Over the last 30 years, Asia’s economic growth has resulted in improved education and healthcare across a broad base of the population, contributing to declining fertility and increasing life expectancy. However, in turn, such changing demographic features are set to have profound repercussions on the continent’s socio-economic and healthcare set-up in the coming decades.
A tale of two Asias
Asia has around 200 million more people classified as ‘old’ (60 or above) than a decade ago, a figure projected to rise to at least 800 million by 2030 and over a billion by 2050. It is anticipated that this ageing trend will be consistent across low-to-middle-income emerging Asian economies including, China, Thailand, Malaysia, Vietnam and Hong Kong.
In the more established economies of Japan, Singapore and South Korea, a significant proportion of the population is already in the older generation. In fact, with the highest life expectancy, Japan has been described as the global front runner when it comes to ageing. Its working-age population has shrunk considerably over the past couple of decades, which has taken a toll on its economic and healthcare set-up.
Similarly, in Singapore, Malaysia and Vietnam, the ratio of working age to elderly people has decreased since 2010 and is expected to continuing dropping. In South Korea, around 18% of the population is already ‘old’, a figure predicted to more than double in coming decades, making it the third most ‘aged’ nation worldwide by 2050 after China and Japan.
In China, restrictive family planning legislation has played a key role in shaping demography. The one-child policy introduced in the late 1970s implemented strict birth control measures to address the nation’s population boom and increased demand for resources, including food. Although the policy controlled the birth rate, it has led to a gradual decline in the working age cohort, worsened by an overall increase in life expectancy. This legislation also adversely impacted gender equality, resulting in a population of 1.2 males to every female.
Decades of strict family planning policy has left China with more senior citizens than all European Union countries combined and ageing continues – it is anticipated that around 44% of China’s population will be above 60 by 2050.
Although the one-child policy has been relaxed, allowing ‘eligible’ families (characterized by one or both parents being an only child) to apply for a permit for a second child, only 10% of ‘eligible’ families were found to be interested in having more than one child in 2013.
Increasing socio-economic pressure to succeed and an increasing number of women choosing to pursue careers are thought to be the underlying reasons why fewer children are still preferred. In fact, the majority of urban the population across the continent share similar preference over family planning where the birth rates are already low. As urbanization continues to increase in these ageing societies, great strain will be imposed on healthcare resources and economic sustainability.
In contrast, lower income countries such as India and Indonesia are still in a state of ‘demographic bonus’, with a large proportion of the population being working age. However, this is set to change, with fertility rates starting to decline, and we can expect the impact of ageing to mimic other established Asian economies.
With established and emerging Asian economies ageing at different speeds, we can expect different healthcare challenges in the years to come. Established Asia, with its burgeoning elderly population, must continue to sustain healthcare privileges for its citizens. On the other hand, emerging Asia is ‘growing old before getting rich’, and it is not yet clear how such economies will achieve basic healthcare provision for their rapidly ageing societies amidst fragmented healthcare infrastructure, limited public health expenditure and escalating healthcare costs. To this end, it is important to consider the potential implications of ageing on overall disease burden.
The growing burden of non-communicable diseases
Although infectious diseases still prevail across emerging Asia, chronic and degenerative diseases are imposing a greater socio-economic burden. For instance, cardiovascular diseases account for the highest number of mortalities amongst Chinese and Indian populations; the prevalence in these two countries alone is already higher than in other, more developed countries.
It can be argued that a rise in urban dwellings is changing Asian societies – Asia has witnessed a 100% rise in its urban population aged 60 and above in the last decade, significantly higher than the 30% increase in its rural population of a similar age group. With increased employment opportunities and household expenditure, urbanization has remodeled lifestyles among middle-to-upper-income groups. Sedentary lifestyles and unhealthy dietary habits have become a common feature of urbanization around the world and Asia is no exception. The incidence of obesity and diabetes is rapidly increasing among the elderly, while other chronic conditions, including COPD and arthritis, will increase in coming decades.
The burden of debilitating neurodegenerative conditions, such as Alzheimer’s disease and Parkinson’s disease, will also increase as people live longer. Although Asia has a long-held tradition of family and community support for the elderly, increasing urbanization and evolving family structures look set to leave fewer young adults to provide care for their elders, so it will fall to the healthcare system to attend to their needs.
Due to the one-child policy in China, for example, there are numerous ‘4-2-1’ families, where two adults support four elderly parents and their own child. At the same time, increased spending power among middle-to-upper-income groups has resulted in a considerable number of nuclear families paying for healthcare providers or care home facilities to look after elderly family members. China already has the highest reported cases of dementia in the world and, with the pace and scale of ageing among its population, it is likely to witness more consequences on its healthcare resources than any other emerging market.
With the expected increase in the ageing population, the prevalence of mental health conditions is also expected to grow. While mental health issues, such as depression and mental impairment, have been neglected in many Asian emerging markets, the culture of ‘keep going’ rather than ‘seek advice’ is changing due to shifting societal attitudes and increasing individual awareness. In addition, increased economic welfare among urban dwellers has played a more important role in making mental health services more accessible.
Challenges and opportunities
While the ageing population will put strain on healthcare resources in coming decades, it will also create opportunities for the pharmaceutical industry. However, to maximize the opportunity, it must better understand the needs of the ageing population and how to improve treatment access for their chronic ailments.
The healthcare systems of Established Asia, with universal or near-universal coverage, is likely to experience strain as fewer working-age people contribute to support the elderly. Increasing healthcare demands are likely to result in cost cutbacks and tightening of access, which may require innovative models of financing or greater financial burden pushed back to the patient.
The healthcare budgets of Emerging Asia – with its lack of universal healthcare, crumbling family support and ever-rising healthcare costs – will also feel the strain. Increasing healthcare needs and restricted healthcare expenditure will create opportunities for pharma but it will likely mean focusing on the segment of the population that is willing and able to pay out of pocket or offering ‘beyond the pill’ services to add value over locally manufactured low-cost generics.
To effectively meet the meets of the growing elderly population over the next few decades, it is crucial that we understand what socio-economic, cultural and political factors will drive their healthcare decision making, especially where out-of-pocket payment will be required.
Market research, grounded in local knowledge and expertise, is a key means of achieving this understanding. Whether via patients directly (recognizing the technological or capability limitations that may exist in the elderly population), or their caregivers (noting that the family has traditionally played an important role in providing care as well as financial support for their elders), or via other healthcare influencers such as doctors, understanding the patient perspective looks set to be increasingly important in ageing Asia.