BRIEFING REPORT: TREND IN POPULATION AGEING AND HEALTH CHALLENGE FOR THE 21st CENTURY

IN SINGAPORE
Demographics and projection
Current features and future projection of ageing population
Singapore was listed as the second fastest greying country in the world with an estimation of 348%
increase of the elderly population between 1985 and 20251. Defined as ‘people 60 years of age’ by
WHO in 20072, this group represents about 15.0% (474,700) of the country’s population in 2010 and
26.0% (853,300) by 20303. This worrisome trend is the direct consequence of the drastic decline of
the total fertility rate (from 4.6 in 1965 to 1.28 per resident female in 2008) accompanied by the
improvement of life expectancy (78.4 years for males and 83.2 for females at birth as of 20084.)
Similarly to the global trend, Singapore senior citizen population is experiencing gender imbalance of
57.6% female and 43.4% male in the older population5. This skewed distribution is more obvious
when observed in the group of 85 years old and above, whose the gender ratio is 495 males to 1000
females in 20094. This is due to female’s greater life expectancy than male’s in general and also, at
older age the mortality of women is lower than that of men.
In the National Survey on Senior Citizen 2005, 92.7% elders responded as living with family members,
either with their spouse or with children and grandchildren. This is a social norm in Asian culture that
Singapore still keeps regardless its metropolis where east meets west. Nevertheless, some concerns
were raised with regards to 7.3% (35,000) living alone respondents since there have been a few cases
of elders dying alone gone unnoticed for a period of time before being reported by neighbours due to
foul smell. This group of elders was also found to have more health problems and thus more
community involvement was pushed forwards to ensure their wellness6.
With the majority population of Chinese ethnic, it hardly came as a surprise for the constitution of
83% of the Chinese, followed by 9.0% Malay, 6.0% Indian and 1.0% of other ethnic in the senior
citizen population in 2009. Regarding to education profile, less than 20% of the senior citizens
attained post secondary school education4. Majority of the elderly speak and understand only their
mother tongue (Chinese, Malay, Tamil and other) and very little English. Hence most of the health
program leaflets for senior citizens are produced in 4 languages.
The dependency ratio specifically of the elderly – termed as the ‘old age support ratio’ was 1:17 in
1970, 1: 8 in 20094 and is projected to be 1:2 in 2030 7. However, this ratio is estimated since there
are older people still working and not all people in working age actively engaging in labour force. In
fact, 69.9% of males between 60 to 64 years old participated in the labour force in 2009. This
percentage is 43.6% in 65 to 70 and 17.6% in 70 and older. The rate was lower in female elders, which
were 33%, 17.7% and 5.2% accordingly8. Without social support system like pension, older people
tend participate in the labour force. Moreover, Singapore government encourages the senior citizens
to join the work force and set retirement age at 62 for both male and female. With compulsory
Medisave - which can be used to pay for hospitalization and medical insurance - under Central
Provident Fund1 (CPF) contribution, an elder is supposed to be able to self support with this
mandatory saving accumulated over his/her period of working life. However, due to raising
hospitalization cost, this saving has proved to be insufficient sometimes and so more often out-of-
pocket payment is disbursed to cover medical expenses 9.

Network of health care and support services

CPF is Central Provident Fund, with a role similar to Superannuation in Australia

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Singapore health system has been used as study model for health reform in many countries for its
low cost and extensive coverage10. But it was only until 1994 when Department of Geriatrics
Medicine was first established in Alexandra Hospital, and subsequently Changi General Hospital and
Tan Tock Seng Hospital to cater health services for the elderly in Singapore. This is to cope with high
volume of older persons’ hospital admission for acute care - which is also available in other 18
hospitals, including private hospitals, 6 specialized clinics and 17 government polyclinics5. Whilst
health service has been segregated to acute and long-term care with most of acute care taken care of
by the government, long-term care is allocated to community and residential level. Within long-term
care, in 2005 there are 4 community hospitals, 2 chronic sick hospitals, 56 nursing homes and 2
hospice care hospitals. Flexible care in term of few hours or few days is provided by Respite Care or
Day Care Centre. Sheltered Home is for ex-mentally ill elder patients who require minimal supervision
and medical attention. There are also 9 active Home Help/Befriender Services to assist elders staying
alone or individuals who prefer home-based service11. Whereas many of these facilities are operated
privately or by Volunteer Welfare Organizations (VWOs), the state plays an important role in
infrastructural subsidy or manpower policy to enable more affordable foreign health workers,
especially geriatrics nurses5.
Besides healthcare services, the government also ensured the integrated efforts from other
ministries to enable “active ageing” with main emphasis on individual self sustainability. This resulted
in the elderly-friendly public premiers with ramps; lift to every floor in housing apartments as well as
all bus and train stations; and the redesigned public transport vehicles assessable to wheelchair
users. 12 The Council for the Third Age or C3A was set up by the government in May 2007 to promote
active ageing, enhancing employability of senior citizens and shifting employer’s mindset. S$77
million is set aside for Wellness programme that covers the next 5 years to promote regular health
screening and social interest groups for the senior citizen community12. In partnership with Ministry
of Community Development, Youth and Sports, C3A also set out a number of outreach programs to
encourage life-long learning, socially activeness and social contribution among the elderly. Launched
in 2002, Eldershied – a low cost insurance scheme caters insurance coverage to elders should severe
disability occur. The government also promotes personal saving by giving incentives on Medisave and
allowing a payable capped amount to expensive services like chemotherapy or dialysis for the elderly
from their children’s Medisave. Since 1993, the government has contributed consistently part of
budget surplus to Medifund to assist less-well-off senior citizens. This fund has grown to
approximately US$500 million in capital and disbursement in 2001 was recorded for 156,800
approved applicants13.

Epidemiology and health condition risk

As the result of successful vaccination and other communicable diseases control effort, over the past
few decades Singapore has seen a major decline in most chronic communication diseases such as
malaria, hepatitis B, and measles with the incidence rates – mostly imported from overseas cases -
less than 3.1 per 100,000 population in 2008. However, HIV/AIDS and tuberculosis are still of concern.
With the incidence rate of 27 per 100,000, tuberculosis is still being monitored closely. The
emergence of recent year communicable diseases such as Severe Acute Respiratory Syndrome and
influenza pose significant risk to the elderly group in view of the fact that this group has lower
immunity and often other underlying medical conditions. However, burden of diseases and mortality
rate in the elderly groups are mostly from non-communicable diseases.

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In the National Survey of Senior Citizen 200514, 92.2% elderly correspondents (55 years old and older)
stated as physical independent and ambulant. 7.3% of the elderly needed some form of assistance to
move around while 0.5% was bed ridden. In the same survey, 64.2% of the elderly reported to have
at least one medical condition. The most common conditions were high blood pressure, arthritis &
chronic joint symptoms, diabetes and hearing problem. The prevalence of these leading morbid
conditions was 39.6% for high blood pressure, 23.6% for arthritis and other joint problem and 17.0%
for diabetes. Of those with long term condition such as high blood pressure, heart problem, diabetes
and cancer, more than 90% of them seek medical treatment. However, hearing difficulty or mental
issues like anxiety or depression did not seem to have sufficient attention given that only about 30%
of the people with this problem actually seek doctor’s advice. Using the World Health Organisation
Five Health Index, the evaluation of mental health in elderly group showed 11.8% poor mental health
prevalence15. The prevalence was higher in females (13.8%) compared to that of males (9.7%). It has
been known that isolation from social withdraw in the elder group might contribute to mental
problems of which depression is the most common (26.0% compared to 9.0% living with other family
members12).

According to the National Health Surveillance Survey 200715, hospital admission was 13.5% of the
senior citizens (55 years old and older), with the highest percentage in the 75 years old and older
group (22.8%.). Regarding overall health status, when given self-rated questionnaire, only 50.7%
senior citizens considered their health as ‘good’, 40.2% self-judged as ‘moderate’ and 0.1% chose
‘very bad’. More than half of the correspondents reported to attend health screening regularly
(64.0%) for blood pressure, Body Mass Index, cholesterol level and other basic health indicators. Even
though colorectal cancer has been known as the number one mortality cause in males, and second in
females, there was relatively low percentage of elderly having Faecal Occult Blood test done (25.0%
males and 19.8% females). Similarly, only 55.6% of females reported to have mammography. On the
other hand, 70.9% females in the age group of 50 to 69 accounted to ever have Pap smear.
Nonetheless, all these results were based on surveys and questionnaires, thus there might be certain
degree of underestimation or overestimation.

The leading causes of mortality in Singapore in 2008 were cancer (29.3% of total death), ischemic
heart disease (20.1%), pneumonia (13.9%) and cerebrovascular diseases (8.3 %)16. As predicted, the
mortality of the elderly group made up a large portion of total deaths in 2009 (75.0%), with the most
number of cases from the older group of 85 years old and above.

Challenges ahead

Facing the outbreaks of non chronic communicable diseases such as SARS and influenza at the
beginning the new century reminded all health practitioners to be ready for what is coming. The
implementation of these control measures need to be plausible for the fast expanding vulnerable
elderly group. This task includes evaluation of possible mass vaccination for senior citizens;
improvement in both acute/rehab care facilities and community-based care and preparation of
manpower. Concerns regarding the limited research and education on geriatrics have also been
raised numerous of time12, 18. The shortage of geriatric nurses at tertiary/acute care level, and the
scarcity of rehabilitation facilities and health workers at community level still remain as a major

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challenge. Even the influx of nurses from the Philippines in recent year did not ease this situation.
That also means the three existing departments of Geriatrics island-wide might not be able to cope
with the fast growing demand.
Year 2012 marks the arriving of the wave of baby boomers reaching 60 years old. This generation has
better education and financial capability. Thus, they will demand higher standard and wider range of
healthcare services. In order to meet the demands, complete integrated service network between
hospital and community cares should be in place. Furthermore, the very old group (more than 75
years old) with more physical, mental and social disadvantages is projected to increase to 7.5% of the
population by 2030 (242,800). Treatment of this group of frail elderly often requires continuous
support from hospital admission stage to community-based care. Aspect of care from home with
family visit by health workers is to be progressed and developed for wider coverage. There is also the
need to identify specific health needs from different subgroups of the elderly for better management
of healthcare resources19. Finally, programs promote healthy lifestyle need to be suitable for the
soon-to-be vast majority of the ageing public.
In summary, with this pace of ageing in Singapore population it is necessary to have strategic and
well-advanced planning to achieve a status of healthy and active ageing population in the 21 st
century.

References
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May 2003;64(3):399-413.
6. Shantakumar G. Ageing and Social Policy in Singapore. Ageing International. 1995;22(2):49-54.
7. Choo PWJ, Lee KS, Owen RE, Jayaratnam FJ. Singapore - An Ageing Society. Singapore Med Journal.
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10. Matt Miller
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