclusion, Financial Citizenship, a 2012
ILC-UK report (17) noted that the UK has a chronic undersaving problem, which has been exacerbated by the financial
crisis and economic downturn. The report noted that a highproportion of UK households have little or no saving orinvestment wealth, and these households are concentrated
among those with the lowest incomes, including many older
people. In the report’s view, what is required is a ‘financial
citizenship’ framework, which outlines the respective
responsibilities of individuals and the state regarding saving
and helps with a new approach to public policy on saving
and the further empowerment of older people.Turning tohealth, recently the UK Design Council (18) held a designcompetition, which was chaired, by Baroness Greengross(Chief Executive ILC-UK), where young designers looked at

Empowerment and Social Participation of Older People in The Future: Focus on India and the U.K.
how they could enhance the lives of people with dementia
through buildings, pavements, lighting, colour and evenodours, which encourage them to eat. If this and similar
programmes progress well, then we are moving towards,
not just age friendly cities, as championed by the World
Health Organisation, but to dementia friendly communities
where people understand the sensitivities and opportunities
of engaging with this vulnerable and growing group in ourcommunity.

3. What strategies have worked/are
working in your country that have, or
have not been successful in addressing
challenges for older people in thisarea? What evidence can you share of
the effectiveness and impact of thesestrategies – with a view to their potential
for replication in other countries?
ILC-India encourages and supports the productive work
done by senior citizens’ and their organizations through its
ILC-I Awards. Yearly since 2010, ILC-I has awarded threesenior citizens’ organizations for their exemplary work forthe development of society under the category “Promoting
Qualitative Excellence in Ageing”. ILC-I also awards threesenior citizens over the age of 70 years with its ‘Lifetime
Achievement Awards’ for their extraordinary achievements
in any field. Such awards also enhance the participatory
and empowerment aspects of the older persons, as they
undertake activities that lead to positive and qualitativechanges to the lives of people, leading to a sense of selfworth and dignity.The future of Ageing in India is in the handsof the older persons of the country. The older persons haverealized that it is up to them now to advocate their cause.
The movement of senior citizens rising to make their voices
heard, their opinions attended to, their problems addressed,
has gained great momentum. It is a united front of thesesenior citizens, and the organizations that they represent,that is bringing the issues and concerns of the older persons
to the forefront. What better example of participatory
empowerment than the one that can be seen in India,
where the older persons have taken upon themselves thechallenge of awakening the country to their issues! ILC-I is
supporting all these ventures of the older persons to accord
them strength in their endeavours. Hopefully a bright future
for the next generations of older persons in India is on thehorizon.
In India, under the guidance of the late Dr. S. D. Gokhale, theFounder President of the International Longevity CentreIndia, (ILC-I) initiated the movement of volunteerism by theelderly to effect qualitative change in society through the useof what is viewed as one of India’s greatest treasures, theknowledge, wisdom and experience of its senior citizens!
The concept was that older persons offer their voluntary
services in their areas of skill, interest or expertise toorganizations that require them. The system, administeredby the Volunteers Bureau, works by matching the skills andinterests of the older persons with the requirements oflocal organizations. For instance, a retired school teacher
goes to an orphanage to assist in training and education; aretired financial expert offers his expertise and knowledge
to voluntary organizations which cannot afford the relevant
professional fees, while some older people run a hospital
Help Desk. Such opportunities for productive engagement
develop a sense of well-being amongst the older people,of still being very productive and participative members ofsociety and helping to keep isolation and loneliness at bay.
This initiative of ILC-I was officially recognized by the Ministryof Social Justice & Empowerment, Govt. of India, (the nodal
ministry for population ageing), as an ‘Innovative Initiative’and had commissioned ILC-I to hold orientation and training
programmes for the setting up of such ‘Volunteer Bureaus’
in the northern and southern zones of India.
In terms of combating Isolation and loneliness, in the UK thework of CTeL has already been highlighted but several other
innovative programmes have been introduced. For example
in 20011 the TV personality Esther Rantzen launched The
SilverLine Helpline (7) which seeks to provide a sign-posting
service to link older people into the many, varied services
that exist around the country and a befriending service tocombat loneliness. A pilot was launched in the north- westof England in November 2012 and the launch of a national
service is planned by the end of 2013. A key componentof healthy ageing is the importance of helping older people
remain in the workplace. Recruitment, selection, training
and career advancement should be open to the best person
for the job, irrespective of age. Older workers, if they areable and willing to do so, should be encouraged to delay
retirement and remain in the labour market for longer. In
the UK one of the policy responses to increasing longevity
has been the raising of the state pension age. However in
its 2011report “Extending Working Lives: A Provocation”(19), ILC-UK noted that raising the state pension age will
only mitigate the economic impact of population ageing if
it leads to longer working lives. The report went onto to
propose that for this to occur we need to create labour
market conditions that allow an older workforce to emerge
and thrive. However some negative stereotypes about older
workers still endure. Common perceptions include thatthey are prone to ill health. However, these assumptions
are largely undermined by evidence about age-relatedchanges to physical and cognitive capacities. Many employers
consider their older workers to be a valuable asset: positive
aspects attributed to them include a strong work ethic,
reliability, loyalty, business experience and specialised
skills. Looking at just one UK employer, in 2009 Lancaster
University Management School compared the performancedata of more than 400 McDonalds restaurants (20). Thosewith at least one worker aged 60 or more showed levels ofcustomer service 20% higher than those with no employee
aged over 50. In addition in a survey of 148 restaurant
managers, 69% said later life workers empathise and connect
well with customers and 47% cited later life workers ability
to “go the extra mile” to deliver best possible customer
service.
Within 20 years, ONS tell us that nearly a quarter of the
UK population will be aged 65 or over (21). People are now
spending an average of seven years longer in retirement thanin the 1970s. However, it is unclear what proportion of these
extra years will be healthy and at present ill-health is a factor
33

in many early retirements.The barriers and opportunities toextending working lives include health and wellbeing status.
Good health and wellbeing is important in maintaining thecapability to work into older age. Plainly a workplace thatencourages and supports health and wellbeing at all ages
will be more supportive of older workers. This is a win- winbecause as well as employees benefiting businesses with ahealthy, engaged and resilient workforce, when wellness is
combined with ‘good work’, – work that is secure, varied andputs employees in control – businesses can look forward
to higher engagement, increased productivity and long term
sustainability

that an impoverished “retirement” will await many in future
generations. In the UK we are starting to understand thatthe assumptions that went behind the design of the Statepension system in the 1940s can no longer be applied. In
other words, the system was simply not designed to copewith today’s circumstances, where most people will get tostate retirement age and will live a long time after it. The
policy response to these impacts include the rise in the statepension age, automatic enrolment into pension saving andthe proposed abolition of the Default Retirement Age. It is
too early to judge if these strategies will prove successful,but early signs are promising

Europe’s anti-discrimination legislation now in place means
that, in theory, older people must enjoy the same levelof opportunities in employment as younger people, but
unfortunately older people are often unable to seek job
opportunities so successfully and are often the first in thefiring line when it comes to letting staff go. In October
2012 the UK Government set out plans to extended theright to flexible working to all employees from 2014, which
aim to boost the participation of women and older people
in the labour market. It will give all employees the right torequest reduced or part time hours and working from homearrangement’ and enable people who are nearing or who
have reached retirement to tailor working patterns to suit
their lives.

Looking at our education systems, we might also ask why
we segregate teenagers and adults, young or older, when
they are all learning. Today, even in a small village we canwatch the world’s best known academics on a screen
and there seems no reason why a fifteen year old and aseventy year old cannot learn politics, social sciences or
languages together in a multi-generational setting. We needto look at this seriously as we proceed in this century ofenhanced communication opportunities and in the UK
the BJF Centre for Intergenerational Practice (6) is a good
example of leadership in this important area.With regard to
health services, we have had the most remarkable medical
successes in recent years in curing or controlling many ofthe diseases which used to be fatal. In consequence we now
have to provide health and social care to people with longterm conditions and the co-morbidities which include highincidences of dementia. Our current health and social careservices are not designed to meet these new challenges
and need to be refocused to encourage long term carewith older people taking an active role in ensuring that
happens. The focus in health care must also change towards
preventing disease and impairment and delaying the onset of
disabling symptoms. For example in the UK we have somesituations, as in the London Borough of Camden, (25) where
older people are encouraged to keep fit outdoors throughadult focused exercise equipment and activities, where older
and younger people work out on the machines or in the
fresh air together. This is not only good for health but also
for promoting intergenerational relationships, participationand co-operation.

In April 2012, ILC-UK challenged the assumption that older
people should automatically cease to contribute after they
have left the labour market. As we mentioned earlier, in its
paper ‘Retirement in flux’ (5) ILC-UK debated the current
purpose of retirement, and proposed that in light of anageing population the current paradigm of contributions
during working life coming to an abrupt halt on retirement is
outdated and unsustainable. In the paper, ILC-UK recognisedthat older people must also have a right to receive support
from both employers and society more generally to enable
them to have longer, more fulfilling working lives.The reportfound support for longer employment amongst the older
population; 46 per cent of over 65s would consider delaying
retirement if their employer offered support for reducing
their hours, or working more flexibly.
According to a 2012 Age UK report (22) flexible working
would allow older workers to manage their health needs,
continue looking after people in their care and enable asmooth transition to retirement. Importantly, and contrary
to common belief, in terms of younger versus older
employment, the situation is not “one in, one out”. In 2012
the Resolution Foundation (23) asserted that boosting
employment among older workers does not automaticallymean younger people are deprived of work. Instead,
expanding employment into older age raises incomes andstimulates demand for other services, which has a positiveeffect on further job creation.
A 2011 ILC-UK paper Understanding the Older
Entrepreneur (24), recognising that people are going to haveto work for longer under the impacts of increased longevity
and inadequate pension provision, noted that the inadequacyof saving and the poor returns available at retirement meant
34

Collaboration between the generations is a tool to promote
active ageing and can help us achieve essential goals in policy
and practice. This applies to the built environment where,
when we design our streets, our lighting and our homes,
we must take note of how the population is changing. In
modern society people are more likely to impaired by age ordisability and yet remain active and older people themselves
need to be included so they make their own decisions about
the services they want and how they should be designed.
In its 2007 paper, Towards Lifetime Neighbourhoods:
Designing Sustainable Communities For All, published inpartnership with the Department of Communities and Local
Government (26) ILC-UK explored how a more age-friendly
vision of public spaces and community could boost social
engagement, good health and the chances of ‘active ageing’
for all. They proposed that not only can an appropriately
planned built environment offer a more accessible, inclusive
space for the frail or disabled, but services, amenities,

Empowerment and Social Participation of Older People in The Future: Focus on India and the U.K.
social cohesion and sense of place can play a key role inthe creation of ‘lifetime neighbourhoods’ which help create
communities that maximise health, wellbeing and social
engagement. In a follow up 2008 paper Building our Futures(27) ILC-UK produced revised guidance and tools for local
planners to prepare for the UK’s ageing population. The
guide recognised that as we age, our homes become a key
environment influencing our health and our independence
and, showing the key relationships between factors such as
tenure, housing type, health and social class gives pointers
to identifying the varied needs of different groups, set out
to help local and regional planners take older people into
account as they plan housing strategies. In its Social Exclusion
report (11), among its recommendations, ILC-UK calledon the UK Government to: Allocate the task of measuring
and developing strategies to overcome material and nonmaterial disadvantage to a specific team within government;
Shift the focus of government policy on ageing towards
prevention of the onset of disabling impairment. ILC-UK
argues that Government should focus on ‘ageing policies’
rather than ‘older people’s policies’ in order to tackle
increasing exclusion among middle aged people; Improve theplanning of neighbourhoods for people of all ages to reducelevels of exclusion from local amenities and decent housing
and public transport.
The collected view is that awards for senior citizens or thesenior citizens’ organizations for doing exemplary work,
is a sound strategy through which the older persons are
and could be motivated to undertake activities that bring inqualitative improvements in the lives of the older persons.
This is a strategy that could be replicated in countries tostimulate, to motivate and to inspire the older persons
to undertake activities that impact society and the elders
positively.

4. What are some other related challenges
in your country?
A first step towards bringing a sea-change in Indian society
towards empowerment in old age is to undertake advocacyof the cause of population ageing. However a major problem
in India is the level of illiteracy in the country and it is thesubsequent ignorance on the part of this illiterate sectionof society, coupled with the lack of interest in the issue on
the part of the literate segments of Indian society, whichmakes the task of advocating old age empowerment more
daunting. Thus an important means of developing an agefriendly society is through the older persons themselves.
And fortunately for India, this has begun, there is a good
degree of awareness amongst the seniors themselves thatthey have to be more proactive and empowered, if they wanta society that is age-friendly and enables them to live a lifeof dignity. The draft ‘National Policy on Senior Citizens’ wasissued in 2011 and the senior citizens movement in India
has an umbrella organization, The All India Senior Citizens’
Confederation (AISCCON) which has a membership ofsenior citizens from across India. This body, though notofficially recognized by the Government of India, is the faceof the older persons’ organizations and the government
regularly interacts with its representatives. AISCCON has
been very proactive, mobilizing senior citizens to participate

in productive activities which enhance the development andwell-being of not just senior citizens themselves but also of
society in general.
In the UK the ageing well and the active ageing programmes
have a long way to go still, but the message is clear: Older
people can and must make decisions for themselves. Older
people can and do make a major contribution to society andworking with the young can make transformative changes.
This has to involve everyone and 2012 the European year ofactive ageing was a very positive first step in ensuring thatit does take place. 2013 is the European Year of Citizenshipwhere, hopefully, we will see more older people becomeaware of their rights and responsibilities. In Britain, and in
the rest of Europe, there is a huge amount of work needed
to educate people about what all of us can do through policy
and practice to enhance the quality of life and encourage
good relationships between the generations. A big prize
awaits if we can improve intergenerational relationships.The
Golden Economy, a 2010 ILC-UK report (24), drew attention
to the importance of older people to the UK economy.
Older people’s spending reached an estimated £97 billion in2008 (65 plus)‚ around 15 per cent of the overall household
expenditure. Those aged 50 or over spent £276 billion in2008‚ making up around 44 per cent of the total family
spending in the UK.The older consumer market is expected
to grow by 81 per cent by 2030 while the 18-59 year oldmarket will only increase 7 per cent. Yet despite the size ofthe market, this report finds that for many older people, theprivate sector does not meet their needs. This is not just astory of poverty or a lack of income to buy products, butof a consumer marketplace which frequently fails to meetthe needs of an ageing population. Across a wide range ofindustries, the older consumer continues to be ignored or
patronised, despite the fact that older people don’t just buy
products for themselves; they also shop for their children
and grandchildren. As well as contributing to isolation andloneliness, alongside poor mobility, a lack of transport is oneof the biggest barriers to older people’s participation in the
consumer market. Also products and services can be mademore attractive to the older consumer by the simple useof inclusive design principals. In addition older people are
far too often, not demanding goods and services to meettheir current needs. Older consumers have been found to
be less likely to complain about products and services thanthe consumer population as a whole.
Moving towards an age neutral society will mean that we
can support those who are not able to contribute owing
to their reduced capability, for example, through ill health.
At the same time, we can acknowledge the considerable
contribution, to local communities and society as a whole,made by many older people and work towards this model
becoming the norm. Additionally, UK decision-makers needto recognise that, as well as the boost to quality of life, thebenefits in physical and cognitive health that can be theresult of remaining involved, engaged and empowered at
all ages. Both ILC-UK and ILC-India are active on all thesefronts but while we have come a long way there is still plentyof work remaining to be done before older people become
sufficiently empowered to make a difference to their own
outcomes and those of the citizenry as a whole.
35

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

“Demographic Profile of Elderly in India”, Pune, ILC-India. Kanitkar, Tara and Shukla Sharvari, 2009
“Demographics of Population Ageing in India”, BKPAI Working Paper No. 1, United Nations Population Fund (UNFPA), New Delhi. Subaiya, Lekha andBansod, Dhananjay. W., December 2011,
The Ageing Population, Key Issues for the New Parliament 2010. House of Commons Library Briefing paper, 2010
Golden oldies? David Cameron favours the elderly because they’re the ones who vote. Mark Thompson Independent Newspaper Ltd., 18th
December 2012Retirement in flux: Changing perceptions of retirement and later life. ILC-UK, 2012
The Beth Johnson Foundation http://www.bjf.org.uk/about-us/what-we-do
The Silver Line. http://www.thesilverline.org.uk/about-the-silver-line
The Amazings - www.theamazings.com/pages/about
The Casserole Club - www.casseroleclub.com
Measuring National Well-being – Older people and loneliness. ONS April 2013
Is Social Exclusion still important for older people? ILC-UK, 2012
Loneliness –the state we’re in. Campaign to End Loneliness and Age UK Oxfordshire, 2012.
Loneliness amongst older people and impact of family connections. WRVS Scotland, 2013
“Empowerment: As Illustrated by a Bear, Napoleon, and Others”, Empowering Older People- An International Approach, edited by Thursz Daniel ,Nusberg Charlotte & Prather Johnnie, London, Cassell. Donelan, Brigid , 1995
“Second Opinion”-Empowering Older People, An International Approach, London, Cassell. Sykes James T. 1995
Nudge or Compel? Can behavioural economics tackle the digital exclusion of older people? ILC-UK, 2012
Financial citizenship. ILC-UK, 2012
Living well with Dementia. UK Design Council, 2012
Extending Working Lives: A Provocation. ILC-UK, 2011
Employers network for equality and inclusion (ENEI) March 2012 & Fairhurst, D (2010) ‘Creating trust-based HRM at McDonald’s’, Lancaster
University. www.lums.lancs.ac.uk/media/view/fairhursttrust ;UK labour market statistics 2012: ONS, 2012
A means to many ends- Older workers’ experiences of flexible working. Age UK, 2012
Gaining from Growth – The final report of the commission for living standards. Resolution Foundation, 2012
Understanding the Older Entrepreneur. ILC-UK, 2011
Keeping fit in a Senior Playground. Age UK, 2012 (http://www.ageuk.org.uk/health-wellbeing/keeping-fit/keeping-fit-at-a-senior-playground/)Towards Lifetime Neighbourhoods: Designing Sustainable Communities For All, published in partnership with the Department of Communities andLocal Government, ILC-UK, 2007
Building our Futures. ILC-UK, 2008
The Golden Economy. ILC-UK, 2010

Speaker Biography

Baroness Sally GreengrossBaroness Sally Greengross has been acrossbench (independent) member of the Houseof Lords since 2000 and chairs five All-Party
Parliamentary Groups: Dementia, Corporate Social
Responsibility, Intergenerational Futures, Continence
Care and Ageing and Older People (Co-Chair). She is
the Vice Chair of the All-Party Parliamentary Groupon Choice at the End of Life, and is Treasurer of the
All-Party Parliamentary Group on Equalities. Sally is
Chief Executive of the International Longevity Centre– UK; Co-President of the ILC Global Alliance; andwas a Commissioner for the Equality and Human
Rights Commission from 2006-12.

Baroness Greengross was Director General of Age Concern England from 1987 until 2000. Until 2000, she was joint Chairof the Age Concern Institute of Gerontology at Kings College London, and Secretary General of Eurolink Age.
Baroness Greengross is Chair of the Advisory Groups for the English Longitudinal Study on Ageing (ELSA) and the New
Dynamics of Ageing (NDA). She is President of the Pensions Policy Institute and Honorary Vice President of the Royal Society
for the Promotion of Health. Baroness Greengross is Patron of the National Association of Care Caterers (NACC) and Patronof Care & Repair England. She holds honorary doctorates from eight UK universities.

36

Dr. Monica
Ferreira
President, ILC, South Africa

Empowerment and Social Participation ofOlder People in South Africa and Argentina
in The Future

Dr. Lía Susana
Daichman

The United Nationsclassifies Argentina
President, ILC, Argentina
and South Africa as“lessdeveloped”
countries(LDCs)(UN, 2009); both arein the “south.” Of
the two countries, population ageing is more advanced inArgentina, which has 6.2 million citizens aged 60 years andover, representing 15 per cent of the total population. South
Africa has an older population of 4 million, representing 8
per cent of its total population. Although the countries haveseveral socio-demographic characteristics in common, theirsocio-political histories differ, and the nature of and scopefor older people’s empowerment and participation in thesocieties are examined within these contexts. The situationin Argentina, examined from a human rights perspective, is
extrapolated to that of the Latin America and Caribbean
region as a whole.

South Africa
People in South Africa who are old today lived through theentire four and a half decades of apartheid and before that
under colonialism. Disenfranchised and disempowered until
the first fully democratic elections were held in 1994, themajority remains cumulatively disadvantaged in old age.
Since 1994, a number of initiatives have aimed to empower
these citizens and to integrate them in mainstream social
life. I examine progress made and challenges that persist in
this regard, and envision ways to optimise older persons’empowerment and social inclusion in the future.
Current situation
Rhetoric on the empowerment and social inclusion ofolder people began in earnest in 1991 with the United
Nation’s declaration of the Principles of Older Persons andwas boosted in 1999 with the United Nations’ campaign
Towards a Society for All Ages. In South Africa, the Ministryof Social Development took a lead in the empowerment
drive, that focused on restoring older people’s dignity andrespect for them in society. A strong impetus was given to
the drive with a countrywide investigation and subsequent
publication of several outcome reports – a key report being
Mothers and fathers of the nation: The forgotten people?
(2001). A focus of the investigation was on elder abuse, andthe ministry’s efforts indeed lifted the lid on the insidious andparlous situation. The efforts highlighted the problem, andolder persons’ vulnerability and marginalisation, and offereda rationale and a vehicle for subsequent empowerment
initiatives, as well as encouraged older persons’ participationin all areas of social life.
However, the efforts tended to be an emotional response,or approach – although certainly earning political gain for
the government because of the visibility of the efforts andemotion around the problem. Unwittingly, the efforts simply
reinforced older people’s segregation, highlighting them as avulnerable group whose plight and predicament warranted
sympathetic responses. Nonetheless, the efforts helped
to introduce the concept of older people as contributors
to society, spawned initially through work of HelpAge
International in several African and other developing
countries (HAI, 1999).
Although lip service is currently paid to fostering intergenerational relations (and older people’s social inclusion),such programmes, that purportedly work towards building“a society for all ages,” have been less prominent. Muchof the government’s efforts have been aimed at rekindlingtraditional reverence for older people, proselytising a time
when families cared for (and supported) their older relatives– which, insidiously, would lessen dependent older persons’burden on government support.
The campaign to create awareness and to fight elder
abuse has certainly been an important vehicle for theempowerment of older people in general. Moreover, efforts
under the campaign have sought specifically to educate
older people on their human rights, and how to withstandthe abuse and violation of their rights.
What has proved to be another tool for older South
Africans’ empowerment is the non-contributory, social old
age pension. The majority, being poor, are eligible to receive
pension benefits equivalent to $140 monthly. Pensioners areentitled moreover to free health care at public facilities. Being
a social pensioner accords the beneficiary an enviable status(Ferreira, 2004). Older persons view pension benefits as aright, rather than an entitlement, and as acknowledgementof the contribution they made to society over a lifetime andaffirmation of their position in society. Pension benefits arethus a powerful empowerment tool: they earn a beneficiary
respect and esteem within his/her family and community;
they empower him/her financially; in turn, a beneficiary isable to empower his/her family through pension sharing, thus
helping to feed, clothe and educate grandchildren, to sustain
unemployed adult kin, and to contribute to development
overall (Sagner & Mtati, 1999; Moller & Sotshongaye, 1996).
A downside of receipt of pension benefits, however, is thatin socially disorganised contexts, the income may render abeneficiary open to abuse and exploitation by family andothers in the community intent on attaching the benefits.
Brief mention must be made of several empowermentspecific initiatives under way over two or three decades,such as literacy training (where a large proportion of theolder population, particularly in rural areas and women inparticular, is illiterate). ABET (Adult Basic Education andTraining) programmes, efforts of the Ministry of Sport andRecreation to establish sports programmes for seniors,
voter education programmes (Moller, 1995), activities37

of groups of veterans (survivors of the struggle against
apartheid – who preserve an identity and status as “struggle
fighters”), activities of groups of volunteers and churchgroups – which similarly lend members status and a senseof contribution and participation, and victim empowerment
groups – where seniors who have been victims of a crime,
exploitation or abuse, or indeed victims of “torture” underapartheid, may be helped to deal with the aftermath of theevents are examples of such initiatives.

older persons as custodians of indigenous knowledge.

A South African Older Persons Forum (SAOPF) wasestablished early in the 2000s, but as of 2013, its future is
uncertain.The forum was intended to be a spokes organ for
older people, for them to articulate concerns and grievances.
However, it was constituted primarily of elected managers
of agencies such as NGOs and politically connected
personalities, who collectively claimed to represent thevoices of older people. More recently, it served mainly as agovernment bureau, funded by the government, which given
an obvious lack of objectivity, defeated the purpose of aforum in the first place.

Overall, and importantly, older persons can be empowered
and their participation in society fostered if their basic needs
are met, they are no longer marginalised in state systems,
they enjoy social justice, and they are accorded respect insociety and enabled to live in dignity.

How might older persons’ well-being and quality of life
be enhanced?
What is needed first, no doubt, is for South Africans toachieve a non-ageist society, following on from which allforms of institutional discrimination against older people
may be eliminated.
Second, older people’s empowerment must be continued,
to encourage them to view themselves as citizens withhuman rights, and entitled to equitable access to all organsof society and resources. Such empowerment, through“training” in human rights – inter alia, will equip them withknowledge and tools to stand up and speak out; and, at
another level, to withstand and fight abuse, exploitationand discrimination, and other violation of their rights.
Intrinsic to such empowerment is knowledge of access:to resources, including information, and to channels for
redress, to seek justice. Strategies already in place to foster
such empowerment include literacy training programmes;
training workshops on human rights offered by several
NGOs that serve older people; health and self-care
education workshops; income generation skills training;financial literacy training; and so on.
Third, older citizens need to be empowered and helped tomobilise, or organise themselves into a group for institutional
representation (Ferreira, 2004). Social pensioners, whoconstitute a vast body, have no representation as such; they
are viewed no more than recipients of welfare and are
voiceless.
Fourth, the government has historically not been receptiveof information or guidance from academia, etc. It lacks
expertise within its ranks and declines to consider, indeed
dismisses or rejects, evidence put to it.
Fifth, greater scope might be given for older persons ofdifferent cultures, as elders, to preserve traditions, and tocontribute to society through transmission of knowledgeof cultural practices and rituals, in organised ways – thus
heightening the visibility and importance of culture and38

Finally, in a catch-all category, initiatives are needed toenhance older people’s visibility – and thus status (which
includes their needs, concerns, aspirations and contributions);
specific initiatives to integrate them in intergenerational
programmes; improved access – as indicated above; andbetter protection – from exploitation, discrimination, abuse
and criminality.

How, then, may ILC South Africa (ILCSA) seek to influenceor determine policy in the above regard? Empowerment
and social participation of older citizens have been andremain two core focal areas of ILCSA’s programmes.
Specifically, these programmes are aimed at a) empowering
older persons through awareness of their human rights,
and b) supporting grandmothers caring for adult children
and grandchildren affected by HIV/AIDS, while fostering thecarers’ social integration. ILCSA’s efforts in these regards
take the form of research and intervention; training support;
advocacy; and dissemination of evidence for decision
support. The efforts, to influence or determine policy, arecontinuing, but challenges are hampering efforts, as outlined
below.
What strategies work and have been successful?
Specific strategies implemented over some four decades,
since the 1970s, to empower older persons, and less directly
to foster their social participation, include the following: A
strong movement was launched in the 1970s, by the former
South African Council for the Aged, now Age-in-Action, in
partnership with the Ministry of Social Welfare at the time, toestablish senior centres countrywide.The centres, operated
by NGOs and subsidised by the government based onmembership, run seniors’ clubs at congenial venues, whereclub members, who pay a nominal monthly membershipfee, congregate during the morning on five days a week toenjoy refreshments, engage in a variety of activities – suchas handicrafts, singing and physical exercises, receive healtheducation and counselling, and enjoy a nutritious, hot lunch.
Many clubs are indeed known as Luncheon Clubs.Time spentat a senior centre affords members respite from householdchores and family responsibilities (the majority resides in
multi-generational households), as well as an opportunity tosocialise with peers, and to relax and learn. The movement
has been a seminal effort to empower older persons and torecognise their personhood.
Variations of the senior centre model have proliferated.
Some centres have become multi-purpose sites, andadditionally may offer day care, health care monitoring (anddispense prescribed medication), life skills training, income
generation opportunities, and advice. All offer peer supportand recreation. Most offer training in human rights. Manyorganise visits to places of interest.
An example of a centre that focuses specifically onEmpowerment and Social Participation of Older People in South Africa and Argentina in The Futureempowerment is the NGO Grandmothers Against Poverty
and AIDS (GAPA) (www.gapa.org.za), whose aim is to offer
peer support and counselling to grandmothers who havelost adult children to AIDS, or whose child (or more than
one child) is terminally ill from the disease, for whom theycare as well as raising affected or orphaned grandchildren.
Started in Khayelitsha outside Cape Town in 2000, GAPA
now has branches in the Eastern Cape and Free State
provinces, and training programmes in Kenya, Tanzania andZimbabwe. Seventeen peer support groups are operated
in Cape Town by grandmothers who joined GAPA initially,
whose self-confidence flourished and who subsequently
became group leaders. GAPA offers its members income
generation opportunities, from selling second-hand clothes,
to making and selling handcrafts, to food gardening andselling vegetables. More recently, it has established a bursary
scheme for members’ grandchildren to enable the children
to attend a crèche (and to give the grandmothers respite),and has established an after school care centre, staffed by
grandmothers, who read stories to the children, and oversee
homework and activities for small remuneration.
Storytelling to young children is a time honoured activityof African older women. Many volunteer to tell stories atcrèches, and to guide young children in appropriate andtraditional behaviour and practices. Thus, such programmes
are intergenerational, enable older participants tocontribute in their community, and contribute to theirsocial participation, empowerment, and sense of dignity andpurpose overall.
Other programmes proven to work well include those thatempower older persons politically: to know their rights, toparticipate in civic affairs, to vote in elections, to take a standand speak out on community issues, and so on – referred toearlier. Older men, in particular, play important roles as civic
guardians by serving on street committees and normalising
behaviour in their neighbourhood.
Overall, participants in all these programmes are empowered
through acquisition of skills and coping strategies, enhanced
self-esteem, and encouragement to stand up, and to demandrespect and respect of their rights – as well as to speak with
one voice.
Persisting challenges
Challenges to the empowerment of older people andfostering their social participation in South Africa, as well
as strategies that are desirable in the future in order toovercome the challenges include the following:••

Poverty eradication and implementation of thegovernment’s development agenda in general, or social
justice, through effective service delivery, needs tobe expedited, so that older people’s livelihoods, andsocial and habitat environments are improved, they areafforded equitable access and opportunity, and theirsense of self-worth and dignity is enhanced, or at least
restored in the process.
Part and parcel of the government’s development efforts
must be urgent reduction of the high unemployment
rate in the young adult population, through job
creation, so that younger kin may have livelihoods, and

•

•

•

•

•

older family members, social pensioners specifically, arerelieved of the burden of support and care for thesekin.
A change of mind-set is needed, on the part of thegovernment, society and older people, away froma welfare approach to older people, towards one ofindividual responsibility for self-sufficiency. Successive
cohorts of social pension beneficiaries – and indeed
all recipients of social welfare – must gradually beweaned off a dependence on the state for theirneeds. At the same time, the state must shake off its
welfarist attitude, whereby it largely absolves itself fromadditional responsibility to poor older citizens throughthe large cash transfer it makes to this population in theform of the social pension. Indeed, the government andpoliticians enjoy high visibility (and political gain) fromthe largesse they are seen to dispense to a perceived
highly vulnerable group, but the government’s functionin this regard is akin to that of a nanny state: it isself-perpetuating, and does nothing to promote selfprovision and self-sufficiency in older citizens. Granted,
a time span of two to three generations is likely
required for successive cohorts to be able to provide
for themselves financially and sufficiently in old age.
Akin to welfarist attitudes in our society are ageist anddiscriminatory practices which persist, and marginaliseand debase, or demean older people, and render themvulnerable to abuse, mistreatment and exploitation.
Mandatory retirement laws and practices need to be
removed or relaxed, to enable older workers, who sochoose, to continue to engage in the formal labour
force. Such an opportunity, to continue to contributeto the economy and development, and to be financiallyself-sufficient, will enhance their self-esteem and earnthem respect in their community.
Older people need to be fully educated on their
human rights and how to exercise them, as well as
knowledgeable about accessing entitlements, andrecourse they have to legal and justice resources. A
more equitable dispensation is needed for older peoplein virtually all areas of social life.
A final challenge lies in the government’s lack of
openness to information and guidance provided
or offered to it by external parties and agencies,
including academic institutions. Government leans on
internal decision making to determine what is in thebest interests of older people (and falls within thegovernment’s set priorities for fiscal expenditure).
Added to the impasse, or conundrum are deep divides
between various ministries with responsibility for older
people, and inertia around a purported Older Persons’
Desk located in the Presidency.

Argentina
Current situation
The equality agenda in Argentina, and indeed in Latin America
as a whole, faces a paradox: Although the elimination ofperceived differences between people is gaining visibility inpolitical debate and public agenda, groups defined by age,gender, religion and ethnic origin are increasingly excluded inmainstream society. Negative connotations, or stereotypes
attached to old age still make it difficult for older people
39to achieve autonomy and independence – individually andcollectively. For a large number, being 60 years and older
seemingly translates into poverty, violation of their rights,
loss of respect, frailty and social exclusion.
Women’s longer life expectancy worldwide leads to agreater number of older women being widowed, andat risk of being poor and alone. Increasing longevity, andconsequent structural changes, have profound implications
for older women’s human rights, and increase the urgency
to address the diverse challenges and discrimination theyexperience, through appropriate gender and age sensitive
policy, budgetary allocation and political will.
Fortunately, over the past decade, and through theemployment of a human rights approach, concern about thestatus of older persons has been making its way into national
policies in this regard. However, the policies of internationaland regional bodies as well as certain state agencies andother stakeholders are not legally binding, and in terms of
ensuring that older persons’ rights are protected, the list ofcensurable reasons for discrimination should be expanded
to include age and gender.
The Committee on the Elimination of Discrimination against
Women (CEDAW) has made a key contribution in the formof General Recommendation No. 27 on older women andthe protection of their human rights, as has the Committee
against Torture with its General Comment No. 2 on theimplementation of article 2 by State parties, published in2008 (Huenchuan, 2011a,b).
At the Inter-American level, in the late 1980s, specificmeasures to protect older persons were included in the
Additional Protocol to the American Convention on
Human Rights in the Area of Economic, Social and Cultural
Rights (Protocol of San Salvador), which is the only binding
instrument to date that specifically addresses the rights ofolder persons.
Recently, particularly since 2007, some LA countries haveopened and/or widened channels for the Participation forOlder Persons, and have encouraged them to participate
in designing national plans concerning their rights.
Constitutional protection and specific legislation on therights of older persons have been discussed. Several LA
countries – Argentina, the Bolivarian Republic of Venezuela,
Brazil, Colombia, Costa Rica, the Dominican Republic, El
Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama,Paraguay, and the Plurinational State of Bolivia – havewritten the rights of older persons into their Constitutions.
Some of these countries include protection from actsof discrimination; others focus mainly on guaranteeing
economic, social and cultural rights.
Thirteen countries of Latin America – Venezuela, Brazil,
Colombia, Costa Rica, Dominican Republic, Ecuador, El
Salvador, Guatemala, Honduras, Mexico, Nicaragua, Paraguay
and Peru – have specific legislation on the matter. Others
are currently considering legislation. An example is a bill toensure the rights of older persons in the Plurinational Stateof Bolivia. In Chile, in July 2010, the Chamber of Deputies
unanimously passed a draft agreement requesting that the40

executive branch send a comprehensive older persons’rights bill to Congress.
In Argentina (Roqué, 2010) and Panama (MIDES, 2010) work
is under way on comprehensive legislation to protect therights of older persons.These laws are of tremendous value
both nationally and regionally in that they are a first attempt
to legislate rights, and so are useful tools for enforcing
constitutional protections. The 13 countries with specificlegislation have made a broad-based effort to set out the
Rights of Older Persons.
Provisions against age discrimination cut across most of
the legislation that is in place. Regardless of their stage of
population ageing, virtually all the countries – Bolivarian
Republic of Venezuela, Brazil, Colombia, Dominican
Republic, El Salvador, Mexico, Nicaragua, Paraguay and Peru
– recognise that old age itself can be a source of violation ofrights, and have put measures in place to prevent and punish
age discrimination.
In almost all the current legislation, rights to health,education and culture are also protected. Most of thislegislation establishes the right to work, while respecting
the physical, intellectual and psychological circumstances ofolder people.
This legislative process, along with jurisprudence in several
states, reveals emerging new understanding and consensus
on the rights of older persons. However, several areas ofolder persons’ lives remain unprotected, including areasin which they are especially exposed to violation of their
human rights. This omission calls for more extensive
discussion, analysis and proposals for further protection of
their rights, and for targeting particular groups within theolder population, including indigenous people, women andprisoners.
Despite sweeping legislation, the essence and structure ofolder persons’ rights are still under discussion.The rights tohealth, a decent standard of living and work do not mean thesame thing in different countries. This lack of homogeneity
leads to a divergence from minimum universal standards ofhuman rights across states. Until there is a legally binding
instrument, there is a pressing need to bring legislation
into line with current treaties, interpretations by oversightbodies, and, above all, global and regional policies on therights of older persons.
A growing international consensus regarding this issue
provides objective and reasonable justification for taking
special or affirmative action, and making specific adjustmentsthat are proportional to the goal of achieving substantive
equality. Above all, such action can lead to greater inclusion,and to the building of more democratic and pluralistic
societies.
How might older persons’ well-being and quality of life
be enhanced?
Discrimination against any social group is unacceptable.
Protection of older persons’ rights can help them lead amore dignified and secure life. According them respect canfacilitate the conditions that enable them to participate inEmpowerment and Social Participation of Older People in South Africa and Argentina in The Futuresociety and to contribute to their own development. Thus,
there is an urgent need to intensify the call to confront thefundamental causes of discrimination against age and gender.

for older people – indeed, a society for all ages. Particularchallenges in this regard are as follow:•

Numerous older people still experience isolation, poverty,
violence and abuse, and have limited access to healthservices, education and legal protection. Over the life
course, many were denied equal opportunities and worked
in poorly paid jobs, in order to provide for themselves andtheir family dependents. Violation of their rights in old age
can result in serious health problems and the consequences.
Nonetheless, the growing scourge of rights violations isleading to a universal effort to increase awareness of themagnitude of the problem, and to develop and implement
prevention and intervention programmes. However, policies,
and health and social programmes may promote or violate
older persons’ human rights, depending on how they aredesigned and implemented. Prevention of human rights
violations requires the involvement of multiple sectors andthe employment of a gender perspective for equality to bepromoted.
Particularly vulnerable groups of older people include thevery old, functionally disabled persons, women and the poor.
Education, and the dissemination of information, formally,
informally and through the media, can help to remove
negative stereotypes of old age, and send out positive
messages to facilitate older persons’ empowerment.
Empowerment should help them to act on their own
accord, to exercise their rights and to advocate in their own
best interests.

Challenges for the future
The Latin American region has limited time to effectchanges that will result in an egalitarian and inclusive society

•

•

•
•

Social and economic transformation, due to internaland external migration, and the liberation of womenand their progressive entry into the labour force – forexample, calls for a rethinking of the roles of the Stateand the private sector, and the concept of the extended
family.
Policy makers must take into account weakening
family support systems and inadequate social service
provision, in order to provide older people with adecent standard of living.
The scope of the challenges means that the public
sector, the private sector and academia should combine
efforts and resources in innovative, multi-sectoral
research.
Older persons must be included in the equality agenda.
Stronger political will and resources are needed tofoster older people’s greater participation in society.

Hence, the LA region – and Argentina in particular in thiscase – needs innovative solutions to enhance older people’s
well-being, to foster their social inclusion, and to ensure age
and gender equality.

Conclusions
The examination of the situation in South Africa describes
the socio-political climate that enables and impedes older
people’s empowerment and social participation. That inArgentina, extrapolated to the Latin America and Caribbean
region, makes out a compelling case for strengthening
older people’s human rights and protection, and thereby
empowering them and fostering their social participation.
A human rights approach to all areas of older people’s lives
can serve as a powerful tool for their future empowerment.

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights, “Protocol of San Salvador.”
OAS Treaty Series No. 69 (1988), enforced November 16, 1999.
Bárcena, A. 2010. Opening remarks at the 33rd session of the Commission, Brasilia, 30 May 2010 [online] http://www.eclac.org/prensa/noticias/
discursossecretaria/8/39678/DiscursoInaugural_Alicia_Barcena_English.pdf.
CEDAW (Committee on the Elimination of Discrimination Against Women). 2009. Concept note on the draft general recommendation on older
women and protection of their human rights (CEDAW/C/2009/II/WP.1/R), May 12.
Ferreira, M. 2004. South African social pensioners: collective identity, the media and influence. In: Les Cahiers de la FIAPA, Action Research on Ageing,
Grey Power,Vol. 2: Economic and social influences, pp. 158-166.
HelpAge International. 1999. The contribution of older people to development. The South African study. London: HAI.
Huenchuan, S. 2011a. “Desafíos de la institucionalidad pública y el abordaje del envejecimiento.” Presentation in the international meeting to follow
up on the Brasilia Declaration and the promotion of the rights of the elderly, 9-10 November.
Huenchuan, S. 2011b. “Legislación comparada sobre personas mayores en Centroamérica y la República Dominicana.” Project document, No. 432(LC/W.432), Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC).
MIDES (Ministry of Social Development of Panama). 2010. “Informe de Panamá en la sesión sobre protección jurídica en materia de envejecimiento:
Momento actual y proyección future.” 10th Riicotec Conference “De la necesidad a los derechos en laspolíticas públicas de discapacidad y
envejecimiento”, Asunción, 22-24 September.
Moller,V. 1995.Voter education and older African first-time voters in South Africa’s 1994 elections. Southern African Journal of Gerontology, 4(1):3-10.
Moller,V. & Sotshongaye, A. 1996. “My family eat this money too”: pension sharing and self-respect among Zulu grandmothers. Southern African
Journal of Gerontology, 1(1): 9-13.
Roqué, M. 2010. “Informe de Argentina en la sesión sobre protección jurídica en materia de envejecimiento: Momento actual y proyección future.”
10th Riicotec Conference “De la necesidad a los derechos en las políticas públicas de discapacidad y envejecimiento”, Asunción, September 22-24.
Sagner, A. & Mtati, R.Z. 1999. Politics of pension sharing in urban South Africa. Ageing and Society, 19(4): 393-416.
South Africa (Republic). Department of Social Development. 2001. Ministerial Committee on Abuse, Neglect and Ill-treatment of Older Persons.
Mothers and fathers of the nation: The forgotten people? Vol.1. Pretoria: Government Printer.
United Nations. Population Division. 2009. Population ageing and development 2009. Wall chart. New York: UNDESA.
United Nations. 1999. Principles of Older Persons. New York: UN.
41

Speaker Biography
Monica Ferreira, DPhil (Sociology), is the President of International Longevity Centre - South Africa (ILC SA), operated
within the Institute of Ageing in Africa (IAA) at the University of Cape Town (UCT), South Africa. She is a Co-President, with
Baroness Sally Greengross (ILC UK), of the ILC Global Alliance. Ferreira retired as the founding Director of the IAA in 2006.
She has worked mainly in Social Demography and Social Gerontology, and specifically on ageing in sub-Saharan Africa.
She has presented and published widely, and was the founding editor of the Southern African Journal of Gerontology (ninevolumes). Ferreira has undertaken consultancies to the United Nations, the World Health Organization and the African
Union. She currently serves on the Advisory Board of the International Institute of Ageing (UN–Malta); on the Board of theAfrican Research on Ageing Network (AFRAN); on the Editorial Board of Ageing International; and as South Africa’s focal
point in the BRICS Countries Forum on Ageing. She previously served on the Advisory Board of the World Demographic andAgeing Forum (2006–2009) and as the Africa Regional Representative of the International Network for the Prevention ofElder Abuse (INPEA) (2001–2009).
Lía Susana Daichman M.D at Cordoba National University, 1970.
Postgraduate in Geriatrics and Psycho Geriatrics, UK, 1972-1977.
Specialist on Gerontology and Geriatrics, Buenos Aires National University, 1980.
Assoc. Professor on Psychology on Ageing, UBE University,1991- 1998.
Coordinator, Specialist Course on Geriatric Medicine, UBA University, 1995- 2003.
Consultant in Gerontology and Geriatrics at the IADT, Buenos Aires, since 1988.
Reelected President to the Buenos Aires Gerontological Society, (AGEBA), 1994.
Chair of the LA Committee for the Prevention of EA(COMLAT - IAGG), since 1995.
INPEA ,unanimously elected President. since 2001.
World Congress, Canada, reelected in 2005 (Brazil).
Elected President of ILC-ARGENTINA, ILC-Alliance Meeting, IAGG World Congress, Brazil, 2005.
Elected UN Representative for the ILC Global ALLIANCE to the Global Alliance for the Rights of Older People,UN andECOSOC Consultive Status, South Africa, 2010.
Dr. Lía Susana Daichman

Dr. Monica Ferreira42

Dr. Françoise
ForetteLifelong Learning in France and in Europe

ILC, FranceThe
Frenchpopulationisageingwith
15,2
ILC, France
million people aged
over 60 years, orMeghan Shineman
approximately
23
percent
of
the
total
Consultant
population of 65,3
million.
In 2030,
20 million Frenchpeople will be morethan 60 years old, and15 million less than 20 years, the most dramatic increase
will be observed in people over 75 years old (x 3) and over
the age of 85 (x 4). This is due to the dual effect of a lower
mortality and the continued decline in fertility since the19th Century, even if it is now stabilized at 2,01 children by
women. For almost 20 years, life expectancy increased by
one quarter every year. The time of life without disability
will increase and the average age of onset of dependence isestimated at 85 years.

Marie-Anne Brieu

The 20 or 30 years of life after retirement – in France, thestatutory retirement age was 62 (2011) – are graduallydifferentiated: 60-75 years “active seniors”, 75-85 years“poly-mini-disability and frailty “ but autonomous, andpeople over 85 years who may be facing dependency.
However, old age does not correspond to an homogeneous
public, including opportunities available to advance one’s
knowledge. In fact, France is expected to experience oneof largest increases in employment rates among persons
aged 55-64 years2 – more than 20% increase, compared toa European average of approximately 16% – between 2010
and 2060; although that may be due to the fact that thecountry currently has one of the lowest employment rates
for those aged 55 – 64 in Europe – 41,4% against 49.1% for
the whole of the European Union in 20093-4.
Lifelong-learning is defined by wikipedia1 as the “ongoing,
voluntary, and self-motivated pursuit of knowledge for
either personal or professional reasons”. Within France,
and throughout Europe generally, older adults have accessto different types of lifelong learning opportunities: such as
volunteering, increasing social interactions, general adulteducation classes (i.e. learning another language, computer
skills), and finally professional development or on-the-job
training.
French Regulations to Protect Older Workers
Mandatory regulations have recently been enacted by the
French government to require employers to meet older
workers’ needs, including training, and to reduce barriers.
In 2002, the French government passed a law requiring therecognition by universities of prior informal and work-

based learning (RPL, also known as “Validation des Acquis del’Expérience” or VAE) and other professional qualifications.
The law effectively organised RPL at a national level, although
universities can develop their strategy of recognition on
their own, and includes competence-based awards andindividual assessments. However, many organisations fail touse or finance the RPL procedure.
Another French law, passed in 2004, grants individuals theright to lifelong-learning (“Droit Individuel à la Formation,DIF), entitling all employees to access a maximum of 120
hours of training/educational sessions over a 6 year period(20 hours/year) during work or free time. DIF is financed
entirely by the employer (1% of the budget is obligatory),
and the cost of the learning is not considered part of thesalary, therefore individuals aren’t taxed on this benefit.
At the beginning of June 2006, the French prime minister
presented a national action plan (National Action Plan for
Seniors Employment) to reach an employment rate of
50% among people aged from 55 to 64 years and improvethe conditions for older workers2. The plan was enforced
between 2006 and 2010. In addition, the French Law for
the Funding of Social Security (“Loi pour le Financement
de la Sécurité Social”, LFSS), enacted in May 2009, protects
elders from forced retirement and requires employers toencourage senior employment – often focused on skills
or professional development – or pay a penalty of 1% of
earnings/profits3.
French and European Innovative Lifelong Learning
ModelsAlthough not yet widespread, we have begun to see pockets
of experimentation, out of the well-established processes
for adult education, regarding lifelong learning for elders
throughout France. These lifelong learning opportunities
for older persons can be found in both public and private
settings, and sometimes may be financed jointly by public
and private sources.
Skills Training
Public:The European Commission established a Lifelong
Learning Programme (LLP) in November 2006 to increasetransnational education and training activities throughout
31 European countries, reaching almost 900,000 European
citizens and 50,000 organisations3. Financed publicly by theEuropean Union, most of the programmes are delivered
through national agencies; in France, the national agency
responsible for managing projects and dispersing funds isthe “Agence Europe Education Formation France4” .The LLP
combines four well-established sub-programmes (Comenius

http://en.wikipedia.org/wiki/Lifelong_learning
http://www.eurofound.europa.eu/eiro/2006/08/articles/fr0608019i.htm
3
http://ec.europa.eu/education/lifelong-learning-programme4
www.europe-education-formation.fr
1
2

43

for schools, Erasmus for higher education, Leonardo daVinci for vocational education and training, and Grundtvig
for adult education). However, except for the Grundtvig
programmes – which have shown to support active ageing
and intergenerational learning – participation decreases
substantially for both lower-skilled and older adults. The
midterm evaluation of the LLP programme acknowledges
that more “progress towards a lifelong learning approach as
opposed to one based on educational sectors is still quite
limited”, which may be a factor of insufficient budgets andother mobility-related barriers5.
The Grundtvig projects effectively engage elders andimprove the capacity of education and training systems. For
example, many of the Grundtvig programmes throughout
Europe focus on improving the skills and competencies
needed for information and communication technology(ICT) – such as the “Learning Partnership E-Com+45
Grundtvig” project for all workers over age 45, and theintergenerational “Simulating ICT Learning for actiVE EU
eldeRs” (SILVER) project3.
The Department of Employment, Social Affairs, andInclusion, also located within the European Commission(EC) European Social Fund, has engaged in many projects
since 1957 throughout France, training older workers on
job skills, such as use of information technologies5 .
Joint:AGE Platform Europe is a European network of around
165 organisations of and for people aged 50+ representing
directly over 30 million older people in Europe since 20016.
Its work is co-financed by its organizational members andby the European Commission. In their attempt to create
an “Age-Friendly European Union by 2020,” they list what
they have identified as best practices throughout Europe on
topics such as employment & active ageing and education &lifelong learning. Specifically within France, they identified afew Grundtvig-funded programs, in addition to “Générations& Talents” – an intergenerational programme of AlcatelLucent and APEC (a French recruitment agency) revolving
around skills development and mentoring/knowledge
sharing.
Adult Education
Joint:The University of the Third Age (U3A) – started in France
at the Faculty of Social Sciences in Toulouse in 1973 –aims to provide continuing education and various culturalactivities for seniors in order to “prolong active life”. Since
its formation, the model has now expanded throughout
Europe – and other places, like Australia and the US. In
http://ec.europa.eu/social/esf_projects/result2.cfm
http://www.age-platform.eu
7
http://www.ufuta.fr
8
http://vu3a.org/
9
http://u-til.org/
10
http://til.cerimes.fr/index2.php
11
http://old-up.eu
12
http://elearningeuropa.info/
5
6

44

1993, it became known as “Union Française des Universités
Tous Ages” (UFUTA7)encouraging intergenerational
exchange, in-person meetings, and less emphasis on formal
registration and graduation processes. The U3A model,
with the exception of one or two locations, is now open
to anyone regardless of age or degree, and can use various
names (such as “University All Ages”, “Inter-Ages”, “For All”,“Retirement and Free Time”,“Third Time”,“Permanent” etc).
In some locations, U3A is offered as a virtual community8– in other words, an online learning community of older
people – with less curriculum structure and more groupinteraction, therefore making the model more accessible
for those who live in isolation (due to geography, health/physical ailments, etc.).
However, in France, the model has remained in-person
and linked with either local universities or associations,and are currently available in 41 French towns. Whilemost U3A programs are privately funded, the UFUTA
programs are dependant on public funding from the
Ministère de l’Éducation nationale. For example, TRANSINNOV LONGEVITY “TIL” project9 was certified on
March 13, 2012, “Excellence in innovative training” (IDEFI)
by the Ministry of Higher Education and Research. TRANSINNOV LONGEVITY (TIL) models an innovative crosstraining inter-university project for both initial training andtraining throughout life. It leverages a system of educational
excellence based on national and international academic
networks, like that of UNF3S.
TIL promotes access to new audiences in new degree
university courses, offering a wide variety of models andlearning paths, built on multi-and transdisciplinary skills,
around a structured but flexible design IDEFI-TIL is aninnovative educational project applied to business inlongevity10.
Private:Some organisations have been developed by older
persons themselves. For example, Old Up11 focuses onintergenerational interactions of their members and training
older persons for useful daily functions – including how to
use the new technologies (i.e., create a Facebook account,call friends and family using Skype), how to cope with death,illness, children, etc.)
In addition, other virtual communities throughout Europe
have also emerged12, which are online community promoting
active ageing through the use of ICT; however, most of theseforums remain small.

Lifelong Learning in France and in Europe
Volunteering
The use of older persons – who are often more experienced,
knowledgeable and motivated – for volunteer activities has
the positive impact of improving quality and capacity of the
programmes.
Public: The “Grundtvig Senior Volunteering Projects” areavailable to all European citizens aged 50+ years, andfunds projects between 2 organizations in 2 different
countries over a 2-year period. A large percentage ofparticipants in Europe thought the experience increased
their technical skills (43%) and language skills (just underhalf). During 2007 and 2009, France led another Grundtvig
project, “Transfert de Competences Acquises et de Savoirs
Techniques (TCAST), which offered the opportunity foryounger generations to benefit from the technical skills
and knowledge of older skilled artisans who are retired or
about to retire. Another Grundtvig program that France
partnered in, “Seniors in Action”, trains older people withspecific skills to informally educate school pupils3.
Private:The Lire et Faire Lire programme, started in France in 1999,
provides older persons the opportunity to read to younger
children3. While the program has successfully expanded
across the country, there remains difficulty in recruitmentof older volunteers since time-frames and locations may
not be ideal.

Private:Road Scholar/Elderhostel15, is an international organisationthat offers travel and learning experiences – sometimes
referred to as “leisure learning” – to adults age 55+
throughout the world. Although it began in the UnitedStates in 1975, it has since expanded offices to otherlocations, including France.
Issues to Consider to Address Best Interests ofOlder People
Many elders do not think about their future. If ILC Centres
want to influence policy related to lifelong learning, thefollowing must be considered:••

Related Lifelong Learning Activities
Many European organisations, both governmental andprivate, have begun to draw attention to the importanceof lifelong-learning for older persons, including multiple
opportunities for professionals working with elders tolearn more about the need to include, educate, and/or trainolder persons.
Public:The European Union’s “Cedefop13” (the European Centre
for Development ofVocational Training) has held conferencesin Brussels the past two years (“Learning Later in Life:
Uncovering the Potential of investing an Ageing Workforce”
in 2011, and “One Step Up in Later Life: Learning for Active
Ageing and Intergenerational Solidarity” in 2012), with theaim of educating the public and professionals working in thefield on why and how to continue engaging, educating, andtraining older persons.
Health literacy of older adults is another important area
to improve the status of older workers. For example, the“Empowering Health Learning for the Elderly14” (EHLE),
offered through the European Commission’s LLP, haspartnered with Italy, France, Spain, and the Netherlands toimprove training so that professionals will be better able toeducate elders to live healthier lives.

••

The recruitment of retirees is a strategy that is being
increasingly turned to in France, particularly in these
employees’ former workplaces. Return-to-worksituations may be available, since some organisations
recognize the contribution that retirees can make intheir capacity of “expert resources” having experiencebased knowledge to pass on. However, as Aline2
Chamahian discovered6, major gaps still exist for older
persons in access to training. Since many retirees workon a contract basis, they are often at risk of being
excluded from internal training programs.
Older workers tend to report considerably morework-related health problems: On average, in Europe
in 2007, 16.8% persons aged 45-54 years report at least
one work-related health problem, which decreases
to 15.8% among those aged 55-64 (although thisexcludes France). Policymakers should consider healthpromotion campaigns in the workplace (or otherlocations) in order to improve the general health ofolder persons, reduce absenteeism associated withsuch problems, and prolong potential working lives2.
Responding to the economic vulnerability of the elderly:
The French have one of the lowest poverty rates for
elders (9.7%), compared to 15.9 % of Europeans aged
65 years or more living below the poverty line in 201016.
However, the parallel link between the lengthening oflife and increased resources is broken; in 2005, theaverage standard of living of pensioners was 10% lower
than that of active people because of the discontinuityof employment. Multiple lifelong-learning (educationaland job training) opportunities should be encouraged
for this population to keep them financial stable.
Trend of New technologies: Beyond the generationaland cultural reticence which will decrease with time,
and their high cost, knowledge of ICT is increasingly
becoming required to advance in the workplace.
Training of new technologies should be a priority whendeveloping lifelong-learning programmes.

www.cedefop.europa.eu
www.ehle-project.eu
15
www.roadscholar.org
16
http://www.inequalitywatch.eu/spip.php?article99&lang=en
13
14

45

References
1.
2.
3.
4.
5.
6.
7.

Pla A. Bilan démographique 2011 : La fécondité reste élevée. INSEE Première n°1385, Janvier 2012. 2012.
Eurostat. Active ageing and solidarity between generations. A statistical portrait of the European Union 2012. 2012.
Learning for Active Ageing and Intergenerational Learning: Final Report. 7 december 2012. European commission. DG Education and Culture. 2012.
European Economy 4/2011. The 2012 Ageing Report: Underlying Assumptions and Projection Methodologies. 2011.
Mid term review of the Lifelong Learning Programme
Report from the Commission to the European Parliament, The Council, The European Economic and Social Committee and The Committee of theRegions 2011
Chamahian AaT, D.G. Ces retraités qui deviennent “experts” : stratégie de recrutement et place de la formation dans la fonction publique.
Télescope,Revue d’analyse comparée en administration publique. 2011;17 (3):103-21.

Speaker Biography

Dr. Françoise Forette

Françoise Forette, MD, Professor of Internal
Medicine and Geriatrics, University Paris V.
CEO of the International Longevity Centre-France (ILCFrance), since 1995.
President of the Board of the Prevention Centre IPC-Etoile.
Member of the Board of Directors of the “ScientificFoundation for Research in Alzheimer’s disease” set up in
the frame of the Presidental Alzheimer Plan.
Former Director of the National Foundation ofGerontology.
President of the French Society of Geriatrics andGerontology, 2002-2004.

Special adviser on Aging to the Minister of Health and to the Minister of Elderly and Disabled, 2005-2007.
232 scientific publications
Author of « La Révolution de la Longévité » Grasset Publisher

46

THE FUTURE OF
AGEING
Published byInternational Longevity Centre Singapore
A Tsao Foundation Initiative© Tsao Foundation, 2014
No reproduction without permission
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#15-01/06 Central Plaza
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The ILC Global AllianceSymposium 2013