Better care solutions for elderly in Shanghai

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The Rotterdam Department of Social affairs and Employement invited me to speak at the Shanghai seminar on elderly care and assessment. An invitation I could not refuse. I spoke about the challenges of social policies in our ageing European societies. Shanghai is a megapolis with the highest percentage of elderly people in China. Shanghai has a registered population of 13.342.300 inhabitants.

Conferentie Shanghai april 2004 - Klik voor vergrotingShanghai is a megapolis with the highest percentage of elderly people in China.
Shanghai has a registered population of 13.342.300 inhabitants.
Rotterdam and Shanghai have a twin city relation since 1989. The project Better care solutions for elderly in Shanghai started in 2004. The seminar was part of the project.

Challenges of social policies in our ageing societies in Europe

Shanghai 14-15 april 2004

I am very pleased and honoured to speak to you today in this beautiful city and on a very important issue of social policies in our ageing societies. I will focus on the implications of an ageing society, or to put it more pro-active, the challenges of social policies in our ageing societies in Europe.
As a - former- Senator and member of the Parliamentary Assembly of the Council of Europe active in social policies, migration and gender issues, and as a Green politician I will not only focus on finances and pension systems but I will also take the social, cultural and environmental challenges on board.


As fertility continues to decline and life expectancy rises, Europe is currently at the forefront of the population ageing process in the world. Both the European context of population ageing and depopulation on the one hand, and the world context of accelerated population growth, on the other, represent considerable economic, social, cultural and environmental challenges and require concerted political action over the short, medium and long term.

Reforms necessary to respond to the challenges of ageing societies in Europe ought to be part of a wider political debate in order:
to create conditions for active ageing in good health;
to make pension systems viable;
to reform healthcare services while guaranteeing access and quality of care;
to increase levels of employment of the working age population;
to improve working conditions in order to reconcile paid work with family life; to achieve more equal sharing of paid and unpaid work between men and women; and finally reduce labour costs through a shift in taxation.

In the long term, the process of ageing will necessitate not only fiscal reforms, reforms in social welfare policies, and reforms in employment patterns, but also changes in attitude and redefinition of individual and societal values.

My talk today can be divided in three parts.
First I will talk about demographic trends and evolution of labour markets in Europe.
Secondly I will talk about the policy implications to offset negative effects of ageing and last but not least I will give a vision for the future.

1. Demographic trends and evolution of labour markets in Europe

Conferentie Shanghai april 2004 - Klik voor vergrotingEurope has been leading the process of population ageing. I said that before.
Life expectancy has been increasing throughout the 20th century and the causes of death have largely shifted from infectious disease to senescent deterioration. As a consequence, younger elderly people aged between 65 and 75 years today reach the third age in relatively good health and the bulk of elderly live under conditions of income security.

The population aged 60 or over in Europe constitutes today about 20% of the population. By 2050, it will most likely account for 33%. The older population has already surpassed the child population (aged 0-14) and by 2050 there will be 2 older persons for every child (16% of the population).

The impact of population ageing is increasingly evident in the old-age dependency ratio, the number of working age persons ( age 15/16- 64 years )per older person that is used as an indicator of the " dependency-burden " on potential workers. Between now and 2050 the old-age dependency ratio will double in developed regions and triple in less developed regions.
The potential socio economic impact on society that may result from an increasing old-age dependency ratio is an area of growing research and public debate.

Very important to note is, that as the tempo of ageing in developing countries is far more rapid than in developed countries, developing countries will have far less time than the developed countries to adapt to the consequences of population ageing.
In a given context of long-term decline in the working age population in Europe, with an ageing work force and an ageing population, and increasingly elderly dependency ratios, it remains to be seen, however, whether future economic conditions and technological changes will create additional job opportunities and increase the demand for labour.
Current statistics on unemployment in Europe show that human resources are not being used to their full potential. Many people of working age are economically inactive. While people out of work may be involved in making other contributions to society, for example through volunteering, caring for the young and elderly or learning, many suffer social exclusion and are more likely to experience low self-esteem and poverty which can lead to disillusionment, depression and ill health.
The labour force participation rate for men has declined in all European regions since the 1970s, while the corresponding rate for women increased.
The relationship between women's labour-force participation and fertility has been a long-standing issue in demography.
Fertility decline in Europe correlated historically with child mortality, urbanization, education and more recently with increased employment rates for women and higher income.
In Western Europe, the fall of fertility has been accompanied by progressive postponement of child-bearing and first marriage. A longer education for women, increased participation in the labour market for younger women, more gender equality and all the social and cultural conditions that characterise so-called post-modern development are associated with later fertility.

In the former socialist regimes of Central and Eastern European countries, governments had encouraged a strong integration of women into the labour market, based on the principle of gender equality. But given the difficult economic situation and low wages, for a comparatively large segment of women, employment was a necessity as well as being normatively expected. Although family policies and provision of state day-care services were able to compensate to some extent, the combination of work and family obligations represented a dual burden for women, which led to lower levels of fertility. More recently, the period of economic transition went in hand with an increase in individual insecurity and a loss of trust in traditional institutions. A dramatic drop in fertility rates has been one of the consequences.

In countries of more advanced development and a strong welfare state such as Scandinavian countries, better conditions for women and greater institutional support are reflected in "modern" patterns of behaviour which are more compatible with fertility. This means that institutional factors can indeed help to reconcile the desire to have children with the changes in the types of union, the later timing, and women's aspirations as regards fulfilling their life both in the family and through a working career.


2. Policy implications to offset negative effects of ageing

Reforms necessary to respond to the challenges of ageing societies ought to be part of a wider political debate.

All European governments are currently faced with the difficult task of harmonising two relatively opposing trends: pressures of a globalised economy to contain public expenditure and reduce labour costs in order to remain competitive; and a justified demand by European citizens to strengthen the European social model as a basis for a stable and socially prosperous Europe.
In order to sustain pension schemes, healthcare systems and social protection in the future, one of the prime objectives of the reform is to contain or decrease the dependency ratio between the economically active population and the non-employed population (= the unemployed, those in retirement, young people, men or women acting as family carers or those suffering long term illness).

Social policy at the EU level was for a long time limited to just a few domains, I name migrant workers and gender equality.
The time has come to rethink social policies in Europe in order to take up the above mentioned challenge. And the EU took up that challenge in 2001.
In that year the European Union finally defined common objectives to be realized in the field of pensions.

Most of the resources available to older people are provided by pension systems. They are usually divided into three distinct pillars: statutory public schemes, occupational schemes, and individual retirement provision (savings, life insurance).
In the overall package of support to people after retirement, pensions represent the largest share, and the main sources of pension income today are statutory public pension schemes.

To guarantee accessibility to pension systems the main objective of the EU.

This meant in detail that systems of the first, second and third pillar had to be developed and that accessibility for everybody had to be guaranteed.
This was rather unproblematic for the first pillar - the statutory pension system.
The second pillar - occupational systems - were only well developed in a few member states.
The same is true for the third pillar - the private pension insurance schemes.
All three pillars had to be developed in a way that they are accessible for a maximum part of the workforce.
This objective has different impact on the various pension systems of the member states. In some member states, systems of the second and third pillar are well established in the pension system. In others, the statutory pensions are the only source of income for retired people.
For example - the United Kingdom and Denmark had no problem to realize the objective of accessibility, because they already had a well-developed three pillar system, whereas other member states (like Germany) just began to introduce the second and third pillar system. In general one can say that systems of the second and third pillar are still underdeveloped in the member states of the EU.

There is a growing consensus that the transition towards retirement should be made more gradual and flexible, allowing for part-time work, self-employment, volunteering, informal care, etc.
However, the compatibility of different types of activities and diversified payments still remains to be regulated.
Pension schemes also have to adapt to changing employment and family patterns. Self-employment, short-term employment, agency work and other types of more "flexible" labour are emerging in response to new demands of the economy. In addition, career breaks or spells of reduced working time are nowadays more frequent for both men and women. They reflect the periods of time spent in further education, career change or unemployment, childcare or informal care of the elderly and sick. Moreover, such "flexible" employment patterns are often less regulated in terms of social protection and pension insurance. This gap remains to be filled in by new regulations.

The sustainability of pension schemes cannot be reduced to the financial dimension, but is subject to a multiple challenge: that of meeting their social aims, ensuring their viability, and responding to the changing needs of society and individuals.
With a wider-ranging approach, the changing role of women in society, more flexible labour markets, greater individual choice and different family and household structures will be addressed more appropriately in the national reform programmes.

The European Union did not confine itself to just regulate the field of pensions, the field of health care and care for elderly is also under consideration. The Commission of the European Union suggested three objectives for the open coordination in this field. These objectives are accessibility, quality and financial viability.

Accessibility means to most member states, that it is necessary to improve the provision of home care. Most elderly people in need of care prefer to live in their home as long as possible. Home care is less expensive than nursing home care and serves thus the objective of financial viability.
In several member states it is necessary to improve the provision with nursing home care. This is especially the case in those member states where waiting lists for nursing homes are long and where the high costs have to be paid by the clients themselves.
In addition to this, it is necessary to improve the diversity of care provision in all member states: Services like sheltered housing or senior flat share have to be introduced or improved. An attempt for better accessibility can be made by giving people more freedom of choice.

The question of quality is debated both in academic and practical circles. The policy of European Union for quality improvement has been concentrated on quality standards in the private sector. More and more quality standards are applied to social service providers, too.

To promote healthy ageing, health systems need to provide equitable access to primary care and a balanced approach to long-term care.
Integration of health and social services is crucial.

Long-term care has evolved from a mix of activities undertaken by informal carers (family, friends and neighbours) and/or professionals (health and social services) to ensure that a person who is not fully capable of self-care can maintain the highest possible quality of life.
The long-term care therefore includes both informal and formal support systems.
They may cover a broad range of community and public health, primary care, palliative care and rehabilitation services as well as institutional care in supportive housing or nursing homes, and treatments to halt or reverse the course of disease and disability.
Mental health services should be an integral part of long-term care.
One of the greatest challenges in future health policies will be to strike a balance between support for self-care of the elderly, informal support through family members or friends, and formal care through health and social services.
Governments ought to develop specific measures to support informal care, through support services to carers and greater recognition of informal care (compatibility with employment, access to social protection and benefits, etc.).

In the long run, there can be expected several developments, not just due to the objectives of the European Union, but also because of the demographic changes in the member states and the subsequent increase in demand for care.

First, there will be a higher coordination in the field of care, probably ending in the institutionalisation of a social care system, as it already exists in a few member states. This development will also support quality and financial controls in care.

Second, there is a trend towards cash benefits. This gives clients or patients a greater freedom of choice and it enables higher financial transparency.

Third, the orientation towards home care and other forms of independent living will increase. This also means that nursing home care will be confined only to those who need high medical treatment in addition to care services.

Fourth, the readiness and ability of families to care for their relatives will keep decreasing. Women participate more and more in workforce, family structures are dissolving further on and therefore a lesser extent of family care can be expected. Care has to be „marketized" for that reason. This means there will emerge a large share of for-profit-organisations that provide care.
To support the ability of people to afford this kind of care, cash benefits can play an important role.

Fifth. Prevention becomes more important.
The care system will not only be a problem solver. It becomes more important to be a problem avoider too. People should live a healthier life to avoid to get in need of care at early stages of life.

Ageing societies also have an effect on the labour force.
Training and continuing education are crucial in helping older workers to adapt to changing demands and opportunities to avoid their involuntary early retirement. The demand for new skills and knowledge places older workers at a disadvantage, as their training earlier in life is likely to be obsolete with rapid changes in technology and production patterns.
Age discrimination underlines many of the difficulties faced by older workers. The ability of older workers to learn new skills is sometimes questioned and these biased attitudes defy the efforts of older workers to find new employment.

3. Vision for the future

Regarding population ageing, I would like to emphasise that the European debate ought to be placed in a global perspective.
While the European population is projected to decline in the course of this century - having risen from 548 million in 1950 to 727 million in 2000, it is projected to decline to 603 million in 2050 - the population of the less developed regions is projected to rise steadily from 4.9 billion in 2000 to 8.2 billion in 2050, bringing the world population from 6.1 billion today to 9.3 billion people in 2050 (medium projection).
In other words, the world population is expected to grow by 50% in the next 50 years.
Many ecologists and scientists wonder about the ecological consequences of this kind of growth.
Within the next twenty-five years, scientists should know if the trend towards global warming, ozone depletion, and species extinction is continuing as they will be able to estimate the damage with more certainty and precision.

In a publication of the United Nations Population Fund entitled "Footprints and milestones: population and environmental change" it says - I quote -
"A child born today in an industrialised country will add more to consumption and pollution over his or her lifetime than 30 to 50 children born in developing countries.
The "ecological footprint" of the more affluent is far deeper than that of the poor and, in many cases, exceeds the regenerative capacity of the earth."
Measures to reduce waste, conserve energy, curb pollution and promote sustainable use of natural resources are essential for sustainable development in the future.
Parallel measures will also be needed to stabilise global population growth.

Twenty years after the first Earth Summit, scientists have made certain progress in evaluating the environmental costs to growth and development.
In most cases global consumption already exceeds the sustainable rate, even though in many countries per capita consumption is low.
If countries such as China increase consumption to northern levels, the planet's carrying capacity will be exceeded many times over and the effects will be catastrophic for everyone.
Should the risk prove threatening to human culture and survival, then an ecological tax ought to be placed upon those resources and the money generated should be used to develop, and install, ecologically safe technology.
Switching some of the revenue burden from taxes on income and employment, to environmental charges on resources, waste collection, and pollution would yield double economic benefits.
The environmental cost that is currently imposed on society would be covered by polluters. This trend would have far reaching consequences for the global economy and consumption patterns. As energy prices would rise, transport costs would be affected, making local production and use of the local workforce much more economically viable.

In conclusion.
As our societies grow older, there will be a growing need to strengthen social welfare as well as levels of individual solidarity.
Human resources in formal healthcare will not be able to cope with future needs unless coupled with informal care provided by families, friends, or volunteers in local communities.
Perceptions and attitudes towards senior members of society will have to change too - no longer perceiving them as passive members of society that represent a social and financial burden, but instead fully recognising their value and contribution in knowledge and experience. Opportunities for diverse types of more active involvement in society remain to be developed.

The increase of women's participation in employment calls for a more equal share of unpaid work between genders. Perceptions and attitudes towards family responsibilities, childcare, involvement in informal care and volunteering will have to change too. The value of unpaid work to society will have to be fully recognised and reflected in new and more flexible patterns of employment for both women and men.

Collective and individual efforts are needed to strengthen solidarity in all its forms:
individual solidarity through informal care, volunteering or community involvement;
intergenerational solidarity through mutual support between generations; solidarity brought about by public policy concerned with social cohesion and the redistribution of wealth; and,
finally, international solidarity in making the distribution of wealth, the use of resources and the ecological footprint more equitable.

I thank you for your attention.

Ans Zwerver, April 2004.

1 reactie

Ans,
Ik ben zelf ook weer terug.
Ik wil namens SoZaWe Rotterdam nog bedanken voor je bijdragen in het programma in Shanghai.
Je speech tijdens het seminar was een prima en duidelijk verhaal, dat ook aansloeg.

Rene van Sluijs

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