Hong Kong: Embracing a Fast Aging Society With Limited Welfare

Abstract

Hong Kong (HK) was a British colony but has become China’s Special Administrative Region since mid-1997. During the colonial era, HK was characterized as a “borrowed place with borrowed time,” in view of the time-limited polity. This sentiment was believed to lead to a lack of commitment to welfare, education, and health and mental health care by the colonial government; political inactivity of citizens; and a mobile population (Cheng & Mak, 2007). Care for the needy rested with the family, and government intervention was believed to be necessary only for “the most needy” (i.e., people who are most deprived), especially for those without family support. A “small government” was to be maintained at low tax rates. Although the government has become more proactive after the return to China, this noninterventionist and family self-reliance ideology prevails. Though there have been some improvements in welfare and service programs, they are for the most part rather basic compared with developed countries. This background poses an interesting question for this aging society—who will pay for the rising welfare and health care costs, and who will care for the many frail and cognitively impaired older people, in a land without universal pension or health insurance?

Demographic Situation

Fueled by years of some of the lowest mortality and fertility rates worldwide, HK has a comparatively accelerated rate of aging, doubling its proportion of older people from 6.6% to 13.9% in the 30-year period of 1981–2011. Life expectancies at birth for both men and women in HK had surpassed those of Japan in 2011 (Ministry of Health, Labour and Welfare, n.d.). The population is characterized by an inverted population pyramid, with the very old being the fastest growing segment (Table 1). As a result, the burden of chronic diseases, such as dementia, will rise dramatically in the coming decades. In fact, the current estimates of dementia prevalence (Table 1) may be too conservative in light of more aggressive efforts toward early diagnosis (Lam et al., 2008a). In terms of living arrangement, 60% of older people in 2011 were living with children, 24.8% with a spouse and no children, and 12.7% were living alone (Census and Statistics Department, n.d.). Looking ahead, it is expected that the future cohorts of older people are more likely to be single and/or living alone, and for those with children, delays in marriage and childbirth will mean the continuation of parenting and the need to provide support to children even into youngold age. Both trends suggest that the traditional reliance on children as primacy caretakers may be fading with time, yet their impact on older people’s development and well-being remains to be seen.

Major Public Policy Issues in Aging

In light of these situations, we consider elder poverty and rebalancing the long-term care (LTC) system to be two key aging policy issues in HK. Using 50% of the median income as the poverty line, a third of all older people were living under poverty in 2010 (Hong Kong Council of Social Services, 2012). According to Census and Statistics Department (2009), the high elder poverty rate is partly due to low educational attainment and partly due to the lack of retirement protection, as only 19% of the current older cohort has retirement protection (with current retirement age being 60 in government and most other organizations). HK does not have a public pension system based on tax revenue. Instead, the government launched the Mandatory Provident Fund Scheme (MPF) in 2000, which is a personal retirement account with contributions from full-time employees and employers. Currently, about 71% of all workers are covered by the MPF system (Mandatory Provident Fund Schemes Authority, 2012).

However, the MPF will take many years to mature and the current cohort of older adults is not benefitting from it. Thus, the welfare programs have become de facto noncontributory public pensions. The government has both means-tested and nonmeans-tested welfare programs for older people; the former is paid at higher levels to provide subsistence support for those in poverty, whereas the latter is a small cash allowance. To alleviate elder poverty, many groups have advocated for a publicly funded universal retirement pension system that also covers the current cohort of elders. Recently, the government has yielded to public pressure and increased cash benefits for low-income elders.

Meanwhile, HK has a very imbalanced LTC system that depends heavily on residential care. In 2012, HK had about 76,000 residential care beds (around 81 beds per 1,000 older people), in sharp contrast to the 7,089 community-care service placements (e.g., adult day care center and meal-on-wheels service) that would allow elders to stay in the community (Social Welfare Department, n.d.). In the 2010–2011 financial year, HKD 2,549 million (pegged at 7.8 HKD to 1 USD) public monies were spent on residential care versus HKD 381 million on community care (Sau Po Centre on Ageing and Department of Social Work and Social Administration, 2011). The institutionalization rate of older people is high, at 6.8% of people aged 65 years and older (Sau Po Centre on Ageing and Department of Social Work and Social Administration, 2011). Still, 28,000 older people are on the waiting list for residential care placement. To rebalance the LTC system, the government is implementing a new community-care voucher program, which is intended to lower the demand for residential care.

The two policy issues of elder poverty and imbalanced LTC interact in the sense that the majority of nursing home residents are from lower socioeconomic classes (Census and Statistics Department, 2009). Furthermore, most LTC services are financed by the government through direct subvention to nonprofit providers, buying beds from for-profit providers, or indirect financing to the for-profit sector when older people use welfare benefits to pay for nursing home stays (Cheng & Chan, 2003). As the HK population is aging rapidly, the LTC system will soon become a big financial burden to the government. Without any major changes in LTC financing, it is likely that the system may collapse on its own weight as the oldest old population swells in the coming future.

Furthermore, despite increasing public recognition for older people’s needs in terms of mental health problems and dementia, there is no mental health or dementia policy in HK. Resources in care delivery are distributed to different medical and social sectors through the Food and Health Bureau, as well as the Labour and Welfare Bureau, in a scattered and fragmented fashion. Pathways to care are lengthy and indirect. Care services are overloaded with long waiting times and inadequate organization. Although the government has initiated consultative activities in mental health service development (Expert Group on Mental Health Services, 2010) and is considering elder service plans in the Hospital Authority, there is a long way to go before any long-term overarching plan will be formulated.

Gerontological Research in HK

In view of the demographic situation and to inform public policies, research on aging-related topics has markedly increased in the recent decade. Table 2 lists full-time academics whose core professional identities and sustained research activities are in gerontology and geriatrics. The list of researchers and the research themes covered subsequently are meant to be illustrative rather than exhaustive. In the interest of space, we will not cover the basic sciences, demography, occupational therapy, and other fields.

For example, cultural differences in aging are prominent in Fung’s aging-in-culture research program. For instance, in both cross-sectional (Yeung, Fung, & Lang, 2008) and longitudinal (Zhang, Yeung, Fung, & Lang, 2011) studies, Fung and colleagues found that the Western finding of age-related decreases in peripheral social partners was evident only among Chinese with lower interdependence. Those with higher interdependence who presumably cared about all social relationships showed a positive association between age and peripheral as well as close social partners. Similarly, in cognition and aging, Fung, Isaacowitz, Lu, and Li (2010) found that only Chinese individuals who were low in interdependence exhibited a preference for positive stimuli in attention and memory with age that was similar to that in American adults. Chinese who were higher in interdependence showed a cognitive bias for both positive and negative stimuli, presumably because positive and negative stimuli were equally important to them for maintaining social harmony.

Cultural issues in the family are also evident in Cheng and colleagues’ work, which shows the continued functional role of the extended family in the context of changing family structures and declining filial piety (Cheng & Chan, 2006; Cheng, Li, Leung, & Chan, 2011). Yet, elders sever ties with children and other relatives when feeling abandoned in institutions (Cheng, 2009b) or when left to shoulder family caregiving responsibilities more or less individually (Cheng, Lam, Kwok, Ng, & Fung, in press). Cheng (2009a) also shows how perceived lack of respect from younger generations can discourage older people from realizing generative goals.

Clinical research for the older population focuses on dementia and related cognitive disorders, as well as depression and suicide. Two epidemiological surveys on the prevalence of dementia were conducted in the mid-1990s and 2000s. There was an almost twofold increase in the prevalence of dementia across the 10-year interval (Chiu et al., 1998; Lam et al., 2008a). The rise could not be explained simply by a change in the diagnostic paradigm toward early detection, but by an increasing proportion of older adults in advanced ages having high risk of cognitive decline. In recent years, there is an increasing interest in interventions for elders with mild cognitive impairments and mild dementia. Lifestyle (physical activity and dietetic) interventions, conducted in both community and institutional settings, have shown encouraging cognitive benefits (Kwok, Lam, Sea, Goggins, & Woo, 2012; Lam et al., 2012). Other than working from a preventive or rehabilitative perspective, researchers have endeavored to identify predictors of mortality in nursing home populations so as to improve advance care planning (Lee, Chau, Hui, Chan, & Woo, 2009). In addition, depression in later life has been a regular item on research agendas. It is increasingly recognized that unidentified psychological symptoms in primary care are common and have significant impact on individuals’ quality of life (Lam et al., 2009). With advances in techniques for neuroimaging and genetic assessments, it is anticipated that translational research exploring the neurounderpinnings of cognitive decline and depression will be a major focus in the near future.

Although research on aging-related issues has made strides in helping us understand HK’s aging population, there are inherent challenges that must be overcome. One of the challenges of doing research in HK is that language and sociodemographic differences prevent the direct adoption of imported research instruments. Due to poverty and war during the early years of life, elders in HK were deprived of opportunities for education and hence literacy level is low. This has affected the acceptance and performance characteristics of conventional testing tools. As a result, short assessment tools have been developed for large-scale community screenings of cognitive impairment and depression. For example, Lam and colleagues (2008b) developed a short cognitive screening tool for mild cognitive impairment and Cheng and colleagues (2010) developed a four-item measure for depression and suicide screening in the community for early detection and intervention. Kwan, Chi, Lam, Lam, and Chou (2000) introduced the Minimum Data Set-Home Care instrument to HK, which was adopted as the standardized assessment instrument for government-funded LTC services. Moreover, data collection is difficult in HK. HK does not have a system whereby data sets are archived for public access. Hence, researchers obtain their own data sets that are often small in scope due to limited funding. Exceptional approval and collaboration of the Census and Statistics Department are required to access the population sampling frame.

Nevertheless, support for research is available. Major recurrent funding sources are the Research Grants Council (General Research Fund) and the Food and Health Bureau (Health and Medical Research Fund). Private foundations may also support gerontological research together with community services. In addition, professional associations, such as the Chinese Dementia Research Association (founded in 2009 by Linda Lam), may play a key role in bringing researchers with similar interests together. Institution-based research centers, such as the Sau Po Centre on Ageing at the University of Hong Kong, have become major hubs for gerontological researchers. For example, following the pioneering work of Nelson Chow and Iris Chi, researchers affiliated with the Sau Po Centre have focused their research on filial piety and family caregiving (Chow, 2006; Chan & Chui, 2011), economic security of older people (Chou, Chow, & Chi, 2004), aging in place (Chui, 2008), successful aging (Chong 2007), bereavement and end-of-life care (Chow, 2010), and mental health and psychological well-being of older people (Lou, Kwan, Leung, & Chi, 2011). It is hopeful that more research centers like this can help consolidate research efforts in HK.

Conclusion

Gerontology and geriatrics is a burgeoning field in HK. Like elsewhere, population aging is drawing more and more researchers into the field. HK is situated in an interesting geopolitical space; although it has many issues of aging to tackle itself, its research activities may also have special relevance for Mainland China (Zhang, Guo, & Zheng, 2012). In fact, some of the researchers in HK are actively collaborating with counterparts in Mainland China and are making contributions beyond HK. For instance, one of us (Cheng, 2012) was invited to address a national gerontological summit to promote research on and services for dementia caregivers in China, and another (Linda Lam) collaborates with the Department of Psychiatry, Peking University for studies on activity participation and cognition. Moreover, the Sau Po Centre on Ageing is funded by the Chinese Government to partner with Peking University to provide training in gerontological research methods in China.

Looking ahead, there are three main issues to consider if the field is to become more robust. First, as can be seen from Table 2, there are researchers, across disciplines and institutions, who have overlapping research interests. More efforts should be made to promote interdisciplinary and interinstitutional collaborations. The Chinese Dementia Research Association mentioned previously is an exemplar of such a vision, but much more needs to be done in other subfields. Second, there need to be tighter links between academia and the service sector to translate science into practice. Currently, many researchers work closely with frontline service providers; yet, to achieve greater synergy between science and practice, transformations in the current training models are necessary. In order for practitioners to realize the importance of evidence-based practice, their research training should be strengthened and, in fact, they themselves should participate in research teams as well. Finally, the healthy growth of the field relies on research funding. However, gerontologists are underrepresented in grant review committees and the significance of aging issues may not be appreciated by scientists in other areas. Thus, researchers and practitioners need to work together and lobby politically for more support from different funding sources.

In closing, we would like to conclude with an observation that will touch the heart of gerontologists around the world. In HK where policies are dominated by the family self-reliance ideology, in order for an impoverished older person to receive subsistence-level public assistance (called Comprehensive Social Security Allowance), all the children (if one has living children) have to make formal declarations of inability or unwillingness to support the parent. This procedure is so stigmatizing that many older people choose to live in poverty without assistance (Cheng & Chan, 2006). Policymakers need to understand that societies have a duty to protect the dignity of older people as well as to provide for their needs.

The previous example illustrates how outdated many policies are and how unprepared developing countries/societies are to respond to accelerated population aging with limited resources. In HK, family self-reliance will continue to dominate policy thinking and the government is expected to maintain its role as providing basic safety nets to the neediest individuals, despite rising expenditures. For those with dependencies, community care has been said to be a future policy direction and an experimental community care voucher is to be implemented in 2013 to address some of the imbalance in LTC and to promote aging in place. However, other than these remedial measures, the government should consider implementing age-friendly employment practices and other social structural changes that enable more productive participation by older people, so that older people can realize their aspirations and remain independent for as long as possible.

Acknowledgment

Alfred Chan provided comments on policy development and Steve Zarit and Joe Gaugler provided editorial assistance, for which we are appreciative.

References

Author notes