Ageing Singapore offers a blueprint for action By Rahul Malhotra, Duke-NUS Medical School

Singapore: Singapore's population is ageing at an unprecedented rate. While it has not solved the whole puzzle associated with that issue, it has taken concrete steps that might offer a blueprint for other countries. Singapore's early policy action and holistic approach towards population ageing are key lessons. Singaporean Prime Minister Lee Hsien Loong said in April that in 2020 one out of every six Singaporeans were aged above 65 — a jump from one out of every ten in 2010. By 2030, it is projected that one in every four residents in Singapore will be over 65. According to estimates from the United Nations, Singapore is poised to transition from being an "aged country" — one with at least 14 percent of the population aged 65 or older— to a "super-aged country", with at least 21 percent 65 or older, from 2021 to 2028.

The swift pace of ageing in Singapore can be attributed to two primary factors: a dramatic decline in the total fertility rate and a rapid increase in life expectancy. Despite being dubbed a "blue zone" where people are claimed to live longer, in a recent Netflix documentary, Singapore faces challenges in addressing its ageing population. Singapore experienced a steep decline in its fertility rate, from 5 children per couple to below the 2.1 replacement level in just 14 years. By contrast, Japan took roughly 30 years to reach this point, the United States 60 years and Australia a century. While Japan and the US saw fluctuations in their fertility rates, Singapore has consistently remained below 2.1 since 1977, despite implementing several child-friendly policies, otherwise known as pro-natalist policies.

These include financial support initiatives like direct cash payments, housing subsidies and tax relief, and initiatives promoting work-family balance like childcare services and parental leave provisions. In 2022, Singapore reported its lowest-ever fertility rate at 1.04, one of the lowest in the world. But pro-natalist policies are known to help increase fertility rate and Singapore could boost that by providing more financial support for child rearing and extending paternity and maternity leave. It could also push for stronger support for parents in the workplace, such as encouraging flexible work arrangements. While Singapore's Parliament has just passed a bill enhancing some of these policies, notably doubling government-paid paternity leave to four weeks, some Members of Parliament suggested more improvements to childcare arrangements to promote a healthy work-family balance.

Another challenge is finding skilled labour for quality care services. Hiring trained personnel from abroad offers a short-term fix, but long-term solutions require building local capacity and making "care" careers appealing. Singapore has started adopting technology-driven solutions to improve patient care and address its shortage of skilled labour. These initiatives include promoting the use of smartphone apps by older adults for managing their health and integrating robots into the healthcare process. Paying for pro-natalist policies and expanding care services is a significant challenge. Singapore raised the Goods and Service Tax from 7 percent to 8 percent in 2023 and plans another 1 percent rise in 2024 to cover the increased spending on an ageing population. Singapore's life expectancy at birth has surged, rising from 50.7 years in 1950 to 82.8 in 2021. This life expectancy increase has far-reaching implications for Singapore's care system.

With age comes a higher likelihood of chronic diseases and difficulties living independently day-to-day. For example, data from the first wave of THE SIGNS Study — a broad-based national study of older Singaporeans that was launched between 2016 and 2017 — showed the proportion of people with two or more chronic diseases was 53.6 percent among those aged between 60 and 69, rising to 72.6 percent among those aged 80 and older. Those experiencing difficulties in performing basic daily activities like walking, bathing, dressing or using the toilet increased from 3.4 percent among those aged between 60 and 69 to 30.3 percent among those aged 80 and older. Singapore's declining fertility rate itself feeds into the care challenges, leading to smaller families with less capacity to help care for older adults. As Singapore's older adult population grows, so too will the demand for healthcare, social services and long-term care. An ageing population mandates adaptation of the care system from one that mostly addresses acute care needs to one that additionally focuses on preventative care, chronic disease management, long-term care and palliative care.

Singapore has adopted a "whole-of-government" and "whole-of-society" approach to address the challenges of population ageing comprehensively. The nation recognised the need for coordinated planning and policymaking early, forming its first inter-ministerial committee for ageing-related issues in 1982, when only 5 percent of the population was aged 65 or older. In 2007, this holistic approach continued through the Ministerial Committee on Ageing, comprising multiple ministries, unions and community stakeholders. Singapore's latest ageing-related policies and initiatives are detailed in two Action Plans for Successful Ageing, released in 2015 and 2023. The 2023 action plan focuses on three key themes: care, contribution and connectedness. This plan emphasises preventative health, community-based "Active Ageing Centres", older adult learning, employment opportunities, intergenerational interactions and digital connectivity. Singapore's policymaking is deeply rooted in evidence-based approaches, using data from national surveys, evaluations of community-based programs, qualitative research and cost analyses. Both action plans were developed using a consultative process allowing for public input, including older adults and other key stakeholders.

The government also supports the collection of data on older adults, such as through THE SIGNS Study, to help cater to their diverse needs. The Singaporean public's trust in government also drives the successful uptake of its programs and initiatives. That trust in the government is considered key to its successful management of COVID-19, with the coverage of COVID-19 vaccines happening faster and at higher levels in Singapore than in other high-income countries. Singapore's response to an ageing population could be a blueprint for a global challenge. It has shown it helps to start developing age-friendly societies early instead of waiting for the country to significantly age. Policymaking should emphasise inclusivity rather than top-down planning, having evidence-based fixes to address real-world needs and relying on regular, detailed data about older adults. It's also critical to build trust in all corners of society — but especially among older adults and their caregivers and families — in government and policies.