Aging in Taiwan: Building a Society for Active Aging and Aging in Place

Abstract

Taiwan’s accelerated rate of aging is more than twice that of European countries and United States. Although demographic aging was not a major concern in Taiwan until 1993, when it became an aging society, aging issues now have become an imperative topic both in policy and in practice in the country. As this article demonstrates, in response to the challenge of the rapidly growing older population and the inspiration of cultural values of filial obligation and respect to elders, the concepts of active aging and aging in place are leading the policies and practices of gerontology to meet the diverse needs of the aging population in Taiwan. However, challenges remain, including the question of how to promote systematic endeavors, both in policies or research on aging, and how to encourage greater involvement of nongovernment organizations in the aging issue. In addition, some emerging issues about aging are addressed in this article including inadequate resources for older rural adults, building an age-friendly environment, and the increasing number of people with dementia.

According to the World Health Organization, a society in which the proportion of people 65 years or older is 7% or higher is known as an “aging society,” 14% or higher is regarded as an “aged society,” and 20% or higher is called a “super-aged society.” Taiwan became an aging society in 1993 and it is estimated that in 2018, Taiwan will enter the era of aged society (National Development Council, 2014). It was not until 1993, that Taiwan entered into an aging society; aging issues became an imperative topic, whether in policy or in practice in the country.

Taiwan is a small island located in East Asia at the western edge of the Pacific Ocean. Its culture is perceived as having both a traditional and modern understanding due to its societal roots in Confucianism—including respect for the aged and wise—as well as the influence of Western cultures, due to its specific geographic location. In response to the challenge of the rapidly growing older population and the inspiration of still-powerful, though disputed, cultural values of filial obligation and respect to elders, this article highlights the concepts of active aging and aging in place that lead the policies and practices of gerontology to meet the current diverse needs of the aging population in Taiwan. Specifically, active aging is designed for healthy older adults and aging in place is guiding the long-term care policies for disabled older adults in Taiwan. However, lack of systematic endeavors, both in policies or research on aging, and finding ways to encourage more nongovernment organizations to be involved in the aging industry, are some of the major challenges in the practice of current gerontology in Taiwan.

The purpose of this paper is to provide a broad view of policies and research of gerontology in Taiwan. First, we briefly review Taiwan’s aging demographic. Then, we discuss key public policy issues on aging, and main area of research on aging. Finally, we address emerging issues on aging in Taiwan including inadequate resources available to senior residences of rural areas; building an age-friendly environment; and the increasing number of people with dementia.

Demographic of Aging

One of the Fastest-Aging Societies in the World

As late as the mid-20th century, Taiwanese society was still largely rural, agricultural, and young; only about 2.5% of Taiwan’s population was over 65 years of age. However, with rapid industrialization and modernization, the age structure of the population has experienced a critical change (Huang, 2010). In 1993, more than 7% of the population was 65 years old or older so Taiwan became a so-called aging society. At the end of 2014, older adults comprised 12% of the population, and it is estimated that by 2018 Taiwan will cross the threshold into an aged society (with the older population growing to 14%) and, by 2025, a super-aged society (20% of the population above the age of 65; Figure 1); in other words, one in every four or five people will be an older adult at that time.

The accelerated rate of aging in Taiwan is more than twice that of European countries and United States. In only 24 years, Taiwan will have progressed from an aging society to an aged society. The time span for this transition in Taiwan is equal to that of Japan; however, Taiwan will only take 7 years to progress to a super-aged society from an aged society, which will be shorter than in Japan. By contrast, it will take approximately 75–150 years for Europe, the United States, and other developed countries to progress from aged to super-aged societies (Asian Productivity Organization, 2011). This demographic shift has affected gerontological policy worldwide. In Taiwan, like in European countries, there is a growing advocacy for active aging to sustain and optimize opportunities for a better social life and better health as people age. In addition, the idea of community-based support system or aging in place is emphasized, in Japan as well as Taiwan, not only because of the cultural considerations but also concern about the increasing number of fragile seniors.

The critical factors that contribute to the speedy aging in Taiwan are a rapidly declining fertility rate and high life expectancy. In the end of 2013, average life expectancy was 79.9 years (76.7 years for men and 83.3 years for women) (Health Promotion Administration, Ministry of Health and Welfare 2014). The fertility rate in 2013 was 1.1 (Executive Yuan, 2015). In addition, other factors that play important roles in accelerating the speed of aging in Taiwan are, first, a great migration from mainland China to Taiwan after the Chinese civil war in 1949. More than 1 million immigrants left China and moved to Taiwan with their families and most of them were 65+ years old by the 1990s. Second, the post-World War II baby boomers began to reach the age of 65 years in 2011 and started to retire (Lin, 2010). Most of those retirees are in good health, so how to keep them active in society is one of the main challenges for gerontology in Taiwan.

The Percentage of Working-Age Adults Began to Fall in 2013

The proportion of the population in their prime 15–64 years peaked in 2012 and began to fall in 2013 (Figure 2). In 2014, there were approximately 6.2 people in their prime to support one older adult; by 2060, the ratio will have fallen to 1.3–1. In 2016, for the first time in Taiwanese history, the percentage of older adults (>65 years old) will exceed the percentage of children (<15 years old) and the gap will continue to grow. It is estimated that by 2051, the population of older adults will be 4.7 times the number of children (National Development Council, 2014). With the continuing growth of that ratio, the demands and costs of elder care will become much more acute for the next working-age generation.

Aging Counties and Aged Townships Call for Better Care System

In comparison to post-war baby boomers with more robust health, education and finances, the “older old” require more services and resources. Among the aging population, the 80+ year-old group is growing most rapidly in Taiwan. By 2060, 26% of the total population will be “older old adults” (Figure 1). In terms of geography, currently three counties in Taiwan have become an “aging county,” in which more than 14% of county population is 65+ years old; 23 townships have turned into an “aged township,” in which more than 20% of township population is 65+ years old (Department of NGO International Affairs, 2012). Most of these counties and townships are in remote areas with fewer resources such as medical services and transportation, and most importantly, a lack of caregivers as young people move to metro areas for jobs and schools. Therefore, these remote areas with a high percentage of aging population necessitate better integration of resources as well as a better long-term care system in Taiwan.

Key Public Policy Issues on Aging in Taiwan

Public issues on aging did not appear in Taiwan’s political discourse until 1980, when the Department of Social Affairs, in the Ministry of Interior, released the first version of the Act of Welfare for Older Adults. It was an initial endeavor of government to address aging issues. Although the government subsequently initiated many plans and programs related to older adults, the policies and administration were still scattered subdivisions within different government agencies. In 2008, in response to a rapidly aging society and a labor shortage, the The Minister of the Interior (2008) released White Paper of Population Policy: Policies for pro-natal, aging, and migration. Furthermore, in 2009, the Executive Yuan (2009; The Executive Yuan is the executive branch of the ROC government, headed by the premier.) released Program of Friendly Care for Senior Service on the health of older adults, which highlighted three themes to guide the action plans: active aging, aging friendly, and intergenerational cohesion. Currently, the Ministry of Health and Welfare is drafting White Paper for Aged Society, which plans to collaborate with private sectors in Taiwan to provide community-based of prevention in primary care for older adults in an aged society. Specifically, the current key policies on aging in Taiwan can be described as follows.

Economic Safety

Launched in 2005, the National Pension serves citizens who are not covered by social insurance programs for laborers, farmers, members of the military, civil servants and teachers, ensuring that the vast majority of citizens receive regular, lifelong pension benefits. Insurants may join the program after 25 years of age and receive monthly payments for the rest of their lives when they reach the age of 65, with each citizen’s payment amount dependant on how much they paid into the system. Those who were already 65 at the time of the program’s implementation are exempt from paying premiums but receive monthly payments of NT$3,500 (US$118). In addition, other subsidies are provided for special needs of older adults. For example, (a) provide living allowance for older adults with low to medium income: seniors with low- to medium-incomes who do not receive public funds may be provided with monthly living allowances based on their family financial situations; (b) provide special care allowance for seniors with low to medium income: for seniors with low- to medium-incomes receiving living allowances and who do not receive sheltering or resettlement services from institutions, the family caregivers may be provided with monthly special care allowances; and (c) establish reverse mortgage system on real estate (pilot program): senior citizens can convert their houses and land into monthly payments, providing senior citizens with an additional option in financial security (Social and Family Affairs Administration, Ministry of Health and Welfare, 2015).

Health Maintenance

Health is one of the issues that most Taiwanese older adults worry about (The Ministry of Health and Welfare, 2013). Therefore, improving access to health care is essential to advance the quality of life for older adults. Taiwan’s government expanded health care coverage for its citizens by introducing the National Health Insurance Program (NHI), a single-payer compulsory social insurance plan. The NHI covers annual health examinations for people 65 years and older. For senior citizens with low to medium incomes, full grants on NHI are provided for those aged 70 years or older, and senior citizens aged 65 to 69 with medium to low incomes are provided grants subject to fiscal constraints of local authorities. In addition, grants for implants of dental prosthesis are provided for seniors with low to medium incomes (National Health Insurance Administration, Ministry of Health and Welfare, 2015).

Long-Term Care Service System

Long-term care for older adults has been a priority for the past decade in Taiwan. According to the 2013 National Health Interview Survey, around 86.3% of older adults have at least one chronic condition (Health Promotion Administration, Ministry of Health and Welfare, 2014). Currently, the policies on long-term care in Taiwan are tied to the concepts of aging in place and community care services. The primary policy of the long-term care system is the 10-Year Long-Term Care Program that was released by the Executive Yuan in 2007. This program is a government-funded initiative that covers the years 2007 through 2016 and offers services to people over the age of 65 with limitations on daily living, people over the age of 50 who possess disability identification, and aboriginal people over the age of 55 (Nursing and Health Care Administration, Ministry of Health and Welfare, 2015). Other initiatives in long term care in Taiwan include improving residential institutions and long-term care service quality, encouraging private-sector groups and communities to establish community care offices and building primary care networks (Social and Family Affairs Administration, Ministry of Health and Welfare, 2015). The primary challenge confronting the long term care system is the lack of both family and paid caregivers and their lack of professional training. In addition, too few potential recipients have requested long-term government services because services are not flexible enough, and some needy recipients do not meet the official qualifications (Taiwan Today, 2011).

Social Participation and Education

In order to encourage older adults to be active and continue to participate in society, Taiwan’s government promotes lifelong learning. In 2006, the Ministry of Education (2006) released a white paper entitled Toward the aged society: Policies on education for older adults. This document emphasizes six principles for older adult learners: social justice and equality; adaptation and empowerment; resource integration and sharing; localization and aging in place; civil engagement and autonomy; and professionalization. Currently, thousands of classes for older adult learning are operating throughout Taiwan.

Main Areas of Research on Aging

In reviewing journal articles and dissertations on aging in Taiwan from 1950 to the present, it was found that before 1990 the main areas of research were social welfare, nursing care for older adults, and the pension system. In 1990s, amid a growing concern about the aging population, more studies related to aging were conducted. In 1998, Taiwan’s government announced the first version of the Welfare Act for Older Adults; since then, programs and research on aging have been systematically promoted. In this decade, the research topics on aging have become varied. We searched the database of Index to Taiwan Periodical Literature System from 2011 through 2014 by using keyword “aging” or “older adults.” Several topics on aging were identified and by counting the number of articles in each topic, we found that in the last three years (2011–2014), the main areas of research on aging have been, in order of popularity, physical health/exercise; mental health; geriatrics; long-term care and community care; and social engagement/learning. However, it seems not much research has been done regarding minority older adults (e.g., indigenous elders, rural older adults, low-income older adults, solitary older adults and disabled older adults); gerontology education; and end of life issues, which are currently valued in gerontology research in other developed countries.

Key Institutes and Research Projects

Demographic aging is recognized as a critical issue, and gerontology is a growing field in Taiwan. However, aging issues still seem a subfield in most academic disciplines and industries. In contrast with the United States, there is no national institute concentrating on aging study in Taiwan. The research projects on aging are conducted at various public and private institutions, including universities. This might contribute to overlap and lack of integration between research projects and services. Most current research projects on aging are done by universities with the funding from government agencies including the Ministry of Health and Welfare, the Ministry of Science and Technology, and the Ministry of Education. In addition, Academia Sinica and the National Health Research Institute (NHRI) are national level research institutes that do not focus on aging study but have been conducting some aging related research.

Among government agencies, many aging related administrations operate under the purview of the Ministry of Health and Welfare (MHW). For example, the Social and Family Affairs Administration in MHW takes care of senior citizens’ welfare, and the Health Promotion Administration in MHW is responsible for health-related issues of aging. However, aging-related work is only part of its responsibilities. The MHW also acts as the main source of research support and carries on several national surveys on aging. Since the late 1980s, MHW, formerly the Department of Health, has conducted several national surveys on aging in Taiwan such as the Senior Citizen Condition Survey, which was started in 1986, and the Taiwan Longitudinal Study on Aging Survey, which was developed in 1988. Presently, the two national surveys are still being conducted by MHW.

The Ministry of Science and Technology (MST; http://www.most.gov.tw/mp.aspx?mp=7) acts as main sources of funding for universities and researchers who apply for research grants. For example, one of the leading integrated projects funded by MST, “Toward aged Society: An Integrated project of Plan for 2025 Taiwanese Society,” was developed in 2005 and led by professors from social work including Dr. Wan-I Lin, Dr. Pau-Ching Lu, and colleagues. This project was an interdisciplinary work for gerontology and provided practical suggestions for aging-related policy in Taiwan. Importantly, a series of community actions were implemented which significantly improved urban and rural older adults’ lives, especially by enhancing their motivation to do volunteer work, to promote self-awareness of their own health and to expand their social network within close friends and relatives (Lin, 2012; Lu, 2012).

Additionally, the Ministry of Education also funded and conducted many studies related to older adult learning. Most of the research projects and publications are publicly accessible. Also since the 2000s, the Ministry of Education has approved several new departments related to gerontology in colleges or universities to train professionals in Taiwan.

Academia Sinica is the highest level academic institution in Taiwan. It supports research activities in a wide variety of disciplines including mathematical and physical sciences; life sciences; humanities and social sciences. Aging-related studies are conducted in some of the institutes in Academia Sinica. For example, the Taiwan Social Change Survey (TSCS), which has been tracking long-term trends of social change by surveying the general adult population since the 1980s, has been based at the Academia Sinica, jointly operated by the Institute of Sociology and the Center for Survey Research. In addition, the TSCS team cooperates with the international community in designing international comparative surveys such as the International Social Survey Programme since 2002, and the East Asian Social Survey since 2003 (Table 1). Another important function of Academia Sinica is its Survey Research Data Archive (SRDA) that systematically acquires, develops, stores and disseminates precious survey research data in Taiwan; some of which are publicly open to access via (https://srda.sinica.edu.tw/intro/index_en).

The NHRI is a nonprofit foundation established by the government in 1995. The Division of Geriatric Research (DGR) in NHRI promotes successful aging in Taiwan through a wide spectrum of gerontological studies based on various scientific models. Also, DGR plays an important role in developing and implementing the geriatric subspecialist training program for sustainable promotion of older adult care and geriatric research in Taiwan (National Health Research Institutes, 2014a). An example of current leading research is the Healthy Aging Longitudinal Study in Taiwan (HALST), which aims to establish a longitudinal cohort of older persons to examine the physiological, environmental, and genetic risk factors for physical disability, frailty, cardiovascular disease, and neuropsychiatric disorders in older persons and to examine the benefit of healthy lifestyles (National Health Research Institutes, 2014b). Specifically, at the beginning of 2015, the Integrated Center on Aging and Health was established following the HALST project. Several other aging projects also have been conducted by DGR, such as A Cohort Study of Areca Quid Chewing and Death in Older Adults (1989–1996), Taipei Centenaries Study, and Nutritional Assessment for Older Adult in Taipei City, etc. For further information, visit (http://english.nhri.org.tw/NHRI_WEB/nhriw001Action.do). However, few datasets on aging in NHRI are completely open to public access.

Table 1 lists major datasets on aging that are available for free by submitting applications from Survey Research Data Archive in Academia Sinica in Taiwan.

Associations of Gerontology

There are many nongovernment organizations that promote gerontology in Taiwan. Firstly, Taiwan Association of Gerontology and Geriatrics (TAGG) was founded in 1982 to improve the health of older adults in Taiwan by advancing the studies of gerontology, geriatrics, and allied specialties. TAGG also publishes a quarterly journal—Taiwan Geriatrics & Gerontology. Secondly, the Federation for the Welfare of the Elderly (FWE), which was established in 1993, was developed by a group of senior citizens. FWE collaborates with other organizations in the nation to advocate and protect elders’ rights. Thirdly, the Taiwan Association of Gerontology (TAG) was founded in February 2012 with a mission to provide a platform for gerontological practitioners and researchers to advocate for gerontology in Taiwan and for international communication in gerontology. TAG consists of scholars and professionals in gerontology and holds an annual international meeting. The initiator and the first president of TAG is Dr. Wan-I Lin; the current president is Dr. Pau-Ching Lu.

Emerging Issues and Conclusions

Taiwan will become an aged society in 2018. However, Taiwan’s government seems lacking in systematic endeavors on aging in terms of policy and research. In addition, too few private agencies and industries in Taiwan are focusing on supporting and developing services for the older population. Some emerging issues on aging include inadequate resources for older rural adults, building an age-friendly environment, and the increasing number of people with dementia.

First, older rural adults have inadequate resources compared with older adults in urban areas. According to Lin’s (2012) study, older adults’ lives in rural cities are much more deficient in medical resources and transportation. Currently, there are many counties where the dependency rate (the number of people 65 and older to every 100 people of traditional working ages) is in excess of 10%. These cities are in remote areas, and they have relatively less resources and lower economic development. Aging issues in these remote cities are more serious than elsewhere including older adults’ care issues, medical access, and transportation. In addition, with an increasing number of Taiwanese women participating in the labor force, women are less available for family caregiving. How to foster aging in place and community-based care in the long-term care system in these remote areas has become a major challenge.

The second challenge is building an age-friendly environment. Although the tradition of filial piety is valued in Taiwan society, according to Huang (2013), Taiwanese undergraduate students have less knowledge about aging and have more negative attitudes toward older adults than students in United Kingdom and United States. This suggests that the Eastern tradition of respecting older adults (e.g., filial piety and the Confucian ethic) may have declined. In addition, although the majority of Taiwanese older adults still live with their families, the percentage is decreasing gradually. Therefore, how to build intergenerational cohesion and an age-friendly environment in Taiwan has become an imperative topic. Given that many areas have become aging counties/cities, Taiwan’s government attempts to promote age-friendly cities throughout the country. Based on the World Health Organization’s publication—Global age-friendly cities: Guide in 2007, Taiwan’s government chose ChiaYi as the first pilot age-friendly city in 2010 as a place to create a friendly environment for older adults. In 2013, there were 22 counties and cities implementing the age-friendly program. The government is attempting to create in Taiwan the highest rate of age-friendly cities in the world. In addition, the concept of age-friendly environments is being applied to health care services by the Ministry of Health and Welfare to advocate age-friendly health care and hospitals. Specifically, in 2014, the average life expectancy of Taiwanese women was 82.47 years and 75.96 years for men (Ministry of Interior, 2014). However, the 2013 National Health Interview Survey demonstrated that more than 80% of seniors reported having been diagnosed with at least one chronic disease, including more women than men. In addition, studies showed that the most common chronic diseases among older adults are hypertension and diabetes mellitus, whereas women are vulnerable to osteoporosis. In order to ensure the quality of life for senior citizens, age- and gender-friendly care services are needed.

Third, dementia has become a national concern. With the increase in both the aged population and the prevalence of dementia, the estimated number of people with dementia in Taiwan in 2012 was approximately four times that in 1992, increasing from 50,970 (3.6%) to 208,012 (8.0%). According to the Ministry of Interior and the latest epidemiological study of dementia published in 2014, more than 130,000 older adults (65+ years) in Taiwan are suffering from mild to severe dementia, and the overall prevalence of dementia higher in women than in men (The Ministry of Health and Welfare, 2014). Specifically, Sun and colleagues (2014) assessed the prevalence of mild cognitive impairment (MCI) and all-cause dementia by conducting a nationwide population-based cross-sectional survey. They concluded that old age, female gender and a low educational level are the critical factors associated with dementia in Taiwan. The authors further explained that among people aged 65 and older, the percentage of women without any formal education (47.4%) is much greater than that of men (15.3 %) in Taiwan. This difference may contribute to the higher frequency of dementia in women found in this study; in addition, the age-specific prevalence of all-cause dementia approximately doubled for every 5-year increase after the age of 70 years in both women and men. The Ministry of Health and Welfare released Taiwan Dementia Policy: A Framework for Prevention and Care in 2014 to guide the dementia programs, specifically, to provide timely diagnosis and early intervention to reduce the impact of dementia, and to ensure good quality services to maintain the dignity and improve the quality of life of people with dementia and their families. Additionally, starting in 2008, the care of people with dementia has been included in the The Year Long-term Care Plan. Through needs assessment, people with dementia can be categorized into different levels of disability and severity, and given access to home care, respite care services, daycare or home nursing care. However, some practical challenges still exist, such as caregivers and facilities. Influenced by cultural values of filial piety, family members have been the main caregivers for their aging parents in Taiwan. However, caring for one’s elder has recently become more difficult for Taiwanese families. Because of changing living arrangements, more older adults do not live with their families; also, the increasing number of educated women in the job market makes women less able to care for an elder relative (Kao, 2003; Lee, Chou, & Chen, 2011). With the decline of family caregivers, eldercare has become a critical problem in Taiwan. In contrast to Japan which has not actively recruited foreign workers in the health care field (Muramatsu & Akiyama, 2011), in Taiwan, women from southeast Asia have become the main source of caregivers in the long-term care system. This trend has raised concern about who are the most appropriate caregivers for aging Taiwanese.

In terms of facilities, promoting the type of senior care facility that fits the cultural values of Taiwanese older adults, such as home-based nursing homes, instead of large capacity nursing homes, is another one of the challenges in the near future in Taiwan.

References

Author notes