AnotherdefinitionAGEING IN MALAYSIA NATIONAL POLICY AND FUTURE …：马来西亚的民族政策和未来老龄化…

AGEING IN MALAYSIA:NATIONAL POLICYAND FUTURE DIRECTION

By

Ong FonSim

Faculty of Business and Accountancy

University of Malaya

KualaLumpur

May,2001

1. INTRODUCTION

In 1990,9%or almost half a billion of world population were over 60 years old.By 2030, this figure is expected to increase to 1.4 billion(World Bank, 1994).Due to thebroad diffusion of medical knowledge and the resultant improvement in health,as wellas declining fertility,developing countries are ageing much faster than the developednations.At present,although the Malaysian population has not reached the ageingproportion, the ageing phenomenon will eventually occur.By year 2020,9.5%of itspopulation will be 60 years and over.The time span taken to reach an ageing societymay be hastened with the continuous improvement in the medical field, the availabilityand accessibility of health care, longer life expectancy as well as declining birth rate.

According to the United Nations World Assembly on Ageing held in Vienna, 1982, “60years and over” is the cut-off age used fordel iberating issues on ageing In Malaysia,pol icymakers have adopted this demarcation in formulating and implementing plans for its seniorcitizens For the purpose of this report, the cut-off age of 60 is used although the retirementage of 55 seems to suggest that the threshold to ageing begins at 55 years of age in Malaysia

Major sources of ageing include decl ining ferti l ity and mortal ity rate, improved healthand l ife expectancy Hence, indicators of ageing include increase in median age of thepopulation, longer l ife expectancy,and proportion of dependency ratio of elderly peoplecompared to the proportion of youth dependency Malaysia, just l ike otherdeveloping

countries in the world, has been experiencing improved health, longer l ife expectancy, lowmortal ityas wel l as decl ining ferti l ity The effectof al l these changes has broughtabout achange in the demographic profi le of its population Overal l , the age structure for the pastthree census, 1970, 1980 and 1991 ,shows that the proportion of younger age groups(15years and below) is decreasing whi le the proportion of elderly is on the rise The median agewas 174 in 1970,21 9 in 1991 and is projected to increase to 271 in year 2020 Within aspan of 30 years(from 1991 to year 2020), the median age increased averagely by 1 7 perdecade The old age dependency ratio is expected to increase to 157 in 2020 from 105 in1970 This is high compared to otherASEAN countries such as Indonesia(101),Thai land

(134),and the Phi l ippines(90),except Singapore,which has an even higher ratio of old agedependency(239)whi le Japan has a dependency ratio of 41 5 Overa period of 50 years,the median age of Malaysian population wi l l increase by 10 whi le the old age dependencyratio,by 5(Department of Statistics, 1998) Currently,Malaysia‟s population may beconsidered as“youthful”as projections from the 1990 Census shows that 61%of the totalpopulation was 60 and above(Department of Statistics, 1998) By year 2020 Malaysia wi l l bea matured societywith 95%of its population aged 60 and above Although the rate ofincrease of its ageing population is not as phenomenal as in countries such as China andSingapore, the considerably rapid and huge increase in the proportion of elderly people wouldmake it impossible forthe government to ignore the impact of social and economic changesbroughtabout by population ageing

Objectives and Scope of Report

This report is the countrystudyof ageing in Malaysia and it is a component of thebigger research project coordinated by Lingnan University,Hong Kong, forAsia DevelopmentResearch Forum(ADRF)Asia Pacific Ageing Research Network(ARN) The main objectiveof this report is to review national pol icy on ageing The fol lowing issues are specific to thisre p o rt:

Review of the situation of ageing in Malaysia from the perspectives of socialsecurity, health,and community care and social services;

Review of pol icies and programs for the elderly;

Examine the main features of the pol icies and programs;

Examine the role of civi l society or NGOs in providing inputs into the formulation ofpol icy;and

Discuss the l ikely developments with respect to pol icies and programs fortheelderlyand suggest recommendations forthe consideration of pol icy makersMethodology

This report rel ies heavi lyon secondary data as wel l as discussions and interviews withexperts in specific areas such as social security, health care and social services As issuesconcerning the elderly are multidiscipl inary in nature,data and information are obtained fromdifferent ministries and departments Data pertaining to the elderly are drawn from thepopulation census conducted in 1980 and 1991 The census conducted in year2000 has yetto be publ ished The onlydisadvantage about using the census is that itdoes not coverdetai ls about issues specificto the elderlysuch as their health status (morbidityand mobi l ity,activities of dai ly l iving etc), their contribution towards society and fami ly, involvement in socialand charitable activities etc Where data gaps exist, they are supplemented with researchfindings from smal lerstudies with l imited geographical coverage Although these studies maybe smal l , the findings provide useful information and hint at impl ications for pol icy makingLiterature Review

Population ageing is represented byan increase in the relative numberof olderpersons in a population Treatment of population ageing is compl icated bythe fact thatpopulation ageing is a concomitant of the approach of a population to stationarity,and thatsome effects of each phenomenon are reinforced by those of the other (Clark and Spengler,

1980)A common definition of ageing is the cut-off age of“60 years and over”Anotherdefinition refers to those over retirement age,which is usual ly measured by the age at whicha person is el igible for pension(Tinker, 1996) In the United Kingdom, the retirementage is 65,whi le the European Commission uses 60,and the United States of America Bureau ofCensus,55(Tinker, 1996) However, it has been stated that whatever cut-off age is selectedto define the“elderly”population, it does not adequately define the diversity and complexity ofski l ls,attitudes, needs and potential of this group of people(Arokiasamy, 1997)

The U S Bureau of Census (1996) projected that by year 2025 the phenomenon ofageing would have spread across the North American Region as wel l as the Asian regionThe increase in the 60-and-over population in the industrial ized nations of Europe and NorthAmerica has general ly outpaced total population growth in recent decades

The proportion of older persons to the total population differs between Asiancountries, from about 4 percent of the population in Cambodia to about 20 percent in Japan(WHO, 1998) Less developed countries in the Asian region show that growth rates of theelderlyaccelerated sharply after 1960 By 1995, the population of those aged 60 and above inAsia was almost comparable to that of the world, at about 9 percent By 2050,Asia isexpected to have 20 percent of its population over the age of 60 years, compared to theglobal percentage of 16 percent (WHO, 1998)

Malaysia has not been spared from demographic transition as experienced worldwideCrude death rates decl ined from 124 per 1000 population in 1957 to 47 per 1000 populationin 1990 Infant mortal ity rate also fel l from 76 per 1000 l ive-births to 12 per 1000 l ive-birthsand the expectation of l ife at birth increased from 57 years to 71 2 years over the same period(Department of Statistics, various years) As a result of this demographic transition, anincreasing proportion of the population is at risk of certain chronic health problems This isassociated with a change in morbidity and disease pattern from one of mainly infectiousdiseases to one where chronic degenerative and non-communicable diseases predominateIn addition to this epidemiological and demographic transition, socioeconomic developmentalso brings about changes in l ife style, behavior and environment which lead to changingpatterns of risk to the population (World Health Statistics Quarterly, 1990) The first majorstudyon ageing took place in Malaysia in 1985 under theWorld Health OrganizationSocial Security

Old-age pension schemes have become social institutions in many, if not most,countries throughout the world The goal of these schemes is to provide al l qual ifyingindividuals with an income stream during their retirement years, which is continuous,adequate, constant (in terms of purchasing power) and capable of maintaining the socio-economic position of the retired in relation to that of the active population (U S SocialSecurity Administration, 1994) The importance of social security schemes increased with theincrease in l ife expectancy Cowgi l l and Holmes(1972 in Ogawa, 1994)pointed out that withmodernization, the responsibi l ity for the provision of economic security for the dependentaged tends to be shifted from the fami ly to the Government As development proceeds, thesource of old-age security for the aged is l ikely to be switched from the fami ly support systemto publ ic support system(United Nations, 1994) Ogawa (1994) in his report, cited a studycarried out by the ILO and World Bank in the 1980s for selected countries (both developedand developing regions) to i l lustrate that there are substantial differences in the developmentof social security schemes among different countries even when their economic developmentare comparable This study regresses social security benefits relative to GDP and per capitaincome Findings suggest that the compositional change in sources of support for the elderly

over the course of economic development is affected by a number of non-economic factors,including demographic, socio-cultural , ideological and historical ones This study found thatsocial security programs in the developing world have l imited coverage Studies by Martin

(1988)and Jones(1988) further substantiated this point Theyfound that only 3 percent of theworking population is covered by pensions in Thai land, 1 1 5 percent in Indonesia, and 228percent in China In other developing countries in Asia, these figures were correspondinglyhigher:50 percent in Sri Lanka,532 percent in the Phi l ippines,and 83 percent in Singapore

For developing countries, the financing schemes are usual ly different from thoseadopted in developed nations Provident fund systems are widely employed in developingregions,whereas pay-as-you-go schemes are general ly in operation among the developedcountries (United Nations, 1994) Provident funds are commonly adopted in former Britishcolonies including countries in Asia, such as India, Singapore and Malaysia Singapore‟sCentral Provident Funds works on roughly the same principles as the Malaysian EmployeeProvident Fund(EPF Website)

Health Care

Health is defined byWorld Health Organization as the state of complete physical ,mental and social wel l-being(WHO, 1995) This hol istic account is one very broad viewthatmeasures the state of complete physical ,social and mental wel l-being(WHO 1985)On theother hand, there is the simple and narrow definition of biomedical account of health,whichsimplyrefers to the absence of disease(Sidel l 1995)Whi le the simple biomedical measurelooks only at the physical aspect, the state of health,which determines the state of wel l-beingis definitely a far more encompassing domain than mere physical health,albeit theinseparabi l ity of one from the other Bowl ing(1991)points out that there is a confl ict betweenresearchers and pol icy makers in relation to the definition and measurement of health Pol icymakers desire straightforward,quantitative measures of health whereas researchers are moreincl ined towards qual itative measures A move towards self-ratings of health is preferred overthe expl icit indicators of health(Sidel l 1995) Certainly some balance between these twoapproaches is desired

Forthe purpose of this study, the physical health status of the elderly is assessed bylooking at three subcategories of physical health: (1)general physical health, (2) the abi l itytoperform basic self-care activities,and(3) the abi l ity to perform more complex self-careactivities that al low for greater independence(Kart 1997) The other aspect of health,socialhealth is related to sense of belonging and state of felt lonel iness Mental health refers to thecapacity of individual , the group and the environment to interact with one another to promotesubjective wel l-being and optimal functioning,and the use of cognitive,affective and rationalabi l ities towards the achievement of individual and col lective goals consistent with justice

(Ministryof Health,Malaysia 2000) Depression,which is a publ ic health problem,appears tobe the most common of the functional psychiatric disorders in the later years,yet it is notoften recognized in older people(Kart 1997:126) Dementia dominates old age psychiatry

Few elderly persons escape the accumulation of chronic pathologies and long termnon-fatal diseases,which are degenerative in nature,as they grow older Consequently,multiple pathologies resulting in multiple symptoms are a common phenomenon among theelderly(Arokiasamy, 1996) They are at risks under the circumstances of a lack of pol icies,orat best, inadequate publ ic pol icies, that could at least ensure some degree of qual ity of l ife inold age Health care is not a problem to the wealthy as they have the means to purchasewhereas forthose who are certifiably poor, they have to depend on city hospitals and cl inics(Kvale 1996) Especial lyfor the case of olderwomen, in which ageing approaches what istermed the feminization of ageing(Butler and Gleason 1985), they are l ikelyto face greaterrisks From the findings of several studies in Malaysia,women remain widowed, no financialsecurity,and experience greater health problems when they enterthe old-old category

In response to the health care needs of the elderly,geriatric medicine,defined bytheBritish Geriatrics Society as„that branch of general medicine concerned with the cl inical ,rehabi l itation,social and preventive aspects of i l lness and health on the elderly‟ , has beendeveloped The aim evolves from the curative to the preservation and restoration functionMany of the degenerative diseases of old age are not responsive to curative actions and theimportant goal is to enable an elderly person to function effectively in the environment of theirchoice as long as possible

Programmes have been developed throughout the Asian region for health of olderpersons The demographical ly“middle-aged”newly industrial ised countries and areas,whichshowclearevidence of population ageing,such as Hong Kong,China and Singapore, havetheir own systems The rapidlydeveloping countries,such as Malaysia and the newlyindustrial ized economysuch as the Republ ic of Korea, have made recent initiatives in thedevelopment of health services for older persons(ILO, 1997)

Community Care

Institutional care brings to mind the thoughtof old folks‟homes One of the maindevelopments in terms of care forthe elderly is the shift from institutional care to what isloosely cal led community care(Tinker, 1996) Explanations for this shift are: firstly, there wereviews about the positive value in terms of qual ity of l ife of being at home There was a generalreaction against institutional care,which led to the bel ief that alternatives were made avai lablefor both existing and potential inhabitants of institutions Secondly, there were practical

problems such as difficulty in obtaining manpower Third, there was no necessity to separatethe elderlyfrom society Fourth, the cost of institutional care is rather high Final ly, there wasa growing recognition that people had the right to l ive among society and not isolated in aninstitution(Tinker 1996)

There seems to be a lack of satisfactory definition of community care and someconfusion to its meaning There is a narrow definition of community care as the provision ofdomici l iary rather than institutional services and there is the i l l-defined cozy picture of a groupof local people „caring‟ for their neighbors (Tinker, 1996) The wider definition of communitycare came from the Seebohm Report (Tinker 1996) The official definition is community carerefers to treatment and care outside hospitals or residential homes(Home Office et al 1968 inTinker 1996) It was also noted that the notion of community care impl ies the existence of anetwork of reciprocal social relationships,which among other things ensure mutual aid andgive those who experience it a sense of wel l-being These community services includecommunity nursing, occupational and speech therapy, physiotherapy and pharmaceutical ,ophthalmic, chiropody and dental services and services for people with hearing loss Theseservices are highlyvalued by patients but are often overlooked in long term planningOrganization of Report

Section I introduces the broad situation of population ageing around the world and inMalaysia It also states the objectives of study,describes briefly the methodology employed,and reviews the l iterature on ageing In Section I I , the profi le,demographic,economic andhealth,of the elderly brings forth the real ityof ageing in Malaysia The National Pol icyfortheElderly 1995 is outl ined in this section Ageing, requiring a multidiscipl inaryapproach hastobe examined from different perspectives:social security is discussed in Section I I I , healthcare in Section IV Community and social services are briefly presented in Section V,whi ledetai led discussions on community care wi l l be covered in the second part of the reportunder “Long-term Care” Section VI discusses the impl ications of ageing and presents theconclusion and suggestions forfuture direction in preparing for an ageing society

2.PROFILE OFAGEINGAND NATIONAL POLICY FORTHE ELDERLYProfi le of Ageing

Ageing by Geographical Distribution

Within the nation, the rate of growth of senior citizens is different,with the ruralpopulation facing a higher rate of growth compared to the urban population In 1991, the rateof growth of ageing population in the rural areas is 65%compared to 53%in the urban areas(Department of Statistics, 1998) This is due in part to the out-migration of young ruralpopulation to the urban areas in search for employment and education opportunities, leavingbehind the elderly The states that have a higher incidence of ageing include Perl is,Perak,Melaka,Pulau Pinang,and Kedah, in which the proportion of ageing population is 7%compared to the national average of 59%in 1991 (Department of Statistics, 1998) Statesthat receive large numbers of internal migrants,who are usual ly young,as wel l as foreignmigrant workers show a significantly lower proportion of elderly people These states includeSelangor,Federal Territory of Kuala Lumpur,Sabah,and Federal Territory of LabuanEthnic Variations

Due in part to the inter-group socio-economic differences,as wel l as the influence ofhistorical , institutional ,and economic factors,experiences of demographic transition vary inboth intensityand timing among the three majorethnicgroups Among them,ageing issignificantly more serious among the Chinese than the other two groups Table 1 gives anindication of differences in the ageing situation byethnic groups and stratum In 1991,76 percent of the Chinese were elderly,a percentage that was much higherthan the proportions ofseniorcitizens among the Malays(54 percent)and Indians(54 percent) This is due totheprevalence of low mortal ity and longer l ife expectancy among the Chinese whi le the lowferti l ity reduced the number of young population substantial ly This two-way effect has beenaround fora much longer period forthe Chinese than the otherethnicgroups This trend isexpected to continue and the proportion of elderly Chinese is projected to be around 144 percent in the year2020 The proportion of Indian senior citizens is projected to be 104 per centin the same yearwhereas the Malays wi l l have 79 per cent of seniorcitizens in 2020

Table 1:Percentage Distribution of Senior Citizens by Ethnic Group and Stratum,

Malaysian 1991 and 2020

Ethnic Group

Source:SeniorCitizens and Population Ageing in Malaysia,Departmentof

Statistics, 1998

Variations by Age: the Young-Old and the Old-Old

The elderly are classified into two groups, namely, the young-old(60-74 years)andthe old-old(those aged 75 and above) The 1991 Census recorded 813 thousand young-oldwhi le the old-old were numbered at 219 thousand(Department of Statistics, 1998) Comesyear 2020, the number of old-old is expected to increase to 574 thousand whereas the young-old is estimated at 2,635 thousand(Table 2) The growth rate wi l l be 39 and 45 per centrespectively, forthe old-old and the young-old This shows that the young-old is expanding ata faster rate than the old-old suggesting that the trend wi l l exhibit an upward turn once thecohort of young-old advances in age

The proportion of young-old and old-old differs among the three major ethnic groupsThe Chinese community has a much higher proportion of old-old persons compared to theotherethnic groups Among the elderly population, the proportion of old-old was 261 percentfor the Chinese, 185 percentfor the Malays and 177 percentforthe Indians in 1991 It isthus clear that the ageing phenomenon is more acute among the Chinese than anyof theother ethnic groups(Table 3)

Table 2:Num‘ber-and’ Percentage of Senior Citizens in‘Young-old–’ (60-74 years)and

Old old (75 years and over)Cohorts,Malaysia, 1980 2020

Year