This book presents an in-depth analysis of population ageing and the attendant policy challenges in Singapore, a small, successful and self-confident city state in the Asia-Pacific region. The author, David Reisman, is a Professor of Economics at Nanyang Technological University in Singapore and Professor Emeritus at the University of Surrey in the United Kingdom. He uses economic arguments to highlight what may be unpalatable conclusions about the growing pressure of old people on health and welfare resources. As claimed, the book indeed presents an original and challenging cross-disciplinary analysis of potential disruptions to the economy, society and even the political status quo if the challenges of ageing are not faced.
As outlined in the Introduction, the consequences of ageing in Singapore are explicitly presented as a growing problem, a characterisation that may not particularly appeal to those looking for a more positive and harmonious view of the success of ‘ageing policies’ in the region. Chapter 2, ‘Old and ill’, sets the tone and ‘summarises the problem’, which is that a still-ageing population will place ‘disproportionate pressure on scarce resources that have alternative uses’. Singapore's very low birth rate, as in some other Asia-Pacific countries, is a prime demographic cause of population ageing. Chapters 3–6 provide detailed and authoritative discussions of the nature and evolution of the health and social security system in Singapore. Chapter 3 considers Singapore's famous Central Provident Fund (CPF) that dates from the mid-1950s and that many see as the ‘centrepiece of Singapore's social economy’, a form of compulsory savings. Singaporeans pay into their CPF accounts for retirement and other purposes including contributions to home purchase. This chapter gives a helpful analysis of the CPF system, which Reisman explains has sought to avoid the pitfalls of both United States Social Security and British National Insurance.
Chapter 4 examines the forms of and principles underlying health policy in Singapore, which has a very special place in the nation, and the issue of affordable health care. The system's tenets are the promotion of good health, the inculcation of responsible attitudes and universal access to basic care, but with a move toward market competition and cost containment. The author does not shrink from addressing issues of income inequality and the high percentage of household expenditure that will need to be devoted to medical care. Chapter 5, ‘Payment for health: Medisave’, continues the CPF discussion and examines the Medisave accounts into which Singaporeans are required to pay. These are drawn on to cover the costs of care, but the saved amount might be insufficient. Chapter 6 continues the theme of paying for health care, and examines two other Singapore ‘Ms’, the MediShield fund, a state insurance that involves risk-pooling, and the Medifund, a sort of state charity. This helps to guarantee basic care for the poorest, as a public-sector safety net for desperate and destitute people that have very low incomes and no family able to help. Important questions are raised about the adequacy, quality and long-term coverage and sustainability of Singapore's 3 M framework, which is acknowledged to be far from perfect, but what system is? This part of the book will make interesting reading for researchers of comparative social-care and health-care financing.
The remaining chapters take readers more into the world of family, life and work in Singapore. Chapter 7 provides some background to the home, family and intergenerational context of Singaporeans, comparing them with examples from other regional countries such as Japan. In Singapore, the families' ‘many helping hands’ have long been held a key source of support in old age. A major question, however, is whether future smaller families with longer-living relatives will still be able to play such an important role. Will the State be able to replace or supplement? Inter-generational relations, altruism and filial piety are enshrined in law. Singapore is renowned for having a Maintenance of Parents Act, dating from the mid-1990s, which established a system of tribunals to encourage children's duties and responsibilities should parents need assistance. Asian solutions to the replacement of filial duties, for example by employing domestic helpers, are also discussed. Chapter 8 considers assets, capital and property, and the worldwide vexing issues of how much people should save for old age and how to unlock cash from their homes, considering options such as equity release, trading down and renting. Chapters 9 and 10 discuss issues relating to retirement and the possible labour shortages that Singapore anticipates. Can older people take over the jobs unfilled because of the low birth rate and falling supply of young workers? Will imported labour be maintained and can retirement age be increased and work reappraised to help address shortages? Surveys have found that retired people in Singapore are relatively happy, and willing to accept a modest fall in standards of living in exchange for a quieter and easier life. International stereotypes notwithstanding, there is often something to do in Singapore.
In Chapter 11, the Conclusion, the author revisits the case for regarding population ageing as a problem in Singapore. The country spends relatively little per capita on health care. The State pays for just over one-third of health-care expenditure and two-thirds of spending is individual and private, approximately the inverse of the situation in many OECD countries. Singapore's future demographic profile will be very different, however, because the population aged 65 or more years will increase by some 370 per cent between 2000 and 2030 and, by 2050, almost 40 per cent of Singaporeans will be aged 60 or more years. Will families be able to continue providing care? Will there be intergenerational conflicts? Will State intervention be the only way to correct a social failure? Reisman suggests that having to be clear about policies and spending for older people and the ill may be the catalyst that forces Singaporeans to reassess what they expect from the State.
The book has an extended bibliography that reflects the author's discipline and focuses on economic and expenditure aspects but overlooks some broader Singaporean, regional and global texts on demographic ageing and gerontology, which might have provided greater social and cultural context for the analysis. There are also relatively few citations to the various internet resources now available on population and ageing-related topics, especially from the United Nations and other international organisations and agencies. Some readers may disagree with the characterisation of the success of ageing in Singapore as a ‘problem’. Others may feel that this assessment does indeed reflect reality, and that both government and the public in Singapore will have to accept varying, and increasing, levels of responsibility for dealing with the ‘problem’. The book is remarkable for its in-depth technical analysis, although one does not particularly obtain a social and cultural feel for ageing in Singapore, or of the filial context for family support. This is a feature of the book's economic rather than socio-cultural orientation but, in many ways, this makes the contribution distinctive. In terms of readership, this book is likely to be most useful for researchers in health economics and development economics. It will be especially valuable to readers with a detailed interest in Singapore and comparable city-states in the Asia-Pacific region, especially those who wish to see data and socio-economic policy considered in a comparative context. It will best serve as ‘additional reading’ rather that a main text for undergraduate gerontology courses, and as an authoritative reference text on empirical aspects of financial and policy features of demographic ageing.
