Global Population Ageing:: Peril or Promise?

Global Agenda Council on Ageing Society
Global Population Ageing:

Peril or Promise?
This book is dedicated to the memory of Dr. Robert N. Butler. An
early chair of the Global Agenda Council on Ageing Society, Bob
inspired us all through his ideas, his optimism, his insights, and his
ability to think and work outside of the box. He was a giant in the field,
a wonderful colleague, a mentor to many, and a friend to us all. He
will be missed but never forgotten.
Suggested Citation: John R. Beard, Simon Biggs, David E. Bloom,

Linda P. Fried, Paul Hogan, Alexandre Kalache, and S. Jay
Olshansky, eds., Global Population Ageing: Peril or Promise, Geneva:
World Economic Forum, 2011.
© World Economic Forum
2012 - All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any
means, including photocopying and recording, or by any information storage and
retrieval system.
Contents
02 Preface
Klaus Schwab, Founder and Executive Chairman, World Economic Forum
03 Foreword
Margaret Chan, Director-General, World Health Organization
04 Introduction
John R. Beard, Simon Biggs, David E. Bloom, Linda P. Fried, Paul Hogan, Alexandre Kalache and S. Jay Olshansky
14 I. The Backdrop: What We Must Contend with and Why We Must Act Now
15 Chapter 1 : The Meaning of Old Age
Laura L. Carstensen and Linda P. Fried
18 Chapter 2 : Ageing and Financial (In)security
Jack Ehnes
21 Chapter 3 : Women and Ageing
Saadia Zahidi
25 Chapter 4 : The Media’s Portrayal of Ageing
Colin Milner, Kay Van Norman and Jenifer Milner
29 Chapter 5 :Ageing and Intergenerational Equity
Norman Daniels
34 II. Investing in Ourselves: How to Release Social Capital
35 Chapter 6 : Population Ageing: Macro Challenges and Policy Responses
David E. Bloom, Axel Börsch-Supan, Patrick McGee and Atsushi Seike
39 Chapter 7 : Social Capital, Lifelong Learning and Social Innovation
Simon Biggs, Laura Carstensen and Paul Hogan
42 Chapter 8 : Leadership: The Elders
S. Jay Olshansky
46 Chapter 9 : Organizational Adaptation and Human Resource Needs for an Ageing Population
Atsushi Seike, Simon Biggs and Leisa Sargent
51 Chapter 10 : Ageing Workforces and Competitiveness: A European Perspective
Giles Archibald and Raymond Brood
56 III. Pursuing Healthy Ageing: What Healthy Ageing Involves
57 Chapter 11 : The Longevity Dividend: Health as an Investment
S. Jay Olshansky, John R. Beard and Axel Börsch-Supan
61 Chapter 12 : Design and Operation of Health Systems in Wealthy Industrial Countries
Linda P. Fried, Paul Hogan and Jack Rowe
65 Chapter 13 : Design and Operation of Health Systems in Developing Countries
David E. Bloom, Ajay Mahal and Larry Rosenberg
69 Chapter 14 : Ageing Africa: Opportunities for Development
Isabella Aboderin
74 Chapter 15 : Modern Medical Education: Meeting the Demands of an Ageing Population
Daniel Ryan and John Wilden
78 Chapter 16 : The Challenge of Non-Communicable Diseases and Geriatric Conditions
Ronald Williams and Randall Krakauer
82 IV. Redesigning Our Environment: What a Better World Might Look Like
83 Chapter 17 : Social Protection of Older People
David E. Bloom, Emmanuel Jimenez and Larry Rosenberg
89 Chapter 18 : Human Rights in Older Age
Alexandre Kalache and Richard Blewitt
93 Chapter 19 : Ageing and Urbanization
John Beard, Alex Kalache, Mario Delgado and Terry Hill
97 Chapter 20 : International Migration and Population Ageing
Hania Zlotnik
103 Chapter 21 : Financial Education and Older Adults
André Laboul
107 Chapter 22 : Technology and Ageing
Gerald C. Davison and Aaron Hagedorn
112 Appendix – Statistics
138 Biographies of Authors
Global Population Ageing: Peril or Promise? 1

Preface
In a world in which much change is unpredictable and immediate,

global ageing – the unprecedented increase in global population over
the age of 60 – is a highly foreseeable long-term trend. It is also, of all
global issues, one of the most amenable to risk management in
terms of identification, measurement and mitigation of possible
consequences. Yet, ageing is widely seen as one of the most
significant risks to global prosperity in the decades ahead because of
its potentially profound economic, social and political implications.
Global ageing, in developed and developing countries alike, will

dramatically alter the way that societies and economies work. The
issues include how individuals find fulfilment, at what age they retire,
and their quality of life once they do retire; how governments devise
Klaus Schwab social contracts to provide financial security; how the older and
Founder and younger generations interact as they divide up the economic pie;
Executive Chairman how businesses staff their jobs to compensate in many countries for
World Economic shrinking workforces; and how health systems respond to the altered
Forum needs of those living longer.
If policy-makers and leaders fail to plan adequately for the changes

ahead, they will be inundated by the effects of global ageing, such as
a dearth of workers, strained pension systems, and overburdened
health care systems. But the good news is that if we act now, in a
creative and proactive manner, we will have the greatest chance of
realizing the potential benefits of the ageing trend – such as utilizing
the immense social capital of older people – while avoiding its perils.
The wide range of ramifications makes ageing a topic appropriate for

treatment by the Network of Global Agenda Councils. This book is
the product of a true collaboration among the business, political,
academic, and other leaders of society that make up the Network.
Driven by David Bloom, the Chair of the Global Agenda Council on
Ageing Society, this book brings together perspectives from multiple
stakeholders to provide a broad range of views on the issues for
policy-makers, business, and political leaders. The essays examine
the interplay between population ageing and many facets of the
modern world, such as urbanization, gerontechnology, international
migration, and social protection programmes.
Global Population Ageing: Peril or Promise is part of the Council’s

long-term work on the issue and will provide the background for its
activities over the next few years. I am extremely proud of the work
undertaken by this Council on this complex issue and look forward to
following an informed debate on possible innovative solutions – such
as new medical and business models and age-friendly cities – as the
Council delves deeper into this new demographic reality.
2 Global Population Ageing: Peril or Promise?

Foreword
Populations around the world are rapidly ageing, and it is less

developed countries that are experiencing the most dramatic
change. This is a cause for celebration. In part, it reflects our
successes in dealing with childhood disease, maternal mortality and
in helping women achieve control over their own fertility.
However, population ageing will also present both challenges and

opportunities. If we do not adapt, it is likely to strain pension and
social security systems, increase demand for acute and primary
health care, require a larger and better trained health workforce and
increase the need for long term care, particularly in dealing with
dementia.
Dr Margaret Chan But the opportunities are just as large. Older people are a wonderful
Director-General resource for their families and communities, and in the formal or
World Health informal workforce. They are a repository of knowledge. They can
Organization help us avoid making the same mistakes again. Indeed, if we can
ensure older people live healthier as well as longer lives, if we can
make sure that we are stretching life in the middle and not just at the
end, these extra years can be as productive as any others. The
societies that adapt to this changing demographic can reap a
sizeable “longevity dividend”, and will have a competitive advantage
over those that do not.
But this will not come easily. We first need to change the way we
think and the way we do business. We need to discard our
stereotypes of what it is to be old. We need to consider the
interaction of ageing with other global trends such as technological
change, globalization and urbanization. We need to “reinvent”
ageing. Above all, we need to be innovative and not simply try to
reinvent the past.
People are already questioning our traditional view of older age. A

recent survey in the United States showed that it was only a small
minority who wanted to retire at the traditional age. Around 80%
wanted to continue to participate – but not in the same way. They
wanted to work part time or start a new career, or launch a small
business. They wanted flexibility.
This is exciting, because if older people can remain active

participants in society, they can continue to contribute to our
socioeconomic development. Engagement also prevents isolation
and loneliness, and ensures their financial security.
At the World Health Organization we see good health as central to

this ambition. This is why we have chosen ageing as our theme for
World Health Day 2012. I welcome this timely book, which deals with
some of the many other perspectives of population ageing. The
diverse chapters within it can help us invent the kind of society we
might want to be part of in the 21st century.

Introduction
In academic and policy circles, ageing is While this ageing trend started in the What are the major drivers of population
becoming a hot topic. The media is flush with developed world, it is now a global ageing? Three drivers stand out:
stories on ageing, and international groups phenomenon, and it is accelerating,
are increasingly singling out ageing for especially in the developing world (Figure 1). • Declining fertility. The world’s total fertility
discussion and debate. The World Health In industrial countries, the share of those rate – that is, the number of children born
Organization (WHO) has dedicated its annual 60-plus has risen from 12% in 1950 to 22% per woman – fell from 5 children per
World Health Day in 2012 to ageing. The today and is expected to reach 32% (418 woman in 1950 to roughly 2.5 today, and
European Union has designated 2012 as the million) by 2050. In developing countries, the is projected to drop to about 2 by 2050.
Year of Active Ageing and Solidarity between share of those 60-plus has risen from 6% in Most of this decline has occurred in the
Generations. The UN General Assembly held 1950 to 9% today and is expected to reach developing world, where the share of
a High-Level Meeting in September 2011 on 20% (1.6 billion) by 2050. The pace of this children in the population is expected to
preventing and controlling non- change means that developing countries will drop by half by 2050 from the 1965 level.
communicable diseases (NCDs) – a threat to have much briefer periods to adjust and As families have fewer children, the
human health and the global economy that is establish the infrastructure and policies older-age share of the population
strongly associated with ageing. necessary to meet the needs of their rapidly naturally increases.
shifting demographics. It also means that • Increased longevity. Globally, life
These activities build on the framework for unlike developed countries, they will need to expectancy increased by two decades
Active Ageing established by WHO in 2002 cope with getting old before they get rich. since 1950 (from 48 years in 1950 to 1955
in its report, Active Ageing: A Policy to 68 years in 2005 to 2010), and is
Framework. “Active ageing is the process of The list of countries that have the highest expected to rise to 75 years by 2050.
optimizing opportunities for health, shares of 60-plus populations will change There are still considerable disparities
participation and security in order to considerably over the next four decades. between the wealthy industrial countries,
enhance quality of life as people age.” This Although ageing is occurring in every at 82 years, and the less developed
framework embraces and emphasizes the country, the 10 that currently have the countries, at 74 years. However, this gap
value of a “life course perspective that highest shares of the 60-plus group are all has narrowed greatly in the last few
recognizes the important influence of earlier developed countries, or countries in decades. The life expectancy of older
life experiences on the way individuals age.” transition, such as Bulgaria and Croatia people has increased particularly rapidly;
(Table 1). The picture will change by 2050 a person who reaches age 60 has more
The WHO framework also defines the when Cuba makes the list, while some richer years of life left than in the past.
multiple determinants of active ageing – from countries (Finland and Sweden), leave it. • Falls in mortality came before falls in
access to health and social services to Remarkably, the UN projects that in 2050 fertility. In the early phases of this
behavioural, personal, physical and social there will be 42 countries with higher shares transition, large cohorts were born, mainly
environments and economic determinants of the 60-plus group than Japan has now, because mortality, especially among
– all influenced by gender and culture. This with the fastest ageing mainly in relatively infants and children, tended to decline
framework guides the work of the World newly industrialized or developing countries before fertility fell. Those cohorts are now
Economic Forum’s Global Agenda Council (Table 2). In fact, China and Brazil will begin reaching working ages and the older ages,
on Ageing Society and informs this to converge with Japan, which by 2050 will and their ranks will swell. In developed
introduction and the essays in this book. have more than 40% of its population 60 and countries in particular, large-sized
older, outpacing the increase in the United post-World War II baby-boom cohorts are
Why is population ageing attracting so much States (Figure 2).
attention now? One reason is that the rapid reaching the older ages.
ageing of humanity is perhaps the most Another reason for an emphasis on ageing
salient and dynamic aspect of modern today is that “doomsday scenarios” abound.
demography. As a result, its influence on These alarmist views typically assume a
public health and national economies will be world of static policy and institutions,
dramatic. The world experienced only a continuing trends involving low fertility, and
modest increase in the share of people aged constant age-specific behaviour and labour
60 and over during the past six decades, outcomes. The resulting scenarios yield
from 8% to 10%. But in the next four stark and shocking images of workforce
decades, this group is expected to rise to shortages, asset market meltdowns,
22% of the total population – a jump from economic growth slowdowns, the financial
800 million to 2 billion people (Box 1). collapse of pension and healthcare systems,
and mass loneliness and insecurity.
Such tales are strongly reminiscent of the

work by Paul Ehrlich and the Club of Rome in
the late 1960s, which predicted mass
starvation and human misery in the 1970s
and 1980s as a result of rapid population
growth, or what was termed “the population
bomb”. But lessons can be learned from this
experience. Although the world population
did double from 1960 to 2000 (from 3 billion
to 6 billion), at the same time per capita
income increased by 115%, life expectancy
rose by more than 15 years, and literacy shot
up as primary school enrolments became
nearly universal in many countries.

Introduction
Food production since the 1940s increased

twice as fast as population growth. The
On the behaviour side, declining fertility and Box 1: Key facts on ageing
increased educational opportunity have
message we should draw from this been and will continue to be associated with • At the global level, the share of those
experience is that both change and changing social roles and greater labour 60-plus has risen from only 8% of world
adaptation are possible and within our force participation by women; and fewer population (200 million people) in 1950
control. Some portion will be individual and children generally yield healthier, smarter and to around 11% (760 million) in 2011, with
natural, and some will be collective and better-educated younger generations. the dramatic increase still ahead as
political. That said, there will be a number of Insofar as health and intellectual those 60-plus are expected to reach
complicating factors: enhancement through education translate 22%
into higher adult productivity – all well- (2 billion) by 2050.
• The meaning of ageing is evolving, established links – lower fertility is
reflecting the new needs, aspirations and tantamount to an increase in the effective • At the global level, the share of those
capacities of people now reaching their labour force, suggesting a further boost to 80-plus has edged up from 0.6% of
60s and 70s. growth. Lower fertility also leads to a decline world population in 1950 (15 million) to
• Ageing is occurring in a range of settings: in youth dependency, which offsets the around 1.6% of world population (110
wealthy industrial countries have more increase in old age dependency. million) in 2011, and is expected to reach
resources to draw upon in confronting 4%
the challenge, though institutional In fact, a recent econometric study (400 million) by 2050.
rigidities and vested interests may limit (referenced in Chapter 6) shows that
the possibilities for effective action. increases in older-age dependency do not • The global population is projected to
• Resources are severely constrained in significantly impede the growth of income increase 3.7 times from 1950 to 2050,
many countries, and all the more so in per capita, unlike increases in youth but the number of 60-plus will increase
the wake of the global financial crisis. dependency. These results support the view by a factor of nearly 10, and the 80-plus
that the negative impulse that high fertility by a factor of 26.
• In the absence of resource transfer conveys to economic growth cannot be
schemes that provide support for older offset by behavioural and institutional • Between 2010 and 2050 the total
people, many developing countries rely on changes, unlike the negative impulse of population will increase by 2 billion,
familial support. But that private safety net increased longevity, which can be offset by while the older population will increase
is fraying as numbers of older people rise, changes in behaviour and policy. by
fertility levels fall, perceptions of family ties 1.3 billion.
change, and children migrate from their Moreover, when people expect to live longer,
less mobile parents to cities or distant they have an incentive to save more for the • Women account for about 55% of the
places for jobs. years after they are no longer working. In 60-plus group, rising to 64% of the
• Many in the media perpetuate negative economic terms, savings translates into 80-plus group, and 82% of the 100-plus
stereotypes of ageing, such as the view investment, which fuels the accumulation of group. On average, women outlive men
that older people are characterized only physical and human capital and by nearly 4.5 years.
by loss, decline, decay, pain, suffering technological progress, the classic drivers of
Note: The UN Population Division uses the terms “more developed
and loneliness. These negative and economic growth. regions” and “less developed regions”, which correspond with
profoundly inaccurate stereotypes “industrial countries” and “developing countries” used in this
influence not only public policy, but also book.
how society thinks about ageing and
how older people think about
themselves. Moreover, with people living
longer than ever before, and in many
cases remaining healthy until later years
than in the past, society has an
opportunity to reap a “longevity
dividend”, in which older people continue
to make substantial contributions for
unprecedentedly long periods.
In an historical context, population ageing is
one of the most remarkable human success
stories of any era, reflecting contributions of
public health, medicine, education and
economic development. But capturing and
unlocking the full benefits of that success
require that we adapt our perspectives and
reform our institutions. The good news is that
there is a wide range of behavioural changes
and public policy responses to population
ageing that would simultaneously avoid a
significant dampening of economic growth
and enhance the quality of life for people
reaching older ages today and for
generations to come.

Introduction
Figure 1: Ageing is accelerating worldwide Table 1: The top 10 for ageing
Countries with the highest shares of 60+ populations in 2011 and 2050 (percentage),
35 (among countries with 2011 population of 1 million or more)
2011 2050
30 Japan 31 Japan 42
Italy 27 Portugal 40
Population 60 and over, per cent
25
Germany 26 Bosnia and Herzegovina 40
Finland 25 Cuba 39
Sweden 25 Republic of Korea 39
20 Bulgaria 25 Italy 38
Greece 25 Spain 38
Portugal 24 Singapore 38
15
Belgium 24 Germany 38
Croatia 24 Switzerland 37
10
Source: UN, World Population Prospects: The 2010 Revision
Table 2: Developing countries ageing fastest

0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Countries with largest percentage increase in 60+ share,
(among countries with 2011 population of 1 million or more)
Industrial countries Developing countries
2011 Increase, 60+ share,
2011-2050 2050
Source: UN, World Population Prospects: The 2010 Revision United Arab Emirates 35 36
Bahrain 29 32
Figure 2: Major developing countries will start converging with Iran 26 33
developed ones Oman 25 29
Singapore 23 38
45 Republic of Korea 23 39
Viet Nam 22 31
40 Cuba 22 39
China 21 34
35 Trinidad and Tobago 21 32
Population 60 and over, per cent
30 Source: UN, World Population Prospects: The 2010 Revision
25
20
15
10
0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
Japan China USA

Spain Brazil India
Source: UN, World Population Prospects: The 2010 Revision

Introduction
A Menu of Policy Responses A third option is reforming health systems. An Box 2: The rationale for
increased emphasis on disease prevention,
It is natural for people to respond to longer
lifespans, particularly longer healthy
health promotion and early screening has investing public resources in
considerable potential to contain the direct
lifespans, by planning on longer working lives treatment cost and the lost income
older people
and other forms of social contribution. occasioned by chronic diseases such as
However, public policy has been extremely There is a range of powerful social
cancer, diabetes and cardiovascular disease. justifications for devoting public resources to
sluggish in adapting to new demographic New models of long-term care need to be
realities as most of the world’s social security the challenges ageing brings:
designed and tested. In addition, there is a
systems create strong incentives for need to train more healthcare providers,
retirement between the ages of 60 and 65. A • Older people are a valuable and
especially in low- and middle-income productive economic resource that
recent study (referenced in Chapter 6) of 43 countries.
countries (about two-thirds of which are should not be stifled by outmoded
industrial) shows that during the 1965 to public policies such as mandatory
The nature of medical training also needs to retirement or other disincentives to work
2005 period, male life expectancy rose an change. Health providers should be better
average of nearly nine years, but the mean beyond certain ages.
able to address the multiple and interrelated
legal retirement age rose by less than half a health conditions specific to the older people • Inherent in the challenge of population
year. who form the bulk of their clientele. Most ageing are huge opportunities, because
broadly, health systems need to adopt a life older people who live healthy lives can
One option currently gaining traction in many course approach to population health
countries, such as France, Greece, Ireland continue to be productive for longer
because prevention efforts at all ages than in the past.
and the United Kingdom, is raising the promote health in old age.
normal legal age of retirement. However,
• On ethical and humanitarian grounds,
even an increase of a couple years has A fourth option is rethinking business devoting resources to older people is
created some social and political tension, practices. Public policy should encourage, arguably the right thing to do, the fair
especially given the high rates of rather than discourage, businesses in the thing to do and a just thing to do.
unemployment in the wake of the 2008 public and private sectors to employ older
economic slowdown. workers, even part-time. This would involve: • Older people have a fundamental
(i) catering to older employees’ desire for human right to make claims on social
A second option is using international flexible roles and schedules; (ii) investing in resources, such as healthcare. These
migration to ameliorate the economic effects worker wellness programmes to enhance claims are grounded in and justified by
of population ageing, with youthful poor attendance and productivity and avoid international law, for example, in the
country populations filling job vacancies in unnecessary healthcare and turnover costs 1948 Universal Declaration of Human
ageing countries. But counterbalancing as the workforce ages; and (iii) taking Rights.
population ageing in this way requires very advantage of the new core business
large migrant flows that have significant opportunities that will accompany population • The formation of social capital and
implications for the broader functioning of ageing, such as designing and marketing societies that are cohesive, peaceful,
society. It is not at all clear that the world will consumer products and services that are equitable, and secure requires that we
capture the large potential benefits of customized to the physical needs, the attend to the needs of all groups,
international migration, as most countries financial capacities, the interests and the especially the most vulnerable, such as
have gone in the opposite direction. They channels of influence that characterize the older people. Doing so will strengthen
have done this by instituting immigration “silver generation”. societal and cross-generational
barriers in an effort to protect their cohesion.
economies from low-wage workers,
preserve traditions, maintain cultural and • Governments have a natural and
ethnic uniformity or respond to anti- fundamental role to play in the health
immigrant sentiments. sector, for everyone, including older
people, because unregulated markets
The fact that social protections are not do a poor job of achieving socially
portable across countries creates desirable and economically efficient
impediments for increased migration and levels of health provision. Infectious
increases the vulnerability of migrants who, disease puts communities at risk, health
themselves, ultimately become part of the providers can use their informational
older population. Increased immigration advantages to exploit health
could therefore offset some of the workforce consumers, and problems of moral
issues posed by population ageing, though hazard and adverse selection exist.
not likely a significant portion.

Introduction
Essay Highlights Section I: The Backdrop - What We Must Wasted social capital and financial insecurity
Contend with and Why We Must Act Now feature especially strongly among older
Against this backdrop, the World Economic women, who tend to have a lower standard
Forum’s Global Agenda Council on Ageing The first group of essays paints a picture of
the social economic, and political of living than older men, we learn in “Women
Society assembled this collection of essays and Ageing” by Saadia Zahidi. Why is this
to help inform and stimulate discourse, environment that will set the stage for policy
decisions on ageing. We see anxious, so? The author suggests that in developed
defuse the perceived threat, and promote a and developing countries “current societal
proactive vision for adaptation to support unprepared societies that are being
bombarded by the media with stories about arrangements cumulatively result in a lifetime
positive population ageing – one that will of unequal and inadequate access to
require forward-thinking frameworks and the “burdens” of growing older.
education and economic participation and
innovations in technology, education and opportunity for women”. To remedy this
policy. It is intended for a broad audience: the In “The Meaning of Old Age”, Laura L.
Carstensen and Linda P. Fried note the irony situation, she recommends policies and
media, the public, political leaders, public practices that protect and empower these
policy-makers, the private sector and that older people, who throughout history
have been portrayed as prophets, saints, women, such as access to quality education
specialists seeking to round out their and removing barriers to women’s access to
knowledge. tribal leaders and healers, are now often the
source of fear and anxiety in discussions on economic activity. Also needed are (i) policies
We examine from myriad perspectives how ageing. The problem, they say, is that and practices that catch women “upstream”,
individuals perceive ageing; how society societies today are “enormously ill-prepared” before they get old; (ii) the application of a
empowers people to live longer, healthier, for populations with more people over 60 gender lens to existing and new measures
and more productive and fulfilling lives; and than under 15. Cultures are youth-oriented, affecting older people to ensure women are
how these realities are affected by the as are physical and social environments and not overlooked; and (iii) policies and products
individual and societal construction of the institutions. The authors contend that if focused on older women’s needs and
notion of the chronological advancement of societies are to reap the social capital that interests.
age. older people offer, they need to (i) “modify
the life course” (that is, invest throughout life Complicating matters, the media (news,
The essays also examine the interplay in health, education, and social integration); television and film) and advertising often
between ageing and many facets of the (ii) improve the care and autonomy of convey images of older people through a
modern world. Some of these are natural disabled older adults; and (iii) build “lens of decline and diminished value”,
concomitants of the treatment of ageing, infrastructure that supports long life and taps according to Colin Milner, Kay Van Norman,
such as social protection and human rights. the talents and potential contributions of and Jenifer Milner in “The Media’s Portrayal
Others, such as urbanization, older people who are healthy, such as of Ageing”. This tactic, they say, confirms
intergenerational equity, leadership, and the wisdom and experience. beliefs and entrenches negative stereotypes,
media portrayal of ageing, explore paths that in turn affecting how older people see
have been less well travelled.In doing so, On the financial front, Jack Ehnes, in “Ageing themselves and how society views and
these essays reflect the key features of and Financial (In)security”, points out that as treats them. What is needed now are realistic
country contexts – paying social attention to people live longer, it is natural for many of portrayals “so depictions encompass the
stage of development and cultural setting, them to develop financial security concerns. many different experiences of ageing without
along with the nature and operation of key But these concerns have been ratcheted up attaching a value judgement”. How can the
public and private institutions (such as the sharply in the wake of the global financial media and advertising reshape perceptions
health system, extended family, and crisis, which resulted in trillions of dollars of of ageing? The authors suggest that one way
mechanisms for promoting economic retirement savings depleted. As a result, he would be to show the financial benefit, that
security among older people). says, there is a “significant questioning of our is, the value of creating marketing messages
underlying retirement and savings models, that resonate with older customers.
Many of the authors identify options and which ultimately bear heavily on the quality of
make recommendations for societal life for seniors, labour market stability, and How should we think about equity across
transformations that are necessary or intergenerational relationships”. He calls for adjacent (as opposed to distant)
desirable to address the challenges – and an urgent rethinking of official retirement generations? In “Ageing and
capture the potential benefits – of population ages and company policies on work after Intergenerational Equity”, Norman Daniels
ageing. retirement in developed countries. And he explains that with global ageing comes a
cautions that Asian countries “lack the sharpening of the problem of
This book consists of 22 essays, divided into institutionalized pension schemes to fill in the intergenerational equity. Developed countries
four themes: setting the scene, investing in gaps from the weakened informal family– worry that they can no longer afford transfers
ourselves, pursuing healthy ageing and based support mechanisms”. to the elderly that were part of a social
redesigning our environment. The central contract over many decades. However,
theme that emerges is the increasingly developing countries – with even fewer
urgent need to adapt to population ageing, resources – do not even have such resource
identify and take advantage of the transfer schemes in place. Daniels discusses
opportunities it offers, and find ways to the Prudential Lifespan Account as a
unlock the human capital resources that framework for thinking about resource
population ageing and our longer lives make allocation over the lifespan that aims to be
available. fair to all age groups, even if they are treated
differently at different stages of life.

Introduction
Section II: Investing in Ourselves – How to In “Leadership: The Elders”, S. Jay III. Pursuing Healthy Ageing – What Healthy
Release Social Capital Olshansky describes a small group of highly Ageing Involves
The second group of essays looks at distinguished older people formed in 2007 to The third group of essays focuses on ways
innovative ways to tap the valuable social help resolve global issues and ease suffering. that we can arrive at old age healthier,
capital that older people offer. The emphasis Over time, the group – known as The Elders whether by investing in preventive care
is on engaging older workers in fruitful – has included Graça Machel, Desmond throughout the life course, modernizing
activities, whether through flexible retirement Tutu, Marti Ahtisaari, Kofi Annan, Ela Bhatt, medical education, effectively managing
policies, age-friendly cultures and working Lakhdar Brahimi, Gro Brundtland, Fernando advanced illness and NCDs, or even delaying
places, lifelong learning, or redesigned Cardoso, Jimmy Carter, Nelson Mandela, the biological process. While we know many
pensions and healthcare systems. Mary Robinson, Aung San Suu Kyi, and people are living longer, evidence that they
Muhammad Yunus. So far, The Elders have are also living healthier is somewhat thin and
In “Population Ageing: Macro Challenges successfully addressed many world still preliminary. Widening and deepening this
and Policy Responses”, David E. Bloom, Axel problems, but the group is equally important evidence base is a high priority because if
Börsch-Supan, Patrick McGee and Atsushi as an example of how older people can people can retain their health as they age, it
Seike note that because of high past fertility make vital contributions to society, in part, is easier for them to remain socially
rates there has been little need for rapid because they are older. Leadership is just connected and participate actively in the
policy changes so far, but this will change as one of many attributes that highlight the need workforce. In the coming decades, a
baby boomers retire, labour force growth to portray ageing as a period of constant significantly greater number of employees,
slows, and the costs of pension and adaptation and transitional phases that can especially those not doing manual labour,
healthcare systems rise – especially in lead to rewards for individuals and societies. may be able to work productively into much
Europe, North America and Japan. To adapt later ages than they do today.
and possibly benefit from population ageing, At the business level, in “Organizational
the authors urge public policy-makers to (i) Adaptation and Human Resource Needs for In “The Longevity Dividend: Health as an
allow greater choice on retirement timing; (ii) an Ageing Population”, Atsushi Seike, Simon Investment”, S. Jay Olshansky, John R.
undertake pension reform; (iii) re-design Biggs, and Leisa Sargent contend that in a Beard and Axel Börsch-Supan advocate
healthcare financing systems with older society with fewer younger people relative to investing in health to live better, not just
people in mind; and (iv) be open to migration mature workers, an organization’s ability to longer. If we can achieve that, society can
of working-age people. The authors also call succeed may hinge on whether it can attract get a healthy return in longer working lives;
on businesses to alter attitudes towards and retain mature workers. At the policy lower healthcare outlays; and social,
older workers and to change practices in a (macro) level, it is vital to establish economic, and health dividends. In fact, the
number of areas, such as work schedules employment conditions and compensation authors say, “the economic value of a rapidly
and routines, training, healthcare, and pay terms that make it desirable to keep working. growing healthy older population is so large
systems – with the emphasis on being At the workplace (mezzo) and personal that healthy ageing should be aggressively
proactive rather than reactive. (micro) levels, the key is age-friendly working pursued, on its own merits, as a societal
environments. Such environments include investment”. How should this dividend be
An important way to move forward, say flexible working practices (career breaks, pursued? The authors say that first, we need
Simon Biggs, Laura Carstensen and Paul part-time work and flexi-place working), to invest in health throughout the life course,
Hogan in “Social Capital, Lifelong Learning health and well-being promotion (supervised so that people are healthier when they reach
and Social Innovation”, is to recognize older fitness programmes), and continuous older ages. Second, we need to better
people’s social capital, which is often learning (updating skills). These initiatives understand the biology of the ageing
obscured by overly negative views of ageing would help promote cultural adaptation to an process, in the hopes of delaying the
that result in underutilized talent and ageing society. infirmities of old age and further compressing
misperceptions about abilities. They contend the morbid years at the end of life.
that despite normal age-related decline in This theme is echoed in “Ageing Workforces
some aspects of functioning, in the absence and Competitiveness: A European For developed countries, Linda Fried, Paul
of dementia or serious illness, age-related Perspective”, by Giles Archibald and Hogan and Jack Rowe argue in “Design and
changes do not prevent people from making Raymond Brood, who call for a new Operation of Health Systems in Wealthy
substantial contributions to workplaces, corporate model to unlock the social capital Industrial Countries” that it is time to redesign
families and communities. Older people in healthy, older populations. If this is not our health systems to better handle the
typically have accrued social and process done, they argue, the demographic profile of altered healthcare and prevention needs that
skills that are particularly useful for service Western countries is likely to be a significant come with living longer. The authors
economies. To release social capital, they hindrance to economic growth. How can advocate (i) re-engineering the 20th-century
advocate a virtuous cycle of lifelong learning business respond? One way is to hold on to medical model, with a stronger focus on
(updated skills); social adaptation (age- current workers, but adopt more flexible pay prevention throughout the life course; (ii)
friendly cultures and working environments); practices. This would enable older workers doing a better job of educating health
and social innovation (activities arising from to reduce responsibilities, but with professionals on geriatrics; (iii) creating a
newly identified potential). commensurate smaller compensation. strong partnership between the government
Another way is to provide more flexibility in and the corporate sector on shared goals
the work-life-care balance. But whatever is and aligned implementation; and (iv)
done, the key is to plan ahead and act now. facilitating the transfer of best practices to
For example, both 3M Europe and Lanxess developing nations. The goal, they say, is “a
(Germany), have begun developing new decreased burden of disease and a
human capital planning models to find ways successful compression of morbidity in the
to maintain productive workforces as the latest points in the human lifespan”, which
average age rises. should lower healthcare costs and “amplify
the benefits to society of being an ageing
world”.

Introduction
Developing countries, however, will have to What role does medical education play? In IV: Redesigning our Environment – What a
cope with population ageing and the “Modern Medical Education”, Daniel Ryan Better World Might Look Like
associated burden of chronic disease before and John Wilden suggest it is time to refocus The final group of essays explores what an
they reach high income levels, as pointed out medical education by shaping a future age-friendly world might look like. One vision
by David E. Bloom, Ajay S. Mahal, and Larry medical workforce of doctors and nurses involves greater social protection for older
Rosenberg in “Design and Operation of designed to meet the needs of an older people, greater clarity and respect for their
Health Systems in Developing Countries”. population. Many older people have multiple rights, better financial education, easier
They warn that a business-as-usual chronic diseases, such as hypertension, labour mobility across borders, age-friendly
approach could lead to an inadequate diabetes and heart failure, in addition to cities, and robots and other technologies to
healthcare supply, out-of-date healthcare functional difficulties, such as incontinence assist them.
systems, insufficient human resources for and cognitive impairments. Yet, the
health and greater health inequality. But this emphasis of medical education is towards In “Social Protection of Older People”, David
bleak outcome can be avoided with a greater specialization, raising concerns over E. Bloom, Emmanuel Jimenez, and Larry
proactive and innovative approach that takes the number of doctors able to adopt a Rosenberg explain that despite the growth
advantage of these countries’ socio- multidisciplinary and geriatric knowledge and extent of social protection programmes
economic development. Top priorities approach. Can this deficit be addressed in rich and poor countries alike, older people
include primary prevention efforts aimed at through training and investment? The remain extremely vulnerable. These
reducing the incidence of NCDs; reform of authors say yes, but that it will require a programmes typically include pensions,
healthcare worker training to focus on NCD seismic shift in priorities that will take many basic healthcare, child benefits, and social
prevention, early detection, treatment and years to achieve. assistance and employment plans but the
care; creation of social health insurance coverage gaps especially in the poorer
programmes; and development of the On the cost front, can we afford an ageing countries, are huge. What can be done to fix
primary healthcare sector. population? In “The Challenge of Non- the problem? First, gather the evidence that
Communicable Diseases and Geriatric there is a problem. This means developing a
One region that would benefit greatly from Conditions”, Ron Williams and Randall comprehensive information system about
investing in older people is Africa, which on Krakauer contend that as long as the financial, physical and social situation of
the face of it seems the least likely to fall into populations age and health technology older people. Second, mobilize a consensus
that category given that it is home to the advances, the cost of healthcare will rise. In on the need for including older people in
world’s youngest population. In “Ageing 2007, total US health outlays stood at 15.7% national social protection – perhaps do a
Africa: Opportunities for Development”, of GDP, about double the world average of “stress test” to assess their coverage – and
Isabella Aboderin tells us that by the year 8.6%. The authors say there will be many devise a strategy. Third, mobilize domestic
2100, Africa’s older population will explode to opportunities to reduce the rate of increase resources. Fourth, seek help from the
716 million from 56 million today, the of healthcare costs by intelligently international community.
sharpest increase for any region. The reality, manipulating the economic levers of
she says, is that investing in older people healthcare. Which levers should we focus What about the rights of older people? In
offers Africa a way to realize key on? One is the effective management of “Human Rights in Older Age”, Alexandre
development goals, such as raising NCDs, which account for the lion’s share of Kalache and Richard Blewitt argue that older
agricultural productivity and sustainability, medical costs for older people. Another is people should enjoy the same intrinsic rights
providing more jobs, and enhancing equity the effective management of advanced and as everyone else. In reality, however, ageism
and stability. Policy options, especially for terminal illnesses. A third is a more (the stereotyping and prejudice against older
older people who are poor, include (i) social collaborative, coordinated and integrated people) and age discrimination (the use of
pension programmes and stronger support healthcare system – from caregivers and age as a reason to treat individuals
for informal, family-based support systems; clinicians, to facilities to health plans. This negatively) is prevalent worldwide. Ageism
(ii) better access to healthcare; (iii) greater would include collaboration among those and age discrimination range from limited
access to agricultural extension services; who provide care and those who finance it to access to services, education, and job
and (iv) intergenerational knowledge transfer. develop a set of incentives that appropriately opportunities to abuse, neglect and
align rewards with effective and efficient abandonment. National laws against age
patient care. discrimination exist in some countries, but
they typically focus on jobs. At the
international level, following the 1948
Universal Declaration of Human Rights, UN
conventions on the rights of children,
women, indigenous populations, ethnic
minorities, immigrants and disabled persons
have been adopted. Is further action required
on behalf of older people? The authors
contend that a gradual consensus is
emerging on the need for strengthening
older persons’ rights within the framework of
international law.

Introduction
With an ever increasing share of the world’s In “Financial Education and Older Adults”,
population residing in cities, in “Ageing and Andre Laboul advocates better financial
Urbanization”, John Beard, Alex Kalache, education and awareness for older people.
Mario Delgado and Terry Hill ask whether The reason is that older people are being
cities can be redesigned to foster more asked to cope with a financial landscape that
active and healthier ageing. Many such increasingly transfers financial risks to
initiatives are under way. They are focused individuals and features ever more
on needs related to participation (access to sophisticated financial products at a time of
information, accessible buildings and public great uncertainty. Yet older people, along
transportation), health (accessible and with many others, are ill equipped to handle
affordable healthcare services and these responsibilities and often overestimate
opportunities to be physically active), their financial skills and awareness. Given
continuing education (models of lifelong that pensions and retirement savings plans
learning), and security (affordable housing are vital for individual and social welfare, they
and services; and home, community and should be a top priority. The education
transportation safety). An indication of the should occur early on, when proactive action
rapid uptake of these ideas globally is the is still possible – savings must be built up
WHO’s Global Network of Age-Friendly over a long period of time – but it is also
Cities, which now counts over 400 affiliated needed in the phase out period, as assets
members from large cities such as New York are being drawn down. In addition, stronger
to small rural communities in Australia. financial consumer protection is essential to
Fortunately, the authors say, the experience protect older people from financial abuse.
of these municipalities is that “many of the
features advocated by the age-friendly cities Finally, is there any chance of helpful robots?
movement are low cost”. In “Technology and Ageing”, Gerald C.
Davison and Aaron Hagedron bring us up to
In “International Migration and Population speed on gerontechnology, which involves
Ageing”, Hania Zlotnik explores whether designing products and services to help
international migration can provide a solution older people with limited physical or cognitive
to labour shortages created by population abilities live more independent lives. We now
ageing. It is true, she says, that dynamic have “smart homes”, tele-health, m-health
economies can rely on migrants to satisfy (mobile phone-based monitoring), assistive
their labour needs. But what most technology (such as a foot orthotic that
researchers have found over the past few improves balance) and socially assistive
decades is that demography, which has a robots for rehabilitation or for behavioural
long gestation and takes a long time to play treatment of dementia symptoms. The
itself out, is not the main driver of authors stress that “perhaps the most
international migration. Rather, it is factors important, but currently overlooked
such as economic and political opportunity” for gerontechnology lies in
developments in both the countries of developing countries, which need basic
destination and origin. The general assistive devices that are more appropriate
conclusion, she notes, is that it would be for a less developed environment and new
difficult, politically, socially and even in terms technology that can cheaply ensure access
of the management of international to diagnostics in remote areas.
migration, to admit continuously and over a
long period the relatively high numbers of
migrants of particular ages that would be
required to counterbalance in a significant
way the ongoing population ageing.

Introduction
Conclusions and Recommendations labour), investing in older people so that • Developing new indicators. We should
they can continue to learn and contribute develop a set of indicators for assessing
The success story of population ageing and to society, rethinking business practices the financial, physical and social situation
longer lives is often accompanied, in the end, (such as work schedules) to facilitate the of older people and the age-friendliness
by tales of doom and gloom; but it is vital that participation of older workers, making of various environments. We should then
the global community not succumb. sure that there are adequate social use the media to hold key stakeholders
Although there are serious challenges, which protections (such as pensions), and (individuals, governments, business and
must be weighed, understood, and in some reforming health systems to better meet civil society) accountable for progress in
cases adapted to, there are also enormous the needs of older people. It also means this realm. Besides the WHO’s guidelines
opportunities that must be seized. The investing in health throughout the life on age-friendly cities, this would include
essays in this book do not point to the course so that people are healthier when studies on the quality of life, health
existence of a magic bullet or uniform plan. they get older. status, economic and physical security,
We will need to customize responses to and vulnerability to crime. It would help
different countries’ social, economic, and • Acting on all levels. Pragmatism dictates
that we start on the path of social, policy-makers determine whether older
political systems and histories. Even so, people are falling through the cracks –
some general principles of change stand out economic, and political change at all
levels – local, national and global. Urban such as not tapping available medical
because of their broad applicability and benefits – when simple measures (such
pragmatic nature. design is a local issue. The legal
retirement age is a national issue. The as free bus passes, transportation to
• Committing at the highest levels. History concept of human rights for older people clinics, or help in filling out forms) might
teaches us that big and complex issues is an international issue. And migration is solve the problem.
need high-level champions. As we saw a bilateral and multilateral issue. • Taking advantage of new technology. It is
with HIV/AIDS, it took public • Better use of existing resources. There is vital that that we tap new technology to
pronouncements from French President considerable scope to use our resources improve the quality and accessibility of
Jacques Chirac in 1997 and US more effectively. This entails everything healthcare for older people. In developed
President George W. Bush in 2003 to from the design of age-friendly cities and countries, “smart homes” integrate a
mobilize enormous resources and assistive robots, to health systems that range of monitoring and supportive
energy to battle the disease, even though place greater emphasis on disease devices to help people age in place more
HIV had been discovered and identified prevention and early screening. It also effectively (for example, wireless sensors
as the cause of AIDS in 1981. In the case entails holistic life course policies such as connected to small computers can
of ageing, a commitment to an age- enabling older people to acquire financial detect functional decline). Social robots
friendly society must come from the top, planning skills and the ability to update can assist in vital activities, such as
given that policy responses include their workplace skills. reminding people about eating and
raising the retirement age, reformed taking medicine. And telemedicine
health systems and encouragement for • Sharing best practices. In demographic enables a patient to connect with
businesses to rethink practices. In terms, the challenge of population ageing clinicians to better manage chronic
addition, councils of distinguished older is historically unprecedented, which diseases at home rather than in a
people, which enjoy a moral authority, means that we should conduct and learn hospital.
should embrace the cause and spread from a multiplicity of experiments in
the word to broaden commitment. developed and developing nations. The supreme goal is to make sure we
These would include: understand and tackle tomorrow’s
• Acting early and swiftly. We cannot wait challenges, not yesterday’s, and in the
for a crisis to act. One reason is that -- The Dutch city of Eindhoven’s
pioneering efforts to become a process, ensure that generations reaching
many of the policy responses – such as a older ages now and in the future are allowed
new medical curriculum that focuses zero-emission community (with the
world’s most interactive urban lighting to experience and express their full potential.
more on prevention and chronic diseases
and less on ever-greater specialization – system) and a healthy city in which
require a long lead time to design and citizens have the latest technologies at
implement. Another reason is that good their disposal to maintain a high quality
options may evaporate as constituencies of life even when suffering from chronic
shift, making gradual responses more diseases
difficult. For example, it would be fairer to -- Shanghai’s ambitious urban policy,
give workers a decade of lead time to which will see the creation of
plan their retirement rather than informing widespread and accessible
them as they prepare to retire in a year or community centres for older residents
two that they must work longer. -- Efforts by the Andalusian province
Moreover, it will be harder to convince (Spain), the State of São Paulo (Brazil),
workers to back higher retirement ages and the State of South Australia to
as they themselves form a bigger share broaden city concerns to the state
of the affected population. level, given that many aspects of urban
• Embracing the new reality of ageing. living that affect the quality of life of
Individually and collectively, we must older people go beyond municipal
change our behaviour, institutions and boundaries (such as housing policies,
public policies to reflect the new meaning public transportation, access to health
of ageing, and along with it, the altered and social services, and recreational
needs and capacities of older people facilities).
(Box 3). This means raising the legal
retirement age (though this change may
focus primarily on those not
predominantly engaged in manual

Introduction
Box 3: Opportunities arising from a longer, Acknowledgements
healthier life This book is a product of the World

Economic Forum’s Global Agenda Council
A longer and more flexible working life. During a period when the (GAC) on Ageing Society. It was prepared
number of people of traditional working age is shrinking, mature-age under the editorial leadership of John Beard,
workers become a valuable resource, so much so that the balance Simon Biggs, David Bloom (GAC Chair and
will change in favour of practices that promote higher levels of labour lead editor), Linda Fried, Paul Hogan,
force participation among older individuals. Alexandre Kalache and Jay Olshansky. The
GAC members are grateful to the World
Volunteering and community contributions. While research on the Economic Forum’s Michael Hanley (Editorial
uptake of voluntary activities is mixed, there is little doubt that many Director), Patrick McGee (Manager of the
older adults make a valuable contribution through voluntary Council), and Tiffany Misrahi for thoughtful
community engagement. This may take the form of civic suggestions and strong support, and to
engagement, from education and healthcare to the environment and Fabienne Stassen Fleming for editorial
homelessness. assistance. We are appreciative of the
patience and help of Kamal Kimaoui and
Enhanced social skills. Research shows that many older adults are Yoren Geromin in the typesetting and
better at interpersonal communication and less prone to immediate production. We would like to thank Martina
emotional reactions than persons of a younger age. This is a set of Gmür (Senior Director, Head of the Global
“people skills” that would be particularly valuable for a service-based Agenda Councils) for her encouragement of
economy. this project. The GAC members would also
to thank the book editors, Dianna Rienstra,
Redesigned environments. Creating age-friendly environments not David Watkiss and Alejandro Reyes, and
only enhances the social participation of older adults and other proofreaders Mary Bridges, Mary McGee
groups, but it also stimulates business innovation in designing the and Ryan Jacobs. The Global Agenda
built environment. New building and retrofitting gives rise to Council on Ageing is also grateful to Marija
employment opportunities in construction, transport and related Ozolins, Larry Rosenberg and Laura Wallace
industries. for their assistance in the editing and
preparation of the Introduction and the
New markets, new consumers. It is estimated that people over the overall book.
age of 60 hold more than 50% of the wealth in developed societies,
with a similar trend occurring in emerging countries. This means that Support for David Bloom’s participation in
the considerable potential of the “silver market” is only just beginning this work was provided by the Program on
to be tapped. the Global Demography of Aging at Harvard
University, funded by Award Number
Intergenerational transfers. Contrary to the view that older P30AG024409 from the National Institute on
generations are a burden on younger ones, most transfers run down Aging. The content is solely the responsibility
the generational tree rather than up it, when viewed across the life of the authors and does not necessarily
course. Parents and grandparents give their children the best start in represent the official views of the National
life they can. Older taxpayers show no indication of refusing to pay for Institute on Aging or the National Institutes of
large infrastructural projects for which they may never reap the full Health.
personal benefit. It may be more accurate to talk about generational
altruism rather than generational burdens.
Caring and family cohesion. Older people, particularly women,

engage in unpaid care work. This contribution not only frees up
others in the workforce, such as their adult children, it currently saves
their national economies considerable costs. When a shrinking
population of working age is combined with increased female
participation, certain sectors – such as the aged-care workforce –
will come under particular strain unless these skills are recognized.

I. The Backdrop:
What we must
contend with and
why we must act
now

I. The Backdrop: What we must contend with and why we must act now
Chapter 1 A Cultural Problem

Population ageing presents a cultural problem.2 The dramatic
The Meaning of Old Age increase in the numbers of people who are making it to their 80s, 90s
and beyond is generating a profound mismatch between the cultural
Laura L. Carstensen and Linda P. Fried norms that guide us through life and the length of our lives.3 Humans
are creatures of culture. We look to culture to tell us when to get an
Even at the beginning of recorded history, a handful of people education, marry, start families, work and retire.
survived to old age. Many of those who did served important
functions in societies. Elders featured in religious texts, mythology Because life expectancy has increased so quickly, we are still
and lore have been portrayed as prophets, saints, tribal leaders and immersed in cultures designed for lives half as long as the ones we
healers, providing cultural continuity, wisdom and concern for the are living. The life course itself is a cultural construction. Two hundred
common good. Thus, there is a twist of irony in the fear and anxiety years ago, human development did not include a distinct stage of life
that characterizes contemporary national and international called “adolescence”. There was no more significance afforded to 65
discussions about anticipated coming hardships imposed by ageing than 55 or 45 years of age. We must ask the question: How can
societies. societies and individuals profit from old age?
But a preparatory state aimed solely at bracing for a crisis presents Yet to approach the topic of population ageing with rose-coloured
more than irony. It ensures that the crisis will arrive. If we are to realize glasses, overlooking the real vulnerabilities associated with
the potential opportunities older populations offer, we must advancing age, would be foolhardy. Societies today are enormously
appreciate how ageing individuals construct meaning in their lives ill prepared for populations in which there are more people over 60
and the social context that surrounds specific cohorts’ collective than under 15. Not only are cultures youth-oriented in the popular
understanding of ageing. We must also actively begin to build sense of favouring the young, but physical and social environments
infrastructure, norms and policies that exploit the potential and institutions are quite literally built by and for young populations.
contributions older people can make to societies.1 The implicit users of staircases, automobiles, telephones, furniture,
parks, highways, train stations, airports and housing are young
It is not the case that life has suddenly been extended beyond a point people. Workplaces and working lives – and even most hospitals –
where people can live healthy, productive lives. Indeed, there is no are tailored to those with considerable endurance.
reason to believe that the human life span – the length of time the
species can live – has changed much, if at all, throughout Medical science, a key part of culture, has focused on cures for
evolutionary history. Until the 20th century, on average, lives were acute diseases far more than prevention of the chronic diseases that
short. Fewer than half of those born reached 50 years of age. What unfold over years and decades. Expectations of workers include
has changed is the sheer number and proportion of each birth speed, agility and facility with new learning. Further, many societal
cohort that now routinely live into their 80s, 90s and 100s. roles were designed when life expectancy was 47 and without the
knowledge of the unique capabilities that older adults could bring to
In less developed regions of the world, life expectancies remain far the workplace and society. Though ageism is often invoked as the
shorter; however, societies there, too, are beginning to live longer and reason for the focus on youth, and though it may play a role, we live in
age rapidly. Within a decade they will be on demographic trajectories a world that only recently included large numbers of older adults.
that will reshape the distribution of age in every country in the world.
The profound and global phenomenon driven by ageing will Age-Related Changes in Biological Systems
transform all aspects of life.
Worlds built for the young are often difficult for the old to navigate.
Will these changes be for better or for worse? Will such demographic Normal ageing brings with it myriad changes, many of which are
shifts inevitably burden economies, or offer unparalleled benefits? unwelcome. Slowing is a key hallmark of ageing. The effects are
Will older people consume resources that would otherwise go to ubiquitous. People move more slowly, metabolize toxins over longer
children? Or will older people become the resource children and time courses. Feeling stiff and sore when you wake in the mornings,
societies in general so badly need? recovering from injuries and illness more slowly, straining to hear a
conversation, reflect “typical” age-related changes. Difficulty
We maintain that if we play our cards right, prolonged lives can allow retrieving the name of a person you know well, forgetting why you
us to redesign them in ways that improve quality at all ages and walked downstairs as you find yourself at the bottom of a staircase,
across generations. The gift of time we received from our ancestors drifting off as you read the morning paper all represent real
in the 20th century presents us with unprecedented opportunities. To consequences of age-related changes in biological systems.
be sure, these opportunities will be missed if we do not begin to
prepare for them. The real challenge, as we see it, is only partly about Towards the end of life, disease and disability are typical. Thus, older
finding ways to care for dependent elderly. Ageing societies will societies have greater morbidity and more functional limitations than
succeed or fail largely as a function of the new meanings we ascribe younger populations. There is a diminution of physical reserves,
to both healthy and unhealthy longer lives. culminating for many, at the end of life, in the onset of frailty, a
medical syndrome of decreased reserves and resilience, and – for
some – disability and loss of independence.4,5 Even those who
escape frailty experience diminished resilience and reserves as they
get older.

Gains Come with Age Importantly, ageing trajectories also vary wildly across individuals.
Scientists have documented considerable variability in older people
The vulnerabilities of ageing must not be overlooked when planning in physical, social, emotional and cognitive capacity. This observation
for ageing societies. Importantly, however, just as sure as there is is important for at least two reasons. For one, variability speaks
loss, there are gains that come with age. The gains have been largely against inevitability. It suggests that ageing per se is not the culprit
overlooked. Paul and Margaret Baltes,6 professors of lifespan when negative outcomes arise. Second, variability is far from a
development, wrote compellingly about the need to recognize the random process. It is important to emphasize that, in developed
gains and losses inherent in all developmental stages. Young people, countries such as the United States, only a fraction of adults 65 and
for example, may be fast and agile, but they lack experience and older are frail (7% to 10% of those in any given community), disabled
knowledge. Their futures demand that they focus on their own (20% or less with difficulty or dependency in managing households
personal advancement more than the broader community. The and/or basic self care, although half may have some difficulty
impressive physical resilience in the young is not matched by walking), or in need of long-term care (5% to 10%).17
emotional resilience, which comes much later in life. We do not
populate the state and federal courts with 20-year-olds, despite their Individuals who are educated and affluent have less functional
cognitive agility. disability and live longer than those who are disadvantaged in
society. Not surprisingly, individuals who exercise regularly are more
In fact, though historically most of the literature on cognitive ageing physically fit than those who do not, and they also show less
has focused on deficiencies, there is growing literature pointing to cognitive decline– into the oldest ages. Although age is a powerful
unique strengths of older adults. As noted above, normal ageing is predictor of length of life, in adulthood, education is even better.18
associated with slowed cognitive processing, memory impairment
and difficulty concentrating. Barring dementia, however, knowledge
continues to grow. Especially in areas of expertise, practice Understanding Variability
compensates well for declines in processing efficiency.7 Experts – From a societal perspective, variability means that age-based
whether musicians, chess players or scientists – often reach peaks in policies, programmes, beliefs, and communities are inherently
their advanced years.8 problematic. People in their late 60s who are extremely sick, possibly
facing the end of their lives, have more in common with 80-year-olds
Even in the general population, vocabularies are larger and in the same physical state than with healthy counterparts at either
knowledge about the world is greater in the old as compared to the age. Discussions about older workers often draw on literature about
young. Recent findings suggest that older people are more likely to cognitive decline in the very old when they should be comparing
change attitudes in light of new information,9 and they appear better 55- to 65-year-olds with 65- to 75-year-olds, where differences are
able to take the perspective of younger people than younger people far smaller and sometimes non-existent.
are able to adopt perspectives of the old.10
Frailty is far more frequent among the very old than the young old.
Presented with cultural and economic disputes over resources, older Again, social class and its correlations place people on very different
people generate more even-handed and acceptable solutions than ageing trajectories. Thus, forward-thinking societies should plan for
younger counterparts.11 Indeed, there is intriguing evidence that there older populations that are heterogeneous and develop plans to help
may be potential upsides even to deficits, like distractibility. Lynn those who need it, while tapping the resources of those who can
Hasher and her colleagues recently demonstrated that contribute. Without doubt, the category of “old age” will be parsed
unsuppressed extraneous information in one situation often into multiple stages, just as adolescence was carved out as a special
becomes relevant and is utilized by older adults when solving transitional stage into adulthood.
problems that later arise. In elegant experiments, she showed that
older people gain advantages from access to extraneous information Because of the magnitude of the demographic shifts underway,
downstream; younger people do not.12 ageing will inevitably have profound implications for entire societies.
Societies top heavy with frail, dependent and disengaged people
In everyday life, this can be associated with creative problem solving with relatively few younger people to support them will endure many
that emerges at older ages. Especially in emotionally charged hardships. We maintain, however, that societies top heavy with
situations, older people tend to generate more effective solutions.13 In experienced citizens will have a resource never before available to
addition, emotional experience and emotional balance improve with our ancestors: large numbers of people with considerable
age. Older people have lower rates of clinical depression, anxiety and knowledge, emotional evenness, practical talents, creative problem-
substance abuse.14 They regulate their emotions better, avoiding solving ability, commitment to future generations, and the motivation
extreme highs and lows.15 In other words, while ageing is associated to use their abilities can improve societies in ways never before
with declines in some aspects of cognitive processing, age-related possible.
gains also come with age. Greater understanding of the world
coupled with emotional balance and improved perspective is, for
many, the definition of wisdom.16

Understanding the Meaning of Age Endnotes

The meaning of age will continue to be a fluid concept and will be 1 MacArthur Network on an Ageing Society (2009) Facts and fictions about an ageing America.
Contexts, 8(4), 16–21.
constructed through complex and iterative processes for decades, if 2 Carstensen, L. L. (2011) A long bright future: Happiness, health and financial security in an age of
not centuries, to come. As the odds of reaching advanced old age increased longevity. New York: Public Affairs.
increase around the globe, people will gradually come to extend their 3 Riley, M. W., Kahn, R. L., Foner, A., & Karin, A. (1994) Age and structural lag: Society’s failure to
individual time horizons and engage in more philosophical thinking provide meaningful opportunities in work, family, and leisure. Oxford: John Wiley & Sons.
about the meaning of lives that last far longer than ever imagined by 4 Fried, L.P., et al. (2001) Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med
Sci, 56(3), 146-56.
our ancestors.19 5 Bandeen-Roche, K., et al. (2006) Phenotype of frailty: characterization in the Women’s Health and
Ageing Studies. J Gerontol A Biol Sci Med Sci, 61(3), 262-6.
In Europe and the United States, because of their numbers, baby 6 Baltes, P. B. & Baltes, M. M. (1990) Successful ageing: Perspectives from the behavioral sciences.
boomers will transform the culture of ageing. Because boomers New York: Cambridge University Press.
came of age during an historic era of considerable progress in 7 Salthouse, T. A. (2010) Major issues in cognitive ageing. New York: Oxford University Press.
gender and race equality, they tend to view themselves as rebellious 8 Ericsson, K. A. & Charness, N. (1994) Expert performance: Its structure and acquisition. American
Psychologist, 49(8), 725-747.
and “youthful” despite their advancing age. The birth cohorts
9 Eaton, A. A., Visser, P. S., Krosnick, J. A., & Anand, S. (2009) Social power and attitude strength
comprising the boomers identify more strongly with younger over the life course. Personality and Social Psychology Bulletin, 35(12), 1646-1660.
generations than older ones and blur long-standing lines that mark 10 Sullivan, S. J., Mikels, J. A., & Carstensen, L. L. (2010) You never lose the ages you’ve been:
age.20 Affective perspective taking in older adults. Psychology and Ageing, 25(1), 229-234.
11 Grossmann, I., et al. (2010) Reasoning about social conflicts improves into old age. Proceedings of
Future generations will continue to write and rewrite the meaning and the National Academy of Sciences of the United States of America (PNAS), 107(16), 7246-7250.
purpose of advanced stages of life. Societies that find ways to 12 Thomas, R. C., & Hasher, L. (2011) Reflections of distraction in memory: Transfer of previous
distraction improves recall in younger and older adults. Journal of Experimental Psychology:
collectively advance new meanings of life that utilize all of their Learning, Memory, and Cognition. (Advance online publication August 15)
citizens will prosper far more than ones in which social structures 13 Blanchard-Fields, F. (2007) Everyday problem solving and emotion: An adult developmental
constrain contributions. To the extent that societies actively build perspective. Current Directions in Psychological Science, 16(1), 26-31.
cultural infrastructures that take advantage of new possibilities, they 14 Charles, S. T., & Carstensen, L. L. (2010) Social and emotional ageing. Annual Review of
Psychology, 61(1), 383-409.
will realize many opportunities and benefits. To fail to do so would
15 Scheibe, S. & Carstensen, L.L. (2010) Emotional ageing: Recent findings and future trends. J
represent a tragic squandering of this gift of life. Gerontol B Psychol Sci Soc Sci, 65(2), 135-144.
16 Ardelt, M. (2004) Wisdom as expert knowledge system: A critical review of a contemporary
Conclusion operationalization of an ancient concept. Human Development, 47(5), 257-285.
17 Fried, L.P., et al. (2004) Untangling the concepts of disability, frailty, and comorbidity: implications
As we stand at the beginning of the 21st century, there is a tension for improved targeting and care. J Gerontol A Biol Sci Med Sci, 59(3), 255-263.
between advocates for the elderly and others with concerns about 18 Olshansky, J. (2011) Two Americas at the dawn of the ageing society: The impact of race and
education on survival. (Manuscript submitted for publication)
the inability to provide seemingly limitless support. In the United
19 Laslett, P. (1991) A fresh map of life: The emergence of the third age. Cambridge: Harvard
States now that more than half of the federal budget is allocated to University Press.
care for older people, it makes sense to worry about other societal 20 Biggs, S., Phillipson, C., Leach, R., & Money, A. (2007) Baby boomers and adult ageing: Issues for
needs. social and public policy. Quality in Ageing and Older Adults, 8(3), 32-40.
We argue for a three-pronged approach:

• First, it is essential that we think programmatically about
investments throughout life in health, education and social
integration that pay off at all ages. Just as early investments in
health and early education paid off with huge reductions in
premature death and early morbidity a century ago, we must now
conceive of lifelong investments that will produce healthy and
engaged populations at all ages, especially among all future
cohorts of older persons.
• Second, we must improve the care and autonomy of disabled
older adults; in part for their own quality of life and in part
because only at its extremes does disability render people
completely dependent. To the extent that those who have
functional disabilities still have access to opportunities to
contribute, we believe that there is reason to predict that
contributions will continue.
• Finally, but arguably most importantly, we must build
infrastructures that tap the real talents and potential contributions
that healthy older people can make to societies. We must get rid
of mixed messages about working and replace them with calls
for all able citizens to contribute to the welfare of societies.
Population ageing will transform the global community. The question
is whether such changes will improve societies or extract net tolls.
Either is possible. If we continue to view the life course as our
ancestors did and simply tack added years on at the end, we face
sure calamity. If instead we begin to modify the life course and build
infrastructures that support long life, societies can begin to utilize the
strengths of older people and support the real vulnerabilities
advanced age brings.

Chapter 2 A Profound Impact on Financial Security

The demographic repercussions of a growing ageing population will
Ageing and Financial have a profound impact on financial security. As life expectancy
increases, natural strains on the sustainability of financial security
(In) Security increase. This growing economic tension would be difficult to
manage on its own, but the economic recession of 2008 has recast
Jack Ehnes this problem severely. The depletion of trillions of dollars of retirement
savings globally has caused a significant questioning of our
The impending flood of baby boomers entering retirement, the underlying retirement and savings models, and ultimately bears
unsettled landscape for retiree healthcare, and the fears of creating heavily on the quality of life of seniors, labour market stability and
burdens of mounting debt for generations to come have framed the intergenerational relationships.
financial landscape in recent years. Although elements of similar
dynamics can be recognized in other economies, the policy debate The recent economic downtown has sharply decreased retirement
is most apparent in the United States. As an important benchmark in savings in workers’ traditional and defined-contributions accounts,
assessing worker confidence, the 2011 Retirement Confidence and also has damaged the equity in their homes. For many workers
Survey found that 22% of workers are not at all confident about with limited savings, home equity has served as an important
having a comfortable retirement.1 This is the highest level of workers’ component of retirement savings.5 A recent Gallup Poll found that
insecurity in the 21 years the survey has been conducted. Gallup Poll among eight major household worries, which included not being able
data indicates that 63% of Americans now expect to work part-time to pay the mortgage and inability to afford medical bills, the most
after retirement, and they are twice as likely to say, “It’s out of severe worry is “not having enough money for retirement”.6
necessity”.2
These demographic shifts anticipated by the retirement of baby
The concerns for retirement security from an enlarging ageing boomers have been studied for some time, but their financial
population are running into the headwinds of pension reform, which implications and their interrelationships to the broader economy have
has placed an increased burden on personal savings. Throughout become central issues for policy-makers today. Both sides of the
the Organisation for Economic Co-operation and Development political aisle in the United States have been loath to speak about
(OECD) countries, systematic reforms are being contemplated, with cuts to entitlement programmes for fear of angering seniors who are
changes ranging from lengthening the pension retirement age to reliable voters. But those positions are less sacred, as politicians
lowering pension benefit entitlements. Within the OECD, “30 make little headway in addressing growing sovereign debt.
countries have made at least some changes … and 16 have made
major reforms that will significantly affect future benefits”.3 While The linkages of ageing to the broader economy are tightly
developed nations struggle with their financial obligations to retirees, intertwined. In a recent New York Times article on the greying
Asian countries bear many of the same demographic trends, but lack population, political economist and demographer Nicholas Eberstadt
the institutionalized pension schemes to fill in the gaps from of the American Enterprise Institute suggested, “Costs associated
weakened family-based informal support mechanisms.4 with population ageing are estimated to account for about half the
public-debt run-up of the OECD economies over the past 20 years”.7
These trends and linkages all underscore that demographics are
mainstream issues for economists and politicians.
While changes have been implemented in retirement schemes over

the past decades, those have often come in reaction to a financial
crisis rather than as a product of thoughtful deliberation. Basic
questions remain in debate, such as:
• Who should bear the investment risk for saving for retirement?
• What is an appropriate retirement age, given the changes in
longevity?
• What is the correct savings target to meet retirement
expectations?
• Can employers change the terms of employment (i.e., the
benefits or retirement age) for current workers and retirees?
• Do we have retirement schemes that are responsive to increased
longevity and flexible approaches such as partial retirement?
• How do we encourage workers to begin saving earlier in their
careers?
• What levels of resources do employers and governments require
to support retirement plans in the long run?
As fundamental as these questions are to financial security in
retirement, largely intractable differences of opinion remain – not
theoretical, but on the front burner –- in countries, states and
municipalities throughout the world.

Strong Resistance to Raising the Retirement Age The global slide towards defined-contribution plans in lieu of
defined-benefit plans has settled well with businesses by limiting their
European media heavily covered the 2010 national strikes in France, exposure to downside risk, which proved highly beneficial to the
when over 1 million French workers took to the streets.8 The cause of bottom line over the past decade. In one survey of CEOs, 71% said
this sharp discontent was not, as one might expect, concerned with that federal, state and local governments should shift to defined-
the global economic crisis per se, but rather with President Sarkozy’s contribution plans, and 7% said that all pensions should be
proposal to increase the retirement age from 60 to 62. In 2011, more eliminated.13 However, the other side of the ledger is far darker. Many
strikes were ignited in countries ranging from India (Kashmir), where argued that the real financial crisis is still to come – the retirement of a
workers protested increasing the retirement age from 58 to 60,9 to massive generation of baby boomers with inadequate retirement
Greece and Nigeria. savings. The median household headed by a worker aged 60 to 62
Although the official retirement ages for most OECD countries fall with a 401(k) is estimated to have less than one-quarter of what is
within a fairly narrow band of 60 to 65, governmental reform needed to maintain his or her standard of living.14
proposals are fairly modest within that range. Even social security in The Employee Benefits Research Institute (EBRI) found in its research
the United States has undergone only two changes to its retirement in 2010 that one-half of baby boomers and GenXers were at risk of
age structure in its 75-year history. In the late 1950s an early eligibility not having sufficient retirement income to cover even basic expenses
age was established, and in the early 1980s, normal retirement age and uninsured healthcare costs.15 While there is a growing body of
was raised from 65 to 67. Thus, regardless of changes in longevity financial literature on the inadequacies of these savings levels for
and labour market participation rates, there is strong institutional and baby boomers, there is little analytic work on the financial stress to
societal resistance to raising the official retirement age. broader social and economic systems. More time has been focused
on lowering costs by restricting direct outlays to pensions than on
High Anxiety about Retirement Prospects determining the new indirect costs that will result from greater
In light of the recession, workers have high anxiety about their reliance on government-supported social services.
retirement prospects. In a recent US survey, 84% expressed
concerns that current economic conditions are impacting their ability Risk of Intergenerational Financial Friction
to achieve a secure retirement.10 Furthermore, Americans have rather To the extent that long-term obligations for health and retirement
low retirement expectations, with 34% defining a secure retirement have been inadequately funded, those financial pressures have the
as simply surviving or living comfortably.11 Not surprisingly, anger and potential to bring about significant intergenerational financial friction
anxiety from the recessions are influencing older workers’ attitudes and conceivably expressions of outright hostility. In the recent
towards proposed changes that impact their opportunities for a best-selling book, 2030: The Real Story of What Happens in
secure retirement. America, one protagonist is a teen gang member. Unlike the gangs of
One of the more aggressive efforts by government leaders to today, however, these alienated children hated “the whole idea that
constrain pension costs has been to curtail or limit the benefits of their lives were going to be tougher than those of their parents –
current workers or retirees. It has been readily accepted that such something that had never happened before in America”.16 While this
changes, regardless of severity, can be introduced in the workplace may well be an exaggerated interpretation of this economic
to impact future workers. However, their desired immediate trajectory, it nevertheless captures the difficulties policy-makers face
budgetary impact in many government or collectively bargained in balancing the economic needs of generations of workers.
settings is often legally constrained. Those definitions of protections The evolving support ratios (number of people of working age
vary considerably by legal jurisdiction and also have come under compared to number of people beyond retirement age) underscore
attack as policy leaders search for reforms that will have a material the deepening economic transformation. Ratios for developed
financial impact. nations hovered in the 3-4 range in 2010, down from the 4-5.5 range
In the United States, for example, three states – Colorado, Minnesota in 1970. Projections just 40 years out predict most of those ratios will
and South Dakota – recently implemented changes that reduced drop under 2.5 and, in a few striking examples like Japan, reach a
cost-of-living benefits for current retirees. Although these rights startling 1.2.17 Not only will there be a much larger senior population
would be protected in many jurisdictions, the three states requiring social services, but the underlying tax support structure will
successfully argued that without these changes, there would be decrease as a ratio per senior.18
significant financial repercussions to their pension plans.
A Shift to “Short-Termism”
Clearly, these changes to public employment retirement schemes
Although funding an adequate retirement plan and maintaining
run counter to efforts to ensure that workers have adequate long-
assets throughout a lengthy retirement should be a long-term
term security. They also have created political tension through
endeavour, the investment environment has noticeably shifted to one
renewed labour-management conflicts. Foreshadowing events of the
described as “short-termism”. With the high turnover of elected
coming months, the Economist featured on its cover at the start of
officials, political systems have historically had a short-term
2011 a headline on the “battle ahead”, arguing that public-sector
orientation. Financial markets have also shifted, in large part due to
unions will be at the centre of the debate over benefits and legal
the influence of money managers, mutual funds and hedge funds
privileges.12
that focus on short-term stock price performance.19 Mutual funds in
In addition to the actions in Europe over retirement age, state particular, which have become the lifeblood of defined-contribution
governments in the United States, even in traditionally moderate plans, have moved retiring workers to products with higher fee
states like Wisconsin and Ohio, not only attempted restrictions to structures and high portfolio turnover. In contrast, traditional pension
benefits, but also have sought to curtail bargaining rights for public plans have been an important source of long-term patient capital,
workers. These sharper political directions have shifted debate from setting asset allocations on long-term capital assumptions.
some of the substantive issues concerning retirement adequacy to
partisan differences on worker rights and political philosophy.

There is considerable debate about whether we have entered a “new Endnotes

normal” period that would have a potentially critical impact on the 1 Helman, R., et al. (2011) The 2011 Retirement Confidence Survey: Confidence Drops to Record
elderly’s long-term savings. Even the modest lowering of investment Lows, Reflecting the “New Normal”. Employee Benefit Research Institute, March Issue Brief, No.
355. Available at: http://www.ebri.org/pdf/briefspdf/EBRI_03-2011_No355_RCS-2011.pdf
assumptions by large institutional investors signifies a conservative
2 Jones, J. (2011) Most Workers Expect to Keep Working after Retirement Age. Gallup Polls, June 1.
shift that will be all the more magnified through defined-contribution Available at: http://www.gallup.com/poll/147866/workers-expect-keep-working-retirement-age.
plans and individual-savings plans, both of which deal poorly with aspx
longevity risk. 3 OECD, Organisation for Economic Co-operation and Development. (2007) Pension Reform: The
Unfinished Agenda. September Policy Brief. Available at: http://www.oecd.org/
dataoecd/16/24/39310166.pdf
Reconciling the short-term volatility of the markets with reliable
4 ADB, Asian Development Bank (2010) Reforming Asia’s Pension Systems. Social Protection
long-term projections has been difficult. Nevertheless, concerns that Project Briefs. Available at: http://www.adb.org/Documents/Brochures/Social-Protection-Project-
nominal GDP growth rates will be 3% to 4%, resulting in a return of Briefs/reg-reforming-pension-systems.pdf
assets of half of what they were during the previous 10 to 20 years, 5 Paul, M. & Weinberg, M. (2010) Public Affluence, Private Squalor. New America Foundation, July
Policy Paper. Available at: http://newamerica.net/publications/policy/public_affluence_private_
will greatly reshape the retirement security of future generations.20 squalor
6 Mendes, E. (2011) Lack of Retirement Funds is Americans’ Biggest Financial Worry. Gallup Polls,
Workers Anticipate Working Longer June 15. Available at: http://www.gallup.com/poll/148058/lack-retirement-funds-americans-
biggest-financial-worry.aspx
How have workers responded to the recession? Given the 7 Freeland, C. (2011) The Problems of a Graying Population. The New York Times, July 28. Available
at: http://www.nytimes.com/2011/07/29/world/americas/29iht-letter29.html
dominance of market-sensitive retirement plans, one would expect
8 BBC News. (2010) Pension Rallies hit French Cities. September 7. Available at: http://www.bbc.
many workers to give serious consideration to working longer, as well co.uk/news/world-europe-11204528
as attempting to increase their savings rate. Research indicates that 9 MSN News. (2011) JK Govt employees to go on 2-day long strike tomorrow. May 8. Available at:
following the 2008 market downturn, 40% anticipate retiring later, http://news.in.msn.com/national/article.aspx?cp-documentid=5343115
expecting delays of four or more years.21 Furthermore, two-thirds of 10 Perlman, B., Kenneally, K., & Boivie, I. (2011) Pensions and Retirement Security 2011: A Roadmap
respondents indicated no change in their contributions to their 401(k) for Policymakers. National Institute for Retirement Security. Available at: http://www.nirsonline.
org/index.php?option=content&task=view&id=571
s and IRAs, although they were spending less. Similarly, Gallup Poll 11 Ibid.
data shows a significant shift over the past 15 years of those that 12 The Economist. (2011) The Battle Ahead. January 8. Available at: http://www.economist.com/
expect to retire after 65 increasing from 12% in 1995 to 37% in node/17851305
2010.22 13 Silicon Valley Leadership Group. (2011) Silicon Valley CEO Survey Business Climate 2011.
Available at: http://svlg.org/docs/2011BusinessClimate_digital.pdf
On an international basis, considerable gaps in pension coverage 14 Browning, E.S. (2011) Retiring Boomers Find 401(k) plans fall short. Wall Street Journal, February
19. Available at: http://online.wsj.com/article/SB1000142405274870395960457615279274870735
remain. The OECD has suggested that, “introducing mandatory 6.html
private pension appears to be the only way to have private pensions 15 VanDerhei, J. (2011) The Power of Pensions: Building a Strong Middle Class and Strong Economy.
that cover significantly more than half the working-age population”.23 Testimony to the Senate Committee on Health, Education, Labor and Pensions, July 12. Available
at: http://help.senate.gov/imo/media/doc/Oakley.pdf
How accurate are retiring workers in estimating their retirement 16 Brooks, A. (2011) 2030: The Real Story of What Happens in America. New York: St. Martin’s
Press.
needs? In 2010, nearly 29% felt they needed less than US$ 250,000
17 The Economist. (2011) Falling Short. April 9. Available at: http://www.economist.com/
at retirement and another 17% indicated US$ 250,000 to US$ node/18502013
499,000.24 Either sum would produce a very modest annuity in 18 Wong, P. & Shen, I.L. (2010) Addressing California’s Pension Shortfalls: The Role of Demographics
retirement. Nevertheless, workers nearing retirement have in Designing Solutions. The Milken Institute, October Research Report. Available at: http://www.
milkeninstitute.org/pdf/cacenter_pensionshortfalls.pdf
accumulated sums on average that are far below even these
19 The Aspen Institute. (2009) Overcoming Short-termism: A Call for a More Responsible Approach
thresholds in their 401(k) accounts, with those in their 50s having an to Investment and Business Management. The Aspen Institute, Business and Society Program.
average balance of US$ 139,932 and workers in their 60s having an Available at: http://www.aspeninstitute.org/sites/default/files/content/docs/pubs/overcome_
short_state0909_0.pdf
average balance of US$ 144,004.25
20 El-Erian, M. & Gross, B. (2009) PIMCO’s Cyclical Outlook and the New Normal. October Economic
Outlook. Available at: http://www.pimco.com/EN/Insights/Pages/New%20Normal%20QA%20
Conclusion Gross%20El-Erian%20Oct%202009.aspx
21 Sass, S., Monk,C., & Haverstick, K. (2010) Workers Response to the Market Crash: Save More,
The financial crisis has collided with the demographic shifts and Work More? Center for Retirement Research Brief, Boston College. Available at: http://crr.bc.edu/
briefs/workers_response_to_the_market_crash_save_more_work_more.html
brought into sharp focus many underlying policy questions that have
22 Newport, F. (2011) In U.S., 53% Worry About Having Enough Money in Retirement. Gallup Polls,
not been adequately addressed. Facing a generation of retiring baby April 25. Available at: http://www.gallup.com/poll/147254/worry-having-enough-money-
boomers, many of whom are clearly ill prepared for retirement, retirement.aspx
governments will be faced with still more financial challenges to their 23 OECD, Organisation for Economic Co-operation and Development. (2007) The Pensions Gap: The
support programmes. Role of Private Pensions. September Policy Brief. Available at: http://www.oecd.org/
24 Helman, R., et al. (2011) The 2011 Retirement Confidence Survey: Confidence Drops to Record
We have reached the point where there will need to be a realistic Lows, Reflecting the “New Normal”. Employee Benefit Research Institute, March Issue Brief, No.
assessment of official retirement ages, modifications to company 355. Available at: http://www.ebri.org/pdf/briefspdf/EBRI_03-2011_No355_RCS-2011.pdf
policies to allow for work after retirement, and recognition that the 25 Ibid.
market’s performance over the past decade has underscored the
weaknesses of exposing workers to retirement schemes that have
placed too much risk on their shoulders.

Chapter 3 Figure 1. Proportion of women among persons aged 40-59, 60+,

80+ and 100+ years (world, 2007)
Women and Ageing 82%
Saadia Zahidi 64%

55%
The proportion of people age 60 and over across the world rose from 50%
8% in 1950 to 11% today, and by 2050 it will rise to 22%.
Furthermore, the population of older persons is itself ageing. Today,
persons aged 80 years or over account for about one in every eight
older persons (60 or over). By 2050, this ratio is expected to increase
to approximately two persons aged 80 or over among every 10 older
persons. 40-59 60+ 80+ 100+
Source: United Nations Department of Economic and Social Affairs, Population Division, “World
On average, women outlive men by nearly 4.5 years, and thus make Population Ageing 2007
up the majority of older people in the world, particularly amongst the
“oldest old”. Women in developed countries have higher life Challenges in Responding to Global Ageing
expectancy at birth and at older ages, than do men. Women usually
have an advantage in developing countries as well. However, high Ageing leads to different outcomes for women and men, with women
maternal mortality, discrimination against women in nutrition, access facing particular challenges of health, economic insecurity and
to healthcare and other areas, and in some cases the killing or greater caregiving burdens. The underlying factors for these gender
neglect of female infants mean that in certain poor countries, gaps are partly women’s longer lifespan, different susceptibility to
women’s life expectancy is about the same as, or even lower than, disease and trends such as globalization and urbanization. However,
men’s. Over the next few decades, as these conditions improve, these factors can ultimately be largely attributed to the persistent
women’s life expectancy in the developing world is expected to social, political and economic inequity girls and women face
increase faster than men’s. As a result, the situation in these throughout their lives and that are manifest or compounded during
countries will come to resemble that in the developed world today. their old age.
Table 1 displays the proportion of women amongst the population of Health Gaps
older people in selected countries.
A universal concern for the elderly is access to healthcare.
Industrialized and less developed countries alike share the challenge
Table 1. Proportion of women among person’s aged of making healthcare affordable and accessible. Health in old age has
60+ and 80+, selected countries to do not only with presence or absence of disease. Availability and
Population of older people, 2012 quality of care are also important. Most older people, even those in
Country Total %60+ %80+ 60+ as % % female % female generally good health, will eventually need more care than they did
population of 15-59 among among earlier in their lives. Therefore, the ways society provides – or fails to
(millions) 60+ 80+ provide – this care can greatly impact an older person’s quality of life.
Australia 22.9 20 4 32 53 60 While this is a concern in relation to all older people, the
Brazil 198.4 11 2 17 55 60
considerations are very different for older women.
China 1,353.6 13 2 20 51 59
First, due to the differential life expectancy of women and men, there
France 63.5 24 6 41 56 65
are simply more older women in the world than older men –
Germany 82.0 27 5 44 56 66 especially among the “oldest old”, those 85 years of age and older,
India 1,258.4 8 1 13 52 55 whose capacities, conditions and needs are different from those in
Indonesia 244.8 9 1 13 55 60 their 60s and 70s. Given that disability rates rise with age, this means
Italy 61.0 27 6 46 56 65 that there are substantially more older women than older men living
Japan 126.4 32 7 57 56 65 with disabilities.
Mexico 116.1 10 1 15 54 60
Republic of Korea 48.6 17 2 25 57 70 Second, even if women on average live more years than men, many
Russian Federation 142.7 19 3 28 66 76 of these years may be spent living with disability or illness. If “healthy
Spain 46.8 23 5 37 56 63 life expectancy” – that is, expected years of life “in full health” – is
Switzerland 7.7 23 5 38 55 65 examined in place of overall life expectancy, women’s advantage
United Kingdom 62.8 23 5 39 54 63 over men often becomes smaller. In many developing countries,
USA 315.8 19 4 31 56 64 social and economic factors mean that women enter old age in
poorer health and, once old, tend to have inadequate access to
Source: The figures in this Table are sourced from the statistics that can be found in the Appendix. healthcare. In their younger years, women are often unable to seek or
receive medical treatment, subordinate their health needs to those of
Currently, women outnumber men by about 70 million among those their families, have limited opportunity to form social contacts, suffer
aged 60 or older. Among those aged 80 or older, women are nearly injuries and other health problems from violence, receive inadequate
twice as numerous as men, and among centenarians women are nutrition, do not get enough exercise, or spend time in hard physical
between four and five times as numerous as men. Figure 1 displays labour. Each of these factors leads to illness and disability in later
the proportion of women among older persons globally. There are a years. Older women often have less access to insurance or enough
number of challenges and opportunities associated with global cash to pay out of pocket, so medical concerns often remain
population ageing. Because women make up the majority of the old, undiagnosed for prolonged periods of time.
and particularly the majority of the oldest old and the most vulnerable
old, defining the particular set of challenges faced by older women
and tailoring responses to these challenges will have to be a critical
part of any efforts to understand, adapt to and respond to global
ageing.

Furthermore, common gender norms mean that it is older women, not Fourth, women’s longer lifespans, combined with the fact that men
men, who are often called upon to be caregivers themselves. Thus, it is tend to marry women younger than themselves and that widowed
not an uncommon occurrence for an older woman to be caring for men remarry more often than widowed women, mean that there are
others, even though she is disabled, has lost her husband and has no vastly more widows in the world than there are widowers; only 43%
one to take care of her. There is little research quantifying the extent of of women aged 60 and older remain married, as compared to 79%
their contribution and the ways it can affect women’s own health and of older men. Given that women in many countries rely on their
disability in later life. husbands for the provision of economic resources and social status,
widows struggle to find economic support from family and
Third, women experience higher rates of chronic illness and disability community because of their lost status as married women. As a
later in life, whereas elderly men suffer from more acute conditions result, a large percentage of older women are at risk of dependency,
that require finite hospital stays. Chronic illnesses such as senile isolation, poverty and neglect. Social isolation of widows is further
dementia require long-term care outside of a medical facility, which compounded by urbanization, emigration, immigration and the literal
places a disproportionate burden on family and community. and figurative movement of younger people away from more
Currently, healthcare professionals in developing countries are not traditional family structures.
adequately trained to handle older age illnesses or educate others on
how to properly manage them. Increasingly, in both developing and Globally, an estimated 19% of women aged 60 or over live alone
developed countries, family cannot be depended upon to provide compared with just 8% of men in that age group. In some cultures,
adequate lifelong support for the growing number of older women destructive attitudes and practices around burial rights and
who not only continue to outlive men, but also live to a very frail age. inheritance may rob widows of their property, health and
independence, and in some cases, their lives. For example, in
Economic Insecurity countries such as Rwanda, Honduras and Ethiopia, it is often illegal
Women make up not only the majority of the old, but also the majority or unconventional for a widow to collect on her husband’s pension,
of the poor old because they generally have less opportunity to earn property or savings; the inheritance is passed on to an eldest son or
a living during their lifetimes, tend to be less economically active in brother with no obligation to support the deceased’s widow.
their older years than men, do not have access to formal social
security systems and tend to have lower social status and economic Women Bear the Caregiving Burden
rights when they are widowed. The health of older persons typically deteriorates with increasing age,
inducing greater demand for long-term care as the numbers of older
First, in both developing and developed countries, current societal persons increase. Older women can serve as caregivers themselves,
arrangements cumulatively result in a lifetime of unequal and as well as being among those who need to be cared for, in both
inadequate access to education, economic participation and developed and developing countries. The burden of caregiving for
opportunity for women. Illiteracy is still common among the older the young and the elderly often falls upon women.
population of less developed regions, with only about one-third of
older women and about three-fifths of older men in developing In addition, women’s traditional role as family caregivers may
countries having basic reading and writing skills. Women spend more contribute to their increased poverty and ill health in older age.
time than men working in informal sectors of the economy. From Women may need to stop working in their prime to fulfill their
childhood and through to retirement age, women are expected to gender-based roles of raising families or to become caregivers for
perform wageless duties such as child rearing and household tasks. their elderly parents. Others never have access to paid employment
because they work full-time in unpaid caregiving roles, looking after
Although these services can be crucial to the family structure, they children, older parents, ill spouses and grandchildren. Thus, the
leave women without marketable skills or an opportunity to build and provision of family care is often achieved at the expense of the female
manage their financial security. In much of the developed and caregiver’s economic security and good health in later life.
developing world, the generation of women that is currently amongst
the older age population did not generally have the opportunity to In parallel, common gender norms mean that it is older women, not
combine paid work and family. Furthermore, women’s access to men, who are often called upon to be caregivers themselves. For
property ownership and inheritance, ability to move about in public example, women, including older women, have had to take on the
as needed, authority to give informed consent and make important caregiver role in countries with a high prevalence of HIV/AIDS.
decisions, confidence and sense of self-worth, are also limited by Numerous studies have found that most adult children with AIDS
existing societal structures, leading to compounded economic return home to die; and female relatives take on the bulk of the care,
insecurity in later life. including that of any orphaned grandchildren. Furthermore, as more
young adults migrate to urban areas or to other countries, the care,
Second, as in their prime years, rates of economic activity among the development and education of any children left behind will fall to
“silver workforce” are different for older women and older men. Just older women who, without significant and timely support structures
13% of men aged 65 years or over are economically active in the put in place, will have few resources with which to provide support.
more developed regions, whereas 39% are in the labour force of the
less developed regions. In the more developed regions, 7% of older Crisis situations such as war, forced migration, famine and epidemics
women are economically active, compared to 15% in the less can further exacerbate the caregiving burden of older women by
developed regions. reducing younger workers and wage earners, who are often the
basis of support on which many older people must rely in the
Third, older women often do not have access to social security absence of public social insurance schemes. These crisis situations
systems and pension benefits. Since the majority of women work leave in their wake orphaned, sick and disabled people who must be
outside traditional labour markets, they have little or no access to cared for. Older women are especially affected by both outcomes
individual pay-as-you-go pension programmes or time to build up because they generally control fewer economic resources and must
any significant wealth or savings for retirement. In most countries the rely more heavily on the support of younger adults. In addition, the
statutory age at which a full pension can be obtained, provided a care of needy children and others is most likely to fall to older women
minimum period of contributions to the pension system is completed in the absence of younger women to do the job.
(i.e., the pensionable age), is the same for women and men or lower
for women, even though women can expect to live longer than men
after age 60. For both men and women, pensionable ages tend to be
higher in developed than in developing countries.

Tailoring Policy and Business Responses Investing in Education and Economic Gender Responsive Policies
Empowerment The reduction of potential support ratios has
Population ageing has major consequences
and implications for all facets of human life. It For policy-makers this implies investment in important implications for social security
is clear that taking steps now to empower, women’s education and economic schemes. Gender-responsive polices in the
protect and understand the oldest empowerment as a means of gaining returns areas of health and social protection will be
demographic will be critical. Women make when the ageing population bulge grows. essential, for their impact on individuals as
up the majority of the old. They face This is in addition to the other multiple well as the multiplier effects on communities.
particular economic, health and caregiving competitiveness gains to be had through Older women are more likely to share their
burdens during old age, have different needs women’s integration into the mainstream pension income with the rest of their
from those of men, and use their time and economy. In developing countries, household, increasing the family’s overall
resources differently. Tailoring policy and particularly those that are growing old before financial position and positively impacting
business responses to match these they grow rich and still have relatively large intergenerational transfer, including playing a
challenges and differences will need to be an gender gaps in education and economic pivotal role in empowering the next
important aspect of the broader responses participation, boosting women’s schooling generation of girls.
to ageing. and workforce participation may be critical to
mitigating their approaching ageing In Latin America, the additional income has
Women make up the majority of older people population challenges (e.g., in India, been shown to slow the rural-urban
because they tend to live longer than men. Indonesia and Mexico). migration that has so profoundly contributed
However, older women also tend to have to the isolation of older women. Given that
lower standards of living compared with Older individuals tend to consume more than women live longer than men and are going to
older men, due to the multiple social and they produce, so a larger share of older people join the workforce in larger numbers in many
economic disadvantages they face in their means a relatively small workforce struggling countries over time, policy-makers will also
youth. As they grow old, further complexity is under a huge burden of elderly dependency. In need to examine the impact on pension
added due to changing intergenerational developed countries, particularly those that systems, as more women will be dependent
social dynamics. This implies that to address already have an ageing population and still on them for longer times.
the challenges faced by older women – have relatively large gender gaps in economic
economic insecurity, health gaps and the participation, boosting women’s workforce
caregiving burden – and to leverage the participation could be critical to reducing the
different choices older women make with older-population-to-workforce ratio over time
their time and resources, there is a need for: (e.g., in Japan, Spain and Italy). Figure 2 shows
the old-age dependency projections for 2030
• Instituting policies and practices that
for select countries and highlights those
catch women “upstream”, before they
countries that face high dependency
get old
projections combined with low levels of
• Applying a gender lens to existing and women’s economic participation and
new measures affecting older opportunity.
populations to ensure that women are
not overlooked
• Developing specific policies, products Figure 2. Old-age dependency projections and women’s economic participation
and innovations that are designed to
focus on the needs and interests of older Median score
60
women
Access to quality education is a critical factor Japan
in women’s social and economic
Old-age dependency ratio (projections for 2030)
50
empowerment and has multiplier effects on Germany
entire families and communities.
Furthermore, removing barriers to women’s Italy
Austria Slovenia
Finland
access to economic activity is necessary for 40

Portugal Switzerland
France Canada
reaping the returns on investments in Korea Rep. Greece
Singapore Sweden
Spain
women’s education. Women’s growing United Kingdom Norway
presence in the workforce may have some United States
negative implications for their ageing parents, 30 Russian Federation
including in particular older women for the Chile Thailand

reasons outlined above. However, in the China
longer term the ability of these women, as 20
Argentina
Brazil
well as that of future generations, to secure Turkey
economic independence will be a crucial
factor in safeguarding their health, economic India
security and social status during their old 10

age.
0
0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00
Economic participation and opportunity score (0.00 - 1.00 scale)
Data from the World Economic Forum’s Global Gender Gap Index 2011 is displayed on a 0-1 scale with 0 representing inequality and 1
representing equality. The Economic Participation and Opportunity subindex includes five variables: labour force participation, estimated
earned income, wage gaps for similar work, professional and technical work positions and legislators, officials and senior managers.

Conclusion For Further Reading

Maintaining the health and well-being of the elderly population is a Daly, K. (2007) Gender Inequality, Growth and Global Ageing. Goldman Sachs, Global Economics
Paper No: 154. Available at: http://pslforum.worldbankgroup.org/docs/Kevin_Daly_Global_Ageing_
universally shared concern. Reasonable access to proper healthcare Gender_Inequality.pdf
is crucial not just for older women themselves, but also for the
households with whom they live. The United Nations and World Silverstein, M. J. & Sayre, K. (2009) The Female Economy. Harvard Business Review, September
Issue. Available at: http://hbr.org/products/R0909D/R0909Dp4.pdf
Health Organization both advocate for prevention and better
management of disabilities prevalent in older women, namely chronic Volunteers of America. (2011) Boomer Bust 2011: Still Unprepared and Unaware. Available at: http://
diseases. www.voa.org/Boomer-Bust-2011
World Health Organization. (2003) Gender, Health and Ageing. Available at: http://www.who.int/
In addition, educating family members on how to manage long-term gender/documents/en/Gender_Ageing.pdf
outpatient care for chronic illnesses needs to be incorporated into Hausmann, R., Tyson, L. & Zahidi, S. (2011) Global Gender Gap Report. World Economic Forum.
healthcare providers’ training. People are living longer in large part Available at: http://www.weforum.org/s?s=gender+gap+report
because of better medical knowledge and treatment. However, as
Annan, K.(1999) Economic and Social Council: Commission on the Status of Women Report. New
the population shifts, so too must the way medicine is practiced York: United Nations. Available at: http://www.un.org/womenwatch/daw/csw/aging.htm
around the world. And it should be practiced with an adequate
gender focus to address the feminization of the ageing population. Badiee, S. (2009) What Is Not Counted Does Not Count - The Importance of Sex-Disaggregated
Statistics for Effective Programs. World Bank. Available at: http://siteresources.worldbank.org/
INTGENDER/Resources/StatisticsNewsletterSpring09.pdf
Owning land, particularly in developing countries, is a source of
wealth and social power. Women who own land are more likely to Chen, W. & Zhao, Z. (2011) China’s Rising Sex Ratio at Birth. East Asia Forum, East Asian Bureau of
Economic Research. Available at: http://www.eastasiaforum.org/2011/06/19/china-s-rising-sex-ratio-
have households with better nutrition, support education of more
at-birth/
children, and circumvent isolation and secure economic
independence later in old age. Globally only 2% of land is owned by Central Intelligence Agency. (2011) Country Comparison: Total Fertility Rate. The World Factbook
Available at: https://www.cia.gov/library/publications/the-world-factbook/rankorder/2127rank.html
women. In the last five years, advocacy programmes in countries
such as Tajikistan, Nicaragua and Ethiopia, among others, have Gavrilov, L. A. & Heuveline, P. (2003) Aging of Population. In: Demeny, P. & McNicoll, G. (eds) The
begun to successfully influence governments to formally protect Encyclopedia of Population. USA: Mac-millan Reference
older women’s and widows’ land entitlements, and to provide HelpAge International. (2002) Gender and Ageing Briefs. London: HelpAge International. Available at:
community education on the topic. Most of these programmes are http://www.humanitarianreform.org/humanitarianreform/Portals/1/cluster%20approach%20page/
replicable and scalable; broader adoption of such successful clusters%20pages/Gender/Gender%20Toolkit%202/1-%20Gender&Ageing%20Briefs.pdf
interventions is required in other countries. AARP Global Network. (2011) Germany to Implement New Immigration Policies for Aging Population.
Available at: https://www.aarpglobalnetwork.org/netzine/Industry%20News/ProductsandServices/
Better understanding, measurement and valuation of the role of older Global%20HR%20Management%20for%2050%20plus/Pages/Germany%20to%20implement%20
new%20immigration
women as caregivers are also needed. For countries whose HIV/
AIDS prevalence rates have produced a generation of orphans, it is Haub, C. (2011) Update on India‟s Sex Ratio at Birth. Behind the Numbers: The PRB Blog on
crucial that older women who have worked only in the informal sector Population, Health, and the Environment, 9 Feb. Available at: http://prbblog.org/index.
php/2011/02/09/india-sex-ratio-at-birth/
have access to social protection in order to provide in the absence of
a biological parent. While such social protection programmes require Heisler, E. J. & Shrestha, L. B. (2009) The Changing Demographic Profile of the United States.
significant investment and administrative costs, the long-term public Congressional Research Service. Available at: http://aging.senate.gov/crs/aging4.pdf
good may outweigh the initial investment burden. Huber, B. (2005) Implementing the Madrid Plan of Action on Ageing. United Nations Working paper.
Available at: http://www.un.org/esa/population/meetings/EGMPopAge/EGMPopAge_21_RHuber.
As consumer preferences change, ageing also holds implications for pdf
the development of new products and services in the areas of Kakwani, N, Son, H. H. & Hinz, R. (2006) Poverty, Old-Age and Social Pensions in Kenya. International
healthcare, insurance, entertainment, retail, food and nutrition, Poverty Centre, United Nations Development Programme. Available at: http://www.ipc-undp.org/
technology, personal development and care. Women in general, pub/IPCWorkingPaper24.pdf
even as their consumption power has grown, are a vastly Kapuya, J. A. (2003) United Republic of Tanzania National Ageing Policy. HelpAge International,
underserved market, particularly in the areas of food, travel, fitness, Available at: http://www.tanzania.go.tz/pdf/NATIONAL%20AGEING%20POLICY%20-%20FINAL%20
apparel, beauty, financial services and health. Older women have PAPER.pdf
specific needs and preferences within these and other areas, but the Stewart, F. & Yermo, J. (2009) Pensions in Africa. Organisation of Economic Cooperation and
“empty nest”, older female demographic is generally ignored by Development, Working Paper on Insurance and Private Pensions. Available at: http://www.oecd.org/
marketers. This implies potential opportunities for business, dataoecd/41/6/42052117.pdf
particularly in developed countries, as larger numbers of educated, United Nations Global Compact. (2009) The Case for Advancing Women in the Global Marketplace
working women, with higher consumption power, go into retirement. - Snapshot of Women Worldwide: Facts and Figures. Available at: http://www.unglobalcompact.org/
docs/news_events/9.1_news_archives/2009_03_05a/women_stats.pdf
World Health Organization. (2011) Women, Ageing and Health: a Framework for Action - Focus on
Gender. Available at: http://www.who.int/en/gender
United Nations Social Policy and Development Division. (2011) The World Bank Activities and Position
on Ageing. Available at: http://social.un.org/index/Ageing/Stakeholders/StakeholdersUNSystem/
TheWorldBankActivitiesandPositiononAgeing.aspx
BBC. (2009) UK Population ‘to Rise to 71.6m’. 21 October. Available at: http://news.bbc.co.uk/2/hi/
uk_news/8318010.stm
World Health Organization. (2009) Women and Health: Today’s Evidence Tomorrow’s Agenda.
Geneva: World Health

Chapter 4 The Origins of “Ageism”

What are the origins of such prevailing negativity about ageing?
The Media’s Portrayal According to Robert N. Butler, founder of the International Longevity
Center (ILC) in New York, answers are found both in the past and the
of Ageing human psyche.
Colin Milner, Kay Van Norman, Jenifer Milner In his introduction to Ageism in America, a 2006 ILC report, Butler
writes that old age was generally valued in primitive societies. “Older
Has the media’s portrayal of ageing influenced society’s views and persons often provided knowledge, experience, and institutional
responses to population ageing? And if so, why? What messages do memory that was of adaptive – even survival – value to their societies.
the mass media send to society about the later years of life? Although nomadic groups in various parts of the world abandoned
the old and disabled when safety and security were at stake, overall
News, television, film and advertising commonly feature stereotypes older people were venerated”, he explains.
that show older adults through a lens of decline and diminished
value, emphasizing the “burdens” of growing old.1 Use of such Butler continues: “However, as the number and percentage of older
stereotypes – as well as negative language about ageing – shapes, persons, especially the frail and demented, increased, the perception
reinforces and reflects society’s attitudes and responses to growing grew that they were burdens to their families and society. It became
older and, by extension, to population ageing. widespread as societies shifted from agrarian economies, where
older men had traditionally owned the land, to industrialized
This one-sided media messaging has created a distorted view of economies, when work was no longer centred in the home and older
ageing. The result, in many cases, is low expectations of ageing2,3 persons lost authority”.8
that extend into all areas of life, including the workplace4 and
healthcare.5,6 Moreover, even with years of advance warning, These are the “the historic and economic circumstances” in which
“societal and economic structures in many industrialized economies the status of today’s older adults and attitudes toward them are
are ill-placed to cope” with an ageing population.7 grounded, Butler notes. Other key influencers include “deeply held
human concerns and fears about the vulnerability inherent in the later
years of life. Such feelings can translate into contempt and neglect”,
he adds.9
These ideas represent the building blocks of ageism, a term that

Butler introduced to the world in 1968.10 Today, more than 40 years
later, ageism still thrives, especially in Western cultures. The ILC
report defines four categories of ageism.11 These include:
Personal ageism – ideas, attitudes, beliefs and practices on the part

of individuals that are biased against persons or groups based on
their age.
Institutional ageism – missions, rules, and practices that discriminate

against individuals and/or groups because of their older age.
Intentional ageism – ideas, attitudes, rules or practices that are

carried out with the knowledge that they are biased against persons
or groups based on their older age. This category includes practices
that take advantage of the vulnerabilities of older persons.
Unintentional (or inadvertent) ageism – ideas, attitudes, rules or

practices that are carried out without the perpetrator’s awareness
that they are biased against persons or groups based on their older
age.
All four types of ageism can be found in the media and marketing
today.

Ageism in the Media Media Responses to Population Ageing

Mass media is a critical platform for communicating the meanings Researcher Julia Rozanova, now an assistant professor at Canada’s
and experiences of ageing between generations, and plays a role in University of British Columbia, published a study in 2009 in which
shaping the agenda for discussing ageing issues.12 Media portrayals she analysed newspaper, television and magazine content for
of ageing not only reflect the widespread ageism in society, but also depictions of ageing in Canada and Russia. Rozanova found that in
largely reinforce negative stereotypes. In addition, when ageing is both cultures older age groups were underrepresented, negative
depicted in a manner that appears positive, the aim is often to push portrayals far outweighed positive portrayals, and older individuals
anti-ageing messages and frame defying ageing as the only example with disabilities were virtually absent from advertising unless they
of successful ageing. were advertising assistive devices.17 This lack of representation in the
mass media may contribute to marginalizing older adults, who
For example, in May 2011, the cable news channel MSNBC reported already feel the effects of ageism and a sense of diminished worth
on a US study showing the disconnect between fashion magazines and participation in society.
and their ageing readers. “An analysis of editorial and advertising
images reveals that despite proportions of older readers ranging as Older adults notice not only how little they are represented in media
high as 23%, fashion magazines portray women over 40 sparingly, if and marketing offerings, but also how poorly. For many, these
at all,” writes LiveScience senior writer Stephanie Pappas. “Even in depictions simply do not resonate. According to market research,
magazines geared toward ageing baby boomers, the images three in four adults over 55 feel dissatisfied with marketing aimed at
collectively present a thin, youthful, wrinkle-free ideal that’s impossible them,18 and 71% say that advertising images largely do not reflect
to maintain later in life.”13 their lives.19 Results from a survey conducted for TV Land, a US cable
television channel, agree. Nearly two-thirds of baby boomers
This ideal has an impact on body image in older women, according responding to this survey said they are growing increasingly
to Denise Lewis, a University of Georgia gerontologist and author of dissatisfied with media that ignores them and they are tuning out.20
research published in the Journal of Ageing Studies.14 “It leads to
issues that have people denying ageing, so going to great lengths to In the United Kingdom, a survey found that 55% of adults over 50 feel
continue to look like that ideal of a youthful person”, Lewis explains. that businesses have little interest in older people’s consumer needs;
This view of ageing promotes the idea that age-related changes in 46% often do not feel that advertising/marketing is aimed at them;
physical appearance are highly undesirable; therefore, all means and 50% find advertising/marketing that is obviously targeting older
should be taken to erase them. people to be patronizing and stereotypical.21 Further, a report by Help
the Aged (now part of the charity Age UK) notes that 75% of
Dove, a global personal care brand, challenged those beliefs through respondents to a survey of people ages 60 and older thought that
its award-winning Campaign for Real Beauty. One advertisement and the media ignored the views of their age group.22
billboard featured a 95-year-old model and posed the question:
“Withered or Wonderful? Will society ever accept old can be Underlying all those findings is the “astonishingly neglectful”
beautiful?” Viewers were invited to log on to the campaign website treatment of older adults, “who feel ignored, unwanted and
and cast their votes. This ad proved a tremendous success, largely by dissatisfied with the negative stereotypes used to portray them in
tapping into society’s negative expectations of ageing and making advertising, which they regard as inappropriate and irrelevant”.23
people reconsider them. Further, the Campaign for Real Beauty Older people’s impressions are well founded: 90% of marketing
translated into tremendous business success for Dove, which claimed dollars are directed towards the under-50 population today, reports
a 700% rise in product sales in the United Kingdom (where the London-based marketing and advertising magazine AdMap.24 Help
marketing effort originated) and 600% in the United States within the the Aged estimates as much as 95% of advertising revenue goes to
first two months of the campaign’s launch.15 the under-35 age group.25 These figures show that the age 50-plus
market remains largely invisible to, and devalued by, marketers and
Marketers make choices every day that have an impact on how advertisers, who misunderstand and misrepresent this population.
society views ageing. Consider a campaign for Circle K convenience
stores in Atlantic Canada that uses drawings of a person in three Why is this happening? It is important to consider that advertising
stages of ageing to illustrate the sizes of “Geezerade” slushy drinks agencies are overwhelmingly staffed by employees under 50 years of
and their cost. The eldest stage, which corresponds to the largest age.26 In fact, fully 95% of employees in UK agencies are under age
and most expensive drink, is an ageing caricature: a bald, toothless, 50, with similar age structures for the advertising workforce in the
wizened old man. Aimed at engaging youngsters, this campaign European Union.27 With so few professionals over 50, is it surprising
blatantly disrespects old age. that this industry lacks insight into the needs, interests and
aspirations of older people, as well as the realities of their daily lives?
On the opposite end of the scale are the campaigns that suggest all
older adults are “super seniors”. Portrayed in the media as healthy, On the promising side, some media responses show a movement
wealthy and defying ageing, super seniors present an image of older towards more realistic views of ageing. For example, Van Selm and
adults that also distorts reality. Such stereotypes make it clear that colleagues compared how Dutch television commercials portrayed
“good” old age requires health, independence, and economic and older adults in 1993 versus 2007. They found that while older-adult
social vitality, reflecting the dominance of independence, roles had not become more prevalent, they were more diverse and
youthfulness, effectiveness and productivity as values in Western less stereotypical in 2007 than in 1993.28
societies.16
Lien and colleagues examined prime time television dramas in
“Bad” old age is characterized by illness, decline and a strain on Taiwan and found that older characters appeared less frequently and
social programmes and economies around the world. Yet, people do in less prominent roles than other adult characters, but were
not have to look a certain way, participate in extreme sports or be predominately portrayed as cognitively sound and physically healthy.
free of functional challenges to be engaged in life, resilient and However, older characters talked about age, linking it to death and
capable of setting an example of wellbeing. despondence to influence younger characters. Dominant behaviour
themes reinforced Chinese age stereotypes and traditional values.29
Too often missing from media portrayals is a balanced view of
ageing; one that reflects the challenges of getting older, while
embracing the opportunities associated with ageing.

In Germany, Kessler and colleagues examined how advertisements Recommendations

portrayed social participation of older adults. They found that only
4.5% of the characters in 656 ads were 60 years or older. However, To transform the experience of ageing and ageism in our societies,
when older adults did appear in ads, these individuals were depicted we must change the way the media and marketers portray ageing.
as socially engaged and open to new experiences.30 Negative stereotypes need to give way to realistic portrayals, so that
depictions encompass the many different experiences of ageing
Many of these more positive depictions of ageing, however, result without attaching a value judgment.
from marketers trying to reach the lucrative baby boomer market
segment with messages of eternal youth. These anti-ageing Today, the concept of ageing is expanding and evolving as the older
messages stigmatize both normal changes associated with the population demonstrates its many aspects and contributions. As
ageing process and ageing with any kind of disability or deficit. new ideas and concepts come into being, new words and meanings
emerge while other words and meanings recede and disappear.
The Impact of Media Portrayals The stage is set for language and imagery that provide a fair,
If positive portrayals of ageing promote the idea that defying ageing is accurate and balanced view of ageing. How do we encourage the
the only way to age successfully, negative stereotypes of ageing then media to acknowledge its influence over society’s conversation
prime (prepare) a person for decline, diminished resilience and the about ageism and to exert a positive influence? One way is to show
subversion of health promotion efforts. the financial benefit.
Age-based stereotypes are often internalized in childhood, long Dove’s Campaign for Real Beauty confounded stereotypes of beauty
before the information is personally relevant, so they are accepted in its advertising and reaped the rewards. Similarly, a vast market of
without critical examination. Termed “pre-mature cognitive potential customers awaits media, marketers and businesses whose
commitment” (PCC), this mindless coding leads people to accept portrayals of ageing resonate with older consumers.
beliefs unconditionally. Later, when people perceive themselves to be
This chapter shows that marketing messages are currently both
ageing, the coding acts as a self-induced prime, causing them to act
missing and missing the mark. To succeed with their outreach, the
in ways consistent with this coding and creating a self-fulfilling
marketing and media professions need new ways of relating to older
prophecy.31 For example, Martin might believe that older adults
populations. Tools to educate and support this shift are key.
cannot easily climb stairs, so he will sell his home with stairs in favour
Recommendations focused on these professions include:
of a one-level style. No longer climbing stairs at home, he finds it
more and more difficult to navigate stairs in the community. Researchers, governments, industry associations and global
Eventually, he is no longer able to climb stairs, confirming his original organizations can create a clearinghouse of media and marketing
belief. research, best practices, communications guidelines and images of
today’s older adults.
Repeated exposure to negative images and messages about ageing
confirms beliefs and entrenches negative stereotypes more deeply, The goals for this clearinghouse will be to educate media and
both consciously and subconsciously. Once people believe they marketing professionals about “real life” ageing, the diversity of older
know something, most will actively look for information consistent adults and the opportunities presented by this market; as well as to
with that belief.32 They do not have to look far. encourage these professionals both to provide effective and accurate
portrayals of ageing and to stop using negative stereotypes and
Media portrayals of ageing are predominately negative. They
language.
contribute to a culture where people are both consciously and
subconsciously primed to follow the negative ageing story. They also Media and marketing companies, including film, news, television and
affect the way older adults see themselves and the way they are publishing, can increase the prevalence and diversity of older adults
viewed and treated by society. represented in their offerings. This visibility will send a strong
message, reinforcing the fact that older adults are part of the fabric of
Dozens of studies have demonstrated how subconscious priming for
society and celebrating the value of experience.42
either positive or negative stereotypes impacts the function of older
adults. Collectively, these studies show that older individuals Governments can provide post-secondary institutions with tax
exposed to positive primes perform better on both physical and incentives to educate future media and marketing professionals
cognitive tasks than those exposed to negative primes.33,34,35 about ageism and the older population. An understanding of ageism
Negative primes had other surprising effects. They heightened and its impact will encourage professionals to recognize the
cardiovascular responses to stress, i.e., heart rate and blood damaging myths, negative stereotypes and false perceptions of
pressure, while positive primes muted these responses. Older adults ageing fuelled by this prejudice and to avoid perpetuating them.
exposed to negative primes were less likely to accept life-prolonging
interventions in hypothetical medical situations than those exposed Governments can provide incentives or tax breaks for businesses,
to positive primes.36 media and marketers to educate themselves and their customers
about healthy, active ageing. This will help them understand the
Other studies demonstrate that adults with positive self-perceptions many possibilities for individuals to lead full lives at any age.
of ageing engage in more health-promotion strategies and take
better care of themselves than those with negative perceptions of Researchers and academic agencies can take a well-rounded view
ageing.37 In addition, negative stereotypes affect an individual’s of ageing when they report about this topic. A more complete,
self-esteem, self-efficacy and resilience – all factors related to balanced approach will help temper “apocalyptic” reports of ageing,
whether older adults perceive that they have control over health which in many cases fuel media coverage, business investment and
outcomes.38,39,40 government spending on the issue.
The impact of negative views of ageing is simple, according to a Researchers and organizations can showcase companies that have
study led by Becca Levy, PhD, Yale School of Public Health. Older succeeded with the older-adult market and highlight how media and
people can literally “think” themselves into the grave 7.6 years early marketing can learn from them. Some potential avenues for sharing
by feeling “bad” about getting old.41 insights and information will include best practices, documentaries
and awards programmes.

Through mass media, negative messages about ageing are 23 Thompson, N. J. (2007) Age Myopia in Marketing: Marketers Must Adapt to the Demographics
Reality. University of Hertfordshire Business School Working Paper. Available at: https://uhra.
becoming increasingly globalized. Efforts to address their impact will herts.ac.uk/dspace/bitstream/2299/4591/1/S119.pdf
be most effective if governments and nongovernmental organizations 24 Age UK & the International Longevity Centre UK. (2010) The Golden Economy–The Consumer
share research and best practices that influence the way media and Marketplace in an Ageing Society. Research by ILC-UK for Age UK October 2010, p. 56. Available
at: http://www.ilcuk.org.uk/record.jsp?type=publication&ID=80
marketing professionals position ageing. Organizations such as the
25 Pickett, J. (2002) Marketing and Advertising to Older People. London: Help the Aged.
World Economic Forum have a role to play in bringing together
26 Thompson, N. J. (2007) Age Myopia in Marketing: Marketers Must Adapt to the Demographics
businesses, governments, media and marketers. The goal of such Reality. University of Hertfordshire Business School Working Paper. Available at: https://uhra.
interactions will be to create and synchronize global strategies that herts.ac.uk/dspace/bitstream/2299/4591/1/S119.pdf
embrace the opportunities of population ageing and better address 27 Ibid.
the challenges. It is important to recognize, however, that societies 28 Van Selm, M., Westerhof, G.J. & deVos, B. (2007) Competent and diverse. Portrayal of older adults
in Dutch television commercials ten years later. Journal of Geriatrics, 38(2), 57-65.
around the world view and respond to ageing in their own ways, and
29 Lien, S.C., Zhang, Y.B, & Hummert, M.L. (2009) Older adults in prime-time television dramas in
each needs to customize approaches to their specific culture. Taiwan: prevalence, portrayal, and communication. Journal of Cross Cultural Gerontology, 24(4),
355-72.
Conclusion 30 Kessler, E.M., Schwender C. & Bowen, C.E. (2010) The portrayal of older people’s social
participation on German prime-time TV. Journal of Gerontology B Psychological Sciences and
Social Sciences, 65B(1), 97-106.
Increased life expectancy is one of the most significant success
31 T. D. ed. (2002) Ageism, Stereotyping and Prejudice against older persons. Cambridge: MIT Press.
stories of our times with global population ageing presenting both
32 Langer, E. J. (2009) Counter Clockwise: Mindful health and the power of possibility. New York:
challenges and opportunities for society. Has the media’s negative Ballantine Books.
portrayal of ageing contributed to a slow and inadequate response to 33 Nelson, T. D. ed. (2002) Ageism, Stereotyping and Prejudice against older persons. Cambridge:
the challenges, as well as a lack of understanding of the MIT Press.
opportunities? Based on all the evidence cited above, this article 34 Langer, E. J. (2009) Counter Clockwise: Mindful health and the power of possibility, Ballantine
Books, New York.
concludes that it has.
35 Levy, B., & Leifheit-Limson, E. (2009). The Stereotype-Matching Effect: Greater Influence on
Functions When Age Stereotypes Correspond to Outcomes. Journal of Psychology and Aging,
Ultimately, if we are to manage population ageing well, we need to 24(1), 230-233.
acknowledge the impact of the media and marketers on shaping 36 Langer, E. J. (2009) Counter Clockwise: Mindful health and the power of possibility, Ballantine
perceptions of ageing, and strive to reform the way they view and Books, New York.
portray people living in this multifaceted stage of life. 37 Ibid.
38 Nelson, T. D. ed. (2002) Ageism, Stereotyping and Prejudice against older persons. Cambridge:
MIT Press.
39 Langer, E. J. (2009) Counter Clockwise: Mindful health and the power of possibility, Ballantine
Books, New York.
Endnotes 40 Fry, P. S.& Keyes, C.L.M. (2010). New Frontiers in Resilient Ageing: Life strengths and wellbeing in
late life. Cambridge: Cambridge University Press.
1 Dahmen, N, & Cozm, R. (2009) Media Takes: On Aging. International Longevity Center. Available
at: http://www.aging.org/files/public/Media.Takes.book.pdf 41 Levy, B., Slade, M., Kunkel, S. & Kasl, S.(2002) Longevity Increased by Positive Self-Perceptions of
Ageing. Journal of Personality and Social Psychology, 83(2), 261–270.
2 Langer, E. J. (2009) Counter Clockwise: Mindful health and the power of possibility. New York:
Ballantine Books. 42 Directorate General for Health and Consumer Policy. (2010) Reflections on Healthy Ageing: Health
Systems-Innovations-Consumers. European Commission. Available at: http://ec.europa.eu/
3 Sarkisian, C. A., Hays, R. D., & Mangione, C. M. (2002). Do older adults expect to age health/ageing/docs/ev_20101011_reflections_en.pdf
successfully? The association between expectations regarding aging and beliefs regarding
healthcare seeking among older adults. Journal of the American Geriatrics Society, 50(11),
1837-843.
4 Fry, P.S. & Keyes, C.L.M. (2010) New Frontiers in Resilient Aging: Life strengths and wellbeing in
late life. Cambridge: Cambridge University Press.
5 Lachs, M. (2010) Treat Me, Not my Age: A doctor’s guide to getting the best care as you or a loved
one gets older. New York: Penguin Group.
6 Jonson, H. & Larsson, A. (2009) The exclusion of older people in disability activism and policies: A
case of inadvertent ageism? Journal of ageing Studies, 23(1), 69–77.
7 Woodward, S., Peridan, R. & Singleton, M. (2010) World Economic Forum Longevity Roundtable.
Swiss Re, Centre for Global Dialogue. Available at: http://cgd.swissre.com/global_dialogue/
topics/ageing_longevity/World_Economic_Forum_Longevity_Roundtable.html
8 Anti-Ageism Task Force. (2006) Ageism in America. New York: International Longevity Center-USA.
9 Ibid.
10 Dahmen, N., & Cozm, R. (2009) Media Takes: On Aging. International Longevity Center-USA.
Available at: http://www.aging.org/files/public/Media.Takes.book.pdf
11 Anti-Ageism Task Force. (2006) Ageism in America. New York: International Longevity
Center-USA.
12 Rozanova, J. (2010) Discourse of successful ageing in The Globe & Mail: Insights from critical
gerontology. Journal of ageing Studies, 24(4), 213-222.
13 Pappas, S. (2011) Despite ageing readership, magazines feature more young women. Some
experts wonder if the trend threatens older women’s sexuality, self-confidence. MSNBC, June 12.
Available at: http://www.msnbc.msn.com/id/43360848/ns/health-skin_and_beauty/t/
despite-aging-readership-magazines-feature-more-young-women/
14 Lewis, D. C., Medvedev, K. & Seponski, D. M. (2011) Awakening to the desires of older women:
Deconstructing ageism within fashion magazines. Journal of ageing Studies, 25(2), 101-109.
15 Brodbeck, M. & Evans, E. (2007) Campaign for Real Beauty Case Study. Public Relations
Problems and Cases Blog, Pennsylvania State University, March 21. Available at: http://
psucomm473.blogspot.com/2007_03_01_archive.html
16 Rozanova, J. (2010) Discourse of successful ageing in The Globe & Mail: Insights from critical
gerontology. Journal of ageing Studies, 24(4), 213-222.
17 Ibid.
18 McCarthy, M. Some consumers want ads for a mature audience. USA Today, 19 November 2002.
Available at: http://www.usatoday.com/money/advertising/2002-11-18-mature2_x.htm
20 Age Wave. (2006) TV Land’s New Generation Gap Study. Available at: http://www.agewave.com/
research/landmark_tvlandGap.php
21 Age UK. (2009). “Youth-obsessed” UK business ignoring £250 bn market. 28 August. Available at:
http://www.ageuk.org.uk/latest-press/archive/youth-obsessed-uk-business-ignoring-250bn-market/

Chapter 5 The Most Important Public Health Problem of the 21st Century
Indeed, global ageing creates what may be the most important
Ageing and Intergenerational public health problem of the 21st century. Health systems in many
developing countries are not prepared to meet the burden of chronic
Equity disease and disability that ageing populations bring with them.4 Few
systems, even in developed countries, are prepared for the numbers
Norman Daniels of frail elderly who will need special living quarters and social
supports, let alone nursing homes, when their needs make home
Although some countries still have high birth rates, many others, in care inadequate.5
most parts of the world, are ageing rapidly. In the United States there
will be more people over 80 in 2040 than there are preschoolers,1 The increased costs of chronic disease are difficult to bear in
though this might be dismissed as a special effect of the post-World developed countries, even as we hope that compression of morbidity
War II US baby boom. The ageing of society elsewhere cannot be so reduces this burden,6 but in developing ones they threaten resource
easily dismissed. Italy, Spain and Japan have fertility rates far below allocation to public health and preventive measures aimed at ongoing
what is needed to reproduce a population. In fact, all European G7 infectious disease problems. Nor are broader social systems in either
countries are below that level. By 2050, half of continental Europe will developed or developing countries prepared for the shifting
be 49 or older.2 population needs that come with societal ageing – income support
for a large population of retirees, special housing and social care
The ageing of society is also significant in Latin America and dramatic needs, and new demands for adult education. At the same time, the
in Asia. By 2050, there will be 332 million Chinese 65 years or over, forces of globalization that have led to massive urbanization and
equivalent to the world’s elderly population in 1990.3 Such societal migration have disrupted older forms of social support for the elderly
ageing is the result of successful policies and social trends that have (see Chapter 19 of this book).
reduced both fertility rates and mortality rates. But success often
creates new problems or sharpens old ones. Thus, with global ageing comes a sharpening of the problem of
intergenerational equity, both in developed and developing countries.
Many developed countries have resource-transfer schemes that
provide support for their elderly populations, but with shrinking
working populations, these schemes face resource constraints. In
the United States and Europe, for example, the current focus on
deficit reduction has put great pressure on existing pension plans for
millions of workers, and threatens national social security and
healthcare schemes.7 The lament in many developed countries is
that they can no longer afford transfers to the elderly that were part of
a social contract over many decades. In effect, existing solutions to
the problem of equity across age groups are threatened by changing
demographics.
What is worse, most ageing developing countries lack such transfer

schemes and must face the emergence of significant elderly
populations without them. Their lament is that they are growing old
before they are rich enough to address the needs of the elderly in the
ways that developed systems have, at least for several decades.
They also lament that the family structures that had provided support
for elderly people are changing with industrialization and migration in
global labour markets, and there is nothing in place to replace them.
The Chinese attempt to mandate filial support for parents in a 1996

law cannot solve the problem, known as the 4-2-1 problem in China:
four grandparents, two parents, one child.8 People cannot be
required to do what cannot be done. In the US, nearly one fourth of
all the elderly in 1989 had no children and another 20% had only one
child; with China’s one child policy,9 even more Chinese elderly may
have no children or at most one.
These problems of intergenerational equity are the focus of this

paper. Specifically, how should we think about equity across
adjacent (as opposed to distant) generations? If the old and the
young in a population are competing for resources, how should we
think about their competing needs? What is fair treatment of different
age groups? Is different treatment by age ever justifiable? If so,
when? Or is differential treatment by age always an example of “age
bias” we should avoid as a matter of justice? How should we think
about the division of responsibility between the state and families?
Are there ways to better engage families in meeting the needs of the
elderly?10,11

Focusing this chapter on the problem of intergenerational equity The Prudential Lifespan Account of the Age Group Problem
means not addressing other important ethical issues facing ageing
societies. Much bioethics literature, for example, discusses decision- It is easy to be misled by an analogy between age discrimination and
making by and on behalf of cognitively impaired elderly12 and the race or gender discrimination. Indeed, anti-age discrimination
challenging topic of end-of-life care.13 More broadly, gerontological legislation in the United States was modeled on anti-race and
literature has focused ethical concern on the difficulties of -gender discrimination and seemed to imply that any differential
constructing work and life patterns that address the non-medical treatment of people by age was problematic.18,19
needs of an elderly population.14 The analogy is problematic despite the fact that there are clear
examples of age discrimination that look very much like race or
Two Problems of Intergenerational Equity gender bias. If, however, we treat people differently by gender or
The term “generation” is systematically ambiguous. It can refer to age race, we create inequalities between persons in liberty, income,
groups, as in the suggestion that there is often tension, if not a war, wealth, opportunity or powers – or health – that are ethically
between the young and the old. And it can refer to birth cohorts, as in problematic. But if we treat people differently at different ages, we do
Tom Brokaw’s labeling of those Americans who grew up in the Great not create inequalities across persons, provided the same rules for
Depression and went on to fight in World War II as “The Greatest different treatment apply across their lifespan. The point is the banal
Generation”.15 Because age groups do not age, but birth cohorts do, one that we all age, or hope to, although we do not change race or
over time different birth cohorts successively occupy the same age gender (with some exceptions). This changes the nature of the
group. A birth cohort has a distinct social history, but age groups distributive problem.
need not; when they do, it is only because birth cohorts comprising
Indeed, we may make people’s lives go better if we do treat them
that age group at different times have a comparable social history.
differently at different ages and do so systematically over their
Age groups and birth cohorts have different criteria of individuation
lifespans. For example, we may charge people an “actuarially unfair”
and are therefore distinct concepts.16
insurance premium or tax for their healthcare when they are younger
These distinct concepts give rise to distinct problems of equity. The and healthier workers, and charge them much less when they are
general problem of age bias – favouring the old over the young or older and less healthy retirees. Such a way of saving resources can
vice versa – is a problem of fairness to age groups. Making one birth improve people’s lives as a whole. It is prudent for them to construct
cohort contribute more and get less than another cohort passing a health plan that meets their needs over their lifespan, even if it is
through a social security system is an issue of fairness between actuarially unfair during any slice of time. Each person is then treated
cohorts. Ideally, we want to design institutions that solve both the same way over a whole life. They pay for more healthcare than
problems together. they receive early in life when their healthcare needs are lower, but
they receive more services than they pay for when they need them
Let us suppose that fair treatment of different birth cohorts involves more later in life.
giving each birth cohort roughly equal benefit ratios when they pass
through institutions that aim to solve the age group equity problem.17 The simplifying assumption that we all age ignores the inequality in
That may mean adjusting the contributions and benefits of groups longevity across persons, which can create some inequity across
over time. For example, if we know that a large cohort, like the US groups that systematically differ in lifespan. But the scheme abstracts
baby boom, will retire over a certain period, we may have to build up from those differences and aims to treat people equally, even if they
a cushion of contributions before it retires that will suffice to provide it are treated differently at different ages. The scheme also abstracts
social security benefits when it stops contributing to the transfer from the behaviours that arguably impact our health as we age.
scheme (as the 1983 reform of the US social security system aimed Attention must be paid in designing institutions so that these
to provide). abstractions and simplifications, including the assumption that rules
remain stable over a lifespan, do not lead to serious inequities.
Of course this solution works only if the bulge is temporary and we
have a way to even out benefit ratios over time. In any case, the To build on this claim that the prudent allocation of a resource over
solution abstracts from other historical contingencies,. For example, the lifespan can serve as a model for fair treatment of age groups, we
the economic climate facing the birth cohorts of working age in the need to make some further assumptions that assure us of
United States during the Great Depression clearly affected their impartiality. Rather than making assumptions about the reasoning of
ability to contribute monetarily to cross-cohort schemes; but it did fully informed individuals – the traditional approach of economic
not undermine their political contribution to securing greater equity agents deliberating about prudent choices – we need to blunt the
and prosperity for subsequent cohorts. bias that might result from people knowing how old they already are.
Imagine, then, people deliberating about the tradeoffs they might be
Although it may be politically hard to adjust benefit ratios and thus to willing to make in healthcare (or education, or some other good) over
solve the problem of equity between birth cohorts, the conceptually a lifespan, provided they assume they will live through each stage of
harder problem is the age-group problem. What is a fair allocation of the life.20
resources to different age groups with different needs?
Healthcare we give to ourselves when we have a cancer late in life will
then involve a tradeoff with healthcare we give to our mothers
prenatally or to ourselves in childhood, assuming we have a lifetime
budget for healthcare. Of course, prevention in early, middle and late
years can lead to a healthier life later, so we have to know what the
effects of tradeoffs really are. If we want to improve our chances of
living a normal lifespan by investing in preventive care early in our
lives, we have to be willing to trade away some care we might give
ourselves late in life.

The point is to think about our needs at each stage of life, while Further Objections
assuming that we have some constraint on resources devoted to
healthcare (or to health policy more generally). The tradeoffs that we Even if we can forgive the Prudential Lifespan Account for its
would accept across stages of our lives because we think they abstractness and its obvious departures from real world conditions, it
improve our lives will then count as fair treatment. Prudence in this faces some further objections. For one thing, it seems to provide an
way is a rough guide to fairness across age groups, assuming integrated solution to the age-group and birth-cohort problems only
(contrary to fact) that we have equitable lifetime shares of various under some conditions – an expanding or stable population, with at
goods. worse temporary population bulges. It does not work as well under
conditions when there is a shrinking population.21 Unless a shrinking
Admittedly, this is a very abstract way to think about equity across population can steadily increase its productivity, it will be unable to
age groups. In its defense, it is an abstraction that is motivated by the provide rough equality in benefit ratios to successive cohorts. Yet
difficulty of getting one age group to see things from the perspective another objection is political. As cohorts age and become politically
of another age group. It tries to substitute the view that we age over more powerful, they may modify the rules to serve themselves and
the lifespan, and so we should think about what makes life as a so undermine the assumption that the approach can tell us how to
whole better for us rather than thinking about “us” now versus “them” construct a stable and fair solution to the age-group problem.22
now. These objections point to potential limits to the use of the account.
But the abstraction is unrealistic in other ways. Many countries do not There are, furthermore, some deeper issues that point to objections
have a global budget for expenditures on health, and so the very to the use of the approach. One of these is ethical: the Prudential
thought of designing lifelong packages of health benefits may seem Lifespan Account allows us to ration certain services if doing so is
completely unrealistic. And, of course, we not only know how old we prudent, and this may allow rationing of lifesaving services purely by
are, but we also know that our lifetime shares of various goods are age under some conditions of scarcity.
not really equitable. Nevertheless, even though prudence is not, in
general, a good guide to thinking about fairness across persons, it For example, suppose a lottery for scarce organs that allowed all age
may give some guidance to thinking about the age group problem. groups to compete on equal terms was judged less prudent than a
(This chapter will return to a further complaint about prudence.) lottery that excluded people older than normal life expectancy (the
latter would increase a winner’s chances of living to a normal life
The appeal to prudence is only a heuristic for thinking about a hard expectancy compared to the former; this is judged prudent). Some
problem. It may mislead us when some of its assumptions are not people find such rationing purely by age ethically unacceptable, so
realistic, but it may also give us some insight into hard questions. For this implication of the Prudential Lifespan Account makes it ethically
example, there may be services such as day-care centers for the problematic.23
elderly that benefit us at various stages of life – when we are adult
children who need to work while not leaving our elderly parents But if pure age rationing is never acceptable because we must never
uncared for, and later when we are those elderly parents. The appeal treat people differently at different stages of their lives, then we may
to prudence may help us think about revising old patterns. If our lives have to overlook the benefits that may come from differential
are much longer than they typically used to be, and if job structures treatment, and that stance would need justification. Others hold a
are less stable, then maybe we need more adult education than has version of a “fair innings” view that gives a more general priority to the
been traditionally provided. young over the old for lifesaving efforts.24,25,26 For them, the
Prudential Lifespan Account is not systematically age-biased
enough.
One further objection to the Prudential Lifespan Account is that

reasonable people will disagree about what counts as prudent, just
as they do about what counts as fair.27 Ordinarily, this creates no
problem for appeals to prudence, because we generally think of
prudence as working within a particular life. If different people have
different preferences, then what makes each of their lives go best will
differ, given their preferences and some lifetime share of resources.
The Prudential Lifespan Account, however, aims for a shared social

solution to a problem of prudent allocation; for example, one that tells
us what allocation of healthcare resources over a lifespan makes
“our” lives go better. The problem is that we may after all disagree
about that, and yet we need a socially acceptable and shared
solution to the issue of what we owe each other over the lifespan.

Some might think that maximizing life expectancy is what a prudent Conclusion
allocation requires. Others may think their life goes better (is more
prudent) if it is shorter but has other qualities instead. So the The Prudential Lifespan Account suffers from abstractness,
objection is that we cannot simply assume there is full agreement simplifying assumptions that idealize it, and from some unavoidable
about what counts as prudent. Specifically, although maximization of complexity. Nevertheless, it has important strengths. Three are worth
some quantity, such as life expectancy or welfare, is what makes our noting.
formal models of prudence manageable, that may not reflect a more First, we cannot arrive at a just or fair policy that aims to be equitable
nuanced account of what is prudent. to all age groups and birth cohorts unless we adopt a longitudinal
This objection has force. One response to it would be to make the view. Such a view makes us think about needs and contributions
Prudential Lifespan Account more complex by adding to it a fair, people make to a common goal over a lifespan. In effect, this pits the
deliberative process for resolving disagreements about what counts search for just policy against an important political tendency. Politics
as prudent. Arguably, such a form of procedural justice is already tends to root decisions in the bargains people can make at a
needed to resolve pervasive disagreements about what counts as a moment when they act as individuals with very specific needs and
fair allocation across persons. Arriving at a social judgment about interests.
prudent allocation thus turns out not to be as simple a task as it Just policy must have a long-term, longitudinal view, even if politics is
might have seemed, but it is no more complex than other things we embedded in the demands people make at a moment. Because of
have to do in order to make decisions that are both legitimate and this tension, searching for a just policy involves needed criticism of
fair. political forces, even as politics constrains the formation of policy.
The message, however, is clear. A longitudinal perspective – some
development of the Prudential Lifespan Account, perhaps – is
needed to secure equity across generations.
A second strength of the approach is that it focuses attention on a

common problem: fair distribution over the lifespan. In this way, it
reminds us that different cohorts and age groups must cooperate to
solve that common problem. All have a common stake in such a
policy.28 Such cooperation, then, means sharing risks across cohorts
– risks of volatility in the economy, of demographic shifts in cohort
size, and of tension with the political forces of the moment.
The alternative, namely trying to put each cohort on its own

economic and social footing -- sometimes seen as a virtue of
privatized savings schemes rather than inter-cohort social compacts
about transfers -- only appears to “solve” the problem of equity
across cohorts. In fact, it substitutes the vagaries of good and bad
fortune – good timing in earnings and retirement – for a goal of fair
treatment, which involves some risk sharing. The idea is to insure
ourselves against the bad fortune of being in the wrong cohort at the
wrong time. Such insurance is by design redistributive, but that is
what fair treatment of age groups and birth cohorts means. The
Prudential Lifespan Account thus affirms that fair treatment of all
groups over time requires a social contract or compact across
cohorts.
A third strength of the approach is the way in which it forces us to

think more broadly about both needs we have and contributions we
can make across the lifespan. It helps us see that ageing societies,
for example, may have health needs not encountered in younger
societies. Compression of morbidity may make this less demanding
over time, but the elderly also have potential for great social
contributions that cannot be achieved if institutions and practices
block their delivery.
An important point of much of the gerontological literature is that our

institutions – job structures, career incentives and education patterns
– can be modified to improve the contribution that older people make
to our social life and, at the same time, improve the adaptability of
younger cohorts to changing life plans. In many rural, agricultural
settings, contributions from the elderly were possible that are difficult
in industrialized settings, at least with standard job structures.
Finally, in many earlier societies, the elderly provided a kind of social

wisdom aimed at the common good. In our societies, we have
fragmented populations into advocacy groups for narrower interests,
such as the elderly. The Prudential Lifespan Account has the virtue of
aiming to unify goals across the lifespan. That perspective may help
undercut the advocacy by vested interests that is so much part of our
shortened time perspective in policy.

Endnotes
1 Peterson, P. (1999) Gray Dawn: How the Coming Age Wave Will Transform America—and the
World. New York: Three Rivers Press.
2 Hewitt, P.S., et al. (2002) Meeting the Challenge of Global Aging. Center for Strategic and
International Studies, Commission on Global Aging. Washington, DC: CSIS.
3 Jackson, R. & Howe, N. (1999) Global Aging: The Challenge of the New Millennium. Center for
Strategic and International Studies, Commission on Global Aging and Watson Wyatt Worldwide.
Available at: http://csis.org/files/media/csis/pubs/globalaging.pdf
4 World Health Organization. 2011. Older People and Primary Health Care (PHC). Available at http://
www.who.int/ageing/primary_health_care/en/index.html
5 Marcoux, A. (2001) Population ageing in developing societies: how urgent are the issues?
Sustainable Development Dept., Food and Agriculture Organization of the United Nations.
Available at: http://www.fao.org/sd/2001/PE0403a_en.htm
6 Bloom, D.E., et al. (2011) The Global Economic Burden of Noncommunicable Disease. Geneva:
World Economic Forum.
7 Whitehouse, D. (2009) Pensions and the Crisis: How should retirement-income systems respond
to financial and economic pressures? Organisation for Economic Co-operation and Development.
Available at: http://www.oecd.org/dataoecd/10/26/43060101.pdf
8 Kaneda, T. (2006) China’s Concern Over Population Ageing and Health. Population Reference
Bureau. Available at: http://www.prb.org/Articles/2006/
ChinasConcernOverPopulationAgingandHealth.aspx
9 Kane, P. & Choi, C.Y. (1999) China’s one child family policy. British Medical Journal, 319, 992-994.
10 Daniels, N. (1988) Am I My Parents’ Keeper? An Essay on Justice between the Young and the
Old. New York: Oxford University Press.
11 Daniels, N. (1985) Just Health Care. Cambridge: Cambridge University Press.
12 Buchanan, A.E. & Brock, D.W. (1990) Deciding for Others: The Ethics of Surrogate Decision
Making (Studies in Philosophy and Health Policy). Cambridge: Cambridge University Press.
13 Lynn, J. & Harrold, J. (2011) Handbook for Mortals: Guidance for People Facing Serious Illness.
2nd ed. New York: Oxford University Press.
14 Butler, R.N. (2008) The Longevity Revolution: The Benefits and Challenges of Living a Long Life.
Philadelphia: Public Affairs, Perseus Book Group.
15 Brokaw, T. (1998) The Greatest Generation. New York: Random House.
17 Ibid.
18 Ibid.
19 Daniels, N. (2008) Justice Between Adjacent Generations: Further Thoughts. Journal of Political
Philosophy, 16(4), 475-94.
21 Daniels, N. (1985) Just Health Care. Cambridge: Cambridge University Press. Ch. 6.
22 Thomson, D. (1989) The Welfare State and Generational Conflicts: Winners and Losers. In P.
Johnson, C. Conrad, & D. Thomson. (1989) Workers versus Pensioners: Intergenerational Justice
in an ageing World. Manchester: Manchester University Press. Ch. 3.
23 Binstock, R. H. (2005) Scapegoating the Aged: Intergenerational Equity and Age-Based Health
Care Rationing. In J. Oberlander, et al. (2005) The Social Medicine Reader. Durham: Duke
University Press. Ch. 9.
24 Williams, A. (1997) Intergenerational equity: An exploration of the fair innings argument. Health
Economics, 6(2), 117-32.
25 Kamm, F. (1993) Morality, Mortality, Vol. 1: Death and Whom to Save From It (Oxford Ethics). New
York: Oxford University Press.
26 Brock, D. (1989) Review: Justice, Health Care, and the Elderly. Journal of Philosophy and Public
Affairs, 18(3), 297-312.
27 Daniels, N. (2008) Justice Between Adjacent Generations: Further Thoughts. Journal of Political
Philosophy 16(4), 475-94.
28 Kingson, E.R. (1986) The common stake: The interdependence of generations. Ann Arbor:
University of Michigan Press.

II. Investing in
Ourselves: How to
release social
capital

II. Investing in Ourselves: How to release social capital
Chapter 6 Workforce Size and Quality

When it comes to economic prosperity, the size and quality of the
Population Ageing: workforce are critical. Yet as people pass through their 50s and
beyond, their likelihood of participating in the labour force tends to
Macro Challenges and decrease. The stock of assets could also fall as the elderly
increasingly rely on their savings – what is known as “dissaving” – to
finance spending. This combination raises concerns that the steeply
Policy Responses ageing countries will experience slower economic growth,1 and for
some, even an economic shrinkage.
David E. Bloom, Axel Börsch-Supan, Patrick McGee and Atsushi
Seike However, a recent study argues that such worries are overblown.2 It
is true that the global labour force participation rate (LFPR) – the ratio
The world’s population is growing older, leading us into uncharted of the global labour force to the population aged 15 and over – has
demographic waters. There will be higher absolute numbers of been declining since 1960 and is expected to fall another 4.4
elderly people, a larger share of elderly in the overall population, percentage points from 2005 to 2050 (Table 1). Part of this change
longer healthy life expectancies and relatively smaller numbers of can be attributed to population ageing. But because of falling fertility
working-age people. These trends, some of which are amplified by rates, especially in developing countries, the labour force as a share
declining fertility rates, are affecting nearly every country. At the of total population (LFTP) has been increasing and is expected to rise
global level, the number of those over age 60 is projected by the by about 1.9 percentage points from 2005 to 2050. Moreover, the
United Nations Population Division to double from just under 800 actual increase might even be greater, given that this projection does
million today, representing 11% of world population, to just over 2 not account for the likely boost of lower fertility to female labour force
billion in 2050, representing 22% of world population. participation.3
There are alarmist views, both popular and serious, being voiced that
an ageing population will spell trouble for business and economic Table 1: Labour force worries may be overblown
performance. But is this the case? Our research suggests that the
economic consequences are not likely to be overwhelming for
(Global labour force: 1960, 2005, and 2050, in per cent)
several reasons:
1960 Actual 2005 Actual 2050 Projected
• The number of young people as a share of the total population LFPR (labour force/pop 15+) 67.4 65.8 61.4
will be declining, especially in developing countries, a
LFTP (labour force/total pop) 42.3 47.1 49.0
development that will tend to counterbalance the movement of
large cohorts of working-age people into their older years. This
Source: Bloom, Canning, and Fink (2010).
trend will mitigate a decline in the working-age share of the
population. Note: The projections assume that each country’s age and gender labour force rates in 2005 remain
constant and apply them to projected demographics in 2050.
• As large portions of the older population become healthier,
some people – especially those not doing manual labour – will
be able to work until later in life.
The key point is that the increase in elderly dependents will be more
• If current trends continue, women will participate in the labour than offset by a decline in youth dependents. And this offset
force in greater proportions. suggests that population ageing does not pose an imminent
economic crisis for the world. Thus, one of the most widely cited
• Markets for goods, services and labour are likely to adjust fears about population ageing – that there will be a crushing rise in
naturally to changes brought about by an evolving age profile; elderly dependency unless the labour force participation of the
for example, with a greater substitution of capital for labour and elderly drastically increases – appears to be unfounded for the world
with more development and use of labour-saving technologies. as a whole, notwithstanding steep rises in particular countries such
as Italy and Japan.
The bottom line is that the challenges raised by an ageing population
are formidable, but not insurmountable. Collectively, we can affect For Organisation for Economic Co-operation and Development
the outcome. The key will be adaptation on all levels: individual, (OECD) countries that already have low fertility rates, such as
organizational, and societal. This chapter explores some potentially Germany, labour force participation rates at old age are also typically
useful responses from governments and businesses. low. Ironically, such low participation rates provide a chance to
counter the negative economic effects of population ageing. This is
Population ageing poses many challenges for the operation and because they leave considerable scope to increase a population’s
financial integrity of healthcare and pension systems, and the total labour force participation by taking steps to encourage people
wellbeing of the elderly. It has also sparked concern about the pace to retire later.4 Indeed, labour force participation among the elderly
of future economic growth. has increased recently in many OECD countries, including Japan.

Chronic Diseases Pensions

Population ageing also signals the advent of a tidal wave of chronic Population ageing also raises questions about the viability of various
diseases (non-communicable diseases, or NCDs), which are types of pension systems. Publicly funded pay-as-you-go (PAYG)
currently responsible for roughly 60% of all deaths and nearly half of pension systems face serious issues, as the number of beneficiaries
the loss of actual and effective life years owing to disability and will increase while the number of contributors will decline. Fully
death.5 They strike a wide segment of the global population, from funded systems, which lie at the other end of the spectrum of
high-income to low-income countries, and from young to old. The pension options, are not necessarily a panacea because they need a
most important ones are cardiovascular disease, cancer, chronic long time before they can deliver substantial pensions. For the baby
respiratory disease, diabetes and mental health conditions (including boomers who have not saved so far, it is simply too late to
Alzheimer’s). Many of the leading chronic diseases share four accumulate sufficient funds. When such systems are voluntary, they
modifiable risk factors – tobacco use, physical inactivity, unhealthy suffer from procrastination; at the same time, mandatory funded
diets and the harmful use of alcohol – and one non-modifiable risk systems can be prone to vexing issues of governance, especially
factor, which is age. because there are so many options for fund management and the
returns can be highly uncertain. A mix of PAYG and fully funded
Especially concerning is the fact that many people living with chronic systems may be the solution to minimize risk.
diseases are undiagnosed, which often results in later and more
costly treatment. Treatment and care costs tend to be relatively high Some countries, such as Germany and Sweden, have successfully
for chronic diseases, with the prospect of even greater costs as solved their pension problems by effectively converting their defined
expensive new medical technologies are introduced and access to benefit systems into a special form of defined contribution systems,
public healthcare becomes increasingly universal. To counterbalance where actual pensions depend on the ratio of workers to retirees,
these cost increases, expect to see a greater emphasis on disease augmented by a compensating funded system.9 The Swedish system
prevention, including the spread of workplace wellness programmes. relies explicitly on “national defined contribution” accounts. In
Business ingenuity and effort may also be expected to usher in a Germany, the defined benefit formula was amended by a
wave of more healthful products and services. “sustainability factor” that reduces the annual pension increase in
proportion to population ageing. Other countries have mimicked both
Although worries about the economic impact of chronic diseases are types of pension reform. Switzerland has taken the unusual step of
only beginning to register on the radar of economy policy-makers, such allowing a pension fund to be established for a child when he or she is
concerns are front and centre for business leaders. In the World born. Efforts to raise the statutory retirement age are also under way
Economic Forum’s 2010 Executive Opinion Survey, which feeds into its in most developed countries, although they are often highly contested
Global Competitiveness Report, business leaders were asked about and accompanied by popular protests.
the expected effects of chronic diseases on business performance in
the next five years. The survey mentioned possible impacts stemming
from death, disability, medical and funeral expenses, productivity and
absenteeism, recruitment and training expenses, and revenues. The
results were striking. Over one-half of respondents expect that chronic
diseases, taken together, will have a serious, somewhat serious, or
moderate impact on their company, and nearly one-third expect the
impact to be more than moderate. These chronic disease concerns are
markedly higher than those about the communicable diseases of HIV/
AIDS, malaria and tuberculosis.
Asset Prices
Another concern centres on the potential effect of population ageing
on asset prices. Specifically, some observers warn that asset prices
will fall as the elderly sell off their assets, known as an asset
meltdown. This type of worry is not new. Some analysts predicted
asset meltdowns in housing markets because of decreased demand
from ageing members of the post-World War II baby boom
generation.6 Fortunately, this and other dire predictions have proven
overly pessimistic. Moreover, mitigating factors such as the potential
for policy change suggest that there will be a rather moderate effect
on asset prices.7,8

Conclusion As for pension reform, which is under way in many countries, it

usually takes place “in instalments”, which is a slow process of many
Public policy-makers and the business community are just beginning small steps, and typically with many dimensions: a reduction in
to acknowledge the coming acceleration of population ageing. Thus benefits, an increase in contributions of the PAYG part of the pension
far, there has been little need for rapid policy changes because system, an expansion of individual accounts and a gradual change in
population ageing has been slow and large baby-boom generations the statutory retirement age. Policy-makers should keep in mind that
have been fuelling business activity and economic growth. But the well-designed reforms affect the entire system and do not create
need for policy adaptations will become more important in the face of loopholes, such as through disability or unemployment insurance,
baby boomers retiring, labour force growth slowing, and the costs of that can discourage work. In addition, index schemes, such as
pension and healthcare systems rising, especially in Europe, North linking benefits to the dependency ratio and retirement age to life
America and Japan. Businesses will soon have little choice but to be expectancy, can reduce political opposition.
more attentive to the needs and capacities of older employees. Or to
put it on a more positive note, their ability to adapt could become a Financing healthcare systems is extremely problematic in many
source of competitive advantage. countries. For example, in the United States, where healthcare
coverage is still not universal, there is considerable proclivity to use
What can be done on an economy-wide scale? Responses to longer expensive new medical technology, and third-party payers account
lifespans will require a series of reforms to public policy and business for a significant portion of healthcare spending. New financing
practices that will supplement the effects of changes in markets for systems will have to account for the greater healthcare needs of the
goods, services and labour, which are likely to take place elderly, especially in light of their increased numbers and older ages,
automatically. and the continued development of expensive new medical
Public Policy technologies.
Allowing people more freedom of choice regarding the timing of Given that NCDs are responsible for such a huge slice of healthcare,
retirement is a good starting point. While life expectancy in 43 selected it is fortunate that there appear to be many options available to
countries, most of which are developed, rose an average of nine years prevent and control these diseases. The World Health Organization
from 1965 to 2005, the average legal retirement age rose by only about has identified a set of interventions it calls “best buys”.12 These
six months.10 Various industrial countries have recently raised the include higher taxes and advertising bans on tobacco and alcohol,
normal legal retirement age. But while these changes have been reduced salt intake, enhanced screening and treatment before
generally accepted in some countries (such as Germany and the United diseases progress and public information campaigns. In addition, the
States), they have led to significant social conflict in others (such as Forum’s 2010 Executive Opinion Survey shows that businesses in
France), indicating that further moves in this direction are possible, but both high- and low-income countries are already carrying out an
may not be easy. array of programmes related to smoking, alcohol, exercise, stress
reduction and physical health.
How can extended working years be encouraged? One way is to
remove incentives to retire between the ages of 60 and 65. Another is One possible option for both sending and receiving countries is
to adjust tax and benefit policies with the aim of encouraging and migration of working-age people to ageing societies. However,
capturing the benefits of prolonged careers. unless people work longer, huge numbers of immigrants would be
necessary to compensate for population ageing,13 and such numbers
In Japan, the government has been wrestling with these issues
would likely face enormous political and social opposition by the
because its public pension system still uses an earnings test, which
electorates in Europe, and to a lesser extent in the United States.
encourages early retirement and part-time work and thus deprives
Immigration is therefore unlikely to be a significant contributor to the
the country of a capable and willing older workforce. Compounding
problems posed by population ageing.
this problem is the predominance of mandatory retirement practices,
typically at age 60. In addition, Japanese workers over age 45 Japan is an interesting case in this regard. Despite its long history of
seeking new employment are often deterred by maximum hiring anti-immigrant feelings, a consensus has now developed in favour of
ages. However, workers in general still have a strong motivation to greater immigration of skilled foreign workers. Indeed, the number of
continue working after age 60, according to a survey by Japan’s professional workers from abroad has been rising, though the pace
Ministry of Health, Labour and Welfare. has been a bit slower than expected. Recently, Japanese companies
have started increasing the recruitment of international students from
To turn the situation around,11 the Japanese government has started
both foreign and Japanese universities.
to raise the pension-eligible age from 60 to 65 and to require
employers to extend employment to age 65. These steps have had a However, the case for unskilled foreign workers is more difficult
significant impact, with the labour force participation rate for men because of worries about the effect on domestic workers’ wages
aged 60 to 64 increasing from 71% in 2006 to 77% in 2009 – and the danger of creating a dual labour market—and thus eventually
considerably higher than in Australia, Canada and the United States. a dual social structure, with the tensions that implies. It may be
possible to overcome these problems by paying careful attention to
In most developed countries, retirement itself is a complex process,
the extent and timing of labour market openings, enforcing labour
often more of a transition, involving early retirement, phased or partial
standards (including minimum wages), ensuring that social security
retirement, or “unretirement”. Changes in the legal retirement age will
applies to all workers and providing subsidies or other incentives for
interact with this process in complicated ways. In most developing
employers to adequately train foreign workers and avoid trapping
countries, by contrast, the legal retirement age applies in practice to
them at the bottom of the labour market.
only a small portion of the labour force, and pensions are relatively
uncommon. People very often work until they can no longer do so
and are then dependent on their children or remittances from
abroad.

Business Practices Endnotes

To adapt and possibly benefit from an increasingly aged world, 1 Börsch-Supan, A., & Ludwig, A. (2009) Ageing, Asset Markets, and Asset Returns: A View from
Europe to Asia. Asian Economic Policy Review, 4, 69–92.
businesses must shift organizational structures and practices in a
2 Bloom, D. E., Canning, D, & Fink, G. (2010) Implications of Population Ageing for Economic
number of areas. Growth. Oxford Review of Economic Policy, 26(4), 583-612.
3 Bloom, D. E., Canning, D., Fink, G., & Finlay, J. (2009) Fertility, Female Labour Force Participation,
• Attitudes and the Demographic Dividend. Journal of Economic Growth, 14(2), 79-101.
Older workers are sometimes seen as a burden, so younger 4 Bloom, D. E., Canning, D, & Fink, G. (2010) Implications of Population Ageing for Economic
candidates are often preferred in recruitment decisions. But in Growth. Oxford Review of Economic Policy, 26(4), 583-612.
an economy where knowledge rules, the experience of older 5 Börsch-Supan, A., & Ludwig, A. (2010). Old Europe is Ageing: Reforms and Reform Backlashes. In
Shoven, J. (ed.) Demography and the Economy. Chicago: University of Chicago Press, 169-204.
workers grows in value and they can serve as role models for
6 For an extended discussion of the rise in, and the economic consequences of, chronic diseases,
younger workers. Employer surveys commonly reveal that see: Bloom, D.E., et al. (2011) The Global Economic Burden of Noncommunicable Disease.
workers over 60 are seen as more experienced, knowledgeable, Geneva: World Economic Forum
reliable and loyal than younger employees. Practice should 7 Mankiw, N.G., & Weil, D. (1989) The Baby Boom, the Baby Bust, and the Housing Market. Regional
Science and Urban Economics, 19, 235-258.
match that perception, which has occurred to some extent in
8 Börsch-Supan, A., & Ludwig, A. (2009) Ageing, Asset Markets, and Asset Returns: A View from
smaller firms. Europe to Asia. Asian Economic Policy Review, 4, 69–92.
9 Poterba, J. (2004) Impact of Population Ageing on Financial Markets in Developed Countries.
• Work Schedules and Routines Federal Reserve Bank of Kansas City Annual Symposium, Jackson Hole, WY.
Older employees who wish to keep working may demand 10 Börsch-Supan, A. (2005) What are NDC Pension Systems? What do they bring to Reform
flexible roles and schedules. Allowing more part-time work and Strategies? In: Robert Holzmann & Edward Palmer. (eds.) Pension Reform – Issues and Prospects
for Non-Financial Defined Contribution (NDC) Schemes. Washington DC: World Bank. Ch. 3.
telecommuting will entice older workers to stay on, extending
11 Bloom, D. E., Canning, D, & Fink, G. (2010) Implications of Population Ageing for Economic
their careers by placing lighter burdens on their stamina. Growth. Oxford Review of Economic Policy, 26(4), 583-612.
Likewise, allocating demanding physical tasks to younger 12 Seike, A. (2008) Pensions and Labour Market Reforms for the Ageing Society. In Conrad, H.,
employees will produce a similar benefit and may potentially Heindorf, V., & Waldenberger, F. (eds.) Human Resource Management in Ageing Societies.
Palgrave Macmillan: Ch. 3.
reduce healthcare costs arising from workplace accidents.
13 World Health Organization. (2010) Global status report on noncommunicable diseases. Geneva:
World Health Organization.
• Training 14 United Nations Population Division. (2000) Replacement Migration: Is it a Solution to Declining and
Ongoing training will help older workers master new skills as the Ageing Populations? New York: UN Population Division.
economy changes. Moreover, longer working lives for 15 The Economist. (2011) Pensions: 70 or Bust. April 7. Available at: http://www.economist.com/
employees allow firms to benefit from greater productivity gains node/18529505?Story_ID=18529505
from past training investments. A higher legal retirement age can
expand these benefits.
• Healthcare
Investing in the health of all employees enhances productivity
and avoids unnecessary costs as the workforce ages. Worker
wellness programmes produce healthier employees at all ages;
onsite clinics save workers time and focus care on prevention
and early disease detection, further lowering costs.
• Pay Systems
Moving from pay systems based on seniority to ones that are
based on performance will invariably lead to a relaxation of
corporate norms surrounding the retirement age. This has
already occurred in many countries, including in the public
sector. Careful thought and skilful negotiation will need to go into
such a transition to ensure economic soundness, fairness and
political support. Moves in this direction have already taken
place in Japan, with the age-based wage profile becoming less
steep in the past two decades.
In designing business organizations of the future, the private sector

– with appropriate public-policy support – should anticipate, rather
than passively await, this trend towards longer lifespans and older
employees. In one example of business opportunities spurred by
ageing, media companies are hoping to profit from ageing viewers
and readers by shifting their target away from the traditional range of
consumers aged 18 to 49.14 Although some adaptations lie on the
more distant horizon, others can be undertaken right now, to the
benefit of both younger and older employees, firms and society.

Chapter 7 The Social Capital of Mature Adulthood

The social capital contained within older populations is a
Social Capital, Lifelong considerable resource that lies largely unused and, as such,
exemplifies a societal failure to adapt to changing circumstances.
Learning and Social Currently, the perception of older adults’ potential contributions to
society is changing rapidly.1 A number of factors have contributed to
this, including the expectations of older adults themselves and their
Innovation direct and indirect economic contribution that goes beyond
demographic change to embrace social and behavioral change.
Simon Biggs, Laura Carstensen and Paul Hogan
Engaging with these positive contributions will require efforts to:
That the world’s population is ageing is by now well known. What is create an ethic that recognizes older workers are in fact capital to be
less well recognized is that this constitutes a cultural as well as a leveraged; instill in older workers a recognition that they are vital and
demographic phenomenon. Perceptions of older adults, particularly have much to offer; stimulate a societal appetite to employ and
in the mature economies, are often negative. Older adults are seen educate older adults; and envision a new cultural paradigm for a
as a burden on society, rather than an achievement. This view productive life.2 Later life is often erroneously assumed to describe a
ignores the social capital held by older adults – accrued knowledge state of continuous decline. However, proprietary research done in
and experience, understanding of the ways things interact with each 2010 for Home Instead Care showed that 62% of men over 85 report
other, and an ability to place single events in their wider perspective. no limitations to daily living. Among the educated and affluent, the
Given the right environment, including access to updated skills picture improves even more.
through lifelong learning and to age-friendly environments, older Further, there is little evidence that younger generations resent the
adults can contribute to innovations that will be necessary as continued participation of older adults. The Marist Poll Organization
societies learn to adapt. These abilities are often different in degree discovered that 60% each of the Millennial and X Generations are not
– rather than less valuable – to those of younger people, yet involve worried about older workers not retiring from their jobs. In fact, 62%
important skills in a world where seemingly different elements of a and 65% of these two groups, respectively, felt that they should be
problem interconnect. encouraged to continue working as they reach retirement age. In
This chapter outlines the new but growing response to adult ageing addition, because mature adults have often been freed from the care
that identifies ways of releasing the social capital made available by of dependent children, they may be an especially good resource.
having more people with longer lives. Society needs to first address Positive changes that occur in social skills may make them
two major challenges if it is to fully capitalize on the social capital, particularly well suited for jobs that require social connection.
learning and innovation provoked by ageing populations: first, how to
tap into a source of accrued social investment that is currently largely Confronting the Myths of Lifelong Learning and Development
unused; and second, how to recognize that the process of Myths and stereotypes about older people contribute to widespread
adaptation – a hallmark of the ageing process – is itself a significant pessimism about ageing societies.3 This pessimism can be
source of innovation and of business opportunity. reinforced by researchers and policy-makers who are influenced by
these same preconceptions in the way they describe and respond to
The social capital of older adults is often unrecognized, yet
ageing trends. For example, the US Federal Interagency Forum on
represents a reservoir of accrued investment that has yet to be fully
Ageing-Related Statistics recently reported that in the US, 42% of
drawn upon. The maintenance and germination of this form of capital
people over 65 have at least one functional limitation.4 This statement
depends upon a positive relationship between lifelong learning, social
reinforces perceptions that older people are a burden and need
innovation and adaptation. It also requires recognizing areas in which
support.
older adults have specific skills and aptitudes. The role of negative
social attitudes in inhibiting the utilization of accrued capital would When described in this way, this information might lead to the
also be an important consideration as would be the recognition that development of more effective systems of care, or even better, health
successful utilization depends upon intergenerational negotiation. promotion. However, if viewed another way, this data indicates that
One of the most important social innovations – learning to live in an the other 58% are not functionally disabled. If presented from this
age-diverse world – would have many productive spinoffs in such perspective, the information may lead policy-makers to consider
arenas as design, retail, workforce participation, cultural adaptation ways of ensuring that older people can continue to participate in and
and getting the balance right between continuity and change. contribute to society.
Underutilizing talented, able and willing citizens is bad for older

people and for societies. For example, consider cognitive functioning.
Behavioural scientists have characterized cognitive decline with
considerable precision. Changes begin in the early 20s, and continue
at roughly the same rate into the 80s, 90s and 100s, and the balance
in strength changes from information processing to the deployment
of accrued knowledge.5 Nonetheless, in the absence of dementia,
age-related changes in cognition do not prevent people from
learning, nor do they significantly cloud thinking.

Far less attention is paid to components of cognitive processing that An Adaptive Approach to Lifelong Learning
are not characterized by trajectories of decline. Not all types of
memory decline. For example procedural memory, or memory of An adaptive approach to lifelong learning means that we now need
how to do things such as ride a bike or type on a computer models that place revolving doors in universities, offering sabbaticals to
keyboard, is barely affected, if at all, by ageing. Even though new workers throughout life for retraining or for pursuing new skills for the
learning is somewhat degraded, learning continues over the years. same job. Part of this adaptation will need to concentrate on aptitudes
Knowledge and expertise in specialized areas continue to improve that may be enhanced with maturity, such as big-picture thinking,
over time. Vocabulary and cultural acumen tend to increase well into attitudes to risk taking, cultural know-how, negotiation and social skills,
old age.6 People over age 50 are also more informed about politics and awareness of the effects of change over time and of cultural
and world affairs than are younger people.7 continuity.
Motivation and emotion change with age as well, and changes in There are at least three issues involved here. First, the training needs
these domains afford greater stability and composure.8 In youth, of older adults tend to be overlooked, in the mistaken belief that their
when the future is typically perceived as vast and uncertain, people ability to learn has been significantly reduced.12 Second, by
are motivated to expand their horizons, acquire information and recognizing the accumulated knowledge, experience and continued
prepare for all sorts of possibilities. As people age, motivation shifts. ability to learn of those who are in mature adulthood, accumulated
They become more interested in investing in the people and projects social capital can be used more effectively.13 14 Third, learning needs
that matter most to them. There is a desire to make a difference, to be tailored to the life priorities and thought processes of older
using acquired expertise. adults and to working in intergenerational contexts.15
In the absence of disease, learning continues throughout life. Formal training is one component of this, but it also requires an
Generational intelligence, or the ability to put oneself in the place of “ethic” which has a bias for optimizing and developing lifelong
other age groups and to negotiate difficult interpersonal situations, learning. Social capital is both an explicit (skill and knowledge
increases.9 Further, the experience of emotion changes, in part accrual) and implicit (cultural and adaptation experience) source of
because of these motivational changes. Mature adults are more likely accrued investment. It requires training and continual updating for its
to let small problems go, so they can be better at solving emotional value to be fully realized.
conflicts.
Social Innovation for and by an Ageing Population
How do these changes affect work performance? Meta-analyses of
As people begin to plan for a long life and businesses need to attract
the existing literature comparing older and younger workers show
older workers, these forces will themselves become a motor for
very little evidence for declines in productivity or performance.10 True,
innovation and the creation of new social relationships. Social
existing studies focus on relatively “young” older workers. But by and
innovation can occur for older adults and by older adults. An ageing
large, work performance is well maintained. Further, working into
population offers novel design and product opportunities, in
mature age has been shown to be a win-win situation, with mature
marketing redesigned products to fit the demands of mature
workers continuing to improve their cognitive functioning. Older
customers,16 creating age-friendly environments17 in the use of
workers are more collaborative and often use better judgment.
information technologies,18 and changing workplace design, such as
Especially when work holds emotional significance, older people take
in the BMW production line programme.19 Older adults often engage
remarkable initiative.
in second, or encore, careers and may be an important source of
In Japan, for example, hundreds of elderly people stepped forward to small- and medium-size business innovation.20
work at the Fukushima nuclear reactor plants. They maintained that
The innovative step is to discover or recognize social roles that can
long-term cancer risks and potential loss of fertility were not issues
accommodate activities that will work intergenerationally, be in
for them, given their age. Their emotional resilience in the face of the
harmony with changing life course capabilities and contribute to
recent disaster is offering practical solutions and generating great
productive social engagement.21 And this may play an important role
national pride.
in achieving sustainable workability for an ageing yet
These patterns present numerous workforce opportunities. Some intergenerational work environment.22
businesses have sought older workers when this demographic could
To capitalize fully on the capabilities outlined above, new models of
offer the best skills and experience for the jobs at hand. For example,
lifelong work practices that prioritize flexibility are becoming
Home Instead Senior Care (2011), a leading international provider of
increasingly popular. Accepting that older workers have unique
in-home care to older adults, employs more than 20,000 caregivers
strengths that can be capitalized in the right environment leads to
who are at least 60 years old. With increasing international concern
workplace adaptation, rethinking disincentives and incentives to
about the availability of an aged-care workforce, older workers are
further contribution, breaking stereotypes and negotiating. Shared
becoming an asset. 11
intergenerational outcomes are becoming increasingly important
This type of business-related social innovation has the potential to sources of innovative adaptation for an ageing society. With their
become a self-perpetuating phenomenon. As older employees stay maturity, perspective and experience, older adults can make their
in the workforce longer, they may help shape the work-related contributions in thought, feeling and social skills and in ways less
attitudes of their younger colleagues, who themselves represent dependent on physical activity – in line with business innovation and
future generations of older workers. knowledge-based economies.
Below, we outline a virtuous circle that taps the reservoir of accrued

social capital, channeled by lifelong learning, and allows new and
effective adaptations to grow. The circle is virtuous because it
generates social innovation and sustains the continuing germination,
development and release of social capital.
Here, social capital provides a wider vision of the productive

contribution of older adults. It recognizes both the diverse contributions
of different age groups and the work that goes into sustaining a viable
social fabric necessary for sustainable economic engagement.

Figure 1: A virtuous circle relationship between social capital, Conclusion

learning, adaptation and innovation
Demographic change will have an influence that is widespread and
will challenge many assumptions about the contributions of older
adults. It will affect processes of production, consumption and the
Social environment in which we all live and work. If societies are to adapt,
steps will need to be taken to release the social capital that is locked
Capital up in their older citizens. This potential would include the application
of accrued social and emotional intelligence, an understanding of the
ways things interact with each other and an ability to place single
Social Lifelong events in their wider perspective.
Innovation Learning
Given access to updated skills through lifelong learning and through
age-friendly design, older adults can contribute to new forms of
adaptive innovation. In fact, a combination of lifelong learning and
Adaptation social adaptation can drive innovation. It leads to a virtuous circle,
releasing further social capital in a way that is imminently suited to a
world needing new ways to interconnect.
In this model, social capital is unlocked via appropriate learning and
education. This unlocking allows adaptation to take place, both for
mature-age workers and between generations, so that the best mix
of age groups for a collective task can be found. Adaptation would Endnotes
result in the two forms of social innovation described in this chapter: 1 Biggs, S. (2005) Beyond appearances: perspectives on identity in later life and some implications
innovation by mature adults and by a society friendly to all ages. for method. J Gerontol B Psychol Sci Soc Sci, 69(B), 118-27.
2 Hogan, P. (2011) Global Aging: Ideas for Lifelong Living and Social Innovation. Available at http://
• Social capital refers to accrued content (such as knowledge and championsforaging.org/2011/07/global-aging-ideas-for-lifelong-learning-and-social-innovation/.
information), process (understanding of the ways things interact), 3 Carstensen, L.L. (2011) A long bright future: Health, Happiness and Financial Security in an Age of
Increased Longevity. New York: Public Affairs Press.
and experience (placing single events in a wider perspective).
4 Federal Interagency Forum on Aging-Related Statistics. (2008). Older Americans 2008: Key
• Lifelong learning refers to the models or ways in which indicators of wellbeing . Washington, DC: U.S. Government Printing Office.
knowledge and skills are communicated, the environments 5 Salthouse, T. A. (2010) Major issues in cognitive aging. New York: Oxford University Press.
(where and at what time) that foster age-friendly accessibility, and 6 Schaie, K. W. (1994) The course of adult intellectual development. American Psychologist, 49,
304-313.
the institutional adaptation to the “stretched life course” where
7 Pew Research Center for the People and the Press. (2007) What Americans Know, 1989-2007:
work, learning and self-development extend across a longer, fitter Public knowledge of current affairs and information revolutions. Washington, DC: Pew.
life. 8 Carstensen, L.L. (2006) The influence of a sense of time on human development. Science, 312,
• Social innovation includes the adaptations that are provoked by a 1913-1915.
changing demographic landscape. It can include innovative 9 Biggs, S. & Lowenstein, A. (2011) Generational Intelligence: a critical approach to age relations.
London: Routledge.
activities by older adults themselves, business and service 10 Waldman, D. A., & Avolio, B. J. (1986) A meta-analysis of age differences in job performance.
innovation to meet newly identified needs, and innovation Journal of Applied Psychology, 71, 33-38.
provoked through the meeting of shared generational goals. 11 Hogan, P. (2011) Global Aging: Ideas for Lifelong Living and Social Innovation. Available at http://
championsforaging.org/2011/07/global-aging-ideas-for-lifelong-learning-and-social-innovation/
• Adaptation – keeping up with changing demographics and
12 Chartered Institute for Personnel Development & Trades Union Congress (2011) Managing Age.
ageing identities – requires a change in ageist attitudes, the London: CIPD.
development of age-friendly (including intergenerationally) 13 Experience Corps. (2011) About Us. Available at: http://www.experiencecorps.org/about_us/
cultures, and redesign of large areas of commerce, workplaces about_us.cfm
and the built environment. 14 Employers Forum on Ageing. (2011) About Us. Available at: http://www.enei.org.uk/pages/
about-us.html
A number of organizations are beginning to collect examples of the 15 Biggs, S. (2005) Beyond appearances: perspectives on identity in later life and some implications
for method. J Gerontol B Psychol Sci Soc Sci, 69(B), 118-27.
use of the social capital of older adults. Arguments for and particular
16 Kolbacher, F. & Herstatt, C. (2008) The Silver Market Phenomenon: business opportunities in an
instances of age-diverse workforces and intergenerational innovation era of demographic change. New York: Springer.
can be found at the websites of Eurofound, Experience Corps, the 17 World Health Organization. (2010) Age Friendly Environments programme. Available at: http://
AARP and Employers Forum on Ageing cited in this chapter’s www.who.int/ageing/age_friendly_cities/en/index.html
reference section.23242526 18 Wang,A., Lindeman, D., Steinmetz, V. & Redington,L. (2011) Technology adoption and diffusion for
older adults. Ageing International, 36(1/2).
19 Loch, C. H., Sting, F. J., Bauer, N., & Mauermann, H. (2010) How BMW is defusing the
demographic time bomb. Harvard Business Review, March, 99-102.
20 AARP (2011) http://www.aarp.org/
21 Biggs, S. & Lowenstein, A. (2011) Generational Intelligence: a critical approach to age relations.
London: Routledge.
22 Ilmarinen J,& Tuomi K (2004) Past, present and future of work ability. Finnish Institute of
Occupational Health, People and Work Research Reports, 65, 1-25.
23 Eurofound. (2011) About Eurofound. European Foundation for the Improvement of Living &
Working Conditions. Available at: http://www.eurofound.europa.eu/about/index.htm
24 Experience Corps. (2011) About Us. Available at: http://www.experiencecorps.org/about_us/
about_us.cfm
25 AARP. (2011) http://www.aarp.org/
26 Employers Forum on Ageing. (2011) About Us. Available at: http://www.enei.org.uk/pages/
about-us.html

Chapter 8 Variable Physical and Cognitive Declines

If these were the only experiences that medical students and young
Leadership: The Elders people were exposed to as a symbol of what it is like to grow old,
they would most certainly get the wrong impression of the reality of
S. Jay Olshansky human ageing for many people in the modern era.
As a way to illustrate to young people what ageing is like first-hand A balanced and honest assessment of human ageing first requires
from the perspective of an older person, a company in Japan created recognition that there will inevitably be physical and cognitive
the Aged Simulation Set – a series of restrictive devices designed to declines for everyone as they grow older. However, the degree to
“demonstrate the inconveniences felt by the aged due to which this occurs is highly variable. For many, the declines are
musculoskeletal, visual and auditory ageing”.1 (See Figure 1.) Features debilitating, and the costs of diagnosis and treatment are high. In
of the set, which the manufacturer says emulates the daily life of the addition, society is already exacting a heavy financial and social toll
aged, include goggles that narrow the field of vision; earplugs to for the privilege of living a long life. However, for others, the changes
restrict sound; and Velcro restraints designed to make it difficult to in their bodies and minds that occur with time are little more than
bend the joints, move up and down stairs, stand up, sit in a chair and nuisances easily compensated for by modern medicine and simple
use the bathroom. technological advances such as hearing aids, reading glasses and
common surgical procedures, such as removal of cataracts.
Scientists at the University of Minnesota created a similar experience
to sensitize medical students to the unique needs of elderly patients, Serious health issues will no doubt rise in prevalence as the
with the goal of reducing widespread negative attitudes toward population ages, but it is important to recognize the other side of the
ageing and the care of elderly patients.2 ageing coin. A notable percentage of the older population today is
physically and mentally healthy, vibrant, sexually active, wanting to
work and fully engaged in every aspect of society. In some instances,
Figure 1: The Aged Simulation Set they are not much different than when they were younger. The
prevalence of this healthy and active segment of older populations is
going to rise rapidly in this century. However, students wearing the
Aged Simulation Set would have no way of knowing this.
Efforts to sensitize younger generations to changes that occur in

human bodies with the passage of time may be well intentioned, but
this is only part of the story of growing older. Given that many older
people are functionally not very different from people decades their
junior, the Aged Simulation Set, as an example of what human ageing
is like or can be, is perhaps the wrong part of growing older that
should be emphasized. Such devices could lead young people and
physicians-in-training to believe this is the inevitable fate for their
patients, and will be their own destinies as they grow older. The fact
is, devices such as these reflect only the negative side of physical
ageing experienced by some.
There is an entirely different and much more positive side to ageing

that is rarely noticeable to young people as a vision of their future.
Examples of the positive side of ageing abound, but this chapter
focuses on only one – leadership and the exemplars of this
experience known as The Elders.
Origin of The Elders

In traditional societies, elder members of clans were viewed as
repositories of wisdom and the source of major conflict resolution. In
the same spirit, a version of global elders for all of humanity emerged
in 2007 following a conversation between entrepreneur Richard
Branson and musician Peter Gabriel. The idea was that in an
increasingly interdependent world characterized by what might best
be thought of as a global village, a small group of independent-
minded elders could help to resolve global issues, ease suffering and
promote the shared interests of all of humanity.
Branson and Gabriel approached Nelson Mandela, who agreed to

support the idea, and with the help of Graça Machel and Desmond
Tutu, brought The Elders together. Current members of The Elders, in
addition to those already mentioned, include Martti Ahtisaari, Kofi
Annan, Ela Bhatt, Lakhdar Brahimi, Gro Harlem Brundtland,
Fernando H. Cardoso, Jimmy Carter and Mary Robinson. Aung San
Suu Kyi is an honorary Elder and Muhammad Yunus is a former
Elder. Brief biographies of current and former members of The Elders
Source: The Koken Aged Simulation Set LM-0601 appear below.

Graça Machel, 66, is a politician and Kofi Annan, 73, is a Ghanaian diplomat who
humanitarian from Mozambique who has served as the seventh secretary-general of
been an international advocate for women’s the United Nations from 1997 to 2006.
and children’s rights. She is the wife of Annan and the United Nations were the
former South African president Nelson co-recipients of the 2001 Nobel Peace Prize
Mandela and the widow of the late president for founding the Global AIDS and Health
of Mozambique Samora Machel. In 1997 she Fund.
was made a British Dame for her
humanitarian work.
Desmond Tutu, 80, is an activist and retired Ela Bhatt, 78, is the founder of the Self-
Anglican bishop from South Africa, well Employed Women’s Association of India
known for his opposition to apartheid. Tutu (SEWA). Trained as a lawyer, Bhatt is a
has been an active defender of human rights, respected leader of the international labour,
and has fought against AIDS, tuberculosis, cooperative, women and microfinance
homophobia, transphobia, poverty and movements.
racism. Tutu received the Nobel Peace Prize
in 1984, the Albert Schweitzer Prize for
Humanitarianism in 1986, the Pacem in
Terris Award in 1987, the Sydney Peace Prize
in 1999, the Gandhi Peace Prize in 2005 and
the Presidential Medal of Freedom in 2009.
Martti Ahtisaari, 74, is a Finnish politician who Lakhdar Brahimi, 78, is a former envoy and
served as the 10th president of Finland from advisor to the United Nations, a member of
1994 to 2000. Ahtisaari was a United Nations the Global Leadership Foundation and the
diplomat and mediator known for his Commission on Legal Empowerment of the
international work on peace. Ahtisaari was a Poor, and the former chair of the Panel on
special envoy to the United Nations at the United Nations Peace Operations. He is
Kosovo status process negotiations that currently a distinguished senior fellow at the
were designed to resolve a long-running Centre for the Study of Global Governance at
dispute in Kosovo. In October 2008, he was the London School of Economics and
awarded the Nobel Peace Prize for decades Political Science.
of work to resolve international conflicts in
Namibia, Indonesia, Kosovo, Iraq and other
areas.

Gro Harlem Brundtland, 72, is a social Jimmy Carter, 87, is a former president of the
democratic politician from Norway where United States. He received the Nobel Peace
she served as the prime minister in 1981, Prize in 2002, created the Department of
1986 to 1989, and 1990 to 1996. Brundtland Energy and Department of Education during
is an international leader in sustainable his term in office, and established the first US
development and public health and has national energy policy. Carter was involved in
served as the director-general of the World the Camp David Accords, the Panama Canal
Health Organization. She now serves as a Treaties and the Strategic Arms Limitation
Special Envoy on Climate Change for the Talks (SALT II).
United Nations. In 2008, she received the
Thomas Jefferson Foundation Medal in
Architecture.
Fernando Cardoso, 80, is a former president Aung San Suu Kyi, 66, is a Burmese
of the Federative Republic of Brazil who is opposition politician and the General
also trained as a sociologist. Cardoso was Secretary of the National League for
presented with the Prince of Asturias Award Democracy. Aung San Suu Kyi received the
for International Cooperation in 2000. Rafto Prize and the Sakharov Prize for
Cardoso is a founding member of the Freedom of Thought and the Nobel Peace
University of Southern California Center on Prize. She was awarded the Jawaharlal
Public Diplomacy’s Advisory Board. Nehru Award for International Understanding
by the Government of India. She was also
awarded the International Simón Bolívar
Prize from the Government of Venezuela.
Mary Robinson, 67, is a former president of Muhammad Yunus, 71, is an economist from
Ireland. Robinson also served as the United Bangladesh and founder of the Grameen
Nations high commissioner for human rights Bank, which provides microcredit to help
from 1997 to 2002. She was a member of impoverished clients establish
the Irish Senate, honorary president of creditworthiness and financial self-
Oxfam International and of the European sufficiency. In 2006, Yunus and Grameen
Inter-University Centre for Human Rights and received the Nobel Peace Prize. Yunus is a
Democratisation. Robinson is Chair of the member of the advisory board at Shahjalal
International Institute for Environment and University of Science and Technology and
Development (IIED) and a founding member was previously a professor of economics at
and Chair of the Council of Women World Chittagong University. Yunus also serves on
Leaders. She is also a member of the the board of directors of the United Nations
Trilateral Commission and is involved in the Foundation and was a founding member of
project Realizing Rights: the Ethical The Elders.
Globalization Initiative. She is Chancellor of
the University of Dublin and is now a
Professor of Practice in International Affairs
at Columbia University. In 2004, she received
Amnesty International’s Ambassador of
Conscience Award for her work in promoting
human rights.

Distinguishing Achievements Other Remarkable Older People

What distinguishes this group of accomplished people is not so By way of example, until a few days before his death at 83, the
much their age, but their lifetime achievements demonstrating a founding director of the US National Institute on Aging – Robert
history of independent thought, international trust, proven integrity Butler – was travelling the globe as a highly sought-after speaker,
and a reputation for inclusive progressive leadership. According to making substantive contributions at conferences and actively
Mandela, “The Elders can speak freely and boldly, working both engaged in scientific research and advocacy for ageing issues.
publicly and behind the scenes. They will reach out to those who
most need their help. They will support courage where there is fear, The violinist and conductor Yehudi Menuhin conducted a master
foster agreement where there is conflict, and inspire hope where class for young students from the Geneva Conservatory of Music
there is despair”. near the end of his life. In Sarasota, Florida, retired physicians, who all
work for free, run a local hospital almost entirely by themselves. Sir
Examples of their tireless work abound. Consistent with discussion Richard Doll, one of the foremost epidemiologists of the 20th century,
of human rights in Chapter 18 of this book, The Elders actively was actively engaged in research and lecturing through his early 90s.
support the United Nations Declaration of Human Rights originally Health and exercise advocate Jack LaLanne promoted healthy
passed in 1948, emphasizing these rights in every aspect of their lifestyles and engaged in amazing feats of strength for more than 30
work. Although The Elders do not explicitly mention age or ageing years past what many consider the normal retirement age. He died in
when discussing human rights, they do take care to emphasize that 2011, at the age of 96.
the Declaration applies to every human being. The Elders have been
actively involved in efforts to eliminate the global stockpile of nuclear There are many more examples of senior “masters” from a broad
weapons, promote equality for women and girls, seek a just and range of professions, including nursing, banking, writing, teaching,
secure peace for all in the Middle East, help to secure the rule of law the sciences, construction and plumbing. The fact is that age is not a
in Myanmar, battle the humanitarian crisis in Zimbabwe, establish the barrier to active and even enhanced engagement for many. It is not
independence of southern Sudan and reunify the island of Cyprus. necessary to have been a well-known politician early in one’s career
to be included among The Elders of our world.
A brief review of past and current activities by members of The Elders
demonstrates that these are hardly the actions of a sick, old and frail Conclusion
subgroup of the population that can no longer see clearly, hear, stand
up and sit down without pain – as portrayed by the Aged Simulation Simulating the lives of older people by focusing exclusively on the
Test. Nor do they appear to be an economic burden on society. physical infirmities that accumulate with age provides a highly biased
view of the reality of ageing for most, and the potential for ageing
In a way, even with eyes that probably do not work as well as when among many. Imagine a simulation device that enables people to
they were younger, The Elders perhaps “see” more clearly than ever experience a profound sense of self-confidence, a level of comfort in
before. These are the actions of a vibrant, fully engaged group of his or her own skin, feelings of accomplishment in life, a sense of
people, all of whom exemplify the best of what humanity has to offer, peace and joy that comes from decades of a loving relationship with
regardless of their age. It may even be reasonable to conclude that a partner, pride in one’s children, the sheer joy in caring for
the measure of success and stature of The Elders exists in part grandchildren, financial security from being at the top of one’s career
because of the experience and wisdom that each has accumulated earnings, and thoughtful reflection and intelligence. If a pill were
during their long careers in public service. The passage of time may invented that enabled us to experience these rewards, everyone
very well be the “entrance exam” that must be endured to become would line up to take it – especially younger people.
part of this unique club.
Although not all of these rewards of ageing exist in everyone, neither
Are The Elders able to participate in active engagement at their is it the case that all of the physical infirmities that appear at later ages
current ages because they have somehow managed to avoid the are concentrated in every older person. If a person reaches later
physical and cognitive infirmities normally associated with older ages with their health intact, there is really not much to distinguish
ages? It is clear that none of The Elders is suffering from debilitating them from any other member of society, regardless of age.
mental illness. What is important to remember about The Elders is
that they have adapted their lives around their own physical Leadership is just one of many attributes common in older people
challenges – enough so that they can continue to lead extraordinarily that represent a suite of desirable characteristics. Taken together,
active and creative lives. these characteristics imply that ageing should not be portrayed as
decline, loss and decay, but rather as a period of constant adaptation
The fact that all of The Elders are past the traditional retirement age of and transitional phases in life that can lead to rewards every bit as
65 is the point. Active engagement in society can occur at the valuable and desirable as physical health.
highest levels regardless of age. What sets The Elders apart is not
just the fact that they were all accomplished during their younger
days, but that they chose to continue, and sometimes even
accelerate, their active engagement even while some are facing the Endnotes
typical physical infirmities that accompany most people later in their 1 Koken Co. (2005) The aged simulation set: LM-060. Available at: http://www.kokenmpc.co.jp/
lives. english/products/life_simulation_models/nursing_education/lm-060/index.html
2 McVey, L., Davis, D., & Cohen, H. (1989) The ‘aging game’: An approach to education in geriatrics.
Is it possible that The Elders are more able to engage fully later in life Journal of the American Medical Association, 262(11), 1507–1509.
because of their high profile positions early in their careers? Perhaps.

Certainly their earlier lives allow entrance into this leadership club. Yet
there is no reason why people from any profession who reach later
ages cannot follow a similar path of senior mentorship and
accomplishment.

Chapter 9 Macro-Adaptation
To cope with an ageing population then, it is extremely important for
Organizational, Adaptation us to promote the employment of older people. If older people can
be encouraged to adopt the will and ability to continue working
and Human Resource Needs beyond the current retirement age, it would directly reduce average
per capita expenditure and indirectly lead to a number of benefits
such as reduced healthcare needs and greater social engagement.
for an Ageing Population An increase in the number of active workers and consumers in later
life would also be a driving force of economic growth in the supply
Atsushi Seike, Simon Biggs and Leisa Sargent side as well as the demand side of the macro economy. However,
Changing demographic profiles create challenges for all sectors of people should not be forced to work against their will, and in this
private and public industry, especially in societies where there are respect, the important issue is to motivate older people to continue
projected to be fewer younger relative to mature aged workers. This working.
is the case in the majority of mature and emerging economies, raising In general, the labour force participation rate declines as populations
the question of how prepared organizations are to adapt. A key get older and public policy has focused on keeping it at as high a
component would be to create the best possible circumstances that level as possible. This policy has been promoted, for example
attract and retain mature-age women and men as a factor in following the Lisbon Agenda (2000) within the European Union. In
achieving future success. This can also have positive consequences addition, the labour force participation rate of older people varies
for the workers themselves. widely by country. For example, the labour force participation rates of
Addressing these challenges would rely on a combination of Japanese and Korean elderly in their 60s is significantly high in
modifications to the external policy environment, also thought of as comparison to other developed countries, such as the relatively low
macroeconomic change. Modifications would also need to be made rates to be found in Europe (Table 1).
to organizations at the mezzo level of individual firms and agencies. To achieve greater participation, the Australian Human Rights
The aim would be to promote flexibility within an increasingly Commission (www.hreoc.gov.au/age/info_age.html) and the
age-diverse workplace. Micro or personal changes would then occur UK-based Employer’s Forum on Ageing (http://www.efa.org.uk/) give
as accommodations between these environments and the changing some useful examples of steps that can be taken. Attempts to
age-based priorities. motivate continued working have resulted in an often politically
Macro adaptation might include promoting employment and difficult review of social security systems and in employment
pensions conditions that make it desirable to continue working. practices in the major European national economies.
Mezzo and micro adaptation would rely on the development of
age-friendly working environments that allow mature-age workers to
participate more effectively. Both require the right balance of Table 1: Employment rates of older workers by % of population
continuity and change and a combination of approaches that fit both aged 55 to 64 across a range of Organisation for Economic Co-
personal age-based life priorities and wider economic imperatives. operation and Development countries
2010
Country-
2010
Country 2000 2009 2010 OECD-Total*
Australia 46.2 59.0 60.6 +6.6

Japan 62.8 65.5 65.2 +11.2
France 29.3 38.8 39.7 -14.3
United Kingdom 50.4 57.5 56.7 +2.7
United States 57.8 60.6 60.3 +6.3
Italy 27.7 35.7 36.6 -17.4
Korea 57.8 60.4 60.9 +6.9
Country 2010-2010 OECD-Total (54%)

Source: OECD Employment Outlook 20111

Pension System Reforms to Promote Employment Table 2: The negative effect of mandatory retirement on labour force
participation
Where countries have established pensions systems that encourage
early pension eligibility, combined with restrictions on earnings while Coefficients on the
drawing a pension, this has increased early exit from the workforce. Observation Year Probability of Labour
Research Papers Estimation Sample Force Participation
Taking Japan as an example, estimated labour supply functions of
older people show that obtaining pension eligibility reduces the Seike (1993) 1983 - men aged 60-69 -0.18***
probability of labour force participation by 13%.2,3
Abe (1998) 1983, 1998, 1992 - men aged 60-69 -0.23***
Public pension systems in many countries also include a component Seike and Yamada(2004) 2000 - man aged 60-69 -0.18***
that encourages pension-eligible workers to retire or reduce working
*** Statistically significant at the respective level of 1%. For details, see Seike (2008).5
hours. This is the public pension’s earnings test, by which a person’s
pension benefit is reduced based on their earnings from work after The second negative impact of mandatory retirement is that it
they have reached the pension eligible age. In the case of Japan, reduces the use of older workers’ potential abilities. Japanese
pension-eligible workers tend to restrict their earnings by reducing workers subjected to mandatory retirement have a lower possibility
working hours, or sometimes retire completely to receive the full of working in a workplace where their abilities are fully used. There
pension to avoid the pension benefit reductions. In the US and the are many reasons for this, including obstacles associated with is the
UK, the earnings test has already been eliminated to avoid the setting of age limits by employers when hiring for job openings.
possible negative impact on labour supply behaviour of pension- Particularly for workers seeking new employment, even before the
eligible workers. Sweden has revised its pension plan to make it age of mandatory retirement for those who become unemployed in
more neutral to labour supply.4 Lifting the pension age has been used mid-career, such age limits in hiring seriously constrain their job
as means to motivate older people to work, but is dependent on chances. Older workers may also be offered low status and
appropriate jobs being available. If this is undertaken insensitively it casualized work and not be offered relevant training opportunities.6
can lead to the casualization and marginalization of the older
workforce. The Australian Federal Government has implemented a number of
schemes, including the certification of experience, re-training, and an
Employment Practices Reforms anti-discrimination commissioner in an attempt to address these
issues and reduce under-employment.7 To develop age-diverse
In the workplace, age-related employment practices can be a major workplaces, with a mix of age groups that reflect changing
obstacle to promoting the employment of older people. The typical demographic circumstances, it may also be necessary to revisit
case is the practice of mandatory retirement. To draw on the seniority-based wages and promotion systems. Without having a
Japanese example, mandatory retirement is still a dominant practice; revision of these, an employer will face increasing numbers of
more than 90% of Japanese firms with 30 or more employees high-wage workers and unnecessary numbers of managers and
currently have mandatory retirement practices (Table 2). In other supervisors.
countries, such as the United States and some members of the
European Union, restrictions based on chronological age have either While a trend toward flattened hierarchies and the stripping out of
been abolished or made more flexible. seniority structures has reduced the numbers of mid-level positions,
this may not have addressed the question of seniority and may have
Because mandatory retirement requires severance simply because even exacerbated problems of career progression. The somewhat
of age, it impacts in two ways on the use of an older workforce. One paradoxical position, whereby Japan has greater participation than
is that it reduces the motivation of older people to continue working. some Western countries, yet mandatory practices, indicates the
As is widely known, mandatory retirement from primary employers culturally specific effects of macro policies.
does not necessarily mean complete retirement from the workforce.
Many older workers go on to secondary job opportunities. However,
as is repeatedly confirmed by empirical analysis, mandatory
retirement is also a major determinant of complete retirement from Table 3: Mandatory retirement practice in Japan
the labour market.
Per cent of companies with
In the case of Japan, researchers (Table 2) have estimated the labour Age of Mandatory retirement
supply functions of older people and found that the experience of
mandatory retirement
(companies with uniform mandatory retirement age = 100)

mandatory retirement significantly reduces the labour force
participation possibilities of these people.1,2 Roughly speaking,
(repeated data
65 and over)
66 and over
mandatory retirement reduces the probability of labour force

59 or less
participation in men aged 60 to 69 in Japan by about 20% if other

conditions are constant. According to the Annual Report on the
60
63
64
65
62
61
Labour Force Survey (actually a detailed tabulation version of it) of

Japan, in which unemployed persons were asked their reasons for 1994 90.5 15.9 77.1 2.0 2.0 2.0 2.0 5.0 0.0 -
not being able to find a new job, the top reason for those over 45 2004 91.5 0.7 90.5 0.6 0.9 0.9 0.0 6.1 0.4 6.5
years old has always been age limits. This means that if people have 2006 95.3 - 90.5 0.5 1.7 1.7 0.0 6.2 0.2 6.3
to change their jobs mid-career or after mandatory retirement, it is 2007 93.2 - 86.6 0.2 2.5 2.5 0.0 9.0 0.0 9.1
very difficult for them to find new jobs simply because of their age. 2008 94.4 - 85.2 0.2 1.1 1.1 0.1 10.7 0.1 10.9
2009 91.8 - 82.4 0.3 1.3 1.3 0.2 12.7 0.7 13.5
2010 93.1 - 82.7 0.5 1.1 1.1 0.5 12.3 1.0 13.3
Source: Ministry of Health, Labour and Welfare: up until 2004 the Survey of Employment
Management; from 2006 the General Survey on Working Conditions

The Value of Mature-Age Workers A shift toward more service–based industries in developed countries
also contributes to the need for such change. According to the
A point that is often overlooked in this debate is that older workers Organisation for Economic Co-operation and Development (OECD),
are adding value to their employers. Organizations that recognize this the services sector now accounts for over 70% of total employment
phenomenon benefit in a range ways. For example, contrary to a and value added in OECD economies. These countries are less
common employer assumption, job performance does not decline dependent on hard physical labour and can harness the knowledge
with age.8 and skills accrued across the lifespan, and thus they are friendlier
Further, certain forms of ability such as crystallized intelligence or toward older workforce employment.
accumulative knowledge actually increase with age.9 Such findings Figure 1: Australia full-time and part-time work, males and females
indicate that there may be important forms of participation that by age, 2006
mature workers can offer, which hinge on a greater understanding of
system relationships and psychosocial aspects of working
100
relationships.10 To the age-specific skills of a mature workforce can Full-time work Part-time work
be added greater reliability than younger workers. From a 90
productivity perspective, mature workers are less likely to engage in 80
Percentage employed
theft from their companies, be absent or quit their jobs.11,12 From a 70
diversity perspective, older workers provide a depth of tacit 60
knowledge both to fellow workers as well as to clients and
50
customers.13
40
This capacity to engage in problem solving and critical thinking at 30
work with customers and co-workers also promotes innovation and 20
supportive workplace practices in mature workers. In addition to this
10
relational aspect of their skills, mature workers have diverse social
networks and social resources they have accumulated across their 0
15-19 20-24 25-34 35-44 45-54 55-64 65 and
lifespans, which organizations can leverage productively. over
Males
Gender and Older Workers 100
90
There have been three important gender-based changes in labour 80 Full-‐7me work Part-‐7me work
Percentage employed
force participation in industrialized societies. First, there is an 70

increase in women’s participation in the workforce. For example, in 60
the United States between 1986 and 2006, there was a 10% 50
increase in working women in the group aged 55 and over working.14 40
Second, while there are more women participating in paid 30
employment proportionally, many are working in part-time or more 20
precarious types of work (Figure 1). Third, women are remaining in
10
paid work longer than men.15
0
15-‐19 20-‐24 25-‐34 35-‐44 45-‐54 55-‐64 65 and
These changes in working patterns have implications for retention Females over
and engagement of mature women in the workforce. Historically Source: Census of Population and Housing, Australia online tables. Cat. No. 2068.0 - 2006 Census
women have experienced labour market segregation both vertically tables, 2006 Census of Population and Housing, Australia, labour force status by age by sex for time
and horizontally. Even though there is equal pay legislation for women series, count of persons aged 15 years and over, based on place of usual residence.
across many nations, the gender wage gap endures and is widest for
mature female workers. Mature women can experience
discrimination in terms of both age and sex.16
Organizational Culture: Mezzo- and Micro-Adaptation
Women face workplace challenges such as harassment and spend As older workers form a larger proportion of a shrinking workforce,
more time in elder and grandchild care. The movement of women in businesses that can keep their existing workers – in whom they have
and out of the paid labour force to participate in childbirth and rearing often invested in and who hold detailed understanding of systems
reduces their access to superannuation (or related plans) across the and practices – and can attract others will have a competitive
life course. This means that women have significantly less advantage. An important factor in increasing the motivation and thus
accumulated financial resources, which has consequences for health the retention of mature workers will be the working environment itself.
and wellbeing.17
Key to maximizing this process is organizational culture, which in this
These challenges are opportunities for organizations. As social context includes the social environment within businesses,
institutions, organizations need to be more proactive and inclusive in institutions and service agencies, as well as the ways in which any
attracting older workers. They need to provide flexible scheduling, one organization manages the boundaries between itself and its’
time banks for eldercare, and a better fit between the employee and social environment. Successful adaptation to demographic change
the job. The lessons of gender-positive work environments – through would include examining non-linear career pathways, looking at
diversity training where all workers are equally valued and respected models of work-life balance and patterns of flexible working, adopting
– will have wider application as demographic change takes place. strategies that promote lifelong skills development and facilitating an
Creating an inclusive and equitable organizational culture makes age-diverse work culture. Indeed, research has shown that even if
sound business sense. It serves to assist the increasing numbers of workers have positive abilities and motivation toward work, a poorly
women and older workers in general in the paid workforce, and it adapted workplace culture will discourage recruitment and retention
helps all workers as it widens acknowledgement of the social and of mature workers.18
motivational value of work flexibility.

Flexible Working Practices Training and Continuing Development

One area that illustrates adaptation to a changing demographic Developing and maintaining skills for jobs and other activities are
occurs at the crossover between the internal culture and the external indispensable requirements for people to be active in their older
environment. Looking at work-life balance and patterns of flexible years. Tertiary-level attainment has risen sharply and is now at 35%
working are important indicators for organizations adapting to the for 25- to 34-year-olds, as compared to 20% for 55- to 64-year-
new demographic environment. Factors include: policies designed to olds.29 So, future generations are much more educated and will also
create greater choice and flexibility about moves in and out of work, value sustaining their knowledge and learning. It is vital that efforts be
such as career breaks and time-credit systems;19 enhancing the made to promote a lifetime of employability and encourage mature
capacity of older workers through training; improvements to the work workers to continue to have up-to-date skills. Companies may
environment; lifelong learning; and anti-discrimination policies.20 consider ways to incentivize up-skilling or re-skilling in older workers.
This also creates new opportunities to develop human-resource
Encouraging flexible working practices for mature aged workers development practices that account for their needs as well as
would include the promotion of gradual retirement and preparation recognize prior learning.
for part-time working, securing greater control over transitions after
the age of 50, and spreading work more evenly across the life Strategies for Retaining and Engaging Mature Workers
course.21 Norwegian research indicates that an existing culture of
flexibility significantly enhances the ability to capitalize on an age- Retention &
Engagement Strategies Description
inclusive approach to organizational culture.22
Part of creating an adaptive organizational culture involves striking a Job design Design jobs that create a quality person-job fit that
accounts for changes across the life course. For
balance between continuity and change, both for individual workers
example, older workers value autonomy and skill variety.
and for the environments in which they work. This includes identifying Offer complex and mentally challenging work, which is
the particular contribution that mature-age workers make and ways important for mature workers’ satisfaction and wellbeing.
to facilitate an age-diverse work culture. For mature-age workers,
parenting responsibilities may be largely over, while in a growing Flexibility Create policies and practices flexible scheduling to
number of cases these are replaced by care for elderly relatives. address eldercare, grandchild care, part-time or
These workers either may be at a high level within an organization, or project working, flexi-place working.
may have realized that they are unlikely, or do not wish, to get there. Training and Promote the development and training of mature
Their motivation has, in other words, largely stabilized at certain levels development workers to encourage generativity.
of power and responsibility.23 Implement training that encourages an inclusive work
environment that embraces age-diversity. Use
At the same time, work can offer a number of advantages beyond language that creates positive images of older workers
financial reward, such as social engagement, physical and mental and fosters interpersonal and intergenerational
health gains. Mature-age adults also bring particular skills to work relationships.
activity, such as being able to see the bigger picture, the interaction
of activities with wider systems and negotiation skills.24 Achieving Health and wellbeing Target health promotion for mature workers; focus on
promotion relevant issues in terms of gender and occupational
balance between workers from different age groups creates an demands such as balance, flexibility and sensory
opportunity to get the skill mix right in adapting to a changing jobs requirements.
market.25
Accommodations Design procedures for accommodation requests in
Promoting Health and Wellbeing in Mature-Age Workers order to proactively manage an age-diverse workforce.
Encouraging occupational health and wellbeing is a valuable ongoing These may include lighting, ergonomic, grip rails, and
effort for organizations. Promotion of health through a range of other sensory and lift policy changes.
interventions (primary, secondary and tertiary) is commonplace
Relational Create systems and practices that maintain social
where health benefits are linked to work employment such as in the management connections with workers such as alumni activities,
United States and some Nordic countries. These include supervised websites and social media tools.
fitness programmes, smoking cessation, nutritional and improved
dietary intake, and return to work programmes.26 Age-diverse Implement each of the aforementioned strategies to
organizational culture facilitate an organizational culture that encourages
There are calls for organizations to place greater emphasis on inclusiveness and engagement of older workers.
interventions and adjustments that adopt a life course perspective in
addressing the health, wellbeing and workability of mature workers.27
This may include work adjustments that account for visual and
hearing changes such as improved lighting, larger signage and
volume-adjusted communication technologies.28 Ergonomic
assessments may also be important as they relate to heavy lifting.
Wellness programmes that account for unique needs of mature
women are also important, for example, osteoporosis prevention.
All these interventions have the capacity to create an organizational

culture that promotes the retention, engagement and generativity of
mature workers. Organizations that initiate these types of health and
wellbeing initiatives exemplify an active ageing approach.

Conclusion Endnotes
Organizational adaptation will be a key element in achieving the 1 OECD, Organisation for Economic Co-operation and Development. (2011) Employment Outlook.
Available at: http://www.oecd.org/employment/outlook
human resource needs for a world with fewer younger workers and 2 Seike, A. & Yamada, A. (2004) The Economics of Older Workers (in Japanese). Tokyo,
greater numbers of older workers. Where older people continue Nihon-Keizai Shinbunsha.
working, it can create a virtuous circle for public policy, whereby 3 Seike, A. (1989) The Effect of the Employee Pension on the Labor Supply of the Japanese Elderly.
individuals continue to pay taxes while not drawing down on benefits RAND Note, June. Available at: http://www.rand.org/pubs/notes/N2862.html
systems. However these policies are often perceived to be politically 4 OECD, Organisation for Economic Co-operation and Development. (2008) Pension country
profile: Sweden. Available at: http://www.oecd.org/dataoecd/22/20/42575076.pdf
difficult and resulting in forced work or work-continuation under 5 Seike, A (2008) Pensions and Labour Market Reforms for the Ageing Society. In H. Conrad, V.
insecure conditions. Heindorf & F. Waldenberger (eds) Human Resource Management in Ageing Societies. New York:
Palgrave Macmillan. Ch. 3.
The advantages of actively attracting mature-age workers are quickly 6 Bowman, D., & Kimberley, K. (2011) Sidelined! Workforce participation and non-participation
among baby boomers in Australia. Melbourne: Brotherhood of St. Laurence.
becoming apparent to individual enterprises. Polices that emphasize
7 Swann, W. (2011) Investing in experience. Speech presented to the Business Leaders Forum,
the “carrot” of age-friendly working environments mean they are Sydney, Australia. 30 March.
better placed to both retain and attract mature workers and achieve 8 Posthuma, R.A., & Campion, M.A. (2009) Age stereotypes in the workplace: Common
wider age diversity. This can be done by focusing on mechanisms stereotypes, moderators ad future research directions. Journal of Management, 35, 158-188.
that proactively engage with an age-diverse workforce from 9 Ackerman, P. L. & Rolfhus, E. L. (1999) The locus of adult intelligence: Knowledge, abilities, and
wellbeing promotion, continuous learning and flexible work practices. non-ability traits. Psychology and Aging, 14, 314-330.
Such mezzo-level initiatives are often overshadowed by macro 10 Biggs, S. & Lowenstein, A. (2011) Generational Intelligence: a critical approach to age relations.
London: Routledge.
attempts to engineer participation by removing incentives not to 11 Broadbridge, A. (2001) Ageism in retailing: Myth or reality? In Golver, I. & Branine, M. (eds.) Ageism
work, but may be equally if not a more effective cultural adaptation to in work and employment. Burlington: Ashgate. 153-174.
an ageing society. 12 Hedge, J.W., Borman, W.C. & Lammlein, S.E. (2006) The aging workforce: realities, myths, and
implications for organizations. Washington D.C: American Psychological Association.
13 Sanders, M.J. & McCready, J.W. (2010) Does work contribute to successful aging outcomes in
older workers. International Journal of Aging & Human Development, 71, 209-229.
14 U.S. Bureau of Labour Statistics (2007) Employment projections: Civilian labor force participation
rates by sex, age, race and Hispanic origin.
15 Kim, H. & Devaney, S.A. (2005) The selection of partial or full retirement by older workers. Journal
of Family and Economic Issues, 26, 371-394.
16 Villosio, C., et al. (2008) Working Conditions of an Ageing Workforce. Dublin: European Foundation
for the Improvement of Living and Working Conditions.
17 Payne, S. & Doyal, L. (2010) Older women, work and health. Occupational Medicine, 60, 172-177.
18 Manninen, O. (2011) Work among the elderly. The 13th International conference on combined
actions and combined effects of environmental factors, 12-14 September, Tampere, Finland.
19 Taylor, P., Brooke, L., McLoughlin, C. & Biase, T. (2010) Older workers and organizational change:
corporate memory versus potentiality. International Journal of Manpower, 31, 374-386.
20 Hirsch, D. (2005) Sustaining working lives: a framework for policy and practice. York: Joseph
Rowntree Foundation.
21 Phillipson, C.R. (2011) Extending Working Life and Re-Defining Retirement: Problems and
Challenges for Social Policy. In Ennals, R. & Salomon, R. (eds.) Older Workers in a Sustainable
Society. New York: Peter Lang International Academic Publishers.
22 Midtsundstad, T. I. (2011). Inclusive workplaces and older ermployees: an analysis of companies’
investment in retaining senior workers. International Journal of Human Resource Management,
22, 1277-1293.
23 Foot, D.K. (2001) Boom Bust & Echo: Profiting from the Demographic Shift in the New Millennium.
Toronto: Stoddart.
24 Biggs, S. & Lowenstein, A. (2011) Generational Intelligence: a critical approach to age relations.
London: Routledge.
25 Employers Forum on Ageing. (2011) http://www.efa.org.uk/22.8.2011
26 McDermott, H.J., Kazi, A., Munir, F. & Haslam, C. (2010) Developing occupational health services
for active age management. Occupational Medicine, 60, 193-204.
27 Bjelland, M.J. et al. (2010) Age and disability employment discrimination: Occupational
rehabilitation implications. Journal of Occupational Rehabilitation, 20, 456-4714.
28 Crawford, J.O., Graveling, R.A., Cowie, H.A. & Dixon, K. (2010) The health safety and health
promotion needs of older workers. Occupational Medicine, 60, 184-192.
29 OECD, Organisation for Economic Co-operation and Development. (2011) Employment Outlook.
Available at: http://www.oecd.org/employment/outlook

Chapter 10 Changing Human Resource Management

The end of the 20th century and the beginning of the 21st century
Ageing Workforces and was characterized by a normal business cycle with an adequate
labour supply to accommodate each phase of the cycle. Other than
Competitiveness – A possibly highly skilled workers, people were not managed as a
scarce resource. This is very different from the way companies
approach the capital goods market or potentially scarce raw
European Perspective materials. Companies use hedge techniques to minimize the risk and
volatility of these production factors, but in the past they have taken
Giles Archibald and Raymond Brood1 labour – particularly unskilled labour – for granted.
After World War II, fertility rates increased substantially in Western Because of the expected decrease of the working population, more
Europe. This led to concerns about possible future overcapacity in careful management is likely to be required on almost every kind of
the workforce. Several governments responded by encouraging job, including those requiring both high and low education levels.
retirement through social programmes and tax breaks for private
pension arrangements. Germany, Ireland, the United Kingdom and Workforce demographics are easy to predict. Yet, strangely enough,
the Netherlands enacted legislation to promote retirement. This corporations on a broad scale have not yet taken them into account.
concern about overcapacity in the workforce lasted about 30 years. However, this is changing. Our company, Mercer, is one of the largest
HR consulting firms. Our case studies, a recent survey (see Box 1)
Due to increasing longevity and falling birth rates, this concern has and personal experiences provide evidence that there is increasing
been superseded by the twin fears of future workforce scarcity and interest among companies in planning their workforce for the long
the economic burden of retirees. In the late 1980s it became clear term.
that unless the effective retirement age and women’s participation
increased, the number of people in the labour force would shrink
relative to the older population. If there were then five workers for one Box 1: Changing populations
retiree, some projections showed it would change by 2030 to
Mercer has completed a round of interviews of multinationals based
perhaps two workers for each retiree in the Netherlands, with even
in the United States, Europe and Asia Pacific to discover their
worse figures projected for Italy and Germany.
reactions to demographic changes. The survey confirmed the
Although the shifting size of the labour and retirement markets was growing awareness of the problem among large employers, which
already clear as a potential problem in the 1980s, it was not on the are considering an array of actions, including:
agenda of the political parties or corporations. Perhaps politicians • More emphasis on employer branding, including alumni networks
feared the social tensions or political consequences that might result
• More global sourcing
from implementing the required changes. Corporations had no
problem recruiting, and pension plans, which might have provided • Enhanced education and training
warning signs, had enjoyed a long period of positive equity returns • Development opportunities through job rotation, mentoring and
that masked the real cost of past promises. buddy programmes
• Flexible work time, locations and rewards
However, it was not a problem that companies and governments
could ignore forever. A change in awareness started in the 1990s and • Work-life balance
gathered pace in the new millennium. The current thinking is that • Improved knowledge management
unless measures are taken to unlock the resources available in • Better communication, including social media
healthy older populations, the demographic profile of Western
countries is a potential major hindrance to growth. • Combination of core, flexitime and temporary workers
• Counselling on financial and pension planning
Consider these two examples. The Dutch Committee on Labour
Market Participation (Commissie Bakker) predicted in 2008 that the
labour market in the Netherlands would shrink by about 8% by 2040.1
The German labour force is expected to shrink by almost 16.5% by Is Immigration the Solution?
2025, predicts market and employment research by the Institute for Perhaps one reason companies have ignored the shrinking labour
Labour (IAB), in Düsseldorf, Germany. Retirement ages are rising force is that they expect immigration will solve the problem. However,
throughout the Western world, but only slowly and, so far, this is likely to be a false hope. Education, language, lifestyle
inadequately to preserve the balance between retirees and actives. differences and the demands of native countries make immigration
only a partial solution at best. An additional, important limiting factor
is that Eastern Europe, a recent past supplier of immigrant labour, is
itself ageing.2
In addition, there is simply the scale of the problem. Based on current

demographic projections, Germany would need very substantial net
immigration to maintain a stable population. To achieve this, the
proportion of the German future workforce that would need to be a
product of immigration, either directly or through their descendants,
would be 28% by 2030. To maintain a constant proportion of those
aged over 65 to those in the 15 to 65 age group, the immigrant
percentage of the population would rise to above 80% (See Table 1).3
It is unlikely that there will be enough young people to immigrate or
who want to immigrate.

Table 1: Per cent of post-1995 migrants and their descendants in How Should Businesses Respond?
total population in 2050, by scenario and country or region
Before examining actions companies can take, it is important to
Scenario I II III IV V address the prejudices that exist against the elder workforce. Many
employers perceive that older workers are more expensive due to
Medium Variant with
Constant age group

higher wages and extra nonfinancial benefits and are less flexible
group 15-64/65
Medium Variant
dealing with change. They also perceive that older workers have
zero Migration
Constant ratio
Constant total
years or older
higher absenteeism. Evidence shows that the frequency of older
Population
worker absenteeism is lower, but the duration is longer; the opposite
15-64
Country or Region
is true with younger workers.
France 0,9 0,0 2,9 11,6 68,3 A study from the University of Utrecht by Professor Joop Schippers
Germany 19,8 0,0 28,0 36,1 80,3 shows that younger workers are more ready for change, more eager
Italy 1,2 0,0 29,0 38,7 79,0
to learn, more capable with modern technology, physically stronger
Russian Federation 5,8 0,0 22,9 27,6 71,9
and more creative.5 However, older workers are more engaged, more
United Kingdom 1,9 0,0 5,5 13,6 59,2
loyal, more client-focused and more accurate, and they have better
United States 16,8 0,0 2,5 7,9 72,7
social skills.
Europe 4,3 0,0 17,5 25,8 74,4
Interestingly, it is not proven that the younger population is more
European Union 6,2 0,0 16,5 25,7 74,7
attractive to employers than the elder cohort. Recent statistics in the
Source: United Nations. (2000) Replacement Migration: Is It a Solution to Declining and Ageing United Kingdom show that employment in the over-50 age group is
Populations? United Nations Population Division. growing slightly faster than the national average.6 The question of
relative differences in compensation costs remains. However,
younger workers on average change jobs over a much shorter
The level of labour shortage awareness varies within the European period. When the recruitment and training costs are factored in, the
Union. Awareness is generally driven by the acuteness of the difference in compensation costs is likely not large.
problem. Where unemployment is low, as in Germany and the
Netherlands, where rates are 4% to 5%, the problem is quickly If companies can develop a compensation culture that allows for
gaining prominence. more flexible pay practices, older workers can perhaps be allowed to
reduce responsibilities and consequently receive reduced pay levels
In the Dutch market, demand could create 600,000 new jobs by consistent with their contribution to the company. Additionally,
2015. However, based on demographics, the labour market will only perhaps a company’s demographics should reflect its clientele. For
grow by 225,000.4 Some industries, such as healthcare, education instance, with an ageing population, is it logical to have mainly young
and transportation, are already sounding alarm bells. employees in the retail sector?
The economic growth rate In Germany likely will be adversely A consensus appears to be building among progressive employers
affected by the country’s demographic profile. Low fertility is taking that, because of their complementary capabilities, a good mix
its toll, as indicated by the fact that apprenticeships remain unfilled. between older and younger workers lowers the workforce related
German policy-makers try to solve the problem with immigration and risks – such as turnover, skills gaps and cultural dislocation with
increased participation of women. However, as noted, immigration is customers -- and has a positive impact on the total productivity. (To
not likely to be a solution. More female workers can help, but they are see an example, refer to a 2011 study by the University Mannheim on
unlikely to be the complete solution. the Mercedes car manufacturer.)7
In other countries with high unemployment, particularly among youth, The solution to this demographic challenge probably lies in
such as France and Spain, the issue is not high on the agenda. On the companies doing more with the people to whom they have access.
basis of entitlement, there is still firm opposition against adequately This could include higher participation of previously retired workers,
raising the retirement age. The result may be that these countries will the partially disabled and women. For the existing workforce, this
lose valuable time to fully address the issue. As a consequence, the might include better engagement, better health, less absence, more
impact of the retirement of the baby boom generation will be more mobility and flexibility, later retirement, life-long learning and
abrupt. retraining.
Research done by Mercer among their clients indicates most
companies currently appear unsure as to how to deal with the issue
of an ageing workforce. This presents an opportunity for the
resourceful to gain a competitive advantage.

Learning and Retraining Case Studies

It is important to take a closer look at the issues of learning and Demographic challenges pose a serious threat to corporate growth.
retraining. Companies should review how they spend their training By advance planning and immediate action, companies can mitigate
budgets. Is more of the budget spent on younger people than on the dangers and turn threats into opportunities. Below are two case
older workers? If so, this could be the wrong answer. In an studies that describe how 3M and Lanxess have begun to address
environment where knowledge becomes obsolete so quickly, people these issues.
become less flexible if their employer stops investing in their human
capital. While less flexible younger people may be able to find jobs 3M Europe’s Human Capital Planning Model
elsewhere, older workers may be more likely to stay, thus burdening
the company with an unproductive cohort. The Issue – Severely tightening labour market in the coming years.
The workforce will age, will retire later and is more generationally
Another issue relates to support for caregivers. To help to ensure that diverse. Individual needs can no longer be captured with collective
no unwanted labour market withdrawals occur, companies must solutions. Because individuals will have to work longer, they need
address the fact that employees in an ageing environment are likely retraining throughout their careers and must accept more rapid
to be distracted by caring for their parents. changes.
Flexibility in the balance among work, life and caregiving can prevent 3M’s Challenge – How do we maintain and improve the productivity
overstretching employees and appears to be an emerging feature of of our workforce when ageing occurs within a tightening labour
progressive employment programmes. market? With an average age of 43 to 48, how do we keep everyone
productive and willing to change and adapt to the new needs?
Key Questions Proposed Solutions
To assess the actions that might work best for an organization, Implement a human capital planning model that enables the
companies should ask the following key questions: organization to adapt to the changing needs of the market and
environment. This involves:
Availability: Where and how fast will labour force shortages appear?
What is the optimum mix among full-time, part-time and flexitime • Talent development – measuring talent resignation, diversity,
work? What trends are businesses experiencing? talent externally hired vs. internally promoted, etc.
• Internal mobility as a percentage of total populations
Ageing: How is the average age of employees shifting? What will the • Human capital positions, including strategic, core, requisite and
distribution of the workforce’s ages look like in the next 8 to 10 years? non-core positions
Labour productivity: How is workforce productivity developing in • Costs of outflow and inflow, and effects of implementing lifecycle
relation to labour costs? Is there an increase due to special labour employment
situations – for instance, older workers? The focus will be on four key issues:
Absenteeism and presenteeism: What will be the expected • Acquisition of top and diverse talent
absenteeism in coming years? Is it worthwhile to invest in healthcare, • Employee engagement and retention
or should a policy to diminish absenteeism be in place? Is the current
labour force engaged, healthy and flexible? Is it as productive as it • Strategic workforce planning and productivity
might be? Can more vigorous health management increase • Talent development and an inclusive growth culture
productivity? (Presenteeism refers to employees who attend work, but
are not fully productive due to illness.) 3M has developed a human capital planning model for Western
Europe. The starting point is the business strategy, which enables
Knowledge: How is knowledge anchored in the organization with the company to determine the requisite human capital. The current
regard to the outflow of people? How does this influence the workforce will be assessed, and the gaps will be identified. This
capability to stay in business? Is there likely to be an outflow of results in a change programme that contains learning and
information when the elder generation of employees retires? development, recruiting and demand planning, and a sustainable
workforce plan.
Based on the answers to these questions, a plan might emerge that:
Lanxess – a Five-Pillar Programme
• Accepts more readily employees’ wishes for flexible working The Issue –The ageing workforce.
• Emphasizes and reinforces the importance of workforce planning
in the medium and long term Lanxess’ Challenge – How do we maintain a productive workforce as
the average age rises?
• Binds people and keeps them engaged
• Takes measures to reduce absenteeism and presenteeism
• Focuses on preventing all aspects of dropping out of the
workforce
• Facilitates lifelong learning and training the elder workforce
• Accepts and helps employees with issues such as elder care,
partial disability, immigrant families, etc.
• Regularly takes the pulse of the organization to obtain input from
employees as to how to address issues related to ageing

Proposed Solutions Endnotes

Flexible work, eldercare, flexible retirement solutions, training and a 1 Dutch Committee on Labour Market Participation. (2008) Towards a Future that Works. Available
at: http://docs.szw.nl/pdf/129/2008/129_2008_3_11930.pdf
focus on working conditions. 2 OECD. Organisation for Economic Co-operation and Development. (2011) Society at a glance
2011: OECD Social indicators. Available at: http://www.oecd.org/els/social/indicators/SAG
In Germany, Lanxess has established a five-pillar programme 3 United Nations. (2000) Replacement Migration: Is It a Solution to Declining and Ageing
consisting of: Populations? United Nations Population Division. p. 25. Available at: http://www.un.org/esa/
population/publications/migration/chap4.pdf
• An additional savings programme. This programme provides 4 Dutch Committee on Labour Market Participation. (2008) Towards a Future that Works. Available
incentives for employees to save, including the possibility of at: http://docs.szw.nl/pdf/129/2008/129_2008_3_11930.pdf
converting part of bonus payments and unused vacation into 5 Schippers, J. (2011) Langer werken gaat niet vanzelf. SERmagazine, April Issue. Available at:
http://www.ser.nl/nl/publicaties/overzicht%20ser%20bulletin/2011/april_2011/01.aspx
savings. This can be used for several purposes, including flexible 6 Office of National statistics. (2011) Labour Force Survey August 2011. Available at: http://www.ons.
retirement, part-time working, sabbaticals, etc. gov.uk/ons/rel/lms/labour-market-statistics/august-2011/lms-time-series-data.html
• A programme of continuous qualification. Lanxess sees the 7 Axel, B.S. & Weiss, M. (2011) Productivity and Age: Evidence from Work Teams at the Assembly
Line. Mannheim Research Institute for the Economics of Aging. Available at: http://www.mea.
demographic shift as a serious challenge to corporate uni-mannheim.de/uploads/user_mea_discussionpapers/1057_MEA-DP_148-2007.pdf
knowledge management. The company makes training available
to all employees, regardless of age. It plans its vocational training
– 500 young people under the various programmes by 2014 –
according to detailed demographic analysis unit by unit.
However, the company stresses that training is the mutual
responsibility of employee and employer.
• A review of working conditions. For example, Lanxess is
rethinking the shift system to make it easier for the older workers
to continue on shift work.
• Health management. This includes such issues as wellness,
ensuring a healthy culture and a change in self-awareness
• Work-life balance. In addition to childcare, for which the company
supports its own kindergarten in Germany, it also makes
eldercare an equally important priority. A company-wide
programme allows employees to reduce their hours on
advantageous financial terms to care for elderly parents. This
programme makes available special loans to employees to pay
for eldercare should they choose to stay in their job.
The largest concentration of Lanxess employees is in Germany.
However, the company is looking to extend the programme
elsewhere in the world.
Conclusion
The message is clear, yet only some companies in a few countries
seem to have heard it. Corporations have the opportunity to gain
competitive advantage through unlocking the resources available in
healthy older populations. Indeed if they fail to do so, the
demographic profile of Western countries is likely a major hindrance
to future growth


III. Pursuing Healthy
Ageing: What
healthy ageing
involves

III. Pursuing Healthy Ageing: What healthy ageing involves
Chapter 11 Highly Valuable Social and Economic Assets

However, while the demographic changes we are experiencing will
The Longevity Dividend: almost certainly present challenges, we contend that older people
are a highly significant and often underutilized resource to their
Health as an Investment community and to society as a whole. The key to unlocking this
resource is health. Without health, older people (like anyone else in
S. Jay Olshansky, John Beard and Axel Börsch-Supan the population) become less financially secure, are less productive
and risk losing their independence. With health, there is much less to
The ageing of humanity is accelerating. While a small number of distinguish older people from younger healthy, active and productive
people is known to have lived to extreme old age throughout members of society.
recorded history, it is only in the modern era that an unprecedented
number is approaching old age with regularity. Rather than being seen as a societal cost, older people in nations
throughout the world are already, in our view, highly valuable social
In the past, the main challenges to human health and longevity were and economic assets. But this significant human resource will not be
maternal mortality and communicable diseases that struck early in fully realized unless we invest in new strategic spending designed to
life; both denied access to old age for the vast majority of people. In foster good health in later life, and new strategic thinking about
developed nations today, and among increasingly larger subgroups ageing and the role of older people in society. Indeed, we contend
of the population in less-developed nations, between 80% and 90% that the economic value of a rapidly growing healthy older population
of all babies born will survive past age 65.1 Combined with falling is so great that healthy ageing should be aggressively pursued on its
fertility, these trends mean that older people are now a much larger own merits as a societal investment.4,5
and rapidly growing proportion of populations around the globe. This
trend is likely to continue until at least the middle of this century. This investment will bear a healthy return in extended years of
employment and reduced outlays for tertiary health care, as well as
Some authors view this radical transformation in our demographics other social, economic and health dividends to current and future
from an overwhelmingly negative perspective,2,3 where population generations. It will also dramatically enhance the quality of life of
ageing is often portrayed as a form of apocalyptic demography. In people reaching older ages.
their narrative, older people are perceived and portrayed only as sick
and costly members of society – threatening to strain national Humanity – Fully Vested in Life Extension
economies, overwhelm health care systems, and bankrupt public
pensions. Investing in health is not a new idea. Humanity made its first large
investment in its own health in the 19th century with the advent of
concepts of public health that made clean water, sanitation,
controlled indoor living and working environments, better nutrition,
and infectious disease control – critical elements in our everyday
lives.6 These investments brought forth the first longevity revolution.
In the 20th century, additional investments in health and longevity

were made through immunizations, modern medicine,
pharmaceuticals and life-extending medical technologies. Thus, the
notion of investing in health and longevity is already at the foundation
of an enormous and still rapidly growing suite of industries that share
one common theme – the preservation and enhancement of life.
Psychologically, economically, emotionally and in every other way,
humanity is already fully vested in life extension.
However, we now face a new and puzzling challenge. The 30 years

of additional life added to the average lifespan in many parts of the
world during the 20th century was the reward for past investments in
life extension. Now that survival to older ages is a common
occurrence, humanity is paying a heavy price for our longer lives
– the rise of a persistent array of unwelcome chronic and disabling
diseases. Cancer, heart disease, stroke, Alzheimer’s disease,
arthritis, sensory impairments and a large number of other familiar
maladies that are common among older people are, in large
measure, a product of the privilege of living long enough to
experience them.
It is important to remember that the diseases of old age should most

appropriately be thought of as products of success, not failure. Few
would challenge that the trade-off of a much longer life has been
worth the rising tide of chronic diseases. Moreover, their negative
effects on functional performance and the enjoyment of life come late
in life, in most countries usually much later than the current retirement
age.

Hence, a strategy to fully exploit the secular change in life course Another reason for the underutilization of older people is the
health patterns requires action in two dimensions. First, we need to prejudice that they are less productive than younger people simply
adapt our social and economic institutions to encourage health because they are older. There is no scientific evidence to support this
improvements at younger ages. Second, enough is now known belief. Rather, modern technology and the dominance of the service
about the etiology and treatment of most chronic diseases that, if industry over manufacturing and agriculture have equalized
identified and dealt with early enough, the maladies of old age could productivity across age ranges. While speed and dexterity have been
represent, for many, little more than nuisances requiring adaptation in shown to decline as a function of age, this is more than compensated
the later stages of an otherwise healthy life. for by increases in experience and even-handedness that often
occur at the same time.
Older Generations – an Underutilized Resource
A third cause, from an employer’s point of view, is that it is often
The extension of healthy life is a great economic advantage to cheaper for a business to discard older people than younger ones,
individuals and populations because the most important economic due to strong incentives in the pension system.9
resource is the human capacity to produce goods and services –
some within the family and society without pay, such as help and Finally, one might think that early retirement is a well-deserved choice
volunteer work, and most via markets and for pay. Extending the for more leisure and freedom from an unwanted job. However, the
years of healthy life creates additional capacity, part of which can be desire for early retirement is less widespread than often thought.
used to finance higher healthcare and pension costs. Surveys suggest that about one-third of retirees would have
preferred to work longer, but were forced to stop either by poor
Often, however, we do not utilize these resources as we could. The health or employer policies that required leaving a position due
dramatic improvement in health at younger ages, and the dynamics exclusively to chronological age. Another one-third had hoped to
of the late onset of functional disabilities due to the “new” chronic become involved in a different kind of occupation upon retirement,
diseases, are in stark contrast to our static concepts of the life course often volunteer work, but for many such opportunities were hard to
transitions, which have developed over the past century or so. These find or required more effort than previously expected. A core strategy
still follow a familiar trajectory: birth; growth and development; for reaping dividends associated with the extension of healthy life is
education; entrance into the labour force for a single lifetime career; the development of policies to foster the active participation of
marriage and family; grandparenthood and retirement. This linear healthy individuals over age 55 in formal work and informal
ordering, and at set times, may have been appropriate at a particular volunteering.
stage of our social evolution, but the dramatic demographic changes
now occurring give pause to reconsider the rigidity of this model. However, while most people up to age 70, or even beyond, in
developed countries – and many in developing countries are indeed
The concept of retirement transition, in particular, has been healthy – less-than-perfect health does prevent some older people
remarkably stable across time and countries, and appears unrelated from working. Another element in a strategy to claim the longevity
to past and current successful efforts at extending life. Even stronger, dividend is, therefore, improving the health of those 55- to 70-year-
labour force participation has fallen dramatically after age 55 in most olds who are not very healthy. Taking Europe as an example,
developed countries since the 1970s and only recently has improving the health of the sickest one-fifth of the population to the
stabilized.7 The same holds true in most developing countries for the level of the second-sickest fifth would raise labour force participation
government sector, often the only sector with a formal pension. among people aged 50 and older by about 10%.
It is a great irony of our times that labour force participation at older
ages is low in countries and sectors where people are rich and
healthy, while those who are poorer and less healthy tend to work in
agricultural or informal jobs such as street vendors until very late in life
Why is the ability to work so vastly underutilized among the richer
and healthier? One rationale often cited, especially by labour unions
and to support the idea that older people are an economic burden, is
the belief that removing them from the labour force helps to create
job openings for the young. This is wrong (the so-called “lump-of-
labour fallacy”) because it assumes a zero-sum game and ignores
the high costs of early retirement that have to be borne by younger
workers, making older workers appear to be more expensive and
thus less likely to be hired. In fact, countries with a higher labour force
participation of older workers have a lower youth unemployment
rate.8

Life Course Investments in the Health of Older Populations More ambitiously, it is worth considering that underlying most of what
goes wrong with our bodies as we grow older are underlying
In high-income countries, 94% of the “burden of disease” results biological processes of ageing that advance regardless of the
from chronic disease and injury,10 and, even in low- and middle- diseases that are commonly expressed throughout the life course.
income countries, chronic disease and injury are already the major Even if deaths from most major killers today are reduced dramatically,
causes of disease burden. These problems are caused by a the biological processes of ageing march on, unaltered by any
combination of genetic susceptibility and, importantly, behaviours progress we make against specific diseases. Of course, this process
and exposures acquired throughout the life course. In fact, diseases is not entirely unrelated to chronic disease, because age is the
expressed among older people today are often a product of events strongest risk factor for almost all of these individual conditions.
that began much earlier in life, including those caused by events over
which we have no control (e.g., the physical, social, and economic This disjointed concept of ageing and disease has evolved into its
environments into which we are born), and those that we modulate current form only in the modern era and poses both a dilemma and
through lifestyle choices. an opportunity. If society can reduce mortality rates from chronic
diseases, we are likely to enjoy moderately longer lives in better
Health events influenced by the choices we make represent the health. However, because ageing itself is unaltered by simply
low-hanging fruit of public health, because a significant proportion of reducing the risk of disease, this approach is likely to run out of steam
the current burden of disease can be reduced by delaying or and eventually yield diminishing gains in both health and longevity.
preventing chronic diseases through interventions to promote healthy
behaviours, or by the early detection and management of either the By contrast, the opportunity that is before us arises from knowing
disease or its behavioural risk factors. Classic examples include that the biological process of ageing is a risk factor for most of what
smoking and the rise of adult-onset and childhood-onset overweight goes wrong with us as we grow older. Slowing down the processes
and obesity. Policies to discourage the adoption of smoking, such as of ageing – even by just a moderate amount – will yield dramatic
taxing cigarettes, or to encourage existing smokers to quit, will improvements in health for current and all future generations.
reduce the subsequent risk of much chronic disease.11 Furthermore, evidence from scientists who study the biology of
ageing suggests that this is a plausible goal for modern medicine in
Because good health in older age is not achieved in isolation from the the near term.20,21,22 Advances in the scientific knowledge of ageing
rest of the life course, investments now in health at younger and middle may thus create new opportunities that allow us, and generations to
ages are therefore likely to yield a healthier and longer-lived older follow, to live healthier and longer lives than our predecessors. We
population in the future. Thus, a sound strategy for investing in the have reached a historical moment, as scientists learn more about
health of older people requires both a life course perspective that slowing the underlying processes of ageing, to postpone a wide
addresses the immediate needs of people who have already reached range of fatal and disabling diseases expressed throughout the
older ages, and a strategy designed to promote healthy behaviours lifespan. The result, if successful, would be health and economic
earlier in life so that younger cohorts today can be healthier when they benefits for current and all future generations.
reach older ages in the future.12
There have recently been enough important new advances in this
These should include policies that promote healthy behaviours; area of science that some find it reasonable to conclude that the
education throughout the life course; regular screening for risk factors technical means to slow ageing in people is a plausible goal. For
and early treatment to minimize the consequences of chronic disease; example, research has dispelled the old belief still held by some that
the effective management of more advanced disease through tertiary ageing is an immutable process that was genetically programmed by
care and rehabilitation; the creation of age-friendly environments that evolution.23 Indeed, because there can be no ageing or death genes
foster both a healthy lifestyle at younger, middle and older ages; and that arose under the direct force of evolution,24,25 interventions
the active participation of older people in society.13 designed to slow ageing in people may have fewer genetic barriers to
success than might be otherwise expected. At least some of the
A New Way to Invest in Health manipulations that appear to slow ageing in animal models do just
There are still many unknowns related to the future course of health and this, maintaining excellent physical and cognitive functioning well
longevity. While it is clear that most nations have extended lives,14 it is beyond the usual ages at which illness and disability start to affect
uncertain how much longer this trend can continue.15 Furthermore, most untreated individuals.26 In fact, interventions that slow ageing
there is mounting evidence that some populations or population have the potential to do what no surgical procedure, behaviour
subgroups may be on the verge of a decline in life expectancy because modification or cure for any one major fatal disease can do; namely,
of worsening health among recent cohorts approaching retirement extend youthful vigour throughout the lifespan.
ages,16 while other subgroups could experience life-expectancy
Combined, these new approaches to health promotion, disease
increases that extend beyond current official government forecasts.17
prevention and ageing itself have been referred to as the pursuit of
Perhaps more importantly, it is uncertain whether the added years of life
the “longevity dividend”,27 although the idea of slowing ageing is not
that are a recent product of investments in life extension are going to be
new.28,29,30,31 This notion is complemented by other scientists who
healthy or unhealthy.18
have documented the economic benefits associated with rising life
What is complicating the portrait of health and longevity today is the expectancy32,33 and discussed the prospects of success in slowing
current medical model that approaches chronic degenerative diseases ageing and the various benefits that would accrue to society as a
in much the same way communicable diseases were addressed more result.34,35,36
than a century ago – one-at-a-time,as they arise. The underlying
premise of this model is that all diseases are treated as if they are
independent of each other19 – having their own independent origin and
etiology. Scientists know this is not true. Many of the behavioural risk
factors for chronic disease relate to more than one condition, and even
the physiologic mechanisms are not unrelated. Older people, in
particular, often suffer from more than one condition at a time. The
broad strategies to foster health in old age therefore need to be
centered on a new horizontal model that seeks to prevent the root
causes of disease and disability, rather than a vertical approach that is
targeted to individual disorders.
Conclusion Endnotes
Investing in health is equivalent to any other type of investment in 1 Human Mortality Database. (2012) www.mortality.org
2 Kotlikoff, L. & Burns, S. (2005) The Coming Generational Storm. Cambridge: MIT Press.
human capital – it has the potential to generate substantive health
3 Peterson, P. (2000) Gray Dawn. New York: Three Rivers Press.
and economic dividends. However, for policy-makers to tap into the
4 Olshansky, S.J., Perry, D., Miller, R.A. & Butler, R.N. (2006) In pursuit of the Longevity Dividend.
vast wealth of current and future generations of older persons, they The Scientist, 20(3), 28-36.
are first going to have to dispel the myth that older people are only a 5 Butler, R.N. et al. (2008) New model of health promotion and disease prevention for the 21st
drain on society. We suggest here that the best way to unlock the century. British Medical Journal, 337, 149-150.
huge social and economic resources of an ageing population is to 6 Riley, J.C. (2001) Rising Life Expectancy: A Global History. Cambridge University Press.
invest in health throughout life, and then to ensure social adaptation 7 Whitehouse, E. & Queisser, M. (2007) Pensions at a Glance: Public policies across OECD
that fosters the ongoing contribution of these resources. A full life countries. Available at: http://mpra.ub.uni-muenchen.de/16349/
8 Gruber, J. & Wise, D. (2001) An International Perspective on Policies for an Aging Society. NBER
course perspective is required that understands and appreciates Working Paper, No. 8103.
how investments in health at all ages produce health and economic 9 Gruber, J. & Wise, D., eds. (1999) Social Security and Retirement Around the World. Chicago:
benefits today and for generations to come. University of
Chicago Press.
Two types of investments in health are warranted, and we contend 10 Lopez, A.D. et al. (2006) Global and regional burden of disease and risk factors, 2001: systematic
that both should be pursued simultaneously. One involves a life analysis of population health data. Lancet, 367, 1747-57.
course perspective where investment in improved health among 11 World Health Organization & World Economic Forum. (2011) From Burden to “Best Buys”:
Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income
older people is achieved by encouraging improvements in Countries. Geneva: WEF.
behavioural risk factors at all ages and by the early detection and 12 World Health Organization. (2002) Active Ageing: A Policy Framework. Available at: http://
treatment of chronic disease. This investment will ensure that healthy whqlibdoc.who.int/hq/2002/who_nmh_nph_02.8.pdf
ageing becomes possible for current older generations, as well as for 13 World Health Organization. (2007) Global Age-friendly Cities: A Guide. Available at: http://
whqlibdoc.who.int/publications/2007/9789241547307_eng.pdf
younger generations that will benefit immediately while they are
14 Christensen, K., Doblhammer, G., Rau, R. & Vaupel, J.W. (2009) Ageing populations: the
young and then later in life as they grow older. challenges ahead. Lancet, 374, 1196-2008.
15 Olshansky, S.J. & Carnes, B.A. (in press) Zeno’s Paradox of Immortality.
The second investment is to attack the seeds of biological ageing 16 Reither, E.N., Olshansky, S.J. & Yang, Y. (2011) Forecasting the Future of Health and Longevity.
itself as a way to postpone all of the infirmities of old age Health Affairs, 30(8),1562-1568.
simultaneously. The latter approach requires modern medicine to 17 Olshansky, S.J. et al. (2009) Aging in America in the Twenty-first Century: Demographic Forecasts
understand and appreciate the weapon that research on ageing from the MacArthur Research Network on an Aging Society. The Milbank Quarterly, 87(4),
842-862.
represents for its ability to postpone the diseases that accompany
18 Crimmins, E. & Beltran-Sanchez, H. (2011) Trends in Mortality and Morbidity: Is there a
old age. Because prolonged, chronic illness is a powerful driver of compression of morbidity? Journal of Gerontology: Social Sciences, 66, 75-86.
medical costs, enormous cost savings would also be achieved if 19 Butler, R.N. et al. (2008) New model of health promotion and disease prevention for the 21st
mortality and morbidity could be compressed within a shorter century. British Medical Journal, 337, 149-150.
duration of time at the end of life. 20 Kirkwood, T. (2008) A systematic look at an old problem. Nature, 451, 644-7.
21 Martin, G.M., Bergman, A. & Barzilai, N. (2007) Genetic determinants of human health span and
Extending the duration of physical and mental capacity would permit life span: progress and new opportunities. PLoS Genet, 3, 125.
22 Miller, R. (2009) “Dividends” from research on aging: Can biogerontologists, at long last, find
people to remain in the labour force longer, amass more income and something useful to do? Journals of Gerontology, Series A: Biological Sciences and Medical
savings, and thereby lessen the effect of shifting demographics on Sciences, 64(2), 157-160.
age-based entitlement programmes, with a net benefit to national 23 Butler, R.N. et al. (2008) New model of health promotion and disease prevention for the 21st
economies for those now alive and for all future generations. century. British Medical Journal, 337, 149-150.
24 Kirkwood, T.B.L. (2005) Understanding the Odd Science of Aging” Cell, 120(4), 437–47.
25 Olshansky, S.J., Hayflick, L. (2011) Public policies intended to influence adult mortality. In: Rogers,
R.G. & Crimmins, E.M. (eds) International Handbook of Adult Mortality. USA: Springer.
26 Baker, D.J. et al. (2011) Clearance of p16Ink4a-positive senescent cells delays ageing-associated
disorders. Nature, 479, 232–236.
27 Butler, R.N. et al. (2008) New model of health promotion and disease prevention for the 21st
century. British Medical Journal, 337, 149-150.
28 Goddard, J.L. (1977) Extension of the Lifespan: A National Goal? In: Neugarten, B.L. & Havighurst,
R.J. (eds.) Extending the Human Life Span: Social Policy and Social Ethics. Chicago: National
Science Foundation. pp. 19–26.
29 Hayflick, L. (1977) Perspectives on Human Longevity. In: Neugarten, B.L. & Havighurst, R.J. (eds.)
Extending the Human Life Span: Social Policy and Social Ethics. Chicago: National Science
Foundation. pp. 1–12.
30 Holliday, R. (1984) The Ageing Process is a Key Problem in Biomedical Research. Lancet, 2,
1386–87.
31 Strehler, B. (1975) Implications of Aging Research for Society. Federation Proceedings, 34(1), 5–8.
32 Murphy, K.M. & R.H. Topel. (2006) The Value of Health and Longevity. Journal of Political
Economy, 114(5), 871–904.
33 Nordhaus, W.D. (1998) The Health of Nations: Irving Fisher and the Contribution of Improved
Longevity to Living Standards. Discussion Papers 1200, Cowles Foundation Yale University.
34 Miller, R. (2009) “Dividends” from research on aging: Can biogerontologists, at long last, find
something useful to do? Journals of Gerontology, Series A: Biological Sciences and Medical
Sciences, 64(2), 157-160.
35 Rattan, S.I.S. (2005) Anti-ageing Strategies: Prevention or Therapy? EMBO Reports, 6, S25–S29.
36 Sierra, F., Hadley, E., Suzman, R. & Hodes, R. (2008) Prospects for Life Span Extension. Annual
Review of Medicine, 60, 457–69.

Chapter 12 Demographic Destiny

By 2030, 16.5% of the world’s population will be 60 and older. This
Design and Operation of will rise to 22% by 2050. In most developed countries, the proportion
of those 60 and older has already arrived at, or exceeds, these levels.
Health Systems in Wealthy Expected longevity at birth in some countries is near or even above
80, and those who reach 65 can expect to live another 15 or more
years, on average.
Industrial Countries It is well recognized that older adults are significant users of
Linda P. Fried, Paul Hogan and John W. healthcare out of proportion to their numbers in the population. This
is because both physiological and social vulnerabilities are greater at
If demography is destiny, then our destiny should be proactively oldest ages and because chronic health problems have had time to
shaped for the better by attention to major demographic changes. A accrue over a lifetime.1
major victory of the 20th century has been the lengthening of lives
due to public health – especially the prevention of disease – and The health status of older adults and medical care use are thus major
medical care, coupled with education and poverty alleviation. The factors in driving healthcare costs for developed countries. At the
health systems of wealthy industrial countries have been at the centre same time, it has also been established that the ageing of
of some of the greatest miracles of human history. They have virtually populations is a major positive factor in the wealth of countries.2 The
eliminated or largely defeated some of the most dread diseases ever economic benefits can be secured if people live their longer lives in
experienced by humans, such as smallpox and polio. They have better health status.3 From an economic perspective, healthy ageing
solved medical mysteries and have provided treatments that extend is a key to controlling healthcare costs.
life and improve the quality of life for millions.
We now understand many of the contributors to healthy ageing and
It is no exaggeration to say that public health and modern medicine health of older people, how they change with age, and how health
must be credited with the most significant contributions to the systems, if matched to this, could both improve health and lower
longevity bonus the world now enjoys. The resulting success of costs. This will require proactive approaches to evolving our health
longer lives is happening worldwide, in almost all developed and systems to support healthy ageing through provision of age- and
developing countries. stage-appropriate prevention, along with care and/or palliation
matched to the goals and needs of the individual. This will require a
Longer lives come with altered healthcare and prevention needs. health workforce educated to accomplish this. We posit that the
Thus, the health systems of wealthy industrialized countries must changes made towards a health system that supports the health of
change in response to the miracle they have produced. This chapter older adults will also be a better health system for people of all ages.
provides background on the lengthening of people’s lives and the
associated changes in health needs. It then covers five fundamental This chapter addresses the health needs and associated directions
areas in which change must come to match these needs. There is in which health systems in developed countries must evolve in
sufficient scientific evidence to indicate recommendations for action. response to the ageing of society and to optimize health across the
The challenge is to set goals and vision and to implement a cross- full life course. However, the principles are also relevant to less
sectoral plan. developed countries, which are ageing rapidly due to successes of
investments in development and public health. In fact, developing
countries will age in the next 40 years to the level that took developed
countries 100 years to achieve.4 They will have the opportunity to
move directly to designing health systems that benefit from the
learned principles articulated below, assuming availability of
resources.

Health Status and Needs of Older Adults Change with Age Optimizing Our Demographic Destiny – Recommendations
Over ages 65-70, about 50% of older adults in the United States have Setting Values and Goals
two or more chronic diseases.5 Some are living with these diseases To evolve a system effectively and favourably, we need to build on
without compromise; others have symptoms or resulting disability. In cutting-edge knowledge of what improves health with ageing; invest
general, half have some difficulty with walking, and 10% to 20% need in systems that can provide prevention, care and palliation in correct
help with tasks of daily life. In addition, the internal changes in the proportions and across an integrated continuum; and offer
body due to ageing itself lead to decreased resilience and reserves, prevention across the life course so that individuals arrive at older age
or frailty; increased vulnerability to stressors such as extremes of healthier. The US Institute of Medicine6 and the World Health
heat and cold; and slower recovery from illness. Organization Active Ageing policy framework7 (Table 1) have
convened several task forces over the last decade which can inform
Frailty and some chronic diseases lead to increased risk for acute goals and conditions for systems needed.
illnesses such as influenza and to disability and falling, with resultant
fractures and injuries. Further, vulnerabilities and health problems can The recommended focus is dual: prevention across the life course
be exacerbated by social and psychological challenges with ageing: including old age, and patient-centered care tailored towards the
whether one has sufficient money for food, housing, medications, needs and goals of the individual. This implies core values of
social supports to prevent isolation and community services to help investing in health promotion for the population broadly and
those who are disabled be able to live in the community. supporting the needs of the individual in a way that optimizes
autonomy and is appropriate to health status. With these goals,
It is anticipated that the growth of the oldest-old population, now the health-related responsibilities need to be allocated clearly,
largest growing segment of older adults, will also bring increased appropriately and cost-effectively to individuals (e.g., for self care
personal care needs. Most of these issues affecting health are highly needs, with necessary education to accomplish these), to the health
amenable to prevention and/or responsive to medical care; others system, communities, government and the private sector. Health is a
are humanely addressed by supportive care. Because there is high cross-sectoral responsibility.
variability in health status and therefore variability in care needs
between different older adults, a health system has to be able to Re-engineering the Medical Model
effectively target both prevention and care to address every patient’s The medical care model of wealthy industrial countries has been
unique goals and health status. challenged by its own success and the resulting costs. The model for
most countries was created at the early stages of the antibiotic era,
and before either the ageing of the population or the development of
our current knowledge as to how to prevent or care for chronic
disease. This chapter proposes that:
1. Demographic pressures, cutting-edge medical and personal-
care support, and prevention knowledge hold the potential to
improve our systems so that they create health for longer lives at
affordable costs. This will require major transitions: (i) paying
more attention to prevention and public health; and (ii) moving
from hospital, acute care and institutuional care to community-
based care.
2. Principles for consideration have been set forth by the US
Institute of Medicine report: Retooling for an Aging America:
Building the Healthcare Workforce.8 As stated in this report, “the
health needs of the older population need to be addressed
comprehensively, services need to be provided efficiently, and
older persons need to be partners in their own care.” The report
recommends principles for a health system that would
accomplish this. “Effective features of new models with the
strongest evidence of success in improving care quality,
health-related outcomes, or efficiency are: interdisciplinary team
care; care management; chronic disease self-management
programmmes; pharmaceutical management; home care (even
including non-medical care); preventive home visits; proactive
rehabilitation; caregiver education and support; and transitional
care.” New models of geriatric care offer cost-effective
approaches to optimizing health outcomes for older adults.9
These systems must be supported by geriatrically
knowledgeable professionals.10 They would most effectively be
organized within a coordinated continuum of both prevention and
care that spans home, community, clinic, hospital and long-term
care settings, with integrated communication across these, and
transitions from one setting to another carefully managed.
Targeting the individual will require matching the model of care
needed to the status and goals of the patient. Increasing illness
complexity, disability and frailty necessitate increased team-
based care.

3. Health systems for older adults that optimize health in ageing Education of Health Professionals
must include more than care to respond to the presence of Health professionals need to be educated in geriatric knowledge
illness. Prevention matters, both for the individual and for about how health needs change with age. They must know how,
communities.12 Prevention for older adults includes primary, when and even where to implement appropriate prevention and care
secondary and tertiary prevention of disease or geriatric for older adults, as well as when a person is at the end of life and
conditions of falls and frailty – such as through physical activity, palliation is appropriate. They must also know the value of – and how
nutrition, smoking cessation and injury, pain, depression and to work in – the systems which support improving health with ageing.
polypharmacy prevention; control of disease, such as diabetes, There is significant evidence that such geriatrically knowledgeable
heart disease and blood pressure to prevent worsening and care contents and systems improve health outcomes and can
sequellae; and prevention of loss of independence from these decrease healthcare costs.13
conditions. These require both individually targeted and
environmental approaches. To accomplish this, health systems also need to support geriatrically
Examples of prevention in communities are the creation of safe competent prevention, as well as treatment of chronic diseases and
places for older adults to walk and to remain active, self-care geriatric conditions, as noted above. Nations need to invest in
programmes for groups of older adults with a chronic disease educating all health professionals to be competent in these issues
such as diabetes, or supportive programmes for grandparents and train an adequate number who are experts in geriatrics.
raising grandchildren or families caring for someone with
Alzheimer’s Disease. Further, prevention of chronic, or non- These medical professionals also need to be well informed regarding
communicable, disease needs to be incorporated into both the new, innovative senior care options that over the last few decades
individual care and community-based prevention for infants, have made the traditional “home or nursing home?” quandary
children, young and middle-aged, as well as older adults, so that completely obsolete. For instance, professional, non-medical home
people are living longer lives in greater health. care has been in formal existence for less than 20 years, but it is now
4. The healthcare needs of the older population are diverse, and helping millions of seniors around the world remain in their own
addressing those needs will require varying models of care and homes, where they generally want to be, for as long as possible.
effective targeting. Moreover, research indicates that non-medical care can very
effectively complement medical care in today’s highly evolved senior
5. Community-based personal care should be offered to support care continuum.
independence, autonomy and ability to age “in place”, in one’s
home. Supportive care is needed by as much as 20% of older These approaches would support the recent recommendations of
adults. This needs to be planned for and delivered across a the Rockefeller-sponsored Global Independent Commission on
variety of settings: home, community and institution. The Education of Health Professionals for the 21st Century.13 This kind of
changes needed require cross-sectoral planning and will health system, designed for the heterogeneity and vulnerability of
necessitate sustained leadership. older adults, would result in a better health system for all ages.
Health Promotion through New Roles and Meaningful Engagement
While the subset of the population who are ill and/or at the end of life,
at whatever age, require supportive medical, community and family
care, many older people are not in that situation and, in fact, now
have a long period of healthy life ahead of them. This extended
period of healthy life, in the 60s, 70s and even 80s, has been called
the “third age”. This offers an opportunity for productive engagement
in ways that are both meaningful to the individual and beneficial to
society and – if well designed – could also be key components of
promoting health for older adults. Proactive preparation will help us
realize this potential.
Defining Sectoral and Cross-sectoral Responsibilities
Transforming health systems to address demographic changes and
implement new knowledge will require partnership across sectors,
i.e., between government and the corporate sector – first, on shared
goals, and second on aligned implementation. The economy in
industrialized countries requires control of, and decreases in,
healthcare costs. All sectors require a healthier population to be
economically productive.14 At the same time, this is a basic
commitment of a government to its people.

Conclusion Endnotes
Advances in re-engineering our current healthcare systems to 1 Fried, L.P. (2011) Epidemiology of Aging: Implications of the Aging of Society. In: Goldman, L. &
Schafer, A, I. (eds) Goldman’s Cecil Medicine. 24th Edition. Ch. 22.
become health systems for populations with longer lives should be 2 European Economy No. 2/2009 — The 2009 Ageing Report : Economic and budgetary
shared between developed countries and developing countries. This projections for the EU-27 Member States (2008-2060) Luxembourg: Office for Official
will require developed countries to bear clear responsibility, with Publications of the European Communities 2009 — 444 pp. — 21 × 29.7 cm ISBN 978-92-79-
11363-5 DOI 10.2765/80301.
systems to communicate and facilitate transfer of best practices in
3 Fried, L.P. (2010) Longevity and aging: the success of global public health. In: Parker, R. &
many directions. Sommer, M. (eds) Routledge Handbook on Global Public Health. London: Routledge.
4 Aboderin, I. et al. (2002) Life Course Perspectives on Coronary Heart Disease, Stroke and
Investment in integrated health systems, including prevention and Diabetes: Key Issues and Implications for Policy and Research. Geneva: World Health
healthcare, that match health needs in an ageing world, should result Organization.
5 Center for Disease Control and Prevention. (2003) Healthy Aging: Preventing Disease and
over the long term in high return on investment for society, and will be Improving Quality of Life Among Older Americans. Department of Health and Human Services.
required to transform to a positive ageing world. Investments in Available at: http://www.cdc.gov/nccdphp/publications/aag/pdf/healthy_aging.pdf
geriatrically informed health systems and in prevention across the life 6 Rowe, J.W. (2008) Retooling for an Aging America: Building the Health Care Workforce.
course are critical to living longer lives and being healthy. Washington, DC: The National Academies Press.
7 World Health Organization. (2002) Active Ageing: A Policy Framework. Available at: http://
whqlibdoc.who.int/hq/2002/who_nmh_nph_02.8.pdf
These approaches will result in a decreased burden of disease and a
8 Rowe, J.W. (2008) Retooling for an Aging America: Building the Health Care Workforce.
successful compression of morbidity into the latest points in the Washington, DC: The National Academies Press.
human lifespan. While not yet experienced broadly, this should 9 Ibid.
decrease healthcare costs and amplify the benefits to society of 10 Ibid.
being an ageing world. 11 Fried, L. P. (In Press) What Are the Roles of Public Health in an Aging Society? In Binstock, R.,
Prohaska, T. & Anderson, L. (eds) Public Health for an Aging Society.
12 Rowe, J.W. (2008) Retooling for an Aging America: Building the Health Care Workforce.
Washington, DC: The National Academies Press.
Table 1: Active Ageing: A Policy Framework, World Health Organization
13 Frenk, J. et al. (2010) Health professionals for a new century: transforming education to strengthen
health systems in an interdependent world. Lancet. 376(9756),1923-58.
Health
14 Bloom DE, Canning D (2009) Population health and economic growth. In: Spence M, Lewis M,
Prevent and reduce the burden of excess disabilities, chronic diseases and editors. Health and growth: commission on growth and development. Washington DC: The World
premature mortality. Bank.
Reduce risk factors associated with major diseases and increase factors that
protect health throughout the life course.
Develop a continuum of affordable, accessible, high quality and age-friendly
health and social services that address the needs and rights of women and
men as they age.
Provide training and education to caregivers.
Participation
Provide education and learning opportunities throughout the life course.
Recognize and enable the active participation of people in economic
development activities, formal and informal work and voluntary activities as they
age, according to their individual needs, preferences and capacities.
Encourage people to participate fully in family and community life as they grow
older.
Security
Ensure the protection, safety and dignity of older people by addressing the
social, financial and physical security rights and needs of people as they age.
Reduce inequities in the security rights and needs of older women.

Chapter 13 Pressure on Health Systems

The fact that populations, including those at low-income levels, are
Design and Operation of older than before erects major hurdles for healthcare systems for two
reasons. First, older people have a higher proportion of NCDs (as
Health Systems in Developing compared with infectious diseases) than younger people. This
means that health systems will need to be reoriented toward treating
NCDs, including the “big four” that were the focus of the United
Countries Nations High Level Summit in September 2011: cardiovascular
disease, chronic pulmonary disease, diabetes and cancer. These
David E. Bloom, Ajay Mahal and Larry Rosenberg1 diseases typically require many years of treatment and care, often
For decades, health systems in developing countries have faced until death. Moreover, it is common for older people to have more
numerous challenges – from populations with both communicable than one chronic disease at a time.
and non-communicable diseases (NCDs) to inadequate resources Second, NCDs are relatively costly to treat, resulting in upward
and political environments that sometimes impede effective pressure on health system expenditures. A recent report2 estimates
responses to almost any problem. Now, another challenge is that the total cost (i.e., the output loss) of the “big four” NCDs over the
emerging. Developing country populations are ageing at an next 20 years in low- and middle-income countries will be roughly
accelerating pace – one that is much quicker relative to income than US$ 14 trillion. By comparison, GDP for these countries in 2010 was
has occurred for today’s rich countries. US$ 20 trillion.3 How about overall healthcare outlays? World Bank
It has become common to point out that developing countries are data for 2009 indicate that total health spending per capita for 129
“getting old before they get rich”. In 1980, as Table 1 shows, only low- and middle-income countries averaged US$ 365 – with average
16% of countries in the second poorest quartile had at least 7% of public spending per capita on health about 55% of that figure (US$
their population aged 60 or over, compared with 81% at the wealthy 202). Among these countries, total health spending and public
end of the spectrum. But by 2010, the figure had risen to 50% for the spending on health both increase on a per capita basis with the
second poorest quartile and to 87% (from 50% in 1980) for those in share of the population aged 60 and over (holding constant 2009
quartile 3. income per capita). If these relationships hold in the years ahead, the
UN Population Division’s 2050 projections of population shares for
those aged 60 and over would translate into a 27% increase in
average total health spending per capita for these countries, and a
Table 1: Developing countries are ageing faster than today’s industrial 29% increase in average public spending on health per capita.4
countries did
With countries assigned to

the 1980 quartile into which
they would fall based on
Fraction of countries with their 2010 income: fraction
Quartile1 60+ share >7% in 1980 with 60+ share >7% in 20102
Q1 (poorest) .03 .06

Q2 .16 .50
Q3 .50 .87
Q4 (richest) .81 .95
Source: Country income levels from World Bank, World Development Indicators, 2011; age data from
UN, World Population Prospects: The 2010 Revision.
1
Measured in terms of GDP/capita, expressed in terms of purchasing power parity.
2
Based on a re-categorization of countries using their 2010 income (with all incomes, in both years,
expressed in constant 2005 international dollars).

All of these challenges are magnified by changes in the context in Business-as-Usual Health System Scenario
which population ageing is taking place, some of which have both
upsides and downsides for health systems. The stepped-up budget and demand pressures from population
ageing will be difficult to respond to. In fact, many countries will not
• Population is increasing. Even without a rise in the older have the resources to adapt, improve, or expand their healthcare
population’s share, a rise in the population’s absolute size will be systems, especially if they have only been able to establish minimal-
accompanied by a corresponding increase in the absolute level services without effective integration. What might a business-
number of older people. as-usual scenario look like?
• Income per capita is rising in most countries. This is a plus, in that Inadequate Healthcare Supply
a higher standard of living should mean more resources to tackle
problems. But it also may mean rising levels of overweight and Increasing numbers of older people will lead to a rising demand for
obese populations, due to higher consumption of unhealthy (high healthcare, and the increasing complexity and chronicity of the
fat/high calorie) food. conditions they have will require more expensive interventions.
Individuals with advanced chronic disease who experience a
• In many countries, the labour force is gradually shifting from diminution of physical and cognitive capacity for self-care, and for
agriculture and manufacturing to services, in which sedentary whom there is no one else to care, will put pressure on hospital beds.
jobs comprise a higher share. Dementia, in particular, whose incidence increases with age, will
• People in nearly all countries are continuing to move to cities. This become more prevalent in the community, with associated demand
is a trend that tends to be associated with less space for for long-term care from family and health/social systems.
recreation and exercise, but could also mean economies of scale
in elder care. Out-of-Date Healthcare Systems
• Many low- and middle-income regions are experiencing a brain As economies continue to develop in parallel with population ageing,
drain of younger skilled individuals, associated importantly with NCDs will become more common, while the prevalence of infectious
international out-migration and the in-migration of medical diseases, maternal and perinatal conditions, and nutritional
personnel to urban areas. This exacerbation of gaps in the health deficiencies will decrease. Health systems that have been designed
workforce undermines the ability of poorer countries and regions to address the latter will need to be re-engineered to respond to
within them to meet the needs of their older populations. more chronic challenges, with more demand for rehabilitation,
longer-term follow-up, and long-term care. In addition, because
• Technological change, driven by improvements in diagnostics some NCDs potentiate others, healthcare providers will increasingly
and treatments in the industrial countries, is making some have to deal with co-morbid NCDs. For example, diabetes often
aspects of healthcare ever more expensive through demands for leads to cardiovascular disease or kidney failure, and mental illness
similar interventions from an increasingly better-informed can increase the risk of diabetes and possibly cardiovascular
population in developing countries. But technological innovation, disease.
such as support for health workers through mobile phones, also
offers exciting opportunities for innovative approaches to Insufficient Human Resources for Health
healthcare delivery in low- and middle-income countries. As people live longer and suffer from conditions that require ongoing
• Healthcare programmes compete with numerous other pressing care, more health workers will be needed at the same time that the
priorities (such as education, infrastructure, security and proportion of the population of traditional working age falls. Health
administration) as governments seek to create a sustainable workers will still, of course, be needed to provide acute care, but
environment for development. because so many will be needed to deal with NCDs (including
• In many developing countries, longstanding assumptions about multiple co-morbid NCDs), their training will have to be modified
families taking care of older people, including healthcare accordingly. This is a difficult shift, as the experiences of more
expenses, are breaking down as young people move to cities, developed, already aged societies have proven, because it requires a
more women enter the labour force, couples have fewer children societal capacity to look ahead, which is particularly tough in
and intergenerational spacing becomes greater. Absent resource-constrained environments.
adequate health insurance, the burden of financing healthcare for Greater Inequalities
older people will increasingly shift to public institutions.
Technology will become ever more important for care delivery. But
Against this backdrop, in which the challenges are very much in flux, because it is most often created in developed countries where cost,
what should policy-makers do? We see two possible routes: passive although important, is not as central a consideration as in developing
acceptance/business-as-usual scenarios or active, innovative countries, its adoption may promote further health inequities
responses. between and within countries. In a large number of countries where
healthcare is at least partially offered on a fee-for-service basis, those
who cannot pay will not benefit from new health technologies, while
those who can will tend to live longer and healthier lives.

Active, Innovative Response Scenario Reforming Healthcare Worker Training

But these bleak outcomes need not occur. A more proactive stance This will include a concentrated effort to refocus healthcare workers’
will allow countries to better respond to the new demands that training on NCD prevention, early detection, treatment and care. In
population ageing and associated circumstances will place on their addition, given that ageing is a lifelong process, and prevention at
health systems. Moreover, because ageing will be occurring in many early ages tends to lead to healthier lives in later years, a life-course
instances alongside socioeconomic development, a number of perspective is paramount, which also requires a shift in the way
opportunities can arise that allow countries to build more effective health professionals are trained.
systems in an affordable and coherent manner. What would an Encouraging Rural Healthcare Workers
active, innovative response scenario entail?
Countries that successfully encourage healthcare workers to settle in
Creating Systemic Building Blocks rural areas and that take measures to combat the departure of
A series of systemic building blocks should be identified that might healthcare workers from those areas (or from the country entirely) will
be put in place at different levels of economic development to ensure clearly benefit. In some countries, older people would benefit
a continuum of coordinated and quality care, once a certain level of disproportionately, as the movement of young people from rural
wealth is achieved. In the early stages of development, key blocks areas to cities has left the countryside with older people whose
would include: treatment and care needs are not being met. One approach that may
be useful is instituting scholarships for healthcare training that are
• Providing a basic level of primary care with a focus on chronic conditional on a period of post-training service (either in-country or in
disease prevention (such as anti-hypertensive therapy) rural areas).5
• Addressing the basic care needs of those with advanced chronic
Focusing on Technology
disease and providing basic palliative care to ensure that people
die with dignity There is an urgent need to develop or adapt technological
innovations appropriate for low- and middle-income countries. This
• Offering universal access to these services for older age groups,
applies equally to prevention, screening, diagnosis, treatment and
such as those over age 70
care. Especially promising are the use of computers in keeping
As economies strengthen, universal access might be extended to patient records and the use of mobile devices in accessing those
younger ages. At the same time, more complex services might be records and in conveying data on patient health to skilled
introduced, with an emphasis on integrating them with the more practitioners who can then provide medical advice in real time.
basic primary care that would already be in place, thereby serving as
a natural conduit to secondary, and ultimately, tertiary, services. Targeting the Poor
Institutional innovations matter greatly if they can meet the challenge
Emphasizing Prevention and Non-Communicable Diseases of scaling up from demonstration projects to much broader
Primary prevention efforts must include measures aimed at reducing populations. In India, the Aravind Eye Care Hospital, a for-profit
the incidence of NCDs, even though in many countries, infectious institution, has treated more than 2 million patients in the past two
diseases and maternal and perinatal conditions still afflict substantial years. Its doctors have performed surgery on more than 300,000
segments of the population. Secondary prevention efforts – early poor Indians, an achievement made possible by cross-subsidies
detection of diseases, treatment to impede their further development from richer patients. Similar innovations are taking place elsewhere in
and complications, and public education to facilitate such prevention India, in the Apollo Hospitals and Narayana Hrudayalaya Hospitals.
– can be more costly, but failure to carry them out can be even more
expensive in the long run. A key aspect of prevention is screening, The Einstein Hospital in São Paulo, Brazil, which supports a
but it must be implemented carefully, given that for many diseases, foundation that provides excellent care to hundreds of thousands of
targeted screening is more cost-effective than mass screening. In poor people, is regarded as one of the city’s best private hospitals.
older segments of the population, however, the cost/benefit ratios Not surprisingly, these efforts are inspiring similar activities in other
are often different than in younger segments, so the efficacy of developing countries.
screening needs to be evaluated in age-specific ways.
But ultimately, cross-subsidies cannot resolve health inequalities
when they are so large. In any case, even though they do not focus
on improving healthcare for older people, such innovations clearly
have the potential to benefit that segment of the population.
Establishing Social Health Insurance Programmes
Such programmes would help large numbers of people obtain the
advantages of risk pooling, but there will be many design issues to
address (such as coverage levels, contributions and co-payments),
along with a plethora of implementation challenges. For countries
that can take larger political and economic steps, universal coverage
with high-quality care can be the goal. Short of that, a country that
can commit to providing healthcare for its older population will have
made a start in moving toward universal coverage.6
However, the provision of insurance should not be confused with

creating a health system. Provider-driven care does not necessarily
lead to an integrated continuum of care, and systems that rely on
fee-for-service payments need to be carefully managed to ensure
that incentives for practice operate to the advantage of patients
rather than providers.

Instituting a Later Retirement Age Endnotes

This can, in principle, ease pressure on health budgets, but only in 1 The authors thank John Beard and Alexandre Kalache for their very useful comments.
situations where workers are contributing in an ongoing and 2 Bloom, D.E. et al. (2011) The Global Economic Burden of Non-communicable Diseases. Geneva:
World Economic Forum.
substantial way to paying national healthcare costs. However, this
3 World Bank. (2011) World Development Indicators. Online database. Available at: http://data.
situation is rather uncommon at present in most developing worldbank.org/indicator
countries. In addition, encouraging people to work until later ages 4 Health expenditure data are from World Bank, World Development Indicators (Ibid.) and are based
may help improve their health and postpone or reduce the incidence on purchasing power parity. Figures are expressed in constant 2005 international dollars.
of health problems because of the effect of greater engagement in Population data and projections are from: United Nations Population Division. (2011) World
Population Prospects: The 2010 Revision. Available at: http://esa.un.org/unpp/
social and work arenas. One caution here is that raising the 5 Bärnighausen, T. & Bloom, D.E. (2009) Conditional Scholarships for Health Worker Education in
retirement age tends to be more applicable to those not doing Developing Countries: A Review of Practices, Proposals and Lessons Learned from Health and
manual labour. Non-Health Sectors. Social Science and Medicine, 68, 544–551.
6 Hsiao, W.C. & R. Paul Shaw, eds. (2007) Social Health Insurance for Developing Nations. World
Developing the Primary Healthcare (PHC) Sector Bank: Washington, D.C.
7 World Health Organization. (2011) Age-friendly Primary Health Care (PHC) Centres Toolkit.
These facilities will continue to be the cornerstone of health systems Available at:
for rapidly ageing developing countries. Care needs to be provided at 8 http://www.who.int/ageing/publications/upcoming_publications/en/index.html
the community level if costly institutional and highly specialized care
is to be avoided. The epidemiological shift from acute to chronic
diseases has already occurred in many countries, and in others it is
fast taking place. Yet acute care is the norm. Building on research
conducted in 12 countries, the World Health Organization has
developed, piloted, and evaluated a toolkit based on age-friendly
PHC facilities.7 It offers a model that can be adapted by any country
willing to implement PHC facilities oriented to the needs of their
ageing populations.
Conclusion
There is no time to dither. With population ageing proceeding apace
in virtually every country – and developing countries ageing much
more rapidly than is widely realized – time is short for policy-makers
to act in a forward-thinking manner. They will need to take into
account the fact that low- and middle-income countries are getting
older before they accumulate the resources needed to comfortably
support an ageing population.
In addition, they will need to prepare for the upcoming surge in

NCDs, which will pose extra difficulties for health systems that are
already unable to adequately serve large segments of a country’s
population. And they would do well to consider active, innovative,
systemic measures that take advantage of new technologies and
lessons learned from the experiences of their more developed
counterparts.

Chapter 14 Few Responses to Ageing

Given this demographic constellation, Africa’s primary focus is on
Ageing Africa: Opportunities building the capacity of, and providing opportunities for, its large
population of youth. This is part of efforts to foster peace, stability
for Development and growth and harness a potential demographic dividend (African
Union, 2006; UNECA, 2011a, 2009, 2006; WEF/World Bank/ADB,
Isabella Aboderin 2011).4,5,6,7,8 Issues of older persons, if considered at all, are viewed at
best as marginal to, and at worst as a distraction from, core national
In contrast to all other parts of the globe, issues of ageing thus far policy interests and development goals.
attract little, if any, attention in public and policy discourses in Africa.
A major reason for this is the radically different demographic context As a result, and notwithstanding progress made by a several
within which the ageing of populations and individuals on the countries in the development of social protection schemes for older
continent is unfolding. Driven by persisting, often alarmingly high persons, most African governments have effected few, if any,
fertility rates, such as up to seven children per woman in Niger, responses to ageing.9,10,11 This is despite their formal commitments to
Africa’s total population will continue to grow rapidly between now such action as signatories to the United Nations Madrid Plan of
and the end of the century: more than three-fold from about 1.1 billion Action on Ageing12 and the African Union (AU) Policy Framework and
today to 3.6 billion by 2100, accounting for 80% of the world’s Plan of Action on Ageing.13
additional people by the turn of the century.1
Yet, ageing is – and must be recognized as – a key issue for the
Africa will remain the youngest world region, characterized by a vast future of Africa’s societies, which, if harnessed, carries important
population of children and youth. The median age on the continent is opportunities for development on the continent.
currently only 19.7 years and will rise to just 26.4 years by 2050,
compared to around 40 or more in all other regions. Similarly, the At the purely demographic level, the relevance of ageing arises in two
population share of older persons (aged 60 years and above) in respects. First, despite low population proportions, Africa overall will
Africa, presently only 5.5%, is projected to rise to only 9.8% by 2050, see a massive, 13-fold growth in the absolute size of its older
compared to increases from around 10% to 25% in Asia and Latin population from 56 million today to 716 million by the end of the
America, and 20% to 30% in Europe and North America, (Figure 1).2 century. This is a sharper rise than for any other world region or any
Africa’s population as a whole will not reach maturity within the younger age group, as illustrated in Table 1.14
horizon of current projections. The contrast to other regions will be Within Africa, the number of older persons will increase most rapidly
even starker if the assumed declines in fertility on which the in countries of Eastern, Western and Middle Africa. Northern and
projections rest does not materialize, and there are signs that they Southern Africa, while seeing more modest absolute rises, can
might not.3 expect considerably larger increases in their population share of
Figure 1: Population share (%) of older persons, 1950 to 2050 – Africa older people – from around 7% today to 30% by 2100, when they will
and other world regions be roughly comparable to those in other world regions.15
Second, contrary to common assumptions, there is considerable

40 longevity within the older population. At the age of 60 Africans can
expect, on average, to live an additional 16 years (men) and 18 years
35 (women) – not dramatically less than their peers in other world
regions, Table 2.16
30
Table 1: Increase in absolute number (millions) of older persons (aged
60 years and above) – Africa and other major world regions
25
20 2010 2050 2100 % increase
Africa 56 215 716 1179

15 Asia 414 1,253 1473 255
Latin America & Caribbean 59 188 236 300
10 North America 64 121 166 159
Europe 161 242 219 36
5 Source: United Nations Population Division (2011) World Population Prospects. The 2010 Revision.
0
1950 1975 2010 2030 2050
Africa LA & Carib. Europe
Asia North America

Source: United Nations Population Division (2011) World Population Prospects. The 2010 Revision

Table 2: Life expectancy at age 60 (years) – Africa and other world Figure 2: Age differences in prevalence of poverty, Kenya
regions
Men Women 51,9
53,2
Africa 15 17 47,9
Asia 19 22 43,9 46,7
44,6
Latin America & Caribbean 17 20
North America 20 24
25,6
Europe 18 22
18,4
Source: United Nations Population Division, 2009. Population Ageing 2009.
Lowest
Policy Options for Development Absolute Hardcore Food
Expenditure
poverty poverty poverty
decile
An active consideration of and engagement with Africa’s older
20-59
people points to major policy options for achieving salient 60+
development goals on four key, but thus far largely unrecognized,
levels: Source: 2005-2006 Kenya Integrated Household Budget Survey
• Exclusion of older persons – policy options for enhancing social

justice and equity
Regarding health, older persons in Africa are consistently shown to
• A full-life course perspective on human capital development –
suffer significantly more disease and impaired function than younger
policy options for raising productivity
age groups.22,23 A certain amount of excess ill health and disability at
• Older persons’ intergenerational roles – policy options for older ages is to be expected, of course, as a result of declining
fostering youth engagement and transformation functional capacity of the human body from early adulthood to old
• Responding to population ageing in mature societies – policy age.24
options for employment creation
A considerable share of the excess in Africa, however, is likely unjust
in that it reflects a greater exclusion of older persons from healthcare.
Exclusion – Policy Options for Enhancing Social Justice and Equity Evidence shows that older people use health services systematically
All indications suggest that there is an apparent systematic, less than younger-age adults. Particular access difficulties faced by
aggregate level disadvantage of older persons relative to younger older people include: physical barriers due to large distances to, or
adults in terms of both wealth and health. This is true notwithstanding long waiting times at, health facilities; financial barriers related to
sharp inequalities within the older population, with privilege service fees or transport costs; lack of relevant information; and a
concentrated among a few.17 perceived lack of quality or unavailability of requisite services in the
public sector.25
Available evidence from various countries suggests a significantly
higher incidence of poverty among older persons compared to In essence, the exclusion of older persons reflects the effects of
younger-age adults across rural and urban areas. An example is capacity and resource constraints at the individual level, coupled with
Kenya, (Figure 2). This underscores a posited link between old age a lack of responsiveness to old-age related health needs at the health
and an elevated risk of deprivation in African settings,18,19,20 which is systems level. The latter arises within a broad health sector context
understood to reflect the combined effects of four factors: that typically combines acute resource constraints with a priority
orientation towards services for younger-aged, Millennium
• Diminished physical, mental or cognitive capacity of older
Development Goals (MDGs) related groups – children; mothers; and
persons to engage in sufficiently productive work, coupled with a
malaria, tuberculosis and HIV/AIDS sufferers. This leaves little
lack of employment and income-generating opportunities
capacity for provision on ageing.26
• Growing inadequacy of customary family-based support systems
due to rising resource constraints and attendant resource Action to mitigate systematic disadvantages of older persons
allocation priorities of younger generations, as well as shifting compared to younger age adults in the areas of health and wealth is
normative ideas and rural-urban out-migration on their part urgently needed; and it would mark important progress in the
• Additional care responsibilities of older persons, most notably for building of equitable and just societies in Africa. Furthermore, the
sick children and orphaned grandchildren in contexts of HIV/AIDS prospect of a secure old age may well foster prudent behaviours and
investments among those in young and middle adulthood.27 Several
• A broad lack of comprehensive social welfare provision for older
health and social sector policy approaches are required to this end.
people in most Sub-Saharan African countries21

Policies for Inclusive, Effective Health Services However, more critical attention must be paid to ensuring that actual
Policy approaches are needed to address major “supply-side” benefits in wellbeing accrue for older beneficiaries themselves, and
access barriers by enhancing the availability and acceptability of that detrimental impacts on intergenerational dynamics within
essential services for old-age related health needs, as well as their recipient households are avoided. Such impacts can arise, for
physical accessibility and affordability.28 Free healthcare policies such instance, in contexts of mass unemployment and lack of social
as Senegal’s Plan Sesame may serve as potential models for welfare provision for working-age adults, where social pensions can
ensuring the latter provided that effectiveness is established through create an unnatural dependency of the middle generation upon the
rigorous impact evaluation. old.36 Social pensions need to be conceived, therefore, as part of a
broader social security architecture that supports and enables
Responses to enhance service availability and acceptability must independence at all adult ages.
focus on:
Strengthening Family-Based Support Systems
• A broad expansion of appropriate training to develop basic A second required policy approach is a strengthening of informal,
gerontological and geriatric capacity especially among frontline family-based support systems for older persons. Interventions to this
health staff end must be individually fashioned to be responsive to societies’
• Ensuring stocks of essential medicines or other materials for the normative views and expectations regarding intergenerational family
prevention, diagnosis or management of key health conditions solidarity and old-age support.37
affecting older persons – in particular cardiovascular and
musculoskeletal conditions, impaired vision, diabetes, One approach required across African countries, however, is an
depression and dementia, and consequent functional disability effort to facilitate the transfer of remittances from rural-urban or
international migrant younger-generation kin to older parents or
• Effective outreach and long term care mechanisms, where
relatives left behind. Action specifically on labour migration, financial
appropriate, through tele-care technology.29
and monetary regulations as well as on banking technologies is
North-South and South-South exchange mechanisms to learn from, needed to support the potentially powerful role that remittances can
or draw on existing gerontological and geriatrics expertise and skills, play in enhancing older persons’ economic wellbeing and security.38
including among the African diaspora and in the few African
countries, such as South Africa, Senegal or Tunisia, that have made A Full Life Course Perspective on Human Capital Development
progress in old age care, should form a starting point for the Policy Options for Raising Productivity
development of such responses.30,31 More broadly, efforts to reorient
African health systems to ageing can and should harness the Africa has the potential to realize important yields through a longevity
framework and momentum provided by the new, UN-led global dividend by optimizing the productive capacity of the older
agenda on non-communicable diseases (NCDs) (UN, 2011).32 population (see Chapter 11). So far, however, this potential has
remained virtually unrecognized.
However, this will require active conceptual work to expand the
scope of the agenda, which in its present form omits ageing-related The basic idea of enhancing human capacity as an investment for
issues on three key levels: prosperity is not unknown to Africa. It lies at the heart of the current
MDGs-led agenda to expand basic education and maternal health
• First, an explicit recognition is needed of the particular healthcare and to address key diseases (tuberculosis, malaria and HIV/AIDS)
access barriers faced by older persons in poor settings. that primarily affect children and younger adults. Such efforts are
• Second, a focus is needed beyond the big four killer NCDs geared, ultimately, to engendering a dynamic, productive working-
(cardiovascular disease, chronic lung disease, cancer and age population as a foundation for realizing a potential demographic
diabetes) on other chronic conditions, such as musculoskeletal dividend.39,40
conditions, impaired vision or dementia. While not major causes
of death, these chronic conditions have immense impacts on the What is lacking thus far is an extension of “investment in health or
lives and livelihoods of older persons. education” thinking to the whole life course, including to old age. In
line with old-age dependency notions, older persons are, implicitly or
• Third, an explicit recognition is required of the pressing need for explicitly, assumed to be unproductive or marginally productive,
long-term care responses. thereby rendering input into their physical or cognitive capacity
redundant.
Expand Social Protection
In the social sector, a prime policy option is an expansion, within and However, such assumptions, as well as the use of old-age
across countries, of social pension programmes to enhance the dependency ratios, are fallacious. Labour statistics for most Sub-
economic capacity and security of poor older persons. The current Saharan African countries show that large, or even majority,
AU-led agenda and momentum for expansion of social protection in percentages of older adults remain economically active, (Table 3).41
Africa33,34 provides an opportune framework for the development of
such responses. Existing social pension schemes, such as in South
Africa, Namibia, Botswana or Uganda, may serve as models upon
which to build. However, rigorous impact evaluations are needed to
indicate their effectiveness. Existing evidence that pension recipients
in South Africa share their grants with younger household members
and effect real improvements in their education and health can
further strengthen the rationale for a rolling-out of social pension
programmes.35

Table 3: Prevalence of economic activity in the older population – An active engagement with older persons to channel and harness
selected African countries their intergenerational roles – to foster their intergenerational
intelligence50 – is needed. It carries a real potential for nurturing youth
Country Age group Prevalence Survey engagement and transformation in agricultural farm production and
possibly in other areas.
Botswana 60+ 59.6% Labour Force Survey, 2006
Kenya 60-64 86.6% Population Census, 1999 Policy options to this end can learn from a few existing community
65+ 72.2% based initiatives, such as the “grandmother approach”.51 Moreover,
Sierra Leone 65+ 36.1% Population Census, 2004 they can be strengthened by invoking customary African values of
Zambia 55-64 66.4% Population Census, 2000 “elders” and “responsive ageing”, which reserve respect only for
65+ 54.1% older persons who actively advance the lives of the younger
Zimbabwe 60-64 81% Labour Force Survey, 1999 generations.52,53
65+ 66.9%
In addition to harnessing intergenerational linkages in rural or other
Source: International Labour Organization (2011) Labour Statistics Database. Laborsta Internet communities, there is a need for creative efforts to foster an “elder”
mentality at the societal level among Africa’s current leaders, a
The gains to be made through investments in the capability of current majority of whom are older persons themselves. Such approaches
cohorts of older adults are arguably greatest in relation to agricultural could draw on already existing schemes such as The Elders (see
and horticultural food production. The bulk of such production in Chapter 8) and the Panel of Eminent African Personalities. If
Africa comes from smallholder farms, which in many communities successful, such initiatives may strengthen younger generations’
are predominated by older farmers – due to the selective rural-urban trust in, and constructive engagement with, national governments
out-migration or HIV-related morbidity or death of younger age and help forge a new social contract.
adults. In Kenya, for example, the estimated average age of a farmer
is 60 years.42 Engagement with Population Ageing in Mature Societies
Policy Options for Creating Employment
At the same time, older farmers’ diminished physical and cognitive
capability – due to age-related chronic diseases such as In addition to realizing opportunities associated with its own older
musculoskeletal conditions or impaired vision, malnutrition and population, Africa can gain from responding to implications of ageing
illiteracy – can severely impair their capacity to grow, process and in already mature or rapidly maturing societies in Europe, Asia and
market their crops effectively, as well as their access to agricultural North America. The extant or looming workforce shortages in such
support (extension) services. Similarly, their experiential knowledge of regions imply a potential for employment creation for Africa’s large
agronomic practices, while potentially valuable in some respects, can population of youth.
limit their receptiveness to innovative farming methods.43,44
A specific policy focus in this respect should be the production and
Policy action to improve the health and education of Africa’s rural supply of long-term care workers, for which a considerable and
older population is urgently needed. It has the potential to promote growing deficit already exists.54 International policy agreements
enhanced and sustainable food production, and thus food security, between sending and receiving countries, as well as domestic
on the continent. Action is also needed to ensure the productive arrangements, can ensure that no “care drain” ensues and, that
capacity of future cohorts of older persons by addressing early life “brain gain” – specifically in gerontological care – is promoted.
antecedents of later life chronic disease among today’s children and
youth. This action must be integrated into core development
Conclusion
agendas, including in a revised set of Millennium Development Goals
after 2015.45 This chapter has highlighted the critical importance of issues of
ageing for Africa, despite and indeed as part of, the continent’s
Older Persons’ Intergenerational Roles primary focus on its large youthful population.
Policy Options for Fostering Youth Engagement and Transformation
Four areas, in particular, have been outlined, in which an active
Older persons play key intergenerational roles in African families and consideration of the older population points to key policy options for
communities, including in the care of grandchildren whose parents realizing salient development goals of raised agricultural productivity
are unavailable, for example because of labour-related migration or and sustainability as well as equity, employment creation and
HIV/AIDS. They also control family resources, such as land, required stability. They represent opportunities that Africa should not miss.
by the working-age generation.
Through their roles and the way they execute them, older persons
directly influence younger generations’ capability for, and
perspectives on, economic engagement. The effects can be highly
beneficial, as in the case of older people’s contribution to raising a
generation of HIV/AIDS-related orphans and vulnerable children.46
However, older persons’ intergenerational impacts may also impede
capacity at individual and societal levels.
In rural farming communities, for example, older persons’ control of

land and inheritance can negatively affect how their adult children
engage or plan to engage in agricultural food production and
enterprise.47,48 Similarly, the nutrition, healthcare and education older
persons provide to grandchildren under their care may not be
optimal.49

Endnotes 40 World Bank. (2006) World Development Report 2007: Development and the Next Generation.
Washington, DC: World Bank.
1 United Nations Population Division. (2011) World Population Prospects: The 2010 Revision. 41 International Labour Organization (2011) LABORSTA. ILO Database on Labour Statistics. Available
Available at: http://esa.un.org/unpp/ at: http://laborsta.ilo.org/
2 Ibid. 42 Olwande, J & Mathenge, M. (2011) “Market Participation Among Poor Rural Households in Kenya”
3 Machiyama, K (2010) A Re-examination of Recent Fertility Declines in sub-Saharan Africa. DHS Working Paper Series 42/2011, Tegemeo Institute of Agricultural Policy and Development, Egerton
working Papers, No.68, Calverton: ICF Macro. University, Nairobi, Kenya.
4 African Union. (2006) African Youth Charter. Available at: http://www.paxafrica.org/documents/ 43 Alliance for a Green Revolution in Africa. (2011) personal consultation. More information at: http://
resources/african-union-documents/african-youth-charter-2006/view www.agra-alliance.org/
5 United Nations Economic Commission for Africa. (2011a) Africa Youth Report. Addis Ababa: 44 Kenya Agricultural Research Institute (2011) personal consultation. More information available at:
UNECA. http://www.kari.org/
6 United Nations Economic Commission for Africa. (2009) ICPD and the MDGs: Working as One. 45 Aboderin, I. & Ferreira, M. (2009) Linking Ageing to Development Agendas in sub-Saharan Africa:
Fifteen-Year Review of the Implementation of the ICPD PoA in Africa – ICPD at 15 (1994 – 2009). Challenges and Approaches. Journal of Population Ageing, 1, 51-73.
Addis Ababa: UNECA. 46 Ferreira, M. (2006) HIV/AIDS and Older People in sub-Saharan Africa: Towards a Policy
7 United Nations Economic Commission for Africa. (2006) Youth and Economic Development in Framework. Global Ageing, 4(2), 56–71.
Africa. An Issues Paper. Addis Ababa: UNECA. Available at: http://www.uneca.org/adfv/docs/ 47 Kimani, E.N. & Maina, L.W. (2011) Older Women’s Rights to Property and Inheritance in Kenya:
Issue_paper_eco.pdf Culture, Policy, and Disenfranchisement. Journal of Ethnic and Cultural Diversity in Social Work,
8 African Development Bank, World Economic Forum & World Bank. (2011) The Africa 19(4), 256-271.
Competitiveness Report. Available at: http://www3.weforum.org/docs/WEF_GCR_Africa_ 48 Alliance for a Green Revolution in Africa. (2011) personal consultation. More information at: http://
Report_2011.pdf www.agra-alliance.org/
9 Aboderin, I. & Ferreira, M. (2009) Linking Ageing to Development Agendas in sub-Saharan Africa: 49 U.S. Agency for International Development. (2009) USAID Office of Food for Peace Burkina Faso
Challenges and Approaches. Journal of Population Ageing, 1, 51-73. Food Security Country Framework FY 2010-2014. Available at: http://www.usaid.gov/our_work/
10 Aboderin, I. (2011) Understanding and Advancing the Health of Older Populations in sub-Saharan humanitarian_assistance/ffp/burkinafscf.pdf
Africa: Policy Perspectives and Evidence Needs. Public Health Reviews, 32(2), 357-376. 50 Biggs, S., Haapala, I. & Lowenstein, A. (2011) Exploring Generational Intelligence as a Model for
11 United Nations Population Fund & HelpAge International. (2011) Overview of Available Policies and Examining the Process of Intergenerational Relationships. Ageing and Society, 31(7), 1107-1124.
Legislation, Data and Research, and Institutional Arrangements Relating To Older Persons - 51 U.S. Agency for International Development. (2009) USAID Office of Food for Peace Burkina Faso
Progress Since Madrid. New York: UNFPA. Food Security Country Framework FY 2010-2014. Available at: http://www.usaid.gov/our_work/
12 United Nations. (2002) Madrid International Plan of Action on Ageing (MIPAA). New York: United humanitarian_assistance/ffp/burkinafscf.pdf
Nations. 52 Apt, N.A. (1996) Coping with Old Age in Africa. Aldershot: Avebury.
13 African Union & HelpAge International. (2003) Policy Framework and Plan of Action on Ageing. 53 Aboderin, I. (2006) Intergenerational Support and Old Age in Africa. Piscataway: Transaction.
Nairobi: HAI Africa Regional Development Centre.
54 Colombo, F. et al. (2011) Help Wanted? Providing and Paying for Long-Term Care. Paris: OECD
14 United Nations Population Division. (2011) World Population Prospects: The 2010 Revision. Publishing.
Available at: http://esa.un.org/unpp/
15 Ibid.
16 United Nations Population Division. (2009) World Population Ageing 2009. New York: United
Nations.
17 Aboderin, I. (2009) Later-life exclusion from basic health care: Perspectives from sub-Saharan
Africa. Paper presented at the 19th Congress of the International Association of Gerontology and
Geriatrics, 5-9 July, Paris.
18 Barrientos, A. (2002) Old Age, Poverty and Social Investment. Journal of International
Development, 14,1133–1141.
19 Gorman, M. & Heslop, A. (2002) Poverty, Policy, Reciprocity and Older People in the South.
Journal of International Development, 14,1143-1151.
20 Kakwani, N. & Subbarao, K. (2005) Ageing and Poverty in Africa and the Role of Social Pensions.
United Nations Development Fund, International Poverty Centre, Working Paper No.8.
21 Aboderin, I. & Ferreira, M. (2009) Linking Ageing to Development Agendas in sub-Saharan Africa:
Challenges and Approaches. Journal of Population Ageing, 1, 51-73.
22 McIntyre, D. (2004) Health Policy and Older People in Africa. In: Lloyd-Sherlock, P. (ed) Living
Longer. Ageing, Development and Social Protection. London: Zed Books, 160-183.
23 Aboderin, I. & Kizito, P. (2010) Dimensions and Determinants of Health in Old Age in Kenya and
Nigeria. Kenyan National Coordinating Agency for Population and Development (NCAPD) Report.
24 World Health Organization. (2002) Active Ageing. A Policy Framework. Geneva: WHO.
25 Aboderin, I. (2011) Understanding and Advancing the Health of Older Populations in sub-Saharan
Africa: Policy Perspectives and Evidence Needs. Public Health Reviews, 32(2), 357-376.
26 Ibid.
27 Ferraro, K. & Shippee, T.P. (2009) Aging and cumulative inequality: How does inequality get under
the skin? Gerontologist. 49, 333-43.
28 Aboderin, I. (2011) Understanding and Advancing the Health of Older Populations in Sub-Saharan
Africa: Policy Perspectives and Evidence Needs. Public Health Reviews, 32(2), 357-376.
29 World Health Organization. (2004) Towards Age-friendly Primary Health Care. Geneva: WHO
30 Aboderin, I. (2008) Advancing Health Service Provision for Older Persons and Age-related
Non-communicable Disease in sub-Saharan Africa: Identifying Key Information and Training
Needs. AFRAN Policy-Research Dialogue Series, Report 01-2008, Oxford Institute of Ageing.
31 Ratha, D. et al. (2011) Leveraging Migration for Africa. Remittances, Skills, Investments.
32 United Nations (2011) Political declaration of the High-level Meeting of the General Assembly on
the Prevention and Control of Non-communicable Diseases. UN Document A/66/L.1.New York:
United Nations
33 African Union. (2008) Social Policy Framework for Africa. First Session of African Union Ministers in
Charge of Social Development, October 2008, Windhoek.
34 United Nations Economic Commission for Africa. (2011b) Assessing Progress in Africa towards the
Millennium Development Goals. Addis Ababa, UNECA.
35 HelpAge International (2004). Age and security. How social pensions can deliver effective aid
topoor older people and their families. London: HelpAge International.
36 Aboderin, I. & Ferreira, M. (2009) Linking Ageing to Development Agendas in sub-Saharan Africa:
Challenges and Approaches. Journal of Population Ageing, 1, 51-73.
37 Aboderin, I. (2006) Intergenerational Support and Old Age in Africa. Piscataway: Transaction.
38 Ratha, D. et al. (2011) Leveraging Migration for Africa. Remittances, Skills, Investments.
39 United Nations Millennium Project. (2005) Investing in Development. A Practical Plan to Achieve
the Millennium Development Goals. New York: United Nations.

Chapter 15 A Continuing Trend in Specialization in Medicine

Classical divisions between medicine and surgery and between
Modern Medical Education: physicians and barber surgeons date back to ancient Egypt.
However, it was only in the 19th century that individual specialities
such as cardiology and neurology became formally established.
Meeting the Demands of an “Specialisation was necessary for the advancement of medicine”,1
according to Jean Emmanuel Gilibert (1741-1814), noted French
Ageing Population physician and early proponent of the scientific method in paediatric
medicine. The rapid expansion of medical knowledge over this
Daniel Ryan and John Wilden crucial period would not have achieved such advances by itself.
The world is facing unprecedented increases in the numbers of older There has been an intensification of sub-specialization in recent
people and the proportion they represent in both developed and times. Techniques of interventional cardiology have successively
developing countries. While significant increases in life expectancy advanced the treatment of blocked coronary arteries initially by
are widely predicted by most observers, the prospects for future balloon angioplasty, followed by bare metal stents and drug-eluting
improvements in healthy life expectancy are less clear. Advances in stents to prevent collapse and restenosis of the coronary artery. The
diagnosing and managing diseases have the potential to extend the next generation of stents will be biodegradable and dissolve as the
period of old age and also to expand morbidity, as increasing coronary artery heals.
numbers of older people live longer with existing conditions or
survive to ages when multiple morbidities can arise. Minimalist surgical techniques offer reduced rates of perioperative
morbidity and faster recovery. The da Vinci robotic system, for
A major public health and medical goal is to create improved health example, reduces the likelihood of cancer recurrence and loss of
during longer life expectancies. New skills are needed for clinicians to function after prostatectomy, while placing additional demands on
achieve this. An increasing range of new treatments and the the skills and resources of the urologist.2
requirement to make optimal use of available resources will challenge
doctors. This is a global challenge for medicine and medical Continuing increases in computing power support rapid further
education, which requires global solutions that address the needs of advances in imaging technology, which will lead to earlier diagnosis
the developed and developing worlds. of disease and place additional demands on the medical education
of radiologists. Coronary computed tomography angiography (CCTA)
enhances the diagnosis of chest pain and coronary artery disease.
CCTA holds the prospect of identifying those at risk, such as
diabetics and those suffering from hyperlipidaemias who may benefit
from more aggressive forms of treatment. Interventional
neuroradiologists can now treat aneurysms in the blood vessels of
the brain by inserting small platinum coils through very thin catheters.
The potential for further development and specialization is both

evident and astounding. But questions remain about how aligned
these potential advances will be with the broader medical needs of
older people.

Meeting the Medical Needs of an Ageing Population Different strategies are necessary to meet the shortfall in geriatric
care over different timescales. A short-term strategy would be to
Many older people have multiple chronic diseases, such as encourage physicians from other specialities to cross-train into
hypertension, diabetes and heart failure, as well as functional geriatric medicine. Doctors should be compensated adequately for
difficulties, such as incontinence and cognitive impairments. the time and effort in developing key skills in complex care and
Healthcare costs and disease prevalence tend to be more highly disease prevention in older patients, especially those who are frail,
concentrated in the final months of life, almost regardless of the age disabled and afflicted by multiple diseases
of the individual. Medicare beneficiaries in the United States who
have four or more chronic disease conditions received a cumulative A medium-term strategy could be centred on the seed potential of a
US$ 468 billion worth of healthcare in 2008.3 Regular primary care core group of current geriatricians, providing them with the
monitoring and appropriate chronic care could significantly reduce necessary funding and support to enhance their educational and
this important fraction of Medicare expenditures. leadership skills. Educational programmes such as the Curriculum
for the Hospitalized Ageing Medical Patients and the Health
The increasingly narrowed focus of further medical training may Resources and Services Administration’s Geriatric Academic Career
restrict doctors’ ability to adopt a multidisciplinary and geriatric Awards provide clear evidence of the capability to create effective
knowledge approach to treating older patients. When a patient is clinical educators. In addition to teaching geriatrics to other
receiving treatment from a number of specialists, drugs may be physicians, these educators could support the training of other
prescribed without due care and attention to current medications. physicians to become local geriatric champions.
This can lead to problems of drug interactions and of patient
compliance through loss of confidence in multiple and conflicting A key role of these geriatrician educators would be to learn from
doctors’ advice. other specialities. Appropriate resources and time must be made
available to ensure the sharing of such information within the geriatric
Doctors are frequently insufficiently trained to provide complex care medical community. Innovations in the management of different
for chronic diseases. Interdisciplinary clinical teams would provide diseases or insights into the development of clinical guidance could
more appropriate care. Doctors must address diseases and enhance the quality of care and potential healthy life expectancy of
symptoms independently and assess interactions between medical, patients.
social and cognitive factors.
These strategies would require major investment, covering the
Recent research into models of chronic care has identified key skills training of geriatric educators and developing new educational
that primary physicians need to possess or develop. They include programmes. There are a number of stakeholders who might be
effective communication with other health professionals, leadership expected to contribute, including national and local governments,
of interdisciplinary teams, process improvement through audit, healthcare providers and insurers, but the needs and benefits would
support to caregivers and efficient use of information technology (IT). have to be clearly analysed and communicated. This would be
While one would expect that most physicians would have strengths further complicated because geriatricians may be less well paid than
in most of these areas, the broad nature of some of these categories other physicians for a variety of reasons. This gap would need to be
may mean further development and training will be required. addressed by training grants or other career awards.
A New Landscape for Geriatric Medicine Looking further into the future, a strategy of greater exposure to
geriatric medicine is required throughout medical school training.
Geriatricians are already masters of these talents, and are ideally
Different international organizations, including the International
suited through their training and practice to act as the fulcrum at the
Association of Geriatrics and Gerontology and the World Health
centre of care delivery for older patients. In the words of Fried and
Organization (WHO), have advanced core competencies that should
Hall, “geriatricians are complexivists, with the cognitive skills to
be addressed in undergraduate medical training for geriatrics,
analyse complex health issues and establish priorities consistent with
regardless of the eventual chosen speciality. A conference involving
patient goals and knowledge of models of care delivery that match
almost half of all US medical schools highlighted the need for
the healthcare needs of patients”.4 This involves not just mediation
competencies in the fields of medication management, self-care,
and coordination of care delivery, but a proactive and closely involved
balance disorders, hospital care, cognitive disorders, unusual
advocacy of the patient’s health with responsibility for defining and
presentation of disease, healthcare planning and palliative care.6
monitoring care needs.
The Teaching Geriatrics in Medical Education Study produced by the
However, just as ageing populations around the world demand
WHO Department of Ageing and Life Course brought together
greater investment in patient-focused holistic approaches to
student leaders from around the world to share insights and build
healthcare, the numbers of geriatricians has not only failed to keep
enthusiasm for the subject of ageing.7 The study evaluated 36
pace, but has actually declined in some countries. We can still
countries through quantitative and qualitative assessment of geriatric
reverse this pattern and use medical education, training and
education and the proportion of the population represented by older
investment to shape a future medical workforce of doctors and
people. As a result, the study was able to evaluate not only whether
nurses to the needs of an elderly population. But this will require a
geriatric education was taking place, but also the quality of such
seismic shift in priorities that will take many years to achieve. We
education.
must seize the opportunity now before it is too late.
There are geriatric centres of excellence around the world, some

supported by philanthropic organizations such as the Reynolds and
Hartford Foundations. These organizations and separate initiatives
have attempted to encourage those with an interest in geriatrics by
shortening the period of required training. This has highlighted the
importance of focusing geriatric expertise on patients that would
benefit most from such care, particularly those over 85 and those
with complex medical problems.5

The assessment was reported using a GERIND index (1-100). Figure Dementia and the Geriatrician’s Role
1 illustrates that countries tended to fall into one of three groupings.
Group A included, perhaps surprisingly, Spain, Portugal, Austria, An immediate challenge is to target geriatric clinical resources to
Germany and Greece. This group of countries was identified as those elderly patients with complex medical problems, particularly
having comparatively limited geriatric education despite having dementia. The progression from mild cognitive impairment, to
relatively older populations. difficulties organizing daily living, to personality fragmentation,
followed by loss of personal identity, incontinence, unsteadiness,
then confinement to bed and finally death is very distressing for
Figure 1 : GERIND Versus Older Population in 2000 patients in the early stages of the disease, as well as for loved ones
and caregivers in the later stages.
100
The multiple causes of dementia are diverse and range over a
Gerind
90
ISL CAN NOR
number of specialities including neurology, neurosurgery, psychiatry,
NED
ISR NZL
endocrinology and metabolic disorders. An individual patient may
MLT CHE
80 SWE have more than one identifiable and treatable cause of dementia.
Geriatricians coordinating management of a patient within this
C
HKG FIN
70 complex medical milieu will require regular updating of skills,
SVK CZE DEN
60
including secondment to other branches of healthcare within the
LTU hospital and community setting.
POL
50
PAN The medical profession began investigating dementia more
A
KWT
40 ESP rigorously following the advent of non-invasive CT (computerized
MKD EST GRE tomography) scans in 1974. Now the question is whether dementia
30 JAM
URY associated with old age, where no specific cause is found, will share
20
GTM
SLV
YUG
AUT
DEU
a common genetic basis with other neurodegenerative disorders; or
CRO
PRT whether a reduction in the number of end capillary arterioles in the
10 GHA
LEB BLG brain, identified as “vascular dementia”, is the predominant cause, or
PAL
UKR
more likely, a combination of both. Currently gene-wide association
0 studies suggest that five genes related to inflammation and metabolic
0 5 10 15 20 25 30 functions within neurons may be of particular importance.12
Percentage of Population +60
At the so-called “preclinical stage”, amyloid in the brain can be
detected by positron emission tomography (PET) scans and by
A review of geriatric education of medical students concluded that specific markers. Magnetic resonance (MR) imaging can assess the
while geriatric education had become more extensive in developed degree of brain atrophy. Whatever the outcome of future intensive
countries in recent years, the majority of older people in the future will research, the combination of geriatric neurology and neurogeriatrics
be living in less developed countries with little – if any –training in has already shaped a new sub-speciality.
geriatric medicine.8 Medical students need to understand not only
disease prevention and management, but also the underlying Demands Placed on Doctors in the Future
physiological basis of ageing.
The challenges posed by geriatric medicine are symptomatic of
Training in geriatrics could be provided as a stand-alone, wider demands on the medical profession in general and will need to
independent module or through acquiring different competencies be addressed. Further sub-specialization will not necessarily address
through existing course structures for particular specialities. the problems of information overload that may lessen doctors’
Evidence to recommend the latter method is provided by a study at abilities to adequately manage complex chronic diseases.
the University of Western Ontario,9 which suggested that there was
poor knowledge retention after one year from a three-hour geriatric To envision the greater demands on doctors, consider how collective
educational session. Interactive sessions, as provided by the understanding of disease processes may improve in coming years.
University of Minnesota,10 where undergraduates take on the role of For example, a more detailed understanding of the genetic and
an older person with different levels of functional disability, are more epigenetic pathways in the natural history of different diseases, and
engaging, and key messages are likely to be retained longer. an expanding range of biomarkers for use in diagnosis and staging of
However, such programmes need to be careful about presenting disease, would improve disease management. However, the sheer
overly negative images of the healthcare needs of an older volume of information may be overwhelming and reduce individual
population. doctors to following centrally developed guidelines for fear of relying
on out-of-date experience.
Further options would be a rotation or secondment for a number of
weeks at a geriatric department or a senior mentoring programme There is no sign that the pace of technological change is slowing.
that links medical students with healthy older persons. Unique New technologies, such as nanotechnologies, modification of gene
elements and experiences are likely to have the greatest impact on expression and generation and implantation of new organs will be
future behaviours. A study by the University of Arkansas suggested developed and become increasingly affordable. The burning
that experience in a hospice was most effectively integrated into question is whether doctors will be able to evaluate the value of such
future clinical practice.11 advances and, if so, can they convince a sceptical public of the
attendant advantages.

Medical Technicians and Advocates Endnotes

Perhaps it is too much to ask of anyone. Perhaps a radical solution is 1 Weisz, G. (2003) The Emergence of Medical Specialisation in the Nineteenth Century. Bulletin of
the History of Medicine, 77(3), 536-574.
needed that positively embraces a new division within the broader 2 Herrell, S. D. et al. (2008) Toward image guided robotic surgery: system validation. Journal of
medical profession – not between medicine and surgery, or even Urology, 181(2), 783-789.
between the various different specialities, but between medical 3 Boult, C., Counsell, S., Leipzig, R. & Berenson, R. (2010) The urgency of preparing primary care
technicians and medical advocates. physicians to care for older people with chronic illnesses. Health Affairs, 29(5), 811-818.
4 Fried, L. & Hall, W. (2008) Leading on behalf of an ageing society. Journal of the American
Geriatrics Society, 56(10), 1791–1795.
Medical technicians would be able to pursue a tightly defined
5 Ibid.
specialist area to its logical depth, drawing on different strands of
6 Mateos-Nozal, J. & Beard, J. (2008) Global approaches to geriatrics in medical education.
medical and physical sciences. They would exhaustively examine European Geriatric Medicine, 2(2), 87-92.
new technologies and computer-assisted analytical techniques with 7 World Health Organisation. (2011) Teaching Geriatrics in Medical Education. Joint Initiative of the
only a limited role in patient interaction. Such an approach might be ALC and the International Federation of Medical Students Associations. Available at: http://www.
who.int/ageing/projects/tegeme/en/index.html
regarded as contrary to the whole ethos of medicine, but in fact it
8 Leipzig, R. (2009) Keeping granny safe on July 1: a consensus on minimum geriatrics
would open medicine to a wider range of talent and expertise. These competencies for graduating medical students. Academic Medicine, 84(5), 604-610.
medical technicians would advance both curative and preventative 9 Diachun, L. et al. (2007) Tracking clerkship experience: just what do clinical clerks see on an Elder
medicine and directly attack the overall burden of disease. Care rotation? Journal of the American Geriatrics Society, 55(7), 1126-1133.
10 McVey, L., Davis, D. & Cohen, H. (1989) The ‘aging game’. An approach to education in geriatrics.
In contrast, medical advocates would be generalists in expertise, Journal of the American Medical Association, 262(11), 1507-1509.
mindset and application. Advocates would unite and extend the 11 Powers, C., Allen, R., Johnson, V. & Cooper-Witt, C. (2005) Evaluating immediate and long-range
effect of a geriatric clerkship using reflections and ratings from participants as students and as
working practices of primary physicians and geriatricians, residents. Journal of the American Geriatrics Society, 53(2), 331-5.
coordinating and enhancing all contacts with the medical 12 Naj, A.C. et al. (2011) Common variants of MS4A4/MS4A6E,CD2AP, CD33 & EPHA1 are
technicians. Advocates would also make decisions over the value of associated with late-onset Alzheimer’s Disease. Nature Genetics, 43, 436-441.
treating any single symptom or disease and help patients understand
and accept the options.
Conclusion
The value of gatekeeping in primary care is often discussed to ensure
that patients see the appropriate specialist at the right time. This is a
two-way process. A key role of medical advocates would be to
ensure that technicians only see the appropriate patient at the right
time. This would have profound benefits for the confidence of
patients, the status of the advocates, and the building of mutual trust
among advocates, technicians and patients.
Medicine is a vocation, an art and a highly technical science. All are

essential to its continued success in shaping our future longevity.
Medicine can offer new students many different paths to follow, but
we cannot overstress how the care and treatment of older patients
will be central to almost all of these paths. The medical education
that students, doctors and nurses receive throughout their careers
must help them embrace the challenges of old age and focus on
outcomes from the patient’s point of view.

Chapter 16 An Historical Perspective

Until the 20th century, average life expectancy worldwide at birth was
The Challenge of 30 years.1 Since the incidence of non-communicable disease
increases with age,2 there was less opportunity for individuals to
Non-Communicable Diseases contract – and die from – now common non-communicable
diseases like diabetes or heart disease. Rather, individuals tended to
die at relatively young ages from communicable diseases, although
and Geriatric Conditions maternal mortality was also high prior to the 20th century.
Ronald Williams and Randall Krakauer Developments in public health and medicine – better sanitation, safe
drinking water and improved maternal care, among others –
Advances in public health, medical interventions, improved lifestyles increased the average life expectancy, particularly in developed
and pharmaceuticals are extending the life expectancy of countries.3 In 2006, there were almost 500 million people age 65 and
populations across the globe. This has been good news for older worldwide. By 2030, that number is expected to climb to 1
individuals and society alike, as many seniors now remain vital, billion, or one in eight people.4 While many seniors will remain healthy
contributing members of their communities well into their later years. and vital, nearly half will have at least one non-communicable
The downside is that longevity increases the incidence and condition, making illnesses like heart disease, pulmonary disease,
prevalence of disabling and sometimes fatal non-communicable hypertension, stroke, diabetes and malignancies more common
diseases, placing a physical and emotional strain on families and a causes of death.5
financial strain on national, local and individual healthcare budgets. Is
there anything that can be done to enhance the quality of life and Non-communicable diseases are by far the leading cause of
simultaneously provide the highest quality care to older adults, while mortality in the world, representing 60% of all deaths. The death rate
stemming the tide of red ink? from non-communicable illness is already pronounced in some low
and middle-income countries.6 Greater longevity means that people
This critical question is confronting many developed countries, have both more productive years and more years suffering from
notably the United States; thus it is useful to examine the issue non-communicable illness, representing both economic contribution
through an American prism. To be sure, if we were to see improved and economic cost.
diets, healthcare, sanitation and public health services in less
developed countries, we would see, or in some cases have seen, a
similar increase in life expectancy and a corresponding rise in illness
and health costs – but perhaps with fewer resources to address
them.

Drivers of Healthcare Costs for Older Populations Advanced and Terminal Illness
Non-Communicable Illnesses Advanced and terminal illnesses are also significant drivers of
The management of non-communicable illnesses is responsible for healthcare costs in older populations. When a non-communicable
the predominant share of medical costs for older persons. Non- illness progresses beyond the point where treatment aimed at
communicable disease care management occurs chiefly in the addressing the underlying pathophysiology yields little benefit, the
ambulatory setting, although in-patient treatment accounts for much patient moves into what is termed “advanced illness”. At this point,
of the cost.7 the most appropriate medical approach is usually palliative care – or
care designed to provide comfort and support, and to relieve
The frequency and severity of illnesses like diabetes, heart disease or symptoms such as pain and discomfort.
malignancy in the older population is staggering. And often, older
individuals have not one but multiple comorbid non-communicable However, much more advanced interventions are often continued
conditions. In fact, in the United States, one in five Medicare despite their limited benefit and high cost. In fact, it is estimated that
recipients currently has five or more non-communicable conditions, between 10% and 12% of total US healthcare expenditures are for
accounting for 73% of total Medicare costs.8 In addition, the care at the end of life, much of it in the final 30 days before death,
prevalence of older adults taking 10 or more medications in any given with perhaps most of it representing little or no real potential for
week has risen to 17% of men and 19% of women – more than medical benefit, comfort or informed patient choice.12
double the number 25 years ago.9 “Bending the Curve”: The Economic Levers of Healthcare
Non-communicable conditions progress over time at varying and An unintended consequence of lengthening lifespans is the potential
irregular rates. With good care management, these conditions can for increasing years of non-communicable illness. There is great
be slowed considerably, often for decades or an entire lifetime, but variability in the health status and overall health costs across
they cannot often be stopped. The greatest limiting factor to this countries. While economies with higher per capita spending tend to
inevitable progression is death. With sufficient access to good quality have longer life expectancies, this trend is less pronounced in those
care, any one patient may die of other causes before progressing to with the highest levels of spending, notably the United States.13
advanced illness.
Despite these differences, all countries have an incentive to slow the
Diabetes is a useful example. Typically, patients first appear with rate of growth in healthcare spending. To do so, it will be necessary
metabolic syndrome or high-risk symptoms or disorders. They to focus on both sides of the healthcare economy – supply and
progress to diabetes, to diabetes with major organ involvement, and demand – and to use multiple economic levers on each side of the
then to advanced illness. At each level, costs increase. A patient with equation. While there is no single solution that will solve the
metabolic syndrome has medical costs that are not much greater healthcare cost crisis, we can take steps to mitigate its impact.
than the costs for a similar healthy patient of comparable age. When
the disease progresses to diabetes, the cost is four times that of a Supply-side restraints have included government-sponsored national
comparable age population. With major organ involvement, and then health plans in most industrialized countries, as well as limitations on
with advanced illness, the cost can increase dramatically.10 the availability of certain elective services. For example, for services
such as magnetic resonance imaging (MRI), availability might be
The scenario of ageing adults with multiple non-communicable based on determined need for such services. This would limit the
illnesses contributes not only to increased medical utilization but also potential and incentive for unnecessary use of such services. Other
to challenges in the delivery of care. Impaired mobility, declining approaches used in the United States and elsewhere include
functional status, and cognitive deficits frequently exacerbate the capitated payments to providers and price controls of various forms
ability of clinicians to intervene successfully. The incidence, in and effectiveness. Generally in the United States, however, supply-
particular, of dementia in older populations not only complicates care side constraints have been limited, and utilization of some medical
but increases cost – a figure currently estimated at US$ 604 billion in services such as MRI have been greater, with little evidence of
2010, or about 1% of the world’s GDP.11 medical benefit.14
Demand controls have classically involved co-payments, deductibles

and utilization management and, more recently, care management,
which shows some cost mitigation promise.15
While health insurance plans have had some success controlling

unnecessary healthcare utilization with increased member cost
sharing, that success generally does not apply to non-communicable
conditions because, among other reasons, much of the care is
medically appropriate. Studies of commercial health plans have not
shown a decrease in preventive care utilization or drug adherence;
therefore, these products should not hinder efforts to improve
long-term health status through encouragement of early intervention
programmes.16
At the same time, utilization management – the goal of which is to get

patients the right care in the right setting at the right time – has had
some impact on lowering cost, but its economic value is limited in
terms of driving down overall cost trends.

Focusing on Prevention This marriage of palliative and curative care improves overall health,
reduces acute care stays and eases the end-of-life experience for
Focusing on prevention by intervening at the cause may seem like a patients and families alike. Published results demonstrate the
viable method to control the cost of non-communicable illness. programme’s success. Patients enrolled in the Compassionate Care
Certainly, there is considerable agreement that preventive medicine programme incurred 82% fewer acute care days.24 With acute care
can have a significant impact on public health. However, there are representing 80% of the cost of terminal illness and terminal illness
limited cases where prevention has been demonstrated to actually representing nearly 30% of the overall cost of Medicare, the
reduce overall costs, including childhood immunization and the use opportunity to control costs is significant.25 Programmes such as this
of low-dose aspirin to prevent heart disease.17 one, focused on the intersection of quality and cost, show
In many other cases, successful prevention can reduce the cost of tremendous promise for reducing healthcare costs.
care for an individual for a period of time, but convincing evidence
that it will reduce lifetime health costs is lacking. Because mortality is Collaborative and Coordinated Care
inevitable, prevention of non-communicable disease will likely add The continued development of a more collaborative, coordinated and
years of life, delaying death and allowing individuals to continue to integrated healthcare system can have a significant impact on
generate higher healthcare costs – and at a higher yearly rate. This slowing rising healthcare costs and improving overall quality of life.
can be offset to an extent by additional productive years, but such Important work is being done to coordinate care across the entire
benefits would not normally accrue directly to healthcare. healthcare system – from caregivers to clinicians to facilities to health
plans. In addition, efforts aimed at shared risk, coordinated care
Prevention has the potential to decrease annual or time-dependent
management, longitudinal planning, health information technology
costs. Whether it can reduce lifetime, hence system, costs is less
and the like are in various stages of maturity across the globe.
clear. There is evidence that for certain conditions it might do so, but
Continuing to nurture such efforts will help blunt the rising cost of
perhaps not for others. Predicting the lifetime benefit of prevention of
care of our ageing population and will have the added benefit of
one risk factor in populations with multiple risk factors is complex.18
improving care quality and patient experience.
Non-Communicable and Advanced Illness Management Collaboration among those who provide care (physicians and
When it comes to bending the healthcare cost curve, the effective facilities) and those who finance it (insurance companies or
management of non-communicable and advanced illness holds governments) is a largely untapped opportunity for helping to control
dramatic promise. Appropriately managing non-communicable costs. While the relationship between these two camps has too often
illness has been demonstrated to improve quality while reducing been adversarial, it would be a good idea for each to recognize the
cost.19 One pertinent example is a randomized trial of care value to be gained through co-operation. In particular, there are two
management for older heart failure patients, which demonstrated a fronts on which both groups share common goals: incentives and
42% reduction in in-patient care days compared to the prior year.20 patient care, which are themselves closely related.
The effective management of non-communicable illness can result in The healthcare system tends to set up perverse incentives that drive
lower utilization of unnecessary services, as shown by this study, as unhelpful and often costly behaviour. In a fee-for-service model,
well as better site of service for care, increased medication providers are paid for each “service” they perform. As a result, providers
compliance, and more timely identification of gaps in care. have an incentive to perform more tests and procedures, sometimes
unnecessarily, which drives up the cost of care. As a way to improve
Even greater potential for reducing healthcare cost can come from patient care and reduce healthcare costs, providers and insurers must
the effective management of advanced illness. In the United States agree on a set of incentives that appropriately aligns rewards with
and other countries, we all too frequently pursue aggressive therapy effective and efficient patient care. Such incentives should be based on
beyond the point where a reasonable chance of favourable outcomes achieved rather than just processes. To ensure quality, they
outcomes is possible. In fact, care in the last year of life represents also should measure care against industry-recognized, evidence-
30% of the total cost of Medicare in the United States.21 In the last based standards, using appropriate adjustment for the risk level of the
month of life, 80% of the care received is in an acute in-patient populations.
setting.22 In many cases, this care is neither medically appropriate nor
reasonable, and is not based on informed patient choice. Indeed, On the patient-care front, we must utilize more effectively the significant
when care managers offer the option of supportive or palliative care, care-management expertise of health plans in collaboration with
over 80% of patients choose it.23 In the United States and elsewhere, providers. One pertinent example is a collaboration between NOVA-
hospice use is increasing, however, it remains well below levels that Intermed and Aetna Medicare. By combining committed primary care
one might expect based on experience with informed patient choice. and case management, acute utilization is 50% lower than that
experienced by unmanaged Medicare patients, exclusive of denials.26
In the United States, Aetna has demonstrated the potential for such This illustrates what can be accomplished at the intersection of cost
efforts with its groundbreaking Compassionate Care programme. and quality when healthcare providers and health plans work together,
The programme removes barriers to needed care and promotes principally through better care management and availability of
choice and autonomy for patients and their families at the end of life. actionable data.
It provides expanded coverage for hospice and palliative care, respite
care for caregivers, bereavement services, enhanced case Such collaboration to provide for better longitudinal care
management and web-based tools and information. management has been cited by the World Health Organization
(WHO) as an important component of an effective healthcare
system.27 The WHO calls for “primary care coordination hubs”, where
primary care teams work cooperatively with specialized services,
organizations and institutions to improve the health of entire
populations. This concept has the potential to “transform care into a
network, where relations between the primary care team and the
other institutions and services are no longer based only on top-down
hierarchy and bottom-up referral, but on cooperation and
coordination”.28

The Future of Healthcare Spending versus GDP Endnotes

Worldwide, the average health expenditure in 2007 was 8.6% of 1 Prentice, T. (2006) Global Health Histories; Health and Philanthropy: Leveraging Change.
University of Indiana.
GDP.29 In the same year, the United States spent roughly double that 2 Kung, H.C., Hoyert, D.L., Xu, J.Q., & Murphy SL. (2005) Deaths: Final Data for 2005. National Vital
figure at 15.7% of total GDP.30 This spending occurred despite the Statistics Reports, 56(10).
fact that the proportion of healthcare expenditures funded by public 3 Novick, L.F. & Morrow, C.B. (2008) Defining Public Health: Historical and Contemporary
programmes is materially less for the US compared to the worldwide Developments. In: Novick, L.F., Morrow, C.B., & Mays, G.P. (eds) Public Health Administration:
Principles for Population-Based Management, 2nd edition. Sudbury: Jones and Bartlett Publisher.
average.31
4 National Institute on Aging. (2007) Why Population ageing Matters: A Global Perspective. U.S.
National Institutes of Health.
As previously discussed, increasing worldwide life expectancies are 5 Anderson, G. (2004) Chronic Conditions: Making the Case for Ongoing Care. Partnership for
driving an increase in the prevalence of non-communicable disease Solutions. Baltimore: John Hopkins University Press.
and creating significant upward pressure on healthcare expenses as 6 World Health Organization. (2005) Preventing Chronic Diseases: A Vital Investment, Geneva:
World Health Organization.
a percentage of GDP. High healthcare costs, particularly in the US,
7 Wu, S.Y. & Green, A. (2000) Projection of Chronic Illness Prevalence and Cost Inflation, Santa
are driven at least partly by unnecessary services for non- Monica: RAND Health.
communicable and particularly advanced illness. Nonetheless, an 8 Anderson, G. (2004) Chronic Conditions: Making the Case for Ongoing Care. Partnership for
ageing population and the associated multiple non-communicable Solutions. Baltimore: John Hopkins University Press.
conditions would be expected to drive increasing health expenditures 9 Slone Epidemiology Center at Boston University. (2006) Patterns of Medication Use in the United
even if utilization of resources could be optimized. States, 2006: A Report from the Slone Survey. Available at: http://www.bu.edu/slone/
SloneSurvey/SloneSurvey.htm
10 Fradkin, J. & Rodgers, G.P. (2008) The Economic Imperative to Conquer Diabetes. Diabetes Care,
While we have outlined several areas of focus for stemming the tide 31(3), 624-625.
of rising healthcare costs – including more effective management of 11 Alzheimer’s Disease International. (2010) World Alzheimer’s Report 2010: The Global Economic
non-communicable and advanced illness and the development of a Impact of Dementia. Available at: www.alz.co.uk/research/files/
WorldAlzheimerReport2010ExecutiveSummary.pdf
more integrated and collaborative healthcare system – perhaps the
12 Eppig, E. (2003) Last Year of Life Expenditures. Centers for Medicare and Medicaid Services.
most important first step is to accept the inevitable. Healthcare costs Available at: www.cms.gov/mcbs/downloads/issue20.pdf
as a percentage of GDP are rising. Some developed nations have 13 OECD, Organisation for Economic Co-operation and Development. (2009) Health Data 2009.
already seen this trend, and the rest of the world is on alert. It is a Available at: http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-
reality that cannot be entirely avoided. That leads to the broader glance-2009_health_glance-2009-en
14 Baker, L.C. (2007) Medical Imaging Capacity and healthcare Spending: Is There Cause for
question – what is a reasonable percentage of a nation’s GDP to Concern? Expert Voices. Available at: http://www.nihcm.org/pdf/ExpertVoices%20Baker.pdf
spend on healthcare? Is it 5%? 10%? What should the benchmark 15 Wade, M.J. et al. (2011) Midwestern Regional Program Abstracts Journal of Investigative Medicine,
be? These are questions that world leaders must wrestle to answer. 59(4), 692-730.
16 Cherkin, D.C., Grothaus, L. & Wagner, E.H. (1990) The Effect of Office Visit Copayments on
Preventive Care Services in an HMO. Inquiry, 27(1), 24-38.
Conclusion
17 The Robert Wood Johnson Foundation. The Cost Savings and Cost-Effectiveness of Clinical
Preventive Care. Research Synthesis Report No. 18, September.
Certainly, no one would want to trade the low-cost and relatively
18 Goldman, D.P., et al (2009). The Benefits of Risk Factor Prevention in Americans Aged 51 Years
ineffective healthcare system of a century ago for today’s highly and Older. American Journal of Public Health, 99(11).
developed medical enterprise. After all, advances in medicine and 19 Naylor, M.D. et al. (2011) High-Value Transitional Care: Translation of Research into Practice.
public health measures have contributed to the rise in life expectancy, Journal of Evaluation in Clinical Practice, 17(4).
yielding along with it significant social, economic and cultural benefits 20 Wade, M.J. et al. (2011) Telemonitoring with Case Management for Seniors with Heart Failure.
that should not be minimized. Many older adults achieve American Journal of Managed Care,17(3), 71-79.
considerable functional, cognitive and psychological wellbeing into 21 Goodman, D.C. et al. (2011) Trends and Variations in End-of-Life Care for Medicare Beneficiaries
with Severe Chronic Illness. The Dartmouth Institute for Health Policy and Clinical Practice.
their eighth, ninth and even 10th decades. But society cannot avoid Available at: www.rwjf.org/qualityequality/product.jsp?id=72192
addressing the challenges such longevity brings – namely, more non- 22 Eppig, E. (2003) Last Year of Life Expenditures. Centers for Medicare and Medicaid Services.
communicable and advanced disease, and the attendant increased Available at: www.cms.gov/mcbs/downloads/issue20.pdf
cost. 23 Krakauer, R.S.(2011) Invictus: Increasing Patient Choice in Advanced Illness and End-of-Life Care.
Frontiers of Health Services Management 27(3), 43-48.
24 Krakauer, R.S., Spettell, C., Reisman, L. & Wade, M.J. (2009) Opportunities to Improve the Quality
As long as populations age and healthcare advances, costs will of Care for Advanced Illness. Health Affairs, 28(5), 1357-1359.
increase. However, as we have suggested, there are considerable 25 Meier, D.E, Isaacs, S.L. & Hughes, R. (2009) Palliative Care: Transforming the Care of Serious
opportunities to exert downward pressure on rising healthcare costs. Illness, San Francisco: Jossey-Bass.
Chief among these is an integrated and coordinated care approach, 26 Hostetter, M. (2010) Case Study: Aetna’s Embedded Case Managers Seek to Strengthen Primary
Care. Quality Matters, August-September Release.
where all parts of the system – healthcare providers, payers, patients,
27 World Health Organization (2008) The World Health Report 2008, Primary Health Care, Geneva:
institutions and information technology – work more closely together World Health Organization.
for the benefit of patients. Governments, institutions and the public 28 Ibid.
must press all players in the healthcare system to make this 29 OECD, Organisation for Economic Co-operation and Development. (2009) Health Data 2009.
coordinated approach a priority. Available at: http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-
glance-2009_health_glance-2009-en
When a coordinated care approach is coupled with the effective 30 Ibid.
management of non-communicable and advanced diseases, we can 31 Ibid.
improve both the personal health of individuals and the healthcare
budgets of nations. By advocating for additional emphasis on
preventing and treating non-communicable illness – and by removing
the barriers to end-of-life care – we can help stem the rising tide of
costs.
While we work to maintain a sustainable healthcare system by

adopting such efforts, we also must acknowledge that there is not a
“magic bullet” solution to easily solve the cost problem. Rather, we
must re-evaluate our perception of what is currently deemed an
acceptable level of spending on healthcare. This may require a shift
in public priorities and some painful economic choices.

IV. Redesigning
Our Environment:
What a better world
might look like

IV. Redesigning Our Environment: What a better world might look like
Chapter 17 Vulnerabilities of Older People

In all countries, both developed and developing, older people face an
Social Protection of Older array of vulnerabilities. Among these are lack of income, health
insecurity and the need for physical care.
People It is not possible to say definitively that older people are always
David E. Bloom, Emmanuel Jimenez and Larry Rosenberg poorer relative to other age groups. With an official poverty rate of
35%, they certainly were in the United States in 1960; but less than
Social protection is a major arena of government activity aimed at 40 years later this rate had fallen to 10%, lower than that for the
ensuring that vulnerable population groups receive appropriate and non-elderly.1 In Eastern Europe and Central Asia, in the years after the
effective public support to safeguard their financial security and their transition from socialist economies, older people, relying on built-up
health. However, despite the growth and extent of social protection assets and generous pensions, were typically better off than other
programmes in both developed and developing countries, most groups.2 Data from the 1990s from a diverse group of countries with
emerging economies have nascent systems, and only a small portion roughly comparable household data sets – Ghana, Pakistan, South
of such efforts addresses the specific vulnerabilities and needs of Africa and Ukraine – indicated that consumption poverty for older
older people. people was higher than the non-elderly, but lower than that of
children.3
The varied situations of older people in countries throughout the
world have led to differing definitions of “older people”. In addition, A recent study in Latin America showed that the population over age
gender differences in labour force participation, retirement age and 60 was not any more likely to be poorer in terms of income than
long-term income security mean that the effects of “old age”, as well others in 15 of 18 countries; but their poverty status was worse in
as societal responses to ageing, will be different for men and women. Colombia, Costa Rica, and Mexico.4 Similarly, poverty rates among
For the sake of simplicity and clarity, this paper considers those aged older people in Sri Lanka, India and several countries in North Africa
60 and above to be “older people”. are equal to or lower than those of the general population.5 What
drives these diverse results? Why are older people more secure in
This paper discusses the vulnerabilities of older people and the terms of well-being in some places and some time periods relative to
benefits of crafting social programmes to address them; describes others?
the nature of social protection and the forms it can take to address
those vulnerabilities; reports descriptive evidence on the availability The answers depend on how older people derive their income and
and use of social protection programmes; and delineates steps that the reliability of the flow. First, older people in nearly all settings are on
can be taken to remedy the shortfalls experienced by older people. average less likely to have paid employment than are younger adults.
Older people often rely for income on a combination of fixed assets,
in many cases meagre savings, government programmes such as
pensions, and support from family members. Savings, aside from
often being small, can lose value to inflation. Frequently, there are
insufficient investment vehicles to counteract savings’ loss of value
over time.
Pensions can be extremely important, but particularly in developing

countries they tend to be small, and coverage is spotty. Even in some
developed countries such as the United States, public pension
programmes like Social Security may not provide sufficient income
for most people during retirement. Family members have traditionally
been the prime source of financial support for older people. In many
societies, this is still true, although in Japan and many other
countries, older people transfer resources to younger generations
until they reach their 80s. But in numerous places, the family ties that
underlie continued support of older people are beginning to fray.
Reasons for this include young people moving away from family
homes in rural areas, the greater tendency for women to work
outside of the home, the tendency for families to be smaller and for
generations to be more spread out. In some instances, cultural
changes are diminishing the expectation that children will take
charge of caring for their parents.
Older people are also vulnerable because they are more likely to have
health issues. In a survey of seven Latin American and Caribbean
cities, more than 77% of those aged 60 and over claim to live with a
disease and 19% have a disability.6,7 When they are ill, older people
often have inadequate access to medical care. When there is
access, they may be unable to pay for the care they require, or the
service may be of low quality. Health insurance is available to some,
but in developing countries, most older people do not have health
insurance.

As a result, older people in many countries lack preventive care, face people’s exposure to risks, and enhancing their capacity to protect
untreated illnesses, are uncertain about new health problems that themselves against hazards and interruption/loss of income”.11
they may have to face in the future, and are unable to pay for the
amount and quality of healthcare they need. Further, the The World Bank is re-evaluating its Social Protection Strategy. The
consequences of chronic disease may limit their capacity to remain publicly available concept note refers to a three-part articulation of
independent and support themselves, and when they have a programmes: prevention against drops in well-being through social
catastrophic condition that requires treatment, they often use up insurance; protection from destitution and catastrophic losses
family savings. As a result, spending on healthcare is a prime reason through social assistance programmes; and promotion of improved
that families with or without older members fall into poverty. opportunities and livelihoods, chiefly through better jobs.12
Finally, older people are vulnerable because they need These definitions encompass a broad swath of government
companionship, physical care and assistance. Companionship may programmes. But that is central to the notion of social protection,
be difficult to find as spouses die and children move away or feel less which does not have as clearly defined boundaries as more
obligation to take care of parents. Reduced mobility may limit their established sectors, such as education, transport or health.
capacity to remain socially engaged outside of the family. The same Addressing risks and vulnerabilities often requires an all-of-
factors affect physical care and assistance. These trends are government approach that cuts across many sectors.
especially true in developed countries where older people tend to live
alone or with a spouse. Changes can occur rapidly, even in traditional It is also useful to state what social protection does not include.
societies. For example, the proportion of older Japanese living with Social protection refers to public programmes, not private efforts to
children is estimated now to be about 42%, which is much lower than guard against the many dangers faced by people of all ages. Social
the 87% in 1960.8 Thus, older people in developing countries, where protection does not encompass two important means by which
they still rely more heavily on family members for care and survival, older people receive support. First, social protection does not refer to
may be confronting wrenching changes soon. One indicator of this is the use of individuals’ savings for their support in old age. Second, it
the difference among countries in the same region. In Latin America, does not refer to various types of financial and social support that
only about 10% to 23% of older people in Central American countries families often provide. As important as these are, they are not social
live alone compared to well over 50% in Argentina and Uruguay.9 activities.
The extent of the vulnerability of older people varies considerably In all definitions, social protection aims to diversify risk. Ensuring a
from one population group to another. Those at the higher end of the certain level of protection for all people means that a society is less
income spectrum are more secure than the poor. Those in good likely to have to deal with the consequences of extreme poverty or
health, or whose health problems are compressed into a relatively acute hunger. Because social protection is ultimately funded by
small portion of their lifespan, have less to deal with than those who governments, it is a social undertaking that bolsters a society’s
are chronically ill. Those without children and those who cannot get resilience by lessening individuals’ vulnerability. It aims to achieve
around by themselves tend to be more vulnerable. Widows often these aims efficiently, but in doing so it also increases equity.
face particularly daunting constraints on their activities, finance and
future relationships.10 Social protection first achieved prominence when Otto von Bismarck
established a welfare programme in Germany to satisfy people’s
Women are generally more vulnerable than men, in part because demands in a way that would avoid the possibility of a socialist
they have typically had less opportunity to amass savings because revolution. Later, the Depression led to the New Deal in the United
they are less likely to have had paid employment and more likely to States. After World War II, the Scandinavian countries moved further
have left the labour force earlier. However, their traditional role as towards implementing broad social welfare programmes. In the
carers may benefit their partners. The “oldest old”, i.e., those aged 80 United Kingdom in 1942, the Beveridge Report led to an expansion
and above, tend to have more limited capacities and more complex of social protection programmes. After the wave of independence
needs than those between ages 60 and 79. As a result, they are from the 1940s through the 1960s, various developing countries
particularly subject to financial and health uncertainties. began to implement or expand existing social protection
programmes.
Social Protection Numerous rationales have supported and continue to undergird
The idea of social protection arises because individual and family social protection programmes. These rationales support action in the
resources are often insufficient to protect members of society from a social protection arena independent of the age of programme
broad array of vulnerabilities. These vulnerabilities include those beneficiaries; they apply to older people as well as to the population
described above in relation to older people but extend to other more as whole. The most fundamental rationale is that we collectively have
specific circumstances, such as unemployment, disability, children a moral obligation and a desire to ensure that people have good lives;
whose needs are unmet, and workers who face problematic working without question, this applies to older people. In response to
conditions. Consideration of social protection also arises from the privation and insecurity in a very wide range of circumstances,
fact that some of the benefits it conveys accrue collectively. Health government action to redress these wrongs in the form of social
insurance, for example, is a benefit to all because it leads to fewer protection resonates with the beliefs of very large numbers of people.
people falling into poverty. Poverty is a condition that has negative
spill-overs for society as a whole. Similarly, the good health of Closely related to this point is the idea that everyone is entitled to a
individuals, which can be abetted by social protection, has positive basic set of human rights, a concept that is enshrined in the Universal
effects on a whole society. Declaration of Human Rights adopted by the United Nations in 1948.
In part as a response to the Declaration, human rights occupy a
International agencies have varying definitions of social protection prominent position in international law and in the laws of many
and focus on different but related goals. Some focus on managing countries, further spurring the development of social protection
risks and others on the importance of responding to economic programmes. By virtue of the explicit statement that human rights
shocks or natural disasters. Still others emphasize the importance of apply to everyone, older people are legally guaranteed an array of
ensuring people’s rights, including their access to good employment. rights realization of which can be bolstered by social protection
The Asian Development Bank takes social protection to mean programmes.
“policies and [programmes] designed to reduce poverty and
vulnerability by promoting efficient [labour] markets, diminishing

Complementing the rights-based rationale is poverty reduction, a Achievements and Gaps

principal policy objective for most nations. The most efficient social
protection strategy would be to include older people within general Social protection programmes of various types are in place in
social assistance programmes. Horizontal equity would then be countries throughout the world. But as applied to older people, the
preserved. But in cases where older people are over represented most significant programmes are limited to pensions and health
among the poor and they are not able to claim their share of these insurance, along with a variety of other payments. Unfortunately,
programmes, direct transfers to them through social programmes there is no fully developed and internally consistent source of data
may be warranted.13 about the reach of social protection programmes, and other than
pensions, even less so about those that apply specifically to older
Finally, there is growing evidence that the gains achieved by social people. Various international agencies have assembled partial data
protection programmes can give an impetus to economic growth. sets, with information based on both a review of government efforts
Families that do not have to struggle for every penny, whose members and survey data, but these sources are not adequate to provide an
are healthier than in the past, or whose elderly individuals receive overall picture.
pensions or welfare payments, are more able to be economically Pensions
productive members of society. These families contribute to their own
well-being and to that of a country as a whole. The recent Pensions may be supplied by either the private sector or the public
Commission on Growth and Development led by Michael Spence sector, but only government-provided pensions fall under the rubric
concluded that, while there is no one policy recipe for sustained of social protection. Most governments in countries that are in the
growth, there are some essential ingredients, one of which is to greatest need of social protection have little in the way of pension
protect people through social safety nets, without which “popular programmes, but South Africa and Ghana are notable exceptions in
support for a growth strategy will quickly erode”.14 their determination to provide income security to older people. The
case of South Africa is particularly interesting, because the large
Social protection involves numerous actors and stakeholders. pensions received by older people also have substantial positive
National governments are the most central participants in social effects on other household members.15 One measure of the
protection programmes, as they have responsibility for the welfare of significance of a country’s pension system is the extent of its
their citizens. Local governments and non-governmental coverage or the share of older people that receive a pension at all.
organizations are often very active in social protection efforts. Another measure is the fraction of a worker’s income that is replaced
International organizations sometimes play a major role. Finally, the by a pension.
for-profit private sector can participate in certain aspects of social
protection, for example in the delivery of services. The most obvious Pension coverage for older people via state-run social protection
stakeholders are the people that social protection seeks to protect: programmes varies greatly across countries. Figure 1 shows that
the poor and the vulnerable. Among these, older people figure coverage is greater than 50% for most developed countries and
prominently in some aspects of social protection, most notably, some developing countries, and below or far below that percentage
pensions. for many developing countries. Among Organisation for Economic
Development and Co-operation (OECD) countries, for example, over
83% of the labour force is covered by mandatory pensions schemes.
This contrasts with about 21% in China.16
Figure 1: Share of elderly who receive a pension via public

programmes
Number of countries :
Less than 20% (46)
Between 20% and 50% (24)
Between 50% and 90% (39)
90% and over (29)
No data (59)
Source: International Labour Office (2010). World Social Security Report 2010/11: Providing coverage
in times of crisis and beyond. Geneva: ILO, 47.

Pension financing typically takes one of two forms. In a pay-as-you- Health Insurance
go (PAYG) system, benefits to retired individuals are financed by Older people are more likely, typically much more likely, to need
contributions from current workers or employers and by any savings healthcare than the rest of a population. In most but not all developed
such a system has accumulated from past contributions. The size of countries, the whole population has access to healthcare, either
the benefits is typically predefined. The US Social Security System is without direct cost to the individual, at rates that are low enough for
an example of a PAYG system in which both workers and employers essentially everyone to afford, or via health insurance. In addition,
make mandatory contributions. In such a system, the availability of some countries, such as Australia and the United States, have
funds to pay retirement benefits to workers depends on a variety of programmes that make medications more affordable for older
factors, including prominently the long-term ability of the economy to people. But in many countries, older people have no reliable,
generate enough employment so that accumulated contributions are unsubsidized means of paying for healthcare expenses, particularly
sufficient. not of the magnitude they encounter as they age. Healthcare
expenses can be devastating to families and are a prime cause of
By contrast, a fully funded system typically functions via workers bankruptcy. Individuals and families borrow from friends and
making defined contributions to individual accounts, which are relatives, but in poor communities the extent to which such
invested in financial assets of various types. The ability of such a borrowing can serve as a long-term solution is quite limited.
system to fund individuals’ retirement depends on the level of a
person’s contributions, but also heavily on the performance of the Numerous developing countries have taken steps to provide
financial sector over a period of decades. As an element of a social healthcare or health insurance to the population. The key issue is
protection programme, a government can seek to implement either often the ability of people to pay, either directly for healthcare or
type of system. In particular, low-income countries can face indirectly via insurance. In most developing countries, a government
difficulties in making either type work. that seeks to guarantee the availability of healthcare to the population
as a whole will need to develop a system that does not depend
Latin American countries have an array of pension systems. Among substantially on individual contributions. Because older people are all
those with publicly operated plans, coverage of employed individuals the less likely to be able to pay for healthcare out of their own
ranges from 52% in Brazil to 14% in Paraguay. In some Latin resources, government-financed healthcare is particularly important
American countries (Argentina, Brazil, Chile and Uruguay), older for them.
people are less likely to be poor than the population as a whole,
whereas the reverse holds in Bolivia, Colombia, Costa Rica, The provision of universal healthcare could potentially resolve the
Honduras and Mexico.17 problem of older people’s access to healthcare. However, even
“universal” programmes often have coverage terms that limit the
India has both defined-benefit and defined-contribution pension extent or type of healthcare services available. Older people
systems, both publicly managed, either by states or the national generally need healthcare services more than the rest of the
government. However, their reach is limited. Most workers in the population. As a result, any limitations are likely to affect them
formal sector (i.e., those employed by government or in registered disproportionately unless there are specific provisions focused on
businesses – about 10% of the workforce) are required to contribute ensuring that their healthcare needs are met.
to one or more of an array of pension programmes, one of which
includes matching contributions from the government. The various Closely related to healthcare are long-term care of older people and
programmes yield benefits of differing types – lump-sum payouts, care for people with disabilities. Older people, being more likely to be
annuities or a set of defined-benefit payments – though some plans disabled than other people, are particularly likely to need long-term
of this latter type are at risk of insolvency. In 2009, the Indian care. Such care may include healthcare delivery, day-to-day support
government made one of its pension plans open to all Indian citizens, for carrying out activities of daily living, or programmes that bring
although there are no matching contributions.18 meals to older people who are unable to obtain or prepare food. In
most countries, older people are unlikely to be able to pay for such
Retirement policy is relevant to the establishment and functioning of care. However, in some countries, such as Germany, Japan and
pension systems. While individuals continue to work and thereby South Korea, long-term care insurance is universally available. Other
support themselves, they can contribute to a pension fund. Once countries, for example in Scandinavia, have tax-funded strategies in
they stop working, they typically begin to draw funds from a pension place to help older people age through community-based
system, if one is operational. In countries where people retire at a care. Responding to these needs in a way that goes beyond
relatively early age, the funds available for pensions will, all things family-based care will often require government financing. Other
equal, be less than in countries where retirement usually occurs later. alternatives have been explored, including subsidizing family-based
As a result, retirement systems that encourage an early end to labour care. In this instance, the Austria case is particularly interesting.20
force participation result in a lower level of funding for pension
systems. Many workers want to retire as early as possible to enjoy Other Forms of Social Protection for Older People
the benefits that retirement can bring. An array of other types of programmes falls under the rubric of social
protection and can make a difference in the lives of older people.
But the fruits of retirement depend crucially, though far from
Transport subsidies or free fares for older people have been
exclusively, on parameters of the pension system. Some focus the
implemented in many countries. Tax breaks on both earned and
debate on adequacy of the replacement rate, which is the pension
unearned incomes of older individuals, along with special protections
relative to the previous earnings level. This varies enormously across
linked to wills and transfer of property, can enhance financial security.
countries – an average of 60% for men in OECD countries to just
above 13% in Singapore.19 However, because pensions are taxed Finally, direct cash payments are a form of social protection that can
differently across countries, the replacement rate may not reflect make a large difference. Depending on the recipient’s financial
whether the retired are well off. In addition, the financial situation of condition, such payments can either help lift an elderly person out of
older people depends not only on pensions, but also on the interplay poverty or make life more comfortable for someone who is already
between public and private institutions, individual circumstances and above the poverty line.
family support.

Impediments and Tools for Circumventing Them The present may be an opportune time for mobilizing such a
consensus – the financial crisis is still fresh in mind at a time when
The primary impediment to implementing social protection most countries are already recovering. This effort would require
programmes for older people is financial. All countries face financial starting with existing national strategies, such as the poverty
constraints, so decisions about providing social protection, for older reduction strategy paper for the poorest countries, or the medium-
people or any other group, take place in an environment where term expenditure plan for others, and doing an elderly “stress test”
resources must be used carefully. Pensions, healthcare provision or on them. Do present programmes cover older people adequately?
health insurance and other types programmes involve direct What more needs to be done? What are the trade-offs? These
expenditures from the government treasury that can only take place strategies should be subject to extensive consultation with civil
at the expense of other possible uses of public funds. society, as it would be the basis for reforming an implicit social
A second important barrier to meeting the needs of older people via compact.
social protection programmes is lack of political will. This absence Third, having gathered the evidence and formulated a strategy,
can arise from a sense of impossibility: why tackle a problem that countries should consider the next step: mobilizing domestic
seems so unlikely to be tractable? This circumstance may not be resources. Many countries could devote more resources to social
helped by the attitude of older people who tend to be less agitated protection programmes for older people and for the population as a
about their own plight. Recent “happiness” surveys, whether they be whole by increasing their tax revenues as a share of GDP. This figure
for the United States, Europe or Latin America and the Caribbean, currently varies greatly among developing countries, reflecting,
indicate that age and happiness have a U-shaped relationship – among other things, different power relations among groups within a
happiness declines until sometime in the 40s, when it rises again country. In many cases, domestic sources of income could be
(after controlling for health).21 The concern is that this may be a tapped and directed toward expanding social protection
“collective tolerance for bad equilibrium”,22 or simply the resignation programmes.
that comes with older ages.
Fourth, many countries can turn to the international community for
A third impediment that is relevant to older people is the absence of a more help. Financially, countries can work with external partners,
focus on their needs. Even if a country has a commitment to using such as developed countries that offer aid and international agencies
social protection programmes to reduce vulnerability and poverty, it that supply grants and loans, to craft programmes that can begin to
may not do so in a manner that addresses the specific address the needs of older people.
circumstances of older people.
The coverage gaps in social protection programmes are large, as
Several different types of actions can potentially help to overcome huge portions of the population in many countries are not able to live
these impediments. These include raising consciousness, gathering decent lives and, in many cases, are barely able to meet their most
robust evidence about the nature of the problem, developing a basic needs. The International Labour Office sought to estimate the
national strategy and marshalling domestic resources to address it, ability of 12 low-income African and Asian countries to fund a basic
and mobilizing international efforts where necessary. social protection package covering pensions, basic healthcare, child
First, as shown in this chapter, the plight of older people varies across benefits, social assistance and employment plans. The study found
countries and can change rapidly over time. Therefore, it is critical to that the countries would be able to do so by spending between 3.8%
develop a comprehensive information system in a country about the (Pakistan) and 10.6% (Burkina Faso) of GDP,25 though such
financial, physical and social situation of older people that can serve expenditures may not be affordable domestically for these countries.
as a crucial point of reference for assessing needs, drafting Joining international campaigns may help with moral suasion in some
programmes and making rough cost estimates. In many countries, cases. For example, the Social Protection Floor Initiative (SPF-I), led
existing census data organized to reflect the circumstances of older by the International Labour Organization and the World Health
people may provide a good start. More ambitious efforts could Organization, seeks to help countries establish an “SP (social
include elderly-specific surveys. These surveys are now beginning to protection) floor” that sets out a “basic set of rights and transfers that
be applied to emerging economies. For example, the US Health and enables and empowers all members of society to access a minimum
Retirement Survey has spawned the China Health and Retirement of goods and services and that should be defended by any decent
Longitudinal Study (CHARLS).23 But analysts need not wait for such society at any time”.26
extensive surveys, because other household-level surveys – for
example the Demographic and Health (DHS) and Living Standards
Measurement Study (LSMS) Surveys – can be used for age-specific
analysis, even if they do not have as much information as one would
like. Access to these and other surveys should be as free as possible
to enable analysts from developing countries to use them.
Second, the inclusion of older people in national social protection

frameworks varies widely across countries. Many emerging
economies are only beginning to develop coherent and extensive
social protection strategies. Political consensus for such strategies is
difficult to achieve during good times when people see no immediate
need for social protection, and programmes are often haphazard
when forged too quickly during crises.24

Conclusion Endnotes
In low- and medium-income countries, poverty is widespread. Older 1 Engelhardt, G. & Gruber, J. (2004) Social Security and the Evolution of Elderly Poverty. NBER
Working Paper 10466. Available at: http://www.nber.org/papers/w10466
people are often poor and frequently have inadequate access to 2 Alam, A., Murthi, M. & Yemtsov, R. (2005) Growth, poverty, and inequality: Eastern Europe and the
healthcare. In high-income countries, older people are often former Soviet Union. Washington, DC: World Bank.
disproportionately represented among the poor.27 In many countries, 3 Deaton, A. & Paxson, C. (1997) Poverty among children and the elderly in developing countries.
changing social circumstances have left older people vulnerable to Center for Research on Child Wellbeing, Princeton University, Working Paper #98-09. Available at:
http://crcw.princeton.edu/workingpapers/WP98-09-Deaton.pdf
losing whatever social or personal safety nets they have.
4 Cotlear, D. & Tornarolli, L. (2011) Poverty, the Aging and the Life Cycle in Latin America. In: Cotlear,
D. (ed.) Population Aging: Is Latin America Ready? Washington DC: The World Bank.
In the face of these difficulties, the need for social protection 5 Robalino, D. A. & Holzmann, R. (2009) Overview and Preliminary Policy Guidance. In: Holzmann,
programmes that address the needs and vulnerabilities of older R. Robalino, D. A. & Takayama, N. (eds.) Closing the Coverage Gap: The role of social pensions
and other retirement income transfers. Washington DC: The World Bank.
people is large. But historical circumstances, ongoing financial
6 Medici, A. C. (2011) How age influences the demand for health care in Latin America. In: Cotlear, D.
constraints and lack of political will have combined to limit the extent (ed.) Population aging : is Latin America ready? Washington, DC: World Bank. Ch. 4.
of existing social protection programmes. The result is a large gap in 7 Studies in some other countries have found much lower numbers: between 2 to 3% of the 65 and
most countries, and especially in developing countries, between the older population were found to have disabilities in Eastern Europe and the former Soviet Union.
needs of older people and programmes that can meet these needs. See: Chawla, M., Betcherman, G. & Banerji, A. (2007) From red to gray: the “third transition” of
aging populations in Eastern Europe and the former Soviet Union. Washington, DC: World Bank.
Ch. 5.
In addressing this gap, policy-makers will have to grapple with the 8 Englehardt, G., Gruber, J. & Perry, C. D. (2005) Social Security and Elderly Living Arrangements.
fact that individual social protection programmes, for example those Journal of Human Resources, 40, 354-72.
focused on pensions or health insurance, do not necessarily work as 9 Cotlear, D. & Tornarolli, L. (2011) Poverty, the Aging and the Life Cycle in Latin America. In: Cotlear,
D. (ed.) Population Aging: Is Latin America Ready? Washington DC: The World Bank. Pg. 123.
effectively as they could if they were well integrated with each other.
10 For an in-depth account of widowhood in India, including the stigma faced by widows, see: Chen,
Regardless of the set of social protection programmes that are M. A. (2000) Perpetual Mourning: Widowhood in Rural India. New Delhi, New York: Oxford
implemented, the overall situation of older people will be affected not University Press.
only by social protection programmes, but also by individual and 11 Asian Development Bank. (2010) Social Protection: Reducing risks, increasing opportunities.
family choices and by the full set of public and private institutions Available at: http://www.adb.org/SocialProtection/
whose actions affect older people. 12 World Bank. (2011) Building Resilience & Opportunity Consultations on the World Bank’s Social
Protection & Labor Strategy 2012-2022. Available at: http://www.worldbank.org/spstrategy
13 Robalino, D. A. & Holzmann, R. (2009) Overview and Preliminary Policy Guidance. In: Holzmann,
There are several compelling rationales for closing the gaps faced by R. Robalino, D. A. & Takayama, N. (eds.) Closing the Coverage Gap: The role of social pensions
older people: a moral imperative, respect for basic human rights, and and other retirement income transfers. Washington DC: The World Bank.
the efficiency gains and impetus to economic growth that can be 14 Commission on Growth and Development. (2008) The Growth Report: Strategies For Sustained
Growth And Inclusive Development. Available at: http://www.growthcommission.org/index.
achieved through social insurance and welfare assistance. Countries php?Itemid=169&id=96&option=com_content&task=view Pg. 6.
on their own may not be able to meet the full range of needs of older 15 Case, A. (2004) Does Money Protect Health Status? Evidence from South African Pensions. In:
people, but they can take some steps to assess these needs and Wise, D. (ed.) Perspectives on the Economics of Aging. Chicago: University of Chicago Press. Pg.
design programmes, often in conjunction with international partners, 287-312.
that make a start in doing so. 16 OECD, Organisation for Economic Co-operation and Development. (2009) Pensions at a Glance:
Asia/Pacific Special Edition. Available at: http://www.oecd.org/dataoecd/33/53/41966940.pdf
17 Dethier, J. J., Pestieau, P. & Ali, R. (2010) Universal Minimum Old Age Pensions: Impact on Poverty
and Fiscal Cost in 18 Latin American Countries. World Bank Policy Research Working Paper 5292.
Available at: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2010
/05/06/000158349_20100506135339/Rendered/PDF/WPS5292.pdf
18 Bloom, D. E., Mahal, A., Rosenberg, L. & Sevilla, J. (2010) Economic security arrangements in the
context of population ageing in India. International Social Security Review, 63 (3-4), 50-89.
19 OECD, Organisation for Economic Co-operation and Development. (2009) Pensions at a Glance:
Asia/Pacific Special Edition. Available at: http://www.oecd.org/dataoecd/33/53/41966940.pdf
20 See for detailed case on Austria: Chawla, M., Betcherman, G. & Banerji, A. (2007) From red to
gray: the “third transition” of aging populations in Eastern Europe and the former Soviet Union.
Washington, DC: World Bank. Pg. 34. See for detailed OECD overview: OECD, Organisation for
Economic Co-operation and Development. (2011) Help Wanted?: Providing and Paying for
Long-Term Care. Available at: http://www.oecd.org/dataoecd/12/62/47903344.pdf
21 Graham, C. (2011) The economics of happiness and health policy. In: Cotlear, D. (ed.) Population
aging : is Latin America ready? Washington, DC: World Bank. Ch. 5.
22 Ibid. Pg. 206.
23 China Health and Retirement Longitudinal Study. (2011) Biennial Survey. National School of
Development, Peking University. Available at: charls.ccer.edu.cn/
24 Grosh, M. et al. (2008) For Protection and Promotion. Washington DC, World Bank.
25 ILO, International Labour Office. (2008) Can low-income countries afford basic social security?
Geneva: International Labour Office, Social Security Department. Table A2.1.
26 ILO, International Labour Office and World Health Organization. (2009) Social Protection Floor
Initiative: Manual and Strategic Framework for Joint UN Country Operations. Available at: www.ilo.
org/gimi/gess/RessFileDownload.do?ressourceId=14484
27 In OECD countries, 17% of people of retirement age are living in poverty, compared to 12% of
working-age individuals (weighted average based on OECD, 2008). For more information see:
OECD, Organisation for Economic Co-operation and Development. (2008) Growing Unequal?
Income Distribution and Poverty in OECD Countries. Available at: http://www.oecd-ilibrary.org/
social-issues-migration-health/growing-unequal_9789264044197-en

Chapter 18 How Are Older Persons’ Rights Being Violated?
There is a worldwide toleration of age discrimination and ageism. Age

Human Rights in Older Age discrimination occurs whenever an individual or individuals are
treated differently simply as a consequence of their age. Age
Alexandre Kalache and Richard Blewit discrimination can be directly experienced, as in a refusal of training
or education because an individual is deemed “too old”, or indirectly,
Older persons have the same intrinsic rights as everyone else, but such as in the non-collection or non-presentation of data on
there are specific realities – from limited access to services, morbidity and/or mortality for people over 65 years – as if illness and
education and job opportunities to elder abuse, neglect and death after a certain age is of no interest to society. This translates
abandonment – that render violation of their rights more frequent and into a failure to develop policies and interventions that could improve
cause them to be one of the most vulnerable population groups in health in older age.
any society.1Worldwide demographic change is resulting in an
unprecedented growth in the number of older persons. Increasing Laws mitigating age discrimination do exist in some countries, but
numbers of women and men will be affected directly by age they are most commonly limited to employment, and even so, the
discrimination and ageism. In addition, many of those who will reach right to work, with its social criticality, is far from assured. Legislative
old age in the near future will have already, throughout their life attention seldom extends to such vital areas as social and health
course, accumulated disadvantages that will heighten their exposure care, long-term support, or provision of other goods and services.
to discrimination. For instance, a woman who is poor, socially The right to adequate social security is significantly under-addressed
excluded, disabled, single and childless will be at a much higher risk globally,5 as is the right to an accessible and affordable healthcare
of violations against her rights in older age than, say, a married man that is appropriate to older persons` needs. In relation to the latter,
from a higher socioeconomic background and educational level. massive gaps persist, and there is a notable incidence of
discrimination and rationing.
Since the 1948 Universal Declaration of Human Rights, specific UN
conventions on the rights of children, women, indigenous At the root of the violations of older persons’ rights is ageism – the
populations, ethnic minorities, immigrants, disabled persons and stereotyping and prejudice against older people – where “people
other subgroups have been adopted. Only one international human cease to be people, cease to be the same people or become people
rights convention (the International Convention of All Migrant Workers of a distinct and inferior kind, by virtue of having lived a specified
and Members of their Families) mandates against age number of years”.6 It ranges from condescension in advertising and
discrimination.2 Older people comprise the largest vulnerable films (Yale University studies have shown that such negative
population still lacking tailored and binding international legal stereotypes have a harmful impact on older people’s self-esteem,
instruments to ensure that their rights are protected. This is despite their memory and even longevity)7 to accusations of witchcraft in
today’s reality that they are the fastest increasing population some countries that can lead to community ostracism and in some
subgroup. All people are entitled to basic rights simply because they cases murder.
are human, irrespective of age, citizenship, nationality, race, ethnicity,
language, gender, sexuality or abilities. This is widely accepted and Ageism facilitates an environment in which older people are
central to a universal understanding of humanity. The concept of particularly susceptible to abuse. Despite a regrettable lack of
modern human rights has developed over time and has its origins in national research and few official statistics, there is compelling
a wide range of philosophical, moral, religious and political traditions. anecdotal evidence to suggest that elder abuse is a global epidemic
There is no single historical narrative charting the evolution of rights to – one that resonates as much in advanced as in emerging
the understanding most societies have of them today. When these economies. There is a clear parallel between elder abuse today and
inherent rights are respected, people are able to live with dignity and the position that domestic violence, child abuse and violence against
equality, and are able to participate in their societies free from women occupied in societies some three or four decades ago.
discrimination and fear. This results in a “more inclusive, equitable Initially mostly denied by governments worldwide, it took time for
and sustainable development”.3 Article 1 of the Universal Declaration studies, with a leadership from the feminist movement, to uncover
on Human Rights states, “all human beings are born free and equal the ugliness of these realities known to us today.
in dignity and rights».4 While this equality theoretically does not
change with age, the freedoms that all older people should be able to Elder abuse is considered by some to constitute one of the last grand
enjoy can only be assured if specific legal mechanisms are in taboos. Certainly it has been seriously investigated only in recent
place: the right to equal protection before the law, the right to own times. The first international multicentric research8 was a qualitative
property, the right to education, the right to work, the right to study among eight countries in 2002 by the World Health
participate in government and decision-making, the right to social Organization (WHO) and the International Network for the Prevention
security, and the right to access appropriate health and social care of Elder Abuse (INPEA). Entitled Missing Voices, the project
services. In most countries such legal frameworks are patchy and highlighted elder abuse as defined by older persons themselves, with
inadequate – a reality that reinforces the need for more robust an emphasis on the institutional – an insidious abuse that was
international instruments at all levels. considered by them to be the most difficult to confront and the
easiest to be denied.
A growing number of research studies9 in both the developed and

the developing world is starting to reveal the magnitude of the
problem in all its forms: physical, emotional, verbal, financial and in
the form of neglect and abandonment. However, according to the
WHO in August 2011, “the scope and nature of the problem is only
beginning to be delineated, many risk factors remain contested, and
the evidence for what works to prevent elder maltreatment is
limited”.10

A clear picture emerges from the hodgepodge of studies that have The Madrid International Plan of Action on Ageing
been conducted so far. The American Psychological Association has In 2002, the United Nations convened the Second World Assembly
estimated that 2.1 million older Americans are victims of abuse every on Ageing, which resulted in the Madrid International Plan of Action on
year.11 It is further believed that, for every single reported instance, Ageing (MIPAA) with detailed recommendations falling into three
there are as many as five unreported cases.12 According to a MetLife priority directions: advancing health and well-being into old age; older
Mature Market Institute study (June 2011), financial abuse robbed persons and development; and ensuring an enabling and supportive
elder Americans of $2.9 billion in 2010, up 12% from 2008.13 Studies environment (physical and social). At the Assembly, countries
by the Institut National des Statistiques14 revealed that at least 10,000 committed to eliminate all forms of age discrimination, to ensure that
older people, mostly in nursing homes, died prematurely in France as “persons, as they age, […] enjoy a life of fulfillment, health, security and
a direct result of the 2003 heat wave. Misleading death certifications active participation in the economic, social, cultural and political life of
almost certainly disguise a much higher number according to the their societies”.17
Bulletin de LÀcademie de Medecine (2004).15 In 2001, 156 deaths
were reported over a period of only two months in a nursing home in While human rights do underpin both the UN Principles and MIPAA,
Rio de Janeiro; subsequent investigations revealed all manner of they are not legally binding instruments. Furthermore, subsequent
medical and nursing malpractice, which triggered further reviews of MIPAA directives have illuminated inconsistent
investigations in other residential care facilities – most presenting implementation and pointed to a need for “hard law” rather than
similar dysfunctions.16 these optional mechanisms for which member states do not feel the
pressure of obligation.
Obviously, not all older people are vulnerable – a generalization which
in itself would involve stereotyping and prejudice. Indeed, older Many argue that there is a “normative gap” (a lack of provision in
people are even less homogenous than other age groups for the human rights law) in relation to the rights of older persons as well as
simple reason that they have lived longer and had more diverse an “implementation gap”. Treaty bodies monitoring human rights
experiences. Gender plays an important role. Older women and men commitments rarely ask questions about the rights of older persons,
experience ageing and old age in different ways. The contrasts are and member states rarely include older people in their reports to the
not only as a result of social constructions. Biological characteristics UN.
can confer diverging susceptibilities to diseases with specific
consequences – a greater risk of frailty for women, for example, can Several regional human rights treaties additionally contain clauses
lead potentially to an increased vulnerability to abuse. People in their that relate to the rights of older persons.18 For example, in the
60s vary widely from those in their 80s. A combination of factors European and Inter-American contexts, the provisions for older
such as culture, educational level, former professional status, people’s rights are found in social, economic and cultural rights
disability, poverty, sexuality and gender create a complex and treaties. The African human rights regime protects those rights
multifactorial heterogeneity which must always be considered when alongside civil and political rights in the African Charter on Human
addressing the issues of rights in old age. and Peoples’ Rights.19 In the European setting, reference should also
be made to the Revised European Social Charter, which sets out in
Dedicated International Instruments broad terms a right to social protection.20
The United Nations Principles for Older Persons Despite these developments, the reality in the international human
In 1991 the UN General Assembly enacted the UN Principles for rights arena is that there is a lack of effective focus on the rights of
Older Persons, the first document related to ageing to embrace a older people.21 Furthermore, where older persons are referenced in
rights-based approach. This UN document broke new ground by existing treaties, they are expressed in terms of economic, social and
including reference to individual development throughout the life cultural rights (ESRC), which are most often regarded as “rights of
course within the context of longevity. Eighteen Principles within five progressive implementation” – for which full and immediate
main groups were adopted: incorporation into each jurisdiction is not required. They are viewed
as goals or aims.22 The UN Committee on Economic, Social and
• Independence: covering aspects such as access to the Cultural Rights felt the need to issue a General Comment in which it
essentials of life (food, water, shelter, clothing, health care); basic deplored the fact that states did not “provide any information in a
income; family and community support; the opportunity to work systematic way on the situation of older persons with regard to
and to gain education; safe environments – to include living at compliance with the Covenant”.23
home for as long as possible
• Participation: with a focus on societal integration, active It is clear that the focus needs to move beyond ESRC to encompass
participation in the formulation and implementation of policies, issues that incorporate access to justice and judicial remedy, the
the sharing of knowledge and skills with younger generations and right to life, freedom from violence, and more broadly, citizenship
the forming of associations and movements itself. Recent discussions have illuminated additional areas that need
• Care: access to the full spectrum of health and social care, to to be addressed, such as legal capacity, informed consent, long-
legal services, to secure environments, and to benefits from term and palliative care, access to social and home-based care, as
family and community care according to societal cultural values well as the complexities related to violence, abuse, neglect and
abandonment.
• Self-fulfillment: through access to the educational, cultural,
spiritual and recreational resources of society and the
opportunities for development of full self-potential
• Dignity: the ability to live in dignity and security, free of exploitation
and physical or mental abuse

Strengthening the Rights of Older Persons at International Some countries at the OEWG, mostly from the developed world,
Level expressed the view that existing mechanisms (i.e., human rights
conventions, treaty bodies and special procedures) are under-utilized
There is a case to be made for strengthening the rights of older but sufficient. Some of them articulated the view that additional
people at the international level, given that: mechanisms would overburden the already-strained existing
• Existing international human rights laws do not sufficiently protect frameworks. In contrast to this position, a body of Latin American
older person’s rights countries, led by Argentina, Brazil, Chile and Uruguay, argued that it
is a unified structure that is missing and reminded other member
• Ageism and age discrimination remain prevalent and are
states that MIPAA is not an agreement that carries the weight of
unacceptable
“hard law”. These countries emphasized the additional reality that it is
• Protection conferred to older persons in relation to their rights precisely in times of financial crisis when the most vulnerable are in
does fundamentally improve lives and communities the most need of specific protection. The view was expressed that, in
• Respect for older persons’ rights leads to conditions that enable the absence of a unitary binding legal instrument, the inevitable
them to participate in and contribute to their own development tendency was toward suppression or indifference to the rights of the
and that of their families and their communities most silent and disregarded subgroups – a process already visible in
• Existing protective instruments are dispersed and often difficult to many of the developed countries most affected by the current global
access crisis.
• Human rights provide standards for service delivery For many in attendance at this second meeting of the OEWG, the
A gradual consensus is emerging toward the need for strengthening main conclusion was that there is a lack of adequate legislation and
older persons’ rights at an international level. Within this context, policies, and that those that exist remain patchy and dispersed.
a UN General Assembly resolution was passed in 2010 to establish Furthermore, many countries reported problems in implementing
an open-ended working group, accessible to all member states, with national plans. The OEWG is expected to reconvene early in 2012 to
the aim of reinforcing the protection of the human rights of older continue the discussion and to further consider ways to strengthen
persons by “considering the existing international framework of the protection of the rights of older persons. The expectation is that
the human rights of older persons and identifying possible gaps and additional substantive and persuasive arguments will be presented
how to address them, including by considering, as appropriate, by member states as well as by civil society organizations strongly
the feasibility of further instruments and measures”.24 committed to the idea of the immediate need for a Convention.
The inaugural meeting of this “open-ended working group” (OEWG) As articulated by Lindsay Judge in 2008: “[It] is arguable that when
took place in April 2011. It focused on the current worldwide status of the rights of certain groups are so obscured, often not through any
older persons’ rights, the current international framework, and the malign intent but simply the result of a particular set of societal
existing regional structures and mechanisms. The second meeting values, there is a basis for a new instrument.”25
took place in August 2011 and emphasized the nature and practice
of discrimination, the right to health in older age, social exclusion,
violence and abuse against older persons, and mechanisms to
increase the social protection of older people worldwide. In both
meetings, gaps in relation to older persons’ rights were highlighted in
four main areas – norms, monitoring, implementation and data
collection.
The OEWG meetings have produced a range of proposals to move

forward. Need was indicated for further research, studies and data
collection; a thorough review of the implementation of MIPAA; full
incorporation of older persons into development efforts, for instance,
addressing the fact that the Millennium Development Goals make no
mention to older persons whatsoever; strengthening existing
standards at national and regional levels; and coordination with the
Universal Periodic Review process for better monitoring.

Conclusion Endnotes
The recent OEWG meetings revealed a growing enthusiasm for the 1 Megret, F. et al. (2009) The Research Project on Human Dignity: Swiss Initiative to Commemorate
the 60th Anniversary of the Universal Declaration of Human Rights, Protecting Dignity: An Agenda
appointment of a Special Rapporteur – an expert designated by the for Human Rights. Available at: http://www.udhr60.ch/report/HumanDignity_Megret0609.pdf
UN and mandated to report on thematic human rights issues to the 2 Global Alliance for the Rights of Older People. (2010) Strengthening Older Peoples Rights: Toward
Human Rights Council. It is intended that she or he would be an a UN Convention. Available at: http://www.inpea.net/images/Strengthening_Rights_2010.pdf
independent officer with the freedom to make an objective 3 HelpAge International. (2009) Why it is time for a Convention on the Rights of Older People.
Position Paper. Available at: http://www.inpea.net/images/Strengthening_Rights_2010.pdf
contribution to the ongoing discussion towards strengthening older
4 United Nations. (1948) The Universal Declaration of Human Rights. Available at: www.un.org/en/
people’s rights globally. In addition, the Special Rapporteur would: documents/udhr/
5 HelpAge International. (2011) The Right to Social Security in Old Age: Bridging the Implementation
• Be tasked with deepening the understanding and knowledge of Gap. Available at: www.helpage.org/download/4edcfafe99ff7/
normative and implementation gaps in the international human 6 Johnson, J. & Blytheway, B. (1993) Ageism: Concept and Definition. Ageing in Later Life, Johnson
rights framework as it applies to older people and Salter, Thousand Oaks CA: Sage Publications.
7 Levy, B. (October 2002) Negative Views about Ageing Affect Longevity. Journal of Personality and
• Directly contribute to the ongoing discussions of the OEWG and Social Psychology. Vol. 33 (9), 261-270.
inform member states about pathways to strengthen the 8 World Health Organization. (2002) Missing voices: views of older persons on elder abuse.
international human rights system Available at: http://whqlibdoc.who.int/hq/2002/WHO_NMH_VIP_02.1.pdf
• Use a global mandate to carry out country-specific visits and 9 Biggs, S. & Goergen, T. (October 2010) Theoretical Development in Elder Abuse and Neglect.
Ageing International, (35), 167-170.
research where they contribute to advancing the knowledge of 10 World Health Organization. (2011) Elder maltreatment. Fact sheet N°357, August. Available at:
the international human rights structure http://www.who.int/mediacentre/factsheets/fs357/en/index.html
11 American Psychological Association. (1998) Elder Abuse and Neglect: In search of Solutions.
The move towards a rights-based framework has been gradual and Available at: http//www.apa.org/pi/aging/elderabuse/html/
remains incomplete. Undoubtedly, international human rights law can 12 Ibid.
significantly advance social change. As nations incorporate human 13 Metlife. (2011) Elder Financial Abuse: Crimes of Occasion, Desperation, and Predation Against
rights norms into their legal systems, a transformative global growth America’s Elders. Available at: http://www.metlife.com/assets/cao/mmi/publications/
studies/2011/mmi-elder-financial-abuse.pdf
in human rights consciousness occurs. And as Israel Doron points
14 Toulemon, L. & Barbieri, M. (2006) The Mortality Impact of the August 2003 Heat-wave in France.
out, “a rights discourse is a power discourse: it enables, empowers Institut National des Etudes Demographiques. Available at: http://paa2006.princeton.edu/
and it stresses dignity not need”.26 download.aspx?submissionId=60411
15 Lecomte, D., et al. (2004) Population domicile a Paris, decedee durant la canicule 2003. LÌnstitut
Medico-Legal, Bulletin de LÀcademie de Medecine, 188(3), 459-470.
16 Guerra, H.L., et al. (2000) Death of Elderly Patients in the Clinica Santa Genoveva: Excess
mortality that the public health system could have prevented. Cadernos de saude Publica, 16(2),
545-51.
17 United Nations. (2002) Report of the Second World Assembly on Ageing: Madrid Political
Declaration and International Plan of Action 2002. Second Assembly on Ageing. Available at:
http://social.un.org/index/Ageing/Resources/UNReportsandResolutions/
SecondAssemblyonAgeing.aspx
18 Eide, A., et al. (2001) Economic, Social and Cultural Rights: a textbook. The Hague: Kluwer Law
International.
19 Rodriguez-Pinzon, D. & Martin, C. (2003) The International Human Rights Status of Elderly
Persons. American University International Law Review, 18, 915-1008.
20 Council of Europe. (1996) The European Social Charter (Revised). Available at: http://conventions.
coe.int/Treaty/en/Treaties/html/163.htm
21 Tang, K. & Lee, J. (2006) Global Justice for Older People: the case for an international convention
on the rights of older people. British Journal of Social Work. 36(7), 1135-1150.
22 Ibid.
23 United Nations. (1995) The economic, social and cultural rights of older persons. Committee on
Economic, Social and Cultural Rights, General Comment number 6. Available at: http://www1.
umn.edu/humanrts/gencomm/epcomm6e.htm
24 UN General Assembly Resolution, 65th Session, 4 February 2011, Agenda Item 27 (c): 65/182/28.
25 Judge, L. (2009) The Rights of Older People: International Law, Human Rights Mechanisms and
the Case for Normative Standards. The International Symposium on the rights of older persons,
Background Briefing Paper. Available at: http://www.globalaging.org/elderrights/world/2008/
internationallaw.pdf
26 Doron, I. & Apter, I. (2010) The Debate Around the Need for an International Convention on the
Rights of Older Persons. The Gerontologist, 50(5), 586-593.

Chapter 19 Ageing in the City

There are many possible ways in which the urban environment may
Ageing and Urbanization influence the health and well-being of older residents. Indeed, older
people may be particularly vulnerable to the influence of urban
John Beard, Alex Kalache, Mario Delgado and Terry Hill characteristics. They may spend more time in their neighbourhoods;
have increased biological, psychological, and cognitive vulnerability;
The early part of the 21st century will see two notable milestones. In have changing patterns of spatial use; and rely more on community
2008, for the first time, the majority of the world’s population lived in sources of integration.3
cities,1 and around 2015, the number of people age 65 and over will
come to outnumber children under age five. This will be the first time Living in an adverse neighbourhood can influence health by directly
since the beginning of recorded history that older people have increasing the likelihood of experiencing personal stressful events
outnumbered young children. such as trauma, violence or unemployment.4 Physical conditions
such as urban decay, physical disorder and high levels of crime may
These events highlight two major underlying demographic shifts: generate more chronic levels of stress and fear.5,6
urbanization and ageing. Both of these trends are most dramatic in
what are currently low- or middle-income countries. This is where the However, good street design, access to public transport and access
majority of older people already live, and where the fastest ageing is to public buildings can make mobility easier. Interesting destinations
occurring. Thus, emerging economies such as China, Thailand and and welcoming neighbourhood shopping may encourage individuals
Brazil will soon have a proportion of older people in their population to remain engaged with their local community and maintain
similar to countries such as the United States. However, these supportive social networks. Such features may also encourage
emerging economies will have only about one-third of the time that walking and other physical activites7,8,9 which not only reduce the risk
the United States had to build the infrastructure necessary to meet of chronic disease, but may also exert protective effects by
the needs of this older population. strengthening the physiological systems of older adults and reducing
functional limitation, for example from osteoarthritis.
Ageing and urbanization are also closely related. It is expected that
one-quarter of urban populations in less developed countries will be While older people generally express a desire to remain active and
over the age of 60 by 2050. In developed countries, 80% of older live independently in their own communities for as long as possible,
people already live in urban areas.2 This might be a mixed blessing an older person’s ability to do so is determined not just by their
for older people who, for example, may have access to resources not functional capacity (i.e., their physical and mental health), but also by
available in less dense settings, but who may also feel more their environment and their ability to adapt to it.10 If an individual has
vulnerable to threats to their safety. In addition, older people living in lost some physical function, a city can provide the physical and social
urban areas often lack the social networks that are more commonly environment that allows them to remain – or prevents them from
available to those living in smaller, more traditional communities. being – independent. For example, disabled access to public
transport and public buildings can be used by even severely disabled
Importantly, these transitions are occurring in the midst of other older people to allow them to participate in social activities.
significant global changes. Globalization, in particular, has
transformed economies in both low- and high-income countries. A positive residential environment may also provide social resources
Older workers may find themselves in shrinking “old” industries, and that buffer the impact of life stressors,11,12,13 present readily accessible
may suffer from employer perceptions that they are obsolete or not and affordable nutrition that makes it easier for older people to eat a
worth the investment to retrain. These pressures may be amplified in healthy diet, or contain physical characteristics such as trees and
times of economic difficulty. parks that foster a sense of well-being and provide a recuperating
environment that supports resilience. Prevailing cultural norms may
These trends are also drivers of significant social transformation. For steer residents to healthy, or in some cases unhealthy, behaviours
example, the proportion of young to older family members has and outcomes.14
shrunk; women have joined the work force, thereby further
diminishing the pool of potential carers for their older relatives if they Urban environments can also influence the social cohesion of local
become sick or frail; and, at the same time, younger people have communities. Economically disadvantaged neighbourhoods have
become more mobile, and, in many countries, feel less obliged to often been associated with higher levels of social disorder,1516 lower
support older generations. social cohesion and less informal social control over problem
behaviours.17 These, in turn, may impede the development of the
How will these changes impact the health, well-being and social social networks that can buffer individuals from the stressors they
engagement of older people? Because so many will live in cities, this face on a daily basis.18
chapter explores the influence the urban environment may have on
older people and whether cities can be designed to foster more Because many of these characteristics can be readily modified by
active and healthier ageing. urban design or through different types of community development,
numerous initiatives have been put in place to modify cities to
become more supportive of older populations. While distinct in their
emphases, these generally share the common goal of addressing
needs related to health (accessible and affordable health and health
care services, opportunities to be physically active and embrace
healthy life styles); continuing education (models of lifelong learning
that foster the acquisition of new skills, new knowledge); participation
(access to relevant information, public transportation, recreational
programmes, social connections, volunteer opportunities, places to
worship, being valued and respected); and security (home and
community safety, transportation safety, financial security, affordable
housing and services).

Creating Urban Environments that Work for Older People Table 2. New York City’s guide to becoming an age-friendly
The Global Network of Age-friendly Cities business
In 2007, the WHO undertook a project to define the characteristics of Products and Services
a city that may make it age-friendly.19 The result is the WHO’s Global
Initiative on Ageing and Urbanization – the WHO Global Network of Offer food, products and/or services that are appropriate for older adults
Age-friendly Cities. Older people and care providers in over 30 cities Make discounts or special offers available for older adults when possible
around the world identified eight domains of city life that might
influence the health and quality of life of older people (Table 1). Offer drop-off and delivery services
Provide respectful human contact, in person and on the phone, and offer extra
Table 1. WHO framework for assessing the age-friendliness of customer service for older adults
a city Communicate through printed materials, the Internet and signs in large, clear
font in appropriate languages
Eight Domains of Age-friendliness Participate in the community
1. Outdoor spaces and buildings

Physical Facilities
2. Transportation
Have a place where customers can sit and rest
3. Housing
Provide a drink of water if asked
4. Social participation
Allow customers to use a restroom
5. Respect and social inclusion
Provide adequate lighting at the entrance and throughout the business
6. Civic participation and employment
Avoid heavy doors or offer electronic doors
7. Communication and information
Be mindful of stair safety: stairs (if there are any) have handrail, are deep or have
8. Community support and health services ramps
Place products on shelves which are reachable, or readily offer help reaching
Source: World Health Organization. Global Age-Friendly Cities: A Guide. World Health Organization, items
Geneva, 2007.
Moderate excessively loud music and noise
This approach was expanded in June 2010 with the establishment of Keep sidewalks free of dirt, snow, leaves, clutter and other obstacles
the WHO Global Network of Age-friendly Cities.20 To participate in the
Network, cities need to commit to an ongoing program of assessing Source: World Health Organization. Global Age-Friendly Cities: A Guide. World Health Organization,
and improving their “age-friendliness”. For the purposes of the Geneva, 2007.
Network, cities are defined in a very broad sense as municipalities
with the necessary authority to administer the changes needed to Manchester City in the UK has created Valuing Older People, a
foster age-friendliness. multi-agency programme that challenges Manchester’s public
agencies, businesses and communities to place older people at the
The Network links participating cities to WHO and to each other, centre of extensive plans for the regeneration and reshaping of the
facilitates the exchange of information and best practices, and city.22 Key components of this initiative are to tackle age
fosters the development of interventions that are appropriate, discrimination and to create “lifetime neighborhoods”.
sustainable and cost-effective for improving the lives of older people.
Hundreds of cities and communities, most from developed Smaller communities are also active in the age-friendly cities
countries, have become connected to this Network, and the original movement. For example, the Projet Villes Amies des Aînés (Age-
conceptual boundaries have become more encompassing to now friendly Cities Project) of the Canadian province of Quebec now
include notions such as sustainability and lifelong learning. involves small rural communities, in addition to large cities such as
Montreal.
Numerous innovative twists to the original model have been
developed by participating cities. For example, New York City has However, with a few notable exceptions, this explosion of innovative
created an Age-friendly New York City Commission composed of ideas has been centred in developed economies. A major challenge
public- and private-sector leaders.21 Among numerous other for this programme is to transfer the notion of age-friendliness to
initiatives, the Commission works with local businesses to make the communities in less developed settings. One factor that may help is
private sector more age-friendly (Table 2). the rapid socioeconomic development that is accompanying
population ageing in countries such as China and Brazil. The rapid
availability of new resources, and in many cases the associated
dramatic changes in urban form, offer scope for significant
intervention. This can be seen in Shanghai, where rapid economic
growth has funded the provision of universal pensions and
healthcare for older people, and where an ambitious urban policy will
see the creation of widespread and accessible community centres
for older residents.
Perhaps the most challenging and potentially rewarding ambition

would be to develop models that can support older people in the
large slum areas that are associated with many megacities in
low- and middle-income countries. Many of the features advocated
by the age-friendly cities movement are low-cost and socially
oriented. It is quite possible that innovative delivery models could
result in major changes in the quality of life of the world’s poorest
elderly.

The City as Part of a Broader Political Framework Developing the Best Infrastructure for Ageing Populations: Inclusive
Many aspects of urban living that affect the quality of life of older and Integrated Design
persons go beyond municipal boundaries; for example, state or The planning and design of infrastructure can have a big impact on
national housing policies, public transportation, access to health and people’s quality of life. Infrastructure can be better understood as
social services, recreational facilities, etc. One of the more being part of a set of complex interactions that inform the city as a
recent developments emerging from the Age-friendly Cities whole along with housing, land-use planning, utility networks,
approach is to broaden it to encompass the regional, state or resource and waste management and social networks. The
national level. integrated design of these interactions can have either a positive or
negative impact on the end user. Unfortunately, older and disabled
Examples include the Andalucia Province of Spain, the State of São people are more likely to feel the negative impacts of bad design that
Paulo in Brazil, and the State of South Australia. Similar strategies does not take into account their special needs. Inclusive design sets
applied in all three states. Once political interest at the broader level about creating environments that take into account and respond to
had been stimulated, formal commitment was sought. When different users’ needs.
granted, this was followed by the establishment of a multi-sectoral
working party including, at a minimum, government representatives The UK Design Council defines inclusive design as “a means of
(officers), civil society organizations (with emphasis on those working designing for transport that is dignified, accessible, affordable, safe
with or for older persons ), and academic institutions. and easy to use”. It means considering all of the various pieces that
help to create an overall comfortable travel experience, such as the
In all three states, engagement of the academic sector followed, and provision of shelters, seating at shelters, lighting/visibility of signs and
a protocol was developed to ensure excellence in applying rigorous audibility of systems, the availability of emergency assistance, ramp
common methodology and devising mechanisms for monitoring and accessibility for the physically impaired, and a neighborhood that
evaluation. This was done in close consultation with the multi- works for everyone regardless of their age. More importantly,
sectoral working party to ensure continuing interest and engagement inclusive design creates a viable way for anyone to get around and
from the government sector and with the participation of older takes into account how the design of infrastructure can affect the
persons throughout the development of the project and overall quality of life for older people.
implementation of activities.
Accessibility and connectivity. The location of infrastructure is
São Paulo is the largest state in terms of population in Brazil and determined at a local, regional or even national scale and is affected
includes over 600 municipalities grouped in 17 regional authorities. It by governing bodies’ investment decisions. It is important that, when
would have been impossible to start the implementation phase in all the location of transportation alternatives is being decided, decision-
of them simultaneously. Instead, at least one city representative of makers consider the relationship between necessary amenities such
each of the various regional authorities was selected (usually the as healthcare, grocery, and pharmaceutical services and the ability
largest, economically most important, and with thriving local of the elderly to physically access those services through accessible
universities). These cities now act as a “head” from which the and quality transport links. And, just as critical, is the ability of the
principles of an age-friendly city roll out as a ripple effect. The capital elderly to participate in social aspects of society so that they are not
of the State of São Paulo, São Paulo, is one of the world’s megacities, cut off and excluded from the vital social benefits of living in a
with a population of over 9 million plus and many more within its community.
metropolitan area, which consists of a dozen other
municipalities. The strategy was to select some barrios, or local Mobility: getting around. The absence of barriers on streets is just as
districts, and four of the municipalities in Greater São Paulo and to important as access to trains and buses. Neighbourhoods need to
use their experiences to broaden the project for the whole have well-designed and well-managed streets that do not act as
metropolitan region. barriers to movement and do not restrict or exclude the participation
of elderly citizens in daily social and economic life. The availability of
Andalucia is also a large province, and the same strategy was used, safe, well-marked bicycle paths are just as important for the elderly
except that two cities per regional authority played the role of as they are for other cyclists.
“heads”, a large one and a town within the region. In South Australia,
the state government’s cabinet launched emblematic initiatives and Environmental quality, health and well-being. The environmental and
interventions, thus combining this top-down approach to the bottom- health impacts of noise and air pollution associated with
up strategy of listening to older people who are critical of the transportation infrastructure as well as general feelings of safety and
Age-friendly Cities movement. security need to be considered with respect to the elderly. Features
such as lighting can help to promote the safety of users and can turn
an unsupervised, formerly derelict place into a more visible and safe
environment. Other access features such as well-lit, visible bridges
across roads and rails can also contribute to a general feeling of
safety and well-being.
Sense of place. Perhaps least well-defined or understood is the

sense of place that older populations can develop over a long period
of time. The design and development of new infrastructure can alter
the whole look and feel of an area, which can challenge the way an
older person feels able to function within their community.
Infrastructure design has the possibility of creating a fluid connection
between a community’s former version of itself and its future iteration,
so that the ageing still feel connected to their environment and can
be excited by future opportunities.

Conclusion
The dramatic demographic changes that will occur during the first
half of the 20th century will see much older and more urbanized
populations in almost all countries. Theory suggests that urban
environments can be used to foster more active and healthy ageing,
and many cities in developed countries are starting to put in place
programmes that can create more age-friendly environments.
What is lacking so far is hard evidence of a positive impact of these

initiatives and models that can be adopted in even the poorest
settings.
Endnotes
1 United Nations Population Fund. (2007) State of the World Population 2007: Unleashing the
Potential of Urban Growth. New York: United Nations Population Fund.
2 Ibid.
3 Wight, R.G., Cummings, J., Karlamangla, R., & Aneshensel, C. (2009) Urban Context and Change
in Depressive Symptoms in Later Life. Journal of Gerontology: Psychological Sciences, 64B,
247-51.
4 McLeod, J.D. & Kessler, R. C. (1990) Socio-economic Status Differences in Vulnerability to
Undesirable Life Events. Journal of Health and Social Behaviour, 31(2), 162-72.
5 Ross, C. E., & Mirowsky, J. (2001) Neighbourhood Disadvantage, Disorder, and Health. Journal of
Health and Social Behaviour, 42, 258-76.
6 Schulz, A. J., et al. (2006) Psychosocial stress and social support as mediators of relationships
between income, length of residence and depressive symptoms among African American women
on Detroit’s eastside. Social Science & Medicine, 62(2), 510-22.
7 Booth, M. L. et al. (2000) Social-cognitive and perceived environment influences associated with
physical activity in older Australians. Preventive Medicine, 31(1),15-22.
8 King, W. C. et al. (2005) Objective measures of neighborhood environment and physical activity in
older women. American Journal of Preventive Medicine, 28(5), 461-9.
9 Wilcox, S. et al. (2003) Psychosocial and perceived environmental correlates of physical activity in
rural and older african american and white women. Journals of Gerontology Series
B-Psychological Sciences & Social Sciences, 58(6), 329-37.
10 Lawton, M. P., Nahemow, L. (1973) Ecology and the aging process. In: Eisdorfer, C. & Nahemow,
L. (eds) The Psychology of adult development and aging. Washington, DC: American Psychology
Association. Pg: 464-88.
11 Wheaton, B. (1983) Stress, personal coping resources, and psychiatric symptoms: an
investigation of interactive models. Journal of Health & Social Behaviour, 24(3), 208-29.
12 Fitzpatrick, K. M, & LaGory, M. (2003) “Placing” health in an urban sociology: cities as mosaics of
risk and protection. City Community, 2(1), 33-46.
13 Wheaton, B. (1985) Models for the stress-buffering functions of coping resources. Journal of
Health & Social Behaviour, 26(4), 352-64.
14 Ostir, G, V., Eschbach, K,, Markides, K. S. & Goodwin, J. S.(2003) Neighbourhood composition
and depressive symptoms among older Mexican Americans. Journal of Epidemiology &
Community Health, 57(12), 987-992.
15 Sampson, R. J., Raudenbush, S. W. & Earls, F. (1997) Neighborhoods and Violent Crime: A
Multilevel Study of Collective Efficacy. Science, Issue 277, 918-924.
16 Sampson, R. J., Morenoff, J. D, & Gannon-Rowley, T. (2002) Assessing “neighborhood effects”:
Social processes and new directions in research. Annual Review of Sociology, 28, 443-78.
17 Ross, C. E., & Mirowsky, J. (2001) Neighbourhood Disadvantage, Disorder, and Health. Journal of
Health and Social Behaviour, 42, 258-76.
18 Lin, N., Ye, X. L. & Ensel, W. M.(1999) Social support and depressed mood: A structural analysis.
Journal of Health and Social Behavior , 40(4), 344-59.
19 World Health Organization. Global Age-Friendly Cities: A Guide, 2007. Plouffe, L., Kalache, A.
2010, Toward global age-friendly cities: determining urban features that promote active aging.
Journal of Urban Health, 87(5): 733-739
20 Available at: http://www.who.int/ageing
21 Age FriendlyNYC. (2011) About Us. Available at: http://www.nyam.org/agefriendlynyc/about-us/
22 Manchester City Council. (2011) Valuing Older People: Introduction to Valuing Older People.
Available at: http://www.manchester.gov.uk/info/500099/valuing_older_people/3428/valuing_
older_people_vop/1

Chapter 20 Because natural increase and net migration are both defined in terms
of differences, each of them can be positive or negative. In virtually
every developing country today, natural increase is positive (births
International Migration and exceed deaths), and the majority (70%) experiences net emigration
– that is, their net migration over the period 1990 to 2010 is negative
Population Ageing (Table 1). Even among developing countries that have below-
replacement fertility, only 33% have had positive net migration over
Hania Zlotnik the past two decades.
Normally, a population grows because of the excess of births over In contrast, 66% of developed countries have experienced positive
deaths, denominated “natural increase”. International migration can net migration during that period. Among the 14 developed countries
also contribute to population growth when a country receives more where deaths exceeded births during 1990 to 2010 (that is, where
immigrants than the number of emigrants it loses. The difference natural increase was negative), only six attracted more immigrants
between the number of immigrants and the number of emigrants is than the emigrants who left and therefore recorded positive net
called “net migration”.1 migration during 1990 to 2010 (Figure 1). That is, net migration
contributed to counterbalance the excess of deaths over births in
Table 1. Distribution of countries by fertility and development level less than half of the developed countries experiencing negative
and the type of combination of natural increase and net migration natural increase during 1990 to 2010.
they experienced during 1990-2010.
Figure 1. Countries where net migration reduces the excess of
Natural increase Natural increase
positive negative deaths over births, 1990-2010
Net migration Net migration
Hungary 59% 59%
Fertility and development level Total Negative Positive Negative Positive
Russian Federation -12413 7128
Czech Republic -168 358
Low-fertility developed 41 7 20 8 6
Germany -2260 5464
Low-fertility developing 33 21 11 — —
Italy -512 4231
Intermediate-fertility developed 4 0 4 — —
Intermediate-fertility developing 61 44 17 — —
Slovenia -3 106
High fertilty 58 40 17 — — Births minus deaths
Net migration
Developing countries 152 105 45 — —
Developed countries 45 7 24 8 6
Source: United Nations, World Population Prospects: The 2010 Revision, CD-Rom Edition, POP/DB/
WPP/Rev.2010.
Low-fertility developed 100 17 49 20 15
Low-fertility developing 97 64 33 — — Figure 2. Countries where net migration accelerates population
Intermediate-fertility developed 100 0 100 — — decline, 1990-2010
Intermediate-fertility developing 100 72 28 — —
High fertilty 98 69 29 — — -5 537
Ukraine
-659
Developing countries 99 69 30
Bulgaria -776
Developed countries 100 16 53 18 13
-548
Source: United Nations, World Population Prospects: The 2010 Revision, CD-Rom Edition, POP/DB/ Belarus -634
WPP/Rev.2010. -30
Notes: All high-fertility countries are developing countries. Romania -591
Two developing countries, Papua New Guinea and the Democratic People’s Republic of Korea have -1 129
zero net migration.
Latvia -208
-203
Croatia -104
-10
Lithuania -97
-276
Estonia -83
-143
Excess deaths over births
Net emigration
Source: United Nations, World Population Prospects: The 2010 Revision, CD-Rom Edition, POP/DB/
WPP/Rev.2010.

Furthermore, in the other eight developed countries experiencing Migration and the Age Distribution of the Population at
negative natural increase during 1990 to 2010, net emigration was Destination
negative and hence contributed to accelerate population decline
(Figure 2). Those eight countries are located in Eastern and Central Because migration is selective by age, it has the potential to modify
Europe and all are former members of the Eastern bloc. the age distribution of the population at destination both directly, by
the addition of people to particular age groups, and indirectly, if the
It has been argued that the persistence of below-replacement fertility fertility of migrant women differs from that of their non-migrant
and the reduction of the population that eventually ensues, together counterparts in the country of destination.
with the ongoing ageing of the population, would by themselves
produce the conditions that would attract migrants. As the cases of Newly available estimates of the migrant stock, classified by age and
Belarus, Bulgaria, Croatia, Estonia, Latvia, Lithuania, Romania and sex in all countries, allow an assessment of the direct contribution of
Ukraine indicate, demographic dynamics by themselves do not migration to changes in the age distribution. Before considering
necessarily set the stage for attracting migrants. If over the past two those data, however, it is useful to use simplified assumptions to
decades most developed countries with low fertility were also net describe what happens to the age distribution of migrants. Consider
importers of people, it is because their economies fared well during the population of an uninhabited island that receives a wave of
most of that period. migrants on year one. From there on, the island receives the same
number of migrants every year with the same age structure as that of
Replacement-level fertility is the level of fertility needed to ensure that the first wave. The children born on the island to migrants are not
every woman has one daughter who survives to the mean age of considered part of the migrant population (they did not “move” to the
procreation. That is, it is the level of fertility needed to ensure that island). The whole population is subjected to fixed mortality risks that
each generation is replaced by a generation of the same size. The do not change over time. Figure 3 shows how the age distribution of
replacement level varies according to the level of mortality. In high the migrant population on the island changes over time.
mortality populations, replacement level can be four children or more
per woman. When mortality in childhood and the young adult ages is Note that on year one, the population has a distribution that is highly
low and virtually everyone survives to their late 20s, replacement level concentrated in the young ages (20 to 29) but, as time elapses, the
is close to 2.1 children per woman. Because even if no one died concentration of the migrant population in a given age group is
before age 30, women would still have to have slightly over two dampened by the ageing of previous cohorts of migrants. Just 30
children on average to have one daughter on average (more boys are years after migration started, the age distribution of the migrants has
born than girls), fertility levels at or below two children per woman are ceased showing a peak, and after 60 years, the migrant population
below replacement level, irrespective of the mortality levels that a has a very flat distribution after age 30. This simplified example
population experiences. shows that, as migrants age, even maintaining a constant inflow of
relatively young migrants will not make the distribution of the
The financial and economic crises that struck in 2008 have provided population younger.
further evidence that demography is not the main driver of
international migration. As economic stringencies have taken hold in To achieve a rejuvenation of the population, the number of young
the developed countries that had been the major magnets for migrants added to the population every year would have to keep
migrants before 2005, migrant inflows have dropped markedly and increasing in order to mimic the effect of above-replacement fertility,
net migration has declined, even if it has not become negative in all which is at the root of the exponential growth of population that
the major receiving countries of the developed world. prevents population ageing.
These observations should be borne in mind when assessing the

feasibility of using migration as an instrument of demographic policy. Figure 3. Simulated evolution of the age distribution of migrants
The question of whether migration can be used to modify the age under constant migration by age and sex
structure of a population has attracted the attention of several
researchers over the past three decades. Yet most of the researchers 7
who have considered the issue have concluded that it would be
difficult – politically, socially and even in terms of the management of
6
international migration – to admit continuously and over a long period
the relatively high numbers of migrants of particular ages that would
be required to counterbalance in a significant way the ongoing 5
Percentage of population by age
population ageing.
The following sections review what is known about the effects of 4

migration on population ageing and the insights that models provide
about why international migration is unlikely to be the solution for
population ageing. 3
0
21
51
81
0
3
6
9
15
18
24
27
30
33
36
39
45
48
54
57
60
63
66
69
75
78
84
12
42
72
Year 1 Year 10 Year 20 Year 30

Year 40 Year 50 Year 60
Source: Calculations by author.

International Migration – Counteracting Population Ageing? The time was ripe, therefore, when in 2001 the United Nations
Population Division issued a report, Replacement Migration: Is it a
Migration is selective by age – that is, people leaving a country are Solution to Declining and Ageing Populations?,6 which generated
not a random sample of the population. On the contrary, they tend to considerable debate, especially in Europe. By making a parallel
be highly concentrated at ages 20 to 29 (Figure 4). In addition, the between the terms “replacement fertility” and “replacement
majority of international migrants move in order to work abroad – that migration”, the report was often misrepresented as implying that the
is, they intend to join the economically active population. Even populations of Europe would be “replaced” by migrants.
migrants that ostensibly move for other reasons, such as to join
family members abroad or to seek asylum, tend to join the labour Yet the actual message of the report was quite different and
force at destination. corroborated the findings of other researchers who had considered
the subject before: in order for a population to keep the age structure
These two characteristics of migrant flows – the concentration of produced by sustained population growth, that growth had to
migrants at young ages at the time of the move and the high labour continue. If fertility was too low to sustain it, the number of migrants
force participation of migrants at destination – are the basis for that had to be admitted needed to be large, sometimes very large.
arguing that admitting international migrants can be one of the Although migrants are young when they arrive, they will themselves
strategies to reduce some of the potentially detrimental effects of age if they are allowed to stay in the country of destination.
population ageing, in particular the dropping proportion or the Consequently, migration inflows have to be sustained over long
outright reduction of the number of persons in the labour force. In periods to have an effect in slowing population ageing.
addition, it has been argued that migration can increase the
economically active population so that social security systems based The following section reviews in more detail the results of key studies
on a pay-as-you-go model remain viable. assessing the impact of international migration on population ageing.
Figure 4. Age distribution of migrant inflows, selected countries Assessing the Impact of Migration on Population Ageing
7 Assessing the impact of international migration on the age
distribution of a population is not straightforward because of the
deficiencies of statistics on international migration and the fact that
6
migration has both a direct effect on the age distribution (the addition
or subtraction of migrants to particular age groups) and an indirect
5 effect through the fertility of migrants. One way of assessing the
Percentage of population by age
overall effect of migration is to take a population at a given moment,

4 project it without migration for over a certain period, and then
compare the actual population with that obtained by assuming that
migration was zero.
3
Le Bras carried out that exercise to assess the impact of post-war

2 migration in several countries.7 The period considered in each case
began in 1946, or a year close to that date, and ended with the
census carried out in the early 1980s in each of the countries
1
considered. For the countries listed in Table 2 this was a period of
large net gains associated with migration because Australia, Canada,
0 France, Germany, Sweden and to a lesser extent Belgium,
experienced major inflows of migrants during the 1950s and 1960s.
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
Denmark 2009 Denmark 2008 Germany 2009

Germany 2008 Italy 2009 Italy 2008 For European countries, that was the era of “guest worker” migration,
Netherlands 2009 Netherlands 2008 Slovenia 2009 when migrants were admitted as workers, and family reunification
Slovenia 2008 Sweden 2009 Sweden 2008
Norway 2009 Norway 2008
was restricted. For the overseas countries of immigration, migration
was a major component of nation building over the whole period
Source: Eurostat, Immigration by sex, age group and citizenship, 2011, obtained from considered. In addition, by the 1970s fertility was low or declining
http://appsso.eurostat.ec.europa.eu/nui/setupModifyTableLayout.do
rapidly in all those countries. The slight increase of fertility associated
with the baby boom of the late 1950s and early 1960s had run its
course, and all the countries considered had reverted to low fertility.
Discussion of whether and to what extent international migration can By 1975 to 1980, all of them had below-replacement fertility.
or should be part of a strategy to address the consequences of
population ageing is of long standing.1,2,3,4,5 In the late 1980s, when it As the results shown in Table 2 indicate, international migration did
became clear that fertility in most European countries and in nearly all contribute to reducing population ageing in all the countries
other developed countries had not only fallen below replacement considered. Thus, in all of them the actual median age8 of the
level, but was remaining well below replacement level for the long run, population is lower than that of the population projected under the
demographers in those countries turned their attention to the possible assumption of zero migration (the “closed” population). However, the
role of international migration in counteracting population ageing. reductions achieved are small, particularly for the European countries
(Figure 5). In five of the six countries considered, the median age
Concomitantly, as migration flows to European countries rose again dropped by less than one year because of migration, and the
after having reached a low during the early 1980s, policy-makers proportion of the population aged 65 years or over was reduced by
became interested in the subject. The late 1980s and the 1990s less than 1% after more than three decades of sustained migration
witnessed important changes in migration flows in Europe, resulting flows. Furthermore, net migration gains over the period were
in part from major historical events (the dissolution of the Soviet substantial, accounting for at least 32% of population growth in
Union, the reunification of Germany and the war in the former Canada and France and for as much as 68% in Germany. That is,
Yugoslavia) and from the increasing prosperity of countries in the although the effect of net migration gains was in the right direction, it
region related to globalization and the expansion of the European was modest at best in terms of reducing population ageing.
Union.

Another perspective on the same issue is obtained from the results of Figure 5. Effects of post-war migration on population ageing,
the projection scenarios produced by the United Nations Population selected countries
Division in 2001.9 The scenarios were developed to assess how
many migrants would be needed to achieve different objectives – to 2,5
maintain:
• The size of the overall population constant at 1995 levels 2,0
• The size of the working age population (persons aged 15 to 64)
constant at 1995 levels
1,5
• The support ratio, that is, the ratio of the population aged 15 to 64
to the population aged 65 years or over, from falling below three
• The support ratio constant at the level it had been in 1995 1,0
The results obtained for one region (Europe) and the eight countries
considered are summarized in Table 3, which shows the estimated
0,5
and projected support ratio for the populations considered. For
1995, 2010, and the medium and zero-migration variants for 2050,
the data shown refer to the most recent set of population estimates 0,0
and projections prepared by the United Nations Population Division.10 Australia Belgium Canada France Germany Sweden
The other data are the result of simulations prepared in 2001 on the
basis of the 1998 Revision of World Population Prospects. Updated Decrease in median age (years) Decrease in percentage aged 65 or over
simulations would have produced somewhat different numbers, but
the general conclusions derived from the simulations would be the Source: United Nations, World Population Prospects: The 2010 Revision, CD-Rom Edition,
same. POP/DB/WPP/Rev.2010.
Table 2. Impact of post-war international migration on the age

distribution and the median age of selected populations assessed
by comparing a closed population with zero migration and the
actual population
Percentage of
"Support ratio Population Natural population
growth increase growth due to
Country Year Population 0-19 20-64 65+ Median age (20-64/65+)” (percentage) (percentage) net migration
Australia 1981 Closed 31,3 56,9 11,8 34,4 4,82 1,94 0,98 49,5
Actual 33,7 56,5 9,8 32,9 5,77
Belgium 1982 Closed 26,4 58,8 14,8 38,1 3,97 0,45 0,26 42,2
Actual 27,3 58,7 14,0 37,3 4,19
Canada 1981 Closed 31,4 58,2 10,5 33,7 5,54 1,86 1,26 32,3
Actual 32,0 58,3 9,7 33,2 6,01
France 1983 Closed 29,2 56,9 13,9 36,5 4,09 0,84 0,57 32,1
Actual 29,8 57,0 13,2 36,0 4,32
Germany 1984 Closed 23,4 61,4 15,2 39,5 4,04 0,62 0,20 67,7
Actual 23,5 61,8 14,7 39,0 4,20
Sweden 1984 Closed 24,8 57,1 18,1 39,9 3,15 0,50 0,28 44,0
Actual 25,3 57,6 17,1 39,2 3,37
Source: Herve LeBras, Demographic impact of post-war migration in selected OECD countries. In Migration: The Demographic Aspects. Organisation for Economic Cooperation and Development, Paris, 1991,
pp. 15-28.

The results presented in Table 3 indicate that net migration gains can The Ageing of Migrants
contribute to increasing the potential support ratio, therefore An additional consideration is that migrants themselves age. Newly
reducing somewhat the effects of population ageing. However, in the available estimates of the age distribution of the migrant population
countries considered, the support ratio projected for 2050 is lower show that it has, itself, been ageing even in countries such as the
than that estimated for 2010 in all scenarios, except for the one United States where net migration gains are substantial. Figure 6
where migration is used to maintain the support ratio constant at the shows the changing age distribution of the migrant population in
level it had been in 1995. According to that scenario, migration has to Europe and in the United States for 1990, 2000 and 2010. In both
be very high in some countries to maintain the favourable support cases, the distribution has been shifting to older ages. Note,
ratios their populations had in 1995. The potential support ratio or however, that these distributions do not incorporate the secondary
support ratio for short is generally defined as the ratio of the effect of migration, that is, the children of migrants born in the country
population of working age, usually considered to be that aged 15 to of destination, which are not part of the migrant population.
64, to the population of retirement age, namely, that aged 65 or over.
It can also be the ratio of the population aged 20 to 64 to that aged Lastly, several authors have noted that the trends in migration
65 or over. Either ratio is an indicator of the maximum number of necessary to achieve demographic objectives, such as stabilization
workers per older person in a population. At the early stages of of the size of the working age population, involve major fluctuations in
population ageing, the potential support ratio is high, with five or the number and age composition of the migrants involved,
more potential workers per older person. fluctuations that would be very difficult to time properly in practice.11,12
Thus, the Republic of Korea, with a population of 48 million in 2010,
would have to import an annual average of 93 million migrants during
1995 to 2050 to maintain the high support ratio it had in 1995. Even
in a country like Germany, whose support ratio in 1995 was a Figure 6. Age distribution of migrants in Europe and the United
moderate 4.4 persons of working age per older person, the net States,1990, 2000 and 2010
annual migrant intake would have to average 3.4 million during
1995-2050 to maintain such a ratio. That number of migrants is over 16
Percentage of population per age group
30 times higher than the number projected in the medium variant

(111,000 annually). 14
12
With the exception of the United States, the migration levels
projected in the medium variant of the 2010 Revision fall far short of 10
the levels required either to maintain constant the overall population
8
or to maintain constant the population of working age (15 to 64). In
other words, although migration is expected to contribute somewhat 6
to slow population decline and population ageing in a number of
low-fertility countries, it is unlikely to counteract significantly the 4
powerful dynamics of population ageing. 2
0
+
15 4
4
9
4
9
4
9
4
9
4
4
9
9
-1
-2
-2
-3
-3
-4
-4
-5
-5
-6
65
0-
5-
-1
10
20
25
30
35
40
45
50
55
60
Europe 1990 2000 2010
14
Percentage of population per age group
12
10
0
+
4
10 9
9
4
4
9
4
9
4
9
4
9
4
0-
5-
-1
65
-1
-2
-2
-3
-3
-4
-4
-5
-5
-6
15
20
25
30
35
40
45
50
55
60
United States 1990 2000 2010
Source: United Nations Population Division, Trends in international migrant stock: Migrants by age
and sex, CD-Rom, POP/DB/MIG/Stock/Rev.2010.

Conclusion Endnotes
International migration is shaped by multiple forces, one of which is 1 Espenshade, T. J., Bouvier, L. F. & Arthur, B. (1982) Immigration and the stable population model.
Demography, 19(1),125-133.
the need for workers in particular sectors of the economy. Because 2 Didier, B. (1989) Regulation the age structure of a population through migration. Population, 44(1),
migration is selective not only with respect to skills and qualifications, 23-37.
but also with respect to age, it has been thought that migration can 3 OECD, Organisation for Economic Cooperation and Development. (1991) Migration: The
be used to counterbalance some of the effects of population ageing Demographic Aspects. Paris: OECD
by, in particular, helping to reduce labour shortages. Actual migration 4 Schmertmann, C. P. (1992) Immigrants’ ages and the structure of stationary populations with
below-replacement fertility, Demography, 29(4), 595-612.
trends have shown that dynamic economies can indeed rely on 5 Gesano,G. (1994) Nonsense and unfeasibility of demographically-based immigration policies.
migrants to satisfy their labour needs, but those needs are not Genus, 50(3-4), 47-63.
necessarily the result of population dynamics. Economic factors are 6 United Nations. (2001). Replacement Migration: Is it a Solution to Declining and Ageing
often more important determinants of the need for additional workers Populations? Available at: http://www.un.org/esa/population/publications/migration/migration.
htm
than population trends, which are of long gestation and take a long
7 Le Bras, H. (1991) Demographic impact of post-war migration in selected OECD countries. In:
time to play themselves out. Migration: The Demographic Aspects. Paris: Organisation for Economic Cooperation and
Development. pp. 15-28.
Thus, migrants have not necessarily been flowing to all countries with 8 The median age is the age that divides the population into two equal parts, that is, half the
slowly growing or even declining populations. Whereas many population falls below that age and half above it. Population ageing makes the median age rise. In
“young” populations, the median age is typically below 25 years.
countries experiencing such population trends are important 9 United Nations. (2001). Replacement Migration: Is it a Solution to Declining and Ageing
destinations for migrants, not all of them attract enough migrants to Populations? Available at: http://www.un.org/esa/population/publications/migration/migration.
counterbalance their emigration flows. Furthermore, migration flows htm
are often volatile, responding as they do to current economic and 10 United Nations. (2011) World Population Prospects: The 2010 Revision. CD-Rom Edition. POP/
DB/WPP/Rev.2010.
political developments in both countries of destination and countries
11 Didier, B. (1989) Regulation the age structure of a population through migration. Population,
of origin. It is therefore by no means certain that migration will English Selection, 44(1), 23-37.
necessarily contribute to reduce the effects of population ageing in all 12 Wattelar, C. & Roumans, G. (1991) Simulations of demographic objectives and migration. In:
the countries that are already far advanced in that process and, even Migration: The Demographic Aspects. Paris: Organisation for Economic Cooperation and
Development, pp. 57-67.
if it does, its effects are likely to be small.
Table 3: Results of simulated scenarios of future population change

according to different assumptions about future migration, 1995-
2050
1995 2010 2050

Constant
Constant population 15-64/65+ not Constant
Region or country Medium variant Zero migration population aged 15-64 lower than 3.0 15-64/65+
Europe 4,8 4,2 2,1 2,0 2,4 2,6 3,0 4,8
France 4,3 3,9 2,3 2,1 2,3 2,5 3,0 4,4

Germany 4,4 3,2 1,8 1,6 2,3 2,4 3,1 4,4
Italy 4,1 3,2 1,6 1,5 2,0 2,3 3,0 4,1
Japan 4,8 2,8 1,4 1,4 2,1 2,2 3,0 4,8
Republic of Korea 12,0 6,5 1,6 1,7 2,5 2,8 3,0 12,6
Russian Federation 5,5 5,6 2,6 2,5 2,9 3,1 3,0 5,6
United Kingdom 4,1 4,0 2,5 2,2 2,5 2,6 3,1 4,1
United States 5,2 5,1 2,8 2,5 2,6 2,7 3,0 5,2
Europe - 738 1 068 - 1 821 2 934 4 274 25 203
France - 63 96 - 27 99 292 1 705

Germany - 82 111 - 324 458 736 3 427
Italy - 61 179 - 235 357 638 2 176
Japan - 127 45 - 312 609 1 724 10 064
Republic of Korea - 48 -16 - 27 117 211 93 617
Russian Federation - 143 158 - 508 650 484 4 675
United Kingdom - 62 148 - 48 114 249 1 087
United States - 310 1 030 - 116 327 816 10 777
Source: United Nations. (2001). Replacement Migration: Is it a Solution to Declining and Ageing
Populations? Available at: http://www.un.org/esa/population/publications/migration/migration.htm

Chapter 21 Financial Education and the Elderly

Much emphasis has been placed on developing the financial literacy
Financial Education and skills of young people.3,4 However, there is an even more urgent need
to support the development of such skills in adults, and particularly
older people, who may not have kept up with the pace of change and
Older Adults face significant risks that could influence their financial well-being.
The approaches will vary between generations with a growing
André Laboul relevance for older generations of consumer protection compared to
The financial landscape of the beginning of the 21st century is financial education, which may come too late.
increasingly characterized by a significant transfer of financial risks to The older population is an especially heterogeneous group, with
individuals and a growing sophistication of financial products. This is large variations in characteristics such as income, education, gender5
happening during a time of great uncertainty and when financial and ethnicity. This group includes some of the most socially
literacy remains low in many jurisdictions. Consumers of financial excluded, with a higher than average likelihood of health issues and
services, particularly the elderly, are ill equipped to face their disabilities and reduced physical access to financial services.
ever-increasing responsibilities and often overestimate their financial
skills and awareness. Older adults are particularly exposed to financial risks and financial
abuses. In 2004, a US study concluded that the number of reported
The gap between levels of financial education and the rapidly cases of abuse of older persons living in domestic settings had
evolving financial marketplace has wide economic, financial and increased dramatically in the past two decades.6 It noted that a
social implications, including for financial stability. A survey by the frequent form of elder abuse is financial exploitation that can occur
Organisation for Economic Co-operation and Development (OECD) through the misuse of powers and guardianships, illegal transfer of
has revealed that the lack of consumer financial education played an property, and outright fraud and theft. The study found that financial
important role in aggravating the effects of the financial crisis.1 There crimes against older persons are particularly difficult to examine
has been considerable policy work and action at the national and because they are often unreported by victims and professionals.
international levels to promote financial education and consumer
protection. This chapter will highlight selected features of financial A 2006 national prevalence study of elder mistreatment in the United
education for the elderly, a vulnerable group, focusing in particular on Kingdom reached similar conclusions.7 More recently, a survey
the risk of inadequate retirement income.2 conducted by the Investor Protection Trust in 20108 found that half of
older Americans exhibit one or more of the warning signs of current
financial victimization, and almost half of those aged 65 or over
provided incorrect answers to at least two out of four questions
relating to basic investment knowledge.9
Older generations often lack the up-to-date knowledge necessary to

make the best financial planning decisions. Research has suggested
that for adults aged 50 and older in the United States financial
knowledge declines with age.10 While 75.9% of those aged 50 to 60
gave a correct response to a question demonstrating a basic
understanding of compound interest, this positive response rate fell
to 67.2% of 60- to 70-year-olds and just 57.6% of those aged 70 and
over. Similar patterns were observed for other basic knowledge
questions. This knowledge deficit makes the elderly especially
vulnerable to financial exploitation, including investment fraud, and
comes at a time when inevitable changes affect older people – a
decline in health, isolation, visual, auditory and motor declines, poor
mobility and cognitive decline. All of these factors impact the
capacity of older people to make informed financial choices.
The financial literacy needs of older adults are particularly acute in

terms of up-to-date knowledge and information presented to them in
an understandable, jargon-free way to protect them against fraud,
scams and abuse. Older people also need to increase their
awareness of the circumstances under which they should seek
external help or advice about financial matters, and where they seek
it.

Challenges for Older Generations Financial Education and Retirement Income

There are some particular challenges when targeting financial Inadequate retirement income is one of the most important risks
education for older generations, due to their declining mobility or low facing older people.18,19 Increasing longevity and unplanned health-
access to educational sources such as the Internet. While older financing needs may add further pressure to inadequate asset
people typically benefit from increased leisure time, their resources accumulation. This comes at a time when ageing populations are
and mobility are often reduced. For example, research in the United challenging the sustainability of public pension schemes, and private
Kingdom indicates that almost 10% of adults aged between 60 and pension schemes are increasingly transferring the risks to individuals.
75 reported difficulty shopping for groceries, while this percentage
increases to nearly 20% for the 80 to 84 age group and more than Individuals save for retirement in a variety of ways, including public
30% for the 85 to 89 age group.11 Even those who are mobile find it pensions, occupational pensions and personal retirement saving
difficult to walk to information and education sites if they live outside plans. However, pensions and retirement savings plans, though
large urban areas. vitally important for individual and social welfare, are some of the
least understood financial products, making some level of financial
The Internet is an appropriate delivery tool for financial education and education imperative. The level of financial education and type of
could potentially help to overcome this mobility problem. Large information required will vary according to the characteristics of the
numbers of adults access information online. However, the same retirement saving product. For example, a deeper level of
research looking at adults aged 52 and older showed that use of the understanding seems necessary for pension systems where
Internet and email is still quite low among older people. While 68% of individual choice is involved and where public pension schemes
adults aged 52 to 54 were using the Internet, the percentage provide only a limited safety net in terms of retirement income. Less
dropped across each age band, and only 38% of those aged 65 to knowledge and information may be required where individuals still
69 reported such use.12 It may therefore be unwise to see the Internet rely on sound public pensions and do not have individual
as the best way to reach the elderly. In terms of credit, research responsibility for investment choices.20
undertaken in the State of Victoria, Australia, in 200813 concluded:
Surveys indicate that individuals are not saving and planning
Older people generally have less access to technological advances sufficiently to ensure an adequate retirement income.21 A lack of
such as Internet banking and need face-to-face services in financial planning is not only common among young respondents,
accessible locations. Older people, and particularly farmers in rural but also among older adults. A survey in the United States shows
areas, are more likely to resist seeking help from financial counsellors that while the proportion of those engaged in financial planning
and related services, and such services must be actively marketed to increases with age, only 51% of respondents 45 to 59 years old and
them. not yet retired had tried to calculate how much they needed to save
for retirement.22 This figure is particularly worrisome because the
While general principles and guidelines fully apply, financial education closer one is to retirement, the less scope there is to take corrective
should be attuned to the needs and specificities of older people.14 action.
Their financial education and literacy needs vary widely according to
their health, living arrangements, employment situation, dependency, In addition, surveys indicate that individuals are not saving wisely.23
gender and ethnicity. Financial education programmes should be An important trend in many countries has been the rise in the
delivered in a range of environments and tailored to the contexts number of workers participating in defined contribution (DC) plans
facing older people at the various stages in their lives. where the contributions, but not the benefits, are defined. Many of
the workers in these plans need help. DC schemes transfer the
These programmes should be developed in consultation with longevity and investment risks to households and individuals. In the
appropriate community organizations and professionals working with absence of proper financial literacy, people may not take appropriate
older people. Educational materials should be available in a variety of actions in terms of their contribution levels and investment choices
formats appropriate to the requirements of older groups. Older and may find themselves without adequate resources when they
generations, if well informed, could be a key educational asset by retire. They may also be exposed to market volatility. Retirees with a
sharing their experience with younger generations and helping to DC pension portfolio heavily invested in equities would suffer
develop their financial literacy. significant losses if they had to convert the portfolio into an annuity at
an inopportune time, such as the height of a financial crisis.
Financial Consumer Protection
Financial education on retirement income issues should be provided
Financial education addressed to older generations may come too as early as possible.24 Retirement income implies long-term decision-
late to be of any benefit or may have only a limited impact. This making that cannot be made at the last minute. Retirement income
makes financial consumer protection especially relevant for this depends on an active accumulation phase that spans a large
vulnerable group that is often the target for financial abuses. Beyond number of years. Moreover, financial education itself takes time and
the need for information and training about elder abuse, specific is a lifelong process. But there is also scope in financial education for
protections for very old people should be considered in light of their financial decisions taken late in the phase-out period, i.e., when
reduced capabilities. These protections could include extended assets are being consumed, and when action may still be needed to
cancellation periods, requirements for a suitability assessment by assure a stable and secure flow of retirement income.
financial service providers before providing a product or service,
request for participation – including information and consent – of a More generally, financial consumer protection and alternative
relevant third party for any major financial decisions made by very old mechanisms will be needed as people get older and become more
individuals,15 and special dedicated and speedy complaint-handling vulnerable at a time when financial education may no longer help
and redress mechanisms. address financial challenges.
While academic literature about elder abuse is expanding, further
data and research are needed to address these issues. Policy-
makers should consider further action to protect this growing
segment of the population.16 The creation of an Office of Financial
Protection for Older Americans by the new US Consumer Financial
Protection Bureau is a good step in this direction.17

Communication and Awareness Campaigns Education and Consumer Protection

The risk of inadequate retirement income calls for proper Hence, communication policies need to be complemented by other
communication and awareness campaigns. Governments should actions such as financial education programmes. Research from the
use national pension communication campaigns at times of major United States suggests that it may be particularly important to build
pension reform to inform individuals about how changes will affect retirement human capital via seminars, educational programmes and
pension entitlements and help individuals take any necessary retirement planning products.29
actions. Campaigns need to be targeted as broadly as possible, as a
lack of understanding of pension issues tends to be fairly Nevertheless, the research notes that one-size-fits-all programmes
widespread.25 Specific programmes targeted at the most vulnerable are unlikely to successfully address saving shortfalls, particularly
groups, such as older generations, migrants and those with the among the elderly, given the very different patterns that can be
lowest income and savings levels, can also have a greater impact. discerned by sex, age, educational levels and race/ethnicity. Instead,
Such programmes should strive to make individuals aware of their programmes must be targeted to address fundamental differences
limited financial knowledge and about pension products in particular, in preferences, saving needs, financial knowledge and sophistication.
with stress placed on the risks of having an inadequate retirement
income. Financial education measures may not be sufficient. Other
mechanisms may be needed to address the behavioural factors
Future retirees need to know the benefits they will receive when mentioned above and the potential decreased capabilities of older
retiring in order to make possible changes in their contributions. In generations. Among such possible additional mechanisms, default
DC arrangements, individuals may face many complex choices that retirement planning mechanisms including automatic pension
will determine the level of their retirement income, ranging from how enrolment should be considered. They convert the option from opt-in
much to save to the kind of benefit payout option to choose. Apart to opt-out.30 Other options may include lifestyle products that convert
from being provided with ready access to plan documents and other the portfolio to less risky investments as the retirement age
relevant contractual material, individuals should receive regular, approaches.
individualized benefit statement information, which should provide
clear benefit projections under prudent assumptions. Such The rights of future and existing retirees need to be properly
projections should ideally include information on how benefits could protected. The OECD’s Core Principles of Occupational Pension
be increased, should additional contributions be made to the DC Regulation promote access to plan participation, equal treatment
plan or should the retirement age be delayed.26 and entitlements under the pension plan, vesting rights, pension
portability and rights of early leavers, entitlement process and rights
Disclosure materials should be readily understandable by pension of redress. These rights may vary in relation to programme features
plan members and their beneficiaries. This may be a particularly (mandatory or voluntary, defined benefit or defined contribution); the
challenging task for members with very low levels of financial literacy, extent of subsidization; or the primary or supplementary nature of the
who may not even understand basic concepts such as compound source of retirement income.
interest or the difference between a share and a bond, and for
vulnerable groups such as older people.27 However, the protection of accrued benefits and timely notice of
change in future benefit accruals should be essential rights,
However, communication is not the panacea. The lack of financial especially for older populations reaching retirement age, as they will
literacy and behavioural factors will affect the nature of awareness of often no longer be in a position to address any significant changes to
the risks and the willingness to take action or even to be informed. their pension rights.
The case of the Swedish “Orange Envelope” in connection with
pensions reform illustrates the limitation of communication
campaigns.28 The Swedish authorities introduced the concept of an
“Orange Envelope” for communicating important pension
information. In 2006, the Swedish social insurance agency
conducted a survey on the use of this envelope among people
receiving it. This envelope contained essential information for their
future retirement income. While most people knew they received this
very visible envelope, 20% did not open it, 50% read only some of it
and 20% compared the results with previous year. Impact has been
improved since then.

A Word on Longevity Endnotes

1 International Network on Financial Education. (2009) Financial Education and the Crisis: Policy Paper
Life expectancy in OECD countries has increased an average of 22 and Guidance. Available at: http://www.financial-education.org/dataoecd/48/31/48646555.pdf
years in the last century during a time when people tended to work 2 The OECD (Organization for Economic Co-operation and Development) has been leading the
international development of principles and guidelines on financial education since 2003. See in
less. This development is generally good news, but can pose particular the OECD Principles and Good Practices for Financial Education and Awareness (2005).
problems for retirement income sustainability. Longevity risk is the This work has recently been carried out through the International Network on Financial Education
(INFE) composed of representatives from governmental institutions from 94 economies and operating
risk that the ageing population outlives its retirement income. under the aegis of the OECD Committee on Financial Markets and the OECD Insurance and Private
Increased longevity affects any pension scheme or retirement plan, Pensions Committee (see www.financial-education.org). The recent crisis triggered new work, for
instance, the OECD Recommendation on Financial Education and Awareness in Credit. More
the main difference being whether the government (and thus the recently, the G20 recognized the importance of reinforcing financial consumer protection. At the 2011
whole population), employers, or individuals bear the longevity risk. Cannes Summit, the G20 leaders endorsed a report by the Financial Stability Board on consumer
finance protection and the high-level principles on financial consumer protection prepared by the
OECD Task Force on Financial Consumer Protection, together with relevant international bodies.
This risk calls for improved communication on benefits with due
3 OECD, Organization for Economic Co-operation and Development. (2005) Recommendation on
account of longevity projections based on updated mortality tables. Principles and Good Practices for Financial Education and Awareness. Available at: http://www.oecd.
There is a clear need to strengthen financial education and org/dataoecd/7/17/35108560.pdf
awareness in this field. This is especially important where increases 4 OECD. (2011) Guidelines on Financial Education at School and Guidance on Learning Framework.
Available at: http://www.oecd.org/dataoecd/15/57/48493142.pdf
in longevity are not compensated by increases in working life.
5 There are differences in financial planning behaviour by gender that are relevant to old age. A MetLife
study on elder financial abuse notes that “women were nearly twice as likely to be victims of elder
Longevity risk is a key issue in the phase-out period, especially for financial abuse as men.” See: Metlife. (2011) The Metlife Study of Elder Financial Abuse: Crimes of
DC plans. While individuals may be reluctant to buy annuities, and Occasion, Desperation, and Predation against America’s Elders. Available at: http://www.metlife.
com/mmi/research/elder-financial-abuse.html#key%20findings
insurers reluctant to offer such products, a minimum level of
6 Rabiner, D. J., Brown, D. & O’Keefe, J. (2004) Financial exploitation of older persons: policy issues and
annuitization of balances accumulated in such plans may be recommendations for addressing them. Journal of Elder Abuse & Neglect, 16(1), 65-84.
necessary as a default measure to protect against longevity risk. This 7 Biggs, S., et al (2009) Mistreatment of older people in the United Kingdom: Findings from the First
minimum level needs to be coherent with the overall structure of the National Prevalence Study. Journal of Elder Abuse & Neglect, 21(1), 1-14.
pension system. 8 See: Investor Protection Trust. (2010) IPT Elder Investor Fraud Survey. Available at: http://www.
investorprotection.org/learn/research/?fa=eiffeSurvey. The same study found that 20% of Americans
aged 65 or older already have been taken advantage of financially in terms of an inappropriate
Recent OECD work suggests the desirability of setting, as a default investment, unreasonably high fees for financial services, or outright fraud. See:
measure, the purchase at the time of retirement of a deferred life 9 For international cases of general elder mistreatment, see: Podneiks, E., et al. (2010) Elder
annuity with longevity insurance that would start paying out at a very mistreatment: an international narrative, Journal of Elder Abuse & Neglect, 22, 131-163.
old age, e.g., at 85 years old.31 The remaining assets could then be 10 Lusardi, A. (2008) Financial literacy: an essential tool for informed consumer choice? Working Paper,
Dartmouth College. Available at: http://www.dartmouth.edu/~alusardi/Papers/Lusardi_Informed_
used for programmed withdrawals, thus providing for continued Consumer.pdf
flexibility, liquidity, provision of bequests and access to potential 11 Atkinson, A. & Hayes, D. (2010) Consumption patterns among older consumers. International
portfolio investment gains. Longevity Center-UK. Available at: http://www.ilcuk.org.uk/files/pdf_pdf_156.pdf
12 Ibid. See also: Berry, R. (2011) Older people and the internet. International Longevity Center-UK.
Available at: http://www.ilcuk.org.uk/files/pdf_pdf_181.pdf
13 Gibson, F. (2008) Financial and Consumer Credit Issues for Older Consumers in Central Victoria.
Loddon Campapse Community Legal Centre. Available at: http://www.law4community.org.au/
Conclusion scope/wp-content/uploads/2010/04/Changing-Times-Report.pdf
14 See for instance OECD and INFE principles, good practices and guidelines. Available at . http://www.
The elderly are very vulnerable to financial risks and abuses. They financial-education.org/document/5/0,3746,en_39665975_39666038_39846725_1_1_1_1,00.html .
need to be aware of these risks and prepared to face them. This calls 15 Relatives may not be necessary the relevant persons as they compose a very significant share of
for adequate financial education and awareness, adapted to the abuse perpetrators.
specificities and heterogeneity of this population group. Financial 16 As this segment will represent an increasing part of the voting population, policy-makers will have
further incentives to act.
education regarding retirement income should be provided early on, 17 See also Rabiner, D. J., Brown, D. & O’Keefe, J. (2004) Financial exploitation of older persons: policy
when proactive action is still possible, but also during the phase-out issues and recommendations for addressing them. Journal of Elder Abuse & Neglect, 16(1), 65-84, for
period. This is all the more important as population ageing and interesting recommendations to address financial exploitation of older persons.
increases in longevity put enormous pressures on public retirement 18 Antolin, P. (2009) How to ensure adequate retirement income from defined contribution pension
plans. Financial Market Trends. 97(2).
income schemes, and as private pension schemes increasingly
19 Antolin, P. (2008) Ageing and the Payout Phase of Pensions, Annuities and Financial Markets.
transfer financial risks to individuals. Financial Market Trends, 95(2).
20 OECD, Organisation of Economic Co-operation and Development. (2008) Improving Financial
The vulnerability of older generations to abuse, fraud and changes Education and Awareness on Insurance and Private Pensions. Available at: http://www.oecd.org/doc
affecting their pension rights, with limited room to recover or adapt, ument/8/0,3746,en_2649_15251491_41210376_1_1_1_1,00.html
21 Ibid.
calls for stronger financial consumer protection and related
22 Lusardi, A. (2011) Americans’ Financial Capability. Working Paper, Pension Research Council,
dedicated policies. Wharton School, University of Pennsylvania. Available at: http://www.pensionresearchcouncil.org/
publications/document.php?file=936
23 OECD, Organisation of Economic Co-operation and Development. (2008) Improving Financial
Education and Awareness on Insurance and Private Pensions. Available at: http://www.oecd.org/doc
ument/8/0,3746,en_2649_15251491_41210376_1_1_1_1,00.html
24 For recommendations on financial education related to private pensions, see: OECD. Organisation of
Economic Co-operation and Development. (2008) Improving Financial Education and Awareness on
Insurance and Private Pensions. Available at: http://www.oecd.org/document/8/0,3746,
en_2649_15251491_41210376_1_1_1_1,00.html
25 Ibid.
26 OECD, Organisation of Economic Co-operation and Development. (2012) Report on pension
statement and communication of pension risks. (Report not yet published)
27 The OECD will issue a study on pension communication policies at beginning of 2012, with related
recommendations.
28 Larsson, L., Sundén, A., & Settergren, O. (2008) Pension Information: The Annual Statement at a
Glance. OECD Journal: General Papers, 2008(3). Available at: http://www.oecd.org/
29 Lusardi, A., Mitchell, O., & Curto, V. (2009) Financial literacy and financial sophistication among older
Americans. Working Paper, Pension Research Council, Wharton School, University of Pennsylvania.
Available at: http://www.pensionresearchcouncil.org/publications/document.php?file=818
30 Sometimes there is a positive contribution of the same “adverse” behavioural factors. Inertia, for
instance, will keep the future retiree in the default option.
31 Antolin, P. (2009) How to ensure adequate retirement income from defined contribution pension
plans. Financial Market Trends. 97(2).
Chapter 22 New Challenges Posed by Health and Longevity

The population in every developed country is rapidly ageing due to
Technology and Ageing declines in birth rates and improvements in health and longevity. Life
expectancy in most developed countries is approaching 80, which is
Gerald C. Davison and Aaron Hagedorn vastly different from the turn of the last century, when it was just 47
years in the United States. Throughout human history, life
Gerontechnology is the study of the interaction between technology expectancy was generally around age 30.1 Living beyond age 50 was
and the unique challenges and needs of older people faced with an accomplishment enjoyed by about only half of the population born
limited physical or cognitive abilities. This emergent interdisciplinary in 1900, whereas 94% of people alive today will live at least that long.2
field has developed in recent years from a confluence of three Dovetailing with the ageing of the population are complex problems
factors: a dramatic increase in life expectancy, with many more older that require extensive assistance for periods of time that can stretch
people in relatively good health and often demanding more from life over more than a decade.
than earlier cohorts; the availability of sometimes ingenious new
technologies that can support longer and higher-quality lives; and an The developing world is beginning to experience serious changes in
appreciation of the importance of how changing the physical population structure as well, as young adults leave rural villages in
environment can profoundly influence how well people live. search of better paying work, leaving older adults with fewer potential
caregivers. However, wireless phones have enabled communication
The ability to create and continually enhance technology is a defining across long distances in places where landlines never reached. The
characteristic of humanity and one of the key reasons for the same issues and opportunities exist in the developing world as well,
unparalleled success of our species. In recent years, various but daunting challenges also exist vis-à-vis economics and
technologies have been introduced for use by older adults, infrastructure.
caregivers, health service providers and service providers to the
elderly to enhance and improve domains of human activity such as While many people live to advanced ages in excellent health, as each
housing, communication, transportation, work, health and leisure. decade passes there are increased risks of disability and
The last few decades have also seen an exponential rise in dependency. In the not-so-distant past, older people could rely on
technological capacity to develop new electronic approaches that their children to care for them. However, rapid cultural shifts in
enable users to be more productive, have easier access to content developed and developing countries such as China and India have
on demand, or use technology to substitute for tasks that would led to changes in family caregiving values and to distant migration of
otherwise require a human to do at either great cumulative expense adult children in search of economic opportunities.
or great emotional strain.
In lieu of dependence on close relatives for support when faced with
Under the aegis of gerontechnology are such innovations as smart old age disability, older adults can potentially turn to paid assistance
homes, social robots, assistive technology, telemedicine, m-health from professional caregivers in their home, or move to medical or
(mobile phone based monitoring), telehealth and a range of software specially-designed residential facilities for older or disabled people. In
applications that enhance safety or quality of life for older people recent years, more and more older adults have been exercising the
faced with some limitations. The devices can be wearable, portable, choice of “ageing in place”, that is, continuing to live in their homes
implantable or stationary. Sometimes the technology is software that with the support of assistive devices and various technologies that
can operate on a range of computers or smartphones; sometimes it enhance their ability to communicate with others, should they be
involves sensing devices including motion detectors, actuators or faced with circumstances that need outside intervention.
accelerometers.
Scientists, engineers and entrepreneurs have collectively seen this as
Gerontechnologists include a broad range of scholars, engineers and an opportunity to design innovative products and services that will
other specialists. Many are professionally linked through the enable older people to live with greater independence. A range of
International Society for Gerontechnology, based in the Netherlands. issues has already been studied regarding older people’s
Research in the field is published in a range of scholarly journals, acceptance of new technology. The data suggest that while age
including prestigious medical, engineering and social science does play some role in predicting technology acceptance, issues of
journals, as well as through a dedicated journal known simply as computer anxiety, self-efficacy, fluid intelligence and crystallized
Gerontechnology (www.gerontechnology.info). intelligence are even more important.3 Even in cases where
individuals do not have technical knowledge or ability, they may be
There is no shortage of opportunities for gerontechnology to willing to use a technology if it is perceived to be useful or easy to
accommodate some of the more serious issues associated with use.4
ageing, including declines in many systems of the body; losses in
muscle strength; reductions in bone density that predispose older
people to higher injury risk from a fall or accident; and declines in the
acuity of essential senses such as vision, hearing and taste, as well
as delayed reflexes in response to extreme hot or cold.
Gerontechnological approaches can also help older adults maintain
mental acuity long after retirement.

Housing and Daily Living Balance and Fall Prevention

Smart Homes Gerontechnology is dramatically changing our understanding of
Smart homes integrate a range of monitoring and supportive devices to balance and fall prevention. In recent years, accelerometer
enable people to age in place more effectively. These homes have technology has become common in smart phones and gaming
technologies that can generally be grouped into six categories: (i) devices, opening up new opportunities for balance testing and fall
physiological monitoring, which usually focuses on vital signs, blood monitoring, as well as improvements in our understanding of
sugar and bladder and bowel output; (ii) functional monitoring for age-related changes in gait.13
emergency detection and response, including measures of general
activity level, gait, and meal intake, or identifying extended time periods Canes and walking sticks have been preventing falls for millennia, but
without activity that might be cause for concern; (iii) safety monitoring new approaches have been developed that address balance in novel
and assistance; (iv) security monitoring and assistance; (v) social ways. While knee and ankle orthotics have been shown in multiple
interaction monitoring and assistance; and (vi) cognitive and sensory studies to help individuals with ambulation,14,15 foot orthotics could be
assistance.5 considered the most helpful for assisting the elderly with ambulation.
Many older adults ignore foot care, either because they cannot reach
The following are some of the most notable university-based smart their feet to care for them properly or because they mistake foot pain,
homes: misshapen appearance or odd coloration as simply an inevitable part
of growing old. More than three-fourths of older adults suffer from
• The Aware Home Research Initiative at the Georgia Institute of significant foot problems that predispose them to discomfort,
Technology constructed a three-story, 5,040 square-foot house to reduced range of motion and impaired ambulation.
design, develop and evaluate future domestic technologies in a
realistic environment. The home evaluates ubiquitous computing Foot orthotics can increase range of motion and improve ambulation
with computer-monitored sensors that can infer activity patterns, as well as effectively combat foot pain, stress and trauma in the
including emergency detection, or identify when people with elderly through weight diffusion and weight dispersion.16 Truly
memory impairment may need assistance.6 advanced orthotics with power-assisted joints are forming a new
• The University of Florida has the Gator Tech Smart House for the type of robotic exoskeleton that could enable people with limited
elderly and disabled that uses environmental sensors to monitor for strength to walk further distances. These include Cyberdyne’s Hybrid
safety and security, reminder and prompting technologies, Assistive Limb (HAL) and Berkeley Bionics’ human exoskeleton.
temperature sensors, activity monitoring, fall detection and
biometric technologies for physiological monitoring.7 A wide range of devices has been developed that can better assess
gait and balance, including gait mats, electronic insoles, pressure
• The MavHome project at the University of Texas at Arlington is
sensitive walkways and optical motion-capture systems.17 Balance
focused on developing context prediction to identify the risk of
training can be enhanced or integrated into everyday activities using
future events, such as a potential fall. Robotics and artificial
the same technology found in the Nintendo Wii balance board.18 A
intelligence are tested to investigate activity patterns.8
combination of motion-detection technology and algorithms can
• The multi-agent systems laboratory at the University of passively monitor activity and signal caregivers when there appears
Massachusetts at Amherst has developed independent intelligent to have been a fall.19
agents that help automate some daily tasks currently done by
humans, with emphasis on improving efficiency and quality of A wide range of approaches has been studied for detecting falls,
service. These agents include water heaters, dishwashers and including specialized belts and mercury tilt switches to detect a lying
vacuum cleaners that operate autonomously, deployed in a position,20 impact-sensitive flooring and low-cost motion-detecting
simulated intelligent-home environment.9 sensors that can be active 24 hours a day and do not depend on a
• At the Massachusetts Institute of Technology, the House_n group, person remembering to wear a specific device. Several motion-
also known as the “house of the future”, proposes a smart services detection based systems with special software programmed to
delivery system that passively collects data on activities in the home analyse patterns of motion, infer lack of activity as a potential fall, and
that can be used to identify moments when human intervention send notification to a caregiver, are already commercially available.
might be needed.10 The system includes sensors that help collect
data about activities of daily living (e.g., bathing, dressing, eating and
toileting) and algorithms for recognizing and classifying activities
that are not directly observed, but inferred, based on patterns of
motion sensor activity.
• In Osaka, Japan, the smart house of Dr K. Matsuoka automatically
detects unusual events that may have been caused by an accident
or a disease through its 167 sensors that translate raw sensor
signals into behavioural data.
• At the University of Missouri-Columbia, the Ageing in Place project,
which includes the Senior Care and TigerPlace initiatives, allows
older adults to remain in the home environment of their choice with
the help of healthcare services. The main goal of this project is to
conduct interdisciplinary research to implement effective methods
of caring for the elderly who desire to “age in place”. For example,
the TigerPlace residence has wireless sensors connected to small
computers that detect functional decline of older persons.
• Supportive robots hold potential for assisting in vital activities
including a new Chinese robot that can cook and deliver a variety of
complex dishes,11 or the robot Pearl, which reminds people about
activities such as eating, drinking, taking medicine and using the
bathroom.12

Communication Health and Home Care

Many older adults spend significant time alone or live in locations Telehealth
where they have limited ability to socialize. Research has shown that Telemedicine, or telecare, provides connectivity with clinicians to
robots can serve an important role for social activities.21 A number of improve the management of chronic disease in the comfort of an
robots designed specifically for interacting with older people have older person’s home rather than in hospital.34 Telehealth consists of
been designed and tested for various purposes that include: telephone, videoconferencing and Internet-based services to provide
rehabilitation and exercise;22,23 calming and relaxation for those with specialist referrals, patient consultations, remote patient monitoring,
Alzheimer’s Disease, as seen in Paro the robot seal;24 or primarily for medical education, and consumer medical and health information
entertainment, with a secondary benefit of monitoring for through networked programmes.
emergencies, as seen in the Nao robot.
Due to concerns about compliance with the US Health Insurance
Social media have changed the face of the Internet. One of the most Portability and Accountability Act of 1996, designed to protect
rapidly growing user bases for services such as Facebook are baby patient privacy, video transmission of health visits in the United States
boomers and their older parents.25 Older people in the United occurs only under highly restricted circumstances. If future
Kingdom who are connected to the Internet use it a great deal. The reimbursement policies allow for videoconferencing to be a billable
fastest growing age group on Facebook are older adults. medical visit, it is likely that chronic disease management can be a
Communication with other generations that have migrated elsewhere more pervasive mode of health service use.35 This has been
can be facilitated by cheap connectivity and videoconferencing, and successfully introduced in countries such as Australia.
phones have been designed with features that allow listeners to slow
down the speed at which they hear a caller. Technology is expected to lead to more cost-effective care through
the use of telehealth monitoring36 and passive remote activity
Support groups on the web can lead to increased knowledge of monitoring via algorithms, which in many cases can potentially delay
one’s health condition and improved psychological wellbeing and or prevent institutionalization,37 leading to significant savings for
health status.26 Some hospitals encourage their long-term recovery healthcare systems.
patients to use Care Pages, an online blog that allows patients to
share their experiences with a select group of friends and family and Memory and Brain Fitness
receive messages of support.
The normal ageing process affects various forms of memory, though
Personal Mobility and Transportation there may be extensive opportunity for plasticity in memory abilities
in advanced ages under the right conditions.38,39 Some of the
Assistive Technologies common age-related changes include declines in working memory40
Research has demonstrated that assistive technologies (AT) can help related to slowed speed of processing,41 limits in capacity,42 and
decrease the need to use some health services. An analysis of the difficulty inhibiting irrelevant information.43 Spatial abilities, tested by
1994 National Long Term Care Survey found that the use of AT mental rotation exercises such as fitting furniture through a tight
equipment was associated with needing fewer hours of help from doorway, decline with age,44 and this decline is associated with
another person, including paid home health aides;27 slower declines confusion when navigating through layers of menus on the Internet.
in physical abilities;28 and reduced hospital and nursing home costs.29
Assistive devices can also lead to improved self-care and daily living The concept of a “cognitive orthotic” is becoming part of the lexicon.
skills,30 which in turn relieves stress on caregivers and family These devices, such as the Autominder software that uses artificial
members.31 intelligence techniques to construct a daily schedule, observe
whether the elder adheres to that schedule, and then chooses when
However, technology can be a double-edged sword. Power it might be appropriate to issue a reminder.45 It can also help people
wheelchairs, for example, can contribute to more rapid physical with mild cognitive impairment follow a routine (e.g., medications and
decline.32 Data from some of the devices that detect lack of motion personal hygiene), as well as periodic tasks, such as remembering
as a potential health problem may be incorrectly interpreted as a fall, doctor visits and important dates. From tasks as simple as hand
when a person may simply be resting or sleeping. This could lead to washing and getting dressed, to more complex activities such as
false alarms, which is not a trivial issue for family members monitoring cooking a meal, research is showing that videos demonstrating basic
their parents. activities can prompt persons with Alzheimer’s disease to perform
tasks correctly that they might otherwise not perform.46 Such
Older people may reject technology because they think they do not support is useful across the lifespan.
need it, or the device itself might not be user-friendly enough. Cohort
effects are also a factor: tomorrow’s 80-year olds may be more Research on gaming and “brain-fitness” is beginning to shed light on
inclined to use technology than those reaching older ages today.33 the potential benefits of specifically targeted games and activities. At
older ages, these can be helpful in maintaining or improving certain
cognitive abilities – such as delayed recall and digit reversal as shown
in the IMPACT study,47 improving visuospatial attention, expanding
useful field of view48 or even assisting in a post-stroke recovery.49
While practice can certainly improve game performance, the more

important question is whether such practice transfers to real life
activities. To date, no definitive evidence has emerged showing a
clear link between games and performance in daily activities, though
many individuals report more confidence in their memory abilities
after engaging in brain training activities.50

Conclusion Endnotes
1 Lancaster, H. O. (1990) Expectations of Life: A Study in the Demography, Statistics, and History of
Gerontechnology can help people cope more effectively with or World Mortality. New York: Springer-Verlag.
compensate for physical and mental declines often associated with 2 CDC, Center for Disease Control. (2006) CDC United States Life Tables. National Vital Statistics
ageing. These technological developments can be simple and Reports, 58(21). Available online at: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_21.pdf
relatively low-tech, such as an assistive device like a foot orthotic that 3 Czaja S. J. et al (2006). Factors predicting the use of technology: findings from the Center for
Research and Education on Aging and Technology Enhancement (CREATE). Psychol Aging, 21(2),
improves balance,51 or highly advanced, such as socially assistive 333–52.
robots for rehabilitation52 or robots for behavioural treatment of 4 Oppenauer, C. (2009) Usability of assistive technologies in ageing and disabilities. International
dementia symptoms.53,54 Journal of Integrated Care, 9(Suppl), 54.
5 Demiris, G. & Hensel, B. K. (2008) Technologies for an Aging Society: A Systematic Review of
Gerontechnology is expected to lead to more cost-effective care “Smart Home” Applications. International Medical Informatics Association Yearbook of Medical
Informatics, 33-40.
through the use of telehealth monitoring55 and passive remote activity 6 Kidd, C. et al. (1999) The Aware Home: A Living Laboratory for Ubiquitous Computing Research.
monitoring via algorithms that can potentially delay or prevent In: Streitz, N., Siegel, J., Hartkopf, V. & Konomi, S. (eds) Lecture Notes in Computer Science:
institutionalization, leading to significant savings for healthcare Cooperative Buildings. Integrating Information, Organizations, and Architecture. Heidelberg:
Springer Berlin. 191-198
systems.56 Interdisciplinary research teams, sometimes involving
7 Helal, S. et al. (2005) The Gator Tech Smart House: A Programmable Pervasive Space. Computer,
several universities, have organized a variety of research labs that 38(3), 50-60.
bring together engineers, psychologists, gerontologists, physical and 8 Cook, D. J., et al. (2003). An agent-based smart home. In: First IEEE International Conference on
occupational therapists, experts in human factors design, and a wide Pervasive Computing and Communications Pervasive Computing and Communications: 521-524.
Available at: http://www.informatik.uni-trier.de/~ley/db/conf/percom/percom2003.html
range of medical and research faculty to develop innovative
9 Intille, S. S. (2006) The goal: smart people, not smart homes. In: Nugent, C. & Augusto, J.C. (eds.)
approaches to everyday issues. Smart Homes And Beyond. Amsterdam: IOS Press.
10 Ma, W., Yan, W., Fu, Z., & Zhao, Y. (2011) A Chinese cooking robot for elderly and disabled people.
Communication with caregivers and relatives can be enhanced with Robotica, 29, 843-852.
automated activity monitoring for at-risk people living alone57 or 11 Pineau, J. et al. (2003) Towards robotic assistants in nursing homes: Challenges and results.
through social networking58,59 or web-based social support groups.60 Robotics and Autonomous Systems, 42 (3-4), 271-281.
Research on gaming and “brain-fitness” is beginning to reveal 12 Merilahti J. et al. (2008) Evaluation of new concept for balance and gait analysis: patients with
neurological disease, elderly people and young people. Gerontechnology, 7(2), 164.
potential benefits of specifically targeted games.
13 Tyson, S., & Kent, R. (2009) Orthotic Devices after stroke and other non-progressive brain lesions.
Cochrane Database of Systematic Reviews, Issue 2.
Perhaps the most important, but currently overlooked, opportunity 14 Zissimopoulos, A., Fatone, S. & Gard, S. (2007) Biomechanical and energetic effects of a
for gerontechnology lies in low- and middle-income countries. The stance-control orthotic knee joint. Journal of Rehabilitation Research and Development, 44(4),
503-514.
following could all make a significant impact on the quality of life of
15 Mitty, E. (2009) Nursing Care of the Aging Foot. Geriatric Nursing, 30(5),350-354.
millions of older people:
16 Ni Scanaill, C., Garattini, C., Greene, B., McGrath, M. (2011). Technology Innovation Enabling Falls
• Reinventing basic assistive devices to be more appropriate or Risk Assessment in a Community Setting. Ageing International, 36(2): 217-231
more robust for a less developed environment 17 Young, W., Ferguson, S., Brault, S. & Craig, C. (2011) Assessing and training standing balance in
older aldults: A novel approach using the ‘Nintendo Wii’ Balance Board. Gait Posture, 33, 303-305
• Finding ways to strengthen the capacity of low- and middle- 18 Noury, N. et al. (2007) Fall detection - Principles and Methods. Engineering in Medicine and
income countries to manufacture assistive devices Biology Society, 1663 – 1666.
19 Lord, S. R., Menz, H. B. & Tiedemann, A. (2003) Physiological profile approach to fall risk
• Developing new technology that can cheaply ensure access to assessment and prevention. Physical Therapy, 83(3), 237-252.
diagnostics or management of chronic conditions in remote 20 Gockley, R. et al. (2005) Designing robots for long-term social interaction. In: IEEE International
areas Conference on Intelligent Robots and Systems, 1338 – 1343. Available at: http://www.cs.cmu.
edu/~reids/papers/Valerie-IROS2005-final.pdf
21 Ibid.
22 Mataric, M. J., Eriksson, J, Feil-Seifer, D. J, & Winstein, C. (2007) Socially assistive robotics for
post-stroke rehabilitation. Journal of NeuroEngineering and Rehabilitation, 4(5).
23 Wada, K., Shibata, T., Saito, T., & Tanie, K. (2004) Effects of robot-assisted activity for elderly
people and nurses at a day service center. Proceedings of the IEEE, 92(11), 1780-1788.
24 Lewis, S. & Ariyachandra, T. (2011). Seniors and Social Networking. Journal of Information
Systems Applied Research, 4(2), 4-18.
25 Carlbring, P. et al (2005) Treatment of panic disorder: Live therapy vs self-help via the Internet.
Behaviour Research and Therapy, 43, 1321-1333.
26 Hoenig, H., Taylor, D. H. & Sloan, F.A. (2003) Does assistive technology substitute for personal
assistance among the disabled elderly? Am J Public Health, 93, 330-337.
27 Mann, W.C. et al. (1999) Effectiveness of assistive technology and environmental interventions in
maintaining independence and reducing home care costs for the frail elderly: A randomized
controlled trial. Archives of Family Medicine, 8, 210-217.
28 Ibid.
29 Gitlin, L. N. et al. (2001) Randomized, controlled trial of a home environmental intervention: Effect
pm efficacy and upset in caregivers and on daily function of persons with dementia. Gerontologist,
41(1), 4-14.
30 Gitlin, L. N. et al. (2002) Evaluating home environments of persons with dementia: Interrater
reliability and validity of the Home Environmental Assessment Protocol (HEAP). Disability and
Rehabilitiation, 24(1-3), 59-71.
31 Iezzoni, L. (2003) When Walking Fails: Mobility Problems of Adults with Chronic Conditions.
Berkeley: University of California Press.
32 Gitlin, L. N. (1995) Why older people accept or reject assistive technology. Generations, 19(1),
41-46.
33 Coughlin, J., Pope, J. & Leedle, B. (2006) Old Age, New Technology and Future Innovations in
Disease Management and Home Health Care. Home Health Care Management and Practice, 18
(3), 196-207.
34 Ibid.
35 Darkins, A. et al. (2008) Care Coordination/Home Telehealth: The Systematic Implementation of
Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran
Patients with Chronic Conditions. Telemedicine and e-Health, 14 (10), 1118-1126.
36 Alwan, M. et al. (2006) Impact of monitoring technology in assisted living: outcome pilot. Institute of
Electrical and Electronics Engineers (IEEE), Transactions on Information Technology in
Biomedicine, 10(1), 192-198.

37 Baltes, P. B. & Lindenberger, U. (1988) On the range of cognitive plasticity in old age as a function
of experience: 15 years of intervention research. Behavior Therapy, 19(3), 283-300.
38 Smith, G. E. et al. (2009) A Cognitive Training Program Based on Principles of Brain Plasticity:
Results from the Improvement in Memory with Plasticity-based Adaptive Cognitive Training
(IMPACT) Study. Journal of the American Geriatrics Society, 57(4), 594–603.
39 Craik, F. (1986) A functional account of age differences in memory. In: Klix, F. & Hagendorf, H. (eds)
Human memory and cognitive capabilities: Mechanisms and performances. New York: Elsevier
Science Publishers. 409-421.
40 Salthouse, T.A., Babcock, R.L. (1991). Decomposing adult age differences in working memory.
Developmental Psychology, Vol 27(5): 763-776.
41 Craik, F. (1986) A functional account of age differences in memory. In: Klix, F. & Hagendorf, H.
(eds.) Human memory and cognitive capabilities: Mechanisms and performances. New York:
Elsevier Science Publishers. 409-421.
42 Hasher, L. and Zacks, R.T. (1988). WOrking memory, comprehension, and aging: A review and a
new view. In G.G. Bower (Ed.), The psychology of learning and motivation. Vol 22, pp. 193-225.
San Diego, CA: Academic Press.
43 Salthouse, T.A. (1992). Why do adult age differences increase with task complexity?
Developmental Psychology, 28(5): 905-918.
44 Pollack, M. (2005) Intelligent technology for an aging population. AI Magazine, 26(2), 9-24.
45 Mihailidis, A., Barbenel, J. C. & Fernie, G. (2004) The efficacy of an intelligent cognitive orthosis to
facilitate handwashing by persons with moderate to severe dementia. Neuropsychological
Rehabilitation, 14(1-2), 135-171.
46 Smith, G. E. et al. (2009) A Cognitive Training Program Based on Principles of Brain Plasticity:
Results from the Improvement in Memory with Plasticity-based Adaptive Cognitive Training
(IMPACT) Study. Journal of the American Geriatrics Society, 57(4), 594–603.
47 Green, C. S. & Bavelier, D. (2006) Effect of Action Video Games on the Spatial Distribution of
Visuospatial Attention. J Exp Psychol Hum Percept Perform, 32(6), 1465–1478.
48 Flynn, S., Palma, P. & Bender, A. (2007) Feasibility of Using the Sony PlayStation 2 Gaming
Platform for an Individual Poststroke: A Case Report. Journal of Neurologic Physical Therapy,
31(4), 180-189.
49 Ercoli, L. M., Cernin, P. A. & Small, G. W. (2011) Peer-Led Memory Training Programs to Support
Brain Fitness. In: Hartman-Stein, P. E. & La Rue, A (eds), Enhancing Cognitive Fitness in Adults
Part 2. New York: Springer Science Publishing. 213-229.
50 Zissimopoulos, A., Fatone, S. & Gard, S. (2007) Biomechanical and energetic effects of a
stance-control orthotic knee joint. Journal of Rehabilitation Research and Development, 44(4),
503-514.
51 Mataric, M. J., Eriksson, J, Feil-Seifer, D. J. & Winstein, C. (2007) Socially assistive robotics for
post-stroke rehabilitation. Journal of NeuroEngineering and Rehabilitation, 4(5).
52 Bemelmans, R,, Gelderblom, G. J., Jonker, P. & de Witte, L. (2010) Socially Assistive Robots in
Elderly Care: A Systematic Review into Effects and Effectiveness. Journal of the American Medical
Directors Association. In Press.
53 Bharucha, A. J., et al (2009) Intelligent Assistive Technology. Applications to Dementia Care:
Current Capabilities, Limitations, and Future Challenges. Am J Geriatr Psychiatry, 17(2), 88-104.
54 Darkins, A. et al. (2008) Care Coordination/Home Telehealth: The Systematic Implementation of
Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran
Patients with Chronic Conditions. Telemedicine and e-Health, 14 (10), 1118-1126.
55 Alwan, M. et al. (2006) Impact of monitoring technology in assisted living: outcome pilot. Institute of
Electrical and Electronics Engineers (IEEE), Transactions on Information Technology in
Biomedicine, 10(1), 192-198.
56 Ibid.
57 Ariyachandra, T., Crable, E. & Brodzinski, J. (2009) Seniors’ Perceptions of the Web and Social
Networking. Issues in Information Systems, 10(2), 324-332.
58 Morris, M. (2005) Social Networks as Health Feedback Displays. IEEE Internet Computing, 9(5),
29-37.
59 Beaudoin, C. E. & Tao, C. C. (2007) Benefiting from Social Capital in Online Support Groups: An
Empirical Study of Cancer Patients. Cyberpsychology and Behavior, 10(4), 587-590.

Appendix Tables:
Trends and Patterns
in Population Ageing,
by Country, Stage of
Development and
Region 1

Appendix Tables: Trends and Patterns in Population Ageing, by Country, Stage of Development and Region
Table 1: Basic data on the population of older people, 2012 Sources

Data for all tables except Table 6 are derived from United Nations
Table 2A: Percentage of population aged 60 and older, selected Population Division (2011), World Population Prospects: The 2010
years, 1950-2050 Revision (United Nations, New York). http://esa.un.org/unpd/wpp
Data for Table 6 are from World Health Organization (2004), World
Table 2B: Percentage of population aged 80 and older, selected Health Report 2004, Annex Table 4.
years, 1950-2050
Data for the map are from World Bank (2011). World Development
Indicators 2011 (World Bank, Washington).
Table 3A: Average annual growth rate of total population (percent),
20-year periods, 1950-2050 Notes
“More developed regions” comprise Europe, North America,
Table 3B: Average annual growth rate of population aged 60 and Australia/New Zealand, and Japan. “Less developed regions”
older (percent), 20-year periods, 1950-2050 comprise Africa, Asia (excluding Japan), Latin America and the
Caribbean, Melanesia, Micronesia and Polynesia. This highly
Table 3C: Average annual growth rate of population aged 80 and aggregated country classification dates from the 1960s and has
been quite stable over time. It changed most notably after the
older (percent), 20-year periods, 1950-2050 breakup of the former Soviet Union in 1991, with Belarus, Estonia,
Latvia, Lithuania, Moldova, Russia and Ukraine being grouped
Table 4A: Percentage of population aged 60 and older (country with the more developed regions (in Europe), and the other new
rankings), 2012, 2030, 2050 countries becoming part of the less developed regions (in Asia).
Before that, the USSR was included among the more developed
regions (in Europe).
Table 4B: Percentage of population aged 80 and older (country
For geographical region definitions, see
rankings), 2012, 2030, 2050
http://esa.un.org/unpd/wpp/Excel-Data/country-classification.pdf
Table 5A: Percentage of population aged 60 and older under The total fertility rate (TFR) is the average number of children that a
woman would bear if she had children in accordance with current
alternative total fertility rate scenarios, 2012, 2030, 2050 age-specific fertility rates.
Table 5B: Percentage of population aged 80 and older under Unless otherwise indicated, all population projections are the
medium-fertility estimates of the UN Population Division. These
alternative total fertility rate scenarios, 2012, 2030, 2050 projections depend critically on trajectories of future fertility,
mortality and migration. The United Nations also makes low and
Table 6: Life expectancy at birth and health life expectancy high population projections, based on TFR trajectories that are 0.5
children below the medium and 0.5 children above the medium,
respectively. Assumptions about migration are based on past
estimates and the policies that countries have adopted. Projected
levels of net migration incorporate a slow decline through 2100.
Life expectancy at birth is the average age at death for a defined

birth cohort, assuming that it is subject to a given set of
age-specific mortality rates, typically those prevailing in its year of
birth. Estimates of future life expectancy are based on historical
country- and sex-specific trends and a model that anticipates
more rapid gains in countries with lower current life expectancy.
Healthy life expectancy at birth is defined by the World Health

Organization as the “average number of years that a person can
expect to live in ‘full health’ by taking into account years lived in
less than full health due to disease and/or injury”.
1 This Appendix was prepared by David Bloom, Larry

Rosenberg and Adam Stein.

Table 1: Basic data on the population of older people, 2012
Total
population 60+ as % of % female % female
(millions) %60+ %60-69 %70-79 %80+ 15-59 among 60+ among 80+
World 7 052,1 11 6 4 2 18 54 62
More developed regions 1 244,6 22 11 7 4 37 57 66

Less developed regions 5 807,6 9 5 3 1 15 53 59
Africa 1 070,1 6 3 2 0 10 54 59
Asia 4 250,4 11 6 3 1 16 53 59
Europe 740,2 22 10 8 4 36 58 67
Latin America & Caribbean 603,2 10 0 3 2 17 55 61
Northern America 350,6 19 10 5 4 32 55 64
Oceania 37,7 16 8 5 3 26 53 60
Afghanistan 33,4 4 3 1 0 7 50 55
Albania 3,2 14 7 5 2 21 52 61
Algeria 36,5 7 4 2 1 11 54 61
Angola 20,2 4 3 1 0 8 55 59
Argentina 41,1 15 8 5 3 25 58 68
Armenia 3,1 15 6 6 3 23 61 67
Aruba 0,1 15 9 5 2 23 56 63
Australia 22,9 20 10 6 4 32 53 60
Austria 8,4 24 11 8 5 38 56 67
Azerbaijan 9,4 9 4 3 1 13 57 63
Bahamas 0,4 11 7 3 1 17 57 69
Bahrain 1,4 4 3 1 0 5 44 52
Bangladesh 152,4 7 4 2 1 11 51 47
Barbados 0,3 17 9 5 3 26 57 67
Belarus 9,5 19 9 7 3 29 65 76
Belgium 10,8 24 11 8 5 40 56 65
Belize 0,3 6 3 2 1 10 52 56
Benin 9,4 5 3 1 0 9 59 65
Bhutan 0,8 7 4 2 1 11 48 53
Bolivia (Plurinational State of) 10,2 7 4 2 1 13 55 60
Bosnia and Herzegovina 3,7 20 10 7 3 31 56 64
Botswana 2,1 7 4 2 1 11 56 64
Brazil 198,4 11 6 3 2 17 55 60
Brunei Darussalam 0,4 6 4 2 1 9 47 54
Bulgaria 7,4 25 13 8 4 41 58 64
Burkina Faso 17,5 4 3 1 0 7 60 62
Burundi 8,7 5 3 1 0 8 59 64
Cambodia 14,5 7 4 2 0 10 61 70
Cameroon 20,5 5 3 2 0 10 54 58
Canada 34,7 21 11 6 4 33 54 62
Cape Verde 0,5 7 3 3 1 12 60 63
Central African Republic 4,6 6 4 2 1 11 56 60
Chad 11,8 5 3 1 0 9 54 60
Channel Islands 0,2 24 12 8 4 39 54 64
Chile 17,4 14 7 4 2 21 56 64
China 1 353,6 13 8 4 2 20 51 59
China, Hong Kong SAR 7,2 19 10 6 4 28 53 60
China, Macao SAR 0,6 12 8 3 2 17 48 64
Colombia 47,6 9 5 3 1 15 56 61
Comoros 0,8 4 3 1 0 8 54 60
Congo 4,2 6 3 2 1 10 54 57
Costa Rica 4,8 10 6 3 2 15 52 57
Côte d'Ivoire 20,6 6 4 2 0 11 46 50
Croatia 4,4 24 11 9 4 39 59 70
Cuba 11,2 18 9 6 3 27 53 58
Cyprus 1,1 17 9 5 3 26 54 60
Czech Republic 10,6 23 13 6 4 36 57 68
Dem. People's Republic of Korea 24,6 14 8 5 1 21 61 83

Total
Democratic Republic of the Congo 69,6 4 3 1 0 8 55 61

Denmark 5,6 24 12 7 4 41 54 63
Djibouti 0,9 6 4 2 0 9 54 60
Dominican Republic 10,2 9 5 3 2 15 51 53
Ecuador 14,9 9 5 3 1 15 53 57
Egypt 84,0 8 5 2 1 14 54 59
El Salvador 6,3 10 5 3 2 16 57 59
Equatorial Guinea 0,7 5 3 1 0 8 47 56
Eritrea 5,6 4 3 1 0 8 61 70
Estonia 1,3 23 10 8 5 38 65 75
Ethiopia 86,5 5 3 2 0 10 53 57
Fiji 0,9 8 6 2 1 13 52 58
Finland 5,4 26 13 8 5 45 56 67
France 63,5 24 11 7 6 41 56 65
French Guiana 0,2 8 5 2 1 13 50 65
French Polynesia 0,3 10 6 3 1 15 51 57
Gabon 1,6 7 4 2 1 11 52 58
Gambia 1,8 4 2 1 0 7 48 48
Georgia 4,3 20 9 8 3 31 60 69
Germany 82,0 27 11 10 5 44 56 66
Ghana 25,5 6 4 2 1 11 51 55
Greece 11,4 25 11 9 5 41 55 59
Grenada 0,1 10 5 3 2 15 57 65
Guadeloupe 0,5 18 9 5 4 30 57 63
Guam 0,2 12 7 3 1 19 52 56
Guatemala 15,1 6 4 2 1 12 53 58
Guinea 10,5 5 3 2 0 10 54 59
Guinea-Bissau 1,6 6 4 2 0 10 54 59
Guyana 0,8 7 4 2 1 11 57 65
Haiti 10,3 7 4 2 1 12 54 58
Honduras 7,9 6 4 2 1 11 52 58
Hungary 9,9 23 12 8 4 38 61 70
Iceland 0,3 17 9 5 4 28 52 59
India 1 258,4 8 5 2 1 13 52 55
Indonesia 244,8 9 5 3 1 13 55 60
Iran (Islamic Republic of) 75,6 8 4 2 1 11 50 47
Iraq 33,7 5 3 2 0 9 58 71
Ireland 4,6 17 9 5 3 28 53 63
Israel 7,7 15 8 4 3 27 56 63
Italy 61,0 27 12 9 6 46 56 65
Jamaica 2,8 11 5 4 2 18 53 62
Japan 126,4 32 14 10 7 57 56 65
Jordan 6,5 6 3 2 1 10 49 49
Kazakhstan 16,4 10 6 4 1 16 64 79
Kenya 42,7 4 3 1 0 8 54 56
Kuwait 2,9 4 2 1 0 6 38 26
Kyrgyzstan 5,4 6 3 2 1 10 59 64
Lao People's Democratic Republic 6,4 6 4 2 1 10 55 60
Latvia 2,2 23 10 8 4 37 65 76
Lebanon 4,3 11 6 4 1 16 54 56
Lesotho 2,2 6 4 2 1 11 60 62
Liberia 4,2 4 3 1 0 8 55 60
Libyan Arab Jamahiriya 6,5 7 4 2 1 11 51 57
Lithuania 3,3 21 10 8 4 33 64 73
Luxembourg 0,5 19 9 6 4 30 55 66
Madagascar 21,9 5 3 1 0 9 53 52
Malawi 15,9 5 3 1 0 10 55 57
Malaysia 29,3 8 5 2 1 13 51 55
Maldives 0,3 7 3 3 1 10 47 41
Mali 16,3 3 2 1 0 7 59 59

Total
Malta 0,4 23 12 7 3 36 55 64
Martinique 0,4 21 10 7 4 34 57 65
Mauritania 3,6 5 3 1 0 8 57 60
Mauritius 1,3 12 7 3 1 18 56 65
Mayotte 0,2 3 2 1 0 6 47 48
Mexico 116,1 10 5 3 1 15 54 60
Micronesia (Fed. States of) 0,1 6 4 2 1 11 53 59
Mongolia 2,8 6 3 2 1 9 57 65
Montenegro 0,6 18 9 6 3 29 56 61
Morocco 32,6 9 5 3 1 13 53 57
Mozambique 24,5 5 3 2 0 10 57 61
Myanmar 48,7 8 5 2 1 13 55 59
Namibia 2,4 6 4 2 1 10 57 61
Nepal 31,0 6 4 2 1 11 55 58
Netherlands 16,7 23 12 7 4 38 54 65
Netherlands Antilles 0,2 16 9 5 2 25 57 63
New Caledonia 0,3 12 7 4 2 20 52 62
New Zealand 4,5 19 10 6 4 31 53 60
Nicaragua 6,0 7 3 2 1 11 54 59
Niger 16,6 4 3 1 0 8 52 53
Nigeria 166,6 5 3 2 0 10 53 57
Norway 5,0 22 11 6 5 36 54 64
Occupied Palestinian Territory 4,3 4 3 1 0 8 51 60
Oman 2,9 5 3 1 0 7 42 53
Pakistan 180,0 7 4 2 1 11 49 48
Panama 3,6 10 6 3 1 16 52 56
Papua New Guinea 7,2 5 3 1 0 8 55 66
Paraguay 6,7 8 5 2 1 13 51 57
Peru 29,7 9 5 3 1 15 53 59
Philippines 96,5 6 4 2 0 10 56 63
Poland 38,3 20 10 6 4 32 60 70
Portugal 10,7 24 11 8 5 40 57 64
Puerto Rico 3,7 18 9 6 3 30 57 62
Qatar 1,9 2 1 1 0 3 29 45
Republic of Korea 48,6 17 9 6 2 25 57 70
Republic of Moldova 3,5 17 9 5 2 25 60 70
Réunion 0,9 12 6 4 2 20 55 60
Romania 21,4 21 10 7 3 33 59 66
Russian Federation 142,7 19 9 7 3 28 66 76
Rwanda 11,3 4 3 1 0 8 54 60
Saint Lucia 0,2 10 5 3 2 15 56 61
Saint Vincent and the Grenadines 0,1 10 5 3 1 15 54 61
Samoa 0,2 8 4 2 1 14 55 64
Sao Tome and Principe 0,2 5 3 2 1 9 57 58
Saudi Arabia 28,7 5 3 1 1 8 48 57
Senegal 13,1 4 3 1 0 7 53 52
Serbia 9,8 20 10 7 3 33 56 60
Sierra Leone 6,1 4 3 1 0 7 51 39
Singapore 5,3 15 9 4 2 23 53 59
Slovakia 5,5 18 10 5 3 27 60 70
Slovenia 2,0 23 11 8 4 38 58 72
Solomon Islands 0,6 5 3 1 0 9 52 54
Somalia 9,8 4 3 1 0 9 54 58
South Africa 50,7 8 5 2 1 12 59 71
Spain 46,8 23 10 7 5 37 56 63
Sri Lanka 21,2 13 7 4 2 21 54 56
Sudan 45,7 6 4 2 0 10 53 56
Suriname 0,5 10 5 3 1 15 56 63
Swaziland 1,2 5 3 2 0 9 57 64
Sweden 9,5 25 12 8 5 44 54 62

Total
Switzerland 7,7 23 11 7 5 38 55 65
Syrian Arab Republic 21,1 6 4 2 1 11 51 55
Tajikistan 7,1 5 3 2 1 8 57 66
TFYR Macedonia 2,1 17 9 6 2 27 55 64
Thailand 69,9 14 8 4 2 21 55 60
Timor-Leste 1,2 5 3 1 0 10 53 57
Togo 6,3 5 3 2 0 10 54 58
Tonga 0,1 8 4 3 1 15 57 66
Trinidad and Tobago 1,4 11 7 3 1 16 59 71
Tunisia 10,7 10 6 3 1 16 52 53
Turkey 74,5 10 6 3 1 15 55 60
Turkmenistan 5,2 6 3 2 1 10 58 68
Uganda 35,6 4 2 1 0 8 55 58
Ukraine 44,9 21 10 8 3 33 65 74
United Arab Emirates 8,1 1 1 0 0 2 26 47
United Kingdom 62,8 23 11 7 5 39 54 63
United Republic of Tanzania 47,7 5 3 1 0 10 55 58
United States of America 315,8 19 10 5 4 31 56 64
United States Virgin Islands 0,1 23 13 7 3 39 55 65
Uruguay 3,4 19 9 6 4 31 59 67
Uzbekistan 28,1 6 3 2 1 10 56 65
Vanuatu 0,3 6 4 2 0 10 49 49
Venezuela (Bolivarian Republic of) 29,9 9 5 3 1 15 53 58
Viet Nam 89,7 9 5 3 1 13 57 62
Western Sahara 0,6 4 3 1 0 6 44 49
Yemen 25,6 4 3 1 0 8 54 58
Zambia 13,9 5 3 1 0 9 55 58
Zimbabwe 13,0 6 3 2 1 11 57 58

Table 2A: Percentage of population aged 60 and older
1950 1970 1990 2010 2030 2050 1950 1970 1990 2010 2030 2050
World 8 8 9 11 17 22 Djibouti 3 4 4 5 8 12
Dominican Republic 4 4 6 9 15 22
More developed regions 12 15 18 22 29 32 Ecuador 8 6 6 9 15 24
Less developed regions 6 6 7 9 14 20 Egypt 5 5 6 8 13 20
El Salvador 6 6 7 10 13 21
Africa 5 5 5 5 7 10 Equatorial Guinea 9 7 7 4 9 9
Asia 7 6 8 10 17 24 Eritrea 5 4 4 4 5 10
Europe 12 15 18 22 29 34 Estonia 15 17 17 23 27 32
Latin America & Caribbean 6 6 7 10 17 25 Ethiopia 5 5 5 5 7 12
Northern America 12 14 17 19 26 27 Fiji 4 4 5 8 15 20
Oceania 11 11 13 15 20 24 Finland 10 14 18 25 31 31
France 16 18 19 23 29 30
Afghanistan 5 4 4 4 4 7 French Guiana 9 7 6 7 13 16
Albania 10 7 8 13 22 34 French Polynesia 4 4 5 9 18 27
Algeria 7 6 5 7 14 26 Gabon 11 11 8 6 9 13
Angola 5 5 4 4 5 8 Gambia 5 4 4 3 5 8
Argentina 7 11 13 15 18 25 Georgia 15 12 15 19 28 35
Armenia 12 8 10 15 23 30 Germany 15 20 20 26 36 37
Aruba 3 7 11 14 29 30 Ghana 4 4 5 6 8 12
Australia 13 12 15 19 25 29 Greece 10 16 20 24 31 36
Austria 15 20 20 23 33 36 Grenada 8 8 11 10 15 29
Azerbaijan 11 8 7 9 18 25 Guadeloupe 7 7 11 17 28 33
Bahamas 7 5 6 10 20 28 Guam 2 3 7 11 19 22
Bahrain 5 4 4 3 15 32 Guatemala 4 5 5 6 8 12
Bangladesh 6 5 6 7 12 22 Guinea 8 5 5 5 6 8
Barbados 9 12 13 16 28 34 Guinea-Bissau 6 6 6 5 6 8
Belarus 13 13 17 18 25 32 Guyana 6 5 7 6 15 22
Belgium 16 19 21 23 30 31 Haiti 6 6 6 7 9 15
Belize 6 7 6 6 11 18 Honduras 6 5 5 6 10 17
Benin 11 7 5 5 6 8 Hungary 12 17 19 23 27 32
Bhutan 4 4 5 7 12 24 Iceland 10 12 15 17 24 29
Bolivia (Plurinational State of) 6 6 6 7 10 15 India 5 5 6 8 12 19
Bosnia and Herzegovina 6 8 10 19 30 40 Indonesia 6 5 6 8 16 25
Botswana 7 5 4 6 8 13 Iran (Islamic Republic of) 8 5 6 7 15 33
Brazil 5 6 7 10 19 29 Iraq 5 7 6 5 6 10
Brunei Darussalam 8 6 4 6 14 23 Ireland 15 16 15 16 23 29
Bulgaria 10 15 19 24 29 36 Israel 6 10 12 15 19 23
Burkina Faso 4 4 4 4 4 7 Italy 12 16 21 27 34 38
Burundi 5 5 5 5 7 12 Jamaica 6 8 10 11 19 26
Cambodia 5 5 5 6 11 19 Japan 8 11 17 30 37 41
Cameroon 6 6 6 5 6 9 Jordan 7 5 5 6 9 18
Canada 11 11 16 20 29 31 Kazakhstan 10 8 10 10 15 20
Cape Verde 10 7 7 7 13 23 Kenya 6 5 4 4 5 9
Central African Republic 8 7 6 6 6 10 Kuwait 4 3 3 4 10 22
Chad 7 6 5 5 5 7 Kyrgyzstan 12 9 8 6 11 17
Channel Islands 17 20 20 23 34 36 Lao People's Democratic Republic 4 5 6 6 10 19
Chile 7 8 9 13 23 30 Latvia 16 17 17 23 27 34
China 8 7 9 12 24 34 Lebanon 10 7 8 10 17 28
China, Hong Kong SAR 4 6 13 18 33 37 Lesotho 7 7 6 6 6 9
China, Macao SAR 5 9 10 12 26 38 Liberia 5 4 4 4 5 8
Colombia 5 5 6 9 16 24 Libyan Arab Jamahiriya 7 4 4 6 12 23
Comoros 6 5 5 4 6 9 Lithuania 13 15 16 21 27 32
Congo 6 6 6 6 6 9 Luxembourg 15 18 19 19 25 30
Costa Rica 8 7 7 10 19 30 Madagascar 5 6 5 5 7 9
Côte d'Ivoire 4 4 4 6 6 10 Malawi 5 4 4 5 4 5
Croatia 11 15 17 23 30 34 Malaysia 7 5 6 8 15 20
Cuba 7 9 12 17 32 39 Maldives 5 4 5 7 14 31
Cyprus 9 14 14 16 23 32 Mali 5 5 5 4 4 6
Czech Republic 12 18 18 22 28 34 Malta 9 13 14 21 30 37
Dem. People's Republic of Korea 4 2 8 14 19 23 Martinique 8 8 13 20 32 37
Democratic Republic of the Congo 6 5 4 4 5 7 Mauritania 3 4 4 4 6 10
Denmark 13 18 20 23 29 30 Mauritius 5 4 7 11 22 29

1950 1970 1990 2010 2030 2050 1950 1970 1990 2010 2030 2050
Mayotte 15 8 4 3 7 12 Togo 7 5 5 5 7 12
Mexico 5 6 6 9 17 26 Tonga 3 4 7 8 10 13
Micronesia (Fed. States of) 6 5 5 6 10 15 Trinidad and Tobago 6 7 8 11 21 32
Mongolia 7 8 6 6 12 20 Tunisia 8 6 7 10 17 29
Montenegro 10 11 13 18 24 31 Turkey 5 6 6 9 16 26
Morocco 5 6 6 8 15 24 Turkmenistan 10 7 6 6 12 20
Mozambique 5 5 5 5 6 7 Uganda 5 4 4 4 4 6
Myanmar 6 6 7 8 15 25 Ukraine 11 14 19 21 25 32
Namibia 7 6 5 6 9 13 United Arab Emirates 6 2 2 1 12 36
Nepal 4 5 5 6 9 17 United Kingdom 16 19 21 23 27 30
Netherlands 11 14 17 22 31 32 United Republic of Tanzania 4 4 4 5 5 6
Netherlands Antilles 9 8 10 15 28 39 United States of America 13 14 17 18 25 27
New Caledonia 6 6 7 12 19 26 United States Virgin Islands 11 6 9 21 32 30
New Zealand 13 12 15 18 26 29 Uruguay 12 13 17 18 22 27
Nicaragua 5 4 5 6 11 21 Uzbekistan 9 9 6 6 12 21
Niger 2 3 4 4 4 5 Vanuatu 4 5 5 5 8 13
Nigeria 5 5 5 5 5 7 Venezuela (Bolivarian Republic of) 3 5 6 9 15 22
Norway 14 18 21 21 27 29 Viet Nam 7 7 7 8 18 31
Occupied Palestinian Territory 7 4 3 4 6 10 Western Sahara 5 4 4 4 12 23
Oman 5 5 3 4 14 29 Yemen 6 5 3 4 5 9
Pakistan 8 6 6 6 9 16 Zambia 4 4 4 5 4 4
Panama 6 6 7 10 16 23 Zimbabwe 5 5 5 6 5 12
Papua New Guinea 6 4 4 5 7 11
Paraguay 5 5 6 8 11 17
Peru 6 6 6 9 14 23
Philippines 6 5 5 6 10 15
Poland 8 13 15 19 27 35
Portugal 10 14 19 24 33 40
Puerto Rico 6 10 13 18 25 31
Qatar 6 3 2 2 9 28
Republic of Korea 5 5 8 16 31 39
Republic of Moldova 11 10 13 16 24 34
Réunion 6 5 8 12 21 26
Romania 9 13 16 20 27 36
Russian Federation 9 12 16 18 25 31
Rwanda 5 4 4 4 5 9
Saint Lucia 6 7 10 9 17 28
Saint Vincent and the Grenadines 6 8 9 10 18 24
Samoa 4 3 6 7 12 13
Sao Tome and Principe 6 7 7 5 6 13
Saudi Arabia 6 5 4 4 9 22
Senegal 5 4 4 4 5 8
Serbia 11 13 15 20 25 32
Sierra Leone 5 5 5 4 5 7
Singapore 4 6 8 14 31 38
Slovakia 10 14 15 17 26 35
Slovenia 11 15 16 22 32 37
Solomon Islands 3 5 4 5 7 12
Somalia 5 5 5 4 5 6
South Africa 6 6 5 7 11 15
Spain 11 14 19 22 31 38
Sri Lanka 12 6 8 12 20 27
Sudan 5 5 5 6 7 11
Suriname 8 6 7 9 16 24
Swaziland 5 4 4 5 6 8
Sweden 15 20 23 25 29 31
Switzerland 14 16 19 23 32 37
Syrian Arab Republic 7 6 5 6 11 18
Tajikistan 7 7 6 5 9 14
TFYR Macedonia 11 9 11 17 25 34
Thailand 5 5 7 13 24 32
Timor-Leste 6 4 3 5 5 7

Table 2B: Percentage of population aged 80 and older
1950 1970 1990 2010 2030 2050 1950 1970 1990 2010 2030 2050
World 1 1 1 2 2 4 Djibouti 0 0 0 0 1 1
Dominican Republic 0 0 1 1 2 5
More developed regions 1 2 3 4 6 9 Ecuador 1 1 1 1 2 5
Less developed regions 0 0 1 1 2 4 Egypt 0 0 0 1 1 3
El Salvador 0 1 1 2 3 4
Africa 0 0 0 0 1 1 Equatorial Guinea 0 0 1 0 0 1
Asia 0 0 1 1 2 5 Eritrea 0 0 0 0 0 1
Europe 1 2 3 4 6 9 Estonia 2 2 3 4 6 8
Latin America & Caribbean 0 0 1 1 3 6 Ethiopia 0 0 0 0 1 1
Northern America 1 2 3 4 5 8 Fiji 0 0 0 0 1 4
Oceania 1 1 2 3 4 6 Finland 1 1 3 5 8 10
France 2 2 4 5 7 10
Afghanistan 0 0 0 0 0 0 French Guiana 1 1 1 1 1 3
Albania 1 1 1 2 3 7 French Polynesia 0 0 0 1 2 6
Algeria 0 1 1 1 1 4 Gabon 1 1 1 1 1 2
Angola 0 0 0 0 0 1 Gambia 0 0 0 0 0 0
Argentina 0 1 1 3 3 5 Georgia 1 2 2 3 4 8
Armenia 1 1 1 3 3 7 Germany 1 2 4 5 8 13
Aruba 0 0 2 1 3 9 Ghana 0 0 0 0 1 1
Australia 1 1 2 4 6 8 Greece 1 2 3 5 7 10
Austria 1 2 4 5 7 12 Grenada 1 1 1 2 2 5
Azerbaijan 1 1 1 1 1 4 Guadeloupe 0 1 2 3 6 11
Bahamas 1 0 1 1 3 6 Guam 0 0 0 1 2 5
Bahrain 0 0 0 0 1 4 Guatemala 0 0 1 1 1 2
Bangladesh 0 0 0 1 1 3 Guinea 0 0 0 0 0 1
Barbados 1 1 2 3 4 9 Guinea-Bissau 0 0 0 0 0 1
Belarus 1 2 2 3 4 6 Guyana 1 0 1 1 1 5
Belgium 1 2 4 5 6 10 Haiti 1 0 0 0 1 2
Belize 0 1 1 1 1 3 Honduras 1 0 0 1 1 3
Benin 1 0 0 0 0 1 Hungary 1 1 3 4 5 7
Bhutan 0 0 0 1 1 3 Iceland 1 2 3 3 5 8
Bolivia (Plurinational State of) 0 0 0 1 1 2 India 0 0 0 1 1 3
Bosnia and Herzegovina 1 1 1 3 5 10 Indonesia 0 0 0 1 2 5
Botswana 0 0 0 0 1 1 Iran (Islamic Republic of) 1 0 0 1 1 5
Brazil 0 0 1 1 3 7 Iraq 0 0 0 0 0 1
Brunei Darussalam 1 0 1 1 2 5 Ireland 2 2 2 3 5 7
Bulgaria 1 1 2 4 5 8 Israel 0 1 2 3 4 6
Burkina Faso 0 0 0 0 0 0 Italy 1 2 3 6 8 13
Burundi 0 0 0 0 0 1 Jamaica 0 1 2 2 3 7
Cambodia 0 0 0 0 1 2 Japan 0 1 2 6 13 15
Cameroon 0 0 0 0 1 1 Jordan 0 1 1 0 1 2
Canada 1 2 2 4 6 10 Kazakhstan 1 1 1 1 1 3
Cape Verde 1 1 1 1 1 4 Kenya 0 0 0 0 0 1
Central African Republic 0 0 0 0 1 1 Kuwait 0 0 0 0 0 2
Chad 0 0 0 0 0 0 Kyrgyzstan 1 1 1 1 1 2
Channel Islands 2 3 3 4 7 12 Lao People's Democratic Republic 0 0 0 1 1 2
Chile 0 1 1 2 4 8 Latvia 2 2 3 4 5 8
China 0 0 1 1 3 8 Lebanon 1 1 1 1 2 5
China, Hong Kong SAR 0 0 1 4 6 13 Lesotho 0 0 0 1 1 1
China, Macao SAR 0 1 1 2 3 10 Liberia 0 0 0 0 0 1
Colombia 0 0 1 1 2 5 Libyan Arab Jamahiriya 0 0 0 1 1 3
Comoros 0 0 0 0 0 1 Lithuania 2 2 3 4 5 8
Congo 0 0 0 1 1 1 Luxembourg 1 2 3 4 5 8
Costa Rica 1 1 1 1 3 7 Madagascar 0 0 0 0 1 1
Côte d'Ivoire 0 0 0 0 1 1 Malawi 0 0 0 0 0 0
Croatia 1 1 2 4 6 9 Malaysia 1 0 0 1 1 3
Cuba 1 1 2 3 6 13 Maldives 0 0 0 1 2 5
Cyprus 1 2 2 3 4 7 Mali 0 0 0 0 0 0
Czech Republic 1 1 2 4 6 8 Malta 1 1 2 3 7 9
Dem. People's Republic of Korea 0 0 0 1 2 4 Martinique 1 1 2 4 7 13
Democratic Republic of the Congo 1 0 0 0 0 1 Mauritania 0 0 0 0 0 1
Denmark 1 2 4 4 7 9 Mauritius 0 0 1 1 3 7

1950 1970 1990 2010 2030 2050 1950 1970 1990 2010 2030 2050
Mayotte 6 1 1 0 1 2 Togo 0 0 0 0 1 1
Mexico 1 1 1 1 2 6 Tonga 0 0 1 1 1 2
Micronesia (Fed. States of) 1 0 0 1 1 2 Trinidad and Tobago 0 1 1 1 3 6
Mongolia 0 1 1 1 1 3 Tunisia 1 0 1 1 2 5
Montenegro 1 2 2 2 4 6 Turkey 0 0 0 1 2 4
Morocco 0 1 0 1 1 4 Turkmenistan 1 1 1 1 1 3
Mozambique 0 0 0 0 1 1 Uganda 0 0 0 0 0 0
Myanmar 0 0 0 1 1 3 Ukraine 1 1 2 3 4 6
Namibia 0 0 0 1 1 2 United Arab Emirates 0 0 0 0 0 4
Nepal 0 0 0 0 1 2 United Kingdom 1 2 4 5 6 9
Netherlands 1 2 3 4 7 11 United Republic of Tanzania 0 0 0 0 1 1
Netherlands Antilles 1 1 2 2 4 10 United States of America 1 2 3 4 5 8
New Caledonia 0 0 1 2 3 6 United States Virgin Islands 1 1 1 3 8 11
New Zealand 1 2 2 3 5 9 Uruguay 1 1 2 4 5 7
Nicaragua 0 0 0 1 2 4 Uzbekistan 1 1 1 1 1 3
Niger 0 0 0 0 0 0 Vanuatu 0 0 1 0 1 2
Nigeria 0 0 0 0 0 1 Venezuela (Bolivarian Republic of) 0 0 1 1 2 4
Norway 2 2 4 5 6 9 Viet Nam 0 0 1 1 2 6
Occupied Palestinian Territory 0 0 0 0 1 1 Western Sahara 0 0 0 0 1 3
Oman 0 0 0 1 1 4 Yemen 0 0 0 0 0 1
Pakistan 1 1 0 1 1 2 Zambia 0 0 0 0 0 0
Panama 0 1 1 1 2 5 Zimbabwe 0 0 0 1 1 1
Papua New Guinea 0 0 0 0 1 1
Paraguay 0 0 1 1 2 3
Peru 0 0 1 1 2 4
Philippines 0 0 0 0 1 2
Poland 1 1 2 3 5 8
Portugal 1 2 3 5 7 12
Puerto Rico 0 1 2 3 5 9
Qatar 0 0 0 0 0 4
Republic of Korea 0 0 1 2 5 12
Republic of Moldova 1 1 1 2 3 6
Réunion 0 1 1 2 3 7
Romania 1 1 2 3 4 8
Russian Federation 1 1 2 3 4 6
Rwanda 0 0 0 0 0 1
Saint Lucia 1 0 1 2 2 6
Saint Vincent and the Grenadines 1 1 1 1 2 4
Samoa 0 0 0 1 1 3
Sao Tome and Principe 1 1 1 1 1 1
Saudi Arabia 0 0 1 1 1 2
Senegal 0 0 0 0 0 0
Serbia 1 1 2 3 4 6
Sierra Leone 0 0 0 0 0 0
Singapore 0 0 1 2 5 13
Slovakia 1 1 2 3 4 7
Slovenia 1 1 2 4 6 10
Solomon Islands 0 0 0 0 1 1
Somalia 0 0 0 0 0 1
South Africa 0 0 0 1 1 2
Spain 1 2 3 5 7 12
Sri Lanka 2 1 1 1 3 6
Sudan 0 0 0 0 1 1
Suriname 1 1 1 1 2 5
Swaziland 0 0 0 0 1 1
Sweden 2 2 4 5 8 10
Switzerland 1 2 4 5 8 13
Syrian Arab Republic 0 1 1 1 1 3
Tajikistan 0 1 1 1 1 2
TFYR Macedonia 1 1 1 2 4 7
Thailand 0 0 1 2 3 8
Timor-Leste 0 0 0 0 0 1

Table 3A: Average annual growth rate of total population (percent)
1950 1970 1990 2010 2030 1950 1970 1990 2010 2030
- 1970 - 1990 - 2010 - 2030 - 2050 - 1970 - 1990 - 2010 - 2030 - 2050
World 1,9 1,8 1,3 0,9 0,6 Denmark 0,7 0,2 0,4 0,3 0,0
Djibouti 4,8 6,2 2,3 1,8 1,2
More developed regions 1,1 0,6 0,4 0,2 0,1 Dominican Republic 3,2 2,3 1,6 1,0 0,4
Less developed regions 2,2 2,2 1,5 1,1 0,6 Ecuador 2,8 2,7 1,7 1,1 0,4
Egypt 2,6 2,3 1,8 1,4 0,7
Africa 2,4 2,7 2,4 2,1 1,7 El Salvador 2,6 1,8 0,7 0,7 0,4
Asia 2,1 2,0 1,3 0,8 0,3 Equatorial Guinea 1,3 1,3 3,1 2,3 1,5
Europe 0,9 0,5 0,1 0,0 -0,2 Eritrea 2,4 2,7 2,5 2,3 1,6
Latin America & Caribbean 2,7 2,2 1,4 0,9 0,3 Estonia 1,1 0,7 -0,8 -0,2 -0,3
Northern America 1,5 1,0 1,0 0,8 0,5 Ethiopia 2,3 2,6 2,7 1,8 1,0
Oceania 2,2 1,6 1,5 1,3 0,8 Fiji 2,9 1,7 0,8 0,5 0,3
Finland 0,7 0,4 0,4 0,2 0,0
Afghanistan 1,9 0,4 4,4 2,6 1,8 France 1,0 0,6 0,5 0,4 0,3
Albania 2,8 2,2 -0,1 0,1 -0,5 French Guiana 3,2 4,4 3,4 2,3 1,6
Algeria 2,3 3,1 1,7 1,0 0,3 French Polynesia 3,0 2,8 1,6 0,8 0,2
Angola 1,8 2,8 3,1 2,4 1,6 Gabon 0,6 2,8 2,4 1,8 1,3
Argentina 1,7 1,5 1,1 0,7 0,4 Gambia 2,6 3,7 2,9 2,4 1,8
Armenia 3,1 1,7 -0,7 0,0 -0,3 Georgia 1,4 0,7 -1,1 -0,7 -0,8
Aruba 2,2 0,3 2,7 0,2 -0,4 Germany 0,7 0,1 0,2 -0,2 -0,3
Australia 2,2 1,5 1,3 1,1 0,6 Ghana 2,8 2,7 2,5 2,0 1,5
Austria 0,4 0,1 0,5 0,1 -0,1 Greece 0,8 0,7 0,6 0,1 0,0
Azerbaijan 2,9 1,7 1,2 0,8 0,3 Grenada 1,0 0,1 0,4 0,1 -0,6
Bahamas 3,8 2,1 1,5 1,0 0,4 Guadeloupe 2,1 0,9 0,9 0,3 -0,1
Bahrain 3,0 4,2 4,7 1,4 0,4 Guam 1,8 2,2 1,5 1,0 0,5
Bangladesh 2,8 2,3 1,7 1,0 0,3 Guatemala 2,7 2,5 2,4 2,3 1,6
Barbados 0,6 0,4 0,3 0,1 -0,3 Guinea 1,5 1,6 2,7 2,3 1,8
Belarus 0,8 0,6 -0,3 -0,4 -0,5 Guinea-Bissau 0,8 2,6 2,0 2,0 1,7
Belgium 0,5 0,2 0,4 0,2 0,2 Guyana 2,9 0,0 0,2 0,3 -0,2
Belize 2,9 2,2 2,5 1,7 0,9 Haiti 1,9 2,1 1,7 1,1 0,6
Benin 1,2 2,6 3,1 2,5 2,0 Honduras 3,0 3,0 2,2 1,7 1,0
Bhutan 2,9 3,1 1,3 1,1 0,3 Hungary 0,5 0,0 -0,2 -0,2 -0,2
Bolivia (Plurinational State of) 2,2 2,3 2,0 1,5 1,1 Iceland 1,8 1,1 1,1 1,0 0,5
Bosnia and Herzegovina 1,5 0,9 -0,7 -0,4 -0,8 India 2,0 2,3 1,7 1,1 0,5
Botswana 2,6 3,5 1,9 0,8 0,3 Indonesia 2,3 2,2 1,3 0,8 0,2
Brazil 2,9 2,2 1,3 0,6 0,1 Iran (Islamic Republic of) 2,5 3,2 1,5 0,7 0,1
Brunei Darussalam 4,8 3,5 2,3 1,3 0,7 Iraq 2,8 2,8 3,0 2,8 2,1
Bulgaria 0,8 0,2 -0,8 -0,7 -0,8 Ireland 0,1 0,9 1,2 0,9 0,6
Burkina Faso 1,5 2,4 2,8 2,8 2,4 Israel 4,1 2,3 2,5 1,4 1,0
Burundi 1,8 2,3 2,0 1,6 0,9 Italy 0,7 0,3 0,3 0,0 -0,1
Cambodia 2,3 1,6 2,0 1,0 0,4 Jamaica 1,4 1,2 0,7 0,2 -0,5
Cameroon 2,1 2,9 2,4 1,9 1,4 Japan 1,2 0,8 0,2 -0,3 -0,5
Canada 2,3 1,2 1,0 0,8 0,5 Jordan 6,6 3,6 3,0 1,5 0,8
Cape Verde 2,2 1,2 1,8 0,9 0,4 Kazakhstan 3,4 1,2 -0,2 0,8 0,6
Central African Republic 1,6 2,4 2,0 1,8 1,4 Kenya 3,1 3,7 2,7 2,4 1,9
Chad 2,0 2,5 3,1 2,5 2,0 Kuwait 8,0 5,1 1,4 1,9 1,3
Channel Islands 0,8 0,7 0,5 0,1 -0,2 Kyrgyzstan 2,7 2,0 1,0 1,1 0,8
Chile 2,3 1,6 1,3 0,7 0,1 Lao People's Democratic Republic 2,3 2,2 2,0 1,1 0,4
China 2,0 1,7 0,8 0,2 -0,4 Latvia 1,0 0,6 -0,8 -0,4 -0,4
China, Hong Kong SAR 3,5 1,9 1,0 0,9 0,5 Lebanon 2,7 0,9 1,8 0,5 0,0
China, Macao SAR 1,2 1,8 2,1 1,6 0,5 Lesotho 1,7 2,3 1,4 0,8 0,4
Colombia 2,9 2,2 1,7 1,0 0,4 Liberia 2,3 2,0 3,2 2,5 2,0
Comoros 2,1 3,0 2,6 2,3 1,9 Libyan Arab Jamahiriya 3,3 3,9 1,9 1,0 0,6
Congo 2,5 2,9 2,6 2,1 1,8 Lithuania 1,0 0,8 -0,5 -0,4 -0,4
Costa Rica 3,2 2,6 2,1 1,0 0,3 Luxembourg 0,7 0,6 1,4 1,1 0,5
Côte d'Ivoire 3,6 4,2 2,3 2,1 1,6 Madagascar 2,4 2,7 3,0 2,7 2,1
Croatia 0,4 0,4 -0,1 -0,3 -0,4 Malawi 2,3 3,6 2,3 3,2 2,8
Cuba 1,9 1,0 0,3 -0,1 -0,5 Malaysia 2,9 2,6 2,2 1,4 0,8
Cyprus 1,1 1,1 1,8 0,8 0,2 Maldives 2,3 3,2 1,8 1,0 0,3
Czech Republic 0,5 0,3 0,1 0,1 -0,1 Mali 1,3 1,8 2,9 2,8 2,3
Dem. People's Republic of Korea 1,9 1,7 0,9 0,4 0,0 Malta -0,1 1,0 0,6 0,2 -0,2
Democratic Republic of the Congo 2,5 2,9 3,0 2,4 1,7 Martinique 1,9 0,5 0,6 0,1 -0,4

1950 1970 1990 2010 2030 1950 1970 1990 2010 2030
- 1970 - 1990 - 2010 - 2030 - 2050 - 1970 - 1990 - 2010 - 2030 - 2050
Mauritania 2,7 2,8 2,8 2,0 1,5 TFYR Macedonia 1,2 1,0 0,4 0,0 -0,4
Mauritius 2,6 1,2 1,0 0,4 -0,1 Thailand 2,9 2,2 1,0 0,3 -0,2
Mayotte 4,4 4,6 4,0 2,6 1,8 Timor-Leste 1,7 1,0 2,1 2,9 2,1
Mexico 3,1 2,4 1,5 0,9 0,3 Togo 2,0 2,8 2,5 1,8 1,2
Micronesia (Fed. States of) 3,3 2,2 0,7 0,7 0,4 Tonga 2,9 0,6 0,4 0,7 0,7
Mongolia 2,5 2,7 1,1 1,2 0,7 Trinidad and Tobago 2,1 1,1 0,5 0,0 -0,2
Montenegro 1,3 0,8 0,2 0,0 -0,2 Tunisia 1,9 2,4 1,2 0,8 0,2
Morocco 2,7 2,4 1,3 0,8 0,2 Turkey 2,6 2,1 1,5 0,9 0,3
Mozambique 1,9 1,8 2,7 2,1 1,7 Turkmenistan 3,0 2,6 1,6 1,0 0,4
Myanmar 2,1 2,0 1,0 0,6 0,1 Uganda 3,0 3,1 3,2 2,9 2,3
Namibia 2,4 3,0 2,4 1,4 0,8 Ukraine 1,2 0,4 -0,6 -0,6 -0,6
Nepal 1,9 2,4 2,3 1,4 0,8 United Arab Emirates 6,0 10,3 7,1 1,7 0,7
Netherlands 1,3 0,7 0,5 0,2 0,0 United Kingdom 0,5 0,1 0,4 0,6 0,2
Netherlands Antilles 1,8 0,9 0,3 0,3 -0,4 United Republic of Tanzania 2,9 3,1 2,8 3,0 2,6
New Caledonia 2,4 2,4 2,0 1,1 0,4 United States of America 1,4 1,0 1,0 0,8 0,5
New Zealand 2,0 0,9 1,3 0,9 0,4 United States Virgin Islands 4,4 2,4 0,3 -0,3 -0,5
Nicaragua 3,1 2,7 1,7 1,1 0,4 Uruguay 1,1 0,5 0,4 0,3 0,1
Niger 2,9 2,9 3,4 3,4 2,9 Uzbekistan 3,2 2,7 1,5 1,0 0,3
Nigeria 2,1 2,7 2,4 2,4 2,1 Vanuatu 2,9 2,7 2,5 2,2 1,6
Norway 0,9 0,4 0,7 0,7 0,4 Venezuela (Bolivarian Republic of) 3,7 3,1 1,9 1,2 0,6
Occupied Palestinian Territory 0,9 3,1 3,3 2,6 1,8 Viet Nam 2,3 2,0 1,3 0,7 0,1
Oman 2,4 4,7 2,0 1,3 0,2 Western Sahara 8,6 5,3 4,4 2,1 0,6
Pakistan 2,3 3,2 2,2 1,5 0,8 Yemen 1,8 3,3 3,5 2,7 2,0
Panama 2,8 2,4 1,9 1,2 0,7 Zambia 2,9 3,2 2,5 3,1 3,0
Papua New Guinea 1,8 2,7 2,5 2,0 1,4 Zimbabwe 3,2 3,5 0,9 1,7 0,8
Paraguay 2,6 2,7 2,1 1,5 0,9
Peru 2,7 2,5 1,5 1,0 0,4
Philippines 3,3 2,8 2,1 1,5 1,0
Poland 1,4 0,8 0,0 -0,1 -0,4
Portugal 0,2 0,7 0,4 -0,2 -0,5
Puerto Rico 1,0 1,3 0,3 0,0 -0,1
Qatar 7,3 7,4 6,6 1,5 0,5
Republic of Korea 2,5 1,6 0,6 0,2 -0,3
Republic of Moldova 2,1 1,0 -1,0 -0,6 -0,8
Réunion 3,1 1,4 1,6 0,9 0,4
Romania 1,1 0,7 -0,4 -0,3 -0,5
Russian Federation 1,2 0,6 -0,2 -0,2 -0,4
Rwanda 3,0 3,2 2,0 2,5 2,0
Saint Lucia 1,1 1,4 1,2 0,7 0,1
Saint Vincent and the Grenadines 1,5 0,9 0,1 0,1 0,1
Samoa 2,8 0,6 0,6 0,5 0,4
Sao Tome and Principe 1,0 2,3 1,8 1,7 1,2
Saudi Arabia 3,1 5,1 2,7 1,7 0,8
Senegal 2,6 2,8 2,7 2,4 1,8
Serbia 1,0 0,8 0,1 -0,2 -0,4
Sierra Leone 1,6 2,1 1,9 1,9 1,3
Singapore 3,5 1,9 2,6 0,8 0,1
Slovakia 1,4 0,8 0,2 0,1 -0,3
Slovenia 0,6 0,7 0,3 0,1 -0,2
Solomon Islands 2,9 3,3 2,8 2,2 1,6
Somalia 2,3 3,0 1,7 2,8 2,7
South Africa 2,5 2,5 1,5 0,4 0,2
Spain 0,9 0,7 0,8 0,4 0,1
Sri Lanka 2,1 1,6 0,9 0,5 0,0
Sudan 2,4 2,9 2,5 2,1 1,5
Suriname 2,7 0,4 1,3 0,7 0,1
Swaziland 2,5 3,3 1,6 1,0 0,7
Sweden 0,7 0,3 0,5 0,5 0,3
Switzerland 1,4 0,4 0,7 0,3 -0,1
Syrian Arab Republic 3,1 3,3 2,5 1,6 0,9
Tajikistan 3,3 2,9 1,3 1,4 0,9

Table 3B: Average annual growth rate of population aged 60 and older (percent)
1950 1970 1990 2010 2030 1950 1970 1990 2010 2030
- 1970 - 1990 - 2010 - 2030 - 2050 - 1970 - 1990 - 2010 - 2030 - 2050
World 2,0 2,3 2,2 3,0 1,9 Denmark 2,1 0,9 1,0 1,4 0,2
Djibouti 5,0 6,8 3,8 3,5 3,7
Egypt 2,7 2,8 3,2 3,6 3,1
Europe 2,1 1,3 1,0 1,4 0,6 Eritrea 1,3 2,9 2,3 2,8 5,8
Latin America & Caribbean 3,3 3,0 3,0 3,5 2,3 Estonia 1,7 0,8 0,6 0,7 0,7
Oceania 1,9 2,6 2,4 2,6 1,6 Fiji 2,1 2,8 3,4 3,6 1,9
Finland 2,4 1,7 1,8 1,4 0,0
Albania 0,7 3,0 2,5 2,8 1,6 French Guiana 2,4 3,0 4,4 5,4 2,6
Angola 1,3 2,4 2,7 3,6 3,8 Gabon 0,4 1,4 1,3 3,4 3,2
Armenia 1,2 2,6 1,2 2,2 1,1 Georgia 0,4 1,8 0,1 1,2 0,3
Aruba 6,5 2,3 4,3 3,7 -0,2 Germany 2,2 0,2 1,4 1,5 -0,1
Australia 2,1 2,6 2,3 2,5 1,4 Ghana 3,2 3,0 3,5 3,5 3,6
Austria 1,7 0,2 1,1 1,9 0,4 Greece 3,2 1,7 1,5 1,3 0,8
Azerbaijan 1,3 1,2 2,1 4,4 2,0 Grenada 1,2 1,8 -0,4 2,4 2,7
Bahamas 2,8 2,9 3,9 4,3 1,9 Guadeloupe 2,5 3,2 3,0 2,8 0,5
Bahrain 2,8 3,4 4,2 8,8 4,2 Guam 3,4 6,1 4,0 3,8 1,3
Barbados 2,4 0,9 1,2 2,8 0,6 Guinea -0,5 1,6 2,5 3,1 3,6
Belarus 1,0 1,8 0,2 1,2 0,7 Guinea-Bissau 0,6 2,5 1,7 2,3 3,7
Belgium 1,4 0,6 1,0 1,5 0,3 Guyana 1,9 1,4 -0,1 4,5 1,8
Belize 3,3 1,6 2,3 5,0 3,6 Haiti 2,3 2,0 2,2 2,6 3,4
Benin -1,0 0,9 2,6 3,5 3,8 Honduras 1,7 3,3 3,2 3,9 3,8
Bhutan 3,0 4,2 2,6 3,6 4,0 Hungary 2,4 0,5 0,7 0,6 0,8
Bosnia and Herzegovina 2,7 2,5 2,4 1,9 0,6 India 2,0 2,8 2,8 3,5 2,7
Bulgaria 2,6 1,5 0,4 0,1 0,3 Ireland 0,2 0,7 1,6 2,6 1,7
Burundi 1,9 1,8 1,7 3,4 4,1 Italy 2,2 1,5 1,6 1,3 0,4
Cambodia 2,4 1,5 3,6 3,8 3,2 Jamaica 3,3 1,9 1,1 3,1 1,1
Cameroon 2,2 2,6 2,3 2,6 3,6 Japan 2,7 3,3 3,0 0,7 0,0
Canada 2,3 2,8 2,3 2,7 0,8 Jordan 4,8 3,5 3,5 3,6 4,4
Cape Verde 0,3 1,3 1,6 3,9 3,3 Kazakhstan 2,3 1,9 0,0 2,9 1,9
Chad 1,5 1,9 2,2 2,8 3,8 Kuwait 5,8 5,0 3,3 6,2 5,5
Channel Islands 1,6 0,7 1,3 2,0 0,1 Kyrgyzstan 1,0 1,6 -0,4 4,1 2,8
China 1,3 3,2 2,4 3,6 1,3 Latvia 1,5 0,6 0,5 0,5 0,7
Congo 2,7 2,7 2,5 2,9 3,5 Lithuania 1,6 1,1 0,8 0,8 0,5
Croatia 1,8 1,1 1,4 1,0 0,3 Malawi 0,7 4,4 3,1 2,3 4,0
Cuba 3,2 2,4 2,0 3,0 0,5 Malaysia 1,4 2,8 3,8 4,6 2,4
Cyprus 3,3 0,9 2,7 2,6 1,8 Maldives 1,4 4,0 3,5 4,5 4,3
Czech Republic 2,4 0,2 1,1 1,3 1,0 Mali 1,1 2,1 1,3 3,1 4,5
Dem. People's Republic of Korea -0,5 7,6 3,8 1,9 1,1 Malta 1,5 1,3 2,8 1,9 0,8
Democratic Republic of the Congo 1,6 2,8 2,7 2,9 3,9 Martinique 2,1 3,1 2,6 2,5 0,2

1950 1970 1990 2010 2030 1950 1970 1990 2010 2030
- 1970 - 1990 - 2010 - 2030 - 2050 - 1970 - 1990 - 2010 - 2030 - 2050
Mauritania 4,3 3,4 2,8 3,9 3,8 TFYR Macedonia 0,0 2,3 2,3 2,0 1,1
Mauritius 2,1 3,7 3,3 3,8 1,4 Thailand 3,2 3,8 3,8 3,5 1,2
Mayotte 1,2 1,8 2,2 6,5 4,7 Timor-Leste 0,4 -0,2 3,8 3,2 3,6
Mexico 3,3 3,2 3,1 3,9 2,5 Togo 0,5 2,6 2,9 3,2 3,8
Mongolia 3,2 1,6 0,7 4,8 3,4 Trinidad and Tobago 2,5 2,1 1,9 3,4 1,9
Montenegro 1,5 1,7 1,8 1,6 0,9 Tunisia 0,5 3,1 2,9 3,5 2,7
Morocco 4,2 2,5 2,6 3,8 2,6 Turkey 3,3 2,3 3,2 3,9 2,6
Myanmar 2,5 2,7 1,6 3,8 2,5 Uganda 2,5 3,2 2,6 2,8 4,3
Namibia 1,6 2,7 2,7 3,5 3,1 Ukraine 2,4 1,9 -0,1 0,4 0,6
Netherlands Antilles 1,4 2,0 2,4 3,2 1,4 United Republic of Tanzania 3,3 3,4 3,4 3,0 4,0
New Zealand 1,7 1,9 2,2 2,6 0,9 United States Virgin Islands 1,1 4,9 4,4 1,7 -0,8
Niger 5,7 4,0 3,9 3,9 3,7 Uzbekistan 3,0 1,2 1,3 4,4 3,1
Nigeria 2,1 2,6 2,6 2,6 3,6 Vanuatu 3,2 3,5 2,6 4,4 3,7
Occupied Palestinian Territory -1,7 1,9 4,5 4,4 4,3 Viet Nam 2,6 1,9 2,1 4,6 2,7
Pakistan 0,8 3,2 2,7 3,2 3,5 Yemen 0,2 1,9 4,3 3,5 5,0
Panama 2,8 2,9 3,3 3,9 2,4 Zambia 2,8 3,3 2,8 1,7 3,9
Papua New Guinea -0,5 2,9 3,3 4,0 3,7 Zimbabwe 2,8 3,1 2,2 1,2 5,0
Paraguay 3,5 3,3 3,2 3,5 3,0
Peru 2,7 3,0 3,2 3,5 2,7
Philippines 2,7 2,5 3,1 4,3 3,1
Poland 3,6 1,5 1,3 1,6 0,9
Portugal 1,8 2,1 1,5 1,4 0,6
Puerto Rico 3,2 3,0 1,8 1,6 1,1
Qatar 4,3 5,7 5,7 9,3 6,3
Republic of Korea 2,7 3,3 4,2 3,6 0,8
Republic of Moldova 1,4 2,4 0,1 1,4 0,9
Réunion 2,6 3,6 3,2 3,8 1,4
Romania 3,2 1,5 0,9 1,1 1,0
Rwanda 2,2 3,0 2,6 3,4 4,5
Saint Lucia 1,9 3,3 0,9 3,5 2,7
Samoa 1,1 4,4 1,6 3,0 0,7
Saudi Arabia 2,8 3,6 3,4 5,4 5,0
Senegal 1,1 3,1 2,4 3,3 4,6
Serbia 1,8 1,6 1,4 1,0 0,9
Sierra Leone 1,4 1,6 0,7 3,1 3,8
Singapore 5,6 3,8 5,2 4,8 1,0
Slovakia 3,0 1,0 1,1 2,0 1,3
Slovenia 2,3 1,2 1,9 1,8 0,6
Somalia 2,6 2,8 1,4 3,6 3,4
South Africa 2,1 2,1 3,3 2,5 1,7
Spain 2,2 2,2 1,6 2,0 1,3
Sri Lanka -1,5 3,4 2,8 3,1 1,5
Sudan 1,7 3,1 3,2 3,4 3,6
Suriname 0,9 1,6 2,5 3,5 2,0
Swaziland 2,4 3,0 2,6 1,7 2,4
Sweden 2,0 1,1 0,9 1,2 0,6
Switzerland 2,2 1,3 1,5 2,0 0,5
Tajikistan 3,3 2,0 0,1 4,3 3,2

Table 3C: Average annual growth rate of population aged 80 and older (percent)
1950 1970 1990 2010 2030 1950 1970 1990 2010 2030
- 1970 - 1990 - 2010 - 2030 - 2050 - 1970 - 1990 - 2010 - 2030 - 2050
World 2,8 3,9 3,1 3,1 3,6 Denmark 3,3 3,2 0,9 2,8 1,5
Djibouti 5,7 7,6 4,6 4,5 4,2
Egypt 5,0 3,8 4,9 4,9 4,3
Europe 2,8 3,2 2,1 1,8 2,1 Eritrea 1,7 4,5 1,7 4,6 3,9
Latin America & Caribbean 3,3 4,7 4,4 3,8 4,1 Estonia 1,4 2,2 1,7 1,3 1,2
Oceania 2,8 3,7 3,8 3,2 2,8 Fiji -0,6 3,7 2,5 6,4 4,6
Finland 2,7 5,1 2,9 3,0 1,1
Albania 1,7 2,8 2,9 3,9 3,5 French Guiana 4,8 2,7 4,4 5,4 5,9
Angola -0,5 4,1 3,8 3,9 4,7 Gabon 0,8 3,0 2,4 2,2 4,3
Armenia 2,9 1,6 3,7 0,6 3,6 Georgia 2,4 0,9 1,7 0,7 2,4
Aruba 3,0 8,0 1,6 4,7 4,3 Germany 4,0 3,3 1,8 2,1 2,3
Australia 2,9 3,8 3,9 3,1 2,6 Ghana 4,5 4,0 4,4 4,4 4,3
Austria 3,2 2,8 1,9 2,1 2,6 Greece 4,2 2,7 2,9 1,7 2,1
Azerbaijan 5,2 -2,7 4,9 1,3 6,6 Grenada -0,6 2,2 2,7 0,1 4,0
Bahamas 3,1 3,1 4,5 5,1 4,8 Guadeloupe 5,3 4,0 4,5 3,0 3,3
Bahrain 6,2 2,6 3,9 4,7 10,4 Guam 3,8 5,8 5,9 4,6 4,4
Barbados 1,9 3,5 1,7 1,7 3,5 Guinea -0,9 2,1 4,5 3,3 4,1
Belarus 1,9 2,5 1,2 0,3 2,3 Guinea-Bissau 0,0 3,7 2,8 3,2 2,8
Belgium 2,5 2,8 2,1 1,5 2,1 Guyana 1,3 4,0 -1,2 4,0 5,7
Belize 5,4 3,2 3,4 3,0 6,0 Haiti -0,8 3,5 2,8 3,3 4,1
Benin -2,2 2,3 2,2 3,7 4,5 Honduras -1,7 4,4 5,6 3,7 4,7
Bhutan 3,4 5,1 5,5 3,9 4,9 Hungary 3,1 2,8 1,9 1,4 1,1
Bosnia and Herzegovina 1,7 3,6 4,6 2,6 2,8 India 1,5 3,6 3,9 4,0 4,4
Bulgaria 4,4 2,4 1,9 1,0 0,9 Ireland 1,5 1,3 2,3 3,4 3,0
Burundi 1,9 4,0 1,9 2,9 4,3 Italy 3,3 3,4 3,2 1,9 2,0
Cambodia 2,1 1,9 4,9 4,6 4,9 Jamaica 7,3 4,8 1,5 1,5 4,4
Cameroon 3,4 3,8 2,6 3,0 3,5 Japan 4,8 5,6 5,1 3,2 0,2
Canada 4,1 3,2 3,6 3,0 2,8 Jordan 8,6 4,5 0,8 4,6 5,1
Cape Verde -1,3 3,2 3,5 1,2 5,7 Kazakhstan 3,9 2,5 0,2 1,7 4,2
Chad 1,2 2,9 2,5 2,9 4,2 Kuwait 6,1 8,9 1,6 5,2 8,7
Channel Islands 2,0 2,3 1,2 3,0 2,4 Kyrgyzstan 2,8 1,8 0,9 0,3 6,3
China 2,1 7,1 3,1 3,8 4,6 Latvia 1,5 2,1 1,1 0,9 1,3
Congo 4,5 3,7 2,8 2,9 3,9 Lithuania 1,5 3,0 1,2 0,9 1,9
Croatia 0,5 3,1 3,0 1,9 1,7 Malawi 0,8 4,7 4,5 4,4 2,7
Cuba 2,6 5,8 2,3 3,2 3,8 Malaysia 1,2 2,9 3,0 5,9 5,2
Cyprus 6,5 1,9 2,8 3,3 2,8 Maldives 0,3 2,7 7,2 5,4 6,2
Czech Republic 2,6 2,7 2,0 2,8 1,2 Mali -0,2 3,8 2,9 3,4 5,4
Dem. People's Republic of Korea 0,9 3,4 7,2 3,4 3,7 Malta 3,1 3,5 3,1 3,9 1,5
Democratic Republic of the Congo -2,5 3,4 2,9 3,4 4,0 Martinique 2,9 6,3 3,8 2,7 3,0

1950 1970 1990 2010 2030 1950 1970 1990 2010 2030
- 1970 - 1990 - 2010 - 2030 - 2050 - 1970 - 1990 - 2010 - 2030 - 2050
Mauritania 7,0 5,0 3,7 4,4 5,8 TFYR Macedonia -0,1 1,4 3,3 2,7 2,8
Mauritius 1,6 4,7 5,6 4,0 4,4 Thailand 3,1 5,1 4,9 3,7 4,0
Mayotte -5,8 3,5 2,9 4,2 7,1 Timor-Leste 1,9 -1,3 4,8 5,3 4,0
Mexico 2,1 4,6 4,1 3,8 4,7 Togo 1,6 2,8 3,7 3,7 4,1
Mongolia 6,2 3,9 0,9 3,0 6,4 Trinidad and Tobago 3,8 2,5 2,3 3,6 4,1
Montenegro 3,0 1,6 1,4 2,5 2,3 Tunisia -3,9 5,9 4,7 3,0 4,9
Morocco 10,3 -0,4 3,8 3,6 5,1 Turkey 2,8 4,9 4,2 4,4 4,9
Myanmar 3,2 4,0 3,2 2,6 5,4 Uganda 3,1 3,4 4,0 3,4 3,6
Namibia 3,3 2,9 3,8 4,0 4,1 Ukraine 1,9 3,3 1,0 0,2 1,6
Netherlands Antilles 0,5 5,0 2,1 3,4 3,8 United Republic of Tanzania 4,8 4,3 4,3 4,6 3,6
New Zealand 3,5 2,9 3,5 3,1 2,8 United States Virgin Islands 2,2 2,7 6,6 5,3 1,1
Niger -0,8 8,2 4,3 5,8 5,1 Uzbekistan 5,0 3,1 1,5 1,7 6,0
Nigeria 3,8 3,3 3,3 3,7 3,4 Vanuatu 4,4 5,9 1,0 4,6 5,7
Occupied Palestinian Territory 0,3 1,2 4,2 5,7 5,6 Viet Nam 3,8 4,3 4,0 3,0 5,9
Pakistan -0,6 2,4 3,2 3,3 4,2 Yemen 1,0 2,5 4,9 4,1 4,8
Panama 4,6 3,8 3,9 4,3 4,5 Zambia 3,5 4,1 3,3 3,8 2,2
Papua New Guinea -1,3 3,1 4,2 4,8 5,2 Zimbabwe 5,3 3,7 3,4 3,0 1,1
Paraguay 3,6 4,2 4,8 3,9 3,9
Peru 2,6 5,4 4,8 4,2 4,2
Philippines 3,1 3,4 2,5 5,1 5,6
Poland 2,7 4,4 2,7 1,9 1,8
Portugal 2,3 3,5 2,8 2,1 1,9
Puerto Rico 6,3 3,4 2,6 2,4 2,2
Qatar 6,5 7,6 3,7 6,1 13,1
Republic of Korea 2,1 4,4 6,1 5,1 4,0
Republic of Moldova 1,3 2,4 1,9 1,1 2,6
Réunion 4,2 4,8 4,3 3,6 4,4
Romania 4,1 3,2 2,4 1,6 2,1
Rwanda 4,4 2,6 4,0 4,1 4,0
Saint Lucia -2,1 6,2 3,3 2,2 4,8
Samoa -0,7 5,1 4,7 2,5 4,3
Saudi Arabia 7,6 6,2 2,4 3,6 5,5
Senegal -1,0 2,5 3,0 4,2 6,2
Serbia 0,7 2,5 3,7 1,0 2,1
Sierra Leone 2,2 0,4 -1,7 4,9 6,3
Singapore 2,1 7,4 5,8 5,9 4,9
Slovakia 2,6 3,5 2,0 2,2 2,4
Slovenia 1,4 4,1 3,1 2,4 2,2
Somalia 5,3 4,5 2,1 3,4 4,8
South Africa 4,9 1,7 3,6 4,3 2,9
Spain 2,9 4,0 3,4 2,0 2,8
Sri Lanka -5,6 4,1 3,8 4,3 3,4
Sudan 2,9 3,0 3,6 4,5 4,4
Suriname -0,3 3,1 2,4 3,3 4,6
Swaziland 4,4 3,5 3,5 3,2 1,5
Sweden 2,8 3,3 1,5 2,4 1,3
Switzerland 3,6 4,1 2,0 2,6 2,5
Tajikistan 6,3 3,1 0,5 1,5 6,3

Table 4A: Percentage of population aged 60 and older (country rankings)
2012 2030 2050 2012 2030 2050
Japan 1 1 1 Thailand 63 56 45
Italy 2 3 7 Albania 64 63 31
Germany 3 2 11 Dem. People's Republic of Korea 65 71 100
Finland 4 15 48 China 66 54 30
Sweden 5 28 55 Sri Lanka 67 68 79
Bulgaria 6 23 19 China, Macao SAR 68 42 9
Greece 7 17 21 New Caledonia 69 73 86
Portugal 8 7 2 Réunion 70 66 88
Croatia 9 20 26 Mauritius 71 65 65
Channel Islands 10 4 22 Guam 72 74 112
Belgium 11 22 52 Trinidad and Tobago 73 67 46
Denmark 12 27 62 Bahamas 74 69 75
France 13 24 56 Jamaica 75 75 85
Austria 14 5 17 Brazil 76 72 67
Slovenia 15 12 14 Lebanon 77 82 76
Switzerland 16 8 13 Tunisia 78 83 71
Hungary 17 41 38 Kazakhstan 79 93 122
Estonia 18 39 37 Costa Rica 80 70 61
Latvia 19 35 28 Panama 81 89 101
United Kingdom 20 34 63 French Polynesia 82 77 82
Czech Republic 21 32 27 Saint Vincent and the Grenadines 83 81 95
Netherlands 22 14 44 El Salvador 84 108 116
Spain 23 18 8 Grenada 85 96 66
Malta 24 21 15 Saint Lucia 86 85 78
United States Virgin Islands 25 10 60 Suriname 87 87 96
Norway 26 36 68 Turkey 88 86 84
Lithuania 27 38 41 Mexico 89 84 87
Ukraine 28 45 43 Ecuador 90 92 98
Romania 29 40 20 Dominican Republic 91 100 111
Canada 30 25 51 Peru 92 103 105
Martinique 31 9 16 Colombia 93 88 97
Serbia 32 47 39 Venezuela (Bolivarian Republic of) 94 97 109
Poland 33 37 24 Azerbaijan 95 80 91
Bosnia and Herzegovina 34 19 3 Viet Nam 96 78 53
Georgia 35 30 23 Morocco 97 99 93
Australia 36 49 69 Indonesia 98 90 89
China, Hong Kong SAR 37 6 12 Myanmar 99 94 92
Luxembourg 38 52 64 Fiji 100 102 119
United States of America 39 46 81 Egypt 101 111 120
New Zealand 40 43 74 Malaysia 102 101 118
Belarus 41 48 40 Tonga 103 129 145
Russian Federation 42 53 50 Paraguay 104 122 129
Uruguay 43 64 80 India 105 113 123
Puerto Rico 44 51 47 Iran (Islamic Republic of) 106 91 34
Montenegro 45 55 54 South Africa 107 125 138
Slovakia 46 44 25 Samoa 108 115 147
Guadeloupe 47 29 35 French Guiana 109 110 133
Cuba 48 11 5 Bolivia (Plurinational State of) 110 131 137
TFYR Macedonia 49 50 29 Cape Verde 111 109 99
Iceland 50 57 72 Bhutan 112 121 94
Barbados 51 31 33 Algeria 113 107 83
Ireland 52 60 73 Guyana 114 98 108
Cyprus 53 59 36 Maldives 115 106 49
Republic of Moldova 54 58 32 Libyan Arab Jamahiriya 116 119 103
Republic of Korea 55 16 6 Bangladesh 117 117 107
Netherlands Antilles 56 33 4 Haiti 118 140 135
Singapore 57 13 10 Gabon 119 139 142
Israel 58 76 106 Nicaragua 120 123 115
Aruba 59 26 59 Botswana 121 147 143
Armenia 60 62 58 Cambodia 122 126 124
Argentina 61 79 90 Pakistan 123 138 134
Chile 62 61 57 Guatemala 124 150 155

2012 2030 2050 2012 2030 2050
Uzbekistan 125 112 114 Niger 187 192 195

Brunei Darussalam 126 105 102 Bahrain 188 95 42
Micronesia (Fed. States of) 127 135 139 Afghanistan 189 191 188
Kyrgyzstan 128 124 130 Burkina Faso 190 190 189
Honduras 129 133 131 Sierra Leone 191 188 182
Nepal 130 136 132 Gambia 192 184 178
Turkmenistan 131 118 121 Mali 193 195 191
Lesotho 132 172 168 Mayotte 194 156 154
Syrian Arab Republic 133 128 128 Qatar 195 144 77
Philippines 134 130 136 United Arab Emirates 196 114 18
Lao People's Democratic Republic 135 132 125
Mongolia 136 116 117
Zimbabwe 137 175 150
Côte d'Ivoire 138 160 163
Ghana 139 148 153
Central African Republic 140 166 164
Namibia 141 145 141
Jordan 142 141 127
Belize 143 127 126
Sudan 144 151 158
Vanuatu 145 146 144
Djibouti 146 149 148
Congo 147 159 166
Guinea-Bissau 148 173 176
Cameroon 149 164 165
Swaziland 150 167 175
Ethiopia 151 153 151
Togo 152 155 156
Nigeria 153 174 183
Sao Tome and Principe 154 161 146
Mozambique 155 170 185
Solomon Islands 156 152 152
Guinea 157 169 174
Tajikistan 158 143 140
Saudi Arabia 159 137 113
United Republic of Tanzania 160 182 190
Malawi 161 193 194
Timor-Leste 162 179 186
Madagascar 163 158 167
Iraq 164 165 162
Papua New Guinea 165 154 157
Burundi 166 157 149
Benin 167 171 179
Zambia 168 196 196
Oman 169 104 70
Equatorial Guinea 170 142 169
Chad 171 185 187
Mauritania 172 162 161
Occupied Palestinian Territory 173 163 159
Somalia 174 180 192
Rwanda 175 178 173
Liberia 176 176 181
Western Sahara 177 120 104
Kenya 178 177 171
Comoros 179 168 172
Democratic Republic of the Congo 180 187 184
Yemen 181 183 170
Eritrea 182 189 160
Kuwait 183 134 110
Angola 184 181 180
Uganda 185 194 193
Senegal 186 186 177

Table 4B: Percentage of population aged 80 and older (country rankings)
2012 2030 2050 2012 2030 2050
Japan 1 1 1 Singapore 63 38 6
Italy 2 2 5 China, Macao SAR 64 65 22
France 3 8 20 Grenada 65 89 87
Germany 4 5 2 Thailand 66 64 48
Belgium 5 19 25 New Caledonia 67 61 69
Greece 6 15 18 Albania 68 63 53
Sweden 7 6 26 El Salvador 69 73 94
Spain 8 12 12 Saint Lucia 70 82 77
Switzerland 9 7 8 Brazil 71 69 60
Portugal 10 9 13 Sri Lanka 72 66 72
Austria 11 10 10 Aruba 73 60 35
Finland 12 3 19 Costa Rica 74 72 56
United Kingdom 13 20 30 Dominican Republic 75 81 85
Estonia 14 27 46 China 76 71 47
Norway 15 21 29 Mexico 77 77 76
Latvia 16 34 45 Mauritius 78 70 58
Slovenia 17 18 17 Saint Vincent and the Grenadines 79 94 100
Croatia 18 25 32 Viet Nam 80 87 67
Martinique 19 16 4 Ecuador 81 78 83
Denmark 20 13 28 Tonga 82 109 129
Channel Islands 21 11 11 Cape Verde 83 113 106
Hungary 22 33 57 Trinidad and Tobago 84 74 73
Bulgaria 23 32 44 Panama 85 79 84
Netherlands 24 14 16 Azerbaijan 86 115 99
Canada 25 22 24 Tunisia 87 92 90
Lithuania 26 40 49 Lebanon 88 91 88
Luxembourg 27 43 38 Guam 89 80 82
China, Hong Kong SAR 28 24 7 Peru 90 84 95
Australia 29 28 36 Suriname 91 90 91
United States of America 30 36 41 Dem. People's Republic of Korea 92 88 102
Czech Republic 31 23 42 Bahamas 93 75 70
Uruguay 32 44 61 Colombia 94 83 80
Poland 33 37 43 Kazakhstan 95 104 118
Guadeloupe 34 26 14 Iran (Islamic Republic of) 96 101 93
New Zealand 35 30 31 French Polynesia 97 86 78
Iceland 36 39 39 Venezuela (Bolivarian Republic of) 98 85 96
Puerto Rico 37 31 34 Samoa 99 102 115
Serbia 38 53 64 Nicaragua 100 98 103
Ukraine 39 54 71 Paraguay 101 97 120
Romania 40 45 50 Turkey 102 93 97
Georgia 41 48 40 Uzbekistan 103 123 112
Belarus 42 57 66 Kyrgyzstan 104 138 128
Malta 43 17 27 Honduras 105 111 124
Cuba 44 29 3 Belize 106 118 114
Barbados 45 51 33 Morocco 107 105 105
Bosnia and Herzegovina 46 41 23 Guatemala 108 119 141
Israel 47 49 75 Myanmar 109 121 113
Russian Federation 48 56 74 Gabon 110 129 146
Ireland 49 42 52 Indonesia 111 95 92
United States Virgin Islands 50 4 15 Turkmenistan 112 131 125
Armenia 51 68 63 Brunei Darussalam 113 96 86
Slovakia 52 50 55 Algeria 114 114 104
Cyprus 53 47 54 Maldives 115 99 81
Argentina 54 59 79 Bhutan 116 117 119
Montenegro 55 55 65 Egypt 117 107 123
Netherlands Antilles 56 46 21 Guyana 118 103 89
Republic of Moldova 57 67 68 Bangladesh 119 124 117
TFYR Macedonia 58 58 62 India 120 116 127
Republic of Korea 59 35 9 French Guiana 121 110 116
Chile 60 52 37 Bolivia (Plurinational State of) 122 120 135
Réunion 61 62 51 Tajikistan 123 145 137
Jamaica 62 76 59 Mongolia 124 126 121

2012 2030 2050 2012 2030 2050
Lesotho 125 144 174 Mauritania 187 187 172

Syrian Arab Republic 126 122 122 Afghanistan 188 189 191
Libyan Arab Jamahiriya 127 108 111 Burkina Faso 189 190 188
Micronesia (Fed. States of) 128 137 142 Mali 190 193 193
Zimbabwe 129 136 164 Gambia 191 195 187
Sao Tome and Principe 130 161 157 Niger 192 192 194
South Africa 131 112 134 Senegal 193 194 190
Pakistan 132 133 143 Qatar 194 188 109
Malaysia 133 106 110 Sierra Leone 195 196 196
Saudi Arabia 134 130 130 United Arab Emirates 196 191 101
Lao People's Democratic Republic 135 140 136
Haiti 136 142 147
Fiji 137 100 108
Jordan 138 127 133
Namibia 139 132 144
Ghana 140 139 148
Congo 141 152 162
Central African Republic 142 158 169
Nepal 143 135 140
Botswana 144 125 149
Oman 145 141 107
Philippines 146 128 131
Madagascar 147 156 155
Cameroon 148 160 165
Cambodia 149 134 138
Vanuatu 150 143 145
Togo 151 150 154
Côte d'Ivoire 152 147 163
Iraq 153 173 160
Equatorial Guinea 154 179 152
Swaziland 155 149 170
Mozambique 156 157 166
Mayotte 157 146 139
Sudan 158 151 158
Guinea 159 168 168
Ethiopia 160 148 153
Kenya 161 170 171
United Republic of Tanzania 162 163 181
Nigeria 163 166 179
Guinea-Bissau 164 171 182
Burundi 165 167 161
Zambia 166 177 195
Benin 167 172 167
Kuwait 168 165 132
Solomon Islands 169 153 151
Rwanda 170 169 175
Malawi 171 175 192
Djibouti 172 159 159
Uganda 173 182 189
Comoros 174 183 176
Occupied Palestinian Territory 175 155 150
Western Sahara 176 162 126
Papua New Guinea 177 164 156
Somalia 178 185 185
Yemen 179 178 173
Bahrain 180 154 98
Chad 181 186 186
Democratic Republic of the Congo 182 184 184
Liberia 183 180 183
Angola 184 181 178
Eritrea 185 176 177
Timor-Leste 186 174 180

Table 5A: Percentage of population aged 60 and older under alternative

total fertility rate scenarios
2012 2030 2050 2012 2030 2050
Medium-
Medium-
Medium-
Medium-
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
High-
High-
High-
High-
Low-
Low-
Low-
Low-
World 11 18 17 16 25 22 19 Democratic Republic of the Congo 4 5 5 4 8 7 6
Denmark 24 30 29 28 34 30 26
More developed regions 22 30 29 27 36 32 28 Djibouti 6 8 8 7 14 12 11
Less developed regions 9 15 14 14 23 20 18 Dominican Republic 9 16 15 14 26 22 19
Ecuador 9 16 15 14 28 24 20
Africa 6 7 7 6 11 10 9 Egypt 8 13 13 12 23 20 18
Asia 11 18 17 16 28 24 21 El Salvador 10 14 13 12 25 21 18
Europe 22 30 29 28 38 34 30 Equatorial Guinea 5 9 9 8 10 9 8
Latin America & Caribbean 10 18 17 16 29 25 22 Eritrea 4 5 5 4 12 10 9
Northern America 19 27 26 24 31 27 24 Estonia 23 28 27 26 37 32 28
Oceania 16 21 20 19 27 24 21 Ethiopia 5 7 7 7 14 12 11
Fiji 8 16 15 14 24 20 18
Afghanistan 4 5 4 4 8 7 6 Finland 26 33 31 30 36 31 28
Albania 14 24 22 21 40 34 29 France 24 31 29 28 34 30 27
Algeria 7 15 14 13 30 26 23 French Guiana 8 14 13 12 18 16 14
Angola 4 5 5 5 9 8 7 French Polynesia 10 20 18 17 31 27 23
Argentina 15 19 18 17 29 25 22 Gabon 7 9 9 8 15 13 11
Armenia 15 24 23 21 35 30 26 Gambia 4 5 5 5 9 8 7
Aruba 15 31 29 28 35 30 26 Georgia 20 30 28 27 41 35 31
Australia 20 26 25 24 33 29 26 Germany 27 38 36 35 42 37 33
Austria 24 35 33 31 41 36 32 Ghana 6 8 8 7 14 12 11
Azerbaijan 9 19 18 17 29 25 22 Greece 25 32 31 29 40 36 32
Bahamas 11 22 20 19 32 28 25 Grenada 10 16 15 14 35 29 25
Bahrain 4 16 15 14 36 32 29 Guadeloupe 18 30 28 27 37 33 29
Bangladesh 7 13 12 11 26 22 19 Guam 12 20 19 18 26 22 19
Barbados 17 29 28 27 39 34 30 Guatemala 6 8 8 7 14 12 10
Belarus 19 27 25 24 37 32 28 Guinea 5 6 6 6 9 8 7
Belgium 24 31 30 28 35 31 28 Guinea-Bissau 6 6 6 5 9 8 7
Belize 6 12 11 10 22 18 16 Guyana 7 16 15 14 26 22 19
Benin 5 6 6 5 9 8 7 Haiti 7 9 9 8 18 15 13
Bhutan 7 12 12 11 28 24 21 Honduras 6 10 10 9 20 17 15
Bolivia (Plurinational State of) 7 11 10 9 17 15 13 Hungary 23 28 27 25 37 32 28
Bosnia and Herzegovina 20 32 30 29 46 40 35 Iceland 17 25 24 23 33 29 26
Botswana 7 9 8 8 16 13 11 India 8 13 12 12 22 19 17
Brazil 11 20 19 18 34 29 25 Indonesia 9 17 16 15 30 25 22
Brunei Darussalam 6 15 14 13 27 23 20 Iran (Islamic Republic of) 8 16 15 14 39 33 29
Bulgaria 25 31 29 28 42 36 32 Iraq 5 6 6 6 11 10 9
Burkina Faso 4 5 4 4 7 7 6 Ireland 17 24 23 22 32 29 26
Burundi 5 7 7 6 14 12 11 Israel 15 20 19 18 25 23 20
Cambodia 7 12 11 10 22 19 16 Italy 27 36 34 33 43 38 34
Cameroon 5 6 6 6 11 9 8 Jamaica 11 20 19 18 31 26 22
Canada 21 31 29 28 35 31 28 Japan 32 39 37 36 47 41 37
Cape Verde 7 14 13 12 27 23 20 Jordan 6 9 9 8 21 18 16
Central African Republic 6 6 6 6 11 10 9 Kazakhstan 10 16 15 14 23 20 17
Chad 5 5 5 5 8 7 6 Kenya 4 5 5 5 10 9 8
Channel Islands 24 36 34 32 40 36 32 Kuwait 4 10 10 9 25 22 20
Chile 14 24 23 22 35 30 26 Kyrgyzstan 6 12 11 11 20 17 15
China 13 26 24 23 39 34 30 Lao People's Democratic Republic 6 10 10 9 22 19 16
China, Hong Kong SAR 19 34 33 31 42 37 34 Latvia 23 29 27 26 39 34 30
China, Macao SAR 12 28 26 25 43 38 34 Lebanon 11 19 17 16 33 28 24
Colombia 9 17 16 15 28 24 21 Lesotho 6 6 6 5 11 9 8
Comoros 4 6 6 6 10 9 8 Liberia 4 5 5 5 9 8 7
Congo 6 7 6 6 11 9 8 Libyan Arab Jamahiriya 7 12 12 11 27 23 20
Costa Rica 10 20 19 18 34 30 26 Lithuania 21 29 27 25 37 32 28
Côte d'Ivoire 6 7 6 6 11 10 9 Luxembourg 19 26 25 23 33 30 26
Croatia 24 32 30 29 39 34 30 Madagascar 5 7 7 6 10 9 8
Cuba 18 33 32 30 45 39 34 Malawi 5 4 4 4 6 5 5
Cyprus 17 25 23 22 37 32 29 Malaysia 8 16 15 14 23 20 18
Czech Republic 23 29 28 26 39 34 30 Maldives 7 15 14 13 36 31 27
Dem. People's Republic of Korea 14 20 19 18 27 23 20 Mali 3 4 4 4 7 6 5

2012 2030 2050 2012 2030 2050
Medium-
Medium-
Medium-
Medium-
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
High-
High-
High-
High-
Low-
Low-
Low-
Low-
Malta 23 32 30 28 42 37 32 Switzerland 23 34 32 31 42 37 33
Martinique 21 34 32 31 42 37 32 Syrian Arab Republic 6 12 11 10 21 18 16
Mauritania 5 7 6 6 11 10 9 Tajikistan 5 9 9 8 16 14 12
Mauritius 12 23 22 21 34 29 25 TFYR Macedonia 17 26 25 24 39 34 30
Mayotte 3 7 7 6 13 12 10 Thailand 14 26 24 23 37 32 28
Mexico 10 18 17 16 30 26 22 Timor-Leste 5 5 5 5 8 7 6
Micronesia (Fed. States of) 6 10 10 9 17 15 13 Togo 5 7 7 7 13 12 10
Mongolia 6 13 12 11 24 20 18 Tonga 8 11 10 10 15 13 11
Montenegro 18 26 24 23 36 31 27 Trinidad and Tobago 11 22 21 20 37 32 27
Morocco 9 16 15 14 28 24 21 Tunisia 10 18 17 16 33 29 25
Mozambique 5 6 6 5 8 7 6 Turkey 10 17 16 16 30 26 23
Myanmar 8 16 15 14 29 25 21 Turkmenistan 6 13 12 11 23 20 17
Namibia 6 9 9 8 16 13 12 Uganda 4 4 4 4 6 6 5
Nepal 6 10 9 9 20 17 14 Ukraine 21 27 25 24 37 32 28
Netherlands 23 33 31 30 36 32 28 United Arab Emirates 1 13 12 12 40 36 33
Netherlands Antilles 16 29 28 26 45 39 35 United Kingdom 23 29 27 26 34 30 26
New Caledonia 12 20 19 18 30 26 23 United Republic of Tanzania 5 5 5 5 7 6 6
New Zealand 19 27 26 25 32 29 25 United States of America 19 27 25 24 30 27 24
Nicaragua 7 12 11 11 25 21 18 United States Virgin Islands 23 34 32 30 34 30 26
Niger 4 4 4 4 5 5 4 Uruguay 19 23 22 21 32 27 24
Nigeria 5 6 5 5 8 7 7 Uzbekistan 6 13 12 12 25 21 19
Norway 22 29 27 26 33 29 26 Vanuatu 6 9 8 8 14 13 11
Occupied Palestinian Territory 4 7 6 6 12 10 9 Venezuela (Bolivarian Republic of) 9 16 15 14 26 22 19
Oman 5 15 14 13 33 29 25 Viet Nam 9 19 18 17 36 31 27
Pakistan 7 10 9 9 18 16 14 Western Sahara 4 12 12 11 26 23 20
Panama 10 17 16 16 27 23 20 Yemen 4 5 5 5 10 9 8
Papua New Guinea 5 7 7 7 13 11 10 Zambia 5 4 4 3 5 4 4
Paraguay 8 12 11 11 20 17 15 Zimbabwe 6 6 5 5 15 12 11
Peru 9 15 14 14 26 23 20
Philippines 6 11 10 9 18 15 13
Poland 20 29 27 26 40 35 31
Portugal 24 34 33 31 46 40 36
Puerto Rico 18 26 25 23 36 31 27
Qatar 2 9 9 8 30 28 26
Republic of Korea 17 33 31 29 44 39 35
Republic of Moldova 17 26 24 23 40 34 29
Réunion 12 22 21 20 29 26 22
Romania 21 28 27 25 41 36 32
Russian Federation 19 26 25 23 36 31 27
Rwanda 4 5 5 5 10 9 8
Saint Lucia 10 18 17 16 32 28 24
Saint Vincent and the Grenadines 10 19 18 17 28 24 21
Samoa 8 13 12 11 15 13 11
Sao Tome and Principe 5 7 6 6 15 13 11
Saudi Arabia 5 10 9 9 25 22 19
Senegal 4 5 5 4 9 8 7
Serbia 20 27 25 24 37 32 28
Sierra Leone 4 5 5 4 9 7 7
Singapore 15 33 31 30 42 38 34
Slovakia 18 27 26 24 40 35 31
Slovenia 23 33 32 30 41 37 33
Solomon Islands 5 7 7 7 14 12 11
Somalia 4 5 5 5 6 6 5
South Africa 8 12 11 10 18 15 13
Spain 23 32 31 29 43 38 34
Sri Lanka 13 22 20 19 32 27 24
Sudan 6 8 7 7 13 11 10
Suriname 10 17 16 16 28 24 21
Swaziland 5 6 6 6 10 8 7
Sweden 25 30 29 27 35 31 27

Table 5B: Percentage of population aged 80 and older under alternative

total fertility rate scenarios
2012 2030 2050 2012 2030 2050
Medium-
Medium-
Medium-
Medium-
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
High-
High-
High-
High-
Low-
Low-
Low-
Low-
Denmark 4 7 7 6 10 9 8
Ecuador 1 2 2 2 6 5 4
Africa 0 1 1 1 1 1 1 Egypt 1 1 1 1 3 3 2
Asia 1 2 2 2 5 5 4 El Salvador 2 3 3 2 5 4 4
Fiji 1 2 1 1 4 4 3
Albania 2 4 3 3 9 7 6 France 6 8 7 7 11 10 9
Algeria 1 1 1 1 4 4 3 French Guiana 1 1 1 1 4 3 3
Angola 0 0 0 0 1 1 1 French Polynesia 1 2 2 2 6 6 5
Argentina 3 4 3 3 6 5 5 Gabon 1 1 1 1 2 2 1
Armenia 3 3 3 3 8 7 6 Gambia 0 0 0 0 1 0 0
Aruba 2 4 3 3 10 9 7 Georgia 3 4 4 4 9 8 7
Austria 5 7 7 7 14 12 11 Ghana 1 1 1 1 2 1 1
Bahamas 1 3 3 2 7 6 5 Grenada 2 2 2 2 6 5 4
Bahrain 0 1 1 1 5 4 4 Guadeloupe 4 6 6 5 13 11 10
Bangladesh 1 1 1 1 3 3 3 Guam 1 2 2 2 6 5 4
Belarus 3 4 4 3 7 6 6 Guinea 0 0 0 0 1 1 1
Belize 1 1 1 1 4 3 3 Guyana 1 2 1 1 5 5 4
Benin 0 0 0 0 1 1 1 Haiti 1 1 1 1 2 2 1
Bhutan 1 1 1 1 3 3 3 Honduras 1 1 1 1 3 3 2
Botswana 1 1 1 1 2 1 1 India 1 1 1 1 3 3 2
Bulgaria 4 6 5 5 9 8 7 Iraq 0 0 0 0 1 1 1
Burundi 0 1 0 0 1 1 1 Israel 3 4 4 4 7 6 5
Cambodia 0 1 1 1 2 2 2 Italy 6 9 8 8 14 13 12
Canada 4 6 6 6 11 10 9 Japan 7 13 13 12 16 15 13
Chad 0 0 0 0 1 0 0 Kenya 0 0 0 0 1 1 1
Channel Islands 4 7 7 7 13 12 11 Kuwait 0 1 0 0 2 2 2
China, Hong Kong SAR 4 6 6 6 14 13 12 Latvia 4 6 5 5 9 8 7
China, Macao SAR 2 3 3 3 11 10 9 Lebanon 1 2 2 2 5 5 4
Comoros 0 0 0 0 1 1 1 Liberia 0 0 0 0 1 1 1
Cuba 3 6 6 5 15 13 12 Malawi 0 0 0 0 0 0 0
Cyprus 3 5 4 4 8 7 6 Malaysia 1 1 1 1 4 3 3

2012 2030 2050 2012 2030 2050
Medium-
Medium-
Medium-
Medium-
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
fertility
High-
High-
High-
High-
Low-
Low-
Low-
Low-
Martinique 4 7 7 6 15 13 12 Syrian Arab Republic 1 1 1 1 3 3 2
Mayotte 0 1 1 1 2 2 2 Thailand 2 3 3 3 9 8 7
Mongolia 1 1 1 1 3 3 3 Tonga 1 1 1 1 3 2 2
Morocco 1 1 1 1 4 4 3 Tunisia 1 2 2 2 5 5 4
Namibia 1 1 1 1 2 2 1 Uganda 0 0 0 0 1 0 0
Nepal 1 1 1 1 2 2 2 Ukraine 3 4 4 4 7 6 5
Netherlands Antilles 2 4 4 4 11 10 9 United Kingdom 5 7 6 6 10 9 8
New Caledonia 2 4 3 3 7 6 5 United Republic of Tanzania 0 1 1 0 1 1 1
Nicaragua 1 2 2 1 5 4 3 United States Virgin Islands 3 8 8 8 13 11 10
Niger 0 0 0 0 0 0 0 Uruguay 4 5 5 4 8 7 6
Norway 5 7 6 6 10 9 8 Vanuatu 0 1 1 1 2 2 1
Occupied Palestinian Territory 0 1 1 1 1 1 1 Venezuela (Bolivarian Republic of) 1 2 2 2 5 4 4
Oman 0 1 1 1 4 4 3 Viet Nam 1 2 2 2 7 6 5
Pakistan 1 1 1 1 2 2 1 Western Sahara 0 1 1 1 3 3 2
Panama 1 2 2 2 6 5 4 Yemen 0 0 0 0 1 1 1
Peru 1 2 2 2 5 4 4
Philippines 0 1 1 1 3 2 2
Poland 4 5 5 5 9 8 7
Portugal 5 8 7 7 13 12 10
Puerto Rico 3 6 5 5 10 9 8
Qatar 0 0 0 0 4 4 3
Réunion 2 4 3 3 9 7 6
Romania 3 5 4 4 9 8 7
Rwanda 0 0 0 0 1 1 1
Saint Lucia 2 2 2 2 7 6 5
Samoa 1 2 1 1 4 3 3
Saudi Arabia 1 1 1 1 3 2 2
Senegal 0 0 0 0 1 0 0
Serbia 3 4 4 4 7 6 6
Sierra Leone 0 0 0 0 0 0 0
Singapore 2 5 5 5 14 13 12
Slovakia 3 4 4 4 8 7 6
Slovenia 4 7 6 6 12 10 9
Solomon Islands 0 1 1 1 1 1 1
Somalia 0 0 0 0 1 1 0
South Africa 1 1 1 1 3 2 2
Spain 5 7 7 7 13 12 10
Sri Lanka 2 3 3 3 7 6 5
Sudan 0 1 1 1 1 1 1
Suriname 1 2 2 2 5 5 4
Swaziland 0 1 1 1 1 1 1
Sweden 5 8 8 7 11 10 8

Table 6: Life expectancy at birth and health life expectancy
expectancy
expectancy
expectancy
expectancy
Healthy life
Healthy life
at birth
at birth
at birth
at birth
Life
Life
1950 1970 1990 2010 2030 2050 2002 1950 1970 1990 2010 2030 2050 2002

Denmark 70 73 75 79 81 84 70
Ecuador 47 58 69 75 78 81 62
Africa 37 45 51 56 63 69 44 Egypt 42 50 62 73 77 79 59
Asia 42 56 64 70 74 77 59 El Salvador 43 57 66 72 76 78 60
Fiji 51 60 66 69 73 76 59
Albania 54 67 72 77 80 82 61 France 66 72 77 81 84 86 72
Algeria 42 53 67 73 77 79 61 French Guiana 52 65 72 76 79 81
Angola 29 37 41 51 58 65 33 French Polynesia 46 60 69 75 78 81
Argentina 61 66 72 76 79 81 65 Gabon 36 47 61 62 68 72 51
Armenia 62 70 68 74 77 80 61 Gambia 31 38 53 58 64 70 50
Aruba 58 69 73 75 78 80 Georgia 60 67 71 74 77 79 64
Austria 66 70 75 81 83 85 71 Ghana 40 49 57 64 69 73 50
Bahamas 59 66 69 75 79 81 64 Grenada 62 64 69 76 79 81 59
Bahrain 41 64 72 75 78 80 64 Guadeloupe 52 65 74 80 82 84
Bangladesh 44 42 59 69 74 77 54 Guam 56 66 72 76 79 81
Belarus 65 71 71 70 74 77 61 Guinea 31 34 44 54 62 68 45
Belize 56 66 72 76 79 80 60 Guyana 48 56 61 70 75 78 55
Benin 32 40 49 56 63 69 44 Haiti 36 47 55 62 67 72 44
Bhutan 36 41 53 67 73 76 53 Honduras 41 52 66 73 77 79 58
Botswana 47 55 64 53 58 64 36 India 37 49 58 65 70 74 53
Bulgaria 60 71 71 73 76 79 65 Iraq 37 58 67 68 74 77 50
Burundi 38 44 46 50 58 65 35 Israel 68 72 76 81 85 87 71
Cambodia 39 44 56 63 70 75 48 Italy 65 71 77 82 84 86 73
Canada 68 73 77 81 83 85 72 Japan 60 72 79 83 86 88 75
Chad 37 44 51 49 57 64 41 Kenya 42 52 59 57 64 69 44
Channel Islands 69 72 75 80 82 85 Kuwait 54 67 72 74 77 79 67
China, Hong Kong SAR 62 72 78 82 85 87 Latvia 65 70 69 73 77 80 63
China, Macao SAR 60 70 76 81 83 86 Lebanon 54 65 69 72 76 79 60
Comoros 40 48 56 61 67 72 55 Liberia 34 41 42 56 64 69 35
Cuba 58 70 74 79 82 83 68 Malawi 36 41 47 54 61 67 35
Cyprus 66 73 77 79 82 84 68 Malaysia 54 64 70 74 77 80 63

expectancy
expectancy
expectancy
expectancy
Healthy life
Healthy life
at birth
at birth
at birth
at birth
Life
Life
1950 1970 1990 2010 2030 2050 2002 1950 1970 1990 2010 2030 2050 2002
Martinique 54 66 75 80 82 84 Syrian Arab Republic 46 60 71 76 79 81 62
Mayotte 44 63 72 77 80 82 Thailand 49 60 73 74 77 80 60
Mongolia 43 56 61 68 73 77 56 Tonga 58 65 70 72 75 77 62
Morocco 42 52 64 72 76 79 60 Tunisia 44 54 69 74 78 80 62
Namibia 40 53 61 62 66 70 43 Uganda 39 50 47 54 60 66 43
Nepal 36 43 54 68 74 77 52 Ukraine 64 71 70 68 73 76 59
Netherlands Antilles 58 69 75 77 79 81 United Kingdom 69 72 76 80 82 85 71
New Caledonia 49 63 71 76 80 82 United Republic of Tanzania 40 47 51 57 66 70 40
Nicaragua 41 54 64 74 77 80 61 United States Virgin Islands 57 68 75 79 82 84
Niger 37 38 41 54 62 68 36 Uruguay 66 69 73 77 80 82 66
Norway 72 74 77 81 83 86 72 Vanuatu 41 52 63 71 75 78 59
Occupied Palestinian Territory 46 56 68 73 76 79 Venezuela (Bolivarian Republic of) 53 64 71 74 77 80 64
Oman 37 51 71 73 76 79 64 Viet Nam 39 48 66 75 78 81 61
Pakistan 40 53 61 65 69 72 53 Western Sahara 35 42 58 67 73 77
Panama 54 65 72 76 79 81 66 Yemen 35 40 56 65 72 76 49
Peru 43 53 66 74 77 80 61
Philippines 55 61 65 68 73 77 59
Poland 59 70 71 76 79 81 66
Portugal 59 67 74 79 82 84 69
Puerto Rico 61 72 74 79 81 83
Qatar 53 66 74 78 81 83 65
Réunion 45 64 72 78 80 82
Romania 60 68 69 74 77 80 63
Rwanda 39 44 33 55 62 68 38
Saint Lucia 54 64 71 74 78 80 63
Samoa 45 55 65 72 76 79 60
Saudi Arabia 39 52 69 74 77 80 61
Senegal 36 41 53 59 65 70 48
Serbia 56 68 72 74 77 80 64
Sierra Leone 29 35 39 47 55 63 29
Singapore 58 68 76 81 83 85 70
Slovakia 62 70 71 75 78 81 66
Slovenia 64 69 73 79 82 84 69
Solomon Islands 44 54 57 67 73 77 56
Somalia 32 40 45 51 58 66 37
South Africa 44 53 62 52 59 65 44
Spain 62 72 77 81 84 86 73
Sri Lanka 51 63 70 75 78 80 62
Sudan 40 45 53 61 68 73 49
Suriname 55 63 67 70 74 77 59
Swaziland 41 48 59 48 54 63 34
Sweden 71 74 78 81 84 86 73

Biographies
Isabella Aboderin, Senior Research Scientist, John Beard, Director, Department of Ageing David E. Bloom, Clarence James Gamble
African Population and Health Research and Life Course, World Health Organization Professor of Economics and Demography,
Center, (APHRC) Nairobi, Kenya; Senior (WHO), Geneva Harvard School of Public Health, Harvard
Research Fellow, Oxford Institute of University, USA
Population Ageing, (OIA) University of MBBS; PhD. Physician. Formerly: worked in
Oxford, UK Aboriginal health; 1991, senior public health 1976, BSc in Industrial and Labour Relations,
and academic roles, Australia; three years as Cornell University; 1978, MA in Economics,
BSc, Cellular and Molecular Pathology; MSc, Senior Epidemiologist, New York Academy Princeton University; 1981, PhD in
Health Promotion Sciences; PhD, Social of Medicine; US; since 2009, current Economics and Demography, Princeton
Policy Studies. Senior Research Fellow, position. University. Formerly: Assistant Professor of
conducting research and coordination of the Economics, Carnegie-Mellon; Assistant and
Institute’s African Research on Ageing Simon Biggs, Professor of Gerontology and Associate Professor of Economics, Harvard;
Network (AFRAN), Oxford Institute of Social Policy, University of Melbourne, Professor and Chairman of Economics,
Population Ageing; Co-Coordinator, African Australia Columbia. Chairman of Global Health and
Research on Ageing Network. Regional Population Dept, HSPH. Currently: Fellow,
Chair for Africa, International Association of Formerly: Community Psychologist; Head of American Academy of Arts and Sciences.
Gerontology and Geriatrics; Member, Policy Development, UK Social Work Faculty Research Associate, Labour Studies,
Advisory Board, World Demographic and Education Council; Professor of Social Ageing, and Health Economics
Ageing Forum; Board Member Elect, Gerontology, Keele University; 2002, Visiting Programmes, National Bureau of Economic
HelpAge International; Member, African Research Fellow, Department of Social Research. Director, Harvard Program on
Union Working Group on Rights of Older Medicine, Harvard University. Director, Global Demography of Aging. Member,
People. Interests: ageing in Africa, Institute of Gerontology, King’s College Board of Trustees: amFAR; PSI.
intergenerational dynamics, ageing and London; since 2010, current position. Links
development, social determinants of health with University of Helsinki and University of Axel Börsch-Supan, Director, Max Plank
in old age. Heidelberg. Research includes: WHO’s Age Institute for Social Law and Social Policy,
Friendly Cities Project; ESRC study of baby Germany
Giles Archibald, Senior Partner, Mercer boomers; study of elder abuse in UK;
(MMCo), United Kingdom intergenerational relationships; the mature PhD, MIT, US. Formerly: with faculties at
workforce. Interests: relationship between Harvard, Dortmund and Dresden; consultant
1973, degree in Mathematics, St Andrews identity and adult ageing, analysis of to governments, OECD and World Bank.
University, Scotland. Since 1977, with Mercer international/national social policy, adult life Currently: Professor of Macroeconomics and
including: international consultant and course, experience of ageing, lifestyle and Public Policy, and Director, Munich Center for
practice leader, Brussels, London and New self-development in later life, counselling, the Economics of Aging, Max-Planck-
York; currently, based in Manchester and psychotherapy, and the baby boomer Institute for Social Law and Social Policy,
London; consulted with US and UK generation. Adviser to EC, Canadian, UK, Germany; current research focuses on
multinationals. Frequent speaker at Australian Govt Ministries. Author of books household retirement and savings behaviour,
conferences on international benefits. Author and papers; contributed to UN Valencia age and productivity, and Survey of Health,
of articles on worldwide employee benefits, Forum and scientific debate in Europe and Ageing and Retirement in Europe; Research
including Retirement Benefits in Europe, a US. Associate, National Bureau of Economic
research paper for Faculty of Actuaries, Research, US; Adjunct Researcher, RAND
focused on methods of benefit financing in Richard Blewitt, Chief Executive, HelpAge Corporation, US. Member: German National
France and Germany. Fellow, Faculty of International, United Kingdom Academy of Sciences; Berlin-Brandenburg
Actuaries, UK. Associate, Society of Academy of Sciences; MacArthur
Actuaries. Master’s in African Politics and Economics. Foundation Aging Societies Network. Former
Formerly, leadership positions with: UN; Chair, Council of Advisers, German
International Red Cross; Save the Children. Economics Ministry, co-chaired German
Interests: development economics, Pension Reform Commission; former
humanitarian response, human rights, Member, German President’s Commission
building broad-based alliances and on Demographic Change.
partnerships.

Biographies
Raymond Brood, Director, Health and Norman Daniels, Mary B. Saltonstall Mario Martin Delgado Carrillo, Minister of
Benefits Benelux, Mercer (MMCo), Professor of Population Ethics; Professor of Education of Mexico City, Mexico
Netherlands Ethics and Population Health, Harvard
School of Public Health, USA Bachelor’s in Economics, Instituto
Degree in Law, University of Rotterdam. Tecnológico Autónomo de México; Master’s
Former Account Manager and worked the PhD. 1969-2002, Professor and former Chair in Economics, University of Essex, UK. 2006,
dealing room, ABN Bank. 1990, with of the Philosophy Department, Tufts appointed by Mayor Ebrard Casaubon
AEGON, responsible for the client University. Currently, Mary B Saltonstall Minister of Finance for Mexico City.
management activities of AEGON Asset Professor and Professor of Ethics and Developed one of the important
Management, then started a new concept Population Health, Department of Global programmes in education, Prepa Si,
for AEGON’s largest Insurance Health and Population, Harvard School of diminishing school desertion from 20% to
Intermediaries. 1996, joined MeesPierson Public Health, directs the Ethics 6% and benefiting more than 200,000
(became Fortis in 1997): Board Member, concentration of the Health Policy PhD and students. Promoter of the inclusion of
Fortis Investments and responsible for teaches courses on ethics and health gender, minorities and human rights into the
commercial activities and client management inequalities and justice and resource City’s budget, leading to the largest social
of the asset manager, the ALM department allocation. Author of numerous books, agenda in the country. Led the renegotiation
and led the pension administration including: Just Health: Meeting Health Needs of the Federal District’s debt for more than
department. 1999, Chairman, Beijer Group Fairly (2008); Setting Limits Fairly: Learning to three billion dollars. Young Global Leader
(Intermediary Captive of Fortis). 2003, joined Share Resources for Health, 2nd edition 2011. 2011, Member, Global Agenda Council
Mercer as Head, Group Benefits; 2005, (2008); From Chance to Choice: Genetics on Skills and Talent Mobility, World Economic
appointed to the Dutch leadership group and and Justice (2000); Is Inequality Bad for Our Forum.
the European H&B leadership group; Health? (2000). Research is on justice and
currently, Senior Partner, Health & Benefits, health policy, including priority setting in Jack Ehnes, Chief Executive Officer,
Benelux; Member of the Benelux Leadership health systems, fairness and health systems California State Teachers’ Retirement
Team and European Health & Benefit reform, health inequalities, and System (CalSTRS), USA
Leadership. intergenerational justice. Recipient, Everett
Mendelsohn Award for mentoring graduate Former: Colorado Insurance Commissioner
Laura Carstensen, Director, Stanford Center students. and Deputy Insurance Commissioner;
on Longevity, USA Chairman of the Board, Colorado Public
Gerald C. Davison, Dean and Executive Employees Retirement Association;
BSc, University of Rochester; PhD in Clinical Director, University of Southern California Vice-President, Corporate Affairs, Great
Psychology, West Virginia University. Davis School of Gerontology and Andrus West Life and Annuity Insurance Company;
Professor of Psychology and Fairleigh S. Gerontology Center, USA Chairman, Council of Institutional Investors.
Dickinson Junior Professor in Public Policy, Currently, Member of the Board: National
Stanford University. Founding Director, 1961, BA, Social Relations, Harvard; Council on Teacher Retirement; National
Stanford Center on Longevity. Author, with 1961-62, Fulbright Scholar, Univ. of Freiburg, Institute on Retirement Security; International
students and colleagues, of over 100 articles Germany; 1965, PhD, Psychology, Stanford. Foundation for Employee Benefit Plans;
on life-span development. Author, A Long 1966-79, Assistant Prof., State Univ. of New Ceres, a network of investors and
Bright Future: Happiness, Health, and York, Stony Brook. With Univ. of Southern environmental organizations focused on
Financial Security in an Age of Increased California: Prof. of Psychology; Chairman, sustainability. Member, World Economic
Longevity (2011). Research supported by Dept of Psychology; Interim Dean, Forum’s Global Agenda Council on Ageing.
National Institute on Aging for more than 20 Annenberg School of Communications;
years. Fellow: Association for Psychological Interim Dean, School of Architecture; since
Science; American Psychological 2007, current position. President, Society of
Association; Gerontological Society of Clinical Psychology, American Psychological
America. Member, Research Network on an Assoc. Fellow, APA; Charter Fellow, Assoc.
Aging Society, MacArthur Foundation. for Psychological Science. Member,
Recipient of awards, including: Guggenheim Gerontological Society of America. Dist.
Fellowship; Distinguished Career Award, Founding Fellow, Academy of Cognitive
Gerontological Society of America. Therapy. Publications emphasize
experimental and philosophical analyses of
psychopathology, assessment, and
therapeutic change. Co-Author of Abnormal
Psychology (2010). Research focuses on
relationships between cognition and a variety
of behavioural and emotional problems.
Recipient of awards, including: Lifetime
Achievement Award, Association for
Cognitive and Behavioral Therapies (2006);
USC Associates Award for Excellence in
Teaching.

Biographies
Linda P. Fried, Dean and DeLamar Professor Terry Hill, Chairman, Arup Group Trust, Arup Emmanuel Jimenez, Director, Human
of Public Health, Mailman School of Public Group, United Kingdom Development, East Asia and Pacific Region,
Health, Columbia University, USA and Editor, World Bank Research Observer,
Experience in civil engineering, economics, World Bank, Washington DC
MD; MPH. Leader in the fields of transport sector. 1976-96 and since 1999,
epidemiology, gerontology and geriatrics. with Arup: led Infrastructure Division, BA (Hons) in Economics, McGill University,
Scientist with expertise in healthy ageing, focusing on consulting, infrastructure and Montreal, Canada; PhD in Economics,
prevention of frailty, chronic diseases and managing major projects. 1996-99, Director, Brown University, US. Formerly, with Faculty,
disability, and creating the basis for a Union Railways, responsible for technical Economics Department, University of
transition to an aging world that benefits all aspects of Channel Tunnel Rail Link. Western Ontario, London, Canada. Various
ages. Currently, Dean, DeLamar Professor of positions with World Bank, including:
Public Health, and Professor of Paul R. Hogan, Chairman and Founder, Development Economics, managed staff
Epidemiology, Mailman School of Public Home Instead Senior Care, USA and research including education and health
Health, Columbia University; concurrently, finance, private provision of social services,
Professor of Medicine, College of Physicians 1985, BSc, University of Nebraska. Over 20 economics of transfer programmes and
& Surgeons, Columbia. Co-Designer and years’ experience in franchising. 1994, urban development; 2002, Sector Director,
Co-Founder, Experience Corps, a Founder, Home Instead Senior Care; 1998 Human Development, East Asia Region,
community-based senior volunteer and 2005, established two foundations responsible for managing operational staff
programme that deploys the social capital of caring for seniors and those who serve them; working on education and health issues;
an aging society to improve the academic 2004, founding Member, National Private member, formally and informally, teams
success of children in elementary schools Duty Association; 2005, delegate to White preparing World Development Reports.
while simultaneously promoting the health of House Conference on Aging; 2008, anchor
the older volunteers. Member: Institute of donor, Home Instead Center for Successful Alexandre Kalache, Senior Advisor, Global
Medicine, National Academy of Sciences; Aging. Author, Stages of Senior Care. Ageing, New York Academy of Medicine,
Global Agenda Council on Ageing, World Recipient of awards: Entrepreneur of the USA
Economic Forum. Recipient of numerous Year, International Franchise Association
awards, including: APHA Archstone Award (2006); E Award, US Department of 1970, degree in Medicine; 1972, specialist in
(2000); Irving Wright Award, American Commerce (2008). Tropical Medicine and 1974, diploma in
Federation for Aging Research; Living Medical Education, Federal University of Rio
Legend in Medicine, US Congress; one of de Janeiro; 1977, MSc in Social Medicine
the Top 100 Women in Maryland; inaugural and 1993, PhD in Epidemiology, University of
Silver Innovator Award, Alliance for Aging London; 1978, Fellow, Public Health, Royal
Research. College of Physicians, London. 1977-84,
Clinical Lecturer, Public Health, University of
Aaron Hagedorn, Assistant Clinical Oxford; 1984-95, Senior Lecturer,
Professor, University of Southern California Epidemiology of Ageing, London School of
(USC), USA Hygiene and Tropical Medicine; 1995, Chief,
Ageing and Health Programme, World
MS/MHA in Health Administration and Health Organization. Interests: public health
Gerontology and PhD in Gerontology, and ageing populations; Latin American
University of Southern California. Currently, literature; development issues.
Assistant Clinical Professor, University of
Southern California, Davis School of
Gerontology, teaching courses and
conducting research on healthy life
expectancy, technological systems designed
to support aging in place, and global health
issues related to population aging. Member:
Reves International Network on Health
Expectancy; Gerontological Society of
America; Population Association of America.
Advisory Board Member, WISE Connections
Aging in Place village project in Santa
Monica, California.

Biographies
Randall Krakauer, National Medical Director, Ajay Mahal, Adjunct Associate Professor of Colin Milner, Founder, International Council
Medicare, Aetna, USA International Health Economics, Harvard on Active Ageing (ICAA), Canada
School of Public Health, USA
1972, graduate, Albany Medical College; Since 1982, involved in health and wellness
training in Internal Medicine, University of MA, MPhil, PhD. Former Associate Professor industry including, President, Idea Health
Minnesota Hospitals and in Rheumatology, of International Health Economics, and Fitness Association. 2001, established
National Institutes of Health and Department of Global Health and Population, International Council on Active Ageing;
Massachusetts General Hospital/Harvard Harvard School of Public Health. Currently, advises: National Institute on Aging, US
Medical School; MBA, Rutgers. Board Finkel Chair of Global Health, Monash Department of Health and Human Services,
Certified in Internal Medicine and University, Melbourne. Research uses European Commission, British Columbia
Rheumatology. More than 35 years of economic analyses to influence public health Ministry of Health; Canadian Association of
experience in medicine and medical policy in developing countries. Research Fitness Professionals; Fitness Business
management, has held senior medical interests: policy issues related to the HIV/ Canada; Active Living by Design: Creating
management positions in several major AIDS epidemic, resource allocation in the Activity-Enhancing Residential Settings work
organizations. Professor of Medicine, Seton health sector, ageing, human resources and group; Active Living Leadership and Club
Hall University Graduate School of Medicine. decentralization and empowerment. Current Success; spokesperson on active aging for
Former Chairman, American College of and ongoing work encompasses a wide Canadian Association of Fitness
Managed Care Medicine. Fellow: American range of topics, including: the growth of the Professionals. Author of over 200 articles on
College of Physicians; American College of medical education sector in India, and aging-related issues.
Rheumatology. Responsible for medical migration among India’s medical graduates;
management strategy and planning diffusion of modern medical technology in Jenifer Milner, Editor-in-Chief, Journal on
nationally for Aetna Medicare members, India and other developing countries; the Active Aging, International Council on Active
including programme development and distribution of public sector health subsidies Ageing (ICAA), Canada
demonstration of impact; has developed in India; health and support systems for the
programmes that have had impact on Indian elderly; economic analysis of injecting Ten years’ experience in the field of ageing.
chronic illness, advanced illness and major drug use behaviour; and the impact of HIV/ Former Communications Manager, Greater
risk factors. Author of publications on AIDS in Botswana and Nigeria. Vancouver Alliance for Arts and Culture,
Medical management, advanced care responsible for creating a series of widely
management and collaborative medical Patrick McGee, Senior Research Analyst, published arts advocacy articles.
management. Global Agenda Councils, World Economic Communications Specialist, Author and
Forum Editor-in-Chief, Journal on Active Aging,
André Laboul, Head, OECD Financial Affairs published by the International Council on
Division and Secretary-General IOPS, MA sociology. 2006-2007 Vice-President of Active Aging (ICAA) in Vancouver, Canada.
Organisation for Economic Co-operation and the African Youth Association in Geneva. Has also edited numerous publications,
Development (OECD), Paris Since 2007 at the World Economic Forum, including Canada’s national fitness business
coordination of Global Agenda Councils magazine, Club Direct.
Degrees from universities of Liège and related to human capital and demography,
Louvain-La-Nueve. Economist and a Lawyer. and programme development for the World
Formerly, in Belgium with Centre for Economic Forum on Africa. Advisory board
European Policy Studies, Centre for Law and member of the International Sport for
Economic Research (CRIDE) and Prime Development and Peace Association.
Minister Services for Science Policy.
Currently, also: Secretary-General,
International Organisation of Pensions
Supervisors; Chair, International Network on
Financial Education; Managing Editor,
Journal of Pension Economics and Finance;
Expert to European Commission group of
experts on financial education. Wrote first
major international studies on bank,
insurance and on regulation of private
pensions; instrumental in OECD
development of international policy projects
including financial education, terrorism
insurance, financial management of
catastrophic risks and financial risk transfers.

Biographies
S. Jay Olshansky, Professor, University of John Rowe, Professor of Health Policy and Leisa Sargent, Associate Professor, Faculty
Illinois, USA Management, Mailman School of Public of Business & Economics, University of
Health, Columbia University, USA Melbourne, Australia
1984, PhD in Sociology, University of
Chicago. Professor, School of Public Health, BS, Canisius College, Buffalo, NY; MD, PhD, University of Toronto, Canada.
University of Illinois, Chicago; Research University of Rochester, School of Medicine Currently, Associate Professor, University of
Associate, Center on Aging, University of and Dentistry. Former Professor of Medicine Melbourne, Australia. Research interests
Chicago and London School of Hygiene and and Founding Director, Division on Aging, revolve around organizational and individual
Tropical Medicine; research focuses on Harvard Medical School, and Chief of responses to change and transitions, with a
estimates of upper limits to human longevity, Gerontology, Beth Israel Hospital. 1998- particular interest in identity and careers.
exploring health and public-policy 2000, President and CEO, Mount Sinai NYU
implications associated with individual and Health. 2000-06, Chairman and CEO, Aetna. Atsushi Seike, President, Keio University,
population aging, forecasts of size, survival Professor, Department of Health Policy and Japan
and age structure of population, pursuit of Management, Columbia University Mailman
scientific means to slow aging in people and School of Public Health. Former Chairman of 1993, PhD, Labour Economics, Keio Univ.
global implications of re-emergence of the Board of Trustees, University of Former: Visiting Scholar, UCLA; Consultant,
infectious and parasitic diseases. Co-Author, Connecticut. Former Director, MacArthur RAND Corp.; Visiting Principal Research
The Quest for Immortality: Science at the Foundation Research Network on Officer, Economic Research Institute,
Frontiers of Aging (2001). Successful Aging; currently leads Research Economic Planning Agency. Since 1992,
Network on An Aging Society. Member, with Faculty of Business and Commerce,
Larry Rosenberg, Research Associate, Institute of Medicine, National Academy of Keio Univ.: 2007-09, Dean; since 2009,
Harvard School of Public Health, USA Sciences; Fellow, American Academy of Arts President. Member of various councils,
and Sciences; Trustee, Rockefeller including: Labor Policy Council, Council on
Graduate, Kennedy School of Government, Foundation and Lincoln Center Theater. the Realization of the New Growth Strategy.
Harvard. Has worked on projects relating to Chairman of the Board, Marine Biological Chairman, Policy Studies Group for an Aged
health, education, demographic change, Laboratory in Woods Hole, Massachusetts. Society. Member, Council for Intensive
economic growth, poverty alleviation, social Recipient of many honours and awards for Discussion on Social Security Reform, and
protection, tax policy, and the Israeli- research and health policy efforts regarding Reconstruction Design Council in Response
Palestinian conflict. Currently, Research care of the elderly, including: Corporate to the Great East Japan Earthquake, Prime
Associate, Harvard School of Public Health. Citizenship Award, Woodrow Wilson Minister’s Office. President, The Japan
Research interests centre on political and International Center for Scholars (2006); Association of Private Universities and
economic development in Latin America and Honorary Leadership Award, American Colleges. Author.
Asia, focusing on steps developing countries Federation for Aging Research (2008).
can take that are distinct from those
advocated by the international financial Daniel Ryan, Head, Research and
institutions. Development for Life and Health, Swiss Re,
United Kingdom
MA in Medical Sciences, University of

Cambridge. Formerly: over 16 years as
Research Consultant, Towers Watson;
2002-10, Founder and principal investigator
for a multi-disciplinary research group for
forum of insurers and re-insurers that used
international data sources to investigate
future possibilities for mortality and disease
at all ages; 2006, Head, Mortality Research
and Consulting. Since August 2010, with
Swiss Re. Published actuarial papers on
Continuing Retirement Care Communities,
international mortality trends and forward-
looking disease-based mortality models.

Biographies
Adam Stein, Undergraduate, University of John Wilden, Executive Director and Chief Saadia Zahidi, Senior Director, Head of
Rochester, USA Executive Officer, Global Health Futures Constituents, World Economic Forum
(GHF), United Kingdom
Junior, University of Rochester, majoring in BA (Hons) in Economics, Smith College;
economics and applied mathematics. Adam Qualified at the Royal Free Hospital, London. Master’s in International Economics,
spent the summer of 2011 working as a International career in neurosurgery, working Graduate Institute of International Studies,
research assistant for the Department of in the UK and USA at prestigious institutions. Geneva. With World Economic Forum:
Global Health and Population at the Harvard main specialities in neurosurgery were in former Economist, Global Competitiveness
School of Public Health. While there, he stereotaxis, brain tumours and head injuries. Programme, responsible for economic
co-authored the report “The Global Performed the first MRI directed stereotactic analysis for the Global Competitiveness
Economic Burden of Non-communicable procedure in the UK and was one of the first reports, Arab World reports and other topical
Diseases” with other researchers from to indicate the importance of rapid and regional studies; currently, Head of
Harvard and the World Economic Forum. resuscitation of severe head injuries in Constituents, responsible for the
papers and presentations to international engagement of religious leaders, NGOs,
Kay Van Norman, Consultant and Author conferences including the American labour leaders, women leaders and gender
Association of Neurological Surgeons, the parity groups; also leads research on gender
Internationally known author, speaker and Congress of Neurosurgeons and a number issues. Founder and Co-Author, Global
consultant specializing in adult wellness. of European academic bodies and Gender Gap Report series, benchmarking
Master’s in Physical Education and Health. organizations. Has served on international countries according to the size of their
Seventeen years as Professor, Montana committees developing clinical trials in these gender gaps on health, education, economic
State University; also directed the Young at disciplines. Co-Founder, Global Health participation and political empowerment.
Heart exercise programme for older adults. Futures (GHF).
Then Director, Keiser Institute on Aging, an Hania Zlotnik, Director, Population Division,
international effort to bridge the gap between Ronald A. Williams, Chairman and Chief Department of Economics and Social Affairs,
research and practice in the fields of Executive Officer, RW2 Enterprises, USA United Nations, New York
gerontology, senior housing, fitness and
older adult wellness. Founder and President, Graduate, Roosevelt University; Master’s Studies at Universidad Nacional Autónoma
Brilliant Aging, a consulting firm specializing degree, Massachusetts Institute of de México; PhD in Statistics and
in improving older adult health, business Technology. Formerly: President, Large Demography, Princeton University.
development opportunities for companies Group Division and President, Blue Cross of Experience in demography, covering
interested in reaching older adult consumers, California, WellPoint Health Networks; analysis of fertility, mortality and migration
and employee wellness. Leading authority in Co-Founder and Senior Vice-President, with emphasis on quantitative aspects.
senior exercise and wellness. Author of the Vista Health; Group Marketing Executive, Formerly: with Committee on Population and
book Exercise Programming for Older Control Data; President and Co-Founder, Demography, National Research Council,
Adults, its revision Exercise and Wellness Integrative Systems. 2006-2011, Chairman, US. Since 1982, with Population Division,
Programs for Older Adults (2010), and Aetna. Chairman, Council for Affordable UN: 1993, Chief, Mortality and Migration
several book chapters. Also Author of Quality Healthcare. Vice-Chairman, Business Section in 1993; 1999; Chief, Population
dozens of journal articles, a national position Council. Member of the Board: Trustees, Estimates and Projections Section; 2003,
paper for the White House Conference on Conference Board; Connecticut Science Assistant Division Director. Vice-President,
Aging, and an issue brief for the National Centre; American Express; North America International Union for the Scientific Study of
Council on Aging’s Center for Healthy Aging. Executive, MIT. Member: Alfred P Sloan Population. Member, Population Association
Management Society; International of America. Drafted UN recommendations
Federation of Health Plans. Since 2011 on International Migration Statistics. Author
Current position. and Editor, published over 35 articles in
books. Expertise: demographic estimation
techniques and international migration
statistics.

Biographies
Members of the Global Agenda Council Colin Milner, Founder, International Council
on Ageing Society on Active Ageing (ICAA), Canada
Isabella Aboderin, Senior Research Fellow S. Jay Olshansky, Professor, University of
and Coordinator, African Research on Illinois, USA
Ageing Network, University of Oxford, United
Kingdom Peng Xizhe, Dean, School of Social
Development and Public Policy, Fudan
Giles Archibald, Senior Partner, Mercer University, People’s Republic of China
(MMCo), United Kingdom
Daniel Ryan, Head, Research and
John Beard, Director, Department of Ageing Development for Life and Health, Swiss Re,
and Life Course, World Health Organization United Kingdom
(WHO), Geneva
Atsushi Seike, President, Keio University,
Simon Biggs, Professor of Gerontology and Japan
Social Policy, University of Melbourne,
Australia
David E. Bloom, Clarence James Gamble

Professor of Economics and Demography,
Harvard School of Public Health, Harvard
University, USA
Axel Börsch-Supan, Director, Munich Center

for the Economics of Aging (MEA), Germany
Laura Carstensen, Director, Stanford Center

on Longevity, USA
Gerald C. Davison, Dean and Executive

Director, University of Southern California
Davis School of Gerontology and Andrus
Gerontology Center, USA
Jack Ehnes, Chief Executive Officer,

California State Teachers’ Retirement
System (CalSTRS), USA
Linda P. Fried, Dean and DeLamar Professor

of Public Health, Mailman School of Public
Health, Columbia University, USA
Paul R. Hogan, Chairman and Founder,

Home Instead Senior Care, USA
Alexandre Kalache, Senior Advisor, Global

Ageing, New York Academy of Medicine,
USA
André Laboul, Head, OECD Financial Affairs

Division and Secretary-General IOPS,
Organisation for Economic Co-operation and
Development (OECD), Paris

The World Economic Forum
is an independent international
organization committed to
improving the state of the world
by engaging business, political,
academic and other leaders of
society to shape global, regional
and industry agendas.
Incorporated as a not-for-profit
foundation in 1971 and
headquartered in Geneva,
Switzerland, the Forum is
tied to no political, partisan
or national interests
World Economic Forum

91-93 route de la Capite
CH-1223 Cologny/Geneva
Switzerland
Tel +41 (0) 22 869 1212

Fax +41 (0) 22 786 2744
[email protected]
www.weforum.org

Global Population Ageing:: Peril or Promise?

Uploaded by

Copyright:

Available Formats

Global Population Ageing:: Peril or Promise?

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Global Population Ageing:: Peril or Promise?

Uploaded by

Copyright:

Available Formats

Global Agenda Council on Ageing Society

Global Population Ageing:

Suggested Citation: John R. Beard, Simon Biggs, David E. Bloom,

© World Economic Forum

2012 - All rights reserved.

Global Population Ageing: Peril or Promise? 1

In a world in which much change is unpredictable and immediate,

Global ageing, in developed and developing countries alike, will

If policy-makers and leaders fail to plan adequately for the changes

The wide range of ramifications makes ageing a topic appropriate for

Global Population Ageing: Peril or Promise is part of the Council’s

2 Global Population Ageing: Peril or Promise?

Populations around the world are rapidly ageing, and it is less

However, population ageing will also present both challenges and

People are already questioning our traditional view of older age. A

This is exciting, because if older people can remain active

At the World Health Organization we see good health as central to

Global Population Ageing: Peril or Promise? 3

Such tales are strongly reminiscent of the

4 Global Population Ageing: Peril or Promise?

Food production since the 1940s increased

Global Population Ageing: Peril or Promise? 5

Figure 1: Ageing is accelerating worldwide Table 1: The top 10 for ageing

Table 2: Developing countries ageing fastest

30 Source: UN, World Population Prospects: The 2010 Revision

Japan China USA

Source: UN, World Population Prospects: The 2010 Revision

6 Global Population Ageing: Peril or Promise?

Global Population Ageing: Peril or Promise? 7

8 Global Population Ageing: Peril or Promise?

Global Population Ageing: Peril or Promise? 9

10 Global Population Ageing: Peril or Promise?

Global Population Ageing: Peril or Promise? 11

12 Global Population Ageing: Peril or Promise?

Box 3: Opportunities arising from a longer, Acknowledgements

healthier life This book is a product of the World

Caring and family cohesion. Older people, particularly women,

Global Population Ageing: Peril or Promise? 13

14 Global Population Ageing: Peril or Promise?

Chapter 1 A Cultural Problem

Global Population Ageing: Peril or Promise? 15

16 Global Population Ageing: Peril or Promise?

Understanding the Meaning of Age Endnotes

We argue for a three-pronged approach:

Global Population Ageing: Peril or Promise? 17

Chapter 2 A Profound Impact on Financial Security

While changes have been implemented in retirement schemes over

18 Global Population Ageing: Peril or Promise?

Global Population Ageing: Peril or Promise? 19

There is considerable debate about whether we have entered a “new Endnotes

20 Global Population Ageing: Peril or Promise?

Chapter 3 Figure 1. Proportion of women among persons aged 40-59, 60+,

Women and Ageing 82%

Saadia Zahidi 64%

Global Population Ageing: Peril or Promise? 21

22 Global Population Ageing: Peril or Promise?

access to economic activity is necessary for 40

including in particular older women for the Chile Thailand

security and social status during their old 10