Ageing in Singapore: Service Needs and the State (Routledgecurzon Contemporary Southeast Asia Series)

Ageing in Singapore

Older persons are often portrayed as social and financial burdens because pensions, health and social care have to withstand increasing old age dependency ratios. Due to a lack of access to representation or a lack of social and economic power, older people have found few opportunities to have their voices heard, making age an immensely political issue. Ageing in Singapore provides an in-depth analysis of the experience of ageing in Singapore, examining key issues such as health, work, housing, family ties and caregiving. It looks at how social categorization enters into everyday life to elucidate the multiple meanings of age and identity encountered in a rapidly changing economy and society. Provisions for older persons are shown to be a product of struggles arising from the unequal distribution of societal resources, with state intervention playing a key role in delimiting the parameters of support. How older people negotiate the complex terrain of legalistic and imagined restrictions inherent in this interpretation of values in order to improve the quality of their lives provides a useful model in comparison to the welfare state or market economy approaches used elsewhere. Providing original critical discourse from Asian writers recording Asian voices, Ageing in Singapore will appeal to a wide readership and will be an invaluable resource for policy makers, service practitioners and scholars working on Asian gerontology. Peggy Teo is Associate Professor of Geography, National University of Singapore. Kalyani Mehta is Associate Professor of Social Work, National University of Singapore. Leng Leng Thang is Associate Professor of Japanese Studies, National University of Singapore. Angelique Chan is Assistant Professor of Sociology, National University of Singapore.

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Ageing in Singapore Service needs and the state

Peggy Teo, Kalyani Mehta, Leng Leng Thang and Angelique Chan

First published 2006 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Simultaneously published in the USA and Canada by Routledge 270 Madison Ave, New York, NY 10016

This edition published in the Taylor & Francis e-Library, 2006. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” Routledge is an imprint of the Taylor & Francis Group, an informa business © 2006 Peggy Teo, Kalyani Mehta, Leng Leng Thang and Angelique Chan All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Ageing in Singapore : service needs and the state / by Peggy Teo ... [et al.]. p. cm. – (Routledge contemporary Southeast Asia series ; 10) Includes bibliographical references and index. ISBN 0-415-37487-1 (hardback : alk. paper) 1. Older people–Singapore–Social conditions. 2. Older people–Services for–Singapore. I. Teo, Peggy. II. Series. HQ1064.S5A34 2006 305.26095957–dc22 2005034249 ISBN10: 0-415-37487-1 ISBN13: 978-0-415-37487-3

Contents

List of figures List of tables Preface Abbreviations 1 Introduction

vi vii ix xi 1

2 Singapore’s ageing population: the demographic profile

16

3 Policy concerns and the framework of support

25

4 Employment, ageism and work

42

5 Is there enough? Financing old age

55

6 Reconciling state perspectives and individual perceptions on health care

72

7 Carers: interfacing family and community

87

8 Home and heart: domestic space as a place for caregiving

106

9 Intergenerational ties that bind

120

10 The journey after widowhood

134

11 Conclusion

147

References Index

154 176

Figures

2.1 2.2 3.1 3.2 8.1

Population pyramids of Singapore, 1970; 1983 and 2003 Total fertility rate, 1960–2004 Planning units under the development guide plan Geographic distribution of older persons, 2000 HDB housing estates

17 20 38 39 108

Tables

1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 2.4 2.5 3.1 3.2 3.3 3.4 4.1 4.2 4.3 4.4 4.5 5.1 5.2

Profile of 1999 survey of transitions in health, wealth and welfare of older Singaporeans Focus group composition of the 2003 study on older persons in Singapore Service providers in the 2003 study on older persons in Singapore Socio-demographic characteristics of carers from the HMMC study Profile of survey and in-depth respondents in the widowhood study Life expectancy at birth and proportion of population aged 65 and above in selected countries Average annual growth rate of older persons, 1990–2000 Life expectancy at birth, 1970–2004 Education profile of persons aged 65–74, 1995, 2000 and estimates to 2030 Resident households with older adults Health services by location, 2005 Social services by location, 2005 Geographic distribution of older persons aged 60 and above, 2000 Services available to senior citizens, 1998 Proportion of individuals working, by age and gender Gross monthly income from work among those older adults currently working, by age Older working adults, by occupation and age Reasons for continuing work, by age Attitudes toward mandatory retirement, by age Amount of CPF that can be withdrawn upon reaching age 55, by balance available in CPF account Sources of income among older adults in Singapore, by age (%)

10 12 13 14 15 18 18 19 22 23 32 34 37 40 49 50 50 51 51 59 60

viii

Tables

5.3 CPF account holders aged 60 and above, 1995, and adequacy of CPF 5.4 Total amount of money in respondents’ CPF account at age 55 5.5 CPF contribution rates for employers and employees 5.6 Monthly individual income of older persons, by age and gender 5.7 Monthly household income, by gender and age 5.8 Adequacy of income 5.9 Reasons given by older adults for difficulty in meeting household expenses 5.10 Main source of funds sought to meet a shortfall in income as reported by older individuals in Singapore 5.11 Person(s) responsible for payment of household expenses among older Singaporeans 7.1 Moral binaries in deinstitutionalization 7.2 Number of frail older persons 7.3 Average stress scores of carers 7.4 Carers’ problems 7.5 Carers’ perception of caregiving 7.6 Principal carer’s perspective on the impact of caregiving to senior adults 7.7 Awareness and use of health-related community support services among population aged 55 and above 7.8 Awareness and use of community-based support services among population aged 55 and above 8.1 Living arrangements of population aged 65 and above, 2000 10.1 Living arrangements and reported ability to cope among survey respondents 10.2 Considerations for negative/positive attitude to remarriage

60 61 64 66 67 67 68 69 69 88 93 94 95 96 96 97 98 113 136 142

Preface

The genesis of this book comes from a project that was funded by the Tan Foundation in Singapore. We were tasked with an examination of the service needs of older people in four areas: health, finances, caregiving and intergenerational relationships. Using a multidisciplinary approach with contributions from geography, social work, anthropology and sociology, we examined the young-old and the old-old using focus group discussions and in-depth qualitative interviews to identify service gaps. Drawing from this study as well as our own previous projects, we observed two things about older people in Singapore – their voices are not heard enough and existing policies and services have good intentions but do not always tally with how older people define their own needs. Conflated with these problems is the notion that is widely (perhaps even universally) held among policy makers that Asian families seldom have problems looking after their older members, whether co-resident or not. This book is an attempt to deal with these shortcomings by unpacking the rationale behind policy on older people and providing feedback from users of services. We hope to bridge the gap between providers and users by rendering a voice to the latter group. This will help to empower them and make good services that are already out there even more effective and relevant. We also argue that while it may be true that older people are given more respect in Singapore (or Asia) than in the West, socio-economic changes and the demands of a working environment that is tied up with the global economy mean that attitudinal changes are at hand. We feel the need to document and address these changes as they occur in our rapidly transforming society and show how important the state is in the visioning of Singapore society. Last but not least, while documentation of trends and descriptions of problems abound, critical analyses of the ageing situation in Singapore are not enough. We want to encourage more work in this direction and see this book as a small and modest contribution. Equally important is the fact that this book reflects our attempts to become more mature researchers. We hope the book conveys that we are researchers who are reflexive in our work, responding to what the older people tell us as well as clarifying our own position. We carry with us our values into research but we have also

x

Preface

tried to report objectively, albeit critically, our reading of the dilemmas of ageing in Singapore. Finally we want to acknowledge all our respondents who shared with us their life stories, their problems as well as their joys; the service providers who were upfront because they are sincere in their desire to help; the ministry officials who support open forum; Lily Kong, Vice Provost, National University of Singapore, who initiated the Tan Foundation project; to the Tan Foundation itself, especially Ms Chew Gek Khim, for giving us the opportunity to work together as a team and for funding; the Hua Mei Mobile Clinic (the Tsao Foundation) for collaborating on the study of family caregivers; the NUS (National University of Singapore) which funded our numerous other projects on older persons; our respective heads of department and the Dean of Faculty of Arts and Social Sciences for encouraging and giving us support; McGraw Hill Asia for the use of Figure 8.1; and finally our families, who have made sacrifices for us, for believing in our work. Peggy Teo, Kalyani Mehta, Leng Leng Thang, Angelique Chan

Abbreviations

ADL AIS ANRPS BEST CDC CPF CPFIS DOS ERC GFAS HDB HMMC HNF HPB HSA HUDC IDAP IMC IMF IRAS LLF MCD

MCDS MCYS MHA MICA MINDS MOF MOH MOL

Activities of Daily Living Approved Investment Scheme Approved Non-residential Properties Scheme Basic Education for Skills Training Programme Community Development Council Central Provident Fund Central Provident Fund Investment Scheme Department of Statistics Economic Review Committee Government Financial Assistance Scheme Housing and Development Board Hua Mei Mobile Clinic Home Nursing Foundation Health Promotion Board Health Sciences Authority Housing and Urban Development Corporation Interim Disability Assistance Programme Inter-ministerial Committee International Monetary Fund Inland Revenue Authority of Singapore Lifelong Learning Fund Ministry of Community Development (formerly Ministry of Social Affairs before it became MCD; renamed Ministry of Community Development and Sports and is now Ministry of Community Development, Youth and Sports) Ministry of Community Development and Sports Ministry of Community Development, Youth and Sports Ministry of Home Affairs Ministry of Information, Communications and the Arts Movement for the Intellectually Disabled of Singapore Ministry of Finance Ministry of Health Ministry of Labour (now renamed Ministry of Manpower)

xii

Abbreviations

MOM MND MSPS NACFA NCETF NCSS NFCSP NGO NL NPB NSSC NTUC NVPC PA PAP RC REAP RSVP SAC SAGE SAVH SCC SDF SGH SIT SRS TFR UNESCAP URA VWO WHO WISE

Ministry of Manpower Ministry of National Development Minimum Sum Plus Scheme National Advisory Council on the Family and Aged National Continuing Education and Training Framework National Council of Social Services National Family Caregivers Support Program Non-Governmental Organization Neighbourhood Link National Productivity Board National Survey of Senior Citizens National Trades Union Congress National Volunteer and Philanthropy Centre People’s Association People’s Action Party Residents’ Committee Re-employment Assistance Programme Retired and Senior Volunteer Programme Senior Activity Centre Singapore Action Group for Elders Singapore Association of the Visually Handicapped Senior Citizens Club Skills Development Fund Singapore General Hospital Singapore Improvement Trust Supplementary Retirement Scheme Total Fertility Rate United Nations Economic and Social Commission for Asia and the Pacific Urban Redevelopment Authority Voluntary Welfare Organization World Health Organization Worker Improvement through Secondary Education Programme

1

Introduction

Two decades ago, James Birren made a point that the study of ageing is ‘data rich but theory poor’ (Birren and Bengston 1988: ix). Twenty years on, many social gerontologists would agree that this research endeavour has seen changes for the better, but the restlessness continues. Rather than a problem, this characterization may be viewed as a healthy sign. The meaning and place of ageing in contemporary society, how much such meanings have influenced social policy and vice versa are best understood as evolving processes that vary by time and place. Understanding the contexts of these meanings for different groups and cohorts of older populations will make us more perceptive of their needs and will help to forward knowledge and outcomes to do with the demographic reality of ageing already happening in many parts of the world. This book is thus an attempt to critically engage the experience of ageing in Singapore at a time when its population is growing old at an average rate of 3.6 per cent per annum (Ang and Lee 2000).1 It argues that while biomedical understandings of physical ageing have always been (and continue to be) important to how policies to cope with older people are formulated, using social constructions of ageing offers valuable alternative insights that can be helpful (Estes et al. 2003; Laws 1995a; Phillipson 1998). By emphasizing the socially constructed features of the ageing experience – how social categories and forms of age enter into everyday life and how these are managed by various social groups – the ‘what’ and ‘why’ of contemporary ageing can be better understood. The focus will thus be on how the multiple meanings of age and identity exert an influence on (and are affected by) the politics of ageing; in fact, we even argue that ageing is as much, and even more, a political experience as it is a physical one. Social constructs in revealing themselves as products of struggles in the unequal distribution of societal resources imply that there will be consequences for all social groups, no less older persons. Despite the fact that the state exerts such a strong influence on many aspects of life in Singapore, social constructions of groups have rarely been applied to understand how they are affected and how they negotiate the complex terrain of moral, legalistic and other restrictions to improve their respective quality of life. Besides this

2

Introduction

application of a more critical analysis of social gerontology in Singapore, we are also mindful that a great deal of research originates from the AngloAmerican West. Asian ageing practices, for example, from Japan and South Korea in which adult children are expected to provide care for older persons, have been disregarded by Western-centric literature as impractical and irrelevant on the basis that Confucianism bears little cultural proximity; moreover, their own experiences tend toward global ageing trends (Liu and Kendig 2000; for an exception, see Doling et al. 2005). Of late, this Western orientation has been questioned as countries find that welfare entitlement as the basis of care policy for older persons in many parts of Europe is too costly and has been found not to meet the emotional needs of older persons. In addition, we also take into consideration Sibley’s (1998: 120) counsel that ‘research on inclusion/exclusion [needs to show] ... an appreciation of other world-views’. In highlighting how older persons are marginalized in the Singapore situation, we acknowledge the importance of place-bound contextualizations in social constructions. The roles that older persons play in Singapore’s economy and in the family unit are different from the experience of the West and will help to illustrate another way in which inclusion/exclusion may be interpreted for this part of the world. In addition, having gone through rapid change in values and in the functioning of economy and society, Singapore’s care provision experience is analytically interesting as the country is receptive to models emanating from outside as much as it attempts to exemplify best practices derived from within. Both the welfare state of the UK and the market economy approach of care characteristic of the US have been explored by Singapore policy makers. This book illustrates some of the lessons we have learnt.

Critical perspectives on ageing Since the 1980s, critical gerontology has undertaken to reconceptualize itself in order to be more effective in ‘decid[ing] on the questions it will ask, let alone answer’ (Gullette 2004: 105). It was generally felt that traditional gerontological theories and perspectives failed to address a ‘crisis in social ageing’ (Phillipson 1998: 1). By this, Phillipson meant the rapid changes in the way production was carried out (becoming more trans-border in configuration than before) and subsequently, issues to do with related topics such as employment, retirement, problems over pensions and the funding of older people’s needs. In addition, an overall increase in awareness of such issues in Europe, North America and elsewhere fuelled imminent concern as the debates and discussions proliferated. Rapid globalization (Giddens 1990; Held et al. 2000) had compressed time and space and revolutionalized the manner in which capital accumulation would be achieved. The new world order supported by capitalist industrialization had and continues to have significant implications for older people. In the first instance, it valorizes the young as productive while fundamentally weakening the value of

Introduction

3

accumulated life experience as a marker of social status (Laws 1995a). In addition, consumption in the globalized context is characterized by complexity and differentiation wherein many markets catering to a diverse range of lifestyles and practices exist side-by-side with ‘unproductive’ old age (Featherstone and Wernick 1995). Without oversimplifying youth and old age (as with other binaries such as male and female or black and white), globalization put on the map not one but plural forms of identity amongst older people, leading to analyses where criss-crosses are made between age and gender, ethnicity, nationality and able-ness. Taken together, these shifts serve to recast the discussions on ageing. Disengagement theory, activity theory, modernization theory and the exchange theory of ageing were the first generation of ageing theories to be discarded because empirical findings were ‘simply not sufficient to support [their] claims’ (Bengston et al. 1997: S76). Amongst these traditional theories, disengagement was the most popular. As older people ‘adjusted’ their ‘activities’ for ‘life satisfaction’, it came across that such acts were almost ‘organic/natural’. A key argument of disengagement theory is the withdrawal of older persons because ‘ego energy’ declines with age (Phillipson 1998: 16). Individuals become more self-preoccupied and less and less responsive to the environment around. As a theory that provided a social dimension to ageing, it stimulated complementary or alternative theories such as modernization, exchange, age stratification and life course theories (for a fuller discussion, refer to Bengston and Schaie 1999; Estes and Associates 2001). For their critiques, however, this type of research only served to create more intolerance and repression of older persons because they helped to legitimate older persons as redundant and a burden to society. As the social problems and conditions faced by older people came to the forefront, one of the radical research approaches which took root in Western discourse was the Marxist-influenced political economy school (Estes 1979). Political economists pointed out that right-wing sympathizers were responsible for attacking the allocation of funds to older people, significantly changing perceptions of this group as having a rightful place in society. As Walker (1981) and Laws (1995a) argued, citizenship rights came to be linked to productivity and performance which were in turn linked to the biomedical model of ageing. With age comes disease and ill health that will be financially problematic, not to mention the strain on caregivers. Radical political economists argued that ageing is viewed as a socially constructed status and that dependency is the ‘consequence of the forced exclusion of older people from work [such that] the experience of poverty, institutionalization, and restricted domestic and community roles’ are socially divisive creations meant to isolate older people from mainstream society (Townsend 1981 cited in Phillipson 1998: 18). The state as a strong supporter of capitalism is intrinsically involved in these negative associations as it is responsible for the allocation of funds and the mediation of various social groups within a political border.

4

Introduction

Where there are foreboding structures such as state and society, political economy tends to assume that older persons passively accept their lot. This, argues Giddens (1984) and Thrift (1983), is overly-deterministic which is a major criticism against the political economy school. In relating to each other within society, recent research (e.g. Leonard and Nichols 1994; Teo and Mehta 2001) shows that people do construct and navigate their life paths in an active manner. As such, we can conceive of individuals as agents capable of acting with information and discernment, even within constrained social structures. In short, agency credits players with abilities to negotiate their positions relative to each other and in response to structural conditions. The radical approach in social gerontology also yielded another thoughtprovoking and fruitful research direction – the work of feminists. Besides the operation of the labour market in discriminating against women, gender constructions also play a role in the ‘double jeopardy’ of older women (Arber and Ginn 1995). As Barbara Macdonald reflects in her book Look Me in the Eye: Old Women, Aging and Ageism (Macdonald and Rich 1984), society perceives her not just as a woman but an old woman. Feminists point out that besides workplaces and home, gender inequalities are pervasive in many other aspects of life, e.g. leisure (Pritchard and Morgan 2000; Teo 1997a; Wearing and Wearing 1996). Gender-sensitive gerontological research declares that ‘gender is not a property of individuals but a socially prescribed relationship, a process, and a social construction’ (Hare-Mustin and Marecek 2001: 101). Masculine and feminine ways of being in the world and relating to others are socially conditioned (Arber and Ginn 1995; Calasanti 1999; Moen 2001), imbricated with socially constructed power relationships, many of which are institutionalized. This inequality of power relations weaves into the very fabric of all social networks, generational as well as intergenerational ones, such that there is a need to discuss openly its consequences for older women. From the gerontological research conducted up to the 1980s, one shortcoming that is apparent is the attentiveness paid to scales of analysis. The political economy approach would, for instance, be considered macro-scale while exchange theory would be micro-scale and disengagement theory straddles micro–macro (Bengston et al. 1997). While this concern has been useful, pigeon-holing analytic methods short-circuits research because academics become side-tracked into essentialist/purist paths that do not concur with the real world situation. The ageing experience occurs relationally across all scales – it is a micro-level individual experience that is also mediated by social others as well as ‘structures’. The nexus of the three scales was thought to reside in the subjective analysis of ageing: Moody’s (1988) work was classically ‘biographical’, emphasizing ageing as an existential experience and employing the humanistic approach to study the subjective. The turnaround to the subjective came about because of disillusionment with the quantitative revolution. Positivist research that had anchored

Introduction

5

much of social gerontology was due for a counterbalance in ways of thinking and this came in the form of the reinsertion of the subjective. This augurs well for critical social gerontology because qualitative research helps give voice to individuals (Gubrium 1993) and empowers the older individual to do ‘ordinary’ theorizing (Gubrium and Wallace 1990: 147).2 Their narratives of ageing have much to offer because they are both relational and reflexive at the same time – we learn about how individuals experience old age in addition to how ageing is constructed. Qualitative work also opened other doors, namely cultural gerontology. As part of post-structuralism discourse, the cultural turn stated that although contextual factors continue to be the main limiting factor to behaviour, structures are not only economic in nature (as Marx would have it). Culture and social power are the other structures that play important roles as well. Since places are indeed different and diverse, a grand theory like structuralism which uses only capitalism as an explanatory tool is limiting. Post-structuralists include Foucault (1991) and Soja (1988) who argue that power is everywhere. They view power as a relationship rather than an entity and emphasize that one’s place/position within a network of relations is fluid, forming a ‘complex strategical situation’ consisting of ‘multiple and mobile fields of force relations’ that are never completely stable (Foucault 1978: 93–102; emphasis added). This constructionist viewpoint is persuasive as it is neither meta nor reductionist in temperament. More important is its appreciation of the recursive relationship between culture, structure and agency which moves it away from the unidirectional causality implied in economics as the ‘base-superstructure’ propounded by political economists (Estes et al. 2003: 21). Variously known as moral economy, the emphasis is on: cultural practices and their relation to power. Its constant goal is to expose power relations and examine how these relationships influence and shape cultural practices; [it seeks] to analyse the social and political context within which (culture) manifests itself ... and is committed to ... a radical line of political action. (Sardar and Van Loon 1997: 8–9) According to Phillipson (1998), subjectivity may be good but it can also be so open-ended that it will never have any of the intended outcomes suggested above. While there is a need not to reify structures of social domination (whether economic, cultural or social), emancipating the older person to a new form of social order significantly different from status quo remains an ambivalent concept. Exactly what emancipates is elusive as it can vary from individual to individual and even if the collective cultural grouping is used, can there really be a common standard and agenda? Emancipation is a lofty goal but emancipate to what remains for the most part open. While the outcome remains elusive, addressing cultural politics nonetheless gave an

6

Introduction

additional critical edge to ageing studies because it is both ‘contemporary as well as historical; theoretically informed yet grounded in empirical work; sympathetic to other conceptions of [how research should be conducted] ... and [is] concerned with a range of cultures and with the cultural politics that this implies’ (Jackson 1989: 8: original emphasis). Finally, postcolonialism is a critical discourse that merits discussion in this book. Postcolonialism upholds heterogeneity of identity and meanings in ageing since its foundation was laid by the cultural turn in social sciences. As an attempt to move away from Western-centric research, the purpose of postcolonial research is to (re)constitute the world in more discursive terms and thus reclaim epistemological space from the West. Postcolonialism does not assume that Western discourse immobilizes; rather by critical analysis, it aims to ‘articulate the silences of the native by liberating the suppressed in discourse’ (Yahya cited in Alatas 1995: 131). As Yeoh (2003: 369) argues, postcolonialism is not a ‘totalizing or monolithic discourse representing one-half of any simple West/non-West bifurcation of the world, but in fact a highly mobile, contestatory and still developing arena where opportunities for insight may be gained at multiple sites’. By refocusing, it is hoped that research (and policy frameworks) will not carry a Western-centred loci in its imaginings. In social gerontology, Harper’s (1992) work on China, Katz and Monk (1993) featuring Sudan, Caribbean and Colombia among others, Chow (2001) on Hong Kong SAR, Phillips (2000) on the Asia Pacific region, Bengston et al. (2000), Jones Finer (2005) and Liu and Kendig (2000) comparing East–West differences and many other indigenous writers are examples of alternate discourses (Chan et al. 2002; Chen 2003; Choi 1996; Li 1997; Mehta 1997a; 1997b; 1997c; Ogawa 2005; Omar 2000; Thang 2001; Teo et al. 2003a; 2003b).

Policy and critical gerontology Current critical gerontology shows a maturing because the discourses make special attempt to move away from the essentialist tendencies of traditional social gerontology. Rather than mega-theories/narratives such as espoused to some extent in the original political economy approach, current critical gerontology recognizes diversity and difference across societies. Paradigm shifts in social science and the rise of social theorizing have helped to refocus research in ageing on dialectical relationships between structures and agency. According to Estes et al. (2003), since theory is interpretive, so is policy. Since neither theory nor policy is neutral, balancing power relations between structures (e.g. state and society) and the agent (e.g. older person) becomes an important research agenda that will elucidate the practice of ageing. As they point out, the question really is, who can press their views into wider consciousness and thus shape outcomes for older persons? Speaking of policy, ideology comes to mind when structures such as governments allocate funds. Ideology is dominant in social constructions of

Introduction

7

older persons and as Estes (1979: 4) argues, ‘ideologies ... as belief systems ... hold major implications for power relations, for in enforcing certain definitions of the situation, they have the power to compel certain types of action while limiting others’. Gramsci’s (1971) ideas on ideological hegemony are helpful as he argues that the imposition of dominant social relations can meet with resistance of an overt or latent kind from agency. More insightful, however, is his explanation that ideology can be communicated and can win over individuals such that hegemony can occur without the use of force. In the neoliberal context of contemporary societies (Singapore included), Fischer and Poland (1998) assert that community policing is not at all coercive, interventionist or visible. Instead, discipline and regulation are unspectacular but nevertheless, persistent and penetrating. Formal processes emanating from the state take a back stage while self-regulatory civil and individual mechanisms come forward in the governance of resources. Using knowledge and raising issues related to risk and responsibility, individuals and communities can be moved to act independently or as a group to manage and reduce harm to society at large. Unlike the obvious actions of governments, self-regulation amongst ‘responsibilized’ subjects (Fischer and Poland 1998: 188) assumes ideological significance because this new interpretation of regulation is more progressive, involving voluntary action and not just state legislation alone. Private, civil and commercial institutions and agencies form the non-state segment for action. Rallying non-governmental organizations (NGOs) into its ambit of influence gives more power to the state and helps to further legitimize its decisions with regard to the allocation of resources. For older people, this is a worthy route of investigation because there are many voluntary organizations which have come into existence, seemingly with good intentions, but may in the end obfuscate rather than clarify power relations. Whether tensions exist, the evaluation of social policy pertaining to work, retirement income, health, and other social service benefits and entitlements remains a central question in critical gerontology as it tries to show that age does matter and not only to those who are older but to everyone at large. Social policy is to be understood as time and place specific because it represents outcomes of social struggles, conflicts and dominant power relations enacted through class, ethnicity, gender and age relations. At the same time, social policy stimulates power struggles along these structural lines. Social policy is thus a powerful determinant of life chances for older persons and it is with this in mind that this book examines the many aspects of life that are influenced by the state in the context of Singapore.

Objectives and structure of the book With the idea of making policy more inclusive of the voices of the older person, this book sets out to:

8

Introduction

1

Explore how structure (the state) and agency (older people, family members and community groups) interact within a specific cultural mix that embodies predominantly Asian values. In this analysis, the rationale for state policies will be explicated as a means to understand the framework responsible for structuring intentions and actions in Singapore. Service provision based on how older people are socially constructed will be discussed in terms of contestations to predetermined or assigned identities. Examine how change in values associated with its global interconnections is affecting both structures and agency. Since Singapore positions itself as an aspiring world-class city, globalization is an inherent part of Singaporeans’ lives. Value changes arising from, for example, more opportunities for women and more opportunities to work outside of Singapore or from the influx of information from Western media, will bear on identity formation. In addition, the importance placed on keeping Singapore competitive in the global economy and the view that this is an umbilical cord that cannot be cut will influence opportunities available to older persons as well as affect the design and delivery of services to this group. Map the spaces of agency in which older persons act. Where structures delimit boundaries around access to resources and care for whatever reasons, we ask, how do older people and other agents negotiate these constraints? For this nation-state, there are many examples to discuss, including employment, housing, health care and even intergenerational relationships.

2

3

Within each of these arenas of tension, we will examine the scope of agency of older persons, their families and the community. How do each of these groups negotiate individually or collectively the restrictions placed upon the definition and provision of resources and care? How do they strategize to empower themselves and bring about changes that will improve care for themselves. Chapter 1 has introduced the concepts of social construction and their bearing on the identity of older persons. The political economy of care services has also been discussed to focus attention on the structures that frame policy decisions regarding care of older persons and it is argued that older people are not passive recipients of services but actively seek to overcome structural constraints. Chapter 1 has also elucidated how qualitative work acts as a complement to quantitative research by allowing the voice of the older person to be heard. This gives more texture to evaluations of policies regarding old age. Chapter 2 explores the ageing trend in Singapore and highlights the demographic implications of this phenomenon. Chapter 3 examines how an overarching national position on older persons was formulated, bearing in mind demographic realities as well Singapore’s need to remain competitive in the global economy. The actual care services and

Introduction

9

number of facilities are explained within the structural framework for the provision of care, one which is premised on self-help. Chapter 4 examines employment and the social construction of ageism in work. It evaluates the employment policies of the public and private sectors in the hiring and keeping of older employees and shows how marginalization is bound up with conceptions of competitiveness in the new international division of labour. Chapter 5 deals with financial strategies created by the state to ensure self-maintenance of the older population. It evaluates the social security scheme in Singapore and shows how older persons are encouraged to hedge against the future. Where a financial shortfall already exists, the strategies that are used by older persons to negotiate a better quality of life will also be discussed. Chapter 6 examines health issues and how acute care takes priority over community care in Singapore, driving up the price of health care. The medicalization of health is proposed as an obstacle to better health care service as it disempowers older people and removes their agency in the making of health care decisions. Chapter 7 analyses the caregivers of older persons and the problems they face in providing care, including the lack of structural supports that may ease their burden. We problematize caregiving as a conflict in the construction of women as both waged worker and caregiver and we show how a nexus for home and the community can alleviate the burden of caregiving. Chapter 8 examines housing options for older persons as the foundational bases for the strengthening of an intergenerational framework. We show how the family (extended as the most ideal but workable even in the more numerically dominant nuclear family unit) is constructed as the main caregiving unit and the home as the best sanctuary for caregiving. Chapter 9 expands the discussion on the family as a unit of care and focuses on older persons as grandparents in giving care to the young and very young in families. It reveals tensions between structural expectations concerning grandparenthood and older people’s desire for more autonomy. While there are no policies that directly address problems faced by the widowed, Chapter 10 examines this group that has little access to resources because they are mostly women who have never worked; care for this group depends to a large extent on how they are socially constructed. Chapter 11, the Conclusion, summarizes the various problems encountered in service provision for older persons, contextualizing these within the needs put forth by older Singaporeans themselves. This, we hope, will go some way to empowering them and helping policy makers ‘see’ beyond facts and figures of demographic statistics and more, the human element in ageing.

A note on methodology The empirical materials used in this book are drawn from several studies which we conducted over a period of time. Where available, important studies conducted by other organizations are also discussed, in addition to

10

Introduction

Table 1.1 Profile of 1999 survey of transitions in health, wealth and welfare of older Singaporeans Profile

No.

%

Ethnicity Chinese Malay Indian Others

1,692 205 62 18

85.6 10.4 3.1 0.9

556 625 218 356 222

28.1 31.6 11.0 18.0 11.3

835 1,142

42.2 57.8

62 951 917 47

3.1 48.1 46.4 2.4

1,977

100.0

Age Less than 65 66–75 76–80 81–85 Greater than 85 Gender Male Female Marital status Never married Married Widowed Divorced Total Source: Authors’ study

secondary statistical sources. The primary research projects conducted by ourselves include our 1999 study on transitions in health, wealth and welfare of older Singaporeans which used as its sample 1,977 respondents drawn from the 4,750 people who participated in the 1995 National Survey of Senior Citizens (NSSC) in Singapore conducted by the Ministry of Health (MOH), Ministry of Community Development (MCD), Department of Statistics (DOS), Ministry of Labour (MOL) and the National Council of Social Services (NCSS). As a longitudinal study, our 1999 survey followed up on most of the aspects covered in the 1995 study but because of attrition, the sample was much smaller which also accounted for the slight over-representation of the Chinese (Table 1.1). The study primarily elaborated on changes with regard to household living arrangements, health status, employment and financial status, and caregiving and social support. In addition, the book draws upon a qualitative study we completed in 2003 with six focus groups and 11 service providers. The focus groups discussed health, financial security, intergenerational relationships, social and recreational activities and the use of community services relating to health,

Introduction

11

caregiving and social activities catering to older persons. For the focus group discussions, there was a total of 42 respondents (15 males and 27 females) who were grouped into two lower- and lower-middle income groups (blue collar workers who may/may not be retired); two middle- and upper-middle income groups (professionals); and two homemaker groups (lower and upper income) (Table 1.2). The focus groups varied in size from four to ten. To ensure that there was not only variety in the income groupings, we included persons who were young-old as well as old-old. The respondents were aged 54 to 81.3 Although it was not intended, the respondents were mostly Chinese, with two Indian and two Eurasian participants. Every effort was made to get Malay respondents but unsuccessfully. Time and money constraints prevented further investigations. Focus groups were used as they allow open discussion and an airing of views on common problems faced by all members in the group. The qualitative nature of the discussions picked up nuances that are usually not available in quantitative surveys. For the 11 service providers interviewed, they comprised two hospitals (with in- and outpatient rehabilitation services); two day care and rehabilitation centres; two nursing homes; four service centres catering for social, educational and other developmental activities, including counselling services and job search; and finally an interview with the Ministry of Community Development, Youth and Sports (MCYS) (Table 1.3). We obtained from all the services a profile of their clients, the exact types of services they provided, what they thought their clients needed and additional insights into the problems their clients faced. They also explained the strategies they took as agency themselves to overcome the constraints set by state structures. To gain insights into the problems of caregiving, we also included a quantitative study on 61 carers. They were selected from the case records (from 1991 to 1995) of a voluntary welfare agency, Hua Mei Mobile Clinic (HMMC). HMMC is a direct service programme of the Tsao Foundation, a non-profit organization that offers ongoing medical care for home-bound older persons at their own homes. The permission of the medical director of the HMMC was obtained prior to the study, and confidentiality in terms of the identity of the clients was assured. Although this was a quantitative study, the sample size was small due to variability in the completeness of case records kept by HMMC. The answers to the questions contained in the four questionnaires used in this study (i.e. the Social Worker Assessment Questionnaires 1 and 2; the Screening Questionnaire; and the Carers’ Stress Scale Questionnaire) that provided the data were not complete for all the cases. In addition, some of the clients of HMMC were single persons living alone and therefore had no family carers, again disqualifying them from the study. While the sample is not representative of Singaporean carers in general, it does capture some common problems faced by carers who are seen by social workers. Table 1.4 summarizes the main characteristics of the carers in the sample.

12

Introduction

Table 1.2 Focus group composition of the 2003 study on older persons in Singapore Profile

n1

n2

n3

n4

n5

n6

n7

n8

n9

n10

FG1: Homemakers Sexa F Age 79 C Ethnicityb M Marital statusc No. of children 6

F 55 C M 3

F 67 C M 6

F 70 C M 4

F 77 C W 2

F 60 C S 0

F 76 C W 3

F 81 C W 4

F 76 C W 2

F 54 C M 3

FG2: Blue collar Sex Age Ethnicity Marital status No. of children

M 68 C S 0

M 75 C M 2

M 68 C M 4

M 70 C M 5

M 69 C M 4

M 62 C M 3

M 68 C M 1

FG3: Blue collar Sex Age Ethnicity Marital status No. of children

M 79 I M 5

M 63 C M 3

F 66 C M 1

F 69 C M 2

FG4: Professional Sex Age Ethnicity Marital status No. of children

M 74 C M 3

F 64 C D 2

F 69 C M 3

F 68 E W 1

FG5: Professional Sex Age Ethnicity Marital status No. of children

M 71 C M 4

F 56 C M 2

F 65 E M 1

F 66 C M 2

M 58 C M 2

M 62 C M 2

F 59 C M 1

FG6: Homemakers Sex F Age 63 Ethnicity C Marital status S No. of children 0

F 60 C M 5

F 55 C M 2

F 75 C W 4

F 73 I M 3

F 62 C M 2

F 64 C M 2

F 68 C M 3

F 78 C W 2

a M = Male; F = Female. b C = Chinese; E = Eurasian; I = Indian. c S = Single; M = Married; D = Divorced; W = Widowed. Source: Authors’ study

Introduction

13

Finally, a quantitative study on 237 widowed persons followed by an in-depth analysis of 25 people (Table 1.5) completed in 1999 provided information on the life experiences of widows and widowers. For this study, the respondents were mostly visitors to the 1997 Golden Years Exhibition. This was a nationwide annual event that aimed to publicize public and private services available to older persons. No record was kept of the attendance rate at this event but it was estimated to run into a few thousand. Respondents were approached randomly. The exhibition yielded a total of 136 respondents. In addition, voluntary organizations such as the Lions Befriender Service, the Moral Senior Activity Centre, the Presbyterian Welfare Services, the Singapore Action Group for Elders (SAGE), Toa Payoh Care Corner, the Ang Mo Kio Family Service and the People’s Association (PA)4 were contacted for name lists of senior citizens registered with them. These clubs service many public housing estates in Singapore, giving a better chance of acquiring a more representative sample. From the name list of 325 names, 85 were willing to co-operate. To add to the sample of 221 respondents, a snowball sampling approach was implemented. It involved asking the participants to suggest names of other widows or widowers who might be interested in taking part in the study. Another 16 participants were obtained using this method. The 25 in-depth interviews were respondents who were willing to participate. In terms of secondary sources, most were obtained from DOS. Other government bodies were also referred to, especially pertaining to statistical information. Together the information sources provided a comprehensive picture of Singapore’s ageing experience.

Table 1.3 Service providers in the 2003 study on older persons in Singapore Type of service provided S1

Day care centre (social activities and physical rehabilitation)

S2

Hospital with day rehabilitation service

S3

Hospital with day rehabilitation service

S4

Social/recreational/skills training and job placement/counselling service centre

S5

Residential home with day rehabilitation service

S6

Day care centre (social activities and physical rehabilitation)

S7

Residential home

S8

Government body

S9

Social/recreational/counselling service centre

S10

Social/recreational/skills training service centre

S11

Social/recreational/skills training/counselling service centre/public education outreach

Source: Authors’ study

14

Introduction

Table 1.4 Socio-demographic characteristics of carers from the HMMC study (N = 61) Profile

No.

%

19 42

31.1 68.9

Gender Male Female Age Less than 40

10

16.4

41–60 Greater than 60

21 30

34.4 49.2

Marital status Single

20

32.8

Married Divorced/widowed

39 2

63.9 3.3

Spouse

25

41.0

Daughter

14

23.0

Son

11

18.0

Daughter-in-law

3

4.9

Grandchild Others

3 5

4.9 8.2

36 25

59.0 41.0

7

11.5

Relationship with patient

Working status Not working Working Income Less than $500 $501–1,000

11

18.0

$1,001–1,500

5

8.2

$1,501–2,000

3

4.9

Greater than $2,000

6

9.8

On Public Assistancea

2

3.3

27

44.3

No income

a Receiving financial assistance from the government. Source: Authors’ study

Introduction

15

Table 1.5 Profile of survey and in-depth respondents in the widowhood study (%) Profile

Survey respondents (n = 237)

In-depth respondents (n = 25)

Gender Male Female

19.4 80.6

24.0 76.0

Age 50–60 61–70 71–80 81 and above

22.8 29.5 29.5 18.2

23.0 34.6 30.8 11.6

Ethnicity Chinese Malay Indian Others

64.2 19.0 13.1 3.7

64.0 24.0 12.0 –

Source: Authors’ study

Notes 1 2 3 4

The average annual growth rate for the old-old defined as 85 and above was 5.9 per cent. As opposed to scientific theorizing done by researchers. In this study, we used the 1990 census cut-off point of 75 and above to define the old-old group. Lions Befriender Service reaches out to over 4,000 lonely older persons. It has a team of over 1,200 volunteers who make weekly island-wide visitations as well as organizing social and recreational activities while also facilitating better coordination of community-based care. The Presbyterian Welfare Services is a Christian welfare service that covers a range of services, including home nursing and financial assistance for older persons. SAGE’s mission statement is to encourage the continued growth and development of older persons through education, employment, recreational and social activities and counselling. It also fosters research on ageing. Toa Payoh Care Corner does mainly physiotherapy counselling but it also provides psychological and emotional counselling to help older persons in their relationship with family members. The Ang Mo Kio Family Service Centre has family-oriented activities that will enhance family relationships and help members to cope with problems they have to face in rapidly changing Singapore. The PA is the statutory board that links community with the state. It nurtures leadership, promotes racial harmony and social cohesion. Active citizenship is achieved through volunteer work. Through the 330 community centres or similar in Singapore, it offers a large number of social, educational and recreational activities for Singaporeans (see Chapter 3). The Moral Senior Activity Centre is one of many such centres whose functions are also fully described in Chapter 3.

2

Singapore’s ageing population The demographic profile

Introduction Since its independence in 1965, Singapore has experienced dramatic changes in its demographic trends. From a population of 2 million in 1970, the small city-state with a land area of 699 km2 has more than doubled its population to 4.2 million in 2004 (DOS 2005a). The increase has been accompanied by the demographic transformation of a young population with high fertility and high mortality to an ageing one with low fertility and low mortality. This is reflected in the age pyramid which over the past three decades has advanced from a bottom heavy to a middle heavy one as the post-war baby boomers enter their forties and fifties (Figure 2.1). The median age of the country’s population has risen from 20 years in 1970 to 24.4 years in 1980 and further to 35.7 years in 2003 (DOS 2005a: 47). This chapter provides an overview of the demography of ageing in Singapore, outlining the dynamic changes to be expected by the baby boomers as they move up the age pyramid.

Rapid ageing According to Gavrilov and Heuveline (2003), a population is ageing when the proportion of persons 65 years and over reaches 8 per cent. Singapore can be said to have just met this criterion round about 1998 (DOS 2002a). What is worrisome is that this percentage is expected to increase to about 19 per cent by the year 2030. At a rate of 3.1 per cent per annum (DOS 2002a), Singapore’s growth rate for those aged 65 and above surpasses even the developed countries for the same period (Table 2.1). In absolute terms, the number of older persons in Singapore is expected to increase from 238,000 in 2000 to 796,000 in 2030 (DOS 2001a; Inter-ministerial Committee (IMC) on the Ageing Population 1999). Besides economic outcomes, the fourfold increase will have social and political implications for this fairly young nation-state. One of the foremost concerns is the change in the old age dependency burden. From the ratio of 5.9 older persons per 100 population aged 15 to 64 in 1970, the old age

Figure 2.1 Population pyramids of Singapore, 1970; 1983 and 2003 Source: Collated from DOS 1992: 30–31; Heng and Png 2004: 13; Tan 2002: 3

18

Singapore’s ageing population

Table 2.1 Life expectancy at birth and proportion of population aged 65 and above in selected countries Country

Life expectancy at birth, 1995–2000 (years)

Japan Canada Switzerland Sweden Hong Kong Spain Australia France Singapore USA New Zealand UK Denmark South Korea Malaysia China

80 79 79 79 78 78 78 78 77 77 77 77 76 72 72 70

Proportion of population aged 65 and over (%) 1998

2030

Growth p.a.

16 12 16 17 10 16 12 16 7 13 12 16 16 6 4 6

26 23 26 22 28 26 19 24 19 20 17 22 21 17 10 14

1.6 2.0 1.5 0.9 3.2 1.5 1.4 1.3 3.1 1.3 1.1 1.0 0.8 3.3 2.8 2.7

Source: DOS 2002a: up

dependency ratio has increased to 10.2 in the year 2000 (DOS 2000a). It is projected that by 2030, the old age dependency ratio will rise to 29.5 per 100 persons aged 15 to 64 (IMC on the Ageing Population 1999). Among the population aged 65 and over, the old-old, i.e. those aged 85 and above, are increasing at a faster pace than the rest. In the decade from 1990 to 2000, while the population aged 65 and over increased at an annual rate of 3.6 per cent, the old-old increased at a rate of 5.9 per cent (Table 2.2) while the resident population increased at a rate of only 1.9 per cent. Ninety per cent of the old-old are female and 80 per cent of them are Table 2.2 Average annual growth rate of older persons, 1990–2000 (%) Gender Males Females Total Source: Ang and Lee 2000: 11

Old-old aged 85 years and over 6.4 5.7 5.9

Older adults aged 65 years and over 3.6 3.5 3.6

Singapore’s ageing population

19

born outside Singapore. With 91 per cent having no formal education, these women characterize the first generation of migrants to Singapore in the early twentieth century (Ang and Lee 2000). As many remained unmarried, they have had to depend on clan associations to take care of them (see Chapter 3); today, those who are still alive rely on state assistance.

A dearth of births and a longer life span The rapid ageing of Singapore’s population can be attributed to two demographic events: increased longevity and a dramatic fall in the birth rate. With good public health measures, effective medicines and an increased standard of living, life expectancy among average Singaporeans has increased from 69 in 1970 to 79.3 years in 2004 (DOS 2005b; MOH 1994). Females have a longer life expectancy of 81.3 years, almost four years more than men (77.4 years) (Table 2.3). The impact of better health care is more evident when life expectancy at age 60 is examined. Among Singaporeans, life expectancy at age 60 years had improved considerably by the 1990s, at 18.4 years and 21.6 years more in 1996, up from 12.9 years and 15.6 years in 1970 among older men and older women respectively (Japan Aging Research Center 1997: 104). By 2004, the life expectancy at 65 years was 17.9 years more for everyone and 16.6 and 19 years respectively for older males and females (MCYS 2005a). In contrast to the increase in life expectancy is the decline in birth rate. In a comparative analysis of fertility rates in East and Southeast Asia (Atoh et al. 2004), it was found that Singapore is among seven countries in this region that has completed its fertility transition. The declining birth rate in Singapore has become a national concern especially since the 1980s, after the total fertility rate (TFR) dropped to below replacement level. Although pro-natalist population policies influenced TFR to a limited extent, contributing to the rebound in TFR from 1.43 in 1986 to 1.62 in 1987 and further to 1.96 in 1988 (Yap 2005), Singapore’s birth rate has been on a downward spiral (Figure 2.2). In 2004, the number of children per woman aged 15 to 44 was at an unprecedented low of 1.24 (DOS 2005c). Table 2.3 Life expectancy at birth, 1970–2004 Year

Total

Males

Females

1970 1980 1990 2000 2004

69.0 72.1 75.3 77.6 79.3

65.9 69.8 73.1 75.6 77.4

72.1 74.7 77.6 79.7 81.3

Source: DOS 2005b: up; MOH 1994: 14

20

Singapore’s ageing population

Figure 2.2 Total fertility rate, 1960–2004 Source: Collated from DOS 2005c: up; Yap 2005: 480

For industrialized countries, the continuous fall in birth rates presents a dilemma. It will lead to a smaller active labour force, especially if low TFR is accompanied by higher old age dependency ratios and early retirement age. This trend will call into question the ability to sustain economic growth. It is estimated that if the TFR remains at 1.5 without immigration or emigration, Singapore’s resident population will dwindle from 3.2 million to 2.7 million in 50 years’ time (Lien 2002).

Characteristics of older persons in Singapore Since Chinese form the majority population in Singapore, it is expected that among those aged 65 and above, the Chinese would comprise the largest at 80 per cent of this cohort while the Malays form 11 per cent and the Indians 8 per cent (Committee on the Family 2005). Looking at the sex and age dependency ratios of the three ethnic groups reveals a more nuanced picture. The 1990 sex ratio statistics revealed that although there were more Chinese older women than men (76 males per 100 females for those aged 60 and over), among Malays and Indians the trend was the reverse (114 males per 100 females for Malays and 266 males per 100 females for Indians) (Cheung 1993: 79). By 2000, the sex ratio statistic for the Chinese was 80.1 males per 100 females aged 60 and above while for the Malays and Indians, it was 94.8 males per 100 females and 168.6 males per 100 females respectively (DOS 2001a). Higher life expectancy may have caused the better balance, in addition to the passing of that cohort of older Chinese samsui women1 and older Indian men who had immigrated to Singapore in the late 1800s to early 1900s. Since the majority population is Chinese, there is some concern about the gender imbalance. Mehta (2005: 48–49)

Singapore’s ageing population

21

notes that for the year 2000, women aged 50 and above had a lower level of education and lower labour force participation rate than men of the same age. In addition, the proportion of widows was higher than widowers. The specific implications of gender imbalance will be explained in subsequent chapters. For the time being, suffice it to say that the gender imbalance will pose a challenge to family members and to state because the current cohort of older women have few financial resources to speak of. The old age dependency ratio (those 65 years and over) for all three ethnic groups increased over the decade of 1990–2000. This reflects an increase in the number of older persons relative to those of working age 15 to 64 years. The Chinese registered the smallest increase from 8.8 to 10.4 older persons per 100 working adults during the decade. For the Malays, the ratio was lowest in 1990 at 6.4 but increased to 8.4 older persons per 100 working adults in 2000. The magnitude of increase for the Indians in the same period was the largest, from 7.2 to 11.2 older persons per 100 working adults. This is more than twice the increase experienced by the Chinese (DOS 2001a). Old age dependency must be viewed together with child dependency. Nationally, the child dependency ratio was 32.3 children under 15 per 100 working population and 30.1 respectively for 1990 and 2000. For the Chinese, because of lower fertility, this ratio dropped from 30.4 to 27.0 in the decade. In contrast, the child dependency ratio for the Malays increased from 43.0 to 45.6 since their TFR is higher at 2.13. The Indians also saw a similar increase from 32.9 to 35.4 (DOS 2001a; 2005a). In terms of the median age, the Chinese population is oldest with a median age of 35, while the Malay population is youngest at 29. The information for the various ethnic groups taken together reveals that the Chinese population is the oldest and its low fertility has merely transferred the problem of dependency up to the older generation. Besides ethnic differences, at the general level, there are already concerns about the character of the population aged 65 and above. In 2000, 58 per cent of those aged 65 and above were married, 37 per cent widowed and 3 per cent single. However, with a longer life span for women, it is expected that they will outnumber men as the population grows older. Hence, in 2000, of those widowed, females formed the majority at 84 per cent (Committee on the Family 2005). The educational profile of older Singaporeans is reflective of the state of the economy and society prior to Singapore’s independence. Many of the immigrants who came as young and able-bodied workers lacked education. Thus in 1995, 89.2 per cent of the population aged 65 to 74 had only primary education or below (including the category ‘No qualifications’) (Table 2.4). By 2000, the proportion had dropped to 80.8 per cent (DOS 2005d). In examining for gender differences, we found that the educational attainment of older women in 1990 was much lower than older men. As high as 96.7 per cent of women aged 60 years and over had below secondary school

22

Singapore’s ageing population

level education. Lower education levels also translate into a lower labour force participation rate among older women. In 1990, men over age 60 comprised 33 per cent of the labour force while women constituted only 8.7 per cent (Shantakumar 1994: 57). By 2000, the proportion for women had dropped marginally to 8 per cent (Mehta 2005: 49). In general, however, the socio-economic profile of older persons is expected to change as the baby-boomer cohort reaches retirement age. The educational profile of older adults shows that each successive cohort of older adults is becoming more educated than the earlier cohort. In 1995, for those in the age group 65 to 74, only 1.4 per cent had received a university education. However, the proportion of tertiary-educated is projected to rise steadily from 3.9 per cent in 2010 to 13.1 per cent in 2030 (Table 2.4). The ambulatory status of older persons may decline with age and the 75 and older age group needs more attention. According to the 1990 census, for those aged 75 and over, the non-ambulant proportion was higher for women, at 4.1 per cent compared to men at 2.5 per cent (Shantakumar 1994: 157). On the whole, however, ambulant older persons regardless of gender formed the overwhelming majority of this population (93.8 per cent) (Shantakumar 1994: 156). In 2000, 88.8 per cent of residents aged 65 and above were ambulant, 7.9 per cent semi-ambulant and 3.3 per cent nonambulant (MCYS 2005a). Living arrangement has often been used as an indicator of family support for older persons. In 2000, about 87.6 per cent of older persons stayed with their spouse and/or children. Given longer life expectancy for women, older women are more likely than older men to be widowed and hence live with their married or unmarried children. In 2000, 54.7 per cent of women lived with their children only, compared to 15.2 per cent of men. Those who lived alone, with non-family members or similar arrangements, made up 12.3 per cent of those aged 65 and above in 2000, with females slightly exceeding males (13.3 percent for females and 11.1 per cent for males) (DOS 2002b). Social changes, such as the preference for nuclear households and the norm of women participating in the workforce, translate into a lack of caregivers for older persons in an ageing society, especially when the Table 2.4 Education profile of persons aged 65–74, 1995, 2000 and estimates to 2030 (%) Educational qualification

1995

2000

2010

2030

Primary and below Secondary Upper secondary University Total

89.2 6.9 2.5 1.4 100.0

80.8 13.2 4.2 1.8 100.0

71.2 16.4 8.5 3.9 100.0

37.8 31.8 17.3 13.1 100.0

Source: DOS 2005d: up; IMC on the Ageing Population 1999: 18

Singapore’s ageing population

23

ambulatory rate is expected to fall with an older age. In general, institutionalization is still an option that is resisted (Teo 1992). Instead, it is more common for children to share the cost of employing a domestic help to take care of their dependent older parents at home, particularly with the relative ease of employing foreign domestic helpers in Singapore. Although many older persons are staying with their (married or single) children, there is a trend towards independent living. While households with older persons have increased slightly from 20.7 per cent in 1990 to 21.4 per cent in 2000, households with only older persons have risen more from 1.6 per cent in 1990 to 2.8 per cent in 2000 (DOS 2002b) (Table 2.5). An expenditure survey conducted recently termed households with nonworking adults aged 60 and above as ‘retiree households’ and found such households to make up of 3.9 per cent of all households (The Straits Times 25 June 2005). A 2003 survey of households in Housing Development Board (HDB) estates that house 84 per cent of Singapore’s population showed a similar trend of older persons living alone (The Straits Times 21 June 2005). The survey showed that 21.1 per cent of older persons living in HDB estates are living alone, and expects this number to rise in the future to 24.3 per cent of older persons. Many in the survey indicated that they would prefer to live by themselves. Living independently, however, does not necessarily mean weakened family ties as mutual support in terms of older parents helping with the care of grandchildren, and adult children supporting in financial ways, are common forms of intergenerational exchanges here. Indeed as many as 75 per cent of older persons cited their adult children as their main means of financial support (Committee on the Family 2005).

Conclusion Today, the ageing of Singapore’s population is widely recognized as a demographic reality by both the state and the people. Whether an alarmist attitude is taken, as expressed by the newpaper headline, ‘Singapore’s ageing population a ticking time bomb’ (The Straits Times 27 November 2002), or a more positive view is upheld, that the emerging older population will be better Table 2.5 Resident households with older adults Households

Households where all persons are aged 65 and above Households where at least one person is aged 65 and above Source: DOS 2002b: up

Number (’000)

As % of resident households

1990

2000

1990

2000

10.4

25.7

1.6

2.8

136.7

197.8

20.7

21.4

24

Singapore’s ageing population

educated and in better health and hence a potential resource to the society, changing demographics signal the need for state to constantly review and revisit policies and programmes catering for older persons. As aptly pointed out in a recent feature on older persons in The Straits Times (25 June 2005), there is no one-size-fits-all solution to an ageing population, and whether the numerous perspectives and interests constitute the majority or not, these differences should be mediated and respected. We must keep in mind the diversity not only in terms of different age cohorts and social-educational status, but also gender and ethnicity which will play a part in affecting the ageing experiences of the individuals.

Note 1

Samsui women came from China and were called ‘Ah Ma Jies’. They came to Singapore to work as labourers in the construction industry and had a reputation for being extremely hardworking and thrifty. They were distinguishable by their blue outfits and their red headgear. Many did not marry and depended on clan associations to provide for their old age needs.

3

Policy concerns and the framework of support

Introduction In a study of five Confucianist-influenced countries in Asia, including Singapore, Goodman et al. (1998: 14–15) proposed that they have similar ‘developmental welfare systems’ characterized by ‘non-state agencies – community, firm and family ... [which are] expected to play a major welfare role in both financing and providing welfare services ... [The] ideological context [of] ... self/mutual help is encouraged and dependence on the state discouraged, indeed stigmatized’. This is in stark contrast to the UK welfare system or even the US social security system where citizens depend on the state to provide or guarantee welfare. Indeed, as Ngiam (2005: 60–61) argues, Singapore’s system is an ‘alternative’. Rather than just give welfare, the government stresses that first, self-care, failing which the family and then community care must be engaged. Articulated as the ‘many helping hands’ approach, the concept sees various sectors coming together to provide a safety net for those in need, albeit in the order of family as the first line of defence, followed by community/neighbourhood or voluntary welfare organizations (VWOs), and state as the last resort (Mehta 2004; Teo 1994; Wong et al. 1999). How exactly does such a structural framework of support influence ageing policies? While subsequent chapters examine indepth how policies arising from such an approach affect older people, this chapter provides the background and development of ageing policy in Singapore resulting in a structural framework that has become the cornerstone of all ageing policies. The discussion is followed by a list of the various policies and services in place for older persons at present.

Background In the effort to cope with a rapidly ageing population, the government of Singapore constantly looks to other countries such as the UK, US and Japan to derive best practices for the nation. Japan, as a developed and Confucianist society in Asia, has been a favourite model in many aspects (Thang and Gan 2003). However, the mistakes of others provide lessons to be learnt. Thus,

26

Policy concerns and the framework of support

unlike Japan which had once attempted to adopt the Western welfare approach in the early 1970s but changed its course in the wake of the oil crises in the later part of that decade, the Singapore government has been steadfast in its non-welfare state philosophy towards care. This was a decision made by the People’s Action Party (PAP), the party in government since 1959 when Singapore achieved self-government from the British colonial administration (Ngiam 2004). The decision took into account the leaders’ concerns with the lack of recurring finances needed to sustain a welfare system. For a country that does not have natural resources and depends solely on its human capital for development, a welfare state approach is also deemed undesirable for fear that it would erode Singapore’s work ethic and affect the island’s competitiveness in the global market (Ngiam 2005). Moreover, the higher taxation needed to sustain a welfare state system will raise tax rates and affect the competitiveness of Singapore in attracting the foreign direct investment upon which it so much depends for economic growth (Yeung 2000). In principle, economic logic largely drives the approach of social welfare and other policy making in Singapore. As Western welfare states began to face a crisis of affordability in welfare provisions from the 1970s, the different approach adopted by Singapore and other economically strong Asian countries has since been examined more seriously (Jones Finer 2005). Singapore’s approach has a long context which goes back to the former colonial government. Indeed, a look at the historical framework of care shows that informal ways of meeting needs were prevalent long before the establishment of modern social welfare services. After the British colonized Singapore in 1819, the development of Singapore into a trading port attracted an influx of immigrants mainly from China, India and other neighbouring regions. With the policy of laissez faire providing hardly any form of support from the colonial government, the immigrants depended on informal help from relatives and others from the same province of origin. Among the Chinese, for example, they established a formal system of mutual aid known as clan associations. These associations were based on commonalities such as surname, village or province. They became an important source of ‘social security’ in the form of a managed savings fund for its members. The money could be brought back to China eventually, or used to ensure that members of the clan would have a decent burial if they eventually died in the foreign land (Wee 2004). Over time, some of these clan associations expanded their functions and became providers of welfare services for older persons, e.g. in the form of rest homes for older people who did not have families in Singapore. The Kwong Wai Shiu Cantonese Association even established a large hospital in 1910 that up to today acts as a step-down facility for the care of frail old people. If there was sickness or need for money, trade and guild associations served the same function as clan associations (Cheng 1985). For the Indian migrants made up of traders, artisans and a very large group of impoverished Indian labourers and convicts who worked the

Policy concerns and the framework of support

27

construction industry in the nineteenth century (Dobbs 2003), there were ethnic associations such as the Indian Association established in 1923. The Indian Association provided accommodation and facilities for sick and destitute immigrants but its help was limited because of a lack of funds. It could do very little to alleviate the hardship suffered by the community (Singapore Indian Association 2003). Malays and Indonesians too had their own mutual help networks in the form of home-origin associations. Like the Chinese clan associations, where the immigrants came from mattered in getting them access to help when needed. They included the Javanese and Boyanese Associations. A more inclusive form of help for the needy came from religious institutions such as the mosque. Together, the guilds, clan, ethnic and religious organizations formed the initial non-familial support system for the needy in Singapore. The colonial government’s efforts to provide welfare were limited. A meagre beginning in welfare service provision started in 1877 when the Chinese Protectorate was set up to help newly arrived Chinese immigrants. Its main goal was to regulate the coolie trade and lessen the misery of the coolies who were subject to merciless exploitation by the secret societies/triad organizations who acted as the main coolie brokers at that time. As a result of this improvement in conditions, the number of Chinese arrivals increased dramatically from the 1880s onwards. Besides the coolies, agents of the Chinese Protectorate often visited domestic servants, some of whom were found to be subjected to especially inhumane conditions. They were sent to a sheltered home for girls, as were young girls wrestled from the brothels (Wee 2004). The efforts to provide social welfare were few and far between. For the most part, the colonial government was tied up building infrastructure such as hospitals and in the management of disease in congested areas such as Chinatown (Yeoh 1996). It was only after World War II, in 1946, when the Social Welfare Department was established that a watershed in the social welfare history of Singapore was crossed. The Department was responsible for the welfare of the poor, women and children. The latter two in particular needed more attention as the fertility rate was rather high at that time. Issues relating to ageing were confined to financial relief for the needy and residential care for the destitute. The following year in 1947, a Social Welfare Council was formed. The Council embodied the principle of recognition for the active role played by VWOs in filling the gap of welfare provision in Singapore. VWOs, active since the post-war colonial period, worked with the disabled and with children, e.g. the Singapore Blind Association (now known as Singapore Association of the Visually Handicapped (SAVH)), the Society for Aid to the Paralysed (now called Society for the Physically Disabled) and the Singapore Association for Retarded Children (now Movement for the Intellectually Disabled of Singapore (MINDS)). Up to the 1980s, looking after older persons was not deemed an urgent need as the population was made up of mostly young people. To look after the old, the British

28

Policy concerns and the framework of support

employed their own welfare model of a pension scheme for civil servants in Singapore. In the private sector, this scheme did not take off because of its high anticipated costs. To provide the population with some means of looking after themselves in old age, a ‘forced savings’ scheme was developed, namely the Central Provident Fund (CPF) in 1955 (Ngiam 2005). In comparing the social policies between the colonial era and the current government, Wee (2004) suggests that there is resemblance in so far as welfare provision in both cases was limited. Difference, where it exists, is in the fact that unlike the colonial government, the Singapore government can be depended upon to provide welfare if all else fails. While the government subscribes to a care-from-afar or at-arm’s-length approach, the government is cautious also to communicate that it is reliable should the need arise: Look after yourselves and do not rely too easily on us, but we will help to organize a ‘many hands approach’ to meeting needs, and we will give every possible support to the voluntary organizations. And if all else fails, we are there for you. (Wee 2004: 76)

Developing a national policy on ageing In the early decades since independence in 1965, planning for ageing services remained sectoral and services were treated mainly as an extension of the existing social welfare schemes (Cheung and Vasoo 1992). There was no agenda on ageing as the state’s concerns were mainly focused on family planning efforts to reduce high fertility. Although Senior Citizens’ Week was introduced in 1979, the broader concerns of the problems and needs of older persons only began in 1982 when successful family planning policies and modernization led to a sustained low birth rate that was below replacement level. The low birth rate helped the state to realize the implications of an ageing population. Among the concerns highlighted in the early 1980s was the need to review the retirement age for employees so that they could stay longer in the workforce (see Chapter 4 for an expanded discussion). While issues such as this remain a concern, we also see the development of a focus on financial support as the widespread use of the CPF for purchase of housing had led to the phenomenon of an asset-rich but cash-poor society (see Chapter 5). The older population had relatively little cash to finance their care in old age. Defining ways to enable older persons to provide for their own care became the basis of new policy measures (Wong et al. 1999). The appointment of a committee to study the problems of the aged in 1982 signified the first serious state effort to address ageing issues. The committee commissioned a comprehensive National Survey of Senior Citizens in the same year. Based on findings of a survey of 5,538 persons aged 55 years and more (Ministry of Social Affairs 1983), the Report of the Committee on the Problems of the Aged was published in 1984 (MOH 1984). Although titled

Policy concerns and the framework of support

29

as ‘problems’, the 1984 report sets the direction of future perceptions about the implications of ageing. By stressing the potential contributions of older persons to society and the importance of incorporating them in socio-economic development while concurrently acknowledging and meeting their special needs, the committee wanted a more inclusive approach that would get the government the support it needed to tackle the ageing phenomenon (Cheung and Vasoo 1992). The report made various policy recommendations, including a deferment of the retirement age to 60; more part-time and flexi-time work for older persons; the age of withdrawal of CPF to be delayed to 60; more earned income relief for older workers; more aged dependents’ tax relief; and measures to foster family and intergenerational cohesion. In 1988, the state commissioned the Advisory Council on the Aged to undertake a comprehensive review of the status of ageing in Singapore. The Council, headed by the Minister of Home Affairs, appointed four committees to work on specific issues of concern, namely communitybased programmes, attitudes towards older persons, residential care programmes and employment aspects to do with older persons. The Report of the Advisory Council on the Aged (Ministry of Home Affairs (MHA) 1989) made recommendations largely similar to the 1984 Report of the Committee on the Problems of the Aged; the new report in fact strengthened the existing policies and programmes for older persons. Its proposals included expanding public education programmes to promote positive perceptions on ageing and the aged; raising the customary retirement age from 55 to 60; adjusting the seniority-based wage system to facilitate the continued employment of older workers; promoting geriatrics as an area of medical and nursing specialization; providing domiciliary health and medical services for frail and bedridden persons so that they could continue to stay in the community; raising the dependents’ tax relief for persons 75 years and above to help families meet the greater cost of looking after them at home; setting aside land adjacent to public housing estates for homes for the aged; and extending the lease for homes run by VWOs. Among these key recommendations was a proposal to set up a National Council on Ageing as a co-ordinating body to monitor the provision and delivery of services and programmes for older persons, as well as providing an avenue for feedback and evaluative research. Unfortunately, this did not come to fruition and the compromise was the establishment of the Committee on the Aged as a sub-committee of the National Advisory Council on the Family and Aged (NACFA) located at the MCD. The Committee monitored the implementation of the recommendations made by the Advisory Council on the Aged, identified gaps and proposed solutions in services for older persons. However, without an overarching specialized body such as the recommended National Council on Ageing, the sharing of control of elderly services by different ministries, namely, MOH and MCYS, often caused problems for service users who found that procedures differed from ministry to ministry. For instance, criteria for

30

Policy concerns and the framework of support

admission and assessment were confusing and complicated because of the different approaches adopted by the different ministries. This issue remains unresolved even today. In the 1990s, policy reviews continued at various levels. To address raising retirement age issues, a tripartite committee of government officials, employers and union leaders was formed to study the impact of higher retirement age on employers and workers. To strengthen the elderly care infrastructure, MOH set up the Division of Elderly Services and formed the IMC on Health Care for the Elderly headed by the Minister of Health in 1997. In September 1998, a high-level IMC on the Ageing Population was formed for a comprehensive look at all the policies. This resulted in a report in November 1999 which forms the basis of ageing policies and programmes that follow (IMC on the Ageing Population 1999). A new Eldercare Master Plan was launched for fiscal years 2001 to 2005 (Ministry of Community Development and Sports (MCDS) 2001). Mehta and Vasoo (2000) note two characteristics in the formation of ageing policies. First, public responses were included in the committee’s deliberations. The committees sought active feedback especially when controversial recommendations were made. Second, the policy formation process of involving representation from various sectors characterizes the government’s problem-solving approach. The 1998 IMC on the Ageing Population, for example, is a 21-member committee including high-level representatives from the ministries and statutory bodies, and involved civic organizations in the gathering of feedback and comments.1 The collaboration signifies the urgency felt by the state in dealing with a rapidly ageing population. The successive policy reviews on issues related to older persons led to the crystallization of a national policy on ageing in Singapore. In tandem with the ‘pragmatic’ style of governance, the government advocates self-help and self-reliance, making a clear distinction from the ‘public burden’ model of welfare where the state provides direct services to older persons (Low 2004). The national policy on ageing reinforces the state’s position that it does not take sole responsibility for the care of older persons. Family is the first line of care, in holistic terms, including the provision of instrumental, financial and emotional support and care. Community and the state play the role of peripheral support, via services from civic organizations such as VWOs, religious institutions, ethnic-based organizations and secular bodies such as clan associations. Community in fact serves as an intermediary agent between the family and the state. The state offers support from a distance such as that provided by the Elderly Development Division in MCYS which funds programmes for older persons, helps to get land leased at special rates for the purpose of building facilities for older people, trains service staff and provides guidance in programme planning (Mehta 2002). This Singapore-style welfare strategy of indirect support from the state has been called ‘supply-side socialism’ (The Straits Times 18 September 1994 cited in Mehta 2002: 158).

Policy concerns and the framework of support

31

A lopsided socialism cannot gain ground if not for its complement of ‘familism’. This ideology is firmly entrenched in the philosophy of the national policy on ageing: ‘the family setting is still the best approach – it provides the elderly with the warmth and companionship of family members and a level of emotional support that cannot be replicated elsewhere’ (then Minister of Health, Mr Yeo Chow Tong cited in Prescott 1998: 2). To preserve the concept of the family as the best social insurance for its members, the ageing policy is a ‘crowding in’ policy, where various measures are established to ensure that family remains largely responsible for care of their ageing members. As a non-welfare state, the government operates according to the funding principle of co-payment (Mehta 2002; Teo 2004; see Chapter 6). Hence, the state subsidizes part of the charges, while the recipient of the services and/or the family pays the rest. One significant legislation that spells out clearly the responsibility of family members is the Parental Maintenance Act introduced in 1996. It imposes a legal obligation on children to support their parents. To ensure family care of older persons, moral education has been introduced in schools to help ‘prepare the younger generation to provide for the elderly’ (Singapore Council of Social Services 1985: 4). Rappa (1999: 132–33) comments that familism ‘makes social sense’ in a Confucian state ‘because it reinforces the importance of kinship and solidarity among family members and imparts to the adolescent and nascent generations the importance of traditional family ties’. More important, it makes economic sense because it shifts the burden to the individual and prevents the depletion of economic reserves in the country. So far, the ‘economic sense’ of the policies to do with ageing is well assured. The state’s expenditure on social security and welfare has been very low for a country with such a high per capita income. In 1994, expenditure on social security and welfare was 3.1 per cent of total expenditure, compared with 36.8 per cent in Japan and 29.2 per cent in the US (International Monetary Fund (IMF) 1996). However, it is becoming increasingly challenging to place primary reliance on the family as rapid social changes – such as the norm of dual-income couples, decline in family size and globalization providing work opportunities outside Singapore – have affected the family’s capacity to provide care. While it makes ‘social’ (as in intergenerational solidarity) and even ‘cultural’ (as in filial bonds)2 sense, the viability of the current approach may be in question (see Chapters 7 and 9 for elaboration).

Services for older persons in Singapore As population ages, exactly what services are available and how these render support to primary caregivers (i.e. the family) is a worthwhile enquiry. This section provides an inventory of the services for older persons in Singapore, their geographical distribution and how they assist the family in the provision of care.

North East Region Ang Mo Kio Serangoon Hougang Sengkang North Region Yishun Sembawang Woodlands Sungei Kadut Western Water Catchment West Region Jurong West Jurong East Clementi Bukit Batok

Location

1 – 1 – – – – – – – – – 1

– – – – –

1 1 – 2

Community hospitals

1 – 6 –

Hospitals; chronic sick hospitals; hospices

Table 3.1 Health services by location, 2005

1 – 2 –

1 – 1 1 1

2 1 7 1

Nursing homes for elderly, dementia, and mentally ill; rehabilitation homes for mentally ill

– 1 1 2

1 – 1 – –

2 1 2 1

Day rehabilitation centres

– – – 2

– 1 – – –

– – 2 –

Dementia day care; day care for mentally ill

– – – –

– – – – –

– – – –

Hospice day care; respite care

– – – –

– – – – –

– – – –

– – – –

– 1 – – –

– – 2 –

Hospice Home home help care service

– – – 1

– – – – –

– – 1 –

Home nursing service

2 2 3 8

2 2 2 1 1

6 2 21 2

Total

– – – 1 – – – – – – – – – – – – – 4

– –

– 2 – –

– 2 8 2 – 1 1 1 – 2 8 38

Note: Some facilities offer more than one type of service. Source: MOH 2004a: up

Bukit Panjang Choa Chu Kang East Region Changi Tampines Pasir Ris Bedok Central Region Bishan Toa Payoh Novena Kallang Geylang Marine Parade Bukit Timah Tanglin Bukit Merah Queenstown Central Area Total 2 6 2 2 1 5 1 – 2 1 – 54

3 2 2 6

– 1

– 1 – 1 2 – – – 1 – – 25

– 3 – 4

– 1

– 2 – – 1 – – – 1 – – 10

– – 1 –

– –

– 1 2 – 1 – – – – – – 6

– 1 – –

– 1

– 1 1 – – – – – 1 – – 4

– 1 – –

– –

– 2 – – – – – – 2 1 – 11

– – – 2

– 1

– 3 1 – 2 – – – 1 1 – 12

– – – 1

1 –

2 18 14 5 7 6 2 1 8 5 8 164

3 10 3 13

1 4

North East Region Ang Mo Kio Hougang North Region Yishun Sembawang Woodlands West Region Jurong West Jurong East Clementi Bukit Batok Bukit Panjang East Region Tampines Pasir Ris Bedok Central Region Toa Payoh Novena Kallang

Location

1 2 1 – 1 1 1 1 1 1 2 1 1 1 1 –

– – –

1 – 1 – –

1 – 3

3 – 1

Day care

1 –

Sheltered homes

Table 3.2 Social services by location, 2005

3 – 6

1 – 5

1 1 – 2 –

1 – –

2 1

Senior activity centres; neighbourhood links

– – –

– – –

– – – – –

– – –

– –

Befriender

– – –

– – –

– – – – –

– 1 –

– –

Care management service

7 1 7

4 1 9

3 2 2 3 1

2 1 1

4 3

Total

1 – 2 – 4 18

– 1 1 – 1 19

1 – 7 2 2 35

– – 1 – – 1

– – 1 – 1 3

2 1 12 2 8 76

Note: Some facilities offer more than one type of service; the Befriender service has its office in one location but provides islandwide outreach to older persons staying alone (see http://www.lionsbefrienders.org.sg). The care management service assists older persons and their families by helping to co-ordinate the services available so as to support the older persons to stay in the community as far as possible; senior citizens clubs and retiree clubs are not included in the table. There are about 330 such clubs under PA (PA 2005) that are located primarily in the community centres/clubs or with the residents’ committees of the public housing estates. These clubs offer recreational activities, sports activities, continuing education courses and talks as well as health screening. Source: MCYS 2005b: up

Geylang Marine Parade Bukit Merah Queenstown Central Area Total

36

Policy concerns and the framework of support

Services for older persons are largely divided into health care services and social services (Tables 3.1 and 3.2). Some, such as acute care hospitals and community hospitals, are under the government. Most, such as those in the community, e.g. day care or the befrienders’ service, are run by VWOs. In terms of geographical distribution, there is a lack of congruency between the location of health services and where older persons are concentrated. Based on the development guide plan that divides the island into smaller geographic units for the purpose of planning (Figure 3.1), older persons seem to concentrate in the Central Region (Table 3.3 and Figure 3.2). The areas where there seem to be health services in disproportionate number to the percentage of older people in the location include Hougang, Bukit Batok and Tampines (Table 3.1 and Figure 3.2). These are relatively newer estates and have better facilities but they are not where the older population is concentrated at present. It is in the Central Area where 21.7 per cent of the population is aged 60 and above that more health services are needed; similarly, Queenstown, Bukit Merah and Kallang (see Figure 3.2). Social services offer a slightly better match between location of service and concentrations of older persons. When comparing the services available in 2005 (Tables 3.1 and 3.2) with that in 1998 (Table 3.4), we see an overall increase which reflects rising demands from an ageing population. The increase is significant with regards to services catering to the needs of older persons staying at home, such as home help services (from 5 to 11), home nursing services (2 to 12) social day care (from 11 to 19) and day rehabilitation centres (from 21 to 25). Services for active older persons have also seen a significant increase, for example, senior activity centres (SACs) and neighbourhood links (NLs) increased from 25 in 1998 to 35 in 2005. This parallels the budget allocated for elderly services in the Eldercare Master Plan. In this budget, the largest proportion was allocated to programmes for healthy older persons ($30.6 million),3 followed by $14.9 million to programmes for frail elderly, $2.6 million to residential care and finally, $0.1 million to caregivers’ programmes (MCDS 2001). The budget allocation reveals a focus on promoting active participation of older persons in the society, as well as an expansion of community-based services to support families in their caregiving role. The array of services available for older persons is consistent with the policy of placing primarily reliance on the individual and the family. The SACs set up under the joint auspices of MCYS and HDB aim to improve the living conditions of older persons residing in one-room HDB rental flats. The centres provide a support network for these residents as well as a range of services that include information and referral services, maintaining a register of the older persons so that they can be matched with services as and when the need arises and as a means to identify older persons who do not have family members in Singapore, forming mutual help groups and promoting friendly social interaction. NLs built since 2001 are enhanced versions of the SACs. Unlike SACs which cater to poor

Table 3.3 Geographic distribution of older persons aged 60 and above, 2000 Location

Number

North East Region Ang Mo Kio Serangoon Hougang Sengkang

21,987 12,760 19,355 4,367

12.2 10.4 9.5 7.2

North Region Yishun Sembawang Woodlands

12,780 2,279 11,915

7.2 7.2 6.4

West Region Tengah Jurong West Jurong East Clementi Bukit Batok Bukit Panjang Choa Chu Kang

6,615 9,495 7,863 10,824 9,124 7,125 7,992

7.2 6.5 8.8 11.9 7.2 7.4 5.9

East Region Changi Tampines Pasir Ris Bedok

128 18,747 6,795 33,737

11.8 7.4 5.8 11.9

Central Region Bishan Toa Payoh Novena Kallang Geylang Marine Parade Bukit Timah Tanglin Bukit Merah Queenstown Central Area

9,033 19,848 6,910 16,677 17,967 7,777 7,893 1,889 27,212 17,342 13,091

10.1 16.4 16.1 18.1 15.2 16.8 12.3 13.7 18.3 17.8 21.7

Source: DOS 2001b: 37–43

% of location’s population

Source: Modified from Urban Redevelopment Authority (URA) (undated): up

Figure 3.1 Planning units under the development guide plan

Source: Collated from DOS 2001b: 37–43

Figure 3.2 Geographic distribution of older persons, 2000

40

Policy concerns and the framework of support

Table 3.4 Services available to senior citizens, 1998 Services Health services (under purview of MOH or NCSS) Acute care hospitals; national specialist clinics; geriatric hospitals Community hospitals Nursing homes

Number

Day rehabilitation Day care for dementia Home medical services Home nursing services Home help services

Available 5 26 VWOs and 24 private 21 5 3 VWOs 2 VWOs 5 VWOs

Social services (under the purview of MCD, NCSS or PA) Sheltered homes Senior activity centres (SACs) Social day care Befriender Meals-on-wheels Counselling Care management Senior citizens clubs (SCCs)

21 25 11 1 VWO 1 VWO Available Available 384

Source: IMC on the Ageing Population 1999: 103

older persons many of whom are receiving subsidies from the government, NLs are meant for a much wider range of people. Basically, they seek to provide a focal point for the residents within a neighbourhood (regardless of income). Just like SACs, NLs are designated spots where a broad array of programmes and activities are available to older as well as younger residents. An NL essentially becomes a focal point for volunteer efforts to assist neighbours in need. The localized network of support and help promotes strong community bonds and is beneficial for all who live there (Family and Community Development @eCitizen 2005). Remaining in the community is an important goal and is integral to family support. As such, both health and social activities meant for older persons are planned at the community level. For instance, 25 day care centres with rehabilitation services and step-down community hospitals are dotted all over Singapore and within easy reach of most public housing estates (Table 3.1). Even families with mentally ill or dementia patients can leave their loved ones at one of the ten day care centres that meet these needs while they are at work. In addition, hospice day care and respite care are available, albeit less readily. If the older person is unable to leave home,

Policy concerns and the framework of support

41

home help service, home nursing service and hospice home care will be brought to their doorstep. Ageing in place is all the more successful if older persons are occupied. Nineteen day care centres, 35 SACs and NLs, as well as 330 senior citizens clubs (SCCs) provide Singaporeans from every corner of the island with recreational, sports, social and educational activities. Some of these even provide health screening services for senior citizens. Via financial assistance, expertise sharing and facilitation, the government has shifted many of the services needed by older people to the voluntary sector. The rationale is framed around the model of economic cost effectiveness as well as individual-level outcomes. While the older individual benefits by remaining in society and getting health care assistance, the state does not have to worry about depleting scarce financial resources for these critical but draining areas. This arrangement has an additional plus: it combines altruism (from which many voluntary programmes draw their inspiration) with filial piety. This is a win-win situation as neither VWOs nor families will be deprived or worn down meeting the needs of the older population as they can draw upon each other at all times.

Notes 1

2

3

Ministry representatives include MCDS, MOH, Ministry of National Development (MND), Ministry of Manpower (MOM), among others. Besides Members of Parliament, there were representatives from NCSS, PA, SAGE, the Tsao Foundation, the Gerontological Society of Singapore, the Singapore National Employers Federation and research institutions like DOS. ‘Respect for elders is an integral apart of our Asian culture and way of life. When extended to our parents, it is filial piety, a duty due from a son or daughter. Filial piety and respect for elders should, therefore, be fostered and preserved’ (MHA 1989: 21). The conversion rate was approximately S$1.61 to US$1 in September 2005.

4

Employment, ageism and work

Introduction This chapter provides an overview of the issues surrounding the employment of older adults in Singapore. Increasingly in modern society, the role of worker comes to occupy a significant part of an individual’s life course. At present, 75.6 per cent of adult males and 54.2 per cent of adult females in Singapore are actively engaged in the labour force (DOS 2005e). Their work history will influence their wellbeing at old age largely through income availability upon reaching that point as well as determining their social status in later life. Throughout their working life, their ability to work as well as the availability of work will be determined by an interaction of individual-level characteristics and state policy. For older persons, ageism is added onto this combination of factors. This chapter explicates the construction and implications of ageism for the older worker in Singapore and elucidates the responses to this inscribed label, especially among the current cohort of older people. The data are drawn from both quantitative and qualitative sources. The quantitative data are derived from the survey of 1,977 older adults in 1999 while the qualitative data come from the 2003 focus group discussions with older respondents and service providers as outlined in Chapter 1. Secondary data are also incorporated to provide a more comprehensive picture where needed.

Economic progress and the older worker In the US, Estes (1979; 1983) and Myles (1991) have argued that crisis construction and management have made significant impacts on the social process of ageing. While demographic ageing and economic and structural conditions are empirically real and can influence policy in a direct fashion, it should also be recognized that social action is ‘inseparable from the socially constructed ideas that define and interpret these phenomena’ (Estes and Associates 2001: 97). Critical gerontologists see crisis as generating uncertainty which gives the public a reason and impetus to change while at the same time preparing them for the necessity of making sacrifices. Finally, crisis

Employment, ageism and work

43

generates anxiety, rendering greater legitimacy to the state to act in order to overcome problems (Edelman 1964 cited in Estes and Associates 2001: 97). The crisis concerning Medicare and Social Security in the US and the crisis surrounding the diminution of the welfare state in the UK have a counterpart in Singapore’s own dilemma. Precisely how has crisis been constructed in this small nation-state? We provide a historical reading of the events in order to better understand policy outcomes that affect the employment of older persons. Singapore’s economy has a long record of being ‘plugged in’ to the global economy. As a major entrepôt trading centre in Southeast Asia in colonial times, Singapore has always been connected to international trade and economic trends. Since independence in 1965, the government has planned and implemented several industrialization strategies and relevant policies to create and sustain Singapore’s economic competitiveness in the face of regional and global competition. For instance, in the 1960s, Singapore embarked on its first industrialization programme. Given that Singapore was resource poor and local entrepreneurs lacked experience, the state saw fit to depend on foreign capital to develop Singapore’s economy (Teo et al. 2004; Yeung 2000). Specifically the government pursued a labour-intensive, export-oriented industrialization programme in manufacturing. The labour force was trained with the relevant expertise to attract major American, European and Japanese manufacturers who were looking for alternative low-cost production sites to relocate their labour-intensive operations. Singapore’s competitiveness provided the ideal choice as low wages, lack of labour unrest, good infrastructure and various tax and other incentives appealed to foreign direct investors. Political stability and favourable geographical location were also important factors. By the 1980s, however, Singapore was no longer cost competitive in labour-intensive manufacturing assembly operations as cheaper production sites were available elsewhere, especially in neighbouring Southeast Asian countries where labour costs were lower (Wong 1993). To regain its global competitiveness, the government revised its economic development strategies away from low-skilled and labour-intensive industries to the promotion of high value added manufacturing and business services. This heralded the ‘second industrial revolution’. Wages were allowed to increase to encourage the relocation of labour-intensive industries to other Southeast Asian countries, while labour productivity and skills were upgraded to attract high-tech manufacturing investments. Singapore thus became an attractive location for computer, electronics and petro-chemical industries in the 1980s (Ho 1994; Tan 1995). In the 1990s, further updates in the form of R&D, wafer plants and pharmaceuticals added to the array of high value added industries (Wong 2001). The industry closest to acquiring worldclass status was certainly financial services which could compete with the likes of Hong Kong and Tokyo.

44

Employment, ageism and work

The transformation had several implications for older people. For one, the population had been convinced by the state that their economic strategy of industrialization benefited the ordinary person in Singapore by improving the country’s overall economic performance. Not only was there a better quality of life for Singaporeans, many had secure jobs. The state gained much credence in the eyes of the population because it essentially ‘delivered the goods’. If the crisis following independence was to build from virtually ground zero a modern economy, the crisis of the 1980s was the destabilization and even jeopardy of Singapore’s achievements because of global competition. To many Singaporeans, the strategy to introduce high-tech manufacturing was deemed necessary to keep the nation-state’s economy afloat and to prevent high unemployment. To keep the economy vibrant, groups of people would have to be ‘set aside’ to help the city-state in its striving to achieve global city status. Inadvertently, marginalization occurred for older workers because Singapore, like elsewhere, put a premium on the ‘productive’ contributions of the young whose education and training placed them in the relevant jobs. For a long part of the country’s relatively short history, the demographic profile had been young and this productive workforce had ensured the continued growth of the economy. When the population aged, suddenly a ‘burden’ had been constructed out of a workforce that was not so technologically savvy and whose know-how was backdated. In contemporary industrialized societies, links between the mode of production and age relations are apparent in the formal, state-sponsored retirement ages for the workforce (Estes and Associates 2001). Mandatory ages of retirement, albeit with extensions, are accompanied by schemes which dictate the salaries, the amount of social security/pensions and the benefits for older people. Scheduling working age may help manage the balance between demand and supply in a workforce but in the First World, there is resistance to the idea of these age categories and to the supposition that older workers are less efficient (Harper 1990). Such struggles are reflected in Singapore as well. The mandatory age of retirement was 55 in keeping with the crisis of development following independence from the British. By 1988, a new perspective had been constructed. The retirement age was revised to 60 to compensate for Singapore’s tight labour market. In the new National Policy on Ageing, 1988 (see Chapter 3), the state explicitly supported moves by private sector and statutory boards to ‘constant[ly] retrain ... [older workers so that they do not] ... stagnate, or worse become redundant’ (then Prime Minister Goh Chok Tong quoted by National Productivity Board (NPB) 1989: i). This rhetoric continues today. Prime Minister Lee Hsien Loong said at his 2005 National Day Rally speech that ‘older workers must learn to adjust, adapt, learn new skills’ (The Straits Times 22 August 2005a: H2). As Singapore advances to a ‘silver society’, people have to ‘work longer ... the key is in changing attitudes – the workers’ attitudes as well as the employers’ attitudes’ so that Singapore will not be eclipsed by its neighbours (The Straits Times 22 August 2005a: H2). He warned:

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The countries which are better than us are getting cheaper and the countries which are cheaper than us are getting better and the scissors are closing and we are in the middle. And if we don’t jump out and do something, we are going to be squeezed. (Business Times 22 August 2005: 1) Older people have many sources of help to keep abreast with Singapore’s vibrant economy. Workers above 40 years old already enjoy preferential course fee funding support under various skills upgrading programmes funded by the Skills Development Fund (SDF) and the Lifelong Learning Fund (LLF). Programmes such as the National Continuing Education and Training Framework (NCETF) and Employability Skills Systems are designed to be readily accessible by the lower skilled and also the older worker as a means to upgrade skills and improve employability (MOM 2005a). These are over and above existing schemes such as the Worker Improvement through Secondary Education Programme (WISE) and the Basic Education for Skills Training Programme (BEST) which do not specifically target the older worker but are available to them. While the crisis of global competition may require Singaporeans to review the contributions that the older worker can make, ageist notions are difficult to deconstruct. Employers still prefer younger (and cheaper) workers. To encourage employers to retain older workers, the state lowered the CPF contributions of both the employer and employee to 11 per cent, approximately half what a younger person enjoys (MHA 1989). In addition, the state also enforced shortened salary scales, modified the notion of wages pegged to seniority to one pegged to the ‘value’ of a job and introduced one-off bonuses instead of increments and other fringe benefits. Mixed signals are conveyed by some of these legislations. For instance, by stipulating the amount of social security an older worker is entitled to, the state puts bounds on the opportunities available to the individual to purchase shares (mostly blue chip shares) under the CPF Approved Investment Scheme (AIS), or the opportunity to buy homes, or to use the money for medical expenses and for education (Teo 1994; see Chapter 5 for elaboration).

Controlling the labour situation The situation faced by Singapore is not unique. For newly industrialized countries across Asia, the labour force participation rate of older males is declining with industrialization and Singapore is no exception (United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) 1999). As Tay (2003) shows, the labour force participation rate of older men aged 60 to 64 has declined from 1970 to 2000. The pattern for older females is less clear. Older women aged 55 to 59 are more likely to be in the labour force in 2000 compared to 1970 which reflects cohort differences in education and work histories. It may also reflect, as Tay (2003)

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suggests, gender differences in type of work, and resources, at older ages. Women typically have fewer resources than men at older ages and thus the need to work. Older women may also be more likely to accept part-time work compared to older men. Women may also re-enter the labour force at older ages after having taken time off for childbearing and childrearing in their twenties and thirties. As long as gender differences in work histories remain, these will generate gender differences in labour force participation rates at older ages. While the gender gap is not unique to Singapore, a challenging problem is the fact that Singapore has no agricultural sector. In neighbouring countries such as the Philippines and Thailand, older adults may find employment in rural areas. As a result, data from the late 1990s show that 41 per cent of older Filipinos and 38 per cent of older Thais are currently working compared to only 18 per cent of older Singaporeans (Hermalin et al. 2002a). Even the oldest country in Asia, Japan, has a farming sector where older people are employed. As a result of rapid population ageing, a lack of natural resources and below replacement fertility, Singapore finds itself having to provide economically productive roles for older adults, and to accomplish this quickly. After 1965, the rapid and significant fall in fertility together with the still modest increase in the number of older people modified the age structure of the population in favour of young adults. This produced a demographic window of opportunity (Bloom et al. 2003) in which working age adults (15 to 64) supported a relatively low social burden for the next two or three decades. This situation gave Singapore a rare opportunity to implement fundamental social policies that became the underlay of Singapore’s spectacular economic development. This demographic window of opportunity will close, however, within the next 10 to15 years as the old age dependency ratio rises. In 2000, there were 10.2 older adults aged 65 and above per 100 working aged adults (15 to 64). In 2030, this ratio will increase to approximately 30:100. Projections by Tay (2003) estimate that by 2030, the proportion of the workforce aged 30 to 49 will have shrunk by 25 per cent. Between 2000 and 2030, the only increase in the labour force will come solely from the older age group of 50 to 64. This has major implications for a country that relies primarily on human resources for economic development. The state is well aware of this. In his 2005 May Day Rally speech, Prime Minister Lee Hsien Loong noted that older workers still find it difficult to adapt to changes in the economy. As the crisis of financing an ageing population looms, Singapore has to maintain a flexible labour market. Prime Minister Lee reiterated his predecessor Goh Chok Tong’s belief that a seniority-based wage system does not make economic sense. He also suggested that employers need to restructure or redesign their operations so as to prepare themselves for increasing numbers of older workers (Singapore Government 2005). An example is the Conservancy Job Redesign Programme which is a pioneer project aimed at reorganizing the work process to improve efficiency

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and, at the same time, help older workers. Flexible working hours, the use of cleaning machinery, monthly instead of daily rated wages and medical and leave benefits have been introduced to help town councils in charge of the maintenance of public housing estates assist the many older workers they have under their charge. This scheme is in line with the intent behind the Reemployment Assistance Programme (REAP) to expand employment through redesign and recreation intiatives. According to MOM (2005b), over a period of six months, 550 jobs were created in the Conservancy Job Redesign Programme and 80 per cent of those employed were above the age of 40 with below secondary education. Other areas are being looked into such as horticultural work, security services and retail where older workers may want jobs. In whatever form the programmes take, they reinforce the main message of Prime Minister Lee Hsien Loong, that older workers still have much to contribute. To further bolster his commitment to this idea, the prime minister set up the tripartite committee mentioned in Chapter 3 to look into issues surrounding the employment of older adults in the country. The committee started its work by addressing workers in their forties and fifties. This age group appears to have a great deal of difficulty regaining employment once they have been retrenched. Data from 2002 when Singapore’s economy performed badly in line with a downturn in the global framework showed that among those workers who were retrenched the previous year, 15 per cent of those who were unable to find work 15 months later were above age 40 (Tay 2003). Recent government estimates suggest that older workers with tertiary education find it more difficult to find jobs compared to their less educated counterparts (The Straits Times 22 January 2005). Nevertheless, the worry remains that older workers may not be adequately equipped to function in technology-intensive jobs. This thought is echoed by Tay (2003) who notes that older workers may not be able to cope with the changing demands of their workplace due to the increasing importance of information technology in Singapore. In response, the state has introduced various retraining schemes to reskill older adults for the new economy. Whether these policy changes have encouraged employers to keep or to hire older workers is unclear. Recent estimates show that the jobless rate for those of 50 years old and above fell to 3.3 per cent in 2004, down from 5.4 per cent in 2003 (The Straits Times 16 June 2005). In trying to disentangle the forces behind the employment of older workers, more information is needed on the individual characteristics of older adults. For example, we know very little about the preferred age of retirement in Singapore and even less about attitudes of older Singaporeans towards work and leisure. In industrialized countries there has been a trend towards earlier retirement (Quinn and Burkhauser 1994). There are several reasons for this, including the availability of pension funds upon retirement, rising individual incomes, and a change in the value placed on work and leisure (Chan et al. 2002). In the event that the Singapore government continues to increase the retirement age, we need to

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understand better the differences between individuals who choose to work and those who do not. Estimating and evaluating the size and quality of the older workforce is critical in determining the nature of financial support in old age. If more older Singaporeans choose to work (supposing that employers will readily accept them), they will generate their own financial support in old age. However, if the percentage of older adults choosing to work declines over time (as it has in industrialized countries), the onus will be on the CPF, individual savings, and the family to provide financial support in old age. At present, older workers are willing to work but finding it hard to gain employment. As mentioned earlier, negative attitudes towards older workers are widespread in a country that prides itself on economic productivity. It was only in 1993 that the Retirement Age Act was established after many years of resistance from employers. According to the Act, the retirement age was raised from 55 to 60 (Tay 2003) and in 1999, it was further raised to 62. Prior to this Act, companies retired employees based on their own individual policy (The Straits Times 22 January 2005). Singapore does not have any other law to prevent age discrimination other than a mandatory retirement age set at 62. In 1999, the Singapore Employers’ Federation and National Trades Union Congress (NTUC) together with MOM sat down and jointly formulated a set of guidelines on non-discriminatory job advertisements to discourage ageism when recruiting (MOM 1999). While these are helpful, it is notable that the speed at which Singapore is ageing has outpaced normative changes in Singaporean society. Normative expectations of older adults are at best unclear and at worst, totally undefined. What is the role of an older person in Singaporean society? In recent years the state has been promoting grandparenting as a healthy option for older adults to occupy their time. By having older parents babysit their grandchildren, the adult children would then be free to go out to work. However, data shows that some older grandparents resist the idea that they should stay at home to take care of their grandchildren (see Chapter 9 for a fuller discussion). As incoming cohorts of older adults have higher education and more resources, their choice to occupy their time may not be in babysitting, but in work and/or leisure. In our focus group data, there was substantial evidence that older parents did not feel it was their responsibility to care for their grandchildren on a daily basis. Rather, their grandchildren were seen as the responsibility of the parent generation and the grandparents’ role was to provide fun, moral guidance, and to transmit values to their grandchildren: ‘You can’t expect grandparents [to babysit grandchildren because they] … are very old … [they] don’t have the energy. Don’t play the fool. Children are very rough, they are very active’ (FG4, n21); ‘I don’t want to. Because this grandchild is not my responsibility. It is my children’s responsibility’ (FG2, n7). Besides leisure activities or other activities that may give meaning to older persons such as volunteering, work remains one of the options for

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Table 4.1 Proportion of individuals working, by age and gender (%) Whether working

Yes No Total

Aged 59–64

65+

Males

Females

Males

Females

60.6 39.4 100.0

17.0 83.0 100.0

14.6 85.4 100.0

4.0 96.0 100.0

Source: Authors’ study

older people. As such, exactly what are the employment opportunities for older persons in Singapore? The next section reveals a rather somber situation. Few older persons work and there is heavy reliance on the family as the main provider of support in old age. If they work, many are in low-paying jobs.

Who works, why and at what? In this segment, data from the 1999 survey are used to illustrate the labour force participation levels of older adults in Singapore, the types of jobs they occupy, and their reasons for continuing to work at older ages. The data revealed that males aged 59 and above were much more likely to be working compared to females in the same age group; however, the percentage dropped sharply with age (Table 4.1). Following the mandatory age of retirement at 62, 60.6 per cent of men aged 59 to 64 were working in 1999. Past the mandatory age, employment levels dropped dramatically. The proportion of men aged 65 and above who were working was a mere 14.6 per cent. Far fewer women aged 59 and above were working compared to men. Only 17 per cent of women aged 59 to 64 and 4 per cent of women aged 65 and above were working. Older women in this generation are less likely ever to have worked during their life course as a result of little or no education and traditional gender role expectations. In a patriarchal society such as Singapore, women of this generation were expected to take care of the family and not expected to work in the formal sector (Wong and Leong 1993). Among those older adults who were working, most earned between $500 and $999 per month as shown in Table 4.2. This correlates with the predominance of older workers in low-level occupations (Table 4.3). Among those older adults working, the majority (27.6 per cent) of individuals aged 59 to 64 worked as cleaners and labourers. Among those individuals aged 65 and above, the majority (35.5 per cent) worked in sales or services. The young-old in this sample, i.e. those individuals aged 59 to 64, were more likely to cite the financial need to work compared to the older adults of 65 and above (Table 4.4). The young-old were also more likely to cite

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Table 4.2 Gross monthly income from work among those older adults currently working, by age (%) (N = 441) Income Less than $250 $250–499 $500–999 $1,000–1,499 $1,500–1,999 $2,000–2,499 $2,500–2,999 $3,000–3,499 $3,500–3,999 $4,000–4,499 $5,000 and above No fixed income Refused/Can’t remember/Don’t know Total

Aged 59–64 1.8 10.8 38.1 24.3 14.0 3.2 2.4 1.0 – 1.0 0.6 1.0 1.8 100.0

65+ 4.4 17.3 43.7 17.7 3.9 2.3 0.7 0.3 2.6 0.7 1.5 1.8 3.1 100.0

Source: Authors’ study

Table 4.3 Older working adults, by occupation and age (%) (N = 441) Present job Administration/managerial Professional Technical and related Clerical Sales/services Production (including transport operators) Cleaners and labourers Total

Aged 59–64 7.4 1.8 4.1 9.2 22.4 27.5 27.6 100.0

65+ 13.3 0.7 – 2.9 35.5 14.5 33.1 100.0

Source: Authors’ study

needing money for future financial security and not enough support from children as reasons for continuing to work compared to individuals aged 65 and above. Financial difficulty appeared to be the main reason for continuing to work for the young-old. This may reflect a change in the economic environment, individual expectations regarding support in old age, and a change in lifestyle over time. The young-old may be trying to maintain a higher standard of living compared to the older cohort, or simply trying to maintain the usual standard of living in the face of rising living costs.

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Table 4.4 Reasons for continuing work, by age (%) (N = 441) Reasona Need money for own and family expense Need money for future financial security Not enough support from children Saving for something specific Can still lead an active life Interested in job Feel bored Others

Aged 59–64 49.5 17.1 12.6 0.9 43.2 4.5 21.6 0.9

65+ 42.5 13.7 6.8 – 45.2 11.0 32.9 –

a Respondents may cite more than one reason. Source: Authors’ study

Insufficient financial support from children may be a result of a variety of factors, including financial inability of adult children to provide sufficient support to parents or attitudinal changes towards old age support. Older parents may have higher expectations regarding old age support compared to the younger generation. Among those older respondents who continued to work, a large majority also cited the need to remain active as a reason for continuing to work: 43.2 per cent of young-old (59 to 64) and 45.2 per cent of the older cohort (65 and above) felt that they could still lead an active life and hence continue to work (Table 4.4). The present generation of older Singaporeans is rather ambivalent regarding mandatory retirement (Table 4.5). When asked whether there should be a compulsory age, 41.3 per cent of those aged 59 to 64 and 57.9 per cent of those aged 65 and above replied, ‘Don’t know’. The young-old (59 to 64) were more likely to report (39.3 per cent) that there should not be a compulsory retirement age compared to individuals aged 65 and above (28.9 per cent). This reflects cohort differences in attitudes towards government policy and individual decision-making. The young-old may prefer to

Table 4.5 Attitudes toward mandatory retirement, by age (%) Should there be a compulsory retirement age? Yes No Don’t know Total Source: Authors’ study

Aged 59–64 19.4 39.3 41.3 100.0

65+ 13.2 28.9 57.9 100.0

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decide individually as to whether to work in old age. The older cohorts (65 and above) may be more used to referring to government policy directives. The divergent responses are the outcomes of dissimilar impacts from the rhetoric surrounding the two economic crises. While the crisis of building a modern economy convinced those 65 and above that they should make way for their younger counterparts, the crisis of global competition engendered a right of refusal to retire. The reality of an ageing population has enabled the young-old actively to negotiate the discrimination of ageism they suffer in the workplace. They have downgraded their expectations about salary (The Straits Times 18 December 2004) and taken advantage of the state’s programmes for retraining in order to remain in the workforce. We now turn to an examination of the attitudes towards ageism to show that while the state may be more accepting of the older worker, ageism is not easy to overcome.

Resisting ageism In the focus group discussions, two main items regarding employment emerged – the need for increasing employment opportunities for older workers and changing ageist attitudes towards older workers. Increased employment opportunities Ageism limits the opportunities for older people to remain employed or to find alternative employment. This was expressed by several service providers who saw their job as educating prospective employers and as a job centre to assist older persons looking for employment: I think one very important area, I would see, [is the] creat[ion of] employment for seniors. I think this is very relevant ... the challenge is really to create jobs that ... tap ... their skills, rather than to expect them only to be trained for, to fit into that [job] ... I think we need to be very creative in terms of coming up with jobs that would be suitable ... [Rather than talk about retraining, what about] redesigning [the] jobs? (S4)2 Hence, to overcome the problems of ageism, structures whether in the form of state or employers must play their part. Service centres feel a strong need to re-educate employers: Like I said ... you probably need a sort of a political will, as well as a commitment and a willingness to devote perhaps a team of people to look into how to redesign jobs, how to create jobs that are suitable, and then really market it with employers. I think employment really helps

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older people to maintain their health ... and their mental capacity ... that’s right ... [Where they are employed, there is] social interaction with others. Definitely help older people to feel better about themselves ... (S4) Altering negative stereotypes about older workers Ageism can be destructive as it robs older people of a sense of accomplishment. According to one service provider (S4): ‘We still have a lot of ageist attitudes amongst the community – corporations, just [the] general public. Once you are over 40, you are over the hill ... or over 45 ... you are not trainable, you are quite redundant.’ A number of focus group respondents echoed this sentiment: It is a known fact that you don’t retain old people. And [if you] ... haven’t achieved a certain level, by the age of a certain time [sic], you are out! You know that? In actual fact, it is a top down ... what we call a ‘syndrome’ that has been handed down, you know? ... Ah, people’s attitude is that ... you, by the time you reach an age, you are actually useless. And this is a mental attitude that [is] in Singapore ... for the past maybe 10 to 20 years. (FG4, n2) What is most endemic in Singapore is the prevalent view about elderly people. Old people, should they be put to pasture? Are you fine with that? [Is this] ... good principles [sic]? And a few of them in their forties: Oh oh! Got to put [them] to pasture! That’s all they [society] have, ideas for old people being put to pasture. Forget them! Get out! Devalue! Dehumanize! (FG5, n1) Resistance to ageism starts at the workplace. Even older people identify with the value of work: ‘After you retire, it is very difficult to lead a meaningful life’ (FG1, n7). Our respondents convey that they want to work and they complain about how they have been unfairly marginalized by employers. Until employers can be convinced that productivity does not necessarily decline with age, the rhetoric behind the crisis of global competition and the demographic reality of an ageing population cannot be translated into social action.

Conclusion Phillipson (1998) in discussing the social construction of retirement emphasized the problem of ageism in excluding older persons from the productive sector. The former template of long work and short retirement held by

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previous generations has long since eroded with changes in the production system worldwide. Instead of continuous employment, there is insecurity in middle and late working life because labour is now organized in a much more flexible way. Work can be moved across national boundaries, going out to cheaper sources as well as receiving low-cost foreign contract workers. While it may be wise not to discredit the concerns of employers that some older people do suffer from physical and mental challenges, it is also premature to disregard the potential contribution of older people in the economic sector. In keeping with a postmodern view of society, an emancipatory vision of work and retirement is necessary in view of the new values with regard to work and leisure (Phillipson 1998). Under the old maxim of generational equity, work can be used to ‘protect’ the resources for the next generation and should not be viewed as a problem. As long as those who can work are given a choice to continue, as they themselves have expressed, they should not be considered a ‘burden’. In rethinking the topic of work and older adults, policy makers would do well to reconceptualize the older person not as a ‘dependent’ after the mandatory retirement age of 62 in Singapore but rather as a national resource. There are some encouraging trends. Large multinational corporations such as Shell and Exxon Mobil Asia Pacific are supportive of hiring older workers (Business Times 20 January 2005). However, it is wise to heed the caution of Estes et al. (2003: 74) that ‘the assumption lying within productive ageing that work is intrinsically good fails to allow space for questions such as “work for whom” and “to what end”’. By focusing on the development and global competition crises, we have elucidated how even positive ageing policies are premised on the economic needs of a nation, based partially on its own demography and partially on its aspirations for its people. The older workforce is now more ‘included’ than in the recent past but there is a danger that the value of productive work is set by the baseline capacities of a younger workforce (Moody 1993). If so, is there unequal competition which further reinforces the subordinate status of older people? Hawker assistant Lee, aged 57, avers, ‘give us some time and we can do it’ (The Straits Times 22 August 2005a: H2). The question is, in fast-paced Singapore, will she be afforded the time?

Notes 1 2

Refer to Table 1.2 for descriptions of the focus group respondents. Refer to Table 1.3 for descriptions of the service providers.

5

Is there enough? Financing old age

Introduction This chapter discusses issues concerning the financing of old age support through the informal and formal sectors. Financial well-being in old age is critically important to the ability to access health care and other necessities, not to mention disposable income. Under the rubric of ‘productive ageing’, older adults are encouraged to work to maintain financial independence. If work is not the option or preferred choice, they rely on the government’s formal social security programme, the Central Provident Fund (CPF) and/or familial support. As only one-third of the current generation of older adults is covered by the CPF and a further small proportion by pension schemes inherited from colonial rule, the family remains the primary support provider (Chan et al. 1999). Given the reality of smaller family sizes and increasing longevity, there are fewer family members available to provide support but older members of society are requiring more years of it. Consequently, the Singapore government has to grapple with instituting the ‘right’ mix of formal and informal schemes in order to provide for older Singaporeans. In both sectors state rhetoric is, increasingly, that the populace cannot depend on the government alone. There must be some level of individual responsibility. As pointed out in Chapter 1, community policing/selfregulation has become prevalent in neoliberal economies and Singapore is no exception. Hence, Singaporeans are encouraged to govern themselves – as responsible social subjects, individuals must ensure that they plan for a secure future and the state’s role is to provide enough backing to bring this to fruition. For informal support, families must look after their own. Hence, since Singapore’s independence, many policies have been put in place toward enhancing and maintaining strong family bonds. Various incentives are provided by the government to encourage family support, including tax incentives and cash grants for those who live with or close to their parents. Even external influences are not spared as Westernization is portrayed as a threat to Asian values – in the 1980s, former Cabinet Minister Goh Keng Swee commented that it was necessary to teach Mandarin in schools as a way to guard against ‘the risk of losing the traditional values of one’s own people

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Is there enough?

and the acquisition of the more spurious fashions of the West’ (The Straits Times 25 October 1998: up). So serious is the government about the responsibility of the family that in 1996, the Parental Maintenance Act was passed (MCYS 2005c). If traditional values fail to be passed down in a family, it is legally enforced upon adult children to provide economic support to their older parents. For formal support through the CPF, even if it appears a more robust scheme than social security schemes in other countries, Singaporeans must also bear some responsibility in planning the use of their CPF funds to ensure that that they will have enough for old age. Amounts beyond a stipulated minimum in CPF funds can be invested in a number of financial investment schemes but account holders are not forced to do this. There are many low risk investment products and insurance schemes to choose from but the exercise of choice remains with the individual (CPF Board 2005a). In view of the pressure on family to provide support as well as the strains that CPF can expect with an ageing population, this chapter outlines how the state problematizes financial security and how effective the strategies it has put into place have been. In particular, we raise issues that show that reliance on only one form, either formal or informal, is impossible. The quantitative data are derived from the survey of 1,977 older adults in 1999 and other secondary sources. Sporadic use of the focus groups will be employed where they inform the discussion.

Tracing the development of the Central Provident Fund Singapore inherited two systems for old age support from the British when the nation gained independence. As mentioned in Chapter 3, the pension scheme is not financially viable in the long run and as a result, Singapore’s CPF instituted in 1955 was meant as an alternative mechanism to provide Singaporeans with financial security in old age. Singapore citizens and permanent residents are eligible to be covered under the CPF scheme wherein they contribute a proportion of their salary as ‘forced savings’ for old age and their employers will also set aside a comparable if not higher proportion. Participation is mandatory for both public and private sector employees. The self-employed have the option to participate and they are strongly encouraged to open at least a medical savings account to help finance health costs in old age.1 The CPF system is a defined-contribution, fully funded scheme whereby individuals save for their own old age financial support. This is in direct contrast to the US or European public old age security programmes that are pay-as-you-go schemes which use payroll taxes to finance benefits. There is not a direct link between contributions and defined benefits since these schemes are meant to redistribute real income across and within generations (World Bank 1994). The CPF scheme was not designed with this redistribution in mind since the state refuses to take a welfare approach. In 2003, CPF balances were in the region of $103.5 billion or 64 per cent of GDP (Chia 2004).

Is there enough?

57

A CPF member has three savings accounts into which their contributions are transferred automatically – an Ordinary Account (for which funds can be used to purchase a home, pay for children’s education and put into approved investments); a Medisave Account (for hospitalization and medical insurance expenses); and a Special Account (a cash account for old age, contingency purposes and investment in retirement-related financial products). The amount invested in each account varies depending on the individual’s age. The bulk of CPF savings is usually deposited into the Ordinary Account. After age 40, the amount deposited into the Medisave and Special Accounts is increased, offset by a reduction in the deposit to the Ordinary Account. Contribution rates vary and are fine-tuned during periods of economic recession. For example, during the 1997/98 Asian economic crisis, the employers’ contribution was decreased to 10 per cent from 20 per cent in 1996 (CPF Board 2005c). This was done in order to reduce costs for employers in the hope of preserving more jobs in Singapore. Numerous stipulations are attached to such retirement savings in the CPF. These rules are meant to guard against overuse of funds prior to retirement in order to ensure that there are adequate savings for old age. For example, members must keep a minimum of $5,100 in their Medisave Account and this will be increased each year until there is a minimum amount of $25,000 (in 2003 dollars) on 1 January 2013 (CPF Board 2005d). Savings in the Special Account can only be withdrawn at age 55. Since 1987, individuals have to maintain what is known as the Minimum Sum in their CPF which is meant to provide a basic retirement income. This amount has been slowly increased over the years. As of July 2005, retirees must maintain a Minimum Sum of $90,000 in their retirement account.2 This Minimum Sum will be raised until it reaches $120,000 (in 2003 dollars) in 2013 (CPF Board 2005d). The Minimum Sum is meant to generate monthly income to cover basic financial needs during retirement (e.g. food, rent and utilities). The CPF Board estimates that an individual would need $297 per month for subsistence living. An individual can also use the Minimum Sum to buy a life annuity with an insurance company or deposit the money with a bank, both of which will yield at least an assured monthly income.3 Buying an annuity may also yield higher interest rates since interest rates on CPF funds range from 2.5 per cent for the Ordinary Account to 4 per cent for the Medisave and Special Accounts. According to Asher (2002a), the 2.5 per cent nominal return on CPF deposits does not even preserve the real value of contributions since the longer term inflation rate in Singapore has been around 3 per cent. Nonetheless, the CPF contributes between 16.1 and 36.2 per cent to the gross national savings rate in Singapore (Asher 2002a). The government invests CPF balances in a variety of physical, financial and strategic assets, although the exact nature of these investments is not immediately evident (Asher 2002b). Since its inception, the CPF has evolved into a savings system that changes the whole concept of social security from provision for retirement to

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Is there enough?

provision for life (Choon and Low 1996). Although the CPF began as an old age security scheme, as Singapore developed, the role of CPF funds in individuals’ lives also changed. Beginning in 1968, the government allowed CPF funds to be withdrawn to finance housing mortgages. Today, financing home mortgages with CPF funds has become de rigueur in Singapore society. Asher (2002b) provides a summary of the various ways in which CPF funds can be utilized. In 1978, the government began to allow the use of CPF funds for investments in approved government investment schemes such as the Singapore Bus Services (1978) Ltd Share Scheme. The Approved Investment Scheme (AIS) was introduced in 1986 and allows members to invest up to 40 per cent of their CPF surplus funds in trustee stocks, approved unit trusts, convertible loan stocks and gold. The Approved Non-residential Properties Scheme (ANRPS) allows CPF members who are not related to use CPF funds to invest in non-residential properties and in shop units developed by the Housing and Development Board (HDB) and the Urban Redevelopment Authority (URA) (Asher 2002b). Next, the government recognized the importance of insurance, particularly as the fertility rate reached replacement level in 1978. In 1982, CPF funds could be used to buy insurance under the home protection insurance scheme (1982) and the dependent’s protection scheme (1989). In view of the pressure on middle-aged adults to finance older parents’ health care needs simultaneously with their children’s education, CPF required its account holders to contribute towards the compulsory Medisave Scheme (1984) which can be used for hospitalization costs and other approved health care services for the account holder as well as dependents such as children and parents. In addition, the 1990 Medishield insurance scheme was introduced as an additional medical insurance scheme that pays its premiums out of Medisave funds. Since 1989, CPF funds can be released to finance children’s tertiary education but children are legally required to repay these funds once they graduate. The combined effect of all the options for which CPF can be used was an unintentional diversion of funds meant for retirement into ‘nest egg’ propositions that were subject to market forces and other constraints. Thus, in 1987, the Minimum Sum mentioned above was instituted which will start paying out a monthly sum upon retirement at age 55 or later. Table 5.1 shows the amounts that CPF members can withdraw depending on the total amount in the CPF account. There is equity – for those who have very low CPF, they can withdraw the total amount. For the majority of Singaporeans who have been contributing to the CPF since they started working, the Minimum Sum applies to ensure that there is sufficient for daily needs and health care into the years post-retirement. However, the historical use of CPF funds to finance housing mortgages meant that the majority of individuals could not reach this Minimum Sum in their lifetime. Thus the government allowed 50 per cent of the Minimum Sum to take the form of pledged property. If CPF funds are used to finance a housing mortgage, the property is automatically pledged as part of the

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Table 5.1 Amount of CPF that can be withdrawn upon reaching age 55, by balance available in CPF account CPF balance at age 55 (in Singapore dollars)

Amount which can be withdrawn

< $5,000 $5,000–10,000 $10,001–180,000 >$180,000

100% Up to $5,000 50% Any amount after setting aside $90,000 and $5,100 in Medisave Account

Source: CPF 2005e: up

Minimum Sum. If the property is sold, the amount pledged must be returned to the CPF Board and into the member’s CPF Minimum Sum account. The fact that older adults in the late 1980s had very little savings in their CPF accounts also resulted in the implementation of a scheme to top up the Minimum Sum. Middle-aged adults could contribute to their older parents’ CPF accounts, or if they did not have one, open an account for them. The emphasis of this policy was to enhance financial support of older adults since the recipient of the top-up had to be at least 55 years old. In order to encourage family members to top up older members’ accounts, a tax relief of $7,000 (in 2006) was awarded to family members who provide the top-up. Although the CPF remains a mandatory savings scheme for all employees and employers in Singapore, some observers (Asher 1999; Ngiam 2005) have questioned whether individual CPF savings will be sufficient for old age support. As the nation has become ‘aged’, it has become increasingly apparent that the CPF may not fulfil its objectives without substantial changes to the system. The CPF Board itself has projected that half of Singaporeans who turn 55 in 2013 will not be able to meet the minimum sum ceiling of $120,000 when it takes effect (NTUC 2005). Even Prime Minister Lee Hsien Loong admitted that the Central Provident Fund Investment Scheme (CPFIS) aimed at giving flexibility to account holders to invest their money had not worked as well as expected: ‘those who invested in unit trusts and investment-linked products ... generally received mediocre returns’ (The Straits Times 26 September 2005a: H3). Between 1993 and 2002, 70 per cent of CPFIS investors earned less than the 2.5 per cent interest they would have received if they had just parked their money at the CPF. The reason he cited was the high cost of investing which came about because of a fragmented market and high overheads. To complicate the situation, data also show that the majority of the current generation of older adults do not not rely on formal sources of support such as the CPF or pension income (Table 5.2). Less than 5 per cent of older Singaporeans cite pension or CPF income as a source of income and this percentage drops with age. Rather, the majority of older respondents, over 75 per cent, cite children as an income source.

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Is there enough?

Table 5.2 Sources of incomea among older adults in Singapore, by age (%) Source Children Income from rental property, savings, stocks, shares Earnings from work Pension or retirement fund Income from family business Relatives Friends/neighbours Others

Aged 59–64

65+

75.3 28.6 22.7 4.1 1.2 1.2 0.4 0.2

78.1 23.7 6.1 2.6 1.5 3.8 0.3 0.1

a Respondents could report more than one source of income. Source: Authors’ study

The data also show that coverage of CPF support is very poor for this cohort of older adults. An overwhelming 83.2 per cent of females and 47.6 per cent of males aged 60 and above in 1995 never had money in a CPF account. Of those with CPF accounts, the majority did not think their CPF savings would be adequate to finance their old age; 59.7 per cent of older males and 67.9 per cent of older females reported that their CPF savings will be inadequate (Table 5.3). As discussed above, many older persons have withdrawn CPF funds over their lifetime to fund mortgages and various other schemes. As a result, many older adults have very little savings in their CPF accounts, and this is particularly true of those aged 65 and above (Table 5.4). More than half (50.9 per cent) of older adults aged 65 and above had less than $5,000 in their CPF accounts at age 55. Focus group data show older adults are well aware of the inadequacies of their CPF savings: ‘The CPF is not sufficient

Table 5.3 CPF account holders aged 60 and above, 1995, and adequacy of CPF (%) Male

Female

Ever had money in a CPF account (N = 4,001) Yes No Total

52.4 47.6 100.0

16.8 83.2 100.0

Of those with CPF accounts (N = 1,053) Adequate for old age Inadequate for old age Total

40.3 59.7 100.0

32.1 67.9 100.0

Source: Authors’ study

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Table 5.4 Total amount of money in respondents’ CPF account at age 55a (%) Amount None Less than $5,000 $5,000–9,999 $10,000–19,999 $20,000–29,999 $30,000–39,999 $40,000–49,999 $50,000–99,999 $100,000–149,999 $150,000 and above Refused to give information Can’t remember Don’t know Total

Aged 59–64 10.5 27.1 7.1 11.3 6.2 4.0 2.5 8.5 3.4 1.1 0.6 6.5 11.2 100.0

65+ 28.3 22.6 5.7 7.4 3.0 2.4 1.9 1.4 0.9 0.9 0.3 7.1 18.1 100.0

a Among those who have ever had a CPF account. Source: Authors’ study

because, costs have gone up. Over the last 10 years, medical ... any kind of fees go up [sic]. Even architectural fees also go up [sic]’ (FG5, n1). Two problems emerge from the above discussion – that family forms the stanchion of support and that CPF is not sufficient. Some sense of the necessity for change in the CPF system had become apparent as early as 2002. In that year, the then Chairman of the NTUC, Lim Boon Heng, called for a decrease in the amount of CPF funds allowed for use to finance home mortgages and an accompanying increase in the amount allotted to retirement savings: We have one of the highest savings rates in the world, yet many do not have enough cash for retirement. Why? Is there too much invested in property? ... I am no revolutionary. The problems before us are big ones. My purpose is merely to highlight some unpalatable truths. (The Straits Times 4 April 2002: up) This represented one of the first acknowledgements that the current system is not providing enough. A year later, in 2003, then Deputy Prime Minister Lee Hsien Loong commented: The CPF is the most sacred cow in Singapore ... If you’re going to make any changes to the most sacred cow, you have to do it very carefully, prepare the ground, develop your ideas, work out what is doable and

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Is there enough? then present them in a way that does not cause unnecessary alarm and misunderstanding. (The Straits Times 23 August 2003: up)

If the CPF is constructed as sacrosanct, surely it must deliver its intended role or the credibility of the government is at stake. As suggested by Estes and Associates (2001: 102), legitimacy problems for the US government arose because the administration placed ‘markets over politics’. The use of this ideology to achieve larger economic and political goals of welfare reform that provide the impetus for attempts to privatize public programmes, entitlements and social insurance led to the undermining of bedrock programmes such as Social Security and Medicare. The US has seen increased privatization, constrained social spending, more movement towards for-profit managed care, and greater and greater individual responsibility in the management of retirement accounts which bear with it higher risk. The remake of the CPF system must take into account similar challenges, which we now address.

The ‘new’ CPF: changes in the new millennium A multi-billion-dollar showpiece that has achieved many social objectives, including creating one of the world’s highest home-owning populations, the 47-year-old fund has recently become a bit of a stumbling block, as the country gears up to tackle a whole new set of challenges. (The Straits Times 16 July 2002a: up) In 2002 the government set up an Economic Review Committee (ERC) to appraise and improve on the CPF system. At the end of this review, the Chairman of the ERC’s sub-committee on taxation, CPF, wages and land commented, ‘The CPF system ain’t broke and our job has not been to jolt the system ... but it needs to evolve with the times’ (The Straits Times 16 July 2002b: up; emphasis added). The main reason why the CPF has not effectively created retirement income is because individuals have been allowed to invest in property using these funds since 1968. While buying property gave Singaporeans a stake in the nation and created a stable workforce and a committed community (see Chapter 8 for elaboration), it also drained the CPF. In the 1980s to early 1990s, a property boom raised property investment even more and many Singaporeans began to ascribe to the logic that property is a ‘sure’ investment in a land-scarce country. For example, in the 1987–2000 period, 72 per cent of contributions were withdrawn and this was mainly for housing (Asher 2002a). The over-investment in property earned Singaporeans the label ‘asset-rich, cash poor’. According to Chia (2004), in 2000, of those who turned 55, 30 per cent with CPF accounts had pledged property as savings. While the CPF contributions in 2003 amounted to about $19 billion, withdrawals came out to be almost $12 billion of

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which two-thirds went into financing of property (CPF Financial Statements 2003 cited in Chia 2004). In an attempt to pre-empt future problems, the government decided to limit the amount of CPF savings that can be used for housing (The Straits Times 22 July 2002). The amount that can be used (including interest drawn) was reduced from 144 per cent (of the value of the property at the time of purchase) in 2004 to 138 per cent in 2005 and will further drop to 120 per cent in 2008. The old CPF scheme seemed sound until market forces redirected savings into assets which were sometimes not liquidated even upon retirement because property is open to the ups and downs of both local and global economic forces.4 Another problem lies in the use of CPF to alleviate macroeconomic problems. As stated earlier, CPF contribution rates vary according to economic performance of the country. Recently, efforts have been made by the CPF Board to encourage the employment of older adults by reducing employers’ contribution rate for workers above 50 to 55 years of age (Table 5.5). By reducing the contribution rate for older workers, the government makes it easier for the employer to retain the worker. In addition, all workers will now contribute an additional percentage point of their monthly salary into their Special Account. Overall, the CPF contributions will reduce from 33 per cent to 27 per cent of monthly wages by the beginning of 2006. The government rationalizes this move as a means to maintain the employability of an ageing workforce. At the same time, multinational corporations will still find it attractive to remain in Singapore because their labour costs are competitive. The logic seems sound but the present cohort of older persons have not benefited because the low contribution rates (to as low as 9 per cent of gross wage) during the 1960s and 1970s have reduced the benefits they can take home now (Asher 2002b). In 2000, 35 per cent of those who turned 55 did not have enough to set aside the Minimum Sum. In fact, Chia (2004) asserts that there is income inadequacy for older persons who live in one to three-room public housing. In the longer term, for all account holders regardless of age, lower contributions also mean diminished savings upon retirement. It is unlikely that CPF contribution rates will go up. The minister of finance explained that CPF changes were intended as long-term structural adjustments, not tactical responses to transient conditions. Although the government wants to strengthen Singapore’s competitiveness, it can never be sure that wage levels will not become too high one day. Should this happen, the minister stressed, Singapore should not bank on another large cut in CPF rates to restore competitiveness, as was done in 1985 and 1998. Since the rate had been reduced to 33 per cent and will further decline, he reasoned that it is less likely that the CPF will be an effective tool for labour cost reduction. Instead, flexible wage structures should be used so that companies can respond quickly to changes in the business environment (Ministry of Information, Communications and the Arts (MICA) 2004).

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Table 5.5 CPF contribution rates for employers and employees (%) CPF contribution rates for workers aged above 50–55 Employer Employee Total

At 1 Jan 2004 13 20 33

At 1 Jan 2005 11 19 30

From 1 Jan 2006 9 18 27

Source: CPF Board 2004: up

In order not to raise expectations, officials have stressed since July 2002 that the CPF is to provide only a basic level of support in old age, beyond which individuals should rely on their own private savings and other arrangements. The key focus remains coverage of basic retirement and health care expenditures, and home ownership. Officials point out that the CPF is designed for the broad majority of Singaporeans, i.e. between the tenth and eightieth percentiles of the income spectrum. Those below the tenth percentile will need other social support schemes to survive. Those above the eightieth percentile should be able to plan for their own financial support during retirement. Beginning on 1 January 2005, the salary ceiling for those who make CPF contributions was reduced from $5,500 to $5,000. It was further lowered to $4,500 on 1 January 2006 (CPF Board 2004). This will allow more people access to the CPF. Meantime, to help this majority of the population further, the private sector has been encouraged to produce innovative financial schemes that are attractive to the general public and encourage them to start buying these products from a much earlier age. An example is the Supplementary Retirement Scheme (SRS) which, through a financial institution, allows buyers to purchase various investment instruments and enjoy tax savings at the same time (Ministry of Finance (MOF) 2005). The Minimum Sum Plus Scheme (MSPS) introduced in January 2001 allows members to use CPF savings beyond their Minimum Sum to buy life annuities at age 55 from private insurance companies. Income from these annuities is tax exempt (CPF Board 2005e). More recently the Medishield insurance scheme has been privatized. Members will now enjoy better benefits including higher annual and lifetime claim limits and lower co-payment at the same or lower premiums (CPF Board 2005f). Mechanisms for formal support in old age are indeed slowly evolving. For example, reverse mortgages are now an option for older Singaporeans who are willing to mortgage their homes for retirement needs. A newspaper article reported that 65 per cent of respondents aged 50 and above surveyed by the NTUC were willing to mortgage their homes for retirement needs (The Straits Times 23 August 2002). However, at present, the current cohort of older adults is not well supported by formal programmes in Singapore. As stated earlier, the current older generation relies primarily on

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family support. As long as the old age dependency ratio remains low, this scenario is potentially sustainable (assuming no changes in norms). However, as discussed in the previous chapter, an increase in the old age dependency ratio is unavoidable. As such, for those who have the means, financial planning should start as early as possible. The financial sector has been liberalized to keep abreast of global competitiveness. As a result, there are a number of schemes available to invest both cash and CPF savings for post-retirement. In September 2005, the prime minister announced a revision in the use of CPF funds which creates more forms of investment. This includes an introduction of a pension plan component and an annuity component. These two schemes may potentially be made automatic (The Straits Times 26 September 2005b). The main message conveyed is that the state alone will not be able to provide support beyond the basics. The responsibility remains with the individual to plan. For the destitute, older adults can apply for government support but the qualification criteria include having no family members since family members are seen as the first line of defence. Between 2000 and 2004, the number of ‘elderly destitute’ on public assistance went up from 1,930 to 2,331 recipients (MCYS 2005d). The government also provides subsidized support for VWOs to render help to their older clients. These subsidies are provided on a sliding scale with higher subsidies for lower income individuals so as to ensure affordability of services (MCDS 2001). The existing Government Financial Assistance Scheme (GFAS) was introduced to encourage VWOs to set up approved programmes and activities. Funding is based on a cost-sharing basis whereby the government funds up to 90 per cent of the capital cost and up to 50 per cent of the operational cost. In early 2005, a new programme ‘ComCare’ was formed and allocated $500 million to fund programmes for the needy, including older Singaporeans. Specifically, the programme provides: Targeted services for needy Singaporeans to achieve self reliance (through ComCare Self-Reliance); helping the children from needy families break out of the poverty cycle (through ComCare Grow); and assisting those who need long-term support including the elderly without family support and persons with disabilities (through ComCare EnAble). (MCYS 2005e: up) However, the government continually stresses the notion of self-reliance and is staunch in its commitment against becoming a welfare state. This is reflected in press statements such as the following by ComCare committee member Mr Matthias Yao: ComCare is different because of its strong focus on helping all our residents to be self-reliant and stand on their own two feet. In other words,

66

Is there enough? we will teach our residents to fish as best as they can, instead of serving them fish on a platter. (MCYS 2005f: up)

Existing data reveal that the current generation of older Singaporeans, particularly older females, have very few or low financial resources. This is examined in the next section which reviews the economic status of the current generation of older adults, paying particular attention to cohort and gender differences.

Income and assets of older Singaporeans An analysis of income levels by cohort and gender shows significant cohort differences among older adults in Singapore. Individual income is generally higher among the young-old (59 to 64) compared to individuals aged 65 and above (Table 5.6). For example, 62.8 per cent of females aged 65 and over have a monthly individual income below $500 compared to 28 per cent of females aged 59 to 64. This reflects higher education levels and increased labour force participation among younger cohorts. The table also shows that older males typically have higher incomes compared to older females, reflecting gender differences in work histories. Males aged 59 to 64 are almost three times as likely as their female counterparts to have monthly incomes above $2,000 and the gap rises to five times for those aged 65 and above. Older women tend to live in households with the lowest monthly incomes and there has been little change over time. As shown in Table 5.7, women aged 59 to 64 are as likely to live in households where the monthly income is less than $1,000, as are women aged 65 and above. This is not true for men. Men aged 59 to 64 are almost three times less likely (13.8 per cent) to live in lower-income households (with household incomes less than $1,000 per month) compared to men aged 65 and above (37.4 per cent). The results also suggest that the proportion of younger men aged 59 to 64 Table 5.6 Monthly individual income of older persons, by age and gender (%) Income

$500 and less $500–999 $1,000–1,499 $1,500–1,999 $2,000 and above Total Source: Authors’ study

Aged 59–64

65+

Males

Females

Males

Females

12.5 25.0 22.3 16.1 24.1 100.0

28.0 33.3 22.2 7.1 9.4 100.0

45.8 29.9 12.1 5.2 7.0 100.0

62.8 24.9 8.9 2.0 1.4 100.0

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Table 5.7 Monthly household income, by gender and age (%) Income

Less than $1,000 $1,000–1,999 $2,000–2,999 $3,000–3,999 $4,000–4,999 $5,000 and above Total

Aged 59–64

65+

Males

Females

Males

Females

13.8 24.8 17.9 15.6 10.1 17.8 100.0

31.3 24.6 17.5 8.1 10.0 8.5 100.0

37.4 24.1 14.5 10.0 5.3 8.7 100.0

38.4 24.9 16.1 8.3 5.5 6.8 100.0

Source: Authors’ study

who live in households with a monthly income of more than $5,000 is more than twice that of men aged 65 and above. The difference in proportion among women aged 59 to 64 is only 1.7 per cent more than women aged 65 and above for this same category of households. Although older Singaporeans do not appear to have very high monthly incomes, economic well-being has objective and subjective components. One possible measure of economic ‘need’ is the perception of income adequacy. Although many older Singaporeans report relatively low incomes, the majority of older Singaporeans perceive their incomes to be adequate (Table 5.8). Most older adults (between 81.3 and 83.7 per cent depending on gender) feel that they have enough money. However, 16.3 to 18.7 per cent of older adults (depending on gender) feel they have some or much difficulty meeting expenses. Interestingly, although there are significant gender differences in actual income amounts as stipulated in Table 5.6, the perception of income adequacy does not vary significantly by gender. Just as many women as men report just enough money and hence no difficulty meeting household expenses. The similarities between older men and women seem to increase with age. Table 5.8 Adequacy of income (%) Adequacy of income

Enough money, with some left over Just enough money, with no difficulty Some difficulty meeting expenses A great deal of difficulty meeting expenses Total Source: Authors’ study

Aged 59–64

65+

Males

Females

Males

Females

24.7 57.1 16.5 1.7 100.0

21.5 61.5 14.1 2.9 100.0

18.2 63.1 16.1 2.6 100.0

20.1 63.6 13.7 2.6 100.0

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These results invoke two possible explanations. The results suggest that as Singaporeans become older, they are more satisfied with their material circumstances. This may be an age effect. Alternatively, this result may be indicative of cohort differences in life course experiences. Those aged 65 and above may be more frugal and feel they require less since they went through the hard times of the Japanese Occupation (1942–45) and the beginning years of Singapore’s economic growth. Among those older adults who report some or much difficulty meeting expenses, the following reasons are given. The high cost of living is the main reason that older adults report not having enough money to pay for household expenses (Table 5.9). Interestingly, this is an even more important reason among individuals aged 59 to 64 compared to those aged 65 and above. This may reflect the increasing costs of living in Singapore. Medical cost is the second most important reason for individuals reporting difficulty in meeting household expenses, and this cost increases with age. Older individuals aged 65 and above are also more likely to cite children not giving enough money as a reason for inadequate income compared to younger individuals aged 59 to 64. The data show that the family is indeed the fallback plan when this current generation of older adults is in need; there are however differences by cohort. When asked how they deal with not having enough money, most of those aged 65 and above reply that they would simply request more money from their children (Table 5.10). This reaction is less prominent among younger individuals aged 59 to 64. The young-old are more likely to draw money from their savings. This reflects a cohort difference in the amount of savings available and possibly attitudes toward reliance on children for financial support. This also appeared in the interviews: I don’t know about you, but I really think that, I personally don’t really expect my children to support me at all. Maybe just pocket money, or

Table 5.9 Reasons given by older adults for difficulty in meeting household expensesa (%) Reasons for difficulty High cost of living High medical/healthcare costs Own income too low/no income Children not giving enough money Children still schooling Others a More than one reason can be given. Source: Authors’ study

Aged 59–64

65+

71.3 25.7 23.8 20.8 8.9 –

61.4 31.5 14.7 30.5 1.0 0.5

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give me gifts, you know. My birthdays, all that ... Probably, that’s probably it, you know. (S4) Women are much more likely to request more money from children compared to men, particularly at older ages (Table 5.10). Men aged 59 to 64 are most likely (47.6 per cent) to draw money from their savings, reflecting higher savings amounts among this generation compared to men aged 65 and above (28.3 per cent). The data also support the notion that the family provides economic support that is not reflected in monthly incomes reported by older Table 5.10 Main source of funds sought to meet a shortfall in income as reported by older individuals in Singapore (%) Source

Aged 59–64 Males

Draw from savings 47.6 Request more money from children 16.7 Request more money from spouse 4.8 Others (e.g. borrow from relatives/friends, sell own assets, spend less) 30.9 Total 100.0

65+

Females

Males

Females

38.1 42.9 7.1

28.3 40.7 4.4

25.3 52.1 1.4

11.9 100.0

26.6 100.0

21.2 100.0

Source: Authors’ study

Table 5.11 Person(s) responsible for payment of household expenses among older Singaporeans (%) Person(s) responsible

Aged 59–64

The respondent and his/her spouse pay most of the expenses. They do not need other family members’ assistance. The respondent and his/her spouse pay most of the expenses but other family members provide assistance to them to meet the balance. Other family members pay most of the expenses. The respondent and his/her spouse pay some of the household expenses. Other family members pay most of the expenses. The respondent and his/her spouse do not have to incur costs. The respondent and other family members share the expenses. Depend on welfare for household expenses. Total Source: Authors’ study

65+

28.2

16.0

12.5

5.4

8.0

4.5

47.2 4.1 100.0

70.7 3.2 0.2 100.0

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family members. In most households where an older person resides with family members, it is the family members who pay most of the expenses (Table 5.11). Among the young-old aged 59 to 64, almost one-third of these individuals (28.2 per cent) pay for most of the expenses without other family members’ assistance. Among the older-old aged 65 and above, this percentage drops to 16 per cent. Those aged 65 and above are most likely to rely on family members to pay most of the expenses and do not provide any assistance (70.7 per cent). As future cohorts become better educated and have higher incomes, the proportion of older adults who rely on family members to pay for household expenses should decrease.

Conclusion For the current generation of older people, Singapore’s formal source of financial support, the CPF, is underutilized because they had little to begin with. Quite clearly, they depend almost entirely on family support or on government subsidies. For middle-aged Singaporeans, the amounts in CPF may be far larger but the worry remains, even for the government, that there is not enough for any more than basic needs. Originally conceived as the main source of income for Singaporeans in old age, withdrawals from CPF for housing, investments, medical and educational expenses have depleted individual savings and created an over-reliance on family for financial support in old age. The Singapore government is currently revising the CPF scheme in order to generate more old age income. At the same time, the government is encouraging individuals to prepare financially for retirement. While the government is not against welfare per se, it certainly will not stand by and allow the wealth built by the people to be consumed indiscriminately and render Singapore less viable in its competitive position in the global economy. Thus, the population is continuously educated about investing carefully and about the risks of depleting their own last safety net in the CPF. In the meantime, budget revenue surpluses are channeled back to the people in the form of state subsidies for VWOs that run programmes for older people. As for the current generation of older adults, the need for government subsidies seems all the more important. Those above 65 have very low income and rely heavily on family support. Older women in particular are at extreme risk of living in poverty. Based on the data analysis above, the conclusion would be that most older Singaporeans live in poverty although there is no official poverty line in Singapore. At present, the majority of older adults live with their children; however, lower fertility, increased longevity and increased migration will make it more and more difficult for the family to support its older members at the current level. The cost of health care is a particularly insidious area demanding concern. It is possible that family savings are decimated if an older member falls ill since the expectation is that family provides primary support. State ideology has created a framework which engenders guilt among those adult children who

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choose not to or are unable to support older parents. In an Asian society where ‘shame’ is used as a tool to ensure filial piety, adult children are compelled to support their older parents even if financial and emotional commitments make the situation unbearable and in some cases may lead to elder abuse. At present, various tax and housing incentives exist to encourage family support of older members. However, additional support mechanisms need to be set in place. These measures would recognize the financial burden families face while caring for older members. Support mechanisms such as hospice and respite care services need to be boosted in the Singapore setting. As far as possible, the public needs to be educated on aspects of ageing, both their own ageing process and that of older generations. Only by recognizing the multifaceted nature of ageing, the physical, psychological and financial, can we truly create a society where intergenerational solidarity is the norm and financial security can be augmented by the family.

Notes 1 2

3

4

Only those who make an annual net trade income of more than $6,000 are required to make Medisave contributions (CPF Board 2005b). Fifty per cent of the Minimum Sum must be in cash. The remainder can be in the form of a pledged property, monies to be returned when the education loan for children comes due and investments in government-approved investment schemes. The government has been trying to encourage CPF members to purchase annuities, which would provide them with a regular monthly income in old age. The take-up rate (16 per cent in 2000) for those who have turned 55 (Chia 2004), however, has been slow, prompting the government to offer several seminars to inform the elderly about annuities. During the property boom, many CPF account holders used their CPF savings to purchase a second property which they rented out and used as income. Many of the rentals came from the expatriate community working for multinational corporations in Singapore.

6

Reconciling state perspectives and individual perceptions on health care

Introduction Health is given a very idealistic definition by the World Health Organization (WHO) (2004: up) as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. As this is difficult to achieve, for those interested in studying health, the point of discussion these days is the availability of resources, both personal and societal, to help each individual achieve their personal health potential. It includes maintenance issues which, for postmodern societies such as the US or the UK, amount to the commodification of health (Gatrell 2002). An individual can, for instance, invest in their health by taking up private insurance. In addition, it is common practice to purchase professional expertise to better manage health. If all of the above is true, why then is there such a big debate about health care for older persons? Surely biomedical innovations are good as they intend to heal, ameliorate or protect, and in a more holistic fashion than in the past. In addition, choice is a key aspect of health care in contemporary society. While there is truth in these statements, it is also the case that the claims of biomedical approaches and their availability to people hide ‘a whole series of imbalances’ (Estes et al. 2003: 79). This chapter proposes to explicate some of these imbalances by using social theory to study the delivery of health care provisions to older persons. For too long, older persons have been portrayed as ‘passive’ recipients of health care (Gilleard and Higgs 2000; McCormack 2002) who never question the value and appropriateness of biomedical interventions. It may be argued that there is literature with evidence to show that some older persons have reclaimed their rights with regard to how their bodies are to be treated (e.g. Nussbaum and Coupland 2004) but in Asia, this is long in coming. Seldom are older persons given a voice with regard to what they think their health condition may be or what they want in terms of health care provisions. Instead, doctors diagnose and prescribe medication, sometimes not even explaining to the older patient why they must submit themselves to a battery of tests nor why some medicines are better than others.1 The reasons

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for the lack of dialogue include ignorance on the part of the older person, and there is also a high correlation with older persons’ generally lower levels of education (Schiller 2004). Gatrell (2002), however, argues otherwise. He posits that the biomedical approach has been largely responsible for this dialogical shortfall because it constructs the body as a ‘machine’ which can be mended when it ‘breaks’ (Gatrell 2002: 27). In a like-minded way, Brown (1995: 163) criticized the construction of the diseased body as a ‘vector of transmission’. The health of various body parts is often investigated and discussed in terms of how deterioration may be arrested. As objects of study, no room is given to the human actor in the study of health. Gould and Wallace (1994: 105) who have written about the contagious and hierarchical nature of the spread of HIV-AIDS put this across very succinctly: ‘Sonnets, no matter how emphatically wrenching, do not stop viruses and do not help us to look ahead ... [In] pos[ing] questions of cause and effect, or in other words, questions of mechanism’, their implicit suggestion is that worthy research does not include a study of the subjective.

Approaches to analysing health care for older persons This chapter has two specific aims. First, it wants to render a greater voice to older persons and hence insert more ‘social’ considerations into health care provision. Critical gerontology requires that the objectivity promulgated by the biomedical perspective be supplemented because it has a tendency to ‘detach the social actor from human concerns’ (Estes et al. 2003: 80). Indeed, biomedicine claims to demythologize unscientific beliefs about ageing; it is ‘enlightening’ and can tell us what ageing ‘is really about’ (Estes et al. 2003: 80). Unfortunately, these claims to universal truths eclipsed alternative knowledge because the holders of biomedical knowledge sought to reinforce its own power (Foucault 1991). Examining older persons’ daily experience of health and illness will counter this tendency and provide insights on power imbalances that influence the effectiveness of helping interventions. Second, through the case study of Singapore, the chapter also provides insights on how Asian discourse on family and care has been harnessed by the state to manage the provision of welfare benefits. We analyse reactions to policy frameworks to show the dialectical relationship behind health care outcomes. In particular, resistance against financial structures is highlighted. Concepts for the discussion will be drawn from post-structuralism as the analytical frame. In Michel Foucault’s (1991) and Nikolas Rose’s (1999) work on governmentality and freedom, they argue that social subjects can be mobilized through political strategies that are aimed at the ‘conduct of conduct’ (Foucault 1991). Essentially, health promotion strategies are used to marshal the subject’s capability to govern itself while also making it seem that the decisions enacted are in the name of freedom and choice: ‘Subjects are to do the work on themselves, not in the name of conformity, but to make them

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free’ (Rose 1999: 268). Responsibility for health is located with the individual who must manage the body through proper practices that reduce/manage risk. Normalizing risk reduction as a discursive truth produces particular moral subject positions that serve to dichotomize healthy and unhealthy population groups (Fullager 2002). For example, older people who do not watch what they eat and who are sedentary require governing in the name of collective good health. Similarly, older people who already have an illness but who do not manage it astutely also jeopardize the health care system which is shared by all. By looking at representations of what it means to be a healthy citizen/an unhealthy but responsible citizen, it is possible to understand why social groups such as older persons are constructed as problematic when it comes to health care costs. According to Petersen and Lupton (1996), the modernist project in public health is to create ‘healthy bodies’ and good health behaviour. Good health care management can also be added to these goals. To achieve these, control and power are exercised through ‘expert knowledge’ emanating from the public health authorities and medical physicians so as to channel or constrain thinking and action (Foucault 1979; 1991). This concept of control and surveillance in poststructuralist thinking was elaborated by Philo (1989) who argued the existence of a panopticon gaze as a means of surveillance. This gaze in neoliberal societies (including Singapore) originates not only from the state but from the community as well. As pointed out in Chapter 1, by Fischer and Poland’s (1998) evaluation, discipline and regulation does not reside in the state alone but civil and individual mechanisms are also co-opted into the policing process. To achieve this level of co-operation, the state must constantly raise awareness on risk and do so authoritatively as a way to ratify the morally valued, self-responsible citizen. The social construction of the ‘healthy body’ as a collective discourse represents but one facet of the embodied subject experience. It is nevertheless useful because it helps to locate perspectives (especially of the state) on older people’s health ‘problems’ and what older persons are expected to do about managing their own health. While this discussion suggests some degree of agency, it still places conceptual emphasis on the state as structure and renders individuals’ contributions to health care decisions and the management of health minimal consideration. We argue for the contrary. As subjects, older people can engage with or refuse certain logics, discourses and norms surrounding the healthy management of the body/good management of the unhealthy body. Gesler and Kearns (2002) point out that as much as structures exert unequal power in shaping social practices and actions, older persons are not powerless and can in turn (re)create social structures. For example, social structures may require that particular activities be carried out at particular times and settings but equally, these structures may themselves be transformed by social actions. A body on the mend is often referred to physiotherapy by doctors who together with other experts such as the physiotherapist specify the type and length of therapy as

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well as the time and the place of the sessions. In doing so, the structure of health care delivery places significant constraints on the subject. Difficulties of getting the older person to the therapy session at the specified times and locations (because family members work) and refusal of older persons to go for therapy have led to a lack of uptake of these services, causing structures to refashion health care resources in time and space. For instance, in many countries, hospitals have transferred the work of physiotherapy to day rehabilitation centres located closer to clients. In addition, state and community organizations now include services to transport older persons to/from therapy. The time of operations has also been reconfigured to better fit the schedules of caregivers who may include working family members. Complaints by patients about the perceived ineffectiveness of Western medical techniques have also led some hospitals to accommodate Eastern traditional medicines and techniques in its delivery of health care. Agency has in this case transformed structure and caused modification of the logic on how to manage the body. This also includes methods of therapy that can be done at home and without the use of expensive equipment. Bearing the structure–agency dialectic in mind, this chapter will discuss the assumptions of health care policies in Singapore. If health care is merely about taking care of an ailing body, containing cost would be an important goal for policy makers as medical research becomes more and more advanced. Assuming this logic has certain implications: choices about health care become ‘rational’ decisions, devoid of embodied subjective positions of individuals. If there is lack of uptake of a health care provision, it is conceived as a failure on the part of the individual rather than the provider. To move towards a more encompassing understanding of health care, this chapter asks what older people have to say about the success of current health care provisions in meeting what they consider to be important needs, and the nature of constraints that must be taken into account when health care decisions have to be made by individuals, often in conjunction with family members. In answering these questions, it will be shown that both social structure and human agency work together in dialectical ways to shape health care outcomes.

The construction of age, health and health care in Singapore While it is obvious that biological ageing occurs, by themselves, biological factors shed little light on the emergence of varied social practices in relation to ‘aged’ populations (Featherstone and Hepworth 1990; Harper and Laws 1995). In the case of Singapore, ageism permeates the functioning of the economy: ‘First, many companies prefer younger workers. Second, older Singaporeans may not be able to pick up easily the skills required in the new industries’ ([then] Prime Minister Goh Chok Tong cited by Agence France Presse 25 August 2003: up). Then Deputy Prime Minister Lee Hsien Loong shared this sentiment: ‘We focused on three main aspects of wage

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reform. The first is to moderate the system of seniority-based pay ... the older worker [is] much less employable should he lose his job’ (MOM 2004: up). However, as populations grow older, this ageist notion is slowly being eroded such that the correlation between age and human capital is no longer as strong. Wage structure, for example, has changed even in Singapore (refer to Chapter 4). As with the US, it is no longer pegged to seniority but is based on productivity. The age of retirement has also shifted from 55 to 62 (Teo 1994; 1996). While these are welcome moves, ‘unproductive’ older persons who leave the workforce face several implications (Laws 1995a): ● ●

●

a decrease in income; changes in material life circumstances even though this is not experienced in the same way by everyone, e.g. between men and women; and powerlessness in influencing decisions that may affect one’s life.

This particular social construction bears strong resemblance to the Western experience whereby industrial capitalism devalues the contributions of older persons. To compensate, there must be legal provisions in welfare policy created by the state to provide for and protect older persons who are ‘unproductive’ members of society. Welfare state policy also has the intention to protect younger caregivers who need to meet conflicting needs. For health, this construction of welfare has immense implications. It essentially transforms older persons into financial and social burdens, especially those who are of ill health. This perspective, as argued in previous chapters, contrasts sharply with the social value of familism and filial piety predominant in Asia. As iterated before, providing for older persons is part of the structural requisites of the system of patriarchy found in these countries. In addition, because Asian societies base social welfare on the family as the fundamental unit of social organization, looking after older people is a collective (familial) responsibility (at least in ideation). Given the different cultural framework from the West, should health care be less of a site of struggle in Singapore? Unfortunately this is not the case. As an expensive item in the budget of most countries with an ageing population, health care in Singapore is likewise a contentious issue, even with the benefits normally associated with Asian values (Teo et al. 2003a). According to the IMC on Health Care for the Elderly (1999: 23), ‘every Singaporean is personally responsible for his own health and well being’. There are two implications arising from this official statement. The first is that the individual as a responsible member of society is expected to keep a surveillance of his own health situation. Medicalization of illness and the concomitant expectations of the high costs of health care have provided the state with reason enough to co-opt citizenry in the management of health care. To encourage Singaporeans to look after themselves, many public programmes have been implemented to spur older Singaporeans into embracing a healthy

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lifestyle. The National Healthy Lifestyle Programme started in 1992 under MOH advertises the healthy body construction by emphasizing balanced eating and the benefits of exercise. Now under the ambit of the Health Promotion Board (HPB), the programme organizes regular educational exhibitions at public places like recreation centres, shopping malls, parks, community clubs and in the foyers of workplaces, clinics, hospitals and other health care facilities. Advertisements on radio/television and in the newspapers are also commonly used mediums. From the ill effects of smoking and drinking to what constitutes a proper diet, the merits of exercise and how to detect the early signs of cancer, cardiovascular problems, hypertension and diabetes, the intent is to educate the public so that they can be empowered to look after themselves. Regular community exercise workouts are also held such as the walk-a-jog led by Prime Minister Lee Hsien Loong involving over 12,000 participants (The Straits Times 6 September 2004). Recently, the Minister of Health, Khaw Boon Wan, called upon Singaporeans to emulate Minister Mentor Lee Kuan Yew (aged 81) who is widely respected locally and recognized worldwide as the architect of Singapore’s development: Just imagine what it will be like if every Singaporean is as disciplined as [then] Senior Minister Lee Kuan Yew [who exercises regularly and watches what he eats] ... getting Singaporeans to embrace a healthy lifestyle [is as necessary as] Americans ... declaring obesity a national epidemic. Thank God we are not there; but we will be if people do not get off their couches more often. (The Straits Times 29 February 2004: 27) The state also provides free annual medical check-ups at community centres for older people. MOH provides a comprehensive outpatient geriatric assessment that includes blood pressure, weight, vision, hearing and continence status vis-à-vis habits such as smoking, drinking and exercise. The degenerative ‘old’ body must be vigilantly avoided as it poses an unnecessary burden on society. Singaporeans are urged to ‘lead a healthy lifestyle, from cradle to grave’ (profile interview with Minister of Health Khaw Boon Wan, The Straits Times 29 February 2004: 28). Second, the anxiety expressed about an ‘over-reliance on state welfare or medical insurance’ (IMC on Health Care for the Elderly 1999: 21) presupposes that health care is an expensive service whose costs can only be contained if the family acts responsibly – staying with the family ‘benefits [older people] psychologically and socially, [ ... they] should be cared for in their own homes as far as possible’ (IMC on Health Care for the Elderly 1999: 23). Asian values are implicated – the ‘ideal’ family need not necessarily be an extended family under one roof but it should be a close-knit one where familial ties are strong and will help in intergenerational transfers of fiscal and non-fiscal types that will go a long way in helping to meet the health needs of older persons.

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The message conveyed is that the financing of health care should be borne by family members and this permeates into the structure of public health care insurance schemes in Singapore (Teo et al. 2003a; Teo 2004). Acute and long-term health care services are financed through Medisave (a forced medical savings scheme for which part of a person’s income is put aside for health care needs; see Chapter 5); Medishield (an optional public insurance scheme for catastrophic illnesses whereby premiums are paid from Medisave); Eldershield (an optional insurance scheme initiated by the state to provide long-term care of older persons with disabilities); private medical insurance schemes; and out-of-pocket payments at the point of consumption. In the case of Medisave (introduced in 1984), 6 to 8.5 per cent of the monthly wages of all CPF holders have to be put aside, up to a ceiling of $30,000 (MOH 2004b). At the end of December 2000, 2.71 million Singaporeans had Medisave accounts (MOH 2001). They can be used for hospitalization and certain outpatient medical expenses incurred by the individual or his/her ill parents/grandparents/children.2 Claims for expenses incurred in community-based day care, day rehabilitation centres and nursing homes are included but there are ceilings, just as there are for hospitalization. Benefits are set at an appropriate level so that individuals and their family members are still expected to co-pay for the service at the point of consumption. In the case of Medishield (started in 1990; revised in 1994; premiums revised again in 2005), an individual can be covered for catastrophic illnesses. It is, however, only available to individuals 75 years and below and coverage was initially only up to the age of 80 before it was revised in 2005 to 85 (The Straits Times 22 August 2005b). The annual or lifetime claim limits are $50,000 and $200,000 respectively (The Straits Times 29 January 2005). It can include young/old dependents for which the insurance will pay for hospitalization and outpatient costs incurred. Twenty per cent of the 2.02 million Medishield holders in 1999 were parent dependents (MOH 2000). To augment insurance availability to older persons, in August 2000, the CPF made available a one-off offer called the Medishield Scheme for the Elderly (aged 61 to 69). Those who signed up received a two year rebate for the premiums they had to pay for Medishield coverage. Applicants who were not insurable because they were already diagnosed with medical problems received the rebate in the form of a top-up in their Medisave accounts. Although this offer provided coverage to more people, Medishield nevertheless continued to impose limitations. As with the main Medisave scheme, claimants must provide certification of their medical condition and disability from accredited health care professionals. Eldershield was introduced in 2002 and is meant for older Singaporeans who require long-term care because of severe disabilities. The policy will give $300 a month up to a maximum of five years to help pay for care at home, at day rehabilitation centres or nursing homes. Only Singaporeans

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aged 40 to 69 are eligible and at the point of application for the insurance scheme, cannot already have a disability that prevents them from walking, eating, moving out of bed, dressing, bathing or going to the toilet without help. For persons aged 70 and above and who already have disabilities, an interim plan (Interim Disability Assistance Programme or IDAP) that will pay $100 to $150 a month up to five years is available. Unlike Medishield, the insurer is not the government but two large private insurers. As far as private insurance schemes go, under the Blue Paper for a National Health Plan recommended by MOH in 1983, the state comes out strongly against a comprehensive health insurance scheme that would cover ‘all kinds of medical services, from hospital care and physician services to dental, eyeglasses and prescription drugs’ (Toh and Low 1991: 37). The obvious effect of total coverage would be a major increase in the demand for health care since the direct costs to patients would be minimized. Instead, insurance for catastrophic illnesses is preferred and even then, a deductible is recommended. While Medisave, Medishield, Eldershield and private insurance schemes are available, the conditions under which they can be used pose as major constraints. As far as the state is concerned, its primary task is to provide an efficient medical service by promoting the primacy of the family in caregiving while minimizing its own role to that of a last-resort safety net. For the indigent, there is Medifund which comes from an endowment fund. There were about 216,000 applicants for this scheme in 2003. A total of $33.9 million was expended in that year (The Straits Times 14 October 2004). The capital sum set aside for Medifund was $1 billion in 2004 although only the interest can be disbursed (MOH 2004b). Last in the basket of policies with regard to individual responsibility is the Advanced Medical Directive implemented in 1997. This allows the individual to state in advance his or her desire to stop receiving life-sustaining treatment when terminally ill. Only 1,904 Singaporeans had signed this directive by 2003, six years after it was introduced. There are ethical issues that were debated in Parliament concerning the Directive. Nevertheless, it was made legal in 1997 which indicates an unapologetic interventionist position of the state with regard to containing costs. In a survey conducted in 2000 on end-of-life issues, of 43 Chinese subjects interviewed at a day care centre, 83.7 per cent never heard of this Directive and only one-third agreed that making such a directive is necessary in old age (Low et al. 2000). The policies designed for Singapore clearly marginalize older persons as expensive burdens and try as much as possible to make individuals pay for their own care. They also harness Asian ideology on family to advantage, as a way of shifting the burden of health care. The way Medisave, Medishield and Medifund are constructed, hospitals are graded by level of care and use of these spaces is restricted by eligibility. Care is categorized as expensive acute care/specialist clinics; long-term care which can come from community or chronic sick hospitals, nursing homes and outpatient polyclinics;

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and care within the home or day care centres. Access to each of these spaces is determined not by the user but by criteria set by the state and carried out by medical doctors and administrators. Individuals are not permitted to decide how long they want to stay at acute care hospitals. After the seventh day, subsidies will no longer apply and the patient will have to pay the full rate (Singapore General Hospital (SGH) 2003). Neither can older persons determine what their Medisave money is to be used for or how much.3 Instead, doctors refer patients to appropriate services according to their own assessments. Sick older persons who want to remain in society do not have the liberty to draw upon their Medisave Accounts indiscriminately. Many have to pay out of their own pockets first in spite of Medisave/Medishield/Eldershield. Even if the family members want to downgrade the older person into a ward that provides more subsidies (Class C or B2) because the illness requires a longer hospitalization period than initially expected, this is not permitted if the patient was already booked into Class B1 and above ward (The Straits Times 9 April 2004). According to MOH, use of health care spaces has to be carefully managed because older persons accounted for 19 per cent of the attendance at polyclinics, 20 per cent of admissions to acute care wards, and 99 per cent of admissions to community and chronic sick hospitals run by VWOs in 1995 and used up almost 3 per cent of the country’s GDP (IMC on Health Care for the Elderly 1999: 35; in 2002, Singapore spent 3.7 per cent of GDP on health care). In 2000, hospital admission rates for those aged 65 and above was 302 per 1,000 resident population compared to the national average of 93 per 1,000 resident population (MOH 2001). Clearly in the case of Singapore, these numbers are a matter of great concern. Two issues can be surmised from the above discussion. First, a Singapore citizen who is older must embrace the healthy body concept and take after Minister Mentor Lee Kuan Yew. Second, if the body is no longer as resilient, it is constructed as problematic and expensive. The burden of cost must be a shared one, with the responsible older person and his/her family members expecting to foot a fair amount of the bill.

Agency, their concerns and strategies of negotiation The cost containment and the case manager approaches adopted in Singapore obviously limit rather than open up options for older persons (Teo 2004). Many older persons face a dilemma in that they have used up their Medisave or do not have enough resources to cope personally with their medical expenses. Thus, from the individual person’s perspective, the non-welfare stance of Singapore is detrimental for older Singaporeans because they cannot bear the cost: If you think Medisave is enough to pay your healthcare, not a bit! Not a speck of it! If you happen to contract ... cancer, or heart disease, or

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anything, the Medisave is not enough to cover, to take care of you till your ripe old age. (FG5, n3) Other respondents share the same sentiment: ‘You can die but don’t fall sick’ (FG2, n4). ‘We are [from] Singapore. Money comes first! Talk comes second! Yes ah [sic], if you don’t have the money, how do you talk?’ (FG1, n7). In addition, there was a general perception that all health care services are chargeable in Singapore. This includes day care, meals-on-wheels, home nursing, respite care and ambulance usage (in addition to the expected paid residential care services). Since the respondents believed that everything has a price, they were asked what their preference for health care was in Singapore. Many expressed a preference for basic care. While older persons find it difficult to overcome the structure of health care provision in Singapore, they are not passive about it. Instead, they attempt to overcome the constraints of expensive health care by disposing of ‘unnecessary medicines: You have this illness ... you [have to] buy ... this treatment or that treatment. When I don’t buy ... I save over a hundred dollars’ (FG2, n7). Where they felt that ‘standard’ medications, e.g. to control high blood pressure and cholesterol, are too costly in Singapore, they bothered to make a trip to neighbouring Malaysia to purchase these standard medicines. Public hospitals and polyclinics have responded by prescribing cheaper substitutes that are approved by the Health Sciences Authority (HSA) (equivalent to America’s Food and Drug Administration). In reality, while older people complain that ‘if you have no money ... you cannot pick your own doctors’ (FG5, n5), they are philosophical about it and will actively circumnavigate high health care costs by being selective: When we seek treatment for illnesses, the majority of us go to common hospitals. The rich people want to go to Mount Elizabeth [a private hospital] and other high-class places. We don’t ask for that standard ... common hospitals ... is good [enough] for me [sic] ... the most basic care. (FG2, n5; emphasis added) Basic or specialized is indeed a bone of contention in Singapore. While the state is promoting Singapore into a world-class medical provider capable of attracting rich clients from Indonesia and the rest of Asia (‘the Mayo Clinic of Asia’), Singaporeans feel that this has driven up health care costs (The Straits Times 21 October 2003; 5 September 2004). According to the respondents, the most effective way to overcome high health care costs is to remove the constraints surrounding the use of Medisave and Medishield. Restricting the schemes to hospitalization expenditures and the treatment of certain illnesses ties the hands of those with ill health. Managing health costs in Singapore is good but the management cannot be based entirely on objective and rational thinking. To many, illness

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is a problem where the need is defined personally and subjectively and they would like to have control over the use of their Medisave accounts, especially if they think the need is long term: Though I have money [in the CPF], they say you [sic] cannot touch it. The Ministry of Health says only this much [indicates small amount with her fingers] is allowed to pay your bills. The rest I have to fork out. Lucky I have some savings. Otherwise, how can I depend on the children because they got their own families to look after. And if everybody digs out from their children ... where do we stand in about 20–30 years time? Yes, CPF should be more liberal. (FG6, n5) When asked if they wanted the CPF to loosen its control over Medisave usage: ‘Certainly. What’s the use of the money when you are dead?’ (FG5, n4). ‘Medisave is your own money, isn’t it?’ (FG5, n2). Most of all, the respondents perceived that doctors are not necessarily the best people to make the decision as to whether Medisave can be used because of their lack of empathy and respect for the desires of their clients: I am of the opinion that health professionals, doctors and so on in Singapore ... are so different ... from those in the US. The West ... give[s] you the impression they are more interested in you and the kind of sickness [you have] ... The West [is] not putting priority on money. They ... [hope] your sickness can help them to develop a new kind of vaccine or whatever. But in Singapore context, it is ‘No money no say’. (FG5, n7) To another respondent, ‘the local doctors never ask you, “Is there any other thing you would like to ask me?” The American doctors all do that’ (FG5, n2). From the responses, it is clear that older people with ill health see their problem subjectively. From their daily experience of coping, they can better assess what interventions they think they need. Most, if not all, interventions will cost but what the older people seem to be saying in their interviews is that they want empowerment to control the use of their own monies. There is definitely apprehension about health care costs. How will they deal with this? Wisely! A common strategy is to spread the costs of their hospitalization episodes across their children, using the Medisave/Medishield accounts of one child per episode. That way, the respondents spread out the burden. Another strategy would be to gather as much information as possible. Information can be very empowering because it allows the older person and family members to evaluate choices. Where they could acquire information on costs of treatments and on hospitalization, ‘it [becomes] not so stressful for our children ... whether you can

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pay or not ... maybe you have to borrow money to pay the bill. So [if] we have some advice, we know what to do before we go for the operation’ (FG3, n3). More and more, the state has responded to the public’s call to provide more information about costs. Transparency has now become a key issue for the MOH: People are intelligent. If informed, they can make rational choices. My job is to push out as much information into the public space as I can and let the people make their choice: Which hospital to go, which doctor to see. (Health minister Khaw Boon Wan, The Straits Times 29 February 2004: 27) This is only a recent development. For too long, structure constrained agency, but active resistance (e.g. well-to-do patients who choose to be warded in highly subsidized wards) and passive resistance (e.g. complaints in the forum pages of the press and letters to the MOH) have caused structure to respond and (re)create itself. In the calculation of costs of health care, it is useful to note that many older persons base their judgment on what to them are real costs. For instance, they include not only the medical care costs (inclusive of medicines), but also the transportation costs: ‘Receiving physiotherapy is very costly ... what about taxi fare? That’s why I go to the medical care nearby nowadays’ (FG1, n6). When the proportion of income spent on getting health care vis-à-vis their total income digs deep into the pocket, older persons become very concerned. The state already provides subsidies for private transport because public transport is not user-friendly to older people in Singapore. There are even subsidies to partially pay for taxi services for low-income households. Respondents acknowledged this but the preference for taxis, private transport and even ambulances for the less ambulant is understandable given that the mass rapid transit, buses, bus stops and even building access in Singapore are not favourable to the disabled (NCSS and MCYS 2005). Other than going to centres that are close by, many older persons have not been effective agents in overcoming this structural problem. The effective agency has instead been the VWOs. Many VWO-run day care centres that offer physiotherapy have bought vehicles that can transport wheelchair-bound persons (interview material, S1). Albeit these are expensive, they nevertheless foot the bill as the clients’ needs come first. Individual taxi drivers have also responded to the needs of the less mobile by offering free services. Subsidies given to older people for health care are often appreciated but there were many complaints about who qualifies for subsidies. Some of the respondents complained that they were unfairly disqualified because they lived in private property which they bought in the 1960s and which have

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since appreciated many times over (there were several property booms in the late 1980s to early 1990s). However, they cannot realize the profit because they would not have a place to stay if they did or because they have married/unmarried children still living with them. A response could be that they downgrade to public housing but the respondents raised issues with regard to ties to a neighbourhood and a sense of rootedness and familiarity. Those affected claimed they were ‘neither here nor there’ (FG6, n9): I live with my children in a landed property. But I have no money, you know. Very poor, you know. So they (the government) will grade me as ‘rich’ because I am staying with my children ... The government should be very fair ... they should give according to age ... It’s not we bear a grudge against them [public housing residents who get subsidies as opposed to private property owners]. Some housing board [referring to the public housing] people can be very rich, you know. (FG9, n7) Caught in a society where the values of independence are embraced as much as filial piety, such older persons are caught in betwixt and between. Singapore has a three-tier subsidy which the state believes is adequate. But the means test used to allocate subsidies takes into account the income of all household members who live with the applicant. Even service providers suggest that means-testing is not a fair exercise. Other information which provides better indicators includes the number of jobs family members hold to meet daily needs, leaving them no time to provide care for older persons; or the number of children the sandwiched generation has to look after and provide for. VWOs as agents overcome the constraints set for subsidies by looking into additional sources of funding on their own so that many more can be helped.

Conclusion The high cost of medical care in Singapore is partly explained by the nation’s drive to become a regional medical centre (The Straits Times 10 March 2005) and by the Asian ideological framework that, since the family should be the main provider of care, resources can be channeled to better medical care rather than to create a welfare situation akin to the UK. Indeed the Senior Minister of State for Health, Balaji Sadasivan, has pointed out the pitfalls of the British system (The Straits Times 20 November 2003). In the interests of efficiency, Medisave and insurance schemes such as Medishield and Eldershield are very limited in their coverage and claimants are not given the chance to use their own money as they like, even if the health problem is genuine. Health Minister Khaw Boon Wan cut to the chase when it came to discussing medical costs:

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Health care is potentially a bottomless pit. No matter how much you throw in, it continues to hunger for more. The reason is that there is no limit to scientific advances. So there will be more new drugs and equipment, often more expensive. (The Straits Times 12 November 2004: 29) The biomedical view of the state renders illness an objective (and rational) problem which can be solved by medicine and money. The trick is in preventing a ‘system that incentivises wrong behaviour, that encourages over-consumption and over-servicing’ (Health Minister Khaw cited in The Straits Times 12 November 2004: 29). The pain and suffering of the subjects in emotional, physical, economic and social terms are ignored. Singapore’s population is ‘aged’ and with this metaphor comes the social construction of older persons as financial and social burdens which must be strictly managed. All Singaporeans, especially older persons must control their own health situation and try as far as possible to embrace the healthy body construct by eating and drinking correctly and exercising the body to prevent degeneration. This chapter also discusses how agency negotiates the constraints placed by structures of health care. In particular, financial structures have been the most problematic and agency has reacted by a combination of strategies, including going overseas to obtain medication (and possibly even treatment); boycotting specialized services in favour of general practitioners; clamouring for more information and for more subsidies as just some examples. The state has reacted to agency and has modified structure in order to deliver better health care. Two of the most important changes have been the switch to cheaper approved medicines in hospitals and polyclinics and greater transparency of the structure of charges across all hospitals in Singapore. Health care is never an easy service to provide. What are sound fundamentals? In the US, Medicare started in the 1960s to pay for the treatment of those over 65, regardless of how rich or poor they are. Now over 20 per cent of Americans are draining the economic resources of the country dry. In the UK, the free health care offered under the National Health Service since the end of World War II is socially equitable but has led to a deterioration of the health system in the country (Senior Minister of State for Health, Sadasivan, cited in The Straits Times 20 November 2003). Are economics the only fundamentals to be concerned about? What of the subjective feelings about health? For too long, HIV-AIDS patients and people who suffer from mental or physical disabilities have been an invisible group in health care. Now older people, by their sheer volume, constitute the largest invisible group. As one service provider (S2) in the interview quipped: doctors should not ‘over-investigate the condition, rather [they should] ... focus on the quality of life’. This is also true not only for the medical physicians but for health policy makers as well.

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Notes 1

2

3

This problem is also pervasive in Singapore. At the inaugural SingHealth Lecture delivered to health care professionals, Senior Minister of State for Health, Dr Balaji Sadasivan, called upon the Singapore Medical Council which is in charge of doctors’ professional conduct in Singapore to persuade doctors to ‘shift from the philosophy of paternalism to one of greater individual autonomy’ (The Straits Times 18 October 2004: H2). Although self-determination by patients carries more risk of litigation to doctors, he said that this is a more democratic and open way of doing things, and in line with the spirit of more relaxed governance in Singapore. Medisave will pay up to $300 per day for hospitalization at restructured or private hospitals, in addition to some surgery fees; up to $150 per day for community hospitals with a cap of $3,500 a year; $50 per day for convalescence homes with a cap of $3,000 a year; up to $20 a day for health care centres with a cap of $1,500 a year; and day surgery. Outpatient expenses that can be claimed include treatment for cancer, renal failure, organ transplant medication, thalassaemia, HIV-AIDS medication, long-term oxygen therapy, Hepatitis B vaccination and assisted conception procedures (MOH 2005). Withdrawals are currently pegged at subsidized rates but will undergo liberalization so that those with more Medisave monies can withdraw more. In addition, from September 2005, the MOH announced that it will allow Medisave to be used for outpatient treatment of chronic illnesses such as diabetes, stroke and asthma. These treatments can be done at public or private sector clinics (The Straits Times 26 September 2005c). There is now more liberal use of Medisave for older persons. For example, it can be used to pay for stays at private hospitals and in Class A and B1 wards, along with some treatments in specialist outpatient clinics. However, this is only applicable to those who are still working and who have enough to meet the mandatory minimum amount (The Straits Times 22 August 2005b; 26 September 2005c).

7

Carers Interfacing family and community

Introduction Since the 1960s there has been a restructuring of care services that involved the closing down or downscaling of large institutions and their replacement by a variety of community-based care networks (Milligan 2001). Neoliberal governments in Europe and North America in fact used deinstitutionalization as the excuse for reducing welfare provision (Dear and Wolch 1987; Walker 1993). According to Gleeson and Kearns (2001), the speed with which reform occurred obscured popular understanding of the nature of human services, simplifying caregiving into notions of ‘right’ and ‘wrong’ care viz. community care in a humane environment is better than the ‘dehumanizing’ nature of institutional care (Philo 1997, cited in Gleeson and Kearns 2001: 62). Three broad ethical issues raised around deinstitutionalization accounted for this shift: a rejection of ‘clinical treatments in asocial facilities which were ineffective and therefore unethical in its therapeutic regime’ (likened to hospital-like care); an understanding that custodial care infringes basic human rights because it removes privacy and freedom amongst a long list of other inhumane conditions purportedly found in institutions; and last, the removal of care recipients from family and community that can aid in recovery to ‘remote, often desperately under-resourced, congregate care facilities’ (Gleeson and Kearns 2001: 64) is detrimental. In turn, deinstitutionalization aims to create an ideal ‘caring community’ that will be helpful to both carers and care recipients but is an ideology which does not materialize in an instant (Gleeson 1999). Casting institutional care as inherently ‘not as good’ as informal care is problematic. It alienates advocates who construct institutions as nurturers of the ‘other’ who would otherwise have to face a hostile world. Examples include asylums and old folks homes. In contrast, new service philosophies sought to normalize individuals staying within a community social setting which provides the least disruption to everyday networks crucial to ‘including’ them rather than ostracizing them. The moral binaries conundrum expressed in Table 7.1 effectively puts pressure on community-based care networks because it implies a demand for compassionate yet professional

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Table 7.1 Moral binaries in deinstitutionalization Social space of care (immoral–moral)

Mode of care (immoral–moral)

institution–community closed–open hospital–home anomie–belonging abnormal–normal

inhumane–humane individual–social medical–social neglect–care rigid–flexible reactionary–emancipatory

Source: Gleeson and Kearns 2001: 65

care at that level which in ideation is attractive but may or may not always be forthcoming in practice. In addition, families who have members already in institutions are faced with the dilemma of insecurity presented by the removal of professional care following neoliberal restructuring of welfare services (for example, see Milligan 2000). This quandary has also surfaced in Singapore. This chapter examines the social construction of care within the home and by the community and contrasts it with institutional care. It examines the articulation of the Asian family ideology and the valorization of volunteerism as a way to provide the support necessary in non-institutional care. Unlike the UK where a history of institutionalization of care had to be deconstructed, Singapore started on the footing of minimal institutionalization for the moral arguments set out above as well as for economic reasons. In addition, we argue that the imagined caring community presupposes that the infrastructure exists. Besides the altruism of carers, the support they need in materialist terms such as proper education on the physical care of sick older persons; education on medicines and therapies; actual buildings for care work to be carried out within the community; physical structures within the home to make this work easier and emotional support, especially pertaining to burnout, must all be available to bring the imagined caring community to fruition. Last but not least, in this chapter, we also give voice to care recipients as agents in the care community, as much as the service providers are in the good delivery of a much needed but improperly understood service. In Singapore, two important global developments, inter alia, have contributed towards the expansion of formal caregiving by institutions: the advance of technology in the health sector and the politics behind ‘welfare state’ service delivery. To recap briefly from Chapter 6, medicalization of ageing alerts us to the dominance of the medical profession in the full array of services for older persons. The medical dispensation of care has a tendency to commodify care, objectifying people so that care is deemed efficient or inefficient; effective or ineffective in overcoming health care problems. The combined effects of medicalization and commodification explain the concentration of funding and government attention towards

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promoting the technological enterprise focusing on older persons’ needs (Estes and Associates 2001). The rationality of this approach is convincing, until we realize that older people have not only medical but also emotional, psychological and social problems. Very often the impact of the latter three aggravates the medical problems and no amount of medicine or technological aids can solve the problem. Commodification reduces the value of older persons, trimming them down to mere objects rather than thinking, feeling human beings. Care cannot be reduced to mechanical treatment which may have its benefits but at the same time exacts high costs in terms of the dignity and self-esteem of the care recipient. Not much will be said here about the second global trend since it has already been discussed in the preceding chapter. Past policies in welfare states gave generous subsidies or handouts for health care services to older persons, increasing the budget of the health care sector. The responsibility of caring for older persons was acknowledged as the government’s duty, as older people were viewed as vulnerable citizens who needed help. In the UK, during the early 1980s, the number of aged care institutions multiplied several times to cater for the demands of an ageing population (Mehta and Briscoe 2004). Once the floodgates were opened, it was a Herculean task to try to even partially close them! Waerness (1996: 233) asserts, ‘as a result of the development of the welfare state, informal care in the private sphere can more adequately be viewed today as a supplement rather than an alternative to public care’. But as Milligan (2001: 1) argues, publicly provided social welfare is being severely retrenched; the ‘changing locus of care’ now resides in the informal sector of the VWOs, the private sector and family members. For Singapore, even though welfarism is inconceivable for the primary reason of costs, it does not mean that alternative interpretations do not exist. The Singapore-style of welfarism, ‘many helping hands’, is exemplary. It does not drain the country of its hard-earned wealth, yet it strives to create a compassionate society. The ‘hands’ include family members, voluntary organizations, religious and clan associations, community, ethnic-based institutions and state. The question then arises, what is the current status of this approach? Mehta and Briscoe (2004: 109) have concluded that the two models of social care, i.e. the UK and Singapore models, despite their different origins, are converging in their current solutions for the challenges of an ageing population. The strong emphasis on family and community-based care is driven by an economic rationale as well as by moral obligations premised on cultural values shared by many members of Singapore society. As expounded in previous chapters, the ideology of the Asian family as the most appropriate social unit to provide care for older persons is invoked by the state to rationalize community-based care. Filial piety which originates from Confucianism has kinship with other Asian religions such as Hinduism and Islam which also place virtue on familial support (see Tilak 1989; Blake 1992 for elaboration). By and large, Singaporeans have been

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socialized from childhood by parents as well as spiritual institutions to adhere to the belief that looking after one’s parents when the latter are old signifies filial behaviour and wins the approval of the community. Thus family caregivers, adult children in particular, have internalized this belief and are convinced that their parents’ welfare is in their ‘hands’ and they have ‘no choice’ but to reify it. The adult children generation has little expectation of help from the government unless they themselves are in dire poverty. As the last resort, an older parent would seek help from the state, well aware of the stigma this brings to the family. Besides Asian family ideology, the MCYS also promotes volunteerism: Volunteerism promotes community bonding. When individuals from different walks of life get together for a charitable cause, a sense of fellowship and camaraderie develops. It strengthens the bonds within the community and facilitates the development of a gentle and gracious society. It builds a sense of belonging to the community. It helps build the people sector, and strengthens the Singapore Heartbeat. As others have observed, the moral test of any society is how it treats its weakest: children, elderly, sick, needy and handicapped. We all have a role to play in making this a reality for our nation. (MCYS 2005g: up) Indeed, the caring community cannot be realized if not for a unified call and from the state at that! In 2000, the National Volunteer Centre (renamed National Volunteer and Philanthropy Centre (NVPC) in 2003) was set up. It is the national co-ordinating body for the promotion of both volunteerism and philanthropy in Singapore. NVPC’s mission is to do this at all levels of society, thereby furthering the Singapore 211 vision of an active citizenry. NVPC involvement is in a number of sectors – the arts and culture, sports, environmental conservation and health, and most importantly, the social service sector. Singapore’s volunteer participation rate, in terms of current volunteers who had volunteered over the past 12 months, increased from 9.3 per cent in 2000 to 15.2 per cent in 2004. There were 440,000 volunteers working in education, health and social services. The reason most cited by the volunteers for participation was to ‘give back’ to society (NVPC 2004). So well publicized is the volunteering agenda that many awards are given to their work, the most prestigious being the President’s Social Service Award. The challenges of caregiving In the literature on caregiving, the terms ‘caring’ and ‘caregiving’ are often used interchangeably. We will do the same in this chapter. The term ‘caregiving’ is derived from ‘care’ which, generally speaking, refers to delivery of concern or compassion. When the caregiver provides care, both emotional and behavioural expressions are transmitted, a point emphasized by

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Cancian and Oliker (2000: 2). The primary carer providing the service of physical care is often supported by a secondary carer who may give financial or other forms of support. The ‘gray’ area between care and support has been refined to distinguish a variety of types of support such as physical/instrumental, emotional, financial and social support. In recent years, medical care has been distinguished from social care; and nursing care from family care. Hence, Cancian and Oliker (2000: 3) conclude that ‘some ambiguity in defining care is unavoidable’. For the purpose of this chapter, we follow the definition in the NSSC survey – the principal/primary carer is defined as ‘the main person who looked after the senior citizen and took care of his/her daily needs’ of bathing, feeding, shopping/marketing, laundry and house-cleaning (MOH et al. 1996: 72). Secondary carers render social, financial or even emotional support. Sometimes the primary carer and the secondary carer are difficult to distinguish as the roles played can be flexible, especially in family-based care. To capture the complexities embedded in caregiving, cross-sectional and longitudinal research would be needed. More important, however, is the implicit assumption that the moral landscape of care is codified into family units in the first instance. Tarlow (1996: 57) stated that ‘caring [is] found to be a process best understood as a phenomenon with a past, present and future’. He developed eight caring concepts derived from 84 interviews with carers. They are time set aside for caregiving, ‘be there’, sensitivity, relating, acting in the best interest of the other, caring as feeling, caring as doing, and reciprocity. The relational aspects of caring, the giving and the receiving between two or more persons, are underscored in his work. The time and process dimensions (which help us understand the exhaustion and burnout of caregivers) and the relational dimensions (which bring to the front the very motivations behind caregiving and why people continue to care even in the most stressful of situations) are key to the development of this chapter. The meaning of caring lies within these dimensions and it can cut across boundaries such as family and community in the remoralization of landscapes of care in postmodern Singapore.

Caregiving for the old: family support Within the context of an ageing society, caregiving conjures the impression that older people are care recipients and the younger generation provides care. This is a myth/stereotype that is reinforced not only by the media but also fundraisers, the medical industry and the profit-driven private market. The reality is that both younger and older persons can be care recipients in different contexts and at different time periods. They can also play both roles at the same time. Some illustrations are a grandchild being looked after by the grandparent; a 70-year-old woman looking after her 77-year-old husband who could be a stroke survivor; and adult children providing care for their frail parents who could have been caregivers for grandchildren in the past.

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The main point is that even in a family unit, caregiving is fluid and flexible, responding to the demands of circumstances and the ability of caregivers. For many countries in the world, it is also true that carers are likely to be females comprising the spouse, daughters, daughters-in-law and perhaps granddaughters (Allen and Perkins 1995). Caregiving is constructed as a gendered role which presents problems to older women because they tend to be worse off financially than older men. They have fewer funds in their CPF accounts, partly due to their intermittent entries and exits in the job market arising from family responsibilities. Should women be rewarded/compensated for their caregiving contributions towards their families so that they have a more comfortable old age? Phillips (1995: 11) argues that ‘feminists have seen women as locked into a dependency of caring’. The phenomenon of women giving up their jobs, or switching from full-time to part-time jobs, is not limited to Singapore (Allen and Perkins 1995). The role strain experienced by care providers in juggling both job and care responsibilities has been discussed at length in the literature (Biegel and Blum 1990; Liu and Kendig 2000; McGraw and Walker 2004; Savundranayagam et al. 2005; Tarlow 1996). The consensus is that there is a strong argument in the idea that the disadvantages women face are cumulative over time. It is thus recommended that policy makers study the idea of a carer allowance for Singaporeans who have to assume this family obligation. Some relief for women caregivers in Singapore comes in the form of the foreign domestic helper/maid. In the survey on transitions in health, wealth and welfare of elderly Singaporeans 1999, daughters and foreign maids were noted to be the main caregivers of older people (Teo et al. 2003a) and this is likely to increase. What are the implications of the notable increase in the utilization of foreign maids for the state? Indeed, they form a resource for the family members to rely on in order that they may continue to be employed and to retain their older family members in the family fold. However, the state may be also concerned about reliance on a foreign source of labour, and whether in the long run, family members may relinquish their caregiving responsibilities. The former concern may be considered valid, but the second is open for debate. According to Li’s (2005: 465) study, ‘informal caregivers do not relinquish caregiving when publicly paid home care is available’. It can be said that the availability of greater care options for families to choose from, offers more channels to the diverse range of multigenerational families in Singapore to carry out their personal responsibilities within their pool of resources. By far, this is a preferred option because the old remain in familiar social settings and have moral and emotional support 24 hours a day as opposed to day care centres that provide support only eight hours a day. In the NSSC of 1995, 24.8 per cent of the primary carers consisted of foreign maids (MOH et al. 1996) while our own study of 1999 showed that 19 per cent of caregiving tasks were performed by these workers while daughters took the bulk at 29.7 per cent.

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While daughters perform gendered roles, male caregivers are filial sons. In the 1995 NSSC, when only family members were compared (excluding foreign maids), it was documented that 24.3 per cent of the principal carers were sons (MOH et al. 1996: 77) but in our 1999 study (again excluding maids), 20.1 per cent of caregiving tasks were done by sons. A related notable trend in family care of older persons is the rising trend of unmarried adults who are looking after their parents, including sons. As primary carers for parents who are bedridden or suffer from dementia, this group of carers have made significant sacrifices but they are subject to marginalization in mainstream society. Labeled as ‘confirmed bachelors’ (and including spinsters), they were not entitled to purchase subsidized housing until 1998 (HDB 1998). Many also complained about the difficulty of balancing caregiving and work and some in fact give up their regular jobs (The Straits Times 22 November 1996). More important, this group rarely, or prefers not to, depend on others to give them reprieve from their caregiving tasks. In the final analysis, adult children are caregivers because of filial piety or because women perform gendered roles they are expected to fulfil in patriarchal Singapore. Now that it is established that family members are the first line of defence in the care of older persons, we elucidate some of the problems they face in this very challenging task. Data are drawn from studies conducted on caregivers by the government and by a voluntary welfare agency, Touch Community Services. The bulk of the analysis is based on an in-depth study by Mehta and Joshi (2001) of 61 carers looking after older persons registered with HMMC. The study gives an emic perspective of the experiences of the carers and outlines the salient currents of ambivalence and emotional turmoil the respondents have to grapple with. The Report of the Inter-ministerial Committee on the Ageing Population (IMC on the Ageing Population 1999) has projected that the number of older persons who cannot carry out activities of daily living (ADL) will easily double between 2010 and 2030 (Table 7.2). This has strong implications for the service needs of family caregivers in the future, as it has been established that caring for someone who is physically disabled is more stressful than caring for someone who is physically mobile. In a community study of Table 7.2 Number of frail older persons Year 2010 2020 2030

Poor ADL (65 years and above) 18,000 30,000 37,000

Source: IMC on the Ageing Population 1999: 101

Poor ADL and social support (75 years and above) 1,900 2,600 4,900

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1,209 older Singaporeans by Yadav (2001), more than 50 per cent of the sample had a disability and women had a higher rate of disability than men. Severity of handicap was directly correlated with age, i.e. the higher the age, the greater the disability. With a population that is ageing rapidly, we are surely going to see greater numbers of the old-old in need of care. Another medical problem which needs attention is senile dementia. It is estimated that almost 2 per cent of the population suffer from dementia (MOH et al. 1996) and about 7.8 per cent suffer from depression (The Straits Times 10 October 2002). Kua and Tan (1997) have studied family caregivers of dementia patients in Singapore and found that 56 per cent indicated that they were experiencing stress. Wandering, hostility, agitation, sleep disturbance and incontinence were main worries for caregivers. The longer the duration of care and the more depressed the recipient, the more challenged was the caregiver. The HMMC study yielded similar results. Most of care recipients in this study suffered from dementia and depression. The average stress scores of the carers are summarized in Table 7.3. On the whole, women suffered a higher level of stress than men and spouses more than adult children. One reason could be their age: caregiving tasks would be more exhausting for them. In addition, more female caregivers felt rundown and exhausted than male caregivers; they also felt they were under constant stress (Table 7.4). Respondents also expressed their emotions with regard to their caregiving work (Table 7.5). One third said they had ‘no choice’ in the matter and many felt it was a ‘heavy responsibility’ requiring ‘sacrifices’. While most accepted the task of caregiving, there was some amount of anger and frustration. This is expected since they said that the most difficult task they faced was dealing with the care recipient’s ‘aggressive behaviour’. Table 7.3 Average stress scores of carers Type of carer Spouse Male spouse Female spouse Children Daughters Sons Othersa Gender of carer Male Female

Average stress score

No. of carers (N = 61)

2.4 3.35

5 20

3.33 1.41 1.5

14 12 10

Mean and std deviation 1.95 ± 2.19 3.14 ± 2.58

Range 0–8 0–10

a Includes cousin, daughter-in-law, and grandchild. Source: Mehta and Joshi 2001: 15 (Modified from table first published in the Hong Kong Journal of Gerontology, Vol 15 (1 and 2))

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Table 7.4 Carers’ problems (N = 61) Problems Feel rundown and exhausted Under constant stress Have restless and disturbed nights Get irritable and hot-tempered Unable to enjoy day-to-day life Feel tightness Incapable of making decisions Get panic attacks Feel nervous Feel that life is not worth living

Female (%)a

Male (%)a

p value

Stress ≥ 5d Stress < 5d (%) (%)

59.5

31.7

0.01b

100

52.4

21.1

0.02c

94.1

22.7

41.6

31.6

0.248

88.2

25.0

40.5

42.1

0.907

17.6

2.3

35.7 28.6

26.3 26.3

0.477 0.859

64.7 76.5

20.5 9.1

21.4 14.3 9.5

10.5 – –

0.313 0.085 0.14

52.9 0.2 29.4

4.5 0.02 2.3

4.9

5.3

0.935

17.6

–

31.8

a As carers were allowed to express multiple problems, % expressed is the proportion of total males and females respectively. b p = 0.1 significance level. c p = 0.05 (p value gives the significant value only for gender difference.) d The cut-off of 5 was used to distinguish between more stressed and less stressed caregivers based on a carer stress scale of 10 items. Source: Mehta and Joshi 2001: 15 (Modified from table first published in the Hong Kong Journal of Gerontology, Vol 15 (1 and 2))

The duration of care provision is critical to the ability to cope. In the NSSC, those who had provided care for less than five years admitted feeling depressed more frequently than their counterparts who had been extending care for more than five years. The care recipients in the first group were in poorer health than the second group. Table 7.6 shows the different ways in which the caregiving role impacted the lives of the caregivers. It must be highlighted that close to 5 per cent felt depressed most of the time and almost 19 per cent felt that their health suffered ‘some of the time’. These results can be viewed as ‘red flags’ demanding attention from the community and the state. In a survey of more than 80 carers conducted by the Touch Caregivers Centre in 2004, 42 per cent found caregiving highly stressful, and 68 per cent felt it was ‘confining’ (The Straits Times 15 April 2005). The Centre, which was set up in 2002, caters to caregivers in general, provides a helpline, and a showroom of equipment to assist older and frail/disabled senior citizens. To date, no representative national caregivers survey has been conducted in Singapore. However, it is estimated that there are

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approximately 210,800 caregivers in Singapore providing care to seniors, children with special needs, the disabled, and the mentally and terminally ill (The Straits Times 12 April 2004). Table 7.5 Carers’ perception of caregiving (%)a Carers’ opinions on caregiving There is no choice It is a heavy responsibility I have to make sacrifices Cognitive acceptance Feeling of resentment due to lack of sibling support Others (commitment, repaying obligation)

30.0 26.4 20.3 6.9 3.5 12.9

Emotions arising from caregiving Emotional acceptance Anger Frustration Resigned Desire to run away Feel like abusing patient physically Others (sense of responsibility, feeling lethargic)

27.9 21.6 11.5 9.5 5.8 5.8 17.9

Perceptions on difficulties of caregiving Handling patient’s aggressive behaviour Transferring patient from bed to chair Meeting personal aspects of caregiving e.g. bathing Concern for the patient’s daily welfare Emotional toll of watching patient deteriorate

50.3 20.0 13.0 10.6 6.1

a Proportion is based on N = 61 for each opinion cited. Source: Mehta and Joshi 2001: 17 (Modified from table first published in the Hong Kong Journal of Gerontology, Vol 15 (1 and 2)).

Table 7.6 Principal carer’s perspective on the impact of caregiving to senior adults (%) Impact on principal carer

Not at all

Some of the time

Most of the time

Total

Social life has suffered Health has suffered Felt resentful of other family members who have not provided help Felt depressed because role is demanding

69.5 77.5

25.8 18.5

4.7 4.0

100.0 100.0

80.1

16.6

3.3

100.0

72.8

22.5

4.7

100.0

Source: MOH et al. 1996: 79

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Family is obviously the most critical caregiving unit. In five out of the six focus groups we conducted in 2003, the family was considered the most important source of care. When families were not available, for instance in the case of the single, childless or divorced older persons, ‘of course, the government should take care of them’ (FG1, n7). Certainly then, caregiving is socially and politically constructed by the state as best when it is from family members: We believe that the family is the primary caregiving unit and the bedrock of support for the older person. The family must be supported and strengthened in its ability to care for its older members to ensure that institutionalization remains a measure of last resort. (IMC on the Ageing Population 1999: 37) If the family does not look after the older person, a stigma is attached to those who become institutionalized: ‘Some Asians do not like to go and stay there [in the old folks homes] because they think the children have abandoned them. Yeah, just dumped them’ (FG6, n5).

Informal care at the community level If care for family members is stressful, the moral high ground that it is the best care may have deleterious effects for this group of people. Support is not far off in the form of community care but at least in the case of Singapore, this complementarity is not taken advantage of and many services which are available are not efficiently used. The NSSC indicated that the caregivers were knowledgeable about some services such as nursing homes to care for sickly older persons (Table 7.7) and homes for the aged and senior citizens’ clubs (Table 7.8) but the usage rates were very low even if they knew. An update in 2004 by MCYS also indicated that awareness of services for caregivers was low among the 200 caregivers sampled (only 27 per cent had heard of the services). However, caregivers of Table 7.7 Awareness and use of health-related community support services among population aged 55 and above (%) Service

Awareness

Used

Nursing homes for the aged Home nursing service Rehabilitative day centres Day care for senile dementia Home help service Domiciliary medical service

36.8 15.4 11.6 7.9 7.6 6.5

0.4 2.2 3.6 1.3 2.2 4.2

Source: MOH et al. 1996: 61

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Table 7.8 Awareness and use of community-based support services among population aged 55 and above (%) Community service

Aware

Used

Home for the aged Senior citizens’ clubs Social day care Counselling service Hotline service Meal centre Befriender service Meal delivery

77.6 58.4 16.4 12.6 10.8 9.2 8.9 8.2

0.4 18.7 10.3 1.8 2.1 5.7 2.5 2.1

Source: MOH et al. 1996: 84–85

disabled older persons had a higher awareness level as compared to carers of older people who are ambulant, a finding which is not surprising as their needs would probably be greater (MCYS 2004: 27). Teo (1997b) suggests that community health services are more popular than services to do with social gatherings and support as most older persons are happy enough with their familial support.

The nexus of family and community If informal services from the community in the form of VWOs are not popular among Singaporeans, does the bridge lie with immediate community members or peers who can empathize? Wherein lie the links between family and community so that the former may experience some relief? Role of neighbours Neighbours were seen as important to care recipients because of their geographical proximity. They can be good substitutes for adult children who would be away at work. Due to mobility problems, many older people have difficulties in travelling. This makes neighbours a very important source of secondary caregiving. Often, neighbours become good friends, who understand older people and meet their varied needs: ‘They [neighbours] are very good! They are very caring towards me. If I have problems, I can just go to them and they will help me ... We have known each other for over 10 years’ (FG1, n7). Encouraging healthy older people to do community work The alternative is to get peers who share the same values and are understanding of the needs of older persons to do voluntary work:

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Now there are a lot of elderly; once they retire, they end up sitting here. There are a lot who were forced to retire due to the economic situation. Not because they wanted to retire. So they feel very lost. Suddenly they don’t know what they want to do. So I feel that in the next few years, what we will face is that we will have to find such retirees and build up their confidence, nurture them to do community work. I mean, do work that is useful to society. (S5) The above statement was made by a member of staff from a neighbourhood link, which is a community-based information and referral centre run by a VWO. As volunteers are needed to run the programmes of VWOs (see MCD 2001 for programmes), and older healthy retirees have the time and the desire to serve society, their potential can be tapped. Such a strategy is also in line with the concept of active ageing (or productive ageing) which MCYS is promoting. As an example, one of our participants suggested that residents’ committees (RCs)2 could mobilize volunteers to prepare food and deliver it within the neighbourhood for needy older people. Volunteerism carries with it the connotation that empathy and concern is foremost and older people are in a good position to understand and can therefore give effective help. Family fostering In Singapore, young children get fostered out to dependable foster mothers during the work day. A woman who holds a job may leave her child with the foster mother until she finishes work or collects the child at weekends. Foster mothers are usually experienced mothers who have time on their hands and find fostering to be a flexible yet productive income. A focus group participant suggested that in some families, the middle-aged couple might be willing to provide a day care service within their home for an older person who may be alone all day: I always think that there are some families, who need some extra income and the children are big, why not we ... let this family take care of one [older] person? Then we have an organization to support them, for example, if they need to send this person to hospital ... or if any emergency, the [foster] family can call [the organization for help]. (FG4, n3) The cost to the family of fostering out their older family member would be much less than sending the older person to a nursing home or even a day care centre. In addition, the older person would probably benefit from the family environment, even if it is not their own.

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Day care Day care centres are considered a viable option that could take care of the lonely older person while their children are at work and still allow the family living arrangement to continue. Trained staff at the day care centres would provide a safe and stimulating environment and the clients would have their social needs met. However, cost was a major hindering factor, according to some focus group participants. Apart from the centre’s charges, the transport charges were also a burden to the family: I feel ... day care should be subsidized by the government ... [The subsidy] would have to depend on the income of the family, I think. It should be on a pro-rated basis. If you can afford it, then you have to pay more. If you can’t afford it then you pay less ... [just] like child care centres are subsidized. (FG4, n2) On the subject of low utilization of day care centres by minority ethnic groups, such as Malays and Indians, the reasons given were language and diet (see also Teo 1997b). As most of the day care centres use English and/or Mandarin as the main languages spoken, older Indians and Malays would feel that they do not fit in. An added reason would be that in the Malay community, family support for older relatives is unproblematic: ‘The Malay culture is very family-orientated’ (FG4, n2). Hence, there is lower utilization of adult day care facilities by these cultural communities. It was felt that food preferences of Singaporeans should be respected. Halal food should be provided at day care centres. Lack of publicity was another reason for low utilization of such services. Many people were ignorant about the day care service and the benefits were not clear to them. In two focus groups it was mentioned that families work out their sums and feel that it is cheaper to hire a foreign maid than to use the day care centres. In addition, most day care centres do not operate at weekends while the maid would be available almost seven days a week. It was suggested that when a foreign maid was hired to look after an older person, the government should not impose the foreign worker levy. After all, the family would still pay the salary, and by keeping the older person at home, the state was saving on other expenses. The advantages of staying in the community should not be denied to those who cannot afford it. A service provider described a scheme that had been started by some religious organizations called ‘Adopt an Elderly’. The scheme would match an older person who is unable to access rehabilitation or day care service due to financial constraints with a sponsor. The sponsor would pay the fees and thus enable an older person to access the social service.

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Support groups Another nexus of family and community lies in support groups for family caregivers. A focus group participant who had emigrated to Canada a few years ago compared the situation there with Singapore. After migrating, he had come down with a major illness and he felt that the support given to him was very good. He could request someone to drive him to the hospital without having to pay for the service. It was seen as a form of mutual help between people. He felt that such support groups are very necessary in Singapore. Such support groups for caregivers also provide the much needed emotional and social assistance, especially so that the caregivers can cope with other commitments such as work, household chores or young children. Such support groups can be organized on a neighbourhood basis or on a specific disease basis, for instance cancer, asthma or arthritis. Within such groups, information could be shared and help rendered to each other on a mutual basis. Friendship bonds could be fostered which would help to relieve signs and symptoms of depression. If medical attention is needed, the support group could arrange for someone to accompany the person. In many ways, the loss of strong community support has come about because of Singapore’s industrialization. The kampong (village) spirit is gone: ‘We’ve lost the “community’s” way and paid a very, very high price’ (FG5, n1). When communities were close-knit in the past, natural support groups existed and therefore did not have to be set up. According to this respondent, political constituencies have replaced social communities! Community Development Councils (CDCs)3 may be grass-roots organizations and are in a better position to know community needs than some of the VWOs or state service providers. However, this respondent did not feel that the kampong as it existed in the past as an organic entity which developed spontaneously out of people living together could ever be replaced by the CDC. Training To create a caring community, training must be provided so that those who want to help can do so effectively. In the first instance, training for family caregivers and foreign maids needs to be addressed. Both focus group participants as well as service providers raised this point (seven out of a total of 11 service providers reiterated this need in our study). A service provider emphasized that lack of caregiving skills among family members sometimes resulted in the lack of confidence and sense of helplessness in caring for a sick parent. This could lead to premature institutionalization. While some training is currently being provided by the South West CDC, the Tsao Foundation, Touch Community Services and by some hospitals, it is only on an ad hoc basis. Insufficient publicity and limited vacancies also reduce the opportunity for people to be trained. For foreign maids to be sent for training, awareness and the approval of the employers

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is absolutely necessary. This may be a drawback for some, as employers may not be so ready to acknowledge the need. In addition, if there was a fee there would be greater reluctance to send the maid. Some focus group participants were vocal in stating that such training should be free or only a nominal charge should be imposed. This would ensure that even the lowincome families could benefit from the training. The training should focus on educating the caregivers about diseases, options such as invasive and non-invasive procedures, recovery problems, equipment required, sources of financial and other assistance, ways to destress and relax, details of available support groups, and recognition of early signs of depression. Other general topics such as improving communication skills, negotiation skills, relaxation methods, and information about community-based resources would enhance the training (see Mehta and Vasoo 2001 for more discussion). Besides the family, training for professional staff in community day care centres and in residential homes is also necessary. Just like family caregivers, volunteers, professionals such as nurses, managers of residential homes and day care centres, social workers and counsellors also require specialized training and support. The training should be at the early stages of employment in the specific field, e.g. working with terminally ill patients, stroke patients or dementia patients. A good example is the training programme of six months that is provided to all nurses who join the Apex Harmony Lodge (a residential home for dementia patients in Singapore). Professional caregivers would benefit from support groups within the organizations, focusing in particular on skills development, management of difficult patients, ways of dealing with issues of death and bereavement and avenues for relaxation. A service provider suggested that all staff of organizations in the care industry for older persons should receive some training in gerontology, and managers should have gerontological counselling skills training. Counsellors who look after families with old parents should be required to undergo courses in gerontology so that their understanding of ageing issues and counselling skills are relevant. As family caregivers can benefit from emotional and social support, professionals can also be rejuvenated through discussion among co-professionals about problems faced on the job, and how they can cope better. Professionals may get attached to particular patients, and when these patients pass away, they may feel depressed. Support and recreational groups for staff working with older populations can help to improve their morale and motivation as well as the quality of their service.

Policy recommendations and conclusion The caregiving enterprise is only as effective as the people who comprise it. In this section, we summarize the suggestions made by care recipients as a

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way to show that they are not just a passive populace who ‘obeyed rules’ but are capable of fuelling change. The information is drawn mainly from our 2003 study in which the focus groups with older persons and in-depth interviews with service providers drew out a wish list of improvements. The first recommendation was for a well co-ordinated publicity and promotion exercise of the care services for older persons. At least two of the focus groups and three of the service providers expressed the view that not enough publicity is given to VWOs, to programmes and to the types of financial assistance available. Information dissemination was thought to be the domain of the government as VWOs often do not have enough funds to do the job properly. Publicity at prominent places and on the radio and television were thought to be ideal as they would reach out to the largest number of people. It should be remembered in relation to publicity that a significant proportion of middle-aged Singaporean family members are not technologically knowledgeable yet. Even if a computer is present in the home, the home may not have internet facilities. Unfortunately, the trend is for the information on services, programmes and criteria to be posted on websites, but our lower middle- and lower-income families may not have the luxury or opportunity of surfing the net. Hence publicity channels and campaigns have to bear this seriously in mind. One way is for much of this information to be disseminated through community centres and SCCs. Posters in the different official languages could be posted at MRT stations, work places and even shopping malls. When knowledge is not disseminated properly, our respondents said that their family members were left in the lurch. The respondents suggested that at the point of discharge from hospitals, there should be proper procedures for informing the families of the patient about services they can tap, financial schemes, wheelchairs/beds/walkers on rental or available for second-hand purchase. Their anxieties should be allayed, and whatever doubts they have should be cleared. A study conducted under the auspices of Singapore General Hospital (SGH) on caregiver issues and problems has shown clearly that at the point of discharge, families of patients (caregivers in particular) experience a great deal of anxiety (SGH 2002). Three factors which contributed to stress were first, the perceived concerns of caregiving including financial issues, performing ADL such as bathing the patient, and social adjustment especially if the caregiver was working. A second factor was the level of physical dependency of the patient – the higher the dependency, the higher the level of stress. Third, if no secondary caregiver were available to give relief, the level of stress increased. The last point shows the importance of family support to the primary caregiver. A balance of the formal and informal care system has to be built as caregiving stress arises from many factors and the family alone cannot meet all the needs of the care recipient(s). The urgency in providing this balance is great, for the family system may burn out very fast and the discharged patient may suffer. One of the more common results when the balance is lacking is hospital readmission of the patient.

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The second recommendation made by our respondents was the urgent need for greater co-ordination and collaboration between ministries, already alluded to in Chapter 3. We stress again that closer and effective collaboration between the different ministries, especially the MCYS and MOH, should be promoted as the field of ageing and issues of ageing families are multidisciplinary. Although an inter-ministry committee on ageing issues exists, many of the pressing needs of older people and their families remain to be addressed. More efforts at working as a team to improve the well-being of older people and their families are needed if Singapore is to be really ready by 2025 for the full-blown effects of an ageing population. Artificial turfs and boundaries separating health from social and familial issues have to be eradicated, as families themselves cannot separate their health needs from their social or financial needs. As mentioned at the beginning of the chapter, health, psychological and social aspects of family and community care merge and interface in the reality of older Singaporeans’ lives. Hence, multi-pronged approaches interweaving their needs are required and the policy makers who are expected to take a bird’s eye view should design policies and services in a holistic framework. The ‘many helping hands’ approach may have economic advantages, but for the service users and their families, a holistic service delivery system is the most important factor determining their level of satisfaction. The government has to balance economic factors with service users’ needs and listen carefully to the ‘voices’ of the seniors themselves. The third recommendation pointed at the lack of concerted and coordinated planning to meet caregivers’ needs. This, they elaborated, could be due to the lack of an umbrella organization that looks at the whole spectrum of needs of senior Singaporeans. VWOs are constrained by lack of funds, and private bodies that look at profitability issues would not be interested. Hence, a not-for-profit organization is required to work with the government as well as VWOs to improve the current situation. In addition, policy makers should prioritize and target particular groups of caregivers for greater impact and expediency such as carers for dementia patients, depressed and physically disabled older persons. Some training for caregivers is conducted by organizations such as hospitals, the Tsao Foundation, and the NCSS but the full range of older persons’ needs is not addressed. A nationwide organization such as a National Association of Caregivers is needed to meet such a challenge and act as an advocacy voice. Fourth, in view of the rapidly graying Singapore population, it is strongly recommended that an institute/central organization be set up that would coordinate the various demands for educational training of family and professional caregivers (not overlooking the foreign maids), and conduct research to inform and monitor the policies and services. It should be formed with input from the public, private and educational sectors, and older Singaporeans should also be consulted for their input in the planning and implementation stages.

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Lastly, a major criticism launched at the implementation of older persons’ care services and programmes is the complicated nature of applications, and delays in processing, as well as a confusing array of criteria that are not at all user-friendly. Simplifying the bureaucratic procedures would enable clients to access the services and programmes. If services are to reach the target populations, they should be made as simple as possible, facilitate accessibility and ‘normalize’ the process of help search from formal agencies as the Asian mindset stigmatizes help search from such agencies (whether government funded or voluntary, or privately run). In conclusion, it may be worth asking whether the service needs of family caregivers as well as informal caregivers in the community are being met in Singapore? In our view, they are being minimally met and there is a strong and urgent need to address them before the burnout and exhaustion perpetuates into negative outcomes such as older persons abuse and neglect. While the rate of older persons abuse is relatively low at about 100 cases a year in the period 1999–2004 (SAGE 2004: 27), we should take note that there is probably much under-reporting and the trend may increase due to caregiver stress and inadequate support and respite for the families providing care. The instrument that has been set up by the government to curb financial abuse, i.e. the Parental Maintenance Act, symbolizes the state’s endorsement of the financial responsibility of children towards their ageing parents. Although the tribunal which oversees the implementation of the Act does not receive a flood of applications, it is used nevertheless when an older person cannot cope financially and is in economic distress. With the spiralling of medical costs and the rising standard of living in Singapore, it is likely that family caregivers will be overburdened in future, and if state help is not forthcoming, the brunt of the negative consequences will be borne by the older generations. From a critical perspective, it is incumbent on scholars and researchers to ‘listen to the voices from the ground’ and enable them to be heard. Only then can the more appealing ‘moral’ care provided by family and community effectively replace or complement the ‘immoral’ care provided by institutions.

Notes 1

2 3

Singapore 21 refers to a programme launched in 1997 which aims to strengthen the ‘heartware’ of Singaporeans in preparation for the challenges of the twentyfirst century. The emphasis is on fostering values that will build social cohesion and by inference, political stability. The catch phrase for the programme is ‘Together, we make the difference’. RCs are grassroots organizations run by residents for the residents. Their aim is to promote neighbourliness, racial harmony and community cohesiveness among the residents within their RC zone. A CDC functions as a local administration of its district, initiating, planning and managing community programmes to promote community bonding and social cohesion. The district is made up of several political constituencies within a region, hence South West CDC, South East CDC, Central CDC, North East CDC and North West CDC (see Figure 3.1 page 38). RCs are smaller units than CDCs.

8

Home and heart Domestic space as a place for caregiving

Introduction While the dwelling is a physical entity, home and household are social constructs. This chapter aims to show the interrelationship between housing and society which we argue are mutually interdependent and affect one another. Barke (2001), for example, shows that tenure of housing varies with the ideology of society. Those societies that have a strong sense of collective welfare will most likely favour widespread provision of public housing. In contrast, societies that focus on the individual will emphasize the accumulation of personal wealth through the ownership of private property whose price is moderated by market competition. Whether more public or private, Barke (2001) also contends that housing is often used by state, private enterprise and urban managers to exert control with the objective of making housing a ‘product of the[ir own] belief systems’ (Barke 2001: 210). Housing becomes manipulated in such a way that social class and roles are (re)produced according to the dominant social and economic structures of the time (Gough 2001). For example, nineteenth-century housing in the UK was organized as ‘long rows of small terraced houses’ with a ‘regular and geometric layout’ which made it easy to provide services but more important, it was also quite effortless to police the industrial workforce (Barke 2001: 211–12). In contrast to the working class, ‘garden suburbs’ that catered to the wealthy were spread out and incorporated elements of nature in order to counter stressful urbanindustrial life. In both cases, housing design and layout were vital to the socialization of the next generation of workers. Viewed this way, home becomes an important signifier of identity. There may be some modifications to the above but for the most part, even in the US, lower- and upper-income housing for contemporary society follow the same principle as in the nineteenth century. Home is not only a construction along class lines, it also bears gender biases. Feminists argue that home is considered by many as the ‘proper’ place of women (Hayden 1984; Peace 1993; Women and Geography Study Group 1984). The home is traditionally constructed as the opposite of the

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world of work in public space; it is regarded as a ‘safe, loving and positive space’ (Valentine 2001: 63) with women expected to maintain the home and reproduce the workforce. The home is thus a place where a matrix of social relations with strong ideological meanings is acted out. This idealization of the home is constantly challenged by feminists because it casts a blind eye to subtle oppression (Valentine 2001). Finally, we address the home as a place endowed with powerful meanings. Sommerville (1992) lists these as shelter, hearth, heart, privacy, roots, abode and paradise. Other than shelter which provides physical security and protection from the elements, for older people, heart is an important characteristic in housing provision. It encapsulates mutual support and affection; it is a site of love, emotion, happiness and stability. Last but not least, home has roots because it is a source of meaningfulness derived from the fact that we ‘belong’ and we are ‘familiar’ with home (Relph 1976). Older people tend to be more concerned about the use or quality of their house rather than its monetary value, regarding it as a permanent place while their younger counterparts tend to treat it as part of a housing career trajectory (Saunders 1989). Each of these themes has some bearing on older people.1 While it would not be too presumptuous to convey the home as a place of heart and hearth for older people, it makes good research and policy sense to unravel the complexities that entwine the home as a site of care for older people. Precisely how important is the home to Singaporeans? In a country which is well known globally as the most successful subsidized housing provider in the world (about 84 per cent of Singapore’s population lives in subsidized public housing), what is the state’s position on housing in general, and housing of older people in particular?

State as provider of homes Even before Singapore’s independence in 1965, the state had already been involved in the provision of shelter. Under British colonial rule, the Singapore Improvement Trust (SIT) was tasked with the relocation of people from the congested central area where crowded conditions posed a health hazard to society. By 1960, when the population had grown to 1.6 million (DOS 1983), it was clear that the scale of housing provision had to be stepped up. A new statutory board, the HDB, was formed. The key issues it addressed included not only affordable housing for the masses but also home ownership as a principal goal (Wong and Yeh 1985). Between 1960 and 1965 during its First Five-Year Plan, the HDB built 50,000 units of apartments. By the Second Five-Year Plan (1966–70), 60,000 units had been added. To achieve this rate, large-scale urban renewal had to take place in the city centre. Many people were displaced but the HDB ensured that they were resettled into new flats within easy reach (6–8 km) of the city centre, e.g. in Queenstown, Whampoa and Kallang (refer to Figure

Figure 8.1 HDB housing estates Source: Teo et al. 2004: 92; this map is reproduced with the permission of McGraw Hill Education Asia

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8.1 for location of housing estates). Since the demand for housing was so great, the HDB offered well-planned but nevertheless basic living environments. The units were standardized as one-, two- and three-room flats. By the Second Five-Year Plan (1966–70), there were more options such as the threeroom improved, four-room, and ‘point block’ five-room flats but even these were fairly homogenous in layout and design. Each estate was equipped with facilities (schools, markets, shops, clinics, transport) and some with light industry so that residents could live and work in the same location. Home ownership in the subsidized housing programme sets Singapore apart from the practice of public housing in many countries. Chua (1997) argues that the ruling party used home ownership as part of a drive to create a property-owning democracy which included the low-income group and extended to the lower middle-income group. The Home Ownership Scheme first set up in 1964 had, by 1968, been finessed to allow purchasers to use their CPF savings to fund the down-payment on their flat as well as for monthly instalments. By encouraging Singaporeans to own rather than rent their homes, a very broad base of Singapore’s population had been securely housed. That being the case, the state could focus its attention on getting this substantial workforce to concentrate on work and raising productivity rather than home matters. Further changes in the 1970s augmented the state’s legitimacy among Singaporeans. During this decade, the HDB emphasized quality housing. As proud home owners, Singaporeans could no longer tolerate the slab blocks that characterized HDB building in the 1960s and early 1970s. Thus, HDB’s architects took to improving the designs of the flats and the blocks by using a greater variety of construction materials to meet the new expectations of a more affluent Singaporean who wanted more than just mere shelter (Wong and Yeh 1985). The second generation of new towns even moved to the suburbs to enable more spacious living environments such as in Clementi, Bedok, Woodlands and Ang Mo Kio (Figure 8.1). In addition, the Housing and Urban Development Corporation (HUDC) (1974) was set up to build homes to cater to the upper middle-income ‘sandwiched class’ who could not afford private property but wanted better homes than those offered by the HDB. The HUDC built what was then called ‘executive maisonettes’. These have since been privatized.

The ‘social’ within housing policy The HDB’s role was not limited to more and better physical buildings only. Managing social differences, community bonding and reinforcing the ‘normal’ Asian family ideology (Chua 1997) also constituted part and parcel of the HDB’s terms of reference. For example, besides putting better designs on the drawing board, the HDB also looked into improving interactions between residents within its estates. To develop a sense of place, the HDB created focal points for community activities such as in the pavilions, courtyards

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and along covered walkways. Neighbourhoods were divided into smaller precincts which are of a more human scale so that more meaningful interaction can take place. In addition, the image of each estate was enhanced by way of distinctive rooflines, materials used on the exterior of the buildings, motifs and so on (Teo and Huang 1996). To enhance community life, RCs were set up and their job was to increase social interaction and cohesion through social and recreational programmes and activities. To manage social differences in Singapore’s population, HDB took to mixing three- and four-room flats so that exclusivity would not emerge. As part of Singapore’s multiracial ideology, ethnic quotas were imposed in order to ensure that down to the block level, there is a racial mix of population roughly equivalent to Singapore’s national composition. In terms of social issues that addressed older people, HDB also took to enhancing family relations. Housing policy was used as a pro-family tool to reinforce the traditional family and strengthen extended family ties. Beginning in 1978, HDB gave priority to the three-generation family because it was the best answer (in their view) to the problems of ageing parents. Three schemes were put in place: the Joint Balloting Scheme (1978); the Mutual Exchange of Flats Scheme (1978/81); and the Reside Near Parents/Married Children Scheme (1979). The most popular was the Joint Balloting Scheme which helped married adult children and their older parents to live in adjoining blocks or in flats within the same estate. Under this scheme, they were also given a $30–40,000 grant to purchase their flat. Further enhancements for the family came in the 1980s when the Multi-tier Scheme (1982) and the Multi-generational Flat Scheme (1986) were started. While the former gave priority allocation to extended-family applicants, the latter encouraged living under the same roof with concessions such as bigger ‘jumbo’ flats. Some of these schemes have since been rationalized and appear as the Married Child Priority Scheme (HDB 2004a). The concept of pro-family has now even been extended to pre-nuptial couples. Under the fiancé/fiancée scheme (HDB 2004b), priority will be given to those who want to live close to their parents. They only need to produce a certificate three months after the registration of their marriage as proof of their eligibility. In 2005, further endorsement for extended families came in the form of a rise in the income ceiling of those who are eligible for the CPF grant of up to $40,000 for three-generation family units. Instead of $8,000 per household per month, the ceiling was raised to $12,000. This effectively increased the number of households who would be eligible for the scheme (The Straits Times 30 August 2005). It is expected that social values will change over time. With so many older people preferring to remain independent and not create a burden on their adult children, the HDB came up with affordable studio apartments for older persons. Many of these were built in more established housing estates such as Bukit Merah View, Jurong East and Tampines so that older persons need not be uprooted from familiar surroundings. In 1998, 650

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units were offered. These were smaller units (400–500 sq ft at $63,000 to $87,000) with 30-year leases. The main complaints against this scheme were the high cost of the flats and the fact that the owner cannot sell the unit (upon death or upon a decision to vacate) in the open market; it has to be sold back to HDB at a pro-rated price. Based on these complaints, the price of studio apartments was reduced in 1999 to an average of $49,000 for the smaller flat and $62,000 for the bigger flat. It is estimated that there are today about 1,000 studio apartment units and the prime minister has promised more to come. According to him, not only will studio apartments ‘provide for a more elderly-friendly environment, [it can also] help people draw on the value of their home as they grow older’ when they cash in their bigger units for the studio apartments (The Straits Times 29 August 2005: 1). In yet another innovative move which took place recently, the HDB announced that studio apartments will no longer be built all within a block but will be integrated with other apartments such as three- and four-room flats. This follows feedback from older persons who criticized age-segregated housing as a spatiality of social life they do not need. Homogeneity of unit types in a block is a merit because it yields economies of scale for the builders and makes maintenance and tracking easier. It is not desirable for older persons because they become the target of rogues and it is mentally depressing to come home to a funeral wake at the void deck2 regularly (The Straits Times 15 January 2003). Another strategy employed by the HDB to curb the outflow of younger people from the older housing estates was to spruce up the public areas of these estates. This upgrading is still taking place. By beautifying the estate, the state makes living space more congenial and convenient for everybody, young and old alike. This upgrading exercise includes landscaping, sheltered walkways, parks, courtyards, improved facades for the blocks, covered car parks, more contemporary designs and materials for the lobby areas of blocks as well as interior improvements such as larger balconies and additional kitchen space/study space. For mature estates with a larger cohort of older people, blocks have been upgraded with features such as a pedestal toilet (instead of the squat version), support handle-bars, non-slip floor tiles, an elevator stop at every floor and a panic button monitored by a control centre. Costing about $16,500 per unit, the state paid the entire cost (The Straits Times 21 December 1994). In 2005, it was announced that another 15 blocks of one-room rental flats will be fitted with ‘elderly-friendly fittings’ over a period of two years (The Straits Times 29 August 2005). This is over and above the 11,000 homes in 38 blocks which have been improved since 1993 (The Straits Times 30 August 2005). Taken together, these programmes are less disruptive for older persons as they don’t have to physically move out of their familiar environments and changes of neighbours are minimized. By and large these programmes have been well received. The only adverse feedback seems to be the affordability of the upgrading exercise to some. While those blocks with a very high proportion of older people may benefit

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from the government’s generosity, for the rest, they will have to come up with between $14,000 and $35,000 to pay for the upgrading (HDB 2003). The exercise does not come free and will be enforced so long as 75 per cent of the residents in the block agree to it. In sum, public housing as an important service rendered by the state must ensure that HDB estates cater to all groups of people and as the population ages, the environment must be conducive for older people. The HDB has done this by physical features ranging from non-slip tiles to elevators stopping at every floor of the high-rise. More important are the social policies that attempt to shape the nature of the household unit in Singapore. While the nuclear family unit forms the basis of most households in Singapore, the term has a slightly different connotation than employed in most Western societies. It does not only refer to adult parents and their children but to ‘a married couple, with/without unmarried child(ren) and/or a parent/grandparent’ (DOS 2001c: 10; emphasis our own). After all, as repeated frequently by cabinet ministers, the family setting is still the best. In 2000, about ‘nine in 10 persons aged 65 years and over lived with their spouse or children ... 37 per cent lived with their spouse and children ... another 37 per cent lived with their children only’ (DOS 2001c: 5) (Table 8.1). Whatever the configuration, these figures are very high. In their fournation comparison of living arrangements of older persons aged 60 and over, Knodel and Debavalya (1997) found that Singapore had the highest proportion of older people living with their children compared to the Philippines, Thailand and Vietnam. Elsewhere in the region, for example in Korea (Choi and Suh 1995) and Japan (Maeda and Ishikawa 2000), the preference for older people to break from the traditional norm of co-residential living with their adult children is rising. Housing older persons in Singapore has apparently come through several revisions. In the first instance, until recently, ageing in place was not an ideal actively pursued (cf. Kong et al. 1996; Teo 1997b). Up to the 1990s, HDB had intended to tear down and rebuild some of the older housing estates. Indeed, many of these estates saw the concomitant upgrade and selective enbloc redevelopment exercise3 going on at the same time. Not only were some older persons displaced but the redeveloped flats cost more as they tended to be in locations which were in high demand because they were close to the city centre. Other schemes which are friendlier towards older persons include the multi-tier and joint selection schemes which draw on the Asian family ideology. These schemes and the newer versions of studio apartments attempt to keep older persons and their families in close proximity to one another. Where older persons still live in the older housing estates, their children can purchase a flat close to them at a discounted rate. Nicknamed ‘intimacy at a distance’, this social value is actively promoted by the state and recognizes that coresidential living is ideal but not always possible. Hence the next best thing is living close by so that familial bonds can continue to thrive. Older persons who wish to move closer to their children who have homes in the newer

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Table 8.1 Living arrangements of population aged 65 and above, 2000 (%) Living arrangement

Total

Males

Females

Living with spouse No children in household With working children in household With non-working children in household Living with children only With working children in household With non-working children in household Not living with spouse or children Alone With other older persons only Others Total

50.4 13.9 33.1 3.4 37.2 33.2 4.0 12.4 6.6 1.3 4.5 100.0

73.7 19.7 48.9 5.1 15.2 13.7 1.5 11.1 5.8 1.5 3.8 100.0

32.0 9.3 20.7 2.0 54.7 48.6 6.1 13.3 7.3 1.0 5.0 100.0

Source: DOS 2001c: 5

estates can ‘downgrade’ to smaller studio apartments available in these estates. According to Lee (2003), downgrading to be close to the homes of adult children is common among Singaporeans. Older persons can also choose a reverse mortgage when they buy smaller units or studio apartments, hence realizing the nest egg which they spent so many years building when they were younger and at the same time benefiting from proximity to significant others. There is therefore a whole range of options available to older Singaporeans. Without a doubt, the state has given thought to how Asian values can continue to be upheld where housing is concerned and it has provided ample choice for Singaporeans wishing to fulfil the role of looking after their parents. In housing, Singapore is distinctively different from the West. This is a situation that comes out of a combination of several specific circumstances – the lack of land in Singapore and the high cost of housing and the ‘cultural inclination towards filial care’ (Mehta 2002: 160). Unlike the West, where suburbs signify an identity of independence and autonomy, Singapore’s public housing mirrors a society of collective support. HDB’s rationale is simple – voluntary family-based welfare arrangement is likely to reduce the government’s share of social welfare costs and responsibilities to the nation’s ageing population. Self-help is the reason behind promoting the family as the fundamental social institution; thus its ideological weight is put into practice in housing policy. So successful has been housing policy in promoting family self-help that older Singaporeans who live in private housing complain that the state is ‘unfair’ in its calculation of entitlement to subsidies. As suggested in Chapter 6, means-testing based on household income will exclude those living in private sector homes but it has been argued that, first, many of such

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homes were bought a long time ago before housing prices became ‘unaffordable’ due to higher and higher costs of living; and second, living in private sector homes with adult children does not necessarily translate into financial support for the older folk, just as may be the case for public housing dwellers. If so, why should this group be ‘automatically’ excluded from subsidy benefits? This is a sore point raised by many in the focus group discussions (FG9 in particular). In practice, there may be no basis for this argument as means testing is based on household income and not on type of dwelling. However, the perception remains that housing is used as a proxy for class divisions in Singapore and as the population ages and as society embraces independence as much as filial piety, further tensions will surface to challenge the bundling of home and financial support for caregiving into an unrealistic whole.

Home as gendered space; caregiving as a gendered role Chapter 7 discussed two important issues – who caregivers are and the problems they face in caregiving as well as the support rendered by community in helping to perform this task. Having outlined these important concerns about caregiving, this section is devoted to teasing out the tensions behind the proposed nexus of family and community. It will do this by deconstructing the spaces behind care provision to show how space can problematize the giving of care. As suggested in the previous section, home space is imbued with multiple meanings. Rowles (1978; 1983) argues that the life space (defined as ‘the entire set of phenomena constituting the world of actuality for a person’ (Williams and Wirth 1965: 3)) of older people shrinks because of physiological decline, economic deprivation and rapid societal changes. In a geographical sense, the ‘spatial and locational dimensions of the experienced milieu’ becomes the proximate environment in which there is an intensification of attachment (Rowles 1978: 22). Because the designed environment of urban areas is seldom constructed with older persons in mind, Golant (1984) also argues the same – that there is a constriction of the life space of older persons. The environmental experience of older persons may therefore be limited to familiar spaces such as the home or the neighbourhood but it is compensated for by a physical ‘insideness’ or ‘sense of place’ (Relph 1976; Tuan 1974). Consequently, home space as a venue for caregiving takes on symbolic connotations. This tallies with Gleeson and Kearns’ (2001) proposition visited in Chapter 7 that there is a moral binary in landscapes of care. Home is the most emancipatory, followed by community. On the ‘other’ side are institutions. Conradson (2003), Milligan (2000; 2001) and Williams (2002) in their investigation of home spaces as caregiving spaces assert that besides the ‘efficient but dehumanized’ nature of care in institutional settings, the high costs of health care in recent years have also helped to shift the site of caregiving to the domestic sphere of the home. Taken together, the home space as the ideal

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caregiving space runs the danger of becoming an élitist association at the expense of other possible care configurations. While we have argued that there is a disproportional dependence on the commitment of women to the tasks of physical and emotional caregiving (Daly and Lewis 1998; Finch and Groves 1983; Morley 2000) in previous chapters, we now add that in constructing care as a gendered concept, a primary consequence is for care to become built around notions of familial ties and obligations for which the affective aspects that require emotional investment are best served by family members (Graham 1991). The emergent subtext is once again that care is a private activity done in the home domain but this time, there is an additional notion that it is best performed by women (Milligan 2003; Twigg 1999; Williams 2002). Such dyadic perspectives of care commit the error of studying caregiving only as a social responsibility and makes us forget that there are embedded political meanings behind that role. For instance, caregivers need to take into account the concerns and needs of others (including but not limited to the one who is cared for) when caregiving is practised (Tronto 1993). Meeting the needs of sick parents will have to be traded off against other critical societal roles played by the caregiver such as work commitments and so on. Which takes precedence depends on societal expectations about gender, class, race, age and able-ness. In addition, by showing that care recipients themselves also give care, Woon (2004/5) in his study of wheelchair bound people4 shows that caregiving is not unidirectional with the ‘dependent’ always as the recipient. By giving emotional support to the family, helping in the preparation of simple meals as well as keeping an eye on young children, care recipients themselves can tilt the balance of power in a household. Mehta (1997a) and Teo and Mehta (2001) found that both older men and women play a significant role in care provision for young children, for the sick and for the family as a whole, especially since many adult women work. Indeed, if caregiving is understood as a relationship rather than an altruistic act which moves only in one direction, interventions that will relieve the caregiver and help the older person at the same time can take form. By drawing attention to the political construction of informal care by family members in Singapore, this section hopes to debunk caregiving as mostly a woman’s responsibility and best done at home. We ask, does the state play a residual role and only offer supplements because family care is insufficient? If so, carer welfare is not at the heart of policy and a gap exists between formal/public space care and informal/private space care. Alternatively, are carers viewed as partners in the caring enterprise which then implies that carers at home are almost akin to semi-professionals who require support so they can continue to provide care?5 The differing approaches have the effect of excluding or including specific sets of social relations because there is a tendency to present care in private and public spheres as generically different. Public sphere care, whether rendered by

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institutions or community, is professional and private sphere care is affective. Whether the two can be bridged is a pressing issue in view of globalization (Devasahayam 2003; Graham et al. 2002). Changes to the traditional family structure as well as more women working mean that informal family care may no longer be taken for granted. A better way is to reconceptualize the interpersonal relationships between the carer and the care recipient to include both familial and non-familial relationships in the giving of care. Opening up the caregiving relationships within both the home and the public/market place requires us to question the polarity between the worlds of formal and informal care. After all, formal care in residential homes of an institutional setting has been known to develop emotional attachment between the caregiver and the care recipient (Milligan 2003). Likewise, informal care at home has been known to entail the need for care respite because of the strains of caregiving. Recognizing the multitudinal ways in which caregiving can be expressed as well as the fluidity in which spaces are conceived in contemporary society will assist in structuring policy to help older people, their families and society at large. We therefore suggest that it may be productive not to define the contours of caregiving according to formal instititutional or community spaces versus informal home spaces. Focusing on the interlocking contrasts between the private and the public serves only to embed the ‘ideology of the home’ (Twigg 1999: 383) as private and impenetrable. The ethic of privacy, the power to exclude others from the home and the home as embodiment of identity (Sixsmith 1986) will generate rules of social behaviour (Twigg 1999) based on clearly demarcated boundaries that serve only to ‘lock the cage door’ (Bondi and Fewell 2003: 527) and prevent others besides family from assisting in caregiving. The tendency to do exactly this in Asian societies is strong. Mehta (2000) and Chee and Levkoff (2001) reveal that caregiving is often a familial responsibility and a private activity. In South Korea, there is a virtual absence of any public social services to meet the needs of older people as the family is supposed to do so. In Singapore where spatial proximity is an advantage, the chances of home care being preferred to public care also means that the idealized Asian family unit as caregiver (see Mehta 1997a on the importance of reciprocity for caregiving in Singapore) is entrenched since the state also supports this notion. Indeed the respondents in our survey said that home is the best place: ‘If your own family members help, then no need to ask others’ (FG1, n1). Many respondents added daughters-in-law, nieces and siblings (FG4, n2; FG4, n3; FG6, n1). ‘The immediate family ... will give a booster to the sick person’ (FG6, n7). Another respondent said, ‘wherever they live, I will make it my home’ (FG2, n6). This tallies with state support of the Asian family ideology. If sick older people cannot be looked after at home, it represents a ‘stigma because of the Asian mentality. You put your grandmother in an old folks’ home shows that you are not filial ... It’s the Asian culture ... There is this preconceived notion that others will think that [you] are not filial’ (FG4, n2).

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It is not just family but women who are conceived as constituting the ‘family’ when it comes to caregiving. Even for women who work, Singaporeans still adhere to women as caregivers and home space as the best care space. For women who work, ‘as long as the government allows people to employ maids, it solves the “real” problem; the “real” need [of caring to be done] in the house’ (FG4, n3). When prodded by the interviewer to give an opinion on whether this was too high an opportunity cost for the woman, the reply was: ‘No, it’s more costly to put [the old folks] in a home [residential care]’ (FG4, n3). State policies are designed in such a way as to assist family members to help look after their parents at home. Besides the housing policies mentioned above, the foreign domestic worker levy is another example. This levy has been dropped from $345 to $250 per month for those families ‘with children aged less than 12 years old, or with elderly persons aged 65 years old and above ... the concession is part of the overall package of measures to make Singapore a great place for families and to support parenthood’ (MOM 2005c: up). Only working women can claim tax relief for the foreign domestic worker levy as the the helper is effectively replacing her duties. In addition, Singaporeans can claim parent relief if they all stay under the same roof. Taxpayers who maintain their parents or grandparents will get a relief of $5,000 for each parent living in the same household. Co-residence emerges again as an acceptable social ideology. The claim is reduced to $3,500 for those who do not stay in the same residence (Yap 2004). To unlock this inclination towards women as caregivers and home spaces as care spaces, there is a need to promote alternatives. Some of the more educated of our respondents recognized this. If caregiving is confined to the family, ‘it’s very stressful for the family ... I am for professional [care], state or otherwise [market]’ (FG5, n1). Even support groups in the community can be a good alternative. According to a long-suffering cancer patient, ‘You don’t actually have to study caregiving ... it is a matter of heart and soul ... the person must have compassion, caring attitude’ (FG5, n2). He was not referring to family but to a cancer support group he received help from. Some respondents suggested that Home Nursing Foundation (HNF) nurses should ‘see for [themselves] the condition in the home. Then help ... Singapore should have more of this; [there is] not enough ... not enough’ (echoed by n4, n3, n1 in FG5). There is a need to break from tradition: ‘We, the Chinese always think face [pride and integrity] comes first ... which is wrong. In reality, you have to face up to it’ (FG5, n7) and seek help wherever possible. It does not have to be in the home nor provided by family members; it can come from professional sources in or from the public sphere or from VWOs. Some options are already specified in Chapter 7 – neighbours, foster families, day care and other VWO facilities. In fact, VWOs in the public domain couldn’t agree more. VWOs, with all their professionalism, often complained that older people were neglected at home, especially amongst lower-income households (interview material

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from S1). As husband and wife often hold jobs, sometimes two jobs, other than at weekends (and sometimes not even then), older people are left without stimulation at home. Some VWOs suggested that the older people would be better off in their care than at home. The VWOs never broached the subject of complete care; instead they always saw their role as augmenting the busy Singaporean family rather than substituting it. However, as long as the home remains a sanctuary which strangers cannot enter, only so much can be done in terms of visits by the HNF personnel or volunteers such as Befrienders who are given limited access; there is not yet a culture of carer rights that will protect the privacy of the home while also easing the burden of the caregiver. The Touch Community Service (Yap 2004) provides a one-stop community resource facility that caters to all ages and disabilities, offering training and consultative help so that caregivers can perform their tasks properly. Caregiver kits give information to facilitate understanding and enhance care provision. This is as far as the bridging has achieved. Domiciliary nursing care, mobile medical clinics, meals-on-wheels and home help are limited in breaching the private–public divide and as Mehta (2000) argues, the importance of filial piety and similar social constructs in the Malay and Indian populations of Singapore translate into anxiety and stress because children remain the primary caregivers and the best care is that provided at home.

Conclusion This chapter has argued that social ideology plays a significant role in the construction of living spaces as idealized caregiving spaces for older persons. In Singapore, the government has explicitly taken on the social agenda of looking after older people through the family foundation. Housing policies are constructed such that they favour adult children who want to live with or close by to their parents. This benefit extends even to those who have not celebrated their nuptials but are planning to do so. Residential spaces for older persons have not moved in the direction of retirement communities like Sun City, Arizona (Laws 1995b) where spatial segregation is the norm and living independently is promoted as a virtue. Nor is sheltered housing prominent. Living together or in close proximity, aided by the small size of the island and the high cost of housing, Singapore’s specific experience in housing is a politically motivated one and premised on the collective efforts of the family in the provision of care. In addition, the chapter shows that the normal ordering of the home as private, secure and an identity marker may not be in the best interest of older people in need of care. Although for many Singaporeans, home and family are still the first line of defence, transgressing the private–public boundary and reordering social relations to be more inclusive of formal caregivers can actually help to make caregiving less of a burden. Of course, formal caregivers must at the same time recognize the power that lies within

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the concept of home space and try as far as possible to respect and accommodate the wishes of the occupants, including not only the care recipient but also other members of the household, for this can be a major bone of contention (Mowl et al. 2000). To date, most of the services that target the well-being of older people still separate formal care in the public domain from informal care at home. That many Singaporeans complain that ferrying sick parents to doctors or for other forms of care can be trying (but nevertheless continue to do so because of commitment) means that transgression of care boundaries is a necessary item for discussion in improving care provision for older persons. The living arrangement for an older person determines to a great extent the quality and nature of care available. Despite the potential strains, many older Singaporeans still prefer to stay with their own families. The house in which they live may symbolize more than a shelter – it has deep emotional meaning in their lives. Therefore, when discussing quality of life for older people, we need to look at the home not only as a sanctuary but also as a place that can respond to changing social values wherein community can augment the family as caregivers in an ideal setting for those who need the care.

Notes 1

2 3

4 5

In addition, the home has been conveyed as an important site where spatial and temporal boundaries are negotiated between members of a household. As a very crude example, an adult’s bedroom can be produced very differently from a teenager’s room. Multiple spatialities and temporalities get produced by these negotiations, the dynamics changing according to whom among the household members can assert more power at what time (Sibley 1995). Home is not a purified environment but can be a place of conflict, the best researched being that which examines adolescence (Sibley and Lowe 1992), but domestic violence and elder abuse have now become prominent (Craig 1997; Flowers 2000; Kwan 1995). This aspect of the home will be investigated in the chapter on widows and has been raised in the chapter on caregiving. A void deck refers to the open area at the bottom of a block of flats. The space may be used as a community space or for activities such as a funeral wake or wedding. These activities require the application of a licence. In this exercise, the HDB selects blocks of flats to redevelop. All residents must vacate but they are given priority for new flats. Under this scheme, many neighbours opt to stay near to each other in their new homes as the scheme gives them priority over others in the selection of flats. The wheelchair-bound in this study included adolescents as well as older persons. There is a third option which is that carers and care recipients are co-clients of formal care services. Intervention is focused on relieving carer stress and in the UK, there is even carer legislation to protect this group. This is, however, not the case in Singapore and is therefore not discussed.

9

Intergenerational ties that bind

Introduction Ageing as a demographic phenomenon can be quite alarmist and can shift the focus of the study of ageing to the inexorable financial burden of a topheavy age pyramid. The unintended outcome is insufficient attention given to social issues associated with older populations and concomitantly, the relationship between this and the younger generations, to which this chapter is addressed. We start by noting that the connections between age groups have changed in many countries. Complexity and diversity increase with globalization and as they do, the roles and responsibilities of individuals have to be redefined and so must social policy dealing with ageing populations. In particular, altered work and leisure patterns, increases in educational opportunities and new definitions of family units have led to a need to reexamine intergenerational relationships. The atomization of the family in contemporary society because of divorce, separation, a low birth rate and increased mobility has meant that grandparents have had to re-examine the roles they play and hence, the identity they derive. Longer life expectancy, better education and greater affluence are in store for many grandparents which will also bring about many transformations. While this is the case, when intergenerational support is mentioned, it is overwhelmingly perceived from the angle of older persons as care recipients, many of whom may be old and frail. However, with longer life expectancy and more years spent in active and healthy post-retirement, there is an increasing realization that older persons have the potential to make, and are in fact already making, important contributions in intergenerational support. Hermalin et al. (1998) agree with our findings that grandparents in Asia are active in providing care for their grandchildren and many take responsibility for a significant number of household chores. On the surface, older persons active in the care of grandchildren fit well into the traditional mainstream gerontology framework of activity theory and its derivations of successful and productive ageing. In a life stage where role loss is problematic, role theorists like Rosow (1985) argue that

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grandparenthood provides the basis for later life satisfaction by creating new responsibilities and by empowering older persons to assist in the running of the day-to-day activities in a household (Bengston and Robertson 1985; Thang and Mehta 2004). However, as critics have shown, the traditional theories and perspectives are not adequate in addressing the structural basis of diversity and heterogeneity of the ageing experience (Estes and Associates 2001; Estes et al. 2003). Traditional perspectives overlook the issues of gender, class and ethnicity which play crucial roles in the construction of differences in ageing experiences. In addition, traditional research also assumes that roles are passively acted out without contestation and redefinition by the role players themselves. By examining the experience of older persons acting their role as grandparents in intergenerational support within the family, we deconstruct the meanings attached to the role and elucidate the agency of grandparents in defining caregiving according to their own terms. When we do this, we include state prescriptions of the responsibility of grandparents as examples of ‘social spaces that encourage certain forms of behaviour and [the] sanction [of] others’ (Estes et al. 2003: 3) and show how this particular social policy of promoting grandparent caregiving can be a ‘site of struggle’ (Estes et al. 2003: 4). It is the text of the older people which we use to read their practice of grandparental roles which will be contrasted to the state’s social construction of grandparenthood (Gilleard and Higgs 2000).

Re-examining grandparenthood in contemporary society While Chapter 7 focused on caring for older persons where care in the family is provided mainly by spouse, children and/or grandchildren, this chapter examines care from the direction of grandparents to grandchildren. As Silverstein et al. (2003: 75) assert, ‘there is little question that grandparents play valuable roles in providing time, labour, financial and symbolic resources to other family members’. Among the valuable contributions of grandparents is the provision of child care to their grandchildren, enabling mothers to remain in the workforce. Grandparents, especially grandmothers, are indeed the most common in providing informal or complementary care to grandchildren in all societies. Empirical findings on informal child care for working parents in urban Britain indicates ‘informal care’ as overwhelmingly ‘grandparent care’ (Wheelock and Jones 2002: 449) which is also predominantly female. Grandparents appear to be on the trend towards greater involvement with their grandchildren than ever before (Silverstein et al. 2003: 85). In Chapter 7, it was pointed out that caregivers face many challenges in the care of older persons and ageing by itself compounds the stress and tensions associated with caregiving for those who are themselves older. Compared to these problems, the issues older persons face as caregivers to grandchildren are even less understood as they are too often invisible in the private sphere of

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the home. These problems have only begun to capture public attention in recent years. One reason for this development is social change that has forced grandparents to provide custodial care in ‘skipped generation’ households, i.e. households where the middle generation is absent and unable or unwilling to provide care due to factors such as parental substance abuse, teen pregnancy, HIV-AIDS, child abuse, neglect and unemployment (Cherlin and Furstenberg Jr. 1986; Goodman 2003). Grandparents in such situations often find themselves obliged to take on the caregiving responsibility, which is often accompanied by financial and physical strains. In the US, the number of children in grandparent-headed families has increased from 2.2 million in 1970 to 4.5 million in 2000 (Goodman 2003: S281). This forms the basis for a critical review on grandparenting, as reflected in a growing body of literature challenging policy emphasis on health care issues, advocating instead for crises such as grandparent-headed families to receive similar support given to traditional parent–child families in crisis (Fuller-Thomson and Minkler 2001). Custodial roles by grandparents have been related to greater depression and lower health status (Goodman 2003). Furthermore, studies of grandparents raising grandchildren in the US also show that although the phenomenon cuts across class and ethnicity, it is particularly prevalent among African Americans (Minkler and Fuller-Thomson 2005: S82). The dominance of grandmothers as caregivers also means that ‘while the care of older people and young children can be meaningful and helps “connect” the family, it can also oppress women’ (Connidis 2000 cited in Teo et al. 2003b: 330). Grandparenthood is thus a negotiated identity, on the one hand welcomed by older persons, while on the other hand, problematic. No doubt grandparenting offers older persons opportunities for new experiences and a sense of satisfaction achieving ‘generativity’1 (Erikson 1997), but the heavy responsibility that comes with taking care of young children all over again may not be what older persons expect or feel prepared to embrace in later life. The tension is felt not only among custodial grandparents who are often the sole providers for their grandchildren, but also among those who have extensive involvement in the care of grandchildren (Fuller-Thomson and Minkler 2001). Extensive care of grandchildren is possibly a role more prevalent among grandparents than custodial care, given the norm of working mothers in many societies. Even in the case where children are placed under formal care, grandparents are overwhelmingly the main source of informal care complementing formal care (Higuchi 2005). If so, what have the grandparents to say and how do they negotiate and strategize to maintain autonomy in an inherently unequal relationship whereby their time and effort is seldom rewarded in any financial form? To what extent does the state, as a structure that endorses grandparents as caregivers to young children, affect the experience of grandparenthood in Singapore? In particular, Asian discourses on the family and care espoused through traditional Confucian values (namely, the structure) will be examined for their effects on the agency of grandparents (Giddens 1991).

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Intergenerational ties and social policy The policy framework of care in Singapore is grounded in the ideology of strong family and intergenerational ties. This is particularly emphasized in elder care mandated through the cultural ideal of filial piety (Low 2004). Strong family and intergenerational ties are encouraged through various policies and measures such as public education, tax relief, housing policies and the Parental Maintenance Act. Housing has already been discussed in Chapter 8. Here, we look at the remaining three. Under the purview of the MCYS, newsletters, videos, pamphlets, handbooks and television programmes to promote strong family ties, including intergenerational relationships, have been set up. Some national programmes include the annual ‘Romancing Singapore’ festival in February, ‘National Family Week’ in June and ‘Senior Citizens’ Week’ in November. Public education efforts are supported by the Family Matters! Committee led by the minister of state, MCYS. Its agenda includes the promotion of marriage and procreation as well as strong family bonding (MCYS 2005h). Grandparenting is strongly encouraged in state rhetoric, with an annual ‘Grandparent of the Year’ and other awards to recognize outstanding grandparents. ‘Grandparents’ Day’ is celebrated on the third Sunday of November as a way to show appreciation for the contributions of grandparents. Events leading to the Grandparents’ Day celebration include competitions for school and preschool children to design postcards dedicated to grandparents. Grandparenting is also promoted through information pamphlets offering tips on grandparenting. These are readily available in polyclinics, community centres and other public places, as well as a free download from the MCYS web site. In line with the policy of encouraging adult children or (great)grandchildren to take care of their dependent parents and/or (great)grandparents, a parent relief is given to adult children or grandchildren for the maintenance of their parents and/or (great)grandparents. Already outlined in Chapter 8, the tax relief for a co-resident parent/(great)grandparent is $5,000 but if the parent/(great)grandparent is disabled, the relief rises to $8,000. Parent relief for those not in co-residence is $3,500 and $6,500 respectively (Inland Revenue Authority of Singapore (IRAS) 2005). We would also like to recap that in alignment with the support given to working women who hire maids to look after young children, families with older persons 65 years and over also pay a reduced amount of maid levy when they employ foreign domestic maids to take on caregiving responsibilities. The scheme most directly related to the care of grandchildren is a new tax relief introduced in August 2004 as part of a new procreation package to boost Singapore’s declining birth rate. The scheme enables working mothers (Singapore citizens with children age 12 and below) whose child is being cared for by unemployed grandparents to receive a grandparent caregiver tax relief of $3,000 (IRAS 2004). However, such a relief directly

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benefits the working mothers rather than the grandparent. Furthermore, it denies grandparents taking care of grandchildren in skipped generations the benefits. In addition, the monetary relief may create the expectation that grandparents will care for grandchildren, which may elevate tension if the subtext that this is a ‘norm’ is not equally shared by both generations. The Parental Maintenance Act firmly prioritizes the family as the first line of support. While this can be interpreted as a form of empowerment for older persons (Low 2004), on the other hand, the enforcement of filial piety may further fragment the already weakened intergenerational ties among family members when parents seek such drastic action. From the state’s point of view, all of the above, from public education to fiscal benefits to help promote family bonding and grandparenting, have many advantages – older persons are kept productive, albeit in the private sphere, and there is great potential in helping to improve the depressed birth rate which achieved a historic low of 1.24 in 2004 (The Straits Times 26 August 2004). Child care is one of the most important concerns of parents and prospective parents, especially where the majority is made up of dualincome couples. Although formal care arrangements are available, including day care, employment of foreign domestic maids as babysitters, foster care and other formal sources of help, grandparents are often acknowledged as the most preferred caregiver because, as part of the family, they can be trusted to show more concern and have the best interests of the children at heart (Wheelock and Jones 2002). Higher life expectancy and more years spent in relatively good health among grandparents thus increases the expectation of involving grandparents in the caring for grandchildren. Moreover, the reciprocity engaged in the caring may strengthen the filial responsibility of the middle generation in taking care of the old in turn when they become frail. For a state which has mandated filial piety as a mechanism for intergenerational support, such a social contract will be especially complementary in ensuring that the responsibility of caregiving for the old (as well as the young) can be kept within the family, leaving the state free of extensive caregiving demands. But is this the picture shared by older Singaporeans? Qualitative research is most appropriate in examining the structureagency engagement in this issue. Similar to the other chapters, voices cited in the following are taken from focus group interviews of older persons as well as interviews with social service providers conducted in 2003.

Older people, their concerns, aspirations and negotiations In studying intergenerational ties between two generations of women in Singapore, Teo et al. (2003b) proposed the concept of ‘ambivalence’ to show that contradictory values can co-exist and that intergenerational ties encapsulate the negotiated outcomes of complex attitudes, values and aspirations. The study revealed that older persons felt worn down by the

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commitment of child care, and many expressed a desire to stop or do less. They are willing to help with child care, but complained about the insensitivity of the parent generation in understanding their needs. The study shows the complexity of intergenerational relationships – while increasingly seen in functional and convenience terms, these relationships are not devoid of emotive interdependence. Ambivalence can be expressed in many ways. Although emotionally attached to grandchildren, an overwhelming number of grandparents in the focus groups did not see the care of grandchildren as the grandparent’s duty but they did recognize the lack of options for the parent generation. One respondent expressed his disapproval of ‘forced’ child care with an example of a retired professor who had to take care of his four grandchildren: ‘Well, this poor man, they dumped their kids – I use that word “dump” – with him. Six days a week ...’ (FG4, n1). But he added that the retiree ‘willingly does [it] ... he complains that “I got no free time!” I say, “never mind, in six years’ time it will be over”’ (FG4, n1). Some respondents considered themselves fortunate to be spared. One female respondent who has five grandchildren, of whom three stay in New Zealand and two are under the care of their own full-time mother, counted herself lucky: I am as free as a bird. Other people my age, I have quite a number of friends, who have to look after grandchildren, and sometimes the Grandpa goes out, Grandma stays at home. They take turns to go out, you know, to enjoy life, and that’s part and parcel of life. If you are in that situation, if you have to do it, got to do it! [If] you are free, then you are lucky, that’s all! (FG5, n5) Child care can be inhibitive especially when retirement is perceived as a relaxing phase of life not to be burdened with heavy responsibilities: Because this grandchild is not my responsibility, it is my children’s responsibility ... Because if you look after someone, you have a responsibility. It wears down one’s [sic] physically. You want to relax. Once you take on such a responsibility, you cannot relax. (FG2, n7) But that’s not the grandparents’ wish [to babysit]! They want to retire, they want to retire gracefully, with leisure ... you [pointing to interviewer] told me that my children should have more grandchildren and therefore I have to look after them. That is civil service thinking, you know. (FG4, n1)

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The resistance to confine retirement years to the care of grandchildren is louder among male respondents. Female respondents, even when they express the opinion that it is not their duty to provide care for grandchildren, are more obliging in making sacrifices for the sake of their adult children. A male respondent whose wife is looking after their grandchild implied that his wife brought it upon herself by encouraging their daughter to work: ‘My wife asked her to work. But I tell my wife, “Don’t tell her to work because looking after the child is more important.” She says since she [the daughter] is young, she should go and make some money first’ (FG3, n2). Besides reflecting on the gendered nature of care for grandchildren, the willingness among older women to take responsibility for child care so as to facilitate the continuation of their daughters in the workforce reflects a selfsacrifice common among women in caregiving roles, but may constitute a dilemma to both generations. While grandmothers find themselves caught in cycles of child care, especially if they have a number of grandchildren, working women who consider quitting their jobs to care for their children may face objections from their mothers or mothers-in-law, who recognize better material comfort for a family with a dual income, and see their voluntary exit from the workforce as ‘a waste’ (Teo et al. 2003b: 336). Women who are better educated with tertiary level education are especially targeted. In contrast, lower-income women have no choice but to work and they are supported by both spouse and their parents or in-laws because this seems the only way to maintain a quality of life they are happy with given the high cost of living in Singapore.2 Other cultural and social norms contribute not only to the willingness to help, but to whether or not to provide more help. Some respondents said they would render more help to their daughters than their daughters-in-law as they feel closer to their maternal grandchildren, resulting in strong ties between maternal grandmother and grandchildren paralleling the findings in other literature (Gattai and Musatti 1999; Goodman and Silverstein 2001; Mills et al. 2001; Thang and Mehta 2004). Adhering to the traditional preference for sons in Chinese households, a respondent commented that she did not like girls and would not want to take care of granddaughters. This shows culture biases that may affect the older person’s willingness to provide care. Chapter 7 discussed the reality of foreign domestic maids in providing caregiving in the family, which includes older members and the very young. In actual fact, one in seven households employs a maid, leading to more than 140,000 domestic maids in Singapore households (The Straits Times 17 February 2003). While they have become inevitable in the domestic landscape as the main caregivers, frequent accidents (e.g. The Straits Times 2 January 2001) and publicized problems (The Straits Times 6 October 2001; 14 June 2003), as well as perceptions of the inexperience and inadequacy of maids have raised families’ awareness of the need for caution when relegating the main caregiving job to them. Ironically, while the

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employment of foreign domestic maids does the trick of providing relief for older persons from the physical care of grandchildren, it has created another set of problems – grandparents may object to being forced into physical caregiving roles, but at the same time, they know that they are the most appropriate caregivers for their grandchildren; not just because they naturally love them, but more so because as grandparents, they perceive themselves as the most appropriate people to assume the role of guardian and transmitter of ‘desired’ values to the younger generation. As one respondent commented about maids as caregivers: When people [grandparents] talk about playing with the children and they have maids, I am always trying to make this point – that the maid’s input to the children’s mind is one of the worst things that can happen. So your [sic] job ... when we [sic] go and see them, is to quickly sort that out. Because they [young children] will soon pick up the stand which their maid has ... I’m sure you realize it. (FG4, n1) The lack of confidence grandparents have in the structures available for child care is supported in the discussion on child care centres as well. In Singapore, child care centres usually accept children who are 18 months and older, making it necessary for working parents to rely on grandparents, foreign domestic maids or foster mothers (sometimes called nannies) for the care of the very young. At the moment, there are about 700 child care centres in Singapore and about 66 infant care centres (for babies of two months to eighteen months old) (MCYS 2005i). The numbers are impressive but many parents still prefer grandparents as child minders (Teo 1997a; Teo and Mehta 2001). When grandparents were asked whether child care centres provide good alternative care, while some felt that child care centres were beneficial for children to learn and socialize, others felt that to leave a child in child care centre from age two was detrimental to child development. It dilutes intergenerational bonds and the child will be deprived of love: When you send the child at about two years old, the bond with the parents and grandparents is not strong. You see what they do – they put them all together, play a little while, give them food, make them sleep and then the day care teaches them at their own time and all that. When evening comes, the parents come and collect [the children]. So there is no love, either with the parents or the grandparents. (FG6, n5) How then do grandparents negotiate to enable themselves to fulfil their grandparenting role if they must? Grandparents seem to think that the answer resides in the maids. They thought it ‘reasonable’ that their children appointed them supervisors over the maids:

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Intergenerational ties that bind Yeah, we would help. I think most of my friends, we all help out, but, there is a maid to look after. We do not do all the difficult work in the house ... I mean, looking after children is not easy, you know? I mean, a lot of ... running around and that sort of thing! Hahahaha.. So if they have a maid, yes, the grandparents can go there, supervise and all that sort of thing ... . (FG4, n2)

Maids allow grandparents to assume their nurturing role to their grandchildren without taxing their own physical stamina. This led one respondent to see the occasional taking care of grandchildren as a hobby: It’s a hobby. My daughter has a maid. So I am just going there to play with them, and to read to them, you know? Pick them up to the playground, swimming, that sort of thing. What else do I do? (FG4, n2) The grandparents’ demand to hire a domestic maid as a strategy to ease their own burden may lead to conflict between the generations. As a letter by a 31-year-old young parent to the forum of The Straits Times (23 May 2004) showed, the younger generation does take it for granted that grandparents, especially those who are healthy, will help in the care of grandchildren. The letter-writer was unhappy that his parents, although healthy and with time on their hands, refused to take care of his two children, aged three years and three months respectively, unless he employed a maid for them. He claimed that this is a problem facing all his friends who have children. He argued that policies to encourage senior citizens to enjoy their golden years will only work against young parents. To him, it is not ideal to leave a child in a child care institution which keeps strict hours but he did not have a choice because financial constraints prevented him from employing a maid. It is increasingly observed that the earlier generations of self-sacrificial grandparents who see care of grandchildren as an expected responsibility is giving way to modern day grandparents who stress their own freedom and space (The Straits Times 8 August 2004). In fact, it is an emerging reality reflected among the respondents, who desire an exciting social life as retirees. They engage in volunteer work, learn new things, go in search of religious spirituality, make new friends and treasure old friendships. The emergence of a healthy and active cohort of older persons coincides with the state’s vision for older Singaporeans to be healthy, active and secure. Under the MCYS Eldercare Master Plan 2001–2005, older persons are urged to age with respect and dignity by leading independent and fulfilling lives. To promote healthy lifestyles and active ageing, the Master Plan allocated more than $30 million to programmes for fit older persons (Mehta 2002: 162). These include activities in senior citizen clubs (e.g. social, recreational, cultural and sports activities

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including line dancing, cooking classes, visits to religious places, etc.), mutual help schemes to form interest groups among older persons so that they can overcome loneliness (e.g. sharing of exercise equipment among those interested in keeping fit or offering assistance to one another) and an active seniors programme (sharing of knowledge and talents among the active seniors so that they can remain abreast of their interests). A cost-sharing initiative was started whereby the state would be willing to pay up to 80 per cent or a cap of $200,000 to help organizations start up innovative projects that promote active ageing (MCYS 2005j). Funding as well as strong support and initiatives from MCYS have led to an expanded array of activities to encourage active ageing from various organizations such as the PA, the NTUC, VWOs, CDCs and the Retired and Senior Volunteer Programme (RSVP). The annual Active Senior Citizen Awards organized on both the state and community levels further endorse an active lifestyle as the benchmark of successful ageing. Besides the community and the care of grandchildren, some respondents turn inward, refocusing on strengthening their own marital bonds. A female respondent who is a retired teacher and now enjoys spending time with her retired husband quipped: And I always say, what a pity, when we were young, we used to fight, we used to argue. When we were young and beautiful, we should love each other, you know? It’s now when we are old, you know, [we] sometimes complain of aches here and there ... We [have] become more loving. When we are [sic] young, we used to fight. Now we dare not fight. Because we have only few ... anytime we can part, you know ... we really treasure each other. (FG4, n3) In other words, older persons are moving towards lifestyle options that are increasingly indistinguishable from those of their adult children’s generation. More important, these are not marginalized options but lifestyles that are endorsed by the state through the policy of active ageing. At first glance, the desire for self-reliance and demand for flexibility, coupled with availability of these opportunities, manifest a ‘postmodern turn’ (Estes et al. 2003: 35) that has contributed to a ‘blurring of what appeared previously to be relatively clearly marked stages’ (Featherstone and Hepworth 1989: 144). Blaikie (1999) concludes that in such postmodern times, there are no rules, only choices. Further analysis, however, shows that the consumption of choices is a complex matter that displays struggles. Older persons, affected by the social construct of grandparenthood, find themselves in negotiation between what they desire and what they are expected to fulfil. The ideal seems to be the ability to enjoy the best of both worlds. One respondent who takes care of her grandson four times a week is persistent about keeping her time as a volunteer once a week. Like young parents troubled by the need to balance

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work and family life, the modern day grandparent, particularly grandmothers, are facing the dilemma of the need to balance their social life with care of grandchildren they find hard to keep at bay (Thang, forthcoming). Throughout the narratives discussed above, ambivalence surfaces as older persons, despite declaring that caring for grandchildren is not their responsibility, continue to do so out of love and concern, whether the sacrifice is out of choice or not. Older persons are positive about grandparenthood and express satisfaction and happiness in having grandchildren. A respondent reflected upon the meaning of grandchildren: To me, the whole world is having a next generation. This way when I die, I will be happy in this world. It is not that how much [sic] certificates I have, how much money I have in the bank, it is not that, you know. It is the continuity of life. (FG3, n2) Becoming a grandparent means feeling a sense of fulfilment in life: I thought the time when your children got married, already you know that you are getting old. Not to say, have grandchildren. When they get married, oh dear! Now they are already grown up, having their own families, you know? And after that their grandchildren come, it’s just a natural thing, part of the family, that sort of thing. Yeah, I think it’s a fulfilment. (FG4, n2) To grandparents who have worked their whole life without engaging in physical care of their own children in the past, the child care role may be an attractive option after retirement. One respondent who has no grandchildren commented: ... I would love to look after grandchildren. When I have grandchildren and when I am retired, I will love to do that. Mainly because when I was young, working and working, I couldn’t have the luxury to be with my children as much as I wanted – put them in nursery, or my first child, I made him take care of my second child ... I just didn’t have the time. I would love to make it up to my grandchildren ... I think it will become the trend in the future. Because for the generation who take care, for them to give up their work and take care of their grandchildren, to take care of their children, is getting less now. And it becomes that, it will become the third generation that we are taking care now. (FG5, n3) In fact, some grandparents are confident that they are better placed and more experienced than their adult children in managing the young:

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To tell you the truth, when I’m angry with the grandchildren, I’m more angry with my daughter, because of spoiling the child rather than anything else. You know what I mean? I tend to be more strict with my grandchildren actually, in the sense that I will tell them ... they listen actually to me. Quite easily. They don’t grumble. ... They are actually better behaved with [me] ... than with their parents, you know? They tend to act up when they are with their parents. Because they hardly see them, so they, they have the tendency to whine and all that sort of thing. But with the grandparents, I think ... I don’t know, I manage my grandchildren better than my daughter. (FG4, n2) This is probably one of the key things. Grandma doesn’t live with them, but Grandma guides them, and tells them certain things. And they like it. Because it is not repeated over and over and over again. That’s why. Secondly, parents tend to give up after a while and find some easy solution out. So the child knows, I can take advantage of the situation. But with Grandma, you can’t. Because she is not there all the time! (FG4, n1) The meaning of grandparenthood articulated by the older population thus shows degrees of mismatch with the social construct of grandparenting in the model emphasizing the provision of physical care of grandchildren. Instead, grandparents prefer engagements in the form of informal play (as in the fun-seeking grandparenting style outlined by Neugarten and Weinstein (1964)) and a companionable relationship as givers and receivers of love and affection (Cherlin and Furstenberg Jr. 1986), on top of being ‘wardens of culture’ – guiding, preserving and transmitting the knowledge, experiences and skills to the next generation (Gutmann 1985). They retreat from full-time involvement in child care. Rather, they map their interactions with grandchildren into their schedule, including social and leisure programmes. As ‘individual agency’ (Hagestad and Dannefer 2001), older persons are deconstructing the meaning of grandparenthood as the care of grandchildren by fully embracing other activities promulgated through policy initiatives that encourage active ageing. They are voicing their unhappiness and asserting their right to have a more balanced life that is not guided by moral duty to the family alone.

Conclusion We recognize two main reactions to the needs of older persons for autonomy and freedom in grandparenthood (Cherlin and Furstenberg Jr. 1986). The first is represented by the conservative critiques of contemporary family who have called for a return to ‘traditional’ family values, including the restoration of the authority of old over young and husbands over wives.

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Arthur Kornhaber (cited in Cherlin and Furstenberg Jr. 1986) warned of a ‘new contract’ and sees weakened families as equating to changes in grandparents’ attitudes towards child care. The second, more critical, perspective rejects the conservative argument. It argues that intergenerational ties are not necessarily affected by changes in family structure, autonomy of grandparents and the issue of care of grandchildren. On the contrary, the emotional ties between the generations are more valued than before. Grandparents and grandchildren may not stay in close proximity but grandparents will continue to remain the central part of the audience in the grandchildren’s achievement (Cherlin and Furstenberg Jr. 1986). The premise remains that grandparents play vital roles in intergenerational support within the family. Grandparents are not abandoning their family commitments in expressing wants of their own leisure and autonomy. Instead, their achieved self-reliance should be viewed positively as a result of better health and economic resources. If grandparents are to engage in the care of grandchildren, whether from skipped generation families or families with working mothers, they equally require support and should not be hidden away as the ‘invisible’ help. Furthermore, there should be recognition that grandmothers are overwhelming providers of care, and ethnicity and socio-economic backgrounds do implicate varying needs. Wheelock and Jones (2002) suggest that a small ‘grandparenting allowance’ is due as a way to publicly recognize the significant role that grandparents play in keeping mothers in the workforce. In Singapore, the current grandparent caregiver relief provided to working mothers seems to be missing the message as it is a relief given to the working mother and does not constitute an allowance to the grandparents which is a more direct form of recognition. In the US, successful advocacy for recognition of grandparents as caregivers for children has led to changes in policy to support caregivers. The National Family Caregivers Support Program (NFCSP) from the 1965 Older Americans Act which provides services to caregivers 60 years and over now allows up to 10 per cent of the funds of the NFCSP to be used to meet the needs of grandparents and other relatives raising children (Snell 2003). Although the sum is viewed as insufficient to the present state of African American grandparent caregivers living in poverty, it is nonetheless an important step forward (Minkler and Fuller-Thomson 2005: S90). Although valued, grandparenting is but one part of the lifestyles desired in postmodern times. In Singapore, older persons like the encouraging support they get in the form of opportunities to play an active social role in leisure, learning and volunteering. However, they are ambivalent about policies that embrace the image of grandparent confined to the role of care provider for grandchildren. The contradictions are complex, but not necessarily antagonistic. What we require is reflexivity and creative policy measures that do not compartmentalize ageing roles and wants, but instead look beyond traditional divisions to engage in what most benefit the older generation. If the state is able to advocate for a work–life balance for employees in the public

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sphere (The Straits Times 20 July 2005), why can’t the state also consider a family – leisure/social life balance for grandparents in the private sphere? It is about time structure responds to agency as we have shown in Chapter 6 on health care. One possibility is to allow grandparents to engage with their grandchildren in a formal child care setting, such as giving grandparents space to visit their grandchildren and involving grandparents in joint activities in the child care/infant care centres. This releases the grandparents from the burden of care but allows emotional ties to develop between the generations. The HDB could explore the setting up of child care/infant centres at the lower levels of the studio apartment blocks built for older residents, allowing for mutual support of formal and informal care for the children. Child care/ infant care centres could also be built adjacent to SACs to encourage mutual development. Such settings have proved to be beneficial to both generations in Japan (Thang 2001). These suggestions require deconstruction of the formal/informal care dichotomy to provide opportunities for various flexible arrangements to be possible. As noted by Estes et al. (2003: 26), ‘a degree of both stability and fluidity is necessary for the creation of identities that ageing adults can comfortably inhabit’. We have read the texts of what the older persons think grandparent roles and meanings are. While an excess of fluidity is not desired, too little of it will suffocate creativity and the ability to adapt to changing circumstances. For grandparenthood to become an enriching experience identified by the older person as benefiting the family, community and self, how state can help them to reach a comfortable zone is a pertinent issue that needs to be addressed.

Notes 1

2

‘Generativity’ is the seventh stage in Erikson’s (1997) psychosocial model detailing eight stages of development of the ego through the life cycle. When an individual achieves ‘generativity’ in the seventh stage, the person establishes a sense of care and concern for the wellbeing of future generations and is forwardlooking rather than stagnating in the past. Although we do not specifically address ethnic differences of ageing in this chapter, it is implied as there is a high correlation between income or education and ethnicity. Dual-income households in Singapore are overwhelmingly Chinese and Indian who have a higher mean household income than Malay households (for details, see Teo 1996 and Teo and Ooi 1996).

10 The journey after widowhood

Introduction Unlike birth and marriage, widowhood is often looked upon as an unwelcome transition into a new phase of life. The widowed have to cope emotionally with the loss of their spouses as well as adapt to new circumstances resulting from the event. With an increase in life expectancy, not only is the likelihood of becoming widowed increased, the time spent as a widowed person is also lengthened. In most countries, within the band of those above the age of 65, widows outnumber widowers. For Singapore, in the year 2000, the number of widows was five times higher than widowers for the age group 65 and above compared to less than four times ten years ago (Tay 2003: 62). The total number of widowed persons in 2000 was 129,237 out of which 118,017 were above the age of 65 (DOS 2000b: 149). As a rite of passage that has devastating effects, scholarly interest in widowhood saw a marked increase in the 1980s and 1990s. The work focused mainly on the challenges faced by widows (DiGiulio 1989; Lopata 1973; 1987; 1996; Matthews 1991; O’Bryant and Hansson 1995), documenting in some detail the consequences of this experience (Campbell and Silverman 1996; Chen and Dreze 2002; Cheng and Ma 2000; Laditka and Laditka 2003). Other studies have focused on the social support given to older widows and widowers and the positive outcomes of such support in the long run (Heinemann 1983; Pickard 1994; Stevens 1995). Additionally, Fry (2001) elaborated the predictive factors of their psychological wellbeing. The tendency in these past studies has been to look at the diminished wellbeing of the older widow, particularly in developing and underdeveloped countries because statistical and anthropological evidence point to their loss of social and economic status in society. There is, however, a parallel trajectory of research that addresses aspects other than a negative picture of widows. For example, Van den Hoonaard (1997) examined through the biographical accounts of ten widows in North America, the process of ‘identity foreclosure’ and the subsequent development of new identities. In keeping with the strategic thrust of this book which emphasizes the human agency, this chapter examines the bereavement experience, the social

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context and the active efforts made by the widows and widowers in carving a niche for themselves within their families and communities. The data for this chapter are derived from primary sources such as a research project in which we surveyed 237 widows and widowers in Singapore, including an in-depth study of 25 of them (see Chapter 1 for details). Secondary sources such as the 2000 Census of Population, vital statistics on marriages and divorces, and other published studies are used where necessary to highlight demographic trends or to supplement our findings. Since they constitute a fairly large group that is likely to increase in the near future, we also identify the shortfall in services that can help to alleviate the burden of ‘going alone’. Women are the main target group of these services although they are not specific to them only.

Older Singaporean widows and widowers Just as there is a feminization of ageing, there is a dominance of females among the widowed and this proportion increases with age. Among women over 70 years of age, 58.7 per cent are widows, and among women over 80 years of age, close to 80 per cent are widows (Shantakumar 2005: 37). Given the very high incidence of widowhood in the older ages, it is useful to know what their profile looks like. In Singapore, they tend to be of low education, have very low level employment skills, and a large proportion have not been involved in the labour force. They have a high level of dependence on family support unlike never-married older women who have had to fend for themselves economically throughout their life course. Most of the widowed live with their families although ethnicity plays a very important determining factor in affecting the choice of which adult child the older person lives with. Among patriarchal cultures such as the Chinese and the Indians, older persons prefer to live with their sons and daughters-in-law while among the Malays, older persons prefer to live with their daughters and sons-in-law (see Mehta et al. 1995 for a more detailed discussion on living arrangements). Within this prescribed cultural directive, there is still agency in so far as the widowed person overrides cultural prescriptives with relational dynamics, i.e. a favourite child gets chosen over what is the cultural norm. Even then, our widowhood study conducted between 1996 and 1999 revealed that widows tended to become economically dependent after the bereavement (Teo and Mehta 2001). Financial transfers from children and grandchildren constituted their main source of income. In fact, social networks became an important aspect of the lives of the widowed. They were close to family members and relatives, more so than widowers who tended to see more of their friends than their relatives. This finding corroborates the trends suggested by Lopata (1996) and Rose (1990) that the social identity of women needs to be reconstructed around significant others within the family. Social constructions of widows as the ‘fifth wheel’ (Lopata 1973: 168) place

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them in a state of liminality until they redefine themselves as a single person, a sibling, a mother/daughter or a kin member so that they have a location to actively pursue life (Stroebe and Stroebe 1993). Given these general descriptions, the question then arises, how well do the widowed cope? Those who live with family members coped better than those living alone (Table 10.1). There was also a direct positive correlation found between health condition and ability to cope. Those in ill health were less able to cope. For this group, as well as the generally healthy, by the time they reach late life, their caregivers are mostly their adult children or children-in-law. From a position of control in their adult life to dependency in their old age, the combination of poorer health and fewer economic resources creates a situation of inequality in reciprocal exchanges. Outcomes expected by the widowed are also linked to structural conditions of the past (e.g. employment opportunities) and the present (e.g. higher female labour force participation leading to grandparents playing surrogate mothering roles) to which we now turn.

The reconstruction of identity post-bereavement Few studies have captured the delicate nuances of the emotional and psychological journey travelled by widows as brilliantly as Lopata (1996) and Van den Hoonaard (2001). To understand the complete experience of older women as widows, they used a feminist approach to study the phenomenon. By doing so, concepts such as inclusiveness can be explicated as a wide range of variables are drawn upon to evaluate gender identity. In addition, the feminist perspective helps to portray the multiplicity of identities that can arise from the experience (Blieszner 1993). Our Singaporean widowhood project is but a modest attempt to elicit these meanings, using quantitative as well as qualitative approaches to get not only the broad picture but also in-depth knowledge of their ‘rich lived experiences’ as expounded in their gendered narratives. Table 10.1 Living arrangements and reported ability to cope among survey respondents Living arrangement With unmarried children With married children/ grandchildren With relatives With non-relatives Alone Total Source: Authors’ study

Cope very well/well 29

(25.4%)

54 (47.4%) 2 (1.7%) 8 (7.1%) 21 (18.4%) 114 (100.0%)

Just manage 33

(33.3%)

33 (33.3%) 2 (2.0%) 8 (8.1%) 23 (23.3%) 99 (100.0%)

Not coping well 8

(33.3%)

5 (20.8%) 1 (4.2%) 3 (12.5%) 7 (29.2%) 24 (100.0%)

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In some ways the widows in our study resembled the ‘widowed selves’ described by Van den Hoonaard (2001). For a long time, widows try to realize their husband’s wishes (e.g. ‘this is what he wanted’; ‘this is what he would have wanted’) and take a long time to ‘let go’. The Asian custom of mourning usually lasts three to six months. Hence the surviving spouse was often occupied with carrying out rituals such as prayers, visiting the temple or performing pilgrimages, for example, to India. While in Van den Hoonaard’s study the church was mentioned as an important comfortable environment for women who have been active members in the past, in our study, respondents ranked visits to religious places of worship one of the three main activities that they participated in (the others included seeing more of immediate family members, friends and neighbours). It is apt at this point to refer to the three functionally interdependent processes that Coleman (1997: 3) has identified as operating across adulthood. They are the: ●

●

●

immunizing processes that mitigate the impact of self-discrepant evidence by denial and by shifting focus to other types of evidence; assimilative processes which include instrumental and compensatory activities aimed at preventing or alleviating losses in areas of life central to self-esteem and identity; and accommodative processes, involving readjustment of personal goals and aspirations which, as a result, dampen or neutralize negative selfevaluations.

Both widows and widowers used all of these processes in their adaptation to the loss of their spouses. Some interesting examples are illustrated in the following quotes, which mirror the processes respectively: ‘My siblings do not visit often because they are working and they have their own problems too. I try to make up by talking to my friends on the phone’ (female, 52, Indian); ‘I started writing my autobiography as I have suffered so much for so many years’ (female, 62, Chinese); ‘I say to my friends “Mother-in-law days are over!” The daughters-in-law now ... control the home. If you want to stay with them, you just got to play along. And I am getting along very well ... been here six years already’ (female, 65, Chinese). Some of the accommodations were mental, such as striving to be contented within the social and economic circumstances they were in, accepting the loss of the spouse as fated or the will of God, and being grateful for the filial care shown by adult children. In response to the question whether they would like anything changed in their past if they were given a chance, 60.3 per cent of our respondents said that they had nothing they would like changed; 15.9 per cent did not answer; 7 per cent said they wished they had received a better education; and the rest were ambivalent. The utilization of secondary controls (such as fate) to adapt to changes or circumstances is a strategy that is common among the Asian older population. Earlier studies

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in the Singapore context have documented this (Mehta 1994; see also Verbrugge et al. 2005). When older persons are ‘caught’ within circumstances that they cannot change, they accommodate by changing their perceptions, which then reduces the negative impact. Accommodation was also manifested in other ways such as the sharing of rooms. Space being a premium in the small apartments of Singapore, sharing is a common phenomenon. Who they share with, however, indicates how much they are willing to tolerate other household members or who they are intimate with. In our study, nearly half of the respondents (46.2 per cent) shared their sleeping spaces with their grandchildren, their unmarried adult children, the parent-in-law and even the family’s domestic help. Dedicating spaces to temporary daytime occupancy such as the ‘study’ is common in Singapore households, hence denying the older adult possible private space. As Van den Hoonaard (2001) asserts, the widowed often showed a great deal of courage, determination and resilience in negotiating their new terrain. Although some were not satisfied with their life circumstances (10 per cent in our study), they faced their challenges not alone but with the help of family, community and government resources. The fact that they sought these sources of help and succeeded in maintaining their self-dignity bears testimony to their indomitable spirit and to their willingness to accommodate. Resolute or not, widows and widowers are still subject to structures that affect their life course. According to Calasanti and Slevin (2001: 193): age is fluid and thus the same individual can be advantaged or disadvantaged by age over the course of the life-span ... .The fluidity of age relations in an individual’s life reveals the social construction of old age in ways that differ from the construction of other social locations. In the process of understanding widowhood beyond the ideological boundaries of adjustment and coping, we take heed of this statement and apply it in this discussion. The life course perspective draws our attention to the cumulative effects of our past experiences casting a shadow on life chances in old age. In our study, the respondents expressed regrets over lack of education and skills, which led to a lack of financial security and to economic dependence especially among older widows (see Mehta 2005 for more discussion on this theme). O’Rand (1996) is more explicit. She describes it as the economically advantaged position of the widowers in contrast to the economically disadvantaged situations of widows. For Singapore, a period effect is also evident because in the early 1900s, Asian parents in Singapore believed that males should be well educated as they had to be the main breadwinners in the family, while females did not need an education since they were going to become homemakers. The cumulative economic disadvantage this has on widows will be more fully elucidated in the section on social security below.

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Turning to cumulative social advantage, gendered roles work for widows. Women as ‘kin-keepers’ are tasked with kin relationship maintenance. This means they can accumulate their social capital over time. When widowhood arrives, they can call upon the social networks they have built with family and relatives. In the Singapore context, the concept of filial piety or respect and courtesy for elders is highly valued by all the ethnic groups, and there is a sense of ‘debt repayment’ from the younger generation toward the older generation, especially the parents and grandparents. As in any society, there will be divergences in its practice but generally speaking, the younger generation in Singapore do feel that they have a duty to look after their parents, at least financially. This works to the advantage of both widows and widowers. The cautionary note would be threats coming from changes in values as Singapore becomes increasingly globalized (see Teo et al. 2003b).

Juxtaposing the traditional and the modern In myriad ways, Singapore represents a colourful blending of the traditional and the modern. Cultural gerontologists may find the juxtaposition of traditionally clad older Singaporeans with scantily clad youth in the latest fashions in contexts such as temples, shopping malls and parks fascinating. However, within a family, intergenerational relations can be highly strained with the meeting of traditional attitudes and 3-G (third generation) opinions and expectations. How do our dependent and traditional widows and widowers fit into contemporary society? For the young-old who may still be working and doing household tasks, the adjustment would be less stressful as they are still deemed to be contributing. However, for the old-old and sometimes disabled, the inability to reciprocate can be burdensome. It is appropriate to include here the fact that older women tend to have higher levels of physical disability in Singapore, as in other parts of the world (Mehta 2005). Following the initial trauma of loss and bereavement, widowed persons turn to their social support systems within the immediate and extended family for emotional support and to cope with their sense of loneliness. Some turned to physical and cultural activities such as tai chi, qigong, handicrafts and religious classes to occupy their time. Rather than inactivity, the widowed were proactive in finding things that would help them avoid being such a burden to their busy adult children whose fast-paced lives in modern society leave them little time to render help. Another example where the traditional did not compromise the modern was the help that the widowed gave to their adult children, in spite of their own emotional needs. The data revealed that widows are not the apolitical recipients of gendered roles we often think they are. Instead, we found widows to be active agents who strategically planned, within the domestic realm of the home space, a role that is useful and even critical for households with dual income (Teo and Mehta 2001). In traditional terms, a woman’s status is defined by her husband’s presence and stature in the family as well as community. It is therefore challenging for her to redefine

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her identity in a modern context without the support of her husband. As a result, widows do what they know best – reproductive roles and functions that are valued by their children and children-in-law. In addition, they would employ intricate strategies to avoid friction with their adult children and children-in-law who have different modern views. By exercising tact and diplomacy and practising non-interference in the spheres where they are not directly involved or welcomed, they are quickly accommodated (Teo and Mehta 2001). Where familial support to redefine identity was not forthcoming to our respondents, they depended on ‘substitute family members’ such as neighbours, friends and professionals and/or volunteers from nearby social service agencies. For those who lived with non-relatives or alone, visitations from family members varied from regular to occasional, sometimes including a meal together. Irregular visits were sometimes due to conflicting relationships. For others who had no family members besides the spouse (because their family members were in their country of origin, e.g. Malaysia, India or China), it appears their relevance to modern society is questionable as they are often deemed to be in need of social support from VWOs that depend on the goodwill of the public as well as the state to support their programmes. As Singapore moves more and more into the ‘I and me first’ mode, VWOs and state may have to play a larger role in their care. Remarriage: a viable option? One of the values we found in our study which resisted change was remarriage. The dichotomous male–female/private–public divide has immense implications for society at large and more so in widowhood – while the wife provided unpaid labour and support for his career, the husband became dependent on this labour and support. Thus it came as no surprise when Matthews (1987) and Connidis (1989) suggested that women lose their identity because their principal role as a wife ceased when their spouse died. By the same argument, men would find that if their spouses died first, they were unable to cope with the daily chores. In fact, they often lamented the absence of a constant companion (Campbell and Silverman 1996; DiGiulio 1989). Not having provided caregiving roles and not accustomed to household management, both of which are confined to the private sphere, widowers are unable to deal with the drastic change to their lives, causing them to find a substitute for their deceased wife. These enduring scenarios work their magic on remarriage rates. Widows have been reported to have wider and more varied social networks and therefore they have many opportunities to socialize. However, this may not equate to reducing their loneliness as a widow. Canadian data shows that rates of remarriage are markedly higher for men than for women among those 60 years and above (Connidis 1989). This trend could be due to a variety of reasons. Men would have more choice to remarry

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than women, due to the fact that men tend to marry women younger than themselves. In addition, women may be reluctant to enter marriage after being widowed because of – fear of betrayal of faithfulness towards the first husband; concern for the welfare of children, e.g. would they be treated well by the step-father?; and fear that they would be duty-bound to become the primary caregiver and therefore experience physical, emotional and mental exhaustion (for more discussion on widowed persons’ attitudes toward remarriage, see Talbott 1998 and Davidson 2001). In Singapore, the widowed face social stigma. This was apparent from the data we collected as well as public reaction to a 58-year-old Malaysian widow who advertised in the Singapore newspapers for a prospective husband (The Straits Times 15 April 2001a). This example of Madam Sim illustrates not only public disapproval of a widow seeking a marriage partner at her age, but also the open method used! Madam Sim has four living children who are all adults; her husband had died of digestive complications in 2000, and she stated in a press interview that her late husband had been an irresponsible man who had not loved her. Hence, she wanted a responsible man ‘who would take care of me.’ Unfortunately, her son reacted very negatively to her advertisement and he threatened to sever ties with her. This, she felt, was very selfish on his part. In the same newspaper, an article entitled Sole Mate (The Straits Times 15 April 2001b) discussed the sense of isolation, stigma and marginalization that widowed persons in Singapore face. The reports reconfirm the results of our widowhood study that society is forgiving of younger widows and widowers seeking to remarry but is not for those above middle age. Our widowhood study included a question on perceptions of remarriage and reasons for positive and negative perceptions (Table 10.2). The fact that some widows and widowers rejected the idea of remarriage due to the negative attitudes of their adult children points to the reality that they are subject to the direct or indirect influence of these children. The subjugation would be compounded if the widow or widower was financially dependent on the adult children. Society’s unjust gaze is also one of the reasons for the negative perception of remarriage: ‘I’m afraid that others will laugh at me and I can’t afford to support her’ (male, 68, Malay). Another respondent asked, ‘What is the point of marrying again? Since we are getting old, we should focus on improving our spiritual aspect of life’ (female, 62, Malay). The ‘cultural scripts’ of the ethnic groups often provide a guide to what older persons should and should not do. For the Malays and Indians, spiritual pursuits are considered appropriate for older persons as such activities prepare one for death and benefit the soul in the afterlife (for more discussion see Mehta 1997c). How do the widows and widowers who do not remarry fulfil their sexual needs? Gerontological literature has debunked the widely held belief that older people are asexual. Bearing in mind that such a topic would be sensitive, particularly for the current cohort of older Singaporeans, this

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Table 10.2 Considerations for negative/positive attitude to remarriage Reasons

No.

%

a

Reasons for negative perceptions of remarriage Too old to consider remarriage Never thought about it Satisfied with present lifestyle Children may not get along with ‘new’ parent Financial insecurity Not keen to make changes in life Still faithful to late spouse Children opposed to remarriage Lose ‘face’/society is negative towards remarriage Suitors not acceptable Against own religion Not sure/no answer Total Reasons for positive perceptions of remarriage Loneliness/need companion Financial reasons Need someone to look after me Children’s encouragement It’s God’s will/it’s fate Not sure Total

49 34 13 10 9 7 6 2 1 1 1 89 222

22.1 15.3 5.9 4.5 4.1 3.2 2.7 0.9 0.4 0.4 0.4 40.1 100.0

5 3 2 1 1 3 15

33.3 20.0 13.3 6.7 6.7 20.0 100.0

a Respondents may give more than one reason. Source: Authors’ study

question was broached only in the qualitative interviews. Two women stated that in their viewpoint, women have more control over their sexual urges: ‘Women belong more to the introvert side. Whatever we do, we think of the children ... Such promiscuous behaviour would [cause our children to] lose their regard for us’ (female, 60, Indian). Two women said that their late husbands had been ill for more than five years prior to their death, and hence they had become accustomed to not having a sex life: ‘It’s like normal because it’s been so long. I don’t remember it any more. We women are like that’ (female, 53, Malay). Three other women said that they had buried their sexual desires with their late husbands as they could not think of ever replacing their late husbands. One female respondent said that she had no sexual urges because her spiritual life had instilled discipline in her. Of the three men who answered this question, one said that he masturbated when he was aroused, another had been to brothels in the past but as he had

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turned 80, he had stopped going. A third said that he would watch ‘romantic movies’ and read Playboy magazines to compensate. What emerges from the findings is that widows and widowers applied gender-specific strategies to meet their sexual needs, and these strategies were influenced by societal expectations, family context, cultural beliefs and personal attitudes. Critical social gerontology helps us to understand the intertwining and recursive relationships between sociocultural structures, beliefs and norms on the one hand and the micro-level conditions and situations that individuals experience on the other. The individual negotiates and works out strategies using his/her own agency as well as strengths, resources and wisdom elicited from past experiences to manage the conditions and situations they face.

The political economy of widowhood There are several themes that run through the individual experiences of widows and widowers in later ages that help us to understand the reasons for certain advantages and disadvantages. However, in this section we want to look at political and economic structures at the macro level that compound the gender effects, and also tease out the ethnocultural factors that intertwine with the structural in contributing towards the current marginalized status of widows and widowers in Singapore. The longer life expectancy of women as well as their secondary position in a predominantly patriarchal society set the background for economic disadvantages for older women. Widowhood is a normative transition for older persons; however, the CPF does not provide sufficient protection for widows who have not been in the labour force, i.e. they have been homemakers throughout their lives. According to Census 2000, 44.5 per cent of women in Singapore (aged 15 and above) were outside the labour force (economically inactive) as compared to 18.9 per cent of men. In the year 2000, there were 398,600 homemakers. The CPF does not provide financial protection to those who work in the informal sector or in non-monetized environments (qua the homemakers). According to Shantakumar (2005: 61), ‘as close to half the female population does not have an active CPF account, [they] are not able to rely on the main social protection mechanism in old age’. Owing to family responsibilities, many married women have a chequered work history, and this prevents the accumulation of adequate financial security in old age. It also prevents them from building up their assets such as in property (see Mehta 2005). Ironically, divorced and never-married women may be better off compared to widows because they have to take full responsibility for preparation for old age while married homemakers relied entirely on their spouses for financial security in later life. The CPF system works on an individual asset management basis, so individuals accrue their own savings, and each CPF account holder nominates a beneficiary. There are no rules regarding this, unlike some developed countries where the social security

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system allows the widow her rights to her late spouse’s funds. However, if no nomination has been made, the CPF savings would be transferred to the Public Trustee to distribute according to the law. Economists have studied gender disparities and found that the gap in the average CPF balances of men and women is growing wider: ‘Although the average balances of both genders have increased steadily over the two decades (1980–2000) the gap between the genders has increased significantly’ (Today 15 February 2005: 1). For example, at ages 50 to 54 years, the per capita balance of men stood at $66,123 compared to women who only had $39,211 (males had about 1.7 times the amount of females). The comparable figure for those above 60 is about 2.2 times more, which reflects that the gap increases with age. What does this mean? It shows that not only is the total figure of females with CPF accounts lower than for males, the actual fund in the account is also much less. The whole intention of the CPF as a comprehensive savings plan for retirement is called into question, a point already made in Chapter 5. Indeed, it can be said that the CPF mechanism is ineffective for protecting the financial concerns of Singaporean older women. Over and above this, in a country that claims to be a family-oriented society, there is an urgent need to make changes to the CPF scheme so that family members such as homemakers, who sacrifice their own personal interest to care for their families, are adequately covered in old age. Without their spouses’ presence, the vulnerable positions of widows are even more precarious, especially if there are children involved, as according to the Intestate Succession Act (Cap. 146) (Ministry of Law 2005), children are entitled to a half share of the assets of the deceased. From anecdotal evidence, we are aware that inheritance patterns in patriarchal cultures are in favour of males in the family. Hence, this cultural norm discriminates against wives, daughters and grand-daughters. There are instances where the male head of household bequeaths the entire estate to the sons and leaves very little for his wife. The intention may be that the sons would be able to manage the economic assets more efficiently, and they would be filial towards their mother. However, this may or may not transpire, and the wife may be stranded in her old age. ‘It is of particular significance that in 2000, the number of widows living alone was 3.5 times higher than that of the widowers’ (Tay 2003: 72). This is an important structural statistic within the context of an Asian society where the family is expected to be the safety net in old age. It is critical to remember that physical disability, in particular lower level of mobility, is more prevalent among women and therefore they would require more physical assistance, for example, in carrying groceries. Comparison of the 1990 and 2000 census data indicated that the percentage of women above 75 years who were non-ambulant had increased from 5 to 7 per cent (Mehta 2005: 50). When we put together the implications of the above findings, it is clear that widows who are physically disabled and living

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alone are highly vulnerable. They suffer high economic and health risks as was found by Hermalin et al. (2002b).

Recommendations for services and programmes and conclusion Some suggestions have been made for improving the wellbeing of the widowed in Singapore: ● ● ● ● ●

information and referral services to help widows/widowers; counselling services; religious and other support groups; community education and preparation for widowhood; and social clubs especially for the widowed.

Widows have been an excluded group in society and this chapter has raised some of the means by which they can negotiate a better position for themselves. Globalization has helped because dual-income households are in need of assistance, especially in the area of child care. If remarriage remains farfetched, widows face a serious problem because they have to depend on their adult children and children-in-law to provide financial and emotional support. Already, women have lower CPF earnings than men; how much more so in the case of homemakers? The home is a prison that traps because they are valued there rather than as waged workers, especially for women in the decades of the 1950s, 1960s and 1970s when Singapore was struggling to gain an economic foothold. For many of these women, information and counsel on legal rights and on financial and health areas would be very helpful. Many issues relating to their legal rights and how to manage finances, especially for health care, had been in the hands of their respective spouses and are now transferred to their adult children. Providing information would give them some degree of empowerment as the availability of choice is made known, even if it is not exercised. When asked about their concerns, our respondents ranked financial concerns as first, health as second and relationships as third. This gives an indication of the kind of topics that public education workshops/talks should focus on, for instance related to legal rights, preparing wills, financing for health care and so forth. What is implicit rather than explicit in the concerns of the widowed is that any decision with regard to their welfare is a burden on their family members. This is because they are seldom part of the decision-making process. If they can be included in the discussions, they would likely feel less of a strain to their family members because they would at least know they have contributed to the decision about their care rather than just a recipient of it. O’Bryant and Hansson (1995) point out that the need for companionship is strong as loneliness is the most common emotional and social challenge in widowhood. Interestingly, Cheng and Ma (2000) who studied widowed persons in Hong Kong SAR found that their respondents appreciated the

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emotional and social support from their families but were dissatisfied with the informational support they gave. Friends were better at furnishing information and they acted as supplementary support. From their study we learn that even though older widowed persons may live well-adjusted lives within their family ambits, friends are an important source of support network also. They not only relieve the family of some degree of caregiving stress, they also give peer support and a listening ear when intergenerational relations may be strained. Thus, social clubs and hobby-related activity groups are key community-based programmes for the benefit of widowed individuals. Access to these permits at least an alternative to the family support which has dominated Asian societies. Our study also confirmed the lack of awareness by respondents of government and voluntary services for the widowed. A large majority (93 per cent of the sample) had not heard of any services for older widowed persons. This finding can be explained by the low levels of access of the sample to virtual media due to their low levels of literacy and IT skills. Some would not even have access to television (due to their low-income status) or newspapers (due to illiteracy). In addition, cultural factors such as ‘face’ would be a contributory factor preventing them from enquiring about ‘welfare services’ as they fear shame would be brought to their families. The current cohort of older Singaporeans hold on fiercely to the conservative Asian values they have been socialized into as these shape their identity and give meaning to their lives. Hence, service providers have to seek ways to convey information about services in a family-focused manner for optimum utilization. The future will witness changing socio-demographic characteristics amongst successive cohorts of widows and widowers. The demographic reality of more older women having to fend for themselves alone will become an even more pressing problem in the near future. However, some of the challenges to provide services to improve the wellbeing of this population group may not be very different as Asian values such as filial piety may endure. Higher levels of education and greater financial stability for the future cohort of widows and widowers may mean that they will be likely to advocate for services that will meet their needs. However, expectations about caring for the old remain, even among adult children. They may be better able to take care of themselves financially but they still expect their children to be part of their lives, if not financially, certainly in terms of keeping family bonds. Living in a time when social supports are already diminishing, the expectations that Madam Sim expressed in her advertisement may disappear but it is unlikely that discriminating barriers to the widowed identity will be readily and easily erased.

11 Conclusion

Using social theory currently employed in social gerontology this book explored, from a critical perspective, services provided to older people in Singapore. As the population ages, many political, economic and social problems have emerged. As answers are sought and policies designed to deal with these problems, very little time is given to reflect on what Estes et al. (2003: 145) call the ‘conceptual tools and related assumptions’ that scholars have about ageing. In the past, a great number of policies (in Singapore and elsewhere) were shaped by understandings of ageing from a biomedical perspective. Ranging from the ageing body which increasingly malfunctions to the implications this has for the mind and for able-ness, health, employment, financial and social services were designed with the idea that ageing leads to more health expenditure, lower economic productivity and more and more disengagement from society and family members. Ultimately, older people become ‘dependent’ and a burden to society. Accepting these ideas as unproblematic is out of step with critical social studies. As an attempt to steer research and discussion into hopefully fruitful deliberations, we outlined some of the new paradigms that have emerged, in particular, how ageing is a social experience, arguing that the practice of ageing is as much political as it is biological. In Chapter 1, the groundwork was laid regarding the importance of social constructions of ageing. It revealed how enhanced sensitivity to the experiences, practices and even spaces of older persons’ everyday interactions across groups (such as intergeneration and/or gender) as well as between professionals and older persons can lead to a more inclusive critical gerontology that can inform social policy in a more enlightened way than in the past. In this chapter, we argued that a balance between biomedical understandings of ageing that underpinned many social treatments of ageing and the social-structural viewpoint is not a chimera. In fact by drawing on the nexus of the humanistic experiential paradigm with structural analysis, the book provides a framework that broadens discussions about ageing and the provision of service in Singapore. Some positivist analyses more popular with the biomedical and early social models were employed to highlight the problems faced by older Singaporeans. It is, nevertheless, in

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the qualitative analyses that the meanings of ageing as experienced by older Singaporeans are given voice, but these would have little significance were it not for the social contextualization of time and place of the ageing experience (Massey 1993; Pain et al. 2001). In the chapter on health care (Chapter 6) in particular, the balance between the biomedical and the social is addressed. When the body does not function as efficiently, medical decisions must be made. Such decisions are often in the hands of professionals with insufficient input from the older patient and the family who become less powerful in charting the course of interventions. We argue that older people want more control and for interventions to take into account their situational contexts, besides just their financial means. We therefore explored the strategies used by older Singaporeans and their family members to negotiate the inhibitive structures of health care in Singapore, including Medisave, Medishield, polyclinic and private clinics, day care usage and medicines. Since 1984, with the installation of the ‘many helping hands’ policy, the state has shifted the burden of medical costs and of routine care provision to the family in the first instance and to community in the second, via VWOs and such (Chapter 3). The range of services provided by the community is wide and covers physiotherapy to social and recreational, including skills retraining and counselling. VWOs are based in both public and private housing estates and many voluntary services are run by CDCs which have grassroots as well as state support. The monies they receive from the state are quite substantial. They effectively become the informal arm of the state in operationalizing the state ideology of ‘many helping hands’. An important area that epitomizes an ideal public welfare service is housing in Singapore. In first providing a roof over our heads followed by nation-building through stakeholding, Singaporeans have become more rooted and identify with the nation (Chua 1997). By complementing the symbolic construction of home space as the place where the best care can be provided, it is argued in Chapter 8 that the state managed not only to feminize caregiving but also to rationalize it. This is not necessarily the best approach given the increase in female labour force participation over the years. A compromise between home space and community provides a more viable alternative but this requires an acceptance that care boundaries have not been transgressed and that respect for the wishes of the care recipient and family members are as crucial as the professional/nonprofessional help rendered. Chapter 7 outlines the many services available for older persons as a means to alleviate the heavy burden that family members bear. Stress on caregivers is often underestimated and with Singapore’s ageing profile, the onus on older members to look after their own family members who are old will become a common situation in the near future. Help from neighbours, community, foreign maids and even foster families are a range of options that will allow the older person to remain in the community rather than be

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institutionalized. As in many other countries, Singapore aims to remoralize the care landscape by minimizing institutional care except for acute cases and transferring care to more emancipatory types such as family and community care. In addition, volunteerism is valorized to broaden the net of involvement from community. Asian family ideology is the basis for help rendered to older people but it also forms the same basis for assistance given by older persons, especially older women (Chapter 9). As caregivers for young children in physical as well as emotional/moral support, the sacrifices made can shift the balance of power in a household since dual-income families depend on (and prefer) grandparents as caregivers for the young. More important, a variety of ‘cultures of ageing’ are beginning to emerge, seeking to establish ‘meaning’ in ageing (Gilleard and Higgs 2000). Within consumer society, older persons have a large number of choices to express and interpret their own ageing. Unlike the past where retirement was an enforced choice connected with a decline in productivity or to absorb the new intake of labour available, the circumstances in which retirement occurs now are more fluid and some are even wealthy enough to pursue lifestyle options. The growth of the idea of retirement as a third age in which self-fufilment and leisure construct the identity now challenges traditional roles expected of grandparents (Gilleard and Higgs 2000; Hockey and James 2003). It is unlikely that practices associated with the third age will be enacted by many, even if there is such an aspiration, because cumulative life course events can deny them financial security. Chapter 5 discussed the CPF system and the instruments available to account holders to improve on the amount of forced savings they accumulate in their working lifetime. Much is made of the process of governmentality in this chapter – that individuals must, as they do their health, organize their own lives and the appropriate role for the state is to be concerned with facilitating acceptable conduct. While the nest egg has not grown substantially for many Singaporeans, it is not for a lack of trying by the government which has time and again made available opportunities for fairly risk-free investments. For certain groups of individuals, structures lock them into marginalized positions for a long time. Feminists make hay out of the disadvantaged position of women, especially those whose prime productive years were spent not in waged work but in the private sphere of the home doing tasks with no monetary reward. For many older women, taking care of young children and performing daily chores such as cooking and cleaning were the only skills they acquired and when they are old, they substitute their children with their grandchildren. Widows in Singapore, in particular, use these skills to negotiate a better position for themselves. Widowers similarly conduct gender appropriate roles such as spiritual and moral education for their grandchildren. The assistance given by both is important; the identity of the widowed is in fact tied up with these roles. They make themselves indispensable to busy family members, especially those where all adult children are working.

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For older women, this strategy is all the more important because their financial status is precarious to begin with. Many have never worked for wages during their whole adult life; dependence is simply transferred from spouse to adult children when widowhood occurs (Chapter 10). Chapter 5 highlighted that many older Singaporeans depend on children for financial support. Some even top up their parents’ Ordinary and Medisave Accounts in the CPF. They also pay for medical insurance such as Medishield and Eldershield. The lack of financial security has prompted the state to revisit the contributions made by older workers. More and more, ageist ideas about productivity are being dismantled (Chapter 4) as the demographic reality of ageing (Chapter 2) makes it impractical to think that older people should stop working. Not only has the retirement age been increased from 55 to 62, there are now many retraining schemes available to encourage the inclusion of older people in the workforce for as long as possible (Chapter 4). Besides productivity-based rather than seniority-based wage structures, flexi-time and part-time work, the state has also redesigned job processes to make it easier for older persons to remain in the workforce. Attitudinal change for employers is an important area that is currently being addressed; ageism cannot be taken apart if employers are unwilling to co-operate. Whether through work, finances, health or everyday routine living activities, people are being called upon to make sacrifices. These include giving for the family and the community giving of itself. These are well worth it because the sum effect is economic and social progress for all Singaporeans, including older persons. Throughout the book, we alluded to these ideologies as under-girding policy: 1

2

The ideology of survival – this is a rhetoric we hear all the time from the state about Singapore’s ability/lack of ability to survive in the competitive global marketplace. As a result, the workforce and the economy must always try to be in a position of advantage so that it can rise to new challenges. For older people, they too must adapt; the implicit message is that those who don’t will get left behind or draw from rather than contribute to the economic growth of the nation-state (see also Hill and Lian 1995; Low and Johnston 2001). The ideology of Asian communitarianism – that we must work as a community and make sacrifices for the good of everyone (Chua 1995). Former Prime Minister Goh Chok Tong, at the National Day Rally in 1996, observed that in many developed countries, since the state took upon itself the responsibility of caring for the sick, indigent and disadvantaged, community and society at large had a diminished role (Vasoo 2002). This is a dilemma to be avoided because it is financially costly. Welfare is instead shifted to the ‘feminized people sector’ (Tan 2001: 113–14) while the state concentrates on the bigger issue of economic prosperity and growth. Thus the terms ‘shared values’ and ‘many helping

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151

hands’ refer to family, VWOs and the community at large who comprise the main bulk of care provision to the extent of state only absorbing acute problems. Volunteerism is spoken about frequently these days with state engines driving voluntary work at grassroots level. For example, the CDCs in Singapore aim to deliver welfare by using their own community to ponder and decide how to disburse funds and do actual voluntary work for people in their own housing estates. The ideology of the Asian ‘family’ – by strategically invoking the family, there is only one preconceived hegemonic representation of the ‘normal’ nuclear (the less preferred) and the Asian extended family (the preferred) systems (Phua and Yeoh 1995 cited in Woon 2004/5; see also Heng and Devan 1995; Wong et al. 2004). As an institution of Confucian values in a predominantly Chinese society, filial piety and collectivism of familial responsibility is oft-publicized rhetoric: The family is an important institution. It brings fulfilment to our lives and is our anchor in this fast-paced, ever-changing environment. Families serve as an important pillar of support for the nation. At the individual level, families are the primary source of emotional, social and financial support. At the national level, they contribute to social stability and national cohesiveness as they help develop socially responsible individuals and deepen the bond Singaporeans have with [their] country. (MCYS 2005k: up)

4

With increasing mobility in the global world and more ambiguity with regard to the structure of a family (Van de Kaa 1993), the state has to constantly reassert the Asian family not only to ‘establish a greater sense of place on a national scale but [also] to continuously mobilize the family unit as a source of individual welfare’ (Woon 2004/5: 30). The ideology of self-help – while family and community are always available, Singapore has since independence conveyed to its people that those who aspire to greater heights will always be rewarded, no matter what their social background. Meritocracy has worked well and has helped many Singaporeans to prove themselves (Quah et al. 1991). For older people, self-governance is a logical outcome of all of the above ideologies. Governing oneself to look after finances and health has become internalized among many Singaporeans as they speak of independence and the desire not to be a burden to their family and to Singapore society as a whole.

When we speak of intervention, it can come in the form of policy, research, treatment or education. In Singapore, policy has helped to shape research directions, the types of treatment and even public education. As such, government plays a significant driving role in how ageing is to be experienced.

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Nonetheless, while we acknowledge the power of structure in identity formation, we make the effort not to generalize about older persons because human ageing is, after all, complex and heterogeneity is the hallmark of postmodern understandings of ageing. For our island-state, small steps indicate that we are moving towards recognition of this diversity in spite of the strong presence of the state. Besides accommodating the decrements and deficiency needs associated with age such as medical care and social security, other aspects of human functioning are beginning to be addressed that allow for self-expression such as education or volunteer work. Indeed, respondents in our studies said they wanted a university of the third age and to become more involved in life-fulfilling activities besides child care or caregiving alone. NGOs such as SAGE are assisted by volunteers of the age group they target; similarly, the RSVP. The pervasive unidirectional view of the life course as one which is production-orientated (i.e. education, work, then retirement) puts boundaries on expression and the activities that older persons can engage in. Unless these are deconstructed, post-industrial societies like Singapore cannot facilitate alternative personal and social meanings of ageing. Social policy is an integral ingredient in this deconstruction process since it provides opportunities and/or places constraints. Throughout the book, we talked about the importance of agency in determining identity. While structures created by the state may inhibit or influence how an older person authors daily life, these can be mediated and even subverted, for example well-to-do people opting for C-class wards in hospitals or persisting in the application for subsidies even though they are told they fail the means test. On the more positive side, financial support from the state for activities such as skills retraining, computer classes, English language classes, mobile libraries and even yoga and tai-chi classes will enable older people to challenge perceptions of them as social burdens to society. Learning from practices conducted elsewhere, especially in the UK and the US, Singapore has avoided using a welfare approach and is well aware that market forces alone cannot deliver an equitable system of care for older people. What this book has attempted to do is to show that in the spirit of postcolonial discourse, framing questions and solutions according to the value systems and issues that are meaningful and important to a country is a useful exercise. Throughout we emphasize Asian values of collectivism and family as important to service provision in Singapore. Western-centred discourses are useful in a certain way but it is in the contextualization of knowledge and circumstance that research, education and policy can move into the realm of relevance. All said, ageing is a phenomenon fractured along several parallel lines that must be investigated together. In this study, we have discussed the who (men or women, intergenerational differences, some class and ethnic differences and most important, the state), when (post-independent Singapore) and where (the uniquely Singaporean experience) of ageing. A recent call by

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Katz (1996: 141) proposes that good researchers should be intellectual nomads who disregard boundaries and well-worn paths so that they can imaginatively reformulate the epistemology of the study of old age. In fact, he asks researchers to pay heed to Simone de Beauvoir’s (1972 cited in Katz 1996: 141) wise counsel that: Once we have understood what the state of the aged really is, we cannot satisfy ourselves with calling for a more generous ‘old-age policy’, higher pensions, decent housing and organized leisure. It is the whole system that is at stake and our claim cannot be otherwise than radical – to change life itself. While this is a bold call, a judgement on what are ‘generous’ old age policies and what are not is fraught with difficulty because it depends on whose life is being changed. If so, by ‘undisciplining’ old age, we get a better understanding of what the experience of ageing is really like. There are two reasons for this suggestion: one, the amount of research work on non-Western populations is still small in comparison to the West and two, ageing is becoming part of the demographic profile of many non-Western countries. In the endeavour to find commonalities in effective policies that can be applied elsewhere, we often forget to stop and reflect on the situatedness of these policies as well as what the research intends to do in the first place. To arrive at a more theoretically informed praxis for older people, social differences and theorizations of the body and of identity need to be examined for how we intend to continue viewing old age within our own contexts. Only then is it possible to think about empowering (because the very term itself is value-laden) older people when services are designed for (more acceptably, with?) them.

References

Agence France Presse (2003) ‘PM Goh to stay in politics after stepping down’, 25 August. Online. Available HTTP: (accessed 4 November 2004). Alatas, S.F. (1995) ‘The theme of “relevance” in Third World human sciences’, Singapore Journal of Tropical Geography 16(2): 123–40. Allen, I. and Perkins, E. (eds) (1995) The Future of Family Care for Older People, London: HMSO. Ang, S.L. and Lee, E. (2000) ‘The old-old in Singapore’, Singapore Statistics Newsletter. Online. Available HTTP: (accessed 10 March 2004). Arber, S. and Ginn, J. (eds) (1995) Connecting Gender and Ageing: A Sociological Approach, Buckingham: Open University Press. Asher, M. (1999) ‘Pension scheme in Singapore: case study and implications’, Economic and Political Weekly 34(52): 3687–94. Asher, M. (2002a) ‘Pension reform in an affluent and rapidly ageing society: the Singaporean case’, Hitotsubashi Journal of Economics 43(2): 105–18. Asher, M. (2002b) Social Adequacy and Equity of the Social Security Arrangements in Singapore, Centre for Advanced Studies Occasional Paper, National University of Singapore, Singapore: Times Academic Press. Atoh, M., Kandiah, V. and Ivanov, S. (2004) ‘The second demographic transition in Asia? Comparative analysis of the low fertility situation in East and South-East Asian countries’, The Japanese Journal of Population 2(3): 42–75. Barke, M. (2001) ‘Housing, space and society’, in R. Pain, M. Barke, D. Fuller, J. Gough, R. MacFarlane and G. Mowl, Introducing Social Geographies, London: Arnold. Bengston, V.L. and Robertson, J.F. (1985) Grandparenthood, Beverly Hills: Sage. Bengston, V.L. and Schaie, K.W. (eds) (1999) Handbook of Theories of Aging, New York: Springer Publishing. Bengston, V.L., Burgess, E.O. and Parrott, T.M. (1997) ‘Theory, explanation, and a third generation of theoretical developments in social gerontology’, The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 52(2): S72–S88. Bengston V.L., Kim, K.D., Myers, G. and Eun, K.S. (2000) Aging in the East and West: Families, States and the Elderly, New York: Springer.

References

155

Biegel, D.E. and Blum, A. (eds) (1990) Aging and Caregiving: Theory, Research and Policy, Newbury Park: Sage. Birren, J.E. and Bengston, V.L. (eds) (1988) Emergent Theories of Aging, New York: Springer. Blaikie, A. (1999) Ageing and Popular Culture, Cambridge: Cambridge University Press. Blake, M. (1992) Growing Old in the Malay Community, CAS Occasional Paper No. 10, Singapore: Times Academic Press and Centre for Advanced Studies, National University of Singapore. Blieszner, R. (1993) ‘The socialist-feminist perspective on widowhood’, Journal of Aging Studies 7(2): 171–82. Bloom, D.E., Canning, D. and Sevilla, J. (2003) The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change, Santa Monica: RAND. Bondi, L. and Fewell, J. (2003) ‘“Unlocking the cage door”: the spatiality of counselling’, Social and Cultural Geography 4(4): 527–47. Brown, M. (1995) ‘Ironies of distance: an ongoing critique of the geographies of AIDS’, Environment and Planning D: Society and Space 13(2): 159–80. Calasanti, T.M. (1999) ‘Feminism and gerontology: not just for women’, Hallym International Journal of Aging 1(1): 44–55. Calasanti, T.M. and Slevin, K.F. (2001) Gender, Social Inequalities and Aging, New York: AltaMira. Campbell, S. and Silverman, P.R. (1996) Widower: When Men are Left Alone, New York: Baywood. Cancian, F.M. and Oliker, S.J. (2000) Caring and Gender, Thousand Oaks: Pine Forge Press. Central Provident Fund Board (2004) Recap: Upcoming CPF Changes From 1 Jan 2005. Online. Available HTTP: (accessed 7 September 2005). Central Provident Fund Board (2005a) My CPF: Making an Investment, Having Peace of Mind – CPF Investor Education. Online. Available HTTP: (accessed 22 September 2005). Central Provident Fund Board (2005b) Latest: Adjustments to the Assumed Income. Online. Available HTTP: (accessed 21 September 2005). Central Provident Fund Board (2005c) Introduction to CPF. Online. Available HTTP: (accessed 8 September 2005). Central Provident Fund Board (2005d) Schemes and Services. Online. Available HTTP: (accessed 8 September 2005).

156

References

Central Provident Fund Board (2005e) CPF Minimum Sum Scheme: Securing your Retirement Income. Online. Available HTTP: (accessed 26 September 2005). Central Provident Fund Board (2005f) Update on the Privatization of Medishield Plus. Online. Available HTTP: <(http://www.cpf.gov.sg/cpf_info/goto.asp? page=News/PressRel/N_15Aug2005B.asp> (accessed 22 September 2005). Chan, A., Ofstedal, M.B. and Hermalin, A.I. (2002) ‘Changes in subjective and objective measures of economic well-being and their interrelationship among the elderly in Singapore and Taiwan’, Social Indicators Research 57(3): 263–300. Chan, A., Straughan, P.T. and Teo, P. (1999) ‘Report on the transitions of health, wealth, and welfare of elderly Singaporeans: 1995–1999’, unpublished report, National University of Singapore, Singapore. Available from main author: [email protected] Chee, Y.K. and Levkoff, S.E. (2001) ‘Culture and dementia: accounts by family caregivers and health professionals for dementia affected elders in South Korea’, Journal of Cross-cultural Gerontology 16(2): 111–25. Chen, M.A. and Dreze, J. (2002) ‘Widowhood and well-being in rural North India’, in V. Madan (ed.) The Village in India, Oxford: Oxford University Press. Chen, T. (2003) ‘Social care and voluntary action in China: the policy of “societalizing social welfare” and its effects’, in C. Jones Finer (ed.), Social Policy Reform in China: Views from Home and Abroad, Aldershot: Ashgate. Cheng, B.B.Y. and Ma, J.L.C. (2000) ‘Stress, social support and quality of life of bereaved spouses in Hong Kong’, Asia Pacific Journal of Social Work 10(1): 37–59. Cheng, L.K. (1985) Social Change and the Chinese in Singapore, Singapore: Singapore University Press. Cherlin, A.J. and Furstenberg, F. Jr. (1986) The New American Grandparent, New York: Basic Books. Cheung, P. (1993) ‘Population ageing in Singapore’, Asia Pacific Journal of Social Work 3(2): 77–89. Cheung, P. and Vasoo, S. (1992) ‘Ageing population in Singapore: a case study’, in D.R. Phillips (ed.), Ageing in East and Southeast Asia, London: Edward Arnold. Chia, N.C. (2004) ‘The Central Provident Fund and financing retirement needs of elderly in Singapore’, paper presented at the Workshop on Ageing and the Status of the Older Population in Southeast Asia, Institute of Southeast Asian Studies, Singapore, 22–23 November. Choi, S.J. (1996) ‘The family and aging in Korea: a new concern and challenge’, Ageing and Society 16(1): 1–25. Choi, S.J. and Suh, H.K. (1995) Aging in Korea, Federation of the Korean Gerontological Societies, Seoul: Chung-Ang Publishers. Choon, A. T. and Low, L. (1996) ‘Social security: how Singapore does it’, AsiaPacific Population Journal of Social Work 6(1): 97–119. Chow, N.W.S. (2001) ‘The practice of filial piety among the Chinese in Hong Kong’, in I. Chi, N.L. Chappell and J. Lubben (eds), Elderly Chinese in Pacific Rim Countries, Hong Kong: Hong Kong University Press.

References

157

Chua, B.H. (1995) Communitarian Ideology and Democracy in Singapore, London and New York: Routledge. Chua, B.H. (1997) Political Legitimacy and Housing: Stakeholding in Singapore, London and New York: Routledge. Coleman, P. (1997) ‘The last scene of all’, Generations Review 7(1): 2–5. Committee on the Family (2005) Executive Summary: Elderly Annex – Wellbeing of Elderly in Singapore. Online. Available HTTP: (accessed 14 September 2005). Connidis, I. (1989) Family Ties and Aging, Toronto: Butterworths. Conradson, D. (2003) ‘Geographies of care: spaces, practices, experiences’, Social and Cultural Geography 4(4): 451–54. Craig, Y.J. (1997) Elder Abuse and Mediation: Exploratory Studies in America, Britain and Europe, Aldershot: Avebury. Daly, M. and Lewis, J. (1998) ‘Introduction: conceptualising social care in the context of welfare state restructuring’ in J. Lewis (ed.), Gender, Social Care and Welfare Restructuring in Europe, Aldershot: Ashgate. Davidson, K. (2001) ‘Latelife widowhood, selfishness, and new partnership choice: a gendered perspective’, Ageing and Society 21(3): 297–317. Dear, M. and Wolch, J. (1987) Landscapes of Despair: From Deinstitutionalisation to Homelessness, Cambridge: Polity Press. Department of Statistics (1983) Economic and Social Statistics: Singapore 1960–1982, Singapore: Department of Statistics. Department of Statistics (1992) Yearbook of Statistics, Singapore: Department of Statistics. Department of Statistics (2000a) Singapore Census Population 2000 Advance Data Release No. 4 – Economic Characteristics of Singapore Resident Population. Online. Available HTTP: (accessed 23 June 2005). Department of Statistics (2000b) Advanced Data Release, Singapore: Singapore Department of Statistics. Department of Statistics (2001a) Trends in Singapore Resident Population 1990–2000, Singapore: Department of Statistics. Department of Statistics (2001b) Census of Population 2000: Geographic Distribution and Travel, Statistical Release No. 4, Singapore: Department of Statistics. Department of Statistics (2001c) Singapore Census of Population 2000 Advance Data Release No. 6: Households and Housing, Singapore: Department of Statistics. Department of Statistics (2002a) Life Expectancy and the Elderly: Statistical Snippets. Online. Available HTTP: (accessed 1 March 2004). Department of Statistics (2002b) Elderly Households. Online. Available HTTP: (accessed 3 March 2004).

158

References

Department of Statistics (2005a) Singapore 2005 Statistical Highlights, Singapore: Department of Statistics. Department of Statistics (2005b) Keystats: Health and Environment – Key Indicators of Health. Online. Available HTTP: (accessed 14 September 2005). Department of Statistics (2005c) Keystats: Demography – Key Indicators of Vital Statistics. Online. Available HTTP: (accessed 14 September 2005). Department of Statistics (2005d) Keystats: Census 2000 – Education. Online. Available HTTP: (accessed 14 September 2005). Department of Statistics (2005e) Keystats: Labour Force Participation Rates. Online. Available HTTP: (accessed 28 August 2005). Devasahayam, T. (2003) ‘Managing caregivers in Singapore organizations: why and how the state should become involved’, paper presented at the Population Association of America Annual Meeting, Minneapolis, Minnesota, 1–3 May. DiGiulio, R. (1989) Beyond Widowhood: From Bereavement to Emergence and Hope, New York: The Free Press. Dobbs, S. (2003) The Singapore River: A Social History, Singapore: Singapore University Press. Doling, J., Jones Finer, C. and Maltby, T. (2005) ‘Lessons to be learnt’, in J. Doling, C. Jones Finer and T. Maltby (eds), Ageing Matters: European Policy Lessons from the East, Aldershot: Ashgate. Erikson, E. (1997) The Life Cycle Completed (extended version), New York: W.W. Norton & Company. Estes, C.L. (1979) The Aging Enterprise, San Francisco: Jossey Bass. Estes, C.L. (1983) ‘Social security: the social construction of a crisis’, Milbank Memorial Fund Quarterly/Health and Society 61(3): 445–61. Estes, C.L. and Associates (2001) Social Policy and Aging: A Critical Perspective, Thousand Oaks: Sage. Estes, C.L., Biggs, S. and Phillipson, C. (2003) Social Theory, Social Policy and Ageing: A Critical Introduction, Maidenhead: Open University Press and McGraw Hill. Family and Community Development @eCitizen (2005) Senior Citizens: Neighbourhood Links/Senior Activity Centres. Online. Available HTTP: (accessed 24 September 2005). Featherstone, M. and Hepworth, M. (1989) ‘Ageing and old age: reflections on the post-modern life course’, in W. Bytheway (ed.), Becoming and Being Old: Sociological Approaches to Later Life, London: Sage Publications. Featherstone, M. and Hepworth, M. (1990) ‘Images of ageing’, in J. Bond and P. Coleman (eds), Ageing in Society: An Introduction to Social Gerontology, London: Sage Publications.

References

159

Featherstone, M. and Wernick, A. (eds) (1995) Images of Aging: Cultural Representations of Later Life, London and New York: Routledge. Finch, J. and Groves, D. (eds) (1983) A Labour of Love: Women, Work and Caring, London: Routledge and Kegan Paul. Fischer, B. and Poland, B. (1998) ‘Exclusion “risk” and social control: reflections on community policing and public health’, Geoforum 29(2): 187–97. Flowers, R.B. (2000) Domestic Crimes, Family Violence and Child Abuse: A Study of Contemporary American Society, Jefferson, North Carolina: McFarland. Foucault, M. (1978) The History of Sexuality; Vol 1: An Introduction, New York: Vintage Books. Foucault, M. (1979) Discipline and Punish, London: Peregrine Books. Foucault, M. (1991) ‘Governmentality’, in G. Burchell, C. Gordon and P. Miller (eds), The Foucault Effect: Studies in Governmentality, London: Harvester. Fry, C. (2001) ‘The unique contribution of key existential factors to the prediction of psychological well-being of older adults following spousal loss’, Gerontologist 41(1): 69–80. Fullager, S. (2002) ‘Governing the healthy body: discourses of leisure and lifestyle in Australian health policy’, Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 6(1): 69–84. Fuller-Thomson, E. and Minkler, M. (2001) ‘American grandparents providing extensive child care to their grandchildren: prevalence and profile’, The Gerontologist 41(2): 201–9. Gatrell, A.C. (2002) Geographies of Health: An Introduction, Oxford: Blackwell Publishing. Gattai, F.B. and Musatti, T. (1999) ‘Grandmothers’ involvement in grandchildren’s care: attitudes, feelings, and emotions’, Family Relations 48(1): 35–42. Gavrilov, L.A. and Heuveline, P. (2003) ‘Aging of population’, in P. Demeny and G. McNicoll (eds), The Encyclopedia of Population, New York: Macmillan. Gesler, W.M. and Kearns, R.A. (2002) Culture/Place/Health, London and New York: Routledge. Giddens, A. (1984) The Constitution of Society, Cambridge: Polity Press. Giddens, A. (1990) The Consequences of Modernity, Cambridge: Polity Press. Giddens, A. (1991) Modernity and Self-identity: Self and Society in the Late Modern Age, Cambridge: Polity Press. Gilleard, C. and Higgs, P. (2000) Cultures of Ageing: Self, Citizenship and the Body, Harlow: Prentice Hall. Gleeson, B.J. (1999) Geographies of Disability, London: Routledge. Gleeson, B.J. and Kearns, R. (2001) ‘Remoralising landscapes of care’, Environment and Planning D: Society and Space 19(1): 61–80. Golant, S. (1984) A Place to Grow Old, New York: Columbia University Press. Goodman, C.C. (2003) ‘Intergenerational triads in grandparent-headed families’, The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 58(5): S281–89.

160

References

Goodman, C.C., and Silverstein, M. (2001) ‘Grandmothers who parent their grandchildren: an exploratory study of close relations across three generations’, Journal of Family Issues 22(5): 557–78. Goodman, R., White, G. and Kwon H.J. (eds) (1998) The East Asian Welfare Model: Welfare Orientalism and the State, London and New York: Routledge. Gough, J. (2001) ‘Work, class and social life’, in R. Pain, M. Barke, D. Fuller, J. Gough, R. MacFarlane and G. Mowl, Introducing Social Geographies, London: Arnold. Gould, P. and Wallace, R. (1994) ‘Spatial structures and scientific paradoxes in the AIDS pandemic’, Geografiska Annaler 76B(2): 105–16. Graham, E., Teo, P., Yeoh, B.S.A. and Levy, S. (2002) ‘Reproducing the Asian family across the generations: “tradition”, gender and expectations in Singapore’, Asia-Pacific Population Journal 17(2): 61–86. Graham, H. (1991) ‘The concept of caring in feminist research: the case of domestic service’, Sociology 25(1): 61–78. Gramsci, A. (1971) Selections from the Prison Notebooks, trans. Q. Hoare and G.N. Smith, London: Lawrence and Wishart. Gubrium, J.F. (1993) ‘Voice and context in a new gerontology’, in T. Cole, W.A. Achenbaum, P. Jakobi and R. Kastenbaum (eds), Voices and Visions of Aging: Toward a Critical Gerontology, New York: Springer. Gubrium, J.F. and Wallace, J. (1990) ‘Who theorizes age?’, Ageing and Society 10: 131–49. Gullette, M.M. (2004) Aged By Culture, Chicago: Chicago University Press. Gutmann, D. (1985) ‘Deculturation and the American grandparent’, in V. Bengston and J. Robertson (eds), Grandparenthood, Beverley Hills, California: Sage Publications. Hagestad, G. and Dannefer, D. (2001) ‘Concepts and theories of ageing: beyond microfication in social science approaches’, in R. Binstock and L. George (eds), Handbook of Ageing and the Social Sciences, 5th edn, San Diego, California: Academic Press. Hare-Mustin, R.T. and Marecek, J. (2001) ‘Gender and the meaning of difference: postmodernism and psychology’, in A.C. Herrmann and A.J. Stewart (eds), Theorizing Feminism: Parallel Trends in Humanities and Social Sciences, 2nd edn, Boulder, Colorado: Westview Press. Harper, S. (1990) ‘The emergence and consolidation of the retirement tradition in post-war Britain’, in M. Bury and J. McNichol (eds), Aspects of Ageing, London: RH Social Policy Papers 3. Harper, S. (1992) ‘Caring for China’s ageing population: the residential option – a case study of Shanghai’, Ageing and Society 12(2): 257–84. Harper, S. and Laws, G. (1995) ‘Rethinking the geography of ageing’, Progress in Human Geography 19(2): 199–221. Hayden, D. (1984) Redesigning the American Dream: The Future of Housing, Work and Family Life, New York: Norton. Heinemann, G.D. (1983) ‘Family involvement and support for widowed persons ‘in T. Brubaker (ed.), Family Relationships in Later Life, London: Sage.

References

161

Held, D., McGrew, A., Goldblatt, D. and Perratton, J. (eds) (2000) Global Transformations: Politics, Economics and Culture, Cambridge: Polity Press. Heng, G. and Devan, J. (1995) ‘State fatherhood: the politics of nationalism, sexuality and race in Singapore’, in A.H. Ong and M.G. Peletz (eds), Bewitching Women, Pious Men: Gender and Body Politics in Southeast Asia, Berkeley: University of California Press. Heng, T.C. and Png, M.T. (2004) ‘Singapore’s Demographic Trends in 2003’, Statistics Singapore Newsletter September 2004. Online. Available HTTP: (accessed 14 September 2005). Hermalin, A.I., Roan, C. and Perez, A. (1998) The Emerging Role of Grandparents in Asia, Elderly in Asia Research Report Series No. 98–52, Ann Arbor: University of Michigan Population Studies Center. Hermalin, A. I., Chan, A., Biddlecom, A. and Ofstedal, M.B. (2002a) ‘Work, retirement and leisure’, in A. I. Hermalin (ed), The Well-Being of the Elderly in Asia: A Four-Country Comparative Study, Ann Arbor: University of Michigan Press. Hermalin, A.I., Ofstedal, M.B. and Mehta, K.K. (2002b) ‘The vulnerable and their potential disadvantages’, in A.I. Hermalin (ed.), The Well-being of the Elderly in Asia: A Four Country Comparative Analysis, Ann Arbor: University of Michigan Press. Higuchi, K. (2005) ‘Sobo ryoku’ (Grandmother power), AERA July 25: 70. Hill, M. and Lian, K.F. (1995) The Politics of Nation Building and Citizenship in Singapore, London: Routledge. Ho, K.C. (1994) ‘Competing to be regional centres: a multi-agency, multi-locational perspective’, Urban Studies 37(12): 2337–56. Hockey, J. and James, A. (2003) Social Identities Across the Life Course, Houndmills, Basingstoke: Palgrave Macmillan. Housing and Development Board (1998) CPF Housing Grants for Singles. Online. Available HTTP: (accessed 30 August 2005). Housing and Development Board (2003) Main Upgrading Programme. Online. Available HTTP: (accessed 6 June 2003). Housing and Development Board (2004a) Married Child Priority Scheme (MCP). Online. Available HTTP: (accessed 8 April 2005). Housing and Development Board (2004b) Fiancé/Fiancée Scheme. Online. Available HTTP: (accessed 8 April 2005). Inland Revenue Authority of Singapore (2004) Marriage and Parenthood (M&P) Measures Announced during National Day Rally: Frequently Asked Questions. Online. Available HTTP: (accessed 13 September 2005).

162

References

Inland Revenue Authority of Singapore (2005) Individual Income Tax: Parents/Handicapped Parents/Grandparents Caregiver Relief. Online. Available HTTP: (accessed 12 September 2005). Inter-ministerial Committee on Health Care for the Elderly (1999) Report of the Inter-ministerial Committee on Health Care for the Elderly, Singapore: Ministry of Health. Inter-ministerial Committee on the Ageing Population (1999) Report of the Interministerial Committee on the Ageing Population, Singapore: Ministry of Community Development. International Monetary Fund (1996) Government Finance Statistics Yearbook, Washington D.C.: International Monetary Fund. Jackson, P. (1989) Maps of Meaning: An Introduction to Cultural Geography, London: Unwin Allen. Japan Aging Research Center (1997) Toshi no Shoshikoreika to Koreika Shakai Taisaku Series I Shanghaishi-Shingaporu (Declining Birth and Ageing in Urban Cities and Social Policies in Ageing Society, Series I – Shanghai city/Singapore), Tokyo: Japan Aging Research Center. Jones Finer, C. (2005) ‘Prospects for pragmatism: trading lessons in social policy between East and West’, in J. Doling, C. Jones Finer and T. Maltby (eds), Ageing Matters: European Policy Lessons from the East, Aldershot: Ashgate. Katz, C. and Monk, J. (eds) (1993) Full Circles: Geographies of Women over the Life Course, London and New York: Routledge. Katz, S. (1996) Disciplining Old Age: The Formation of Gerontological Knowledge, Virginia: University Press of Virginia. Knodel, J. and Debavalya, N. (1997) ‘Living arrangements and support among the elderly in Southeast Asia’, Asia Pacific Population Journal 12(4): 5–17. Kong, L., Yeoh, B.S.A. and Teo, P. (1996) ‘Singapore and the experience of place in old age’, Geographical Review 86(4): 529–49. Kua, E.H. and Tan, S.L. (1997) ‘Stress of caregivers of dementia patients in the Singapore Chinese family’, International Journal of Geriatric Psychiatry 12(4): 466–69. Kwan, A.Y.H. (1995) ‘Elder abuse in Hong Kong: a new family problem for the old East’, in J. Kosberg and J.L. Garcia (eds), Elder Abuse: International and Crosscultural Perspectives, New York: Haworth Press. Laditka, J.N. and Laditka, S.B. (2003) ‘Increased hospitalization risk for recently widowed older women and protective effects of social contacts’, Journal of Women and Aging 15(2/3): 7–28. Laws, G. (1995a) ‘Understanding ageism: lessons from feminism and postmodernism’, The Gerontologist 35(1): 112–18. Laws, G. (1995b) ‘Embodiment and emplacement: identities, representation and landscape in Sun City Retirement Communities’, International Journal of Aging and Human Development 40(4): 253–80. Lee, D. (2003) ‘The upside of downgrading’, The Graduate June/July issue: 8–12.

References

163

Leonard, P. and Nichols, B. (1994) ‘The theory and politics of aging’, in B. Nichols and P. Leonard (eds), Gender, Aging and the State, Montreal: Black Rose Books. Li, C. (1997) ‘Shifting perspectives: filial morality revisited’, Philosophy East and West 47(2): 211–32. Li, L. (2005) ‘Longitudinal changes in the amount of informal care among publicly paid home care recipients’, Gerontologist 45(4): 465–73. Lien, L. (2002) ‘Marriage and procreation: to intervene or not – a policy-making perspective’, paper presented at the International Workshop on Fertility Decline, Below Replacement Fertility and the Family in Asia: Prospects, Consequences and Policies, National University of Singapore, Singapore, 10–12 April. Liu, W. and Kendig, H. (eds) (2000) Who Should Care for the Elderly: An East–West Divide, Singapore: Singapore University Press and World Scientific. Lopata, H.Z. (1973) Widowhood in an American City, Cambridge, Massachusetts: Schenkman. Lopata, H.Z. (1987) Widows: The Middle East, Asia and the Pacific, Durham, North Carolina: Duke University Press. Lopata, H.Z. (1996) Current Widowhood: Myths and Realities, Thousand Oaks: Sage Publications. Low, G. (2004) ‘A changing gerontoscape: the Chinese ageing experience in Singapore’, paper presented at the 7th Global Conference of the International Federation on Ageing, Singapore, 4–7 September. Low, L. and Johnston, D.M. (2001) Singapore Inc.: Public Policy Options in the Third Millennium, Singapore: Asia Pacific Press. Low, J.A., Ng, W.C. and Yap, K.B. (2000) ‘End-of-life issues: preferences and choices of a group of elderly Chinese subjects attending a day care centre in Singapore’, Annals, Academy of Medicine 29(1): 50–56. Macdonald, B. and Rich, C. (1984) Look Me in the Eye: Old Women, Aging and Ageism, London: The Women’s Press. McCormack, J. (2002) ‘Acute hospitals and older people in Australia’, Ageing and Society 22(5): 637–46. McGraw, L.A. and Walker, A.J. (2004) ‘Negotiating care: ties between aging mothers and their caregiving daughters’, Journal of Gerontology: Social Sciences 59B(6): S324–32. Maeda, D. and Ishikawa, H. (2000) ‘Ageing in Japan: retirement, daily lives, pensions and social security’ in D.R. Phillips (ed.), Ageing in the Asia-Pacific Region: Issues, Policies and Future Trends, London and New York: Routledge. Massey, D. (1993) Space, Place and Gender, Minneapolis: University of Minnesota Press. Matthews, A.M. (1987) ‘Widowhood as an expectable life event’, in V. Marshall (ed.), Aging in Canada: Social Perspectives, Ontario: Fitzhenry and Whiteside. Matthews, A.M. (1991) Widowhood in Later Life, Toronto: Butterworth. Mehta, K.K. (1994) ‘The dynamics of adjustment of the very old in Singapore’, unpublished doctoral thesis, Department of Social Work and Psychology, National University of Singapore, Singapore.

164

References

Mehta, K.K. (1997a) ‘Cultural scripts and the social integration of older people’, Ageing and Society 17(3): 253–75. Mehta, K.K. (1997b) Untapped Resources: Women in Ageing Societies across Asia, Singapore: Times Academic Press. Mehta, K.K. (1997c) ‘The impact of religious beliefs and practices on aging: a crosscultural comparison’, Journal of Aging Studies 11(2): 101–14. Mehta, K.K. (2000) ‘Caring for the elderly in Singapore’, in W. Liu and H. Kendig (eds), Who Should Care for the Elderly: An East-West Divide, Singapore: Singapore University Press and World Scientific. Mehta, K.K. (2002) ‘National policies on ageing and long-term care in Singapore: a case of cautious wisdom?’, in D.R. Phillips and A.C.M. Man (eds), Ageing and Long-term Care: National Policies in the Asia-Pacific, Singapore: ISEAS, IDRC and Asian Development Research Forum. Mehta, K.K. (2004) ‘Social work and social development’, in K. Mehta and A.Wee (eds), Social Work in Context: A Reader, Singapore: Marshall Cavendish Academic. Mehta, K.K. (2005) ‘The ageing experience of Singaporean women’, in K.K. Mehta (ed.), Untapped Resources: Women in Ageing Societies Across Asia, 2nd edn, Singapore: Marshall Cavendish Academic. Mehta, K.K. and Briscoe, C. (2004) ‘National policy approaches to social care for elderly people in the United Kingdom and Singapore 1945–2002’, Journal of Aging and Social Policy 16(1): 89–112. Mehta, K.K. and Joshi, V. (2001) ‘The long journey: stress among family carers of older persons in Singapore’, Hong Kong Journal of Gerontology 15(1 and 2): 11–22. Mehta, K.K. and Vasoo, S. (2000) ‘Community programmes and services for the long-term care of the elderly in Singapore: challenges for policy-makers’, Asian Journal of Political Science 8(1): 125–40. Mehta, K.K. and Vasoo, S. (2001) ‘Organization and delivery of long-term care in Singapore: present issues and future challenges’, in I. Chi, K. Mehta and A. Howe (eds), Long-Term Care in the Twenty-first Century: Perspectives from Around the Asia-Pacific Rim, New York: Haworth Press. Mehta, K.K., Osman, M. M. and Lee, A.E.Y. (1995) ‘Living arrangements of the elderly in Singapore: cultural norms in transition’, Journal of Cross-cultural Gerontology 10(1 and 2): 113–43. Milligan, C. (2000) ‘“Bearing the burden”: towards a restructured geography of caring’, Area 32(1): 49–58. Milligan, C. (2001) Geographies of Care: Space, Place and the Voluntary Sector, Aldershot: Ashgate. Milligan, C. (2003) ‘Location or dis-location? Towards a conceptualization of people and place in the care-giving experience’, Social and Cultural Geography 4(4): 455–70. Mills, T.L., Wakeman, M.A. and Fea, C.B. (2001) ‘Adult grandchildren’s perceptions of emotional closeness and consensus with their maternal and paternal grandparents’, Journal of Family Issues 22(4): 427–55.

References

165

Ministry of Community Development and Sports (2001) Eldercare Master Plan FY2001 to FY2005, Singapore: Ministry of Community Development and Sports. Ministry of Community Development, Youth and Sports (2004) Needs Assessment Study for Well, Disabled (and Frail) Elderly and their Caregivers, Singapore: Ministry of Community Development, Youth and Sports. Ministry of Community Development, Youth and Sports (2005a) Statistics and Resources: Information on Elderly. Online. Available HTTP: (accessed 16 September 2005). Ministry of Community Development, Youth and Sports (2005b) Directory of Eldercare Services. Online. Available HTTP: (accessed 6 September 2005). Ministry of Community Development, Youth and Sports (2005c) Tribunal for Maintenance of Parents. Online. Available HTTP: (accessed 19 September 2005). Ministry of Community Development, Youth and Sports (2005d) Statistics: Social Support. Online. Available HTTP: (accessed 21 September 2005). Ministry of Community Development, Youth and Sports (2005e) ‘Launch of ComCare: a springboard for the needy’, MCYS Media Release No. 23/2005. Online. Available HTTP: (accessed 16 September 2005). Ministry of Community Development, Youth and Sports (2005f) ‘High-level committee working to help needy Singaporeans’, MCYS Media Release: 21/2005. Online. Available HTTP: (accessed 16 September 2005). Ministry of Community Development, Youth and Sports (2005g) Promotion of Volunteerism. Online. Available HTTP: (accessed 29 August). Ministry of Community Development, Youth and Sports (2005h) Family Matters! Singapore. Online. Available HTTP: (accessed 12 September 2005). Ministry of Community Development, Youth and Sports (2005i) Statistics on Child Care Services. Online. Available HTTP: (accessed 16 September 2005). Ministry of Community Development, Youth and Sports (2005j) Active Seniors Programme. Online. Available HTTP: (accessed 17 September 2005). Ministry of Community Development, Youth and Sports (2005k) Introduction. Online. Available HTTP: (accessed 2 May 2005). Ministry of Finance (2005) Supplementary Retirement Scheme. Online. Available HTTP: (accessed 20 September 2005).

166

References

Ministry of Health (1984) Report of the Committee on the Problems of the Aged, Singapore: Ministry of Health. Ministry of Health (1994) Population and Development Issues: Singapore – National Report for the International Conference on Population and Development, Cairo 1994, Singapore: Ministry of Health. Ministry of Health (2000) Annual Report 2000, Singapore: Ministry of Health. Ministry of Health (2001) Annual Report 2001, Singapore: Ministry of Health. Ministry of Health (2004a) Elderly Care Services. Online. Available HTTP: (accessed 7 September 2005). Ministry of Health (2004b) Medisave, Medishield and Other Subsidy Schemes. Online. Available HTTP: (accessed 24 March 2005). Ministry of Health (2005) Summary of Medisave Withdrawal Limits. Online. Available HTTP: (accessed 1 September 2005). Ministry of Health, Ministry of Community Development, Department of Statistics, Ministry of Labour and National Council of Social Service (1996) National Survey of Senior Citizens in Singapore 1995, Singapore: Ministry of Health, Ministry of Community Development, Department of Statistics, Ministry of Labour and National Council of Social Service. Ministry of Home Affairs (1989) Report of the Advisory Council on the Aged, Singapore: Ministry of Home Affairs. Ministry of Information, Communications and the Arts (2004) Singapore Government Press Release: Budget Statement 2004 – Building a Future of Opportunity. Online. Available HTTP: (accessed 27 September 2005). Ministry of Law (2005) Distribution of Estates of Deceased Persons Administered by the Public Trustee. Online. Available HTTP: (accessed 20 May 2005). Ministry of Manpower (1999) Older Workers. Online. Available HTTP: (accessed 8 September 2005). Ministry of Manpower (2004) Keynote Address by Deputy Prime Minister Lee Hsien Loong at the National Tripartite Conference on Wage Restructuring at Singapore, International Convention Centre. Online. Available HTTP: (accessed 4 November 2003). Ministry of Manpower (2005a) MOM Speeches: Committee of Supply – Responses by Minister for Manpower, Dr Ng Eng Hen to Members of Parliament on Employability of Older Workers and CPF. Online. Available HTTP: (accessed 9 September 2005). Ministry of Manpower (2005b) MOM Speeches: Speech by Dr Ng Eng Hen, Minister for Manpower and Second Minister for Education at the WDA

References

167

Conservancy Job Redesign Pledge Signing Ceremony, 31 January 2005, at The Grassroots’ Club. Online. Available HTTP: (accessed 9 September 2005). Ministry of Manpower (2005c) Foreign Domestic Worker Levy Concession. Online. Available HTTP: (accessed 11 April 2005). Ministry of Social Affairs (1983) Report on the National Survey of Senior Citizens, Singapore: Ministry of Social Affairs. Minkler, M. and Fuller-Thomson, E. (2005) ‘African grandparents raising grandchildren: a national study using the census 2000 American community survey’, The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 60(2): S82–92. Moen, P. (2001) ‘The gendered life course’, in R. Binstock and L.K. George (eds), Handbook of Aging and the Social Sciences, 5th edn, San Diego: Academic Press. Moody, H.R. (1988) ‘Toward a critical gerontology: the contribution of the humanities to theories of aging’, in J.E. Birren and V.L. Bengston (eds), Emergent Theories of Aging, New York: Springer. Moody, H.R. (1993) ‘Overview: what is critical gerontology and why is it important?’, in T.R. Cole (ed.), Voices and Visions of Aging: Toward a Critical Gerontology, New York: Springer. Morley, D. (2000) Home Territories: Media, Mobility and Identity, London and New York: Routledge. Mowl, G., Pain, R. and Talbot, C. (2000) ‘The ageing body and the homespace’, Area 32(2): 189–97. Myles, J. (1991) ‘Postwar capitalism and the extension of social security into a retirement wage’, in M. Minkler and C.L Estes (eds), Critical Perspectives on Aging: The Political and Moral Economy or Growing Old, Amityville, New York: Baywood. National Council of Social Services and Ministry of Community Development, Youth and Sports (2005) ‘Physical Disability: accessibility and transport’, Disability Portal. Online. Available HTTP: (accessed 3 August 2005). National Productivity Board (1989) The Next Lap: Managing an Ageing Workforce, Singapore: National Productivity Board. National Trades Union Congress (2005) Speeches: Keynote Address by Mr Lim Boon Heng, NTUC Secretary-General at the NTUC-DGB Seminar on ‘Global Challenges and Union Response’ on 11 January 2005, at NTUC Centre, Seminar Room 701. Online. Available HTTP: (accessed 27 September 2005). National Volunteer and Philanthropy Centre (2004) The State of Giving, Singapore: National Volunteer and Philanthropy Centre. Neugarten, B.L. and Wienstein, K.K. (1964) ‘The changing American grandparent’, Journal of Marriage and the Family 26(2): 199–204.

168

References

Ngiam, T.L. (2004) ‘Contemporary welfare policy and social well-being’, in K.K. Mehta and A.Wee (eds), Social Work in Context: A Reader, Singapore: Marshall Cavendish Academic. Ngiam, T.L. (2005) ‘Population ageing in Singapore: the challenge of using the Central Provident Fund for retirement needs’, in J. Doling, C. Jones Finer and T. Maltby (eds), Ageing Matters: European Policy Lessons from the East, Aldershot: Ashgate. Nussbaum, J.F. and Coupland, J. (eds) (2004) Handbook of Communication and Aging Research, New Jersey: Lawrence Erlbaum Associates. O’Bryant, S.L. and Hansson, R.O. (1995) ‘Widowhood’, in R. Bleiszner and V.H. Bedford (eds), Handbook of Aging and the Family, Westport, Connecticut: Greenwood Press. O’Rand, A.M. (1996) ‘The precious and the precocious: understanding cumulative disadvantage and cumulative advantage over the life course’, The Gerontologist 36(2): 230–38. Ogawa, T. (2005) ‘Intergenerational equity and social solidarity: Japan’s search for an integrated policy on ageing’, in J. Doling, C. Jones Finer and T. Maltby (eds), Ageing Matters: European Policy Lessons from the East, Aldershot: Ashgate. Omar, R. (2000) Health: Bridging the Gaps, Kuala Lumpur: University of Malaya Press. Pain, R., Barke, M., Fuller, D., Gough, J., MacFarlane, R. and Mowl, G. (2001) Introducing Social Geographies, London: Arnold. Peace, S. (1993) ‘The living environments of older women’, in M. Bernard and K. Meade (eds), Women Come of Age, London: Edward Arnold. People’s Association (2005) ‘Senior Citizens’ Clubs’ (personal communication 5 October). Petersen, A. and Lupton, D. (1996) The New Public Health: Health and Self in the Age of Risk, London: Sage Publications. Phillips, D.R. (ed.) (2000) Ageing in the Asia-Pacific Region: Issues, Policies and Future Trends, London and New York: Routledge. Phillips, J. (1995) ‘Balancing work and care in Britain’, in J. Phillips (ed.), Working Carers: International Perspectives on Working and Caring for Older People, Aldershot: Avebury. Phillipson, C. (1998) Reconstructing Old Age: New Agendas in Social Theory and Practice, London: Sage Publications. Philo, C. (1989) ‘Enough to drive one mad: the organisation of space in 19th century lunatic asylums’, in J. Wolch and M. Dear (eds), The Power of Geography: How Territory Shapes Social Life, Boston: Unwin Hyman. Pickard, S. (1994) ‘Life after a death: the experience of bereavement in South Wales’, Ageing and Society 14(2): 191–217. Prescott, N. (1998) ‘Keynote address’, Proceedings of the Conference Choices in Financing Health Care and Old Age Security, Institute of Policy Studies and World Bank, Singapore, 8 November 1997.

References

169

Pritchard, A. and Morgan, N.J. (2000) ‘Privileging the male gaze: gendered tourism landscapes’, Annals of Tourism Research 27(4): 884–905. Quah, S., Chiew, S.K., Ko, Y.C. and Lee, S.M. (1991) Social Class in Singapore, Singapore: Centre for Advanced Studies and Times Academic Press. Quinn, J.F. and Burkhauser, R.V. (1994) ‘Retirement and labour force behavior of the elderly’, in L.G. Martin and S.H. Preston (eds), Demography of Aging, Washington D.C.: National Academy Press. Rappa, A. (1999) ‘The politics of ageing in Singapore: perspectives from state and society’, Southeast Asia Journal of Social Science 27(2): 123–38. Relph, E. (1976) Place and Placelessness, London: Pion. Rose, N. (1999) Powers of Freedom: Reframing Political Thought, Cambridge: Cambridge University Press. Rose, X. (1990) Widow’s Journey: A Return to the Living, London: Souvenir Press. Rosow, I. (1985) ‘Status and role change through the life cycle’, in R.H. Binstock and E. Shanas (eds), Handbook of Ageing and the Social Sciences, 2nd edn, New York: Van Nostrand. Rowles, G. (1978) Prisoners of Space: Exploring the Geographical Experience of Older People, Boulder: Westview Press. Rowles, G. (1983) ‘Geographical dimensions of support in rural Appalachia’, in G. Rowles and O. Russell (eds), Ageing and Milieu: Environmental Perspectives on Growing Old, New York: Academic Press. Sardar, Z. and Van Loon, B. (1997) Introducing Cultural Studies, New York: Totem. Saunders, P. (1989) ‘The meaning of home in contemporary English culture’, Housing Studies 4: 177–92. Savundranayagam, M.Y., Hummert, M.L. and Montgomery, R.J.V. (2005) ‘Investigating the effects of communication problems on caregiver burden’, The Gerontologist 60B(1): S48–S55. Schiller, B.R. (2004) The Economics of Poverty and Discrimination, New Jersey: Pearson Prentice Hall. Shantakumar, G. (1994) The Aged Population of Singapore, Census of Population 2000 Monograph No. 1, Singapore: Department of Statistics. Shantakumar, G. (2005) ‘Beyond youth: women growing older and poorer’, unpublished AWARE-TSAO Position Paper, Singapore. Sibley, D. (1995) Geographies of Exclusion: Society and Difference in the West, London and New York: Routledge. Sibley, D. (1998) ‘The problematic nature of exclusion’, Geoforum 29(2): 119–21. Sibley, D. and Lowe, G. (1992) ‘Domestic space, modes of control and problem behaviour’, Geografiska Annaler 74B(3): 189–97. Silverstein, M., Giarrusso, R. and Bengston, V.L. (2003) ‘Grandparent and grandchildren in family systems: a socio-developmental perspective’, in V.C. Bengston and A. Lowenstein (eds), Global Ageing and its Challenge to Families, New York: Adline De Gruyter. Singapore Action Group for Elders (2004) Say ‘No’ to Elder Abuse, Singapore: SAGE Counselling Centre.

170

References

Singapore Council of Social Services (1985) Report on Elderly Homes Affiliated to the Council, Singapore: Singapore Council of Social Services. Singapore General Hospital (2002) Report of the SGH Study on Caregivers’ Issues and Problems, Singapore: Singapore General Hospital. Singapore General Hospital (2003) Inpatient Service Charges. Online. Available HTTP: (accessed 12 November 2003). Singapore Government (2005) Speech by Mr Lee Hsien Loong, Prime Minister and Minister for Finance at May Day Rally, Media Release. Online. Available HTTP: (accessed 1 August 2005). Singapore Indian Association (2003) Passage of Indians, Singapore: Singapore Indian Association. Sixsmith, A. (1986) ‘Independence and home in later life’, in C. Phillipson, M. Bernard and P. Strang (eds), Dependency and Interdependency in Old Age, London: Croom Helm. Snell, K. (2003) ‘National survey reveals extensive need for training on relative caregiving’, Together (Generations United Newsletter) 8(3): 18–19. Soja, E.W. (1988) Postmodern Geographies: The Reassertion of Space in Critical Social Theory, New York: Verso. Sommerville, P. (1992) ‘Homelessness and the meaning of home: rooflessness or rootlessness?’, International Journal of Urban and Regional Research 16(4): 529–39. Stevens, N. (1995) ‘Gender and adaptation to widowhood in later life’, Ageing and Society 15(1): 37–58. Stroebe, M.S. and Stroebe, W. (1993) ‘The mortality of bereavement’, in M.S. Stroebe, W. Stroebe and R.O. Hansson (eds), Handbook of Bereavement: Theory Research and Intervention, Cambridge: Cambridge University Press. Talbott, M.M. (1998) ‘Older widows’ attitudes towards men and marriage’, Journal of Aging Studies 12(4): 429–49. Tan, C.H. (1995) Venturing Overseas: Singapore’s External Wing, Singapore: McGraw Hill. Tan, K.P. (2001) ‘“Civil society” and the “new economy” in patriarchal Singapore: emasculating the political, feminizing the public’, Crossroads 15(2): 95–124. Tan, Y.L. (2002) ‘Singapore’s current population trends’ Statistics Singapore Newsletter September 2002, Singapore: Department of Statistics. Tarlow, B. (1996) ‘Caring: a negotiated process that varies’, in S. Gordon, P. Benner and N. Noddings (eds), Caregiving: Readings in Knowledge, Practice, Ethics and Politics, Philadelphia: University of Pennsylvania Press. Tay, B.N. (2003) The Graying of Singapore: Process, Consequences and Responses, Singapore: Humanities Press. Teo, P. (1992) ‘Is institutionalisation the answer for the elderly? The case of Singapore’, Asia-Pacific Population Journal 7(1): 65–79. Teo, P. (1994) ‘The national policy on elderly people in Singapore’, Ageing and Society 14(3): 405–27. Teo, P. (1996) ‘Ageing in Singapore’, Journal of Cross-Cultural Gerontology 11(3): 269–86.

References

171

Teo, P. (1997a) ‘Older women and leisure in Singapore’, Ageing and Society 17(6): 649–72. Teo, P. (1997b) ‘Space to grow old in: the availability of public spaces for elderly persons in Singapore’, Urban Studies 34(3): 419–39. Teo, P. (2004) ‘Health care for older persons in Singapore: integrating state and community provisions with individual support’, Journal of Aging and Social Policy 16(1): 43–67. Teo, P. and Huang, S. (1996) ‘A sense of place in public housing: a case study of Pasir Ris’, Habitat International 20(2): 307–25. Teo, P. and Mehta, K.K. (2001) ‘Participating in the home: widows cope in Singapore’, Journal of Aging Studies 15(2): 127–44. Teo, P. and Ooi, G.L. (1996) ‘Ethnic differences and public policy in Singapore’, in D. Dwyer and D. Drakakis-Smith (eds), Ethnicity and Development: Geographical Perspectives, Chichester: John Wiley and Sons. Teo, P., Chan, A. and Straughan, P. T. (2003a) ‘Providing health care for older persons in Singapore’, Health Policy 64(3): 399–413. Teo, P., Graham, E., Yeoh, B.S.A. and Levy, S. (2003b) ‘Values, change and intergenerational ties between two generations of women in Singapore’, Ageing and Society 23(3): 327–47. Teo, P., Yeoh, B.S.A., Ooi, G.L. and Lai, K. (2004) Changing Landscapes of Singapore, Singapore: McGraw Hill. Thang, L.L. (2001) Generations in Touch: Linking the Old and Young in a Tokyo Neighborhood, Ithaca: Cornell University Press. Thang, L.L. (forthcoming) ‘Experiencing leisure in later life: a study of retirees and activity in Singapore’, Journal of Cross-Cultural Gerontology. Thang, L.L. and Gan, S.K. (2003) ‘Deconstructing “Japanisation”: reflections from the “Learn from Japan” campaign in Singapore’, New Zealand Journal of Asian Studies 5(1): 91–106. Thang, L.L. and Mehta, K.K. (2004) ‘Grandparents, how do I view thee?’ Indian Journal of Gerontology 18(3 and 4): 375–90. The Business Times (2005) ‘Firms to study proposal to employ elderly: many employers say age is not their main criteria’, 20 January. The Business Times (2005) ‘A global city called home’, 22 August. The Straits Times (1994) ‘Project to help elderly widened’, 21 December. The Straits Times (1996) ‘They care for handicapped mums’, 22 November. The Straits Times (1998) ‘How to be Singaporean, Chinese and modern all at once’, 25 October. Online. Available HTTP: (accessed 19 September 2005). The Straits Times (2001) ‘Indonesian maid falls to her death in Yishun’, 2 January. The Straits Times (2001a) ‘Widow of opportunity’, 15 April. The Straits Times (2001b) ‘Sole mate’, 15 April. The Straits Times (2001) ‘Maid jailed for crying rape’, 6 October. The Straits Times (2002) ‘NTUC chief suggests less CPF for housing’, 4 April. Online. Available HTTP: (accessed 19 September 2005).

172

References

The Straits Times (2002a) ‘Bringing the CPF back to its roots – carefully’, 16 July. Online. Available HTTP: (accessed 19 September 2005). The Straits Times (2002b) ‘CPF freeze for older workers’, 16 July. Online. Available HTTP: (accessed 19 September 2005). The Straits Times (2002) ‘Singapore government accepts all ERC recommendations on CPF changes’, 22 July. Online. Available HTTP: (accessed 19 September 2005). The Straits Times (2002) ‘Elderly keen on reverse mortagages’, 23 August. Online. Available HTTP: (accessed 19 September 2005). The Straits Times (2002) ‘Largest survey on depression and anxiety soon’, 10 October. The Straits Times (2002) ‘Singapore’s ageing population a ticking time bomb’, 27 November. The Straits Times (2003) ‘Elderly prefer to live among young folk’, 15 January. The Straits Times (2003) ‘Kids more likely to have problems when maid plays mum’, 17 February. The Straits Times (2003) ‘Maid serves up soup – with detergent’, 14 June. The Straits Times (2003) ‘Slaughtering the most sacred cow’, 23 August. Online. Available HTTP: (accessed 13 September 2005). The Straits Times (2003) ‘Big push for foreign patients’, 21 October. The Straits Times (2003) ‘Should health care be free?’, 20 November. The Straits Times (2004) ‘Acting Minister says: my ideal health-care system has no patients’, 29 February. The Straits Times (2004) ‘Sympathy for “rich” who go to C class wards’, 9 April. The Straits Times (2004) ‘Looking after the needs of caregivers’, 12 April. The Straits Times (2004) ‘Grandparents, please help out’, 23 May. The Straits Times (2004) ‘What grandmas are saying “NO” to...’, 8 August. The Straits Times (2004) ‘Parenthood gets a $300m boost’, 26 August. The Straits Times (2004) ‘Medical tourists will bring in $500m this year’, 5 September. The Straits Times (2004) ‘PM steps up to push healthy living’, 6 September. The Straits Times (2004) ‘Medifund helped 216,000 last year’, 14 October. The Straits Times (2004) ‘Don’t “brain” it like Beckham, Balaji tells docs’, 18 October. The Straits Times (2004) ‘Picking up a political hot potato – good for health?’, 12 November. The Straits Times (2004) ‘Can you afford to retire?’, 18 December. The Straits Times (2005) ‘Breaking the age-old barrier’, 22 January. The Straits Times (2005) ‘What next in health care?’, 29 January. The Straits Times (2005) ‘The Singapore road map to being best in health’, 10 March.

References

173

The Straits Times (2005) ‘Caregivers’ welfare no laughing matter’, 15 April. The Straits Times (2005) ‘Older laid-off workers get jobs faster’, 16 June. The Straits Times (2005) ‘More elderly people want to live alone’, 21 June. The Straits Times (2005) ‘Taking the wrinkle out of old age’, 25 June. The Straits Times (2005) ‘Work-life balance: attitude change needed’, 20 July. The Straits Times (2005a) ‘Give older workers a chance’, 22 August. The Straits Times (2005b) ‘Use of Medisave broadened’, 22 August. The Straits Times (2005) ‘More elderly friendly flats are on the way’, 29 August. The Straits Times (2005) ‘Rules eased for elderly flat buyers’, 30 August. The Straits Times (2005a) ‘CPF pension idea for better returns: many members lost out under current fund investment plan’, 26 September. The Straits Times (2005b) ‘Proposals to make CPF go further’, 26 September. The Straits Times (2005c) ‘Medisave rules eased to cover more services’, 26 September. Thrift, N. (1983) ‘On the determination of social action in space and time’, Environment and Planning D: Society and Space 1(1): 23–57. Tilak, S. (1989) Religion and Aging in the Indian Tradition, Albany, N.Y.: State University of New York Press. Today (2005) ‘The widening CPF gap’, 15 February. Toh, M.H. and Low, L. (1991) Health Care Economics, Policies and Issues in Singapore, Singapore: Centre for Advanced Studies and Times Academic Press. Tronto, J. (1993) Moral Boundaries: A Political Argument for the Ethic of Care, London: Routledge. Tuan, Y.F. (1974) Topophilia: A Study of Environmental Perception, Attitudes and Values, Englewood Cliffs: Prentice Hall. Twigg, J. (1999) ‘The spatial ordering of care: public and private in bathing support at home’, Sociology of Health and Illness 21(4): 381–400. United Nations Economic and Social Commission for Asia and the Pacific (1999) Population Ageing and Development: Implications for Asia and the Pacific. Online. Available HTTP: (accessed 25 August 2005). Urban Redevelopment Authority (undated) The Making of the New Master Plan (Brochure), Singapore: Urban Redevelopment Authority. Valentine, G. (2001) Social Geographies, Harlow: Pearson Education and Prentice Hall. Van de Kaa, D. (1993) ‘Europe’s second demographic transition’, in L. Tepperman and S.J. Wilson (eds), Next of Kin, Englewood Cliffs: Prentice Hall. Van den Hoonaard, D.K. (1997) ‘Identity foreclosure: women’s experiences of widowhood as expressed in autobiographical accounts’, Ageing and Society 17(5): 533–51. Van den Hoonaard, D.K. (2001) The Widowed Self: Older Women’s Journey through Widowhood, Waterloo, Ontario: Wilfred Laurier University Press. Vasoo, S. (2002) ‘New directions of community development in Singapore’, in N.T. Tan and K.K. Mehta (eds), Extending Frontiers: Social Issues and Social Work in Singapore, Singapore: Eastern University Press.

174

References

Verbrugge, L.M., Mehta, K.K. and Wegenfeld-Heintz, E. (2005) Views of Disability in the US and Singapore, Asia Research Institute Working Paper Series No. 35, National University of Singapore. Waerness, K. (1996) ‘The rationality of caring’, in S. Gordon, P. Benner, and N. Noddings (eds), Caregiving: Readings in Knowledge, Practice, Ethics and Politics, Philadelphia: University of Pennsylvania Press. Walker, A. (1981) ‘Towards a political economy of old age’, Ageing and Society 1(1): 73–94. Walker, A. (1993) ‘Under new management: the changing role of the state in the care of older people in the United Kingdom’, Journal of Aging and Social Policy 5(1 and 2): 127–154. Wearing, B. and Wearing, S. (1996) ‘Refocusing the tourist experience: the “flaneur” and the “chorister”’, Leisure Studies 15(4): 229–44. Wee, A. (2004) ‘Concepts in context’, in K.K. Mehta and A.Wee (eds), Social Work in Context: A Reader, Singapore: Marshall Cavendish Academic. Wheelock, J. and Jones, K. (2002) ‘Grandparents are the next best thing: informal child care for working parents in urban Britiain’, Journal of Social Policy 31(3): 441–64. Williams, A. (2002) ‘Changing geographies of care: employing the concept of therapeutic landscapes as a framework in examining home space’, Social Science and Medicine 55(1):141–54. Williams, R.H. and Wirth, C. (1965) Lives Through the Years: Styles of Life and Successful Aging, New York: Atherton. Women and Geography Study Group (1984) Geography and Gender: An Introduction to Feminist Geography, London: Hutchinson. Wong, A.K. and Leong, W.K. (1993) Singapore Women: Three Decades of Change, Singapore: Times Academic Press. Wong, A.K. and Yeh, S.H.K. (eds) (1985) Housing a Nation: 25 Years of Public Housing in Singapore, Singapore: Housing and Development Board. Wong, J. (1993) ‘Asean economies: continuing dynamic growth in the 1990s’, in C. Dixon and D. Drakakis-Smith (eds), Economic and Social Development in Pacific Asia, London: Routledge. Wong, P.K. (2001) ‘From leveraging multinational corporations to fostering technopreneurship: the changing role of S&T policy in Singapore’, in L. Low and D.M. Johnston (eds), Singapore Inc.: Public Policy Options in the Third Millennium, Singapore: Asia Pacific Press. Wong, G.H.M., Ooi, G.L. and Phua, K.H. (1999) Annotated Bibliography on Ageing and the Elderly in Singapore, Singapore: Housing Policy and Development Research Team, Faculty of Architecture, Building and Real Estate, National University of Singapore. Wong, T., Yeoh, B.S.A., Graham, E. and Teo, P. (2004) ‘Spaces of silence: single parenthood and the “normal family” in Singapore’, Population, Space and Place 19(1): 43–58.

References

175

Woon, C.Y. (2004/5) ‘Reforming care, enabling lives: rethinking the social policy of care for disabled people in Singapore’, unpublished honours thesis, Department of Geography, National University of Singapore, Singapore. World Bank (1994) Averting the Old Age Crisis: Policies to Protect the Old and Promote Growth, New York: Oxford University Press. World Health Organization (2004) About WHO. Online. Available HTTP: (accessed 10 January 2005). Yadav, S.S. (2001) ‘Disability and handicap among elderly Singaporeans’, Singapore Medical Journal 42(8): 360–67. Yap, M.T. (2004) ‘Singapore’s response to an ageing population’, paper presented at the Workshop on Ageing and the Status of the Older Population in Southeast Asia, Institute of Southeast Asian Studies, Singapore, 22–23 November. Yap, M.T. (2005) ‘Fertility and population policy: an update on the Singapore experience’, in H. Kojima (ed.), Comparative Research on Declining Birth Rate and Policy on Declining Birth Rate in Korea, Taiwan, Singapore and Other Countries, Tokyo: Institute of Population Problems. Yeoh, B.S.A. (1996) Contesting Space: Power Relations and the Urban Built Environment in Colonial Singapore, Kuala Lumpur: Oxford University Press. Yeoh, B.S.A. (2003) ‘Postcolonial geographies of place and migration’, in K. Anderson, M. Domosh, S. Pile and N. Thrift (eds), Handbook of Cultural Geography, London: Sage Publications. Yeung, H.W.C. (2000) ‘State intervention and neoliberalism in the globalizing world economy: lessons from Singapore’s regionalization programme’, The Pacific Review 13(1): 133–62.

Index

Active Senior Citizen Awards 129 activities of daily living (ADL), inability numbers 93–4 ‘Adopt an Elderly’ 100 Advanced Medical Directive 1997 79 Advisory Council on the Aged 29 ageing policy see support framework ageism 42, 52–3; altering negative stereotypes 48, 53, 75, 150; increasing employment opportunities 52–3; social construction 1, 4, 6, 9, 53, 74, 76–85, 88, 135, 147, see also older persons agency-structure debate 73–5, 152 agricultural work 46 ambulatory status 22 Approved Investment Scheme (AIS) 45, 58, 71 Approved Non-residential Properties Scheme (ANRPS) 58 Asian communitarianism 150–3 Asian family 31, 76, 88, 89–90, 109, 112, 116, 131–2, 149, 150 Barke, M. 106 Beauvoir, Simone de 153 Bengston, V.L. 1, 3, 4, 6, 121 bereavement see widowhood Birren, J. 1 birthrate see population Briscoe, C. 89 Brown, M. 73 bureaucratic procedures, simplification 105 Cancian, F.M. 91 carers 11, 14, 87–105, 119, 148–9; bureaucratic procedures,

simplification 105; VWOs 117–19; caring/caregiving, definitions 90–100; co-ordination 90, 104; deinstitutionalization 87–8; duration of provision 95; emotions of 95 Table; family as 91–106; and gender 114–27; grandparents as 121–2; and informal community care 97; men as 93; perceptions of 95 Table; policy recommendations 102–5; and private–public boundaries 115–18, 118–19; problems of 94 Table; publicity/promotion 103; recipients 91–101; socio-demographic characteristics 15 Table; stress 94–6, 103; tasks of 95 Table; training 101–21; unmarried adults as 93; VWOs 117–19; women as 92 catastrophic illnesses 78 Central Provident Fund (CPF) 28, 29, 45, 48, 56–7; adequacy 60–71; balances 56; as basic support 64; changes 62–6, 70; constraints on use 82; development 56–71; eligibility 56; gender disparities 143–4; and housing mortgages 58, 62–3; investment schemes 65; Minimum Sum 57, 58–9; other income sources 59–60; reduced employers’ contribution rates 63–4; savings accounts 57; as savings system 57–8; withdrawal amounts at age 56, 57, 58 Table Cheng, B.B.Y. 145–6 child care centres 127, 133 child dependency ratio 21 Chinese: gender biases 126; mutual aid 26–7; population 20–1; Protectorate 27; and widowhood 135–7

Index Chow, N.W.S. 6 clan associations (Chinese) 26 Coleman, P. 137 colonial period 26–8 ComCare 65–6 communitarianism 150–60 community, and family 97–124 community care, informal 97 Community Development Councils (CDCs) 101 community level provision 40–41, 77 community support services, awareness 97 Table community work, by peers 98–9 Confucianism 25, 89–90, 122 Connidis, I. 140 Conradson, D. 114 Conservancy Job Redesign Programme 46–7 counselling skills training 102 crisis construction/management 42–3 critical gerontology 2–6, 147; and crisis construction/management 42–3; and health care 73–4; and policy 6–7; and widowhood 143 cultural gerontology 5–6, 139 day care centres 40–41, 100; training 102 Debavalya, N. 112 deinstitutionalization 87–8 dementia: provision for 40–1; rates of 94 demography see population dependancy changes 16–18 dependency ratios 18, 20–1, 46, 65 depression 94, 101–2, 122 destitution 65 development guide plan, planning units 36, 38 Fig disabilities: rates 93–4; severe 78–9 disengagement theory 3–4 domestic helper/maid, foreign 23, 92, 126–8 economic progress 42–5, 51, 150 educational profile 21–2 Eldercare Master Plan 30, 36, 128–9 elderly see older persons Eldershield 78–80, 84–5 Estes, C.L. 6–7, 42, 53, 62, 133, 147 ethnic differences 20–1, 152

177

family 149; Asian 31, 76, 89–90, 116, 131–41, 149, 150; as carers 91–7, 116–18; and community 97–24; familism 31, 76, 89–90, 131–41, 149; fostering 99; and health care finance 77–8; and housing provision 112; information for 103; support 55–6, 65–6, 69–70, see also grandparents; intergenerational support feminism and research 4 finance 55–5, 70–80; funds for income shortfall 68 Table; income and assets 66–70; perceptions of income adequacy 67–8; persons responsible for household expenses 69 Table; reasons for income adequacy 68–9 Fischer, B. 7, 74 focus group composition 12 Table foreign domestic helper/maid 92, 126–8 fostering, family 99 Foucault, M. 5, 73–4 Gatrell, A.C. 72–3 Gavrilov, L.A. 16 gender: biases 126; and child care attitudes 126; and CPF 143–4; and home 106–7, 114–18; and widowhood 135–6, see also men; women gender-gap 45–6, 49 gender-sensitive research 4 generativity 122, 132n gerontology: cultural 5–6, 139; social 147; training 102, see also critical gerontology Gesler, W.M. 74 Giddens, A. 4 Gleeson, B.J. 87, 114 globalization 2–3, 8, 31, 43, 45, 52, 120, 145, 150 Goh, C.T. 44, 46 Goh, K.S. 55–6 Golant, S. 114 Goodman, R. 25 Gould, P. 73 government see state Government Financial Assistance Scheme (GFAS) 65 Gramschi, A. 7 grandparents: ambivalent attitudes 124–31; as carers 121–2, 124; lifestyle options 128–9, 132–3; recognition 121–3, 132; and social

178

Index

policy 123–4; and tax relief 123–4, see also family; intergenerational support Grandparents’ Day 123 Hansson, R.O 145 Harper, S. 6, 44 health: definition 72; services, by location 32 Table, 36; survey of transitions 10 Table health care 72–3, 84–5, 148; and agency 80–4, 85; analytical approaches 73–5; cost issues 80–4; finance issues 77–80; medicalization 81, 84, 88; as personal responsibility 76–7; promotion 76–7; subsidies 83–4 Health Sciences Authority (HSA) 81 Hermalin, A.L. 46, 120, 145 Heuveline, P. 16 Hinduism 89 home: and gender 106–7, 114–18; meaningfulness 107; and private–public boundaries 118–19, see also housing provision; property hospice provision 40, 41 hospitals, community 40–41 Housing and Development Board (HDB) 108–211 housing provision 106–7, 118–19, 148; and community interactions 109–10; and family 112; and gender 114–18; mortgages 58, 62–3; for older persons 112–14; public areas, upgrading 111–12; social strategies 109–114; subsidized 107–9, 113–14 ideologies 6–7 IMC on the Ageing Population 16, 18, 22, 30 independent living 23 Indians: and day care centres 100; mutual help 27; population 20–21; and widowhood 135, 141 Indonesians, mutual help 27 industrialization programmes 43–4 infant care centres 127, 133 informal community care 97 inheritance patterns 144 institutionalization 23, 88, 97 intergenerational support 120–1, 131–3, see also family; grandparents

internet facilities 103 Islam 89 Japan 18, 25–6, 31, 46, 112 Jones Finer, C. 6, 26 Jones, K. 132 Joshi, V. 93 kampong spirit 101 Katz, C. 6 Kearns, R. 87, 114 Kearns, W.A. 74 Kendig, H. 6 Khaw Boon Wan 77, 84–5 Knodel, J. 112 Kornhaber, A. 132 labour force participation 45–6; by age and gender 49; by income 49–51; occupation and age 49–51; reasons for working 51 laissez faire 26 Laws, G. 3 Lee, H.L. 44–5, 46, 59, 61–2, 77 life expectancy 120, 124; at birth 19 Table; international comparisons 18 Table Liu, W. 6 Lopata, H.Z. 135, 136 Lupton, D. 74 Ma, J.L.C. 145–6 Macdonald, B. 4 maid, foreign 92, 126–8 Malays: and day care centres 100; mutual help 27; population 20–1; and widowhood 135, 141 Marx, K. 3, 5 Matthews, A.M. 140 means-testing 83–4, 113–14 medical care see health care medical check-ups 77 medicalization 81, 84, 88 Medifund 79 Medisave 58, 78–91, 84–5 Medishield 78–91, 84–5 Mehta, K.K. 30, 89, 93, 115 men: as carers 93; labour force participation 45, see also gender; women mentally ill, provision for 40–41 meritocracy 151 methodology 9–15, 152–3

Index Milligan, C. 89, 114 Monk, J. 6 Moody, H.R. 4 Myles, J. 42 National Family Caregivers Support Program (NFCSP) 132 National Survey of Senior Citizens (NSSC) 10, 28–9, 91, 97 National Volunteer and Philanthropy Centre (NVPC) 90 neighbourhood links (NLs) 36, 40, 41 neighbours 98 neoliberalism 7 Neugarten, B.L. 131 Ngiam, T.L. 25 non-governmental organizations (NGOs) 7, 152 objectives/structure 7–9 O’Bryant, S.L. 145 old age dependency ratio 21, 46 older persons: abuse 105; ADL inability, numbers 93–4; ambulatory status 22; annual growth rate 18–19; characteristics 20–23; destitution 65; and economic progress 42–5, 52; educational profile 21–2; formal support mechanisms 64–6; frailty numbers 93–4; geographic distribution 37 Table, 39 Fig; housing provision for 112–19; income and assets 66–70; intergenerational ties 120–33; international comparisons 18 Table; living arrangements 22–3, 113 Table; non-CPF income sources 59–60; perceptions of income adequacy 67–8; reasons for income adequacy 68–9; sexual needs 141–6 older workers: employment opportunities 52–3; employment restructuring 46–8; marginalization 44; negative stereotypes 53; reduced CPF contribution rates 63–4; skills development 45, see also labour force participation Oliker, S.J. 91 Parental Maintenance Act 1996 31, 56, 105, 124 parents see family People’s Action Party (PAP) 26

179

Petersen, A. 74 Phillips, D.R. 6, 92 Phillipson, C. 2, 5, 53 Philo, C. 74 physiotherapy 74–5 planning units (development guide plan) 38 Fig Poland, B. 7, 74 political economy school 3–4 population 16, 23–4; ageing process 16–19; birth rate decline 19–20, 28; characteristics 20–3; international comparisons 18 Table; pyramids 17 Fig; tax relief for procreation 123–4 post-structuralism 5, 73–5 postcolonialism 6 private insurance schemes 79 procreation, tax relief for 123–4 property: investment 58, 62–3; mortgaging for retirement 64 Re-employment Assistance Programme (REAP) 47 residents’ committees (RCs) 99 Retired and Senior Volunteer Programme (RSVP) 129 retirement: ages 28, 29, 44, 76; mandatory 51 Table, see also older persons Rose, N. 73–4 Rosow, I. 120 Rowles, G. 114 Sadasivan, B. 84 scale of analysis 4–5 second industrial revolution 43–4 self-help/reliance 151, see also welfarestate approaches senile dementia see dementia senior activity centres (SACs) 36, 40, 41, 133 senior citizens clubs (SCCs) 41 Senior Citizens’ Week 28 service providers, in study 13 Table severe disabilities 78–9 sex ratio statistics 20–1 sexual needs 141–6 Sibley, D. 2 Silverstein, M. 121 Sim, Madam 141, 146 Singapore Improvement Trust (SIT) 107 skills development 45

180

Index

social construction 1–2, 75–80, 135–6, 147–8, 152 social gerontology 147 social services, by location 35 Table Social Welfare Department/Council 27–8 Soja, E.W. 5 state: government support 65, 70; healthcare subsidies 83–4; and housing provision 107–9; ideologies 150–3; indirect support 30, see also welfare-state approaches structure-agency debate 73–5, 152 supply-side socialism 31 support framework 25; historical context 25–8; ideologies 150–3; national policy, development 28–31; services available 31–41 support groups 101 Tarlow, B. 91 tax relief for procreation 123–4 Tay, B.N. 45–6 Teo, P. 115, 124–5 third age see older persons Thrift, N. 4 total fertility rate (TFR), decline 19–20 Touch Caregivers Centre 95 Touch Community Services 93; training, of carers 101–2 Van den Hoonaard, D.K. 134, 136, 137, 138 Vasoo, S. 30 voluntary sector 41 voluntary welfare organizations (VWOs) 25, 29, 65, 70, 80, 98; and carers 117–18; and community work, by peers 98–9; post-war 27–8; and widowhood 140 volunteerism 90, 151

Waerness, K. 89 Walker, A. 3 Wallace, R. 73 wealth, survey of transitions 10 Table website information 103 Wee, A. 28 Weinstein, K.K. 131 welfare: Singapore-style 89–90; survey of transitions 10 Table welfare-state approaches 26, 65–6, 70, 76, 84, 89, see also state Westernization 55–6, 76 Wheelock, J. 132 widowers see widowhood widowhood 134–5, 145–6, 149–50; ability to cope 136; accommodative processes 137–8; assimilative processes 137; and critical gerontology 143; economic disparities 143–5; gender differences 135–6; immunizing processes 137; living arrangements 136; mourning 137; post-bereavement identity 136–9; profile 15 Table; remarriage 140–6; services/programmes 145, 146; and social advantages 138–9; traditional and modern responses 139–52 Williams, A. 114 women: as carers 92, 126; income and assets 66–70; labour force participation 45–6, 49; and widowhood 139–40, see also gender; men Woon, C.Y. 115 Yeoh, B.S.A. 6